Form CMS-2540-10 SKILLED NURSING FACILITY AND SKILLED NURSING FACILITY HE

Skilled Nursing Facility and Skilled Nursing Facility Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, and 413.106

R5p241F

Skilled Nursing Facility and Silled Nursing Facility Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, and 413.106

OMB: 0938-0463

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11-12

FORM CMS-2540-10

4190 (Cont.)

This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim
payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).
SKILLED NURSING FACILITY AND SKILLED NURSING
PROVIDER CCN:
FACILITY HEALTH CARE COMPLEX COST REPORT
CERTIFICATION AND SETTLEMENT SUMMARY

PERIOD :
FROM ______________
TO ________________

FORM APPROVED
OMB NO. 0938-0463
WORKSHEET S
PARTS I, II & III

PART I - COST REPORT STATUS
Provider
1.
[ ]
Electronic filed cost report
Date:____________
Time:____________
use only
2.
[ ]
Manually submitted cost report
3.
If this is an amended report enter the number of times the provider resubmitted this cost report. _______
Contractor
4.
[ ] Cost Report Status
5. Date Received _____________
use only:
[ 1 ] As Submitted:
6. Contractor No. _____________
[ 2 ] Settled without audit
7. [ ] First Cost Report for this Provider CCN
[ 3 ] Settled with audit
8. [ ] Last Cost Report for this Provider CCN
[ 4 ] Reopened
9. NPR Date: __________
[ 5 ] Amended
10. If line 4, column 1 is "4": Enter number of times reopened ______
11. Contractor Vendor Code ________

PART II - CERTIFICATION
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL, CIVIL, AND
ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED
THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE ILLEGAL, CRIMINAL, CIVIL, AND ADMINISTRATIVE ACTION, FINES
AND/OR IMPRISONMENT MAY RESULT.
CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDERS)
I HEREBY CERTIFY that I have read the above certification statement and that I have examined the accompanying electronically filed or manually submitted cost report
and the Balance Sheet and Statement of Revenue and Expenses prepared by _________________________{Provider Name(s) and Provider CCN(s)} for the cost reporting
period beginning _______________ and ending _______________ and that to the best of my knowledge and belief, this report and statement are true, correct, complete and
prepared from the books and records of the provider in accordance with applicable instructions, except as noted. I further certify that I am familiar with the laws and regulations
regarding the provision of health care services, and that the services identified in this cost report were provided in compliance with such laws and regulations.

OFFICER OR ADMINISTRATOR OF PROVIDER
Printed Name___________________________________________

Signed________________________________________________

Title__________________________________________________

Date__________________________________________________

PART III - SETTLEMENT SUMMARY
TITLE XVIII
TITLE V
1

A
2

1 SKILLED NURSING FACILITY
2 NURSING FACILITY
3 I C F-Mentally Retarded
4 SNF - BASED HHA
5 SNF - BASED RHC
6 SNF - BASED FQHC
7 SNF - BASED CMHC
100 TOTAL
The above amounts represent "due to" or "due from" the applicable Program for the element of the above complex indicated.

B
3

TITLE XIX
4
1
2
3
4
5
6
7
100

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-0463. The time required to complete this information collection is estimated 202 hours per response, including the time to review instructions,
search existing resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions
for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Report Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4103)

Rev. 4

41-303

4190 (Cont.)

FORM CMS-2540-10

SKILLED NURSING FACILITY AND SKILLED NURSING
FACILITY HEALTH CARE COMPLEX
IDENTIFICATION DATA

Skilled
1
2
3

11-12

PROVIDER CCN:

Nursing Facility and Skilled Nursing Facility Complex Address:
Street:
City:
County:

P.O. Box:
State:
CBSA Code:

PERIOD :
FROM ______________
TO ________________

WORKSHEET S-2
PART I

1
2
3

ZIP Code
Urban / Rural:

SNF and SNF - Based Component Identification:

Component
0
4
5
6
7
8
9
10
11
12
13
14
15
Type of
16
17
18

SNF
Nursing Facility
I C F - Mentally Retarded
SNF-Based HHA
SNF-Based RHC
SNF-Based FQHC
SNF-Based CMHC
SNF-Based OLTC
SNF-Based HOSPICE
OTHER (specify)
Cost Reporting Period (mm/dd/yyyy)
Type of Control (see instructions)

Component Name
1

From:

Provider
CCN
2

Miscellaneous Cost Reporting Information
19 Is this a low Medicare utilization cost report, enter "Y" for yes or "N" for no.
19.01 If the response to line 19 is "Y", does this cost report meet your contractor's criteria for filing a low utilization cost report? (Y/N)
Depreciation - Enter the amount of depreciation reported in this SNF for the method indicated on lines 20 - 22.
20 Straight Line
21 Declining Balance
22 Sum of the Year's Digits
23 Sum of line 20 through 22
24 If depreciation is funded, enter the balance as of the end of the period.
25 Were there any disposal of capital assets during the cost reporting period? (Y/N)
26 Was accelerated depreciation claimed on any assets in the current or any prior cost reporting period? (Y/N)
27 Did you cease to participate in the Medicare program at end of the period to which this cost report applies? (Y?N)
28 Was there a substantial decrease in health insurance proportion of allowable cost from prior cost reports? (Y/N)

V
4

Payment System
(P, O or N)
XVIII
5

XIX
6
4
5
6
7
8
9
10
11
12
13
14
15

To:

Freestanding Skilled Nursing Facility
Is this a distinct part skilled nursing facility that meets the requirements set forth in 42 CFR section 483.5?
Is this a composite distinct part skilled nursing facility that meets the requirements set forth in 42 CFR section 483.5?
Are there any costs included in Worksheet A that resulted from transactions with related
organizations as defined in CMS Pub. 15-1, chapter 10? If yes, complete Worksheet A-8-1.

Date
Certified
3

Y/N
16
17
18

19
19.01

20
21
22
23
24
25
26
27
28

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4104)

41-304

Rev. 4

11-12

FORM CMS-2540-10

SKILLED NURSING FACILITY AND SKILLED NURSING
FACILITY HEALTH CARE COMPLEX
IDENTIFICATION DATA

4190 (Cont.)

PROVIDER CCN:

PERIOD
FROM_____________
TO_____________

If this facility contains a public or non-public provider that qualifies for an exemption from the application of the lower of
costs or charges, enter "Y" for each component and type of service that qualifies for the exemption.
29 Skilled Nursing Facility
30 Nursing Facility
31 I C F / M R
32 SNF-Based HHA
33 SNF-Based RHC
34 SNF-Based FQHC
35 SNF-Based CMHC
36 SNF-Based OLTC

WORKSHEET S-2
PART I

Part
A

Part
B

Other
29
30
31
32
33
34
35
36

Y/N
37 Is the skilled nursing facility located in a state that certifies the provider as a SNF regardless of the level of care given for Titles V & XIX patients. (Y/N)
38 Are you legally required to carry malpractice insurance? (Y/N)
39 Is the malpractice a "claims-made" or "occurence" policy? If the policy is "claims-made," enter 1. If the policy is "occurence", enter 2.
Premiums

37
38
39
Paid Losses

41 List malpractice premiums and paid losses:

Self insurance
41

Y/N
42 Are malpractice premiums and paid losses reported in other than the Administrative and General cost center?
Enter Y or N. If "Y", check box, and submit supporting schedule listing cost centers and amounts.
43 Are there any home office costs as defined in CMS Pub. 15-1, chapter 10?
44 If line 43 = "Y", and there are costs for the home office, enter the applicable home office chain number in column 1.
If this facility is part of a chain organization, enter the name and address of the home office on the lines below.
45 Name:
46 Street:
P.O. Box:
47 City
State
ZIP Code

42
43
44

Contractor Name:

Contractor Number:

45
46
47

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4104)

Rev. 4

41-305

4190 (Cont.)

FORM CMS-2540-10

SKILLED NURSING FACILITY AND SKILLED NURSING
FACILITY HEALTH CARE COMPLEX
REIMBURSEMENT QUESTIONNAIRE

PROVIDER CCN:

11-12
PERIOD :
FROM ______________
TO ________________

WORKSHEET S-2
PART II

General Instruction: For all column 1 responses, enter in column 1, "Y" for Yes or "N" for No
For all dates responses, use the format mm/dd/yyyy.
Completed by All Skilled Nursing Facilities
Y/N
1

Provider Organization and Operation
1 Has the provider changed ownership immediately prior to the beginning of the cost reporting period?
If column 1 is "Y", enter the date of the change in column 2. (see instructions)

Date
2
1

Y/N
1

Date
2

V/I
3

2 Has the provider terminated participation in the Medicare Program? If column 1 is "Y",
enter in column 2 the date of termination and in column 3, "V" for voluntary or "I" for involuntary.
3 Is the provider involved in business transactions, including management contracts, with individuals or
entities (e.g., chain home offices, drug or medical supply companies) that are related to the provider or
its officers, medical staff, management personnel, or members of the board of directors through
ownership, control, or family and other similar relationships? (see instructions)

2
3

Y/N
1

Financial Data and Reports
4 Column 1: Were the financial statements prepared by a Certified Public Accountant? (Y/N)
Column 2: If yes, enter "A" for Audited, "C" for Compiled, or "R" for Reviewed. Submit complete copy
or enter date available in column 3. (see instructions) If no, see instructions.
5 Are the cost report total expenses and total revenues different from those on the filed financial
statements? If column 1 is "Y", submit reconciliation.

Type
2

Date
3
4

5

Y/N
1

Approved Educational Activities
6 Column 1: Were costs claimed for nursing school? (Y/N)
Column 2: Is the provider the legal operator of the program? (Y/N)
7 Were costs claimed for allied health programs? (Y/N) (see instructions)
8 Were approvals and/or renewals obtained during the cost reporting period for nursing school and/or
allied health program? (Y/N) (see instructions)

Y/N
2
6
7
8

Y/N
1

Bad Debts
9 Is the provider seeking reimbursement for bad debts? (Y/N) (see instructions)
10 If line 9 is "Y", did the provider's bad debt collection policy change during this cost reporting period? If "Y", submit copy.
11 If line 9 is "Y", are patient deductibles and/or coinsurance waived? If "Y", see instructions.

9
10
11

Bed Complement
12 Have total beds available changed from prior cost reporting period? If "Y", see instructions.

PS&R Report Data
13 Was the cost report prepared using the PS&R only?
If either col. 1 or 3 is "Y", enter the paid-through date of the PS&R used
to prepare this cost report in cols. 2 and 4 . (see Instructions)
14 Was the cost report prepared using the PS&R for total and the provider's records
for allocation? If either col. 1 or 3 is "Y", enter the paid-through date of the PS&R
used to prepare this cost report in columns 2 and 4.
15 If line 13 or 14 is "Y", were adjustments made to PS&R data for additional claims that
have been billed but are not included on the PS&R used to file this cost report?
If "Y", see instructions.
16 If line 13 or 14 is "Y", were adjustments made to PS&R data for corrections of other
PS&R Report information? If yes, see instructions.
17 If line 13 or 14 is "Y", were adjustments made to PS&R data for Other?
Describe the other adjustments:________________________________
18 Was the cost report prepared only using the provider's records? If "Y", see instructions.

12
Y/N
Part A
1

Date
Part A
2

Y/N
Part B
3

Date
Part B
4
13

14

15

16
17
18

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4104.1)

41-306

Rev. 4

11-12

FORM CMS-2540-10

SKILLED NURSING FACILITY AND
SKILLED NURSING FACILITY HEALTH CARE COMPLEX
STATISTICAL DATA

4190 (Cont.)
PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

WORKSHEET S-3
PART I

PART I - STATISTICAL DATA

Component
1
2
3
4
5
6
7
8

Bed
Days
Available
2

Title
V
3

Title
XVIII
4

Inpatient Days / Visits
Title
XIX
5

Other
6

Total
7

Title
V
8

Title
XVIII
9

Discharges
Title
XIX
10

Other
11

Total
12

Skilled Nursing Facility
Nursing Facility
ICF-Mentally Retarded
Home Health Agency
Other Long Term Care
SNF-Based CMHC
Hospice
Total (sum of lines 1-7)

Component
1
2
3
4
5
6
7
8

Number
of
Beds
1

1
2
3
4
5
6
7
8

Title
V
13

Average Length of Stay
Title
Title
XVIII
XIX
14
15

Total
16

Title
V
17

Skilled Nursing Facility
Nursing Facility
ICF - Mentally Retarded
Home Health Agency
Other Long Term Care
SNF-Based CMHC
Hospice
Total (sum of lines 1-7)

Title
XVIII
18

Admissions
Title
XIX
19

Other
20

Total
21

Full Time
Equivalent
Employees
Nonpaid
on Payroll
Workers
22
23
1
2
3
4
5
6
7
8

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4105)

Rev. 4

41-307

4190 (Cont.)
SNF WAGE INDEX INFORMATION

FORM CMS-2540-10
PROVIDER CCN:

11-12
WORKSHEET S-3
PARTS II & III

PERIOD :
FROM ______________
TO ________________

PART II - DIRECT SALARIES

Amount
Reported
1

Reclass.
of Salaries
from Wkst.
A-6
2

Adjusted
Salaries
( col. 1 ±
col. 2 )
3

Paid Hours
Related
to Salary
in col. 3
4

Average
Hourly Wage
( col. 3 ÷
col. 4 )
5

SALARIES
1 Total salary (see instructions)
2 Physician salaries-Part A
3 Physician salaries-Part B
4 Home office personnel
5 Sum of lines 2 through 4
6 Revised wages (line 1 minus line 5)
7 Other Long Term Care
8 Home Health Agency
9 CMHC
10 Hospice
11 Other excluded areas
12 Subtotal excluded salary (sum of lines 7 through 11)
13 Total adjusted salaries (line 6 minus line 12)
OTHER WAGES AND RELATED COSTS
14 Contract Labor: Patient Related & Mgmt
15 Contract Labor: Physician services-Part A
16 Home office salaries & wage related costs
WAGE RELATED COSTS
17 Wage related costs core (see Pt. IV)
18 Wage related costs other (see Pt. IV)
19 Wage related costs (excluded units)
20 Physicians Part A - WRC
21 Physicians Part B - WRC
22 Total adjusted wage related cost (see instructions)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

PART III - OVERHEAD COST - DIRECT SALARIES

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

Reclass.
of Salaries
from
Wkst. A-6
2

Adjusted
Salaries
( col. 1 ±
col. 2 )
3

Paid Hours
Related
to Salary
in col. 3
4

Employee Benefits
Administrative & General
Plant Operation, Maintenance & Repairs
Laundry & Linen Service
Housekeeping
Dietary
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Nursing and Allied Health Ed. Act.
Other General Service (specify _______________)
Total (sum lines 1 through 13)

Average
Hourly Wage
( col. 3 ÷
col. 4 )
5
1
2
3
4
5
6
7
8
9
10
11
12
13
14

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4105.1 - 4105.2)

41-308

Rev. 4

11-12

FORM CMS-2540-10

SNF WAGE RELATED COSTS

PROVIDER CCN:

4190 (Cont.)
PERIOD :
FROM ______________
TO ________________

PART IV - Wage Related Cost
Part A - Core List
RETIREMENT COST
1 401k Employer Contributions
2 Tax Sheltered Annuity (TSA) Employer Contribution
3 Qualified and Non-Qualified Pension Plan Cost
4 Prior Year Pension Service Cost
PLAN ADMINISTRATIVE COSTS (Paid to External Organizations)
5 401K/TSA Plan Administration fees
6 Legal/Accounting/Management Fees-Pension Plan
7 Employee Managed Care Program Administration Fees
HEALTH AND INSURANCE COST
8 Health Insurance (Purchased or Self Funded)
9 Prescription Drug Plan
10 Dental, Hearing and Vision Plan
11 Life Insurance (If employee is owner or beneficiary)
12 Accidental Insurance (If employee is owner or beneficiary)
13 Disability Insurance (If employee is owner or beneficiary)
14 Long-Term Care Insurance (If employee is owner or beneficiary)
15 Workers' Compensation Insurance
16 Retirement Health Care Cost (Only current year, not the extraordinary
accrual required by FASB 106 Non cumulative portion)
TAXES
17 FICA - Employers Portion Only
18 Medicare Taxes - Employers Portion Only
19 Unemployment Insurance
20 State or Federal Unemployment Taxes
OTHER
21 Executive Deferred Compensation
22 Day Care Cost and Allowances
23 Tuition Reimbursement
24 Total Wage Related cost (sum of lines 1 -23)
Part B Other than Core Related Cost
25 Other Wage Related Costs (specify)_________________________________________

WORKSHEET S-3
PART IV

Amount
Reported
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

17
18
19
20
21
22
23
24

25

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4105.3)

Rev. 1

41-309

4190 (Cont.)
SNF REPORTING OF
DIRECT CARE EXPENDITURES

OCCUPATIONAL CATEGORY
Direct Salaries
Nursing Occupations
1 Registered Nurses (RNs)
2 Licensed Practical Nurses (LPNs)
3 Certified Nursing Assistants/Nursing Assistants/Aides
4 Total Nursing (sum of lines 1 through 3)
5 Physical Therapists
6 Physical Therapy Assistants
7 Physical Therapy Aides
8 Occupational Therapists
9 Occupational Therapy Assistants
10 Occupational Therapy Aides
11 Speech Therapists
12 Respiratory Therapists
13 Other Medical Staff
Contract Labor
Nursing Occupations
14 Registered Nurses (RNs)
15 Licensed Practical Nurses (LPNs)
16 Certified Nursing Assistants/Nursing Assistants/Aides
17 Total Nursing (sum of lines 14 through 16)
18 Physical Therapists
19 Physical Therapy Assistants
20 Physical Therapy Aides
21 Occupational Therapists
22 Occupational Therapy Assistants
23 Occupational Therapy Aides
24 Speech Therapists
25 Respiratory Therapists
26 Other Medical Staff

FORM CMS-2540-10
PROVIDER CCN:

Amount
Reported
1

11-12
PERIOD :
FROM ______________
TO ________________

Fringe
Benefits
2

Adjusted
Salaries
( col. 1 +
col. 2 )
3

WORKSHEET S-3
PART V

Paid Hours
Related
to Salary
in col. 3
4

Average
Hourly Wage
( col. 3 ÷
col. 4 )
5

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

14
15
16
17
18
19
20
21
22
23
24
25
26

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4105.4)

41-309.1

Rev. 4

This page intentionally left blank.

4190 (Cont.)
SNF - BASED HOME HEALTH AGENCY
STATISTICAL DATA

FORM CMS-2540-10
PROVIDER CCN:

11-12
PERIOD :
FROM ______________
TO ________________

HHA CCN :

WORKSHEET S-4

HOME HEALTH AGENCY STATISTICAL DATA
1 County

DESCRIPTION
2 Home Health Aide Hours
3 Unduplicated Census Count (see instructions)

1
Title V
1

Title XVIII
2

Title XIX
3

Other
4

Total
5
2
3

Staff
1

HOME HEALTH AGENCY - NUMBER OF EMPLOYEES (FULL TIME EQUIVALENT)
4 Enter the number of hours in your normal work week
5 Administrator and Assistant Administrator(s)
6 Directors and Assistant Director(s)
7 Other Administrative Personnel
8 Direct Nursing Service
9 Nursing Supervisor
10 Physical Therapy Service
11 Physical Therapy Supervisor
12 Occupational Therapy Service
13 Occupational Therapy Supervisor
14 Speech Pathology Service
15 Speech Pathology Supervisor
16 Medical Social Service
17 Medical Social Service Supervisor
18 Home Health Aide
19 Home Health Aide Supervisor
20 Other (specify)

Contract
2

Total
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

HOME HEALTH AGENCY CBSA CODES
21 Enter in column 1 the number of CBSAs where you provided services during the cost reporting period.
22 List those CBSA code(s) in column 1 serviced during this cost reporting period (line 22 contains the first code).

PPS ACTIVITY DATA
23 Skilled Nursing Visits
24 Skilled Nursing Visit Charges
25 Physical Therapy Visits
26 Physical Therapy Visit Charges
27 Occupational Therapy Visits
28 Occupational Therapy Visit Charges
29 Speech Pathology Visits
30 Speech Pathology Visit Charges
31 Medical Social Service Visits
32 Medical Social Service Visit Charges
33 Home Health Aide Visits
34 Home Health Aide Visit Charges
35 Total Visits (sum of lines 23, 25, 27, 29, 31, and 33)
36 Other Charges
37 Total Charges (sum of lines 24, 26, 28, 30, 32, 34 and 36)
38 Total Number of Episodes (standard/non outlier)
39 Total Number of Outlier Episodes
40 Total Non-Routine Medical Supply Charges

Full Episodes
Without
With
Outliers
Outliers
1
2

21
22

LUPA
Episodes
3

PEP only
Episodes
4

Total
( cols. 1
through 4 )
5
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4106)

41-310

Rev. 4

11-12

FORM CMS-2540-10

SNF - BASED RURAL HEALTH CLINIC
FEDERALLY QUALIFIED HEALTH CENTER
STATISTICAL DATA

Check applicable box:

Clinic
1
2
3

[

] RHC

4190 (Cont.)

PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

COMPONENT CCN :

[

WORKSHEET S-5

] FQHC

Address and Identification:
Street:
City:
Designation (for FQHC's only) - "U" for urban or "R" for rural

County:
Zip Code:

State:

Source of Federal funds:
4 Community Health Center (Section 330(d), PHS Act)
5 Migrant Health Center (Section 329(d), PHS Act)
6 Health Services for the Homeless (Section 340(d), PHS Act)
7 Appalachian Regional Commission
8 Look - Alikes
9 Other (specify)

1
2
3

Grant Award

Date
4
5
6
7
8
9

1

2

10 Does the facility operate as other than an RHC or FQHC? Enter "Y" for yes or "N" for no in column 1. If yes, indicate the number of other operations in column 2.

10

Facility hours of operations (1)
Sunday
Type of Operation
0

from
1

Monday
to
2

from
3

to
4

Tuesday
from
to
5
6

Wednesday
from
to
7
8

Thursday
from
to
9
10

Friday
from
11

to
12

Saturday
from
to
13
14

11 Clinic

11

(1) Enter clinic hours of operation on line 11 and other type operations on subscripts of line 11 (both type and hours of operation).
List hours of operation based on a 24 hour clock. For example: 8:00am is 0800, 6:30pm is 1830, and midnight is 2400.
1
12 Have you received an approval for an exception to the productivity standard?
13 Is this a consolidated cost report in accordance with IOM CMS Pub. 100-04, Chapter 9, §30.8? Enter "Y" for yes or "N" for no in column 1.
If yes, enter in column 2 the number of providers included in this report. List the names of all providers and numbers below.
14 Provider Name:

2
12
13

CCN Number:

14

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4107)

Rev. 4

41-311

4190 (Cont.)

FORM CMS-2540-10

SKILLED NURSING FACILITY BASED COMMUNITY
MENTAL HEALTH CENTER AND OTHER OUTPATIENT
REAHBILITATION PROVIDER STATISTICAL DATA

Check applicable box:

[ ] CMHC

[ ] CORF

11-12

PROVIDER CCN:
COMPONENT CCN:

[ ] OPT

PERIOD :
FROM ______________
TO ________________

[ ] OOT

[ ] OSP

Staff
1

Contract
2

WORKSHEET S-6

Enter the number of hours in your normal workweek ________

NUMBER OF EMPLOYEES (FULL TIME EQUIVALENT)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

Administrator and Assistant Administrator(s)
Director(s) and Assistant Director(s)
Other Administrative Personnel
Direct Nursing Service
Nursing Supervisor
Physical Therapy Service
Physical Therapy Supervisor
Occupational Therapy Service
Occupational Therapy Supervisor
Speech Pathology Service
Speech Pathology Supervisor
Medical Social Service
Medical Social Service Supervisor
Respiratory Therapy Service
Respiratory Therapy Supervisor
Psychiatric/Psychological Service
Psychiatric/Psychological Service Supervisor
Other (specify)
Other (specify)

Total
( col. 1 + col. 2 )
3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4108)

41-312

Rev. 4

11-12

FORM CMS-2540-10

PROSPECTIVE PAYMENT FOR SNF
STATOSTOCA; DATA

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50

PROVIDER CCN:

4190 (Cont.)
PERIOD :
FROM ______________
TO ________________

GROUP
1
RUX
RUL
RVX
RVL
RHX
RHL
RMX
RML
RLX
RUC
RUB
RUA
RVC
RVB
RVA
RHC
RHB
RHA
RMC
RMB
RMA
RLB
RLA
ES3
ES2
ES1
HE2
HE1
HD2
HD1
HC2
HC1
HB2
HB1
LE2
LE1
LD2
LD1
LC2
LC1
LB2
LB1
CE2
CE1
CD2
CD1
CC2
CC1
CB2
CB1

WORKSHEET S-7

Days
2
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4109)

Rev. 4

41-313

4190 (Cont.)
PROSPECTIVE PAYMENT FOR SNF
STATISTICAL DATA

51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
99
100

FORM CMS-2540-10
PROVIDER CCN:

11-12
PERIOD:
FROM ________
TO ___________

GROUP
1
CA2
CA1
SE3
SE2
SE1
SSC
SSB
SSA
IB2
IB1
IA2
IA1
BB2
BB1
BA2
BA1
PE2
PE1
PD2
PD1
PC2
PC1
PB2
PB1
PA2
PA1
AAA
Total

A notice published in the "Federal Register" Vol. 68, No. 149 August 4, 2003 provided for an increase in the RUG payments beginning 10/01/2003.
Congress expected this increase to be used for direct patient care and related expenses. For lines 101 through 106: Enter in column 1
the amount of expense for each category. Enter in column 2 the percentage of total expenses for each category to total SNF revenue
from Worksheet G-2, Part I line 1 column3. Indicate in column 3 "Y" for yes or "N" for no if the spending reflects increases associated
with direct patient care and related expenses for each category. (If column 2 is zero, enter N/A in column 3) (see instructions)
Expenses
Percentage
1
2
101 Staffing
102 Recruitment
103 Retention of employees
104 Training
105 Other (Specify)
106 Total SNF revenue (Wkst. G-2, Pt. I, line 1, col. 3)

WORKSHEET S-7

Days
2
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
99
100

Y/N
3
101
102
103
104
105
106

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4109 - 4109.1)

41-314

Rev. 4

11-12

FORM CMS-2540-10

HOSPICE IDENTIFICATION DATA

4190 (Cont.)

PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

HOSPICE CCN :

WORKSHEET S - 8

PART I - ENROLLMENT DAYS

Title XVIII
1
1
2
3
4
5

Title XIX
2

Title XVIII
Skilled Nursing
Facility
3

Unduplicated Days
Title XIX
Nursing
Facility
4

All
Other
5

Total
( sum of
col. 1, 2 & 5 )
6

Continuous Home Care
Routine Home Care
Inpatient Respite Care
General Inpatient Care
Total Hospice Days

1
2
3
4
5

PART II - CENSUS DATA

Title XVIII
1
6
7
8
9

Title XIX
2

Number of patients receiving hospice care
Total number of unduplicated Continuous Care hours billable to Medicare
Average length of stay (line 5 / line 6)
Unduplicated census count

Title XVIII
Skilled
Nursing facility
3

Title XIX
Nursing
Facility
4

All
Other
5

Total
( sum of
col. 1, 2 & 5 )
6
6
7
8
9

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4110)

Rev. 4

41-315

4190 (Cont.)

FORM CMS-2540-10

RECLASSIFICATION AND ADJUSTMENT
OF TRIAL BALANCE OF EXPENSES

Cost Center Description
A
B
C
GENERAL SERVICE COST CENTERS
1 0100 Capital-Related Costs - Buildings & Fixtures
2 0200 Capital-Related Costs - Moveable Equipment
3 0300 Employee Benefits
4 0400 Administrative and General
5 0500 Plant Operation, Maintenance and Repairs
6 0600 Laundry and Linen Service
7 0700 Housekeeping
8 0800 Dietary
9 0900 Nursing Administration
10 1000 Central Services and Supply
11 1100 Pharmacy
12 1200 Medical Records and Library
13 1300 Social Service
14 1400 Nursing and Allied Health Education
15
Other General Service Cost
INPATIENT ROUTINE SERVICE COST CENTERS
30 3000 Skilled Nursing Facility
31 3100 Nursing Facility
32 3200 ICF - Mentally Retarded
33 3300 Other Long Term Care
ANCILLARY SERVICE COST CENTERS
40 4000 Radiology
41 4100 Laboratory
42 4200 Intravenous Therapy
43 4300 Oxygen (Inhalation) Therapy
44 4400 Physical Therapy
45 4500 Occupational Therapy
46 4600 Speech Pathology
47 4700 Electrocardiology

11-12

PROVIDER CCN:

SALARIES
1

OTHER
2

TOTAL
( col. 1 + col. 2 )
3

RECLASSIFICATIONS
Increase/Decrease
( from Wkst. A-6 )
4

PERIOD:
FROM ______________
TO _________________
RECLASSIFIED
ADJUSTMENTS
TRIAL
TO EXPENSES
BALANCE
Increase/Decrease
( col. 3 +/- col. 4 )
( from Wkst. A-8 )
5
6

WORKSHEET A

NET EXPENSES
FOR COST
ALLOCATION
( col. 5 +/- col. 6 )
7

A
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
30
31
32
33
40
41
42
43
44
45
46
47

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4113)

41-316

Rev. 4

09-11

FORM CMS-2540-10

RECLASSIFICATION AND ADJUSTMENT
OF TRIAL BALANCE OF EXPENSES

Cost Center Description
A
B
C
48 4800 Medical Supplies Charged to Patients
49 4900 Drugs Charged to Patients
50 5000 Dental Care - Title XIX only
51 5100 Support Surfaces
52
Other Ancillary Service Cost
OUTPATIENT SERVICE COST CENTERS
60 6000 Clinic
61 6100 Rural Health Clinic (RHC)
62 6200 FQHC
63
Other Outpatient Service Cost
OTHER REIMBURSABLE COST CENTERS
70 7000 Home Health Agency Cost
71 7100 Ambulance
72
Outpatient Rehabilitation (specify)
73 7300 CMHC
74
Other Reimbursable Cost
SPECIAL PURPOSE COST CENTERS
80 8000 Malpractice Premiums & Paid Losses
81 8100 Interest Expense
82 8200 Utilization Review
83 8300 Hospice
84
Other Special Purpose Cost
89
SUBTOTALS (sum of lines 1 through 84)
NON REIMBURSABLE COST CENTERS
90 9000 Gift, Flower, Coffee Shops and Canteen
91 9100 Barber and Beauty Shop
92 9200 Physicians' Private Offices
93 9300 Nonpaid Workers
94 9400 Patients' Laundry
95
Other Nonreimbursable Cost
100
TOTAL

4190 (Cont.)

PROVIDER CCN:

SALARIES
1

OTHER
2

TOTAL
( col. 1 + col. 2 )
3

RECLASSIFICATIONS
Increase/Decrease
( from Wkst. A-6 )
4

PERIOD :
FROM ______________
TO ________________
RECLASSIFIED
ADJUSTMENTS
TRIAL
TO EXPENSES
BALANCE
Increase /Decrease
( col. 3 +/- col. 4 )
( from Wkst. A-8 )
5
6

WORKSHEET A (Cont.)

NET EXPENSES
FOR COST
ALLOCATION
( col. 5 +/- col. 6 )
7
48
49
50
51
52
60
61
62
63
70
71
72
73
74
-0-0-0-

80
81
82
83
84
89
90
91
92
93
94
95
100

FORM CMS-2540-10 (09/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4113)

Rev. 2

41-317

4190 (Cont.)

FORM CMS-2540-10

09-11

RECLASSIFICATIONS

EXPLANATION OF RECLASSIFICATION(S)

PROVIDER CCN:

CODE
(1)
1

COST CENTER
2

INCREASE
LN NO.
3

SALARY
4

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
100 TOTAL RECLASSIFICATIONS (Sum of columns 4 and 5 must equal
sum of columns 8 and 9 (2)

NON SALARY
5

COST CENTER
6

PERIOD :
FROM ______________
TO ________________

DECREASE
LN NO.
7

SALARY
8

WORKSHEET A-6

NON SALARY
9
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
100

(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
(2) Transfer the amounts in columns 4, 5, 8 and 9 to Worksheet A, column 4, lines as appropriate.

FORM CMS-2540-10 (09/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4114)

41-318

Rev. 2

05-11

FORM CMS-2540-10

ANALYSIS OF CHANGES IN
CAPITAL ASSET BALANCES

4190 (Cont.)

PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

Acquisitions

Description
1
2
3
4
5
6
7
8
9

Beginning
Balances
1

Purchases
2

Donation
3

Total
4

Disposals
and
Retirements
5

Land
Land Improvements
Buildings and Fixtures
Building Improvements
Fixed Equipment
Movable Equipment
Subtotal (sum of lines 1-6)
Reconciling Items
Total (line 7 minus line 8)

Ending
Balance
6

WORKSHEET A-7

Fully
Depreciated
Assets
7
1
2
3
4
5
6
7
8
9

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4115)

Rev. 1

41-319

4190 (Cont.)

FORM CMS-2540-10

ADJUSTMENTS TO EXPENSES

1
2
3
4
5
6
7

Description (1)
0
Investment income on restricted funds
(Chapter 2)
Trade, quantity and time discounts
on purchases (Chapter 8)
Refunds and rebates of expenses
Chapter 8)
Rental of provider space by suppliers
Chapter 8)
Telephone services (pay stations
excluded) (Chapter 21)
Television and radio service
(Chapter 21)
Parking lot (Chapter 21)

PROVIDER CCN:

Basis
for
Adjustment (2)
1

8 Remuneration applicable to providerbased physician adjustment
9 Home office costs (Chapter 21)
10 Sale of scrap, waste, etc.
(Chapter23)
11 Nonallowable costs related to certain
Capital expenditures (Chapter 24)
12 Adjustment resulting from transactions
with related organizations (Chapter 10)
13 Laundry and Linen service

Amount
2

05-11
PERIOD :
WORKSHEET A-8
FROM ______________
TO ________________
Expense Classification on Wkst. A
to/from which the amount is to be adjusted
Cost Center
Line No.
3
4
1
2
3
4
5
6
7

Worksheet
A-8-2

8
9
10
11

Worksheet
A-8-1

12
13

14 Revenue - Employee meals

14

15 Cost of meals - Guests

15

16 Sale of medical supplies to other than patients

16

17 Sale of drugs to other than patients

17

18 Sale of medical records and abstracts

18

19 Vending machines

19

20 Income from imposition of interest,
finance or penalty charges (Chapter 21)
21 Interest expense on Medicare overpayments
and borrowings to repay Medicare overpayments
22 Utilization review--physicians'
compensation (Chapter 21)
23 Depreciation--buildings and fixtures

20

24 Depreciation--movable equipment

21
Utilization Review- SNF

82

22

Capital Related Cost- Building

1

23

Capital Related Cost-Movable

2

24

25 Other Adjustment
100 TOTAL (sum of lines 1 through 99)
(transfer to Wkst. A, col. 6, line 100)

25
100

(1) Description - all chapter references in this column pertain to CMS Pub. 15-1
(2) Basis for adjustment (see instructions)
A. Costs - if cost, including applicable overhead, can be determined
B. Amount Received - if cost cannot be determined

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4116)

41-320

Rev. 1

05-11

FORM CMS-2540-10

STATEMENT OF COSTS OF SERVICES
FROM RELATED ORGANIZATIONS AND
HOME OFFICE COSTS

PROVIDER CCN:

4190 (Cont.)
PERIOD :
FROM ______________
TO ________________

PART I - COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED
ORGANIZATIONS OR CLAIMED HOME OFFICE COSTS
Amount
Amount
Allowable
Included in
Line No.
Cost Center
Expense Items
In Cost
Wkst. A., col. 5
1
2
3
4
5
1
2
3
4
5
6
7
8
9
10 TOTALS (sum of lines 1-9)
(Transfer column 6, line 10 to Wkst. A-8, col. 3, line 12)

WORKSHEET A-8-1

Adjustments
( col. 4 minus
col. 5 )
6
1
2
3
4
5
6
7
8
9
10

PART II - INTERRELATIONSHIP TO RELATED ORGANIZATION(S) AND / OR HOME OFFICE
The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires that you furnish
the information requested under Part II of this worksheet.
This information is used by the Centers for Medicare and Medicaid Services and its intermediaries/contractors in determining that the costs applicable to
services, facilities, and supplies furnished by organizations related to you by common ownership or control represent reasonable costs as determined under
section 1861 of the Social Security Act. If you do not provide all or any part of the requested information, the cost report is considered incomplete and not
acceptable for purposes of claiming reimbursement under title XVIII.

(1)
Symbol
1

Name
2

Percentage
of
Ownership
3

Name
4

Related Organization(s)
Percentage
of
Ownership
5

Type of
Business
6

1
2
3
4
5
6
7
8
9
10
(1) Use the followings symbols to indicate interrelationship to related organizations:
A. Individual has financial interest (stockholder, partner, etc.)
in both related organization and in provider.
B. Corporation, partnership or other organization has financial
interest in provider.
C. Provider has financial interest in corporation, partnership,
or other organization.
D. Director, officer, administrator or key person of provider or
organization.

1
2
3
4
5
6
7
8
9
10

E. Individual is director, officer, administrator or key person of provider
and related organization.
F. Director, officer, administrator or key person of related organization
or relative of such person has financial interest in provider.
G. Other (financial or non-financial) specify ______________________
_____________________________________________________

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4117)

Rev. 1

41-321

4190 (Cont.)

FORM CMS-2540-10

PROVIDER - BASED PHYSICIANS ADJUSTMENTS

Cost Center /
Physician
Identifier
2

Wkst. A
Line No.
1
1
2
3
4
5
6
7
8
9
10
11
100

05-11
PROVIDER CCN:

Total
Remuneration
3

Professional
Component
4

Provider
Component
5

PERIOD :
FROM ______________
TO ________________

RCE
Amount
6

Physician /
Provider
Component
Hours
7

Unadjusted
R C E Limit
8

WORKSHEET A-8-2

5 Percent of
Unadjusted
R C E Limit
9
1
2
3
4
5
6
7
8
9
10
11
100

TOTAL

Cost Center /
Physician
Identifier
11

Wkst. A
Line No.
10
1
2
3
4
5
6
7
8
9
10
11
100

Cost of
Memberships
& Continuing
Education
12

Provider
Component
Share of
Col. 12
13

TOTAL

Physician
Cost of
Malpractice
Insurance
14

Provider
Component
Share of
Col. 14
15

Adjusted
R C E Limit
16

RCE
Disallowance
17

Adjustment
18
1
2
3
4
5
6
7
8
9
10
11
100

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4118)

41-322

Rev. 1

09-11

FORM CMS-2540-10

COST ALLOCATION - GENERAL SERVICE COSTS

NET EXPENSES
FOR COST
ALLOCATION
( from Wkst. A, col. 7 )

Cost Center Description
GENERAL SERVICE COST CENTERS
1 Capital-Related Costs - Buildings & Fixtures
2 Capital-Related Costs - Moveable Equipment
3 Employee Benefits
4 Administrative and General
5 Plant Operation, Maintenance and Repairs
6 Laundry and Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Central Services and Supply
11 Pharmacy
12 Medical Records and Library
13 Social Service
14 Nursing and Allied Health Education
15 Other General Service Cost
INPATIENT ROUTINE SERVICE COST CENTERS
30 Skilled Nursing Facility
31 Nursing Facility
32 ICF - Mentally Retarded
33 Other Long Term Care
ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost

4190 (Cont.)

PROVIDER CCN:

0

CAP. REL
BUILDINGS
& FIXTURES
1

PERIOD :
FROM ______________
TO ________________
CAP. REL
MOVABLE
EQUIPMENT
2

EMPLOYEE
BENEFITS
3

WORKSHEET B
PART I

SUBTOTAL
( sum of
cols. 0 - 3 )
3A

ADMINISTRATIVE
& GENERAL
4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
30
31
32
33
40
41
42
43
44
45
46
47
48
49
50
51
52

FORM CMS-2540-10 (09/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)

Rev. 2

41-323

4190 (Cont.)

FORM CMS-2540-10

COST ALLOCATION - GENERAL SERVICE COSTS

NET EXPENSES
FOR COST
ALLOCATION
( from Wkst. A, col. 7 )

Cost Center Description
OUTPATIENT SERVICE COST CENTERS
60 Clinic
61 Rural Health Clinic (RHC)
62 FQHC
63 Other Outpatient Service Cost
OTHER REIMBURSABLE COST CENTERS
70 Home Health Agency Cost
71 Ambulance
72 Outpatient Rehabilitation (specify)
73 CMHC
74 Other Reimbursable Cost
SPECIAL PURPOSE COST CENTERS
83 Hospice
84 Other Special Purpose Cost
89 Subtotals
NON REIMBURSABLE COST CENTERS
90 Gift, Flower, Coffee Shops and Canteen
91 Barber and Beauty Shop
92 Physicians' Private Offices
93 Nonpaid Workers
94 Patients' Laundry
95 Other Nonreimbursable Cost
98 Cross Foot Adjustments
99 Negative Cost Center
100 Total

09-11

PROVIDER CCN:

0

CAP. REL
BUILDINGS
& FIXTURES
1

PERIOD:
FROM ________________
TO ________________
CAP. REL
MOVABLE
EQUIPMENT
2

EMPLOYEE
BENEFITS
3

SUBTOTAL
( sum of
cols. 0 - 3 )
3A

WORKSHEET B
PART I

ADMINISTRATIVE
& GENERAL
4
60
61
62
63
70
71
72
73
74
83
84
89
90
91
92
93
94
95
98
99
100

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)

41-324

Rev. 2

09-11

FORM CMS-2540-10

COST ALLOCATION - GENERAL SERVICE COSTS

Cost Center Description
GENERAL SERVICE COST CENTERS
1 Capital-Related Costs - Buildings & Fixtures
2 Capital-Related Costs - Moveable Equipment
3 Employee Benefits
4 Administrative and General
5 Plant Operation, Maintenance and Repairs
6 Laundry and Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Central Services and Supply
11 Pharmacy
12 Medical Records and Library
13 Social Service
14 Nursing and Allied Health Education
15 Other General Service Cost
INPATIENT ROUTINE SERVICE COST CENTERS
30 Skilled Nursing Facility
31 Nursing Facility
32 ICF - Mentally Retarded
33 Other Long Term Care
ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost

4190 (Cont.)

PROVIDER CCN:

PLANT OPER.
MAINTENANCE
& REPAIRS
5

LAUNDRY
& LINEN
SERVICE
6

HOUSE
KEEPING
7

PERIOD:
FROM ________________
TO ________________

DIETARY
8

NURSING
ADMINISTRATION
9

CENTRAL
SERVICES
& SUPPLY
10

WORKSHEET B
PART I

PHARMACY
11
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
30
31
32
33
40
41
42
43
44
45
46
47
48
49
50
51
52

FORM CMS-2540-10 (09/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)

Rev. 2

41-325

4190 (Cont.)

FORM CMS-2540-10

COST ALLOCATION - GENERAL SERVICE COSTS

Cost Center Description
OUTPATIENT SERVICE COST CENTERS
60 Clinic
61 Rural Health Clinic (RHC)
62 FQHC
63 Other Outpatient Service Cost
OTHER REIMBURSABLE COST CENTERS
70 Home Health Agency Cost
71 Ambulance
72 Outpatient Rehabilitation (specify)
73 CMHC
74 Other Reimbursable Cost
SPECIAL PURPOSE COST CENTERS
83 Hospice
84 Other Special Purpose Cost
89 Subtotals
NON REIMBURSABLE COST CENTERS
90 Gift, Flower, Coffee Shops and Canteen
91 Barber and Beauty Shop
92 Physicians' Private Offices
93 Nonpaid Workers
94 Patients' Laundry
95 Other Nonreimbursable Cost
98 Cross Foot Adjustments
99 Negative Cost Center
100 Total

09-11

PROVIDER CCN:

PLANT OPER.
MAINTENANCE
& REPAIRS
5

LAUNDRY
& LINEN
SERVICE
6

HOUSE
KEEPING
7

PERIOD:
FROM ________________
TO ________________

DIETARY
8

NURSING
ADMINISTRATION
9

CENTRAL
SERVICES
& SUPPLY
10

WORKSHEET B
PART I

PHARMACY
11
60
61
62
63
70
71
72
73
74
83
84
89
90
91
92
93
94
95
98
99
100

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)

41-326

Rev. 2

09-11

FORM CMS-2540-10

COST ALLOCATION - GENERAL SERVICE COSTS

Cost Center Description
GENERAL SERVICE COST CENTERS
1 Capital-Related Costs - Buildings & Fixtures
2 Capital-Related Costs - Moveable Equipment
3 Employee Benefits
4 Administrative and General
5 Plant Operation, Maintenance and Repairs
6 Laundry and Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Central Services and Supply
11 Pharmacy
12 Medical Records and Library
13 Social Service
14 Nursing and Allied Health Education
15 Other General Service Cost
INPATIENT ROUTINE SERVICE COST CENTERS
30 Skilled Nursing Facility
31 Nursing Facility
32 ICF - Mentally Retarded
33 Other Long Term Care
ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost

4190 (Cont.)

PROVIDER CCN:

MEDICAL
RECORDS
& LIBRARY
12

SOCIAL
SERVICE
13

NURSING &
ALLIED
HEALTH
EDUCATION
14

PERIOD:
FROM ________________
TO ________________
OTHER
GENERAL
SERVICE
COST
15

SUBTOTAL
16

POST
STEP-DOWN
ADJUSTMENTS
17

WORKSHEET B
PART I

TOTAL
18
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
30
31
32
33
40
41
42
43
44
45
46
47
48
49
50
51
52

FORM CMS-2540-10 (09/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)

Rev. 2

41-327

4190 (Cont.)

FORM CMS-2540-10

COST ALLOCATION - GENERAL SERVICE COSTS

Cost Center Description
OUTPATIENT SERVICE COST CENTERS
60 Clinic
61 Rural Health Clinic (RHC)
62 FQHC
63 Other Outpatient Service Cost
OTHER REIMBURSABLE COST CENTERS
70 Home Health Agency Cost
71 Ambulance
72 Outpatient Rehabilitation (specify)
73 CMHC
74 Other Reimbursable Cost
SPECIAL PURPOSE COST CENTERS
83 Hospice
84 Other Special Purpose Cost
89 Subtotals
NON REIMBURSABLE COST CENTERS
90 Gift, Flower, Coffee Shops and Canteen
91 Barber and Beauty Shop
92 Physicians' Private Offices
93 Nonpaid Workers
94 Patients' Laundry
95 Other Nonreimbursable Cost
98 Cross Foot Adjustments
99 Negative Cost Center
100 Total

09-11

PROVIDER CCN:

MEDICAL
RECORDS
& LIBRARY
12

SOCIAL
SERVICE
13

NURSING &
ALLIED
HEALTH
EDUCATION
14

PERIOD:
FROM ________________
TO ________________
OTHER
GENERAL
SERVICE
COST
15

SUBTOTAL
16

POST
STEP-DOWN
ADJUSTMENTS
17

WORKSHEET B
PART I

TOTAL
18
60
61
62
63
70
71
72
73
74
83
84
89
90
91
92
93
94
95
98
99
100

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)

41-328

Rev. 2

09-11

FORM CMS-2540-10

COST ALLOCATION - STATISTICAL BASIS

4190 (Cont.)

PROVIDER CCN:

Cost Center Description
0

CAP. REL.
BUILDINGS
& FIXTURES
( Square
Feet )
1

GENERAL SERVICE COST CENTERS
1 Capital-Related Costs - Buildings & Fixtures
2 Capital-Related Costs - Moveable Equipment
3 Employee Benefits
4 Administrative and General
5 Plant Operation, Maintenance and Repairs
6 Laundry and Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Central Services and Supply
11 Pharmacy
12 Medical Records and Library
13 Social Service
14 Nursing and Allied Health Education
15 Other General Service Cost
INPATIENT ROUTINE SERVICE COST CENTERS
30 Skilled Nursing Facility
31 Nursing Facility
32 ICF - Mentally Retarded
33 Other Long Term Care
ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost

PERIOD :
FROM ______________
TO ________________
CAP. REL.
MOVABLE
EQUIPMENT
( Dollar Value or
Square Feet )
2

EMPLOYEE
BENEFITS
( Gross
Salaries )
3

WORKSHEET B - 1

RECONCILIATION
4A

ADMINISTRATIVE
& GENERAL
( Accumulated
Cost )
4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
30
31
32
33
40
41
42
43
44
45
46
47
48
49
50
51
52

FORM CMS-2540-10 (09/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)

Rev. 2

41-329

4190 (Cont.)

FORM CMS-2540-10

COST ALLOCATION - STATISTICAL BASIS

09-11

PROVIDER CCN:

Cost Center Description
0

CAP. REL.
BUILDINGS
& FIXTURES
( Square
Feet )
1

OUTPATIENT SERVICE COST CENTERS
60 Clinic
61 Rural Health Clinic (RHC)
62 FQHC
63 Other Outpatient Service Cost
OTHER REIMBURSABLE COST CENTERS
70 Home Health Agency Cost
71 Ambulance
72 Outpatient Rehabilitation (specify)
73 CMHC
74 Other Reimbursable Cost
SPECIAL PURPOSE COST CENTERS
83 Hospice
84 Other Special Purpose Cost
89 Subtotals
NON REIMBURSABLE COST CENTERS
90 Gift, Flower, Coffee Shops and Canteen
91 Barber and Beauty Shop
92 Physicians' Private Offices
93 Nonpaid Workers
94 Patients' Laundry
95 Other Nonreimbursable Cost
98 Cross Foot Adjustment
99 Negative Cost Center
102 Cost to be allocated (Per Wkst. B, Pt I.)
103 Unit Cost Multiplier (Wkst. B, Pt I.)
104 Cost to be allocated (Per Wkst. B, Pt. II)
105 Unit Cost Multiplier (Wkst B, Pt. II)

PERIOD:
FROM ________________
TO ________________
CAP. REL.
MOVABLE
EQUIPMENT
( Dollar Value or
Square Feet )
2

EMPLOYEE
BENEFITS
( Gross
Salaries )
3

RECONCILIATION
4A

WORKSHEET B - 1

ADMINISTRATIVE
& GENERAL
( Accumulated
Cost )
4
60
61
62
63
70
71
72
73
74
83
84
89
90
91
92
93
94
95
98
99
102
103
104
105

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)

41-330

Rev. 2

09-11

FORM CMS-2540-10

COST ALLOCATION - STATISTICAL BASIS

Cost Center Description

4190 (Cont.)

PROVIDER CCN:

PLANT OPER.
MAINTENANCE
& REPAIRS
( Square
Feet )
5

LAUNDRY
& LINEN
SERVICE
( Pounds of
Laundry )
6

GENERAL SERVICE COST CENTERS
1 Capital-Related Costs - Buildings & Fixtures
2 Capital-Related Costs - Moveable Equipment
3 Employee Benefits
4 Administrative and General
5 Plant Operation, Maintenance and Repairs
6 Laundry and Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Central Services and Supply
11 Pharmacy
12 Medical Records and Library
13 Social Service
14 Nursing and Allied Health Education
15 Other General Service Cost
INPATIENT ROUTINE SERVICE COST CENTERS
30 Skilled Nursing Facility
31 Nursing Facility
32 ICF - Mentally Retarded
33 Other Long Term Care
ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost

HOUSE
KEEPING
( Hours of
Service )
7

DIETARY
( Meals
Served )
8

PERIOD:
FROM ________________
TO ________________
NURSING
CENTRAL
ADMINISSERVICES
TRATION
& SUPPLY
( Direct
( Costed
Nrsing Hrs. )
Requisitions )
9
10

WORKSHEET B - 1

PHARMACY
( Costed
Requisitions )
11
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
30
31
32
33
40
41
42
43
44
45
46
47
48
49
50
51
52

FORM CMS-2540-10 (09/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)

Rev. 2

41-331

4190 (Cont.)

FORM CMS-2540-10

COST ALLOCATION - STATISTICAL BASIS

Cost Center Description

09-11

PROVIDER CCN:

PLANT OPER.
MAINTENANCE
& REPAIRS
( Square
Feet )
5

LAUNDRY
& LINEN
SERVICE
( Pounds of
Laundry )
6

OUTPATIENT SERVICE COST CENTERS
60 Clinic
61 Rural Health Clinic (RHC)
62 FQHC
63 Other Outpatient Service Cost
OTHER REIMBURSABLE COST CENTERS
70 Home Health Agency Cost
71 Ambulance
72 Outpatient Rehabilitation (specify)
73 CMHC
74 Other Reimbursable Cost
SPECIAL PURPOSE COST CENTERS
83 Hospice
84 Other Special Purpose Cost
89 Subtotals
NON REIMBURSABLE COST CENTERS
90 Gift, Flower, Coffee Shops and Canteen
91 Barber and Beauty Shop
92 Physicians' Private Offices
93 Nonpaid Workers
94 Patients' Laundry
95 Other Nonreimbursable Cost
98 Cross Foot Adjustment
99 Negative Cost Center
102 Cost to be allocated (Per Wkst. B, Pt I.)
103 Unit Cost Multiplier (Wkst. B, Pt I.)
104 Cost to be allocated (Per Wkst. B, Pt. II)
105 Unit Cost Multiplier (Wkst B, Pt. II)

HOUSE
KEEPING
( Hours of
Service )
7

DIETARY
( Meals
Served )
8

PERIOD:
FROM ________________
TO ________________
NURSING
CENTRAL
ADMINISSERVICES
TRATION
& SUPPLY
( Direct
( Costed
Nrsing Hrs. )
Requisitions )
9
10

WORKSHEET B - 1

PHARMACY
( Costed
Requisitions )
11
60
61
62
63
70
71
72
73
74
83
84
89
90
91
92
93
94
95
98
99
102
103
104
105

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)

41-332

Rev. 2

09-11

FORM CMS-2540-10

COST ALLOCATION - STATISTICAL BASIS

Cost Center Description

4190 (Cont.)

PROVIDER CCN:

MEDICAL
RECORDS
& LIBRARY
( Time
Spent )
12

SOCIAL
SERVICE
( Time
Spent )
13

NURSING &
ALLIED
HEALTH
EDUCATION
( Assigned Time )
14

GENERAL SERVICE COST CENTERS
1 Capital-Related Costs - Buildings & Fixtures
2 Capital-Related Costs - Moveable Equipment
3 Employee Benefits
4 Administrative and General
5 Plant Operation, Maintenance and Repairs
6 Laundry and Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Central Services and Supply
11 Pharmacy
12 Medical Records and Library
13 Social Service
14 Nursing and Allied Health Education
15 Other General Service Cost
INPATIENT ROUTINE SERVICE COST CENTERS
30 Skilled Nursing Facility
31 Nursing Facility
32 ICF - Mentally Retarded
33 Other Long Term Care
ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost

PERIOD:
FROM ________________
TO ________________
OTHER
GENERAL
SERVICE
COST
15

SUBTOTAL
16

POST
STEP-DOWN
ADJUSTMENTS
17

WORKSHEET B - 1

TOTAL
18
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
30
31
32
33
40
41
42
43
44
45
46
47
48
49
50
51
52

FORM CMS-2540-10 (09/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)

Rev. 2

41-333

4190 (Cont.)

FORM CMS-2540-10

COST ALLOCATION - STATISTICAL BASIS

Cost Center Description

09-11

PROVIDER CCN:

MEDICAL
RECORDS
& LIBRARY
( Time
Spent )
12

SOCIAL
SERVICE
( Time
Spent )
13

NURSING &
ALLIED
HEALTH EDU
EDUCATION
( Assigned Time )
14

OUTPATIENT SERVICE COST CENTERS
60 Clinic
61 Rural Health Clinic (RHC)
62 FQHC
63 Other Outpatient Service Cost
OTHER REIMBURSABLE COST CENTERS
70 Home Health Agency Cost
71 Ambulance
72 Outpatient Rehabilitation (specify)
73 CMHC
74 Other Reimbursable Cost
SPECIAL PURPOSE COST CENTERS
83 Hospice
84 Other Special Purpose Cost
89 Subtotals
NON REIMBURSABLE COST CENTERS
90 Gift, Flower, Coffee Shops and Canteen
91 Barber and Beauty Shop
92 Physicians' Private Offices
93 Nonpaid Workers
94 Patients' Laundry
95 Other Nonreimbursable Cost
98 Cross Foot Adjustment
99 Negative Cost Center
102 Cost to be allocated (Per Wkst. B, Pt I.)
103 Unit Cost Multiplier (Wkst. B, Pt I.)
104 Cost to be allocated (Per Wkst. B, Pt. II)
105 Unit Cost Multiplier (Wkst B, Pt. II)

PERIOD:
FROM ________________
TO ________________
GENERAL
SERVICE
COST
COST
15

SUBTOTAL
16

POST
STEP-DOWN
ADJUSTMENTS
17

WORKSHEET B - 1

TOTAL
18
60
61
62
63
70
71
72
73
74
83
84
89
90
91
92
93
94
95
98
99
102
103
104
105

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)

41-334

Rev. 2

09-11

FORM CMS-2540-10

ALLOCATION OF CAPITAL - RELATED COSTS

Cost Center Description
GENERAL SERVICE COST CENTERS
1 Capital-Related Costs - Buildings & Fixtures
2 Capital-Related Costs - Moveable Equipment
3 Employee Benefits
4 Administrative and General
5 Plant Operation, Maintenance and Repairs
6 Laundry and Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Central Services and Supply
11 Pharmacy
12 Medical Records and Library
13 Social Service
14 Nursing and Allied Health Education
15 Other General Service Cost
INPATIENT ROUTINE SERVICE COST CENTERS
30 Skilled Nursing Facility
31 Nursing Facility
32 ICF - Mentally Retarded
33 Other Long Term Care
ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost

4190 (Cont.)

PROVIDER CCN:

DIRECTLY
ASSIGNED
CAPITAL
RELATED COSTS
0

CAP. REL
BUILDINGS
& FIXTURES
1

CAP. REL.
MOVABLE
EQUIPMENT
2

PERIOD :
FROM ______________
TO ________________

SUBTOTAL
2A

EMPLOYEE
BENEFITS
3

WORKSHEET B
PART II

ADMINISTRATIVE
& GENERAL
4

PLANT OPER.
MAINTENANCE
& REPAIRS
5
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
30
31
32
33
40
41
42
43
44
45
46
47
48
49
50
51
52

FORM CMS-2540-10 (09/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4121)

Rev. 2

41-335

4190 (Cont.)

FORM CMS-2540-10

ALLOCATION OF CAPITAL - RELATED COSTS

Cost Center Description
OUTPATIENT SERVICE COST CENTERS
60 Clinic
61 Rural Health Clinic (RHC)
62 FQHC
63 Other Outpatient Service Cost
OTHER REIMBURSABLE COST CENTERS
70 Home Health Agency Cost
71 Ambulance
72 Outpatient Rehabilitation (specify)
73 CMHC
74 Other Reimbursable Cost
SPECIAL PURPOSE COST CENTERS
83 Hospice
84 Other Special Purpose Cost
89 Subtotals
NON REIMBURSABLE COST CENTERS
90 Gift, Flower, Coffee Shops and Canteen
91 Barber and Beauty Shop
92 Physicians' Private Offices
93 Nonpaid Workers
94 Patients' Laundry
95 Other Nonreimbursable Cost
98 Cross Foot Adjustments
99 Negative Cost Center
100 Total

09-11

PROVIDER CCN:

DIRECTLY
ASSIGNED
CAPITAL
RELATED COSTS
0

CAP. REL
BUILDINGS
& FIXTURES
1

CAP. REL.
MOVABLE
EQUIPMENT
2

PERIOD:
FROM ________________
TO ________________

SUBTOTAL
2A

EMPLOYEE
BENEFITS
3

ADMINISTRATIVE
& GENERAL
4

WORKSHEET B
PART II

PLANT OPER.
MAINTENANCE
& REPAIRS
5
60
61
62
63
70
71
72
73
74
83
84
89
90
91
92
93
94
95
98
99
100

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4121)

41-336

Rev. 2

09-11

FORM CMS-2540-10

ALLOCATION OF CAPITAL - RELATED COSTS

Cost Center Description
GENERAL SERVICE COST CENTERS
1 Capital-Related Costs - Buildings & Fixtures
2 Capital-Related Costs - Moveable Equipment
3 Employee Benefits
4 Administrative and General
5 Plant Operation, Maintenance and Repairs
6 Laundry and Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Central Services and Supply
11 Pharmacy
12 Medical Records and Library
13 Social Service
14 Nursing and Allied Health Education
15 Other General Service Cost
INPATIENT ROUTINE SERVICE COST CENTERS
30 Skilled Nursing Facility
31 Nursing Facility
32 ICF - Mentally Retarded
33 Other Long Term Care
ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost

4190 (Cont.)

PROVIDER CCN:

LAUNDRY
& LINEN
SERVICE
6

HOUSE
KEEPING
7

PERIOD:
FROM ________________
TO ________________

DIETARY
8

NURSING
ADMINISTRATION
9

CENTRAL
SERVICES
& SUPPLY
10

WORKSHEET B
PART II

PHARMACY
11
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
30
31
32
33
40
41
42
43
44
45
46
47
48
49
50
51
52

FORM CMS-2540-10 (09/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4121)

Rev. 2

41-337

4190 (Cont.)

FORM CMS-2540-10

ALLOCATION OF CAPITAL - RELATED COSTS

Cost Center Description
OUTPATIENT SERVICE COST CENTERS
60 Clinic
61 Rural Health Clinic (RHC)
62 FQHC
63 Other Outpatient Service Cost
OTHER REIMBURSABLE COST CENTERS
70 Home Health Agency Cost
71 Ambulance
72 Outpatient Rehabilitation (specify)
73 CMHC
74 Other Reimbursable Cost
SPECIAL PURPOSE COST CENTERS
83 Hospice
84 Other Special Purpose Cost
89 Subtotals
NON REIMBURSABLE COST CENTERS
90 Gift, Flower, Coffee Shops and Canteen
91 Barber and Beauty Shop
92 Physicians' Private Offices
93 Nonpaid Workers
94 Patients' Laundry
95 Other Nonreimbursable Cost
98 Cross Foot Adjustments
99 Negative Cost Center
100 Total

09-11

PROVIDER CCN:

LAUNDRY
& LINEN
SERVICE
6

HOUSE
KEEPING
7

PERIOD:
FROM ________________
TO ________________

DIETARY
8

NURSING
ADMINISTRATION
9

CENTRAL
SERVICES
& SUPPLY
10

WORKSHEET B
PART II

PHARMACY
11
60
61
62
63
70
71
72
73
74
83
84
89
90
91
92
93
94
95
98
99
100

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4121)

41-338

Rev. 2

09-11

FORM CMS-2540-10

ALLOCATION OF CAPITAL - RELATED COSTS

Cost Center Description
GENERAL SERVICE COST CENTERS
1 Capital-Related Costs - Buildings & Fixtures
2 Capital-Related Costs - Moveable Equipment
3 Employee Benefits
4 Administrative and General
5 Plant Operation, Maintenance and Repairs
6 Laundry and Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Central Services and Supply
11 Pharmacy
12 Medical Records and Library
13 Social Service
14 Nursing and Allied Health Education
15 Other General Service Cost
INPATIENT ROUTINE SERVICE COST CENTERS
30 Skilled Nursing Facility
31 Nursing Facility
32 ICF - Mentally Retarded
33 Other Long Term Care
ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost

4190 (Cont.)

PROVIDER CCN:

MEDICAL
RECORDS
& LIBRARY
12

SOCIAL
SERVICE
13

NURSING &
ALLIED
HEALTH
EDUCATION
14

PERIOD:
FROM ________________
TO ________________
OTHER
GENERAL
SERVICE
COST
15

SUBTOTAL
16

POST
STEP-DOWN
ADJUSTMENTS
17

WORKSHEET B
PART II

TOTAL
18
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
30
31
32
33
40
41
42
43
44
45
46
47
48
49
50
51
52

FORM CMS-2540-10 (09/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4121)

Rev. 2

41-339

4190 (Cont.)

FORM CMS-2540-10

ALLOCATION OF CAPITAL - RELATED COSTS

Cost Center Description
OUTPATIENT SERVICE COST CENTERS
60 Clinic
61 Rural Health Clinic (RHC)
62 FQHC
63 Other Outpatient Service Cost
OTHER REIMBURSABLE COST CENTERS
70 Home Health Agency Cost
71 Ambulance
72 Outpatient Rehabilitation (specify)
73 CMHC
74 Other Reimbursable Cost
SPECIAL PURPOSE COST CENTERS
83 Hospice
84 Other Special Purpose Cost
89 Subtotals
NON REIMBURSABLE COST CENTERS
90 Gift, Flower, Coffee Shops and Canteen
91 Barber and Beauty Shop
92 Physicians' Private Offices
93 Nonpaid Workers
94 Patients' Laundry
95 Other Nonreimbursable Cost
98 Cross Foot Adjustments
99 Negative Cost Center
100 Total

09-11

PROVIDER CCN:

MEDICAL
RECORDS
& LIBRARY
12

SOCIAL
SERVICE
13

NURSING &
ALLIED
HEALTH
EDUCATION
14

PERIOD:
FROM ________________
TO ________________
OTHER
GENERAL
SERVICE
COST
15

SUBTOTAL
16

POST
STEP-DOWN
ADJUSTMENTS
17

WORKSHEET B
PART II

TOTAL
18
60
61
62
63
70
71
72
73
74
83
84
89
90
91
92
93
94
95
98
99
100

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4121)

41-340

Rev. 2

05-11

FORM CMS-2540-10

POST STEP DOWN ADJUSTMENTS

PROVIDER CCN:

Description
1

4190 (Cont.)
PERIOD :
FROM ______________
TO ________________

Worksheet B
Part No.
Line No.
2
3

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50

WORKSHEET B-2

Amount
4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4122)

Rev. 1

41-341

4190 (Cont.)

FORM CMS-2540-10

RATIO OF COST TO CHARGES
FOR ANCILLARY AND OUTPATIENT
COST CENTERS

PROVIDER CCN:

Cost Center Description
ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost
OUTPATIENT SERVICE COST CENTERS
60 Clinic
61 Rural Health Clinic (RHC)
62 FQHC
63 Other Outpatient Service Cost
71 Ambulance
100 Total

05-11
PERIOD :
FROM ______________
TO ________________

Total
( from Wkst. B,
Pt. I, col. 18 )
1

WORKSHEET C

Total
Charges
2

Ratio
( col. 1 divided
by col. 2 )
3
40
41
42
43
44
45
46
47
48
49
50
51
52
60
61
62
63
71
100

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4123)

41-342

Rev. 1

12-11

FORM CMS-2540-10

APPORTIONMENT OF ANCILLARY AND
OUTPATIENT COST

Check applicable box:
Check applicable box:

4190 (Cont.)

PROVIDER CCN:

[
[

] Title V (1)
] SNF

[
[

] Title XVIII
] NF

[
[

] Title XIX ( 1 )
] ICF/MR

[

] Other

PERIOD :
FROM ______________
TO ________________

______________________

[

WORKSHEET D
PART I

] PPS - Must also complete Part II

PART I - CALCULATION OF ANCILLARY AND OUTPATIENT COST

Cost Center Description

Ratio of
Cost to
Charges
( from Wkst. C,
col. 3 )
1

ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost
OUTPATIENT COST CENTERS
60 Clinic
61 Rural Health Clinic (RHC)
62 FQHC
63 Other Outpatient Service Cost
71 Ambulance (2)
100 Total (sum of lines 40 - 71)

Health Care
Program Charges
Part A
2

Healthcare
Program Cost
Part B
3

Part A
( col. 1 x col. 2 )
4

Part B
( col. 1 x col. 3 )
5
40
41
42
43
44
45
46
47
48
49
50
51
52
60
61
62
63
71
100

(1) For titles V and XIX use columns 1, 2 and 4 only.
(2) Line 71 columns 2 and 4 are for titles V and XIX. No amounts should be entered here for title XVIII.

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4124)

Rev. 3

41-343

4190 (Cont.)

FORM CMS-2540-10

APPORTIONMENT OF ANCILLARY AND
OUTPATIENT COST

12-11

PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

WORKSHEET D
PARTS II & III

TITLE XVIII ONLY

PART
1
2
3

II - APPORTIONMENT OF VACCINE COST
Drugs charged to patients - ratio of cost to charges (from Wkst. C, col. 3, line 49)
Program vaccine charges ( From your records or the PS&R report)
Program costs (line 1 x line 2) (Title XVIII, PPS providers, transfer this amount to Wkst. E, Pt. I, line 1)

1
2
3

PART III - CALCULATION OF PASS THROUGH COSTS FOR NURSING & ALLIED HEALTH

Cost Center Description

Total Cost
( from Wkst. B,
Pt. I, col. 18 )
1

ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost
100 Total (sum of lines 40 - 52)

Nursing &
Allied Health
( from Wkst. B,
Pt. I, col. 14 )
2

Ratio of Nursing
& Allied Health
Costs to Total
Costs - Part A
( col. 2 / col. 1 )
3

Program
Part A Cost
( from Wkst. D.,
Pt. I, col. 4 )
4

Part A
Nursing & Allied
Health Costs for
Pass Through
( col. 3 x col. 4 )
5
40
41
42
43
44
45
46
47
48
49
50
51
52
100

FORM CMS-2540-10 (12/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4124.1)

41-344

Rev. 3

05-13

FORM CMS-2540-10

COMPUTATION OF INPATIENT
ROUTINE COSTS

Check applicable box:
Check applicable box:

[
[

] Title V
] SNF

PROVIDER CCN:

[
[

] Title XVIII
] NF

[
[

4190 (Cont.)
PERIOD :
WORKSHEET D-1
FROM ______________ PARTS I & II
TO ________________

] Title XIX
] ICF/MR

PART I - CALCULATION OF INPATIENT ROUTINE COSTS
INPATIENT DAYS
1 Inpatient days including private room days
2 Private room days
3 Inpatient days including private room days applicable to the Program
4 Medically necessary private room days applicable to the Program
5 Total general inpatient routine service cost
PRIVATE ROOM DIFFERENTIAL ADJUSTMENT
6 General inpatient routine service charges
7 General inpatient routine service cost/charge ratio (line 5 divided by line 6)
8 Enter private room charges from your records
9 Average private room per diem charge (private room charges on line 8 divided by private room days on line 2)
10 Enter semi-private room charges from your records
11 Average semi-private room per diem charge (semi-private room charges on line 10 divided by semi-private room days)
12 Average per diem private room charge differential (line 9 minus line 11)
13 Average per diem private room cost differential (line 7 times line 12 )
14 Private room cost differential adjustment (line 2 times line 13)
15 General inpatient routine service cost net of private room cost differential (line 5 minus line 14)
PROGRAM INPATIENT ROUTINE SERVICE COSTS
16 Adjusted general inpatient service cost per diem (line 15 divided by line 11)
17 Program routine service cost (line 3 times line 16)
18 Medically necessary private room cost applicable to program (line 4 times line 13)
19 Total program general inpatient routine service cost (line 17 plus line 18)
20 Capital related cost allocated to inpatient routine service costs (from Wkst. B, Pt. II, col. 18, line 30 for SNF; line 31 for NF; or
line 32 for ICF/MR)
21 Per diem capital related costs (line 20 divided by line 1)
22 Program capital related cost (line 3 times line 21)
23 Inpatient routine service cost (line 19 minus line 22)
24 Aggregate charges to beneficiaries for excess costs (from provider records)
25 Total program routine service costs for comparison to the cost limitation (line 23 minus line 24)
26 Enter the per diem limitation (1)
27 Inpatient routine service cost limitation (line 3 times the per diem limitation line 26) (1)
28 Reimbursable inpatient routine service costs (line 22 plus the lesser of line 25 or line 27)
(Transfer to Wkst. E, Pt. II, line 4) (see instructions)

PART
1
2
3
4
5

II - CALCULATION OF INPATIENT NURSING & ALLIED HEALTH COSTS FOR PPS PASS-THROUGH
Total inpatient days
Program inpatient days (from Wkst. S-3, Pt. I, cols. 3, 4 or 5, line 1 or 2 as applicable)
Total nursing & allied health costs (see instructions)
Nursing & allied health ratio (line 2 divided by line 1)
Program nursing & allied health costs for pass-through (line 3 times line 4)

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

1
2
3
4
5

(1) Lines 26, 27 and 28 are not applicable for title XVIII, but may be used for title V and or title XIX

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4125)

Rev. 5

41-345

4190 (Cont.)
CALCULATION OF
REIMBURSEMENT SETTLEMENT
TITLE XVIII

FORM CMS-2540-10
PROVIDER CCN:

05-13
PERIOD :
FROM ______________
TO ________________

WORKSHEET E
PART I

PART
1
2
3
4
5
6
7
8
9
10
11
12
13
14
14.99
15

A - INPATIENT SERVICE PPS PROVIDER COMPUTATION OF REIMBURSEMENT
Inpatient PPS amount (see instructions)
Nursing and Allied Health Education Activities (pass through payments)
Subtotal (sum of lines 1 and 2)
Primary payor amounts
Coinsurance
Reimbursable bad debts (from your records)
Reimbursable bad debts for dual eligible beneficiaries (see instructions)
Adjusted reimbursable bad debts (see instructions)
Recovery of bad debts - for statistical records only
Utilization review
Subtotal (see instructions)
Interim payments (see instructions)
Tentative adjustment
Other adjustment (see instructions)
Sequestration amount (see instructions)
Balance due provider/program (see instructions)
(Indicate overpayment in parentheses)
16 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2

PART
17
18
19
20
21
22
23
24
24.01
24.02
25
26
27
28
28.99
29

B - ANCILLARY SERVICE COMPUTATION OF REIMBURSEMENT LESSER OF COST OR CHARGES - TITLE XVIII ONLY
Ancillary services Part B
Vaccine cost (from Wkst. D, Pt. II, line 3)
Total reasonable costs (sum of lines 17 and 18)
Medicare Part B ancillary charges (see instructions)
Cost of covered services (lesser of line 19 or line 20)
Primary payor amounts
Coinsurance and deductibles
Reimbursable bad debts (from your records)
Reimbursable bad debts for dual eligible beneficiaries (see instructions)
Adjusted reimbursable bad debts (see instructions)
Subtotal (sum of lines 21 and 24.02 , minus lines 22 and 23)
Interim payments (see instructions)
Tentative adjustment
Other Adjustments (Specify ______________) (see instructions)
Sequestration amount (see instructions)
Balance due provider/program (see instructions)
(indicate overpayments in parentheses)
30 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2

1
2
3
4
5
6
7
8
9
10
11
12
13
14
14.99
15
16

17
18
19
20
21
22
23
24
24.01
24.02
25
26
27
28
28.99
29
30

FORM CMS-2540-10 (05/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4130)

41-346

Rev. 5

11-12

FORM CMS-2540-10

CALCULATION OF
REIMBURSEMENT SETTLEMENT
FOR TITLE V and TITLE XIX ONLY

Check applicable box:
Check applicable box:

[
[

] Title V
] SNF

PROVIDER CCN:

[
[

] Title XIX
] NF

[

4190 (Cont.)
PERIOD :
FROM ______________
TO ________________

WORKSHEET E
PART II

] ICF/MR

COMPUTATION OF NET COST OF COVERED SERVICES
1 Inpatient ancillary services (see instructions)
2 Nursing & Allied Health Cost (from Wkst. D-1, Pt. II, line 5)
3 Outpatient services
4 Inpatient routine services (see instructions)
5 Utilization review - physicians' compensation (from provider records)
6 Cost of covered services (sum of lines 1 - 5)
7 Differential in charges between semiprivate accommodations and less
than semiprivate accommodations
8 Subtotal (line 6 minus line 7)
9 Primary payor amounts
10 Total reasonable cost (line 8 minus line 9)
REASONABLE CHARGES
11 Inpatient ancillary service charges
12 Outpatient service charges
13 Inpatient routine service charges
14 Differential in charges between semiprivate accommodations and less
than semiprivate accommodations
15 Total reasonable charges
CUSTOMARY CHARGES
16 Aggregate amount actually collected from patients liable for payment for
services on a charge basis
17 Amounts that would have been realized from patients liable for payment for services
on a charge basis had such payment been made in accordance with 42 CFR 413.13(e)
18 Ratio of line 16 to line 17 (not to exceed 1.000000)
19 Total customary charges (see instructions)
COMPUTATION OF REIMBURSEMENT SETTLEMENT
20 Cost of covered services (see instructions)
21 Deductibles
22 Subtotal (line 20 minus line 21)
23 Coinsurance
24 Subtotal (line 22 minus line 23)
25 Reimbursable bad debts (from your records)
26 Subtotal (sum of lines 24 and 25)
27 Unrefunded charges to beneficiaries for excess costs erroneously collected
based on correction of cost limit
28 Recovery of excess depreciation resulting from provider termination or a decrease
in program utilization
29 Other adjustments (Specify ______________) (see instructions)
30 Amounts applicable to prior cost reporting periods resulting from disposition of
depreciable assets (if minus, enter amount in parentheses)
31 Subtotal (line 26 plus or minus lines 29, and 30, minus lines 27 and 28)
32 Interim payments
33 Balance due provider/program (line 31 minus line 32)
(indicate overpayments in parentheses) (see instructions)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4130.2)

Rev. 4

41-347

4190 (Cont.)

FORM CMS-2540-10

ANALYSIS OF PAYMENTS TO PROVIDERS
FOR SERVICES RENDERED

11-12
PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

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

mm/dd/yyyy
1

Program
to
Provider

SUBTOTAL (sum of lines 3.01 - 3.49 minus sum of lines 3.50 - 3.98)
4 TOTAL INTERIM PAYMENTS (sum of lines 1, 2 & 3.99)
(Transfer to Wkst. E, Pt. I, line 12 for Part A, and line 26 for Part B.)

SUBTOTAL (sum of lines 5.01 - 5.49 minus sum of lines 5.50 - 5.98)
6 Determine net settlement amount (balance
due) based on the cost report (1)
7 TOTAL MEDICARE PROGRAM LIABILITY (see instructions)
8 Name of Contractor

Part B
Amount
2

mm/dd/yyyy
3

Amount
4
1
2

Provider
to
Program

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

WORKSHEET E-1

Program
to
Provider
Provider
to
Program
Program to Provider
Provider to Program

.02
.03
.04
.05
.50
.51
.52
.53
.54
.99

.01
.02
.03
.50
.51
.52
.99
.01
.02
Contractor Number

3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54
3.99
4

5.01
5.02
5.03
5.50
5.51
5.52
5.99
6.01
6.02
7
8

(1) On lines 3, 5, and 6, where an amount is due "Provider to Program," show the amount and date on which the provider agrees to the amount of repayment even though total repayment is not accomplished until a later date.

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4131)

41-348

Rev. 4

05-11

FORM CMS-2540-10

BALANCE SHEET
(If you are nonproprietary and do not maintain fund-type
accounting records, complete the "General Fund" column only.)

Assets
CURRENT ASSETS
1 Cash on hand and in banks
2 Temporary investments
3 Notes receivable
4 Accounts receivable
5 Other receivables
6 Less: allowances for uncollectible notes
and accounts receivable
7 Inventory
8 Prepaid expenses
9 Other current assets
10 Due from other funds
11 TOTAL CURRENT ASSETS
(sum of lines 1 - 10)
FIXED ASSETS
12 Land
13 Land improvements
14 Less: Accumulated depreciation
15 Buildings
16 Less Accumulated depreciation
17 Leasehold improvements
18 Less: Accumulated Amortization
19 Fixed equipment
20 Less: Accumulated depreciation
21 Automobiles and trucks
22 Less: Accumulated depreciation
23 Major movable equipment
24 Less: Accumulated depreciation
25 Minor equipment - Depreciable
26 Minor equipment nondepreciable
27 Other fixed assets
28 TOTAL FIXED ASSETS
(sum of lines 12 - 27)
OTHER ASSETS
29 Investments
30 Deposits on leases
31 Due from owners/officers
32 Other assets
33 TOTAL OTHER ASSETS
(sum of lines 29 - 32)
34 TOTAL ASSETS
(sum of lines 11, 28 and 33)
(

PROVIDER CCN:

Specific
Purpose
Fund
2

General
Fund
1

(

)

4190 (Cont.)
PERIOD :
FROM ______________
TO ________________

(

)

WORKSHEET G

Endowment
Fund
3

(

)

Plant
Fund
4

(

)

1
2
3
4
5
6
7
8
9
10
11

(

)

(

)

(

)

(

)

(

)

(

)

(

)

(

)

(

)

(

)

(

)

(

)

(

)

(

)

(

)

(

)

(

)

(

)

(

)

(

)

(

)

(

)

(

)

(

)

12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28

29
30
31
32
33
34

) = contra amount

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4140)

Rev. 1

41-349

4190 (Cont.)

FORM CMS-2540-10

BALANCE SHEET
(If you are nonproprietary and do not maintain fund-type
accounting records, complete the "General Fund" column only.)

Liabilities and Fund
Balances
CURRENT LIABILITIES
35 Accounts payable
36 Salaries, wages & fees payable
37 Payroll taxes payable
38 Notes & loans payable (short term)
39 Deferred income
40 Accelerated payments
41 Due to other funds
42 Other current liabilities
43 TOTAL CURRENT LIABILITIES
(sum of lines 35 - 42)
LONG TERM LIABILITIES
44 Mortgage payable
45 Notes payable
46 Unsecured loans
47 Loans from owners:
48 Other long term liabilities
49 Other (specify)
50 TOTAL LONG TERM LIABILITIES
(sum of lines 44 - 49)
51 TOTAL LIABILITIES
(sum of lines 43 and 50)
CAPITAL ACCOUNTS
52 General fund balance
53 Specific purpose fund
54 Donor created - endowment fund
balance - restricted
55 Donor created - endowment fund
balance - unrestricted
56 Governing body created - endowment
fund balance
57 Plant fund balance - invested in plant
58 Plant fund balance - reserve for
plant improvement, replacement and
expansion
59 TOTAL FUND BALANCES
(sum of lines 52 thru 58)
60 TOTAL LIABILITIES AND
FUND BALANCES
(sum of lines 51 and 59)
(

PROVIDER CCN:

General
Fund
1

Specific
Purpose
Fund
2

05-11
PERIOD :
FROM ______________
TO ________________

Endowment
Fund
3

WORKSHEET G

Plant
Fund
4
35
36
37
38
39
40
41
42
43

44
45
46
47
48
49
50
51

52
53
54
55
56
57
58

59
60

) = contra amount

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4140)

41-350

Rev. 1

09-11

FORM CMS-2540-10

STATEMENT OF CHANGES IN FUND BALANCES

General Fund
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

4190 (Cont.)
PROVIDER CCN:

2

Fund balances at beginning of period
Net income (loss) (from Wkst. G-3, line 31)
Total (sum of line 1 and line 2)
Additions (credit adjustments)

Total additions (sum of lines 5 - 9)
Subtotal (line 3 plus line 10)
Deductions (debit adjustments)

Total deductions (sum of lines 13 - 17)
Fund balance at end of period per balance sheet (line 11 - line 18)

Special Purpose Fund
3
4

PERIOD :
FROM ______________
TO ________________

WORKSHEET G - 1

Endowment Fund
5

Plant Fund
6

7

8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

FORM CMS-2540-10 (09/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4140)

Rev. 2

41-351

4190 (Cont.)
STATEMENT OF PATIENT REVENUES
AND OPERATING EXPENSES

FORM CMS-2540-10
PROVIDER CCN:

09-11
PERIOD :
FROM ______________
TO ________________

WORKSHEET G - 2
PARTS I & II

PART I - PATIENT REVENUES
Revenue Center
General Inpatient Routine Care Services
1 Skilled nursing facility
2 Nursing facility
3 ICF-Mentally Retarded
4 Other long term care
5 Total general inpatient care services
(sum of lines 1 - 4)
All Other Care Service
6 Ancillary services
7 Clinic
8 Home health agency
9 Ambulance
10 RHC/FQHC
11 CMHC
12 SNF based hospice
13 Other (specify)
14 Total patient revenues (sum of lines 5 - 13)
(transfer to Wkst. G-3, col. 3, line 1 )

INPATIENT
1

OUTPATIENT
2

PART II - OPERATING EXPENSES
1 Operating Expenses (per Wkst. A, col. 3, line 100)

TOTAL
3
1
2
3
4
5

6
7
8
9
10
11
12
13
14

1

2 Add ( Specify )

2

3

3

4

4

5

5

6

6

7

7

8 Total Additions (sum of lines 2 - 7)

8

9 Deduct (Specify)

9

10

10

11

11

12

12

13

13

14 Total Deductions (sum of lines 9 - 13)

14

15 Total Operating Expenses (sum of lines 1 and 8, minus line 14)

15

FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4140)

41-352

Rev. 2

11-12

FORM CMS-2540-10

STATEMENT OF REVENUES
AND EXPENSES

1
2
3
4
5

PROVIDER CCN:

4190 (Cont.)
PERIOD :
FROM ______________
TO ________________

Total patient revenues (from Wkst. G-2, Pt. I, col. 3, line 14)
Less: contractual allowances and discounts on patients accounts
Net patient revenues (line 1 minus line 2)
Less: total operating expenses (fom Wkst. G-2, Pt. II, line 15)
Net income from service to patients (line 3 minus 4)
Other income:
Contributions, donations, bequests, etc.
Income from investments
Revenues from communications (telephone and internet service)
Revenue from television and radio service
Purchase discounts
Rebates and refunds of expenses
Parking lot receipts
Revenue from laundry and linen service
Revenue from meals sold to employees and guests
Revenue from rental of living quarters
Revenue from sale of medical and surgical supplies to other than patients
Revenue from sale of drugs to other than patients
Revenue from sale of medical records and abstracts
Tuition (fees, sale of textbooks, uniforms, etc.)
Revenue from gifts, flower, coffee shops, canteen
Rental of vending machines
Rental of skilled nursing space
Governmental appropriations
Other miscellaneous revenue (specify ______________)
Total other income (sum of lines 6 - 24)
Total (line 5 plus line 25)
Other expenses (specify ________________)

6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30 Total other expenses (sum of lines 27 - 29)
31 Net income (or loss) for the period (line 26 minus line 30)

WORKSHEET G-3

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

FORM CMS-2540-10 (09/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4140)

Rev. 4

41-353

4190 (Cont.)

FORM CMS-2540-10

ANALYSIS OF PROVIDER - BASED
HOME HEALTH AGENCY COSTS

11-12
PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

HHA CCN :

COST CENTER DESCRIPTIONS
GENERAL SERVICE COST CENTERS
1 Capital Related - Bldgs. and Fixtures
2 Capital Related - Movable Equipment
3 Plant Operation & Maintenance
4 Transportation (see instructions)
5 Administrative and General
HHA REIMBURSABLE SERVICES
6 Skilled Nursing Care
7 Physical Therapy
8 Occupational Therapy
9 Speech Pathology
10 Medical Social Services
11 Home Health Aide
12 Supplies (see instructions)
13 Drugs
14 DME
15 Telemedicine
HHA NONREIMBURSABLE SERVICES
16 Home Dialysis Aide Services
17 Respiratory Therapy
18 Private Duty Nursing
19 Clinic
20 Health Promotion Activities
21 Day Care Program
22 Home Delivered Meals Program
23 Homemaker Service
24 All Others
25 Total (sum of lines 1-24)

SALARIES
1

EMPLOYEE
BENEFITS
2

TRANSPORTATION
( see
instructions )
3

CONTRACTED/
PURCHASED
SERVICES
4

OTHER
COSTS
5

TOTAL
( sum of cols.
1 thru 5 )
6

RECLASSIFICATIONS
7

RECLASSIFIED
TRIAL BALANCE
( col. 6 + col. 7 )
8

ADJUSTMENTS
9

WORKSHEET H

NET
EXPENSES FOR
ALLOCATION
( col. 8 + col. 9 )
10
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Column, 6 line 25 should agree with the Worksheet A, column 3, line 70, or subscript as applicable.

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4141)

41-354

Rev. 4

11-12

FORM CMS-2540-10

COST ALLOCATION - HHA GENERAL SERVICE COST

4190 (Cont.)
PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

HHA CCN :
NET EXPENSES
FOR COST
ALLOCATION
( from Wkst. H,
col. 10 )
0

WORKSHEET H-1
PART I

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

GENERAL SERVICE COST CENTERS
1 Capital Related - Bldgs. and Fixtures
2 Capital Related - Movable Equipment
3 Plant Operation & Maintenance
4 Transportation (see instructions)
5 Administrative and General
HHA REIMBURSABLE SERVICES
6 Skilled Nursing Care
7 Physical Therapy
8 Occupational Therapy
9 Speech Pathology
10 Medical Social Services
11 Home Health Aide
12 Supplies
13 Drugs
14 DME
15 Telemedicine
HHA NONREIMBURSABLE SERVICES
16 Home Dialysis Aide Services
17 Respiratory Therapy
18 Private Duty Nursing
19 Clinic
20 Health Promotion Activities
21 Day Care Program
22 Home Delivered Meals Program
23 Homemaker Service
24 All Others
25 Total (sum of lines 1-24)

PLANT
OPERATION &
MAINTENANCE
3

TRANSPORTATION
4

SUBTOTAL
( cols. 0 through 4 )
4A

ADMINISTRATIVE
& GENERAL
5

TOTAL
( cols. 4A + 5 )
6
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4142)

Rev. 4

41-355

4190 (Cont.)

FORM CMS-2540-10

COST ALLOCATION - HHA STATISTICAL BASIS

11-12
PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

HHA CCN :

NET EXPENSES
FOR COST
ALLOCATION
0

CAPITAL
RELATED COSTS
BLDGS. &
MOVABLE
FIXTURES
EQUIPMENT
( Square
( Dollar Value
Feet )
or Square Feet )
1
2

GENERAL SERVICE COST CENTERS
1 Capital Related - Bldgs. and Fixtures
2 Capital Related - Movable Equipment
3 Plant Operation & Maintenance
4 Transportation (see instructions)
5 Administrative and General
HHA REIMBURSABLE SERVICES
6 Skilled Nursing Care
7 Physical Therapy
8 Occupational Therapy
9 Speech Pathology
10 Medical Social Services
11 Home Health Aide
12 Supplies
13 Drugs
14 DME
15 Telemedicine
HHA NONREIMBURSABLE SERVICES
16 Home Dialysis Aide Services
17 Respiratory Therapy
18 Private Duty Nursing
19 Clinic
20 Health Promotion Activities
21 Day Care Program
22 Home Delivered Meals Program
23 Homemaker Service
24 All Others
25 Total (sum of lines 1-24)
26 Cost to be allocated
27 Unit Cost Multiplier

PLANT
OPERATION &
MAINTENANCE
( Square
Feet )
3

TRANSPORTATION
( Mileage )
4

RECONCILIATION
5A

ADMINISTRATIVE
& GENERAL
( Accumulated
Cost )
5

WORKSHEET H-1,
PART II

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

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4142)

41-356

Rev. 4

11-12

FORM CMS-2540-10

ALLOCATION OF GENERAL SERVICE
COSTS TO HHA COST CENTERS

4190 (Cont.)
PROVIDER CCN:

PERIOD:
FROM __________________
TO ________________

HHA CCN :

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

HHA COST CENTER
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
Telemedicine
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Totals (sum of lines 1-20) (2)
Unit Cost Multiplier: column 18, line 1
divided by the sum of column 18,
line 21, minus column 18, line 1,
rounded to 6 decimal places.

From
Wkst.
H-1,
Pt. I,
col. 6,
line
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

HHA
TRIAL
BALANCE
(1)
0

WORKSHEET H-2,
PART I

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

EMPLOYEE
BENEFITS
3

SUBTOTAL
( cols. 0
through 3 )
3A

ADMINISTRATIVE &
GENERAL
4

OPERATION
OF PLANT
5

LAUNDRY
& LINEN
SERVICE
6
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

(1) Column 0, line 21 must agree with Wkst. A, col. 7, line 70.
(2) Columns 0 through 18, line 21 must agree with the corresponding columns of Wkst. B, Pt. I, line 70.

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4143)

Rev. 4

41-357

4190 (Cont.)

FORM CMS-2540-10

ALLOCATION OF GENERAL SERVICE
COSTS TO HHA COST CENTERS

11-12
PROVIDER CCN:

PERIOD:
FROM __________________
TO ________________

HHA CCN :

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

HHA COST CENTER
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
Telemedicine
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Totals (sum of lines 1-20) (2)
Unit Cost Multiplier: column 18, line 1
divided by the sum of column 18,
line 21, minus column 18, line 1,
rounded to 6 decimal places.

HOUSE
KEEPING
7

DIETARY
8

NURSING
ADMINISTRATION
9

CENTRAL
SERVICES &
SUPPLY
10

PHARMACY
11

MEDICAL
RECORDS &
LIBRARY
12

WORKSHEET H-2,
PART I

SOCIAL
SERVICE
13
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

(2) Columns 0 through 18, line 21 must agree with the corresponding columns of Wkst. B, Pt. I, line 70.

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4143)

41-358

Rev. 4

11-12

FORM CMS-2540-10

ALLOCATION OF GENERAL SERVICE
COSTS TO HHA COST CENTERS

4190 (Cont.)
PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

HHA CCN :

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

HHA COST CENTER
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
Telemedicine
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Totals (sum of lines 1-20) (2)
Unit Cost Multiplier: column 18, line 1
divided by the sum of column 18,
line 21, minus column 18, line 1,
rounded to 6 decimal places.

NURSING
AND ALLIED
HEALTH
EDUCATION
14

OTHER
GENERAL
SERVICE
15

SUBTOTAL
( sum of
cols. 3A
through 15 )
16

POST
STEPDOWN
ADJUSTMENTS
17

SUBTOTAL
( cols. 16 ± 17 )
18

ALLOCATED
HHA
A&G
( see Pt. II )
19

WORKSHEET H-2,
PART I

TOTAL
HHA COSTS
20
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

(2) Columns 0 through 18, line 21 must agree with the corresponding columns of Wkst. B, Pt. I, line 70.

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4143)

Rev. 4

41-359

4190 (Cont.)

FORM CMS-2540-10

ALLOCATION OF GENERAL SERVICE
COSTS TO HHA COST CENTERS
STATISTICAL BASIS

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

HHA COST CENTER
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
Telemedicine
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Totals (sum of lines 1-20)
Total cost to be allocated
Unit Cost Multiplier

11-12

PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

HHA CCN :
CAPITAL
RELATED COSTS
BLDGS. &
MOVABLE
FIXTURES
EQUIPMENT
( Square
( Dollar Value
Feet )
or Square Feet )
1
2

EMPLOYEE
BENEFITS
( Gross
Salaries )
3

RECONCILIATION
4A

ADMINISTRATIVE &
GENERAL
( Accumulated
Cost )
4

OPERATION
OF PLANT
( Square
Feet )
5

WORKSHEET H-2,
PART II

LAUNDRY
& LINEN
SERVICE
( Pounds of
Laundry )
6
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4143)

41-360

Rev. 4

11-12

FORM CMS-2540-10

ALLOCATION OF GENERAL SERVICE
COSTS TO HHA COST CENTERS
STATISTICAL BASIS

HHA COST CENTER
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

4190 (Cont.)
PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

HHA CCN :

HOUSEKEEPING
( Hours of
Service )
7

DIETARY
( Meals
Served )
8

Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
Telemedicine
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Totals (sum of lines 1-20)
Total cost to be allocated
Unit Cost Multiplier

NURSING
ADMINISTRATION
( Direct
Nurs. Hrs. )
9

CENTRAL
SERVICES &
SUPPLY
( Costed
Requis. )
10

PHARMACY
( Costed
Requis. )
11

MEDICAL
RECORDS &
LIBRARY
( Time
Spent )
12

WORKSHEET H-2,
PART II

SOCIAL
SERVICE
( Time
Spent )
13
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4143)

Rev. 4

41-361

4190 (Cont.)

FORM CMS-2540-10

ALLOCATION OF GENERAL SERVICE
COSTS TO HHA COST CENTERS
STATISTICAL BASIS

HHA COST CENTER
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

11-12
PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

HHA CCN :
NURSING
AND ALLIED
HEALTH
EDUCATION
( Assigned
Time )
14

OTHER
GENERAL
SERVICE
( SPECIFY )
15

Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
Telemedicine
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Totals (sum of lines 1-20)
Total cost to be allocated
Unit Cost Multiplier

SUBTOTAL
( sum of
cols. 3A
through 15 )
16

POST
STEPDOWN
ADJUSTMENTS
17

SUBTOTAL
( cols. 16 ± 17 )
18

ALLOCATED
HHA A&G
( see Pt. II )
19

WORKSHEET H-2,
PART II

TOTAL
HHA COSTS
20
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4143)

41-362

Rev. 4

05-13

FORM CMS-2540-10

APPORTIONMENT OF PATIENT SERVICE COSTS

4190 (Cont.)

PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

HHA CCN:
Check applicable box:
[ ] Title V
[ ] Title XVIII
[ ] Title XIX
PART I - COMPUTATION OF THE AGGREGATE PROGRAM COST
Cost Per Visit Computation
From,
Facility
Shared
Total
Wkst.
Costs
Ancillary
HHA
H-2,
( from
Costs
Costs
Pt. I,
Wkst. H-2.
( from
( col. 1 +
Total
col. 20,
Pt. I )
Pt. II )
col 2 )
Visits
Patient Services
line 1
2
3
4
1 Skilled Nursing Care
2
2 Physical Therapy
3
3 Occupational Therapy
4
4 Speech Pathology
5
5 Medical Social Services
6
6 Home Health Aide
7
7 Total (sum of lines 1-6)

Average
Cost
Per Visit
( col. 3
÷ col. 4 )
5

Part A
6

Program Visits
Part B
Not Subject
Subject
to Deductibles
to Deductibles
& Coinsurance & Coinsurance
7
8

WORKSHEET H-3,
Parts I & II

Cost of Services
Part B

Part A
9

Not Subject
to Deductibles
& Coinsurance
10

Subject
to Deductibles
& Coinsurance
11

Total
Program Cost
( sum of
cols. 9-10 )
12
1
2
3
4
5
6
7

Patient Services by CBSA

Program Visits
Part B
CBSA
No. (1)
1

8
9
10
11
12
13
14

Part A
2

Not Subject
to Deductibles
& Coinsurance
3

Subject
to Deductibles
& Coinsurance
4

Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Total (sum of lines 8-13)

8
9
10
11
12
13
14

Supplies and Drugs Cost
Computations

Other Patient Services
15 Cost of Medical Supplies
16 Cost of Drugs

From
Wkst. H-2,
Pt. I,
col. 20,
line 8
9

Facility
Costs
( from
Wkst.
H-2,
Pt. I )
1

Shared
Ancillary
Costs
( from
Pt. II )
2

Total
HHA
Cost
( cols. 1 + 2 )
3

Total
Charges
( from
HHA
records )
4

Ratio
( col. 3
÷ col. 4 )
5

Part A
6

Program Covered Charges
Part B
Not Subject
Subject
to
to
Deductibles & Deductibles &
Coinsurance
Coinsurance
7
8

PART II - APPORTIONMENT OF COST OF HHA SERVICES FURNISHED BY SHARED SKILLED NURSING FACILITY DEPARTMENTS
From
Cost to Charge
Wkst. C,
Ratio
col. 3, line 1
1 Physical Therapy
44
2 Occupational Therapy
45
3 Speech Pathology
46
4 Cost of Medical Supplies
48
5 Cost of Drugs
49

Part A
9

Cost of Services
Part B
Not Subject
Subject
to
to
Deductibles &
Deductibles &
Coinsurance
Coinsurance
10
11
15
16

Total HHA Charges
( from provider records )
2

HHA Shared Ancillary Costs
( col. 1 x col. 2 )
3

Transfer to
Pt. 1 4
col. 2, line 2
col. 2, line 3
col. 2, line 4
col. 2, line 15
col. 2, line 16

1
2
3
4
5

(1) The CBSA numbers flow from Wkst. S-4, line 22, and subscripts as indicated should be replicated on lines 8-13.
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4144)

Rev. 5

41-363

4190 (Cont.)

FORM CMS-2540-10

CALCULATION OF HHA
REIMBURSEMENT SETTLEMENT

PROVIDER CCN:
HHA CCN :

Check applicable box:

[ ] Title V

[ ] Title XVIII

05-13
PERIOD :
WORKSHEET H-4,
FROM ______________ Parts I & II
TO ________________

[ ] Title XIX

PART I - COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES
Part B

Description
Reasonable Cost of Part A & Part B Services
1 Reasonable cost of services (see instructions)
2 Total charges
Customary Charges
3 Amount actually collected from patients liable for payment
for services on a charge basis (from your records)
4 Amount that would have been realized from patients liable
for payment for services on a charge basis had such
payment been made in accordance with 42 CFR 413.13(b)
5 Ratio of line 3 to line 4 (not to exceed 1.000000)
6 Total customary charges (see instructions)
7 Excess of total customary charges over total reasonable
cost (complete only if line 6 exceeds line 1)
8 Excess of reasonable cost over customary charges
(complete only if line 1 exceeds line 6)
9 Primary payer amounts

Part A
1

Not Subject to
Deductibles
& Coinsurance
2

Subject to
Deductibles
& Coinsurance
3
1
2
3
4

5
6
7
8
9

PART II - COMPUTATION OF HHA REIMBURSEMENT SETTLEMENT

10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
30.99
31
32
33
34
35

Description
Total reasonable cost (see instructions)
Total PPS Reimbursement - Full Episodes without Outliers
Total PPS Reimbursement - Full Episodes with Outliers
Total PPS Reimbursement - LUPA Episodes
Total PPS Reimbursement - PEP Episodes
Total PPS Outlier Reimbursement - Full Episodes with Outliers
Total PPS Outlier Reimbursement - PEP Episodes
Total Other Payments
DME Payments
Oxygen Payments
Prosthetic and Orthotic Payments
Part B deductibles billed to Medicare patients (exclude coinsurance)
Subtotal (sum of lines 10 through 20 minus line 21)
Excess reasonable cost (from line 8)
Subtotal (line 22 minus line 23)
Coinsurance billed to program patients (from your records)
Net cost (line 24 minus line 25)
Reimbursable bad debts (from your records)
Reimbursable bad debts for dual eligible beneficiaries (see instructions)
Total costs - current cost reporting period (line 26 plus line 27)
Other adjustments (see instructions) (specify)
Sequestration amount (see instructions)
Subtotal (line 29 plus/minus line 30)
Interim payments (see instructions)
Tentative settlement (for contractor use only)
Balance due provider/program (see instructions )
Protested amounts (nonallowable cost report items) in accordance with
CMS Pub. 15-2, section 115.2

Part A Services
1

Part B Services
2
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
30.99
31
32
33
34
35

FORM CMS-2540-10 (05/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4145)

41-364

Rev. 5

11-12

FORM CMS-2540-10

ANALYSIS OF PAYMENTS TO PROVIDER BASED HHAs FOR SERVICES
RENDERED TO PROGRAM BENEFICIARIES

4190 (Cont.)
PROVIDER CCN:
HHA CCN :

PERIOD :
FROM ______________
TO ________________

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

mm/dd/yyyy
1

Program
to
Provider

SUBTOTAL (sum of lines 3.01 - 3.49 minus sum of lines 3.50 - 3.98)
4 TOTAL INTERIM PAYMENTS (sum of lines 1, 2, and 3.99)
(Transfer to Wkst. H-4, Part II, column as appropriate, line 32)

SUBTOTAL (sum of lines 5.01 - 5.49 minus sum of lines 5.50 - 5.98)
6 Determine net settlement amount (balance
due) based on the cost report (1)
7 TOTAL MEDICARE PROGRAM LIABILITY (see instructions)
8 Name of Contractor

Part B
Amount
2

mm/dd/yyyy
3

Amount
4
1
2

Provider
to
Program

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

WORKSHEET H-5

Program
to
Provider
Provider
to
Program
Program to Provider
Provider to Program

.02
.03
.04
.05
.50
.51
.52
.53
.54
.99

.01
.02
.03
.50
.51
.52
.99
.01
.02
Contractor Number

3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54
3.99
4

5.01
5.02
5.03
5.50
5.51
5.52
5.99
6.01
6.02
7
8

(1) On lines 3, 5, and 6, where an amount is due "Provider to Program," show the amount and date on which the provider agrees to the amount of repayment even though total repayment is not accomplished until a later date.

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4146)

Rev. 4

41-365

4190 (Cont.)

FORM CMS-2540-10

ANALYSIS OF SNF - BASED RURAL HEALTH
CLINIC / FEDERALLY QUALIFIED
HEALTH CENTER COSTS

Check applicable box:

[

11-12

PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

COMPONENT CCN :

] RHC

[

WORKSHEET I-1

] FQHC

COMPENSATION

OTHER
COSTS
2

TOTAL
( col. 1 + col. 2 )
3

RECLASSIFICATIONS
4

FACILITY HEALTH CARE STAFF COSTS
1 Physician
2 Physician Assistant
3 Nurse Practitioner
4 Visiting Nurse
5 Other Nurse
6 Clinical Psychologist
7 Clinical Social Worker
8 Laboratory Technician
9 Other Facility health care staff costs
10 Subtotal (sum of lines 1 - 9)
COSTS UNDER AGREEMENT
11 Physician Services Under Agreement
12 Physician Supervision Under Agreement
13 Other costs under agreement
14 Subtotal (sum of lines 11 - 13)
OTHER HEALTH CARE COSTS
15 Medical Supplies
16 Transportation (Health Care Staff)
17 Depreciation - Medical Equipment
18 Professional Liability Insurance
19 Other health care costs
21 Subtotal (sum of lines 15 - 19)
22 Total cost of health care services
(sum of lines 10, 14, and 21)
COSTS OTHER THAN RHC / FQHC SERVICES
23 Pharmacy
24 Dental
25 Optometry
26 All other non reimbursable costs
28 Total nonreimbursable costs (sum of lines 23 - 26 )
FACILITY OVERHEAD
29 Facility costs
30 Administrative costs
31 Total facility overhead (sum of lines 29-30)
32 Total facility costs (sum of lines 22, 28 and 31)

RECLASSIFIED
TRIAL
BALANCE
( col. 3 +/- col. 4 )
5

ADJUSTMENTS
6

NET EXPENSES
FOR
ALLOCATION
( col. 5 +/- col.6 )
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
21
22

23
24
25
26
28
29
30
31
32

* The net expenses for cost allocation on Worksheet A for the RHC/FQHC cost center line must equal the total facility costs in column 7, line 32 of this worksheet.

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4148)

41-366

Rev. 4

05-13

FORM CMS-2540-10

ALLOCATION OF OVERHEAD
TO RHC / FQHC SERVICES

PROVIDER CCN:
COMPONENT CCN:

Check applicable box:

[

] RHC

[

4190 (Cont. )
PERIOD :
FROM ______________
TO ________________

WORKSHEET I-2

] FQHC

PART I - VISITS AND PRODUCTIVITY
Number
of FTE
Personnel
1
1
2
3
4
5
6
7
8
9
10
11

PART
12
13
14
15
16
17
18
19
20

Physicians
Physician Assistants
Nurse Practitioners
Subtotal (sum of lines 1 - 3)
Visiting Nurse
Clinical Psychologist
Clinical Social Worker
Medical Nutrition Therapist (FQHC only)
Diabetes Self Management Training (FQHC only)
Total FTEs and visits (sum of lines 4 - 9)
Physician Services Under Agreements

Total
Visits
2

Productivity
Standard
(1)
3
4200
2100
2100

Minimum
Visits
( col. 1 x col. 3 )
4

II - DETERMINATION OF TOTAL ALLOWABLE COST APPLICABLE TO RHC / FQHC SERVICES
Total costs of health care services (from Wkst. I-1, col. 7, line 22)
Total nonreimbursable costs (from Wkst I-1, col 7, line 28)
Cost of all services - excluding overhead (sum of lines 12 and 13)
Ratio of RHC / FQHC services (line 12 divided by line 14)
Total facility overhead (from Wkst. I-1, col. 7, line 31)
Parent provider overhead allocated to facility (see instructions)
Total overhead (sum of lines 16 and 17)
Overhead applicable to RHC / FQHC services (lines 15 X line 18)
Total allowable cost of RHC / FQHC services (sum of lines 12 and 19)

Greater of
Column 2 or
Column 4
5
1
2
3
4
5
6
7
8
9
10
11

12
13
14
15
16
17
18
19
20

(1) Productivity standards established by CMS are: 4200 visits for each physician, and 2100 visits for each nonphysician practitioner.

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4149)

Rev.5

41-367

4190 (Cont.)

FORM CMS-2540-10

CALCULATION OF
REIMBURSEMENT
SETTLEMENT FOR
RHC / FQHC SERVICES
Check applicable box:
Check applicable box:

PART I 1
2
3
4
5
6
7

PROVIDER CCN:
COMPONENT CCN:

[
[

] Title V
] RHC

[
[

] Title XVIII
] FQHC

[

05-13
PERIOD :
WORKSHEET I-3
FROM ______________
TO ________________

] Title XIX

DETERMINATION OF RATE FOR RHC / FQHC SERVICES
Total allowable cost of RHC/FQHC services (from Wkst. I-2, Pt. II, line 20)
Cost of vaccines and their administration (from Wkst. I-4, line 15)
Total allowable cost excluding vaccine (line 1 minus line 2)
Total FTEs and visits (from Wkkst. I-2, col. 5, line 10)
Physicians' visits under agreement (from Wkst. I-2, col. 5, line 11)
Total adjusted visits (line 4 plus line 5)
Adjusted cost per visit (line 3 divided by line 6)

CALCULATION OF LIMIT
Lines 8 through 14: Fiscal year providers use columns 1 and 2.
Lines 8 through 14: Calendar year providers use column 2 only.
8 Rate per visit limit (from your contractor)
9 Rate for Program covered visits (see instructions)

1
2
3
4
5
6
7
Prior to
January 1
1

PART II - CALCULATION OF SETTLEMENT
10 Program covered visits excluding mental health services (from contractor records)
11 Program cost excluding costs for mental health services (line 9 x line 10)
12 Program covered visits for mental health services (from contractor records)
13 Program covered cost for mental health services (line 9 x line 12)
14 Limit adjustment for mental health services (see instructions)
15 Total Program cost (sum of line 11 cols. 1 and 2, plus line 14 cols. 1 and 2)
15.01 Total Program charges (see instructions) (from contractor records)
15.02 Total Program preventive charges (see instructions) (from provider records)
15.03 Total Program preventive costs ((line 15.02/line 15.01) times line 15)
15.04 Total Program non-preventive costs ((line 15 minus lines 15.03 and 17) times .80)
15.05 Total Program cost (see instructions)
16 Primary payer amounts
17 Less: Beneficiary deductible for RHC only (see instructions) (from contractor records)
18 Less: Beneficiary coinsurance for RHC/FQHC services (see instructions) (from contractor records)
19 Net Program cost excluding vaccines (see instructions)
20 Program cost of vaccines and their administration (from Wkst. I -4, line 16)
21 Total reimbursable Program cost (line 19 plus 20)
22 Reimbursable bad debts
22.01 Adjusted reimbursable bad debts (see instructions)
23 Reimbursable bad debts for dual eligible beneficiaries (see instructions)
24 Other adjustments
25 Net reimbursable amount (see instructions)
25.01 Sequestration amount (see instructions)
26 Interim payments (from Wkst. I-5, line 4)
27 Tentative settlement (for contractor use only)
28 Balance due component/Program (see instructions)
29 Protested amounts (nonallowable cost report items) in accordance with CMS Publ. 15-2, § 115.2

On or after
January 1
2
8
9

10
11
12
13
14
15
15.01
15.02
15.03
15.04
15.05
16
17
18
19
20
21
22
22.01
23
24
25
25.01
26
27
28
29

FORM CMS-2540-10 (05/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4150)

41-368

Rev. 5

11-12

FORM CMS-2540-10

COMPUTATION OF PNEUMOCOCCAL
AND INFLUENZA VACCINE COST

PROVIDER CCN:
COMPONENT CCN :

Check applicable box:
Check applicable box:

[
[

] Title V
] RHC

[
[

] Title XVIII
] FQHC

[

4190 (Cont.)
PERIOD :
FROM ______________
TO ________________

WORKSHEET I-4

] Title XIX

CALCULATION OF COST

PNEUMOCOCCAL
1

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Health care staff cost (from Wkst. I-1, col. 7, line 10)
Ratio of pneumococcal and influenza vaccine staff time to total health care staff time
Pneumococcal and influenza vaccine health care staff cost (line 1 x line 2)
Medical supplies cost - pneumococcal and influenza vaccine (from your records)
Direct cost of pneumococcal and influenza vaccine (sum of lines 3 and 4)
Total direct cost of the facility (from Wkst. I-1, col. 7, line 22)
Total overhead (from Wkst. I-2, line 18)
Ratio of pneumococcal and influenza vaccine direct cost to total direct cost (line 5 divided by line 6)
Overhead cost - pneumococcal and influenza vaccine (line 7 x line 8)
Total pneumococcal and influenza vaccine cost and its (their) administration (sum of lines 5 and 9)
Total number of pneumococcal and influenza vaccine injections (from your records)
Cost per pneumococcal and influenza vaccine injection (line 10 divided by line 11)
Number of pneumococcal and influenza vaccine injections administered to Medicare beneficiaries
Medicare cost of pneumococcal and influenza vaccine and its (their) adminstration (line 12 x line 13)
Total cost of pneumococcal and influenza vaccine and its (their) administration (sum of
cols. 1 and 2, line 10) (transfer to Wkst. I-3, line 2)
16 Total Medicare cost of pneumococcal and influenza vaccine and its (their) administration (sum of
cols. 1 and 2, line 14) (transfer to Wkst. I-3, line 20)

INFLUENZA
2
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4151)

Rev. 4

41-369

4190 (Cont. )

FORM CMS-2540-10

ANALYSIS OF PAYMENTS TO
SNF - BASED RURAL HEALTH
CLINIC AND FEDERALLY
QUALIFIED HEALTH CENTERS
Check applicable box:

11-12

PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

COMPONENT CCN :

[

] RHC

[

WORKSHEET I - 5

] FQHC

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

mm/dd/yyyy
1

1
2

Program
to
Provider

Provider
to
Program
SUBTOTAL (sum of lines 3.01 - 3.49 minus sum of lines 3.50 - 3.98)
4 TOTAL INTERIM PAYMENTS (sum of lines 1, 2, and 3.99)
(Transfer to Wkst. I-3, line 26)
TO BE COMPLETED BY CONTRACTOR
5 List separately each tentative settlement
payment after desk review. Also show
date of each payment.
If none, write "NONE," or enter a zero. (1)

SUBTOTAL (sum of lines 5.01 - 5.49 minus sum of lines 5.50 - 5.98)
6 Determine net settlement amount (balance
due) based on the cost report (1)
7 TOTAL MEDICARE PROGRAM LIABILITY (see instructions)
8 Name of Contractor

Amount
2

Program
to
Provider
Provider
to
Program
Program to Provider
Provider to Program

.01
.02
.03
.04
.05
.50
.51
.52
.53
.54
.99

3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54
3.99
4

.01
.02
.03
.50
.51
.52
.99
.01
.02

5.01
5.02
5.03
5.50
5.51
5.52
5.99
6.01
6.02
7
8

Contractor Number

(1) On lines 3, 5, and 6, where an amount is due "Provider to Program," show the amount and date on which the
provider agrees to the amount of repayment, even though total repayment is not accomplished until a later date.

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4152)

41-370

Rev. 4

11-12

FORM CMS-2540-10

ALLOCATION OF GENERAL SERVICE COSTS
TO COST CENTERS FOR CMHC

PROVIDER CCN:
COMPONENT CCN :

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

COMPONENT COST CENTER
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Respiratory Therapy
Psychiatric/Psychological Services
Individual Therapy
Group Therapy
Individualized Activity Therapy
Family Counseling
Diagnostic Services
Appr. Patient Training & Education
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies
Medical Appliances
Durable Medical Equipment - Rented
Durable Medical Equipment - Sold
All Other
Totals (sum of lines 1-21) (1)
Unit Cost Multiplier (see instructions)

NET
EXPENSES
FOR COST
ALLOCATION
0

CAPITAL RELATED COST
BUILDS. &
MOVABLE
FIXTURES
EQUIPMENT
1
2

4190 (Cont.)
PERIOD :
FROM ______________
TO ________________

EMPLOYEE
BENEFITS
3

WORKSHEET J-1
PART I

SUBTOTAL
( cols. 0
through 3 )
3A

ADMINISTRATIVE
&
GENERAL
4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

(1) Columns 0 through 18, line 22 must agree with the corresponding columns of Worksheet B, Part I, line 73, (subscripted line).

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4153)

Rev. 4

41-371

4190 (Cont.)
ALLOCATION OF GENERAL SERVICE COSTS
TO COST CENTERS FOR CMHC

FORM CMS-2540-10

11-12

PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

COMPONENT CCN :

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

COMPONENT COST CENTER
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Respiratory Therapy
Psychiatric/Psychological Services
Individual Therapy
Group Therapy
Individualized Activity Therapy
Family Counseling
Diagnostic Services
Appr. Patient Training & Education
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies
Medical Appliances
Durable Medical Equipment - Rented
Durable Medical Equipment - Sold
All Other
Totals (sum of lines 1-21) (1)
Unit Cost Multiplier (see instructions)

PLANT
OPERATION
MAINTENANCE
& REPAIRS
5

LAUNDRY
& LINEN
SERVICE
6

HOUSE KEEPING
7

WORKSHEET J-1
PART I

DIETARY
8

NURSING
ADMINISTRATION
9
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

(1) Columns 0 through 18, line 22 must agree with the corresponding columns of Worksheet B, Part I, line 73, (subscripted line).

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4153)

41-372

Rev. 4

11-12

FORM CMS-2540-10

ALLOCATION OF GENERAL SERVICE COSTS
TO COST CENTERS FOR CMHC

4190 (Cont.)

PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

COMPONENT CCN :

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

COMPONENT COST CENTER
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Respiratory Therapy
Psychiatric/Psychological Services
Individual Therapy
Group Therapy
Individualized Activity Therapy
Family Counseling
Diagnostic Services
Appr. Patient Training & Education
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies
Medical Appliances
Durable Medical Equipment - Rented
Durable Medical Equipment - Sold
All Other
Totals (sum of lines 1-21) (1)
Unit Cost Multiplier (see instructions)

CENTRAL
SERVICES
& SUPPLY
10

PHARMACY
11

MEDICAL
RECORDS
& LIBRARY
12

SOCIAL
SERVICES
13

WORKSHEET J-1
PART I

NURSING &
ALLIED
HEALTH
EDUCATION
14

OTHER
GENERAL
SERVICE
15
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

(1) Columns 0 through 18, line 22 must agree with the corresponding columns of Worksheet B, Part I, line 73, (subscripted line).

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4153)

Rev. 4

41-373

4190 (Cont. )
ALLOCATION OF GENERAL SERVICE COSTS
TO COST CENTERS FOR CMHC

FORM CMS-2540-10

11-12

PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

COMPONENT CCN :

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

COMPONENT COST CENTER
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Respiratory Therapy
Psychiatric/Psychological Services
Individual Therapy
Group Therapy
Individualized Activity Therapy
Family Counseling
Diagnostic Services
Appr. Patient Training & Education
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies
Medical Appliances
Durable Medical Equipment - Rented
Durable Medical Equipment - Sold
All Other
Totals (Sum of lines 1-21) (1)
Unit Cost Multiplier (see instructions)

SUBTOTAL
16

POST
STEP-DOWN
ADJUSTMENTS
17

SUBTOTAL
18

WORKSHEET J-1
PART I

ALLOCATED
A&G
( see Pt. II )
19

TOTAL
( sum of cols.
18 and 19 ()
20
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

(1) Columns 0 through 18, line 22 must agree with the corresponding columns of Worksheet B, Part I, line 73, (subscripted line).

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4153)

41-374

Rev. 4

11-12
ALLOCATION OF GENERAL SERVICE COSTS
TO COST CENTERS FOR CMHC

FORM CMS-2540-10
PROVIDER CCN:
COMPONENT CCN :

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

COMPONENT COST CENTER
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Respiratory Therapy
Psychiatric/Psychological Services
Individual Therapy
Group Therapy
Individualized Activity Therapy
Family Counseling
Diagnostic Services
App. Patient Training & Education
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies
Medical Appliances
Durable Medical Equipment - Rented
Durable Medical Equipment - Sold
All Other
Totals (sum of lines 1-21)
Total cost to be allocated
Unit Cost Multiplier

CAPITAL RELATED
MOVABLE
BUILDS.
EQUIPMENT
& FIXTURES
( Dollar Value or
( Square Feet )
Square Feet )
1
2

4190 (Cont.)
PERIOD :
FROM ______________
TO ________________

EMPLOYEE
BENEFITS
( Gross Salaries )
3

WORKSHEET J-1
PART II

RECONCILIATION
4A

ADMINISTRATIVE
& GENERAL
( Accumulated
Cost )
4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4153)

Rev. 4

41-375

4190 (Cont.)
ALLOCATION OF GENERAL SERVICE COSTS
TO COST CENTERS FOR CMHC

FORM CMS-2540-10

11-12

PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

COMPONENT CCN :

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

COMPONENT COST CENTER
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Respiratory Therapy
Psychiatric/Psychological Services
Individual Therapy
Group Therapy
Individualized Activity Therapy
Family Counseling
Diagnostic Services
App. Patient Training & Education
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies
Medical Appliances
Durable Medical Equipment - Rented
Durable Medical Equipment - Sold
All Other
Totals (sum of lines 1-21)
Total cost to be allocated
Unit Cost Multiplier

PLANT
OPERATION
MAINTENANCE
& REPAIRS
( Square Feet )
5

LAUNDRY
& LINEN
SERVICE
( Pounds of
Laundry )
6

HOUSE KEEPING
( Hours of
Service )
7

WORKSHEET J-1
PART II

DIETARY
( Meals
Served )
8

NURSING
ADMINISTRATION
( Direct Nursing
Hours of Service )
9
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4153)

41-376

Rev. 4

11-12

FORM CMS-2540-10

ALLOCATION OF GENERAL SERVICE COSTS
TO COST CENTERS FOR CMHC

4190 (Cont.)

PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

COMPONENT CCN :

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

COMPONENT COST CENTER
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Respiratory Therapy
Psychiatric/Psychological Services
Individual Therapy
Group Therapy
Individualized Activity Therapy
Family Counseling
Diagnostic Services
App. Patient Training & Education
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies
Medical Appliances
Durable Medical Equipment - Rented
Durable Medical Equipment - Sold
All Other
Totals (sum of lines 1-21)
Total cost to be allocated
Unit Cost Multiplier

CENTRAL
SERVICES
& SUPPLY
( Costed
Requisitions )
10

PHARMACY
( Costed
Requisitions )
11

MEDICAL
RECORDS &
LIBRARY
( Time Spent )
12

SOCIAL
SERVICES
( Time Spent )
13

WORKSHEET J-1
PART II

NURSING &
ALLIED
HEALTH
EDUCATION
( Assigned Time )
14

OTHER
GENERAL
SERVICE
(

)
15
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4153)

Rev. 4

41-377

4190 (Cont.)

FORM CMS-2540-10

COMPUTATION OF CMHC
REHABILITATION COSTS

11-12

PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

COMPONENT CCN :

PART I - APPORTIONMENT OF CMHC COST CENTERS
Total Costs
( from Wkst. J-1,
Pt. I, col. 20 )
1
1 Administrative and General
2 Skilled Nursing Care
3 Physical Therapy
4 Occupational Therapy
5 Speech Pathology
6 Medical Social Services
7 Respiratory Therapy
8 Psychiatric/Psychological Services
9 Individual Therapy
10 Group Therapy
11 Individualized Activity Therapy
12 Family Counseling
13 Diagnostic Services
14 App. Patient Training & Education
15 Prosthetic and Orthotic Devices
16 Drugs and Biologicals
17 Medical Supplies
18 Medical Appliances
19 Durable Medical Equipment - Rented
20 Durable Medical Equipment - Sold
21 All Other
22 Totals (sum of lines 2-21)

Total
Charges
2

Ratio of
Costs to
Charges
3

Title V
Charges
4

Costs
( col. 3 x col. 4 )
5

WORKSHEET J - 2
PART I

Title XVIII
Charges
6

Costs
( col. 3 x col. 6 )
7

Title XIX
Charges
8

Costs
( col. 3 x col. 8 )
9
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4154)

41-378

Rev. 4

05-13

FORM CMS-2540-10

COMPUTATION OF CMHC
REHABILITATION COSTS

4190 (Cont.)

PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

COMPONENT CCN:

PART II - APPORTIONMENT OF COST OF CMHC SERVICES FURNISHED BY SHARED DEPARTMENTS
Ratio of
Costs to
Charges
3
23 Oxygen (Inhalation) Therapy
24 Physical Therapy
25 Occupational Therapy
26 Speech Pathology
27 Medical Supplies Charged to Patients
28 Drugs Charged to Patients
29 Other Costs Furnished by shared Departments
30 Total (sum of lines 23 through 29)
31 Total component cost (sum of Pt. I, line 22 and Pt. II, line 30)
(Transfer to Wkst. J-3)

Title V
Charges
4

Costs
( col. 3 x col. 4 )
5

WORKSHEET J - 2
PART II

Title XVIII
Charges
6

Costs
( col. 3 x col. 6 )
7

Title XIX
Charges
8

Costs
( col. 3 x col. 8 )
9
23
24
25
26
27
28
29
30
31

(1) Part II - From Wkst. C, col. 3, lines as applicable

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4154)

Rev. 5

41-379

4190 (Cont.)

FORM CMS-2540-10

CALCULATION OF REIMBURSEMENT SETTLEMENT
OF COMMUNITY MENTAL HEALTH CENTER
PROVIDER SERVICES

Check applicable box:

[ ] Title V

[ ] Title XVIII

PROVIDER CCN:
COMPONENT CCN :

05-13
PERIOD :
FROM ______________
TO ________________

WORKSHEET J-3

[ ] Title XIX
PROGRAM
COST

1 Cost of component services (from Wkst. J-2, Pt. II, line 31)
2 PPS payments received excluding outliers
3 Outlier payments
4 Primary payer payments
5 Total reasonable cost (see instructions)
CUSTOMARY CHARGES
6 Total charges for program services
7 Excess of customary charges over reasonable cost (see instructions)
8 Excess of reasonable cost over customary charges (see instructions)
COMPUTATION OF REIMBURSEMENT SETTLEMENT
9 Total reasonable cost (see instructions)
10 Part B deductible billed to program patients
11 Part B coinsurance billed to program patients (from provider records)
12 Net cost (line 9 minus lines 10 and 11)
13 Reimbursable bad debts (from provider records) (see instructions)
13.01 Adjusted reimbursable bad debts (see instructions)
14 Reimbursable bad debts for dual eligible beneficiaries (see instructions)
15 Net reimbursable amount (see instructions)
16 Other adjustments (see instructions) (specify)
17 Total cost (line 15 plus or minus line 16)
17.01 Sequestration amount (see instructions)
18 Interim payments (see instructions)
19 Tentative settlement (for contractor use only)
20 Balance due component/program (line 17 minus lines 18 and 19)
21 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2

1
2
3
4
5
6
7
8
9
10
11
12
13
13.01
14
15
16
17
17.01
18
19
20
21

FORM CMS-2540-10 (05/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4155)

41-380

Rev. 5

11-12
ANALYSIS OF PAYMENTS TO
PROVIDER - BASED CMHC
FOR SERVICES RENDERED
TO PROGRAM BENEFICIARIES
Description
1 Total interim payments paid to provider
2 Interim payments payable on individual bills, either submitted
or to be submitted to the intermediary/contractor for services
rendered in the cost reporting period. If none, enter zero.
3 List separately each retroactive lump sum
adjustment amount based on subsequent revision of
the interim rate for the cost reporting period
Also show date of each payment.
If none, write "NONE," or enter a zero. (1)

FORM CMS-2540-10

mm/dd/yyyy
1

SUBTOTAL (sum of lines 5.01 - 5.49 minus sum of lines 5.50 - 5.98)
6 Determine net settlement amount (balance
due) based on the cost report (1)
7 TOTAL MEDICARE PROGRAM LIABILITY (see instructions)
8 Name of Contractor

WORKSHEET J - 4

Amount
2
1
2

Program
to
Provider

SUBTOTAL (sum of lines 3.01 - 3.49 minus sum of lines 3.50 - 3.98)
4 TOTAL INTERIM PAYMENTS (sum of lines 1, 2, and 3.99)
(Transfer to Wkst. J-3: Pt. I, line 18)

Also show date of each payment.
If none, write "NONE," or enter a zero. (1)

PERIOD :
FROM ______________
TO ________________

COMPONENT CCN :

Provider
to
Program

TO BE COMPLETED BY CONTRACTOR
5 List separately each tentative
settlement payment after desk review.

4190 (Cont.)

PROVIDER CCN:

Program
to
Provider
Provider
to
Program
Program to Provider
Provider to Program

.01
.02
.03
.04
.05
.50
.51
.52
.53
.54
.99

3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54
3.99
4

.01
.02
.03
.50
.51
.52
.99
.01
.02

5.01
5.02
5.03
5.50
5.51
5.52
5.99
6.01
6.02
7
8

Contractor Number

(1) On lines 3, 5, and 6, where an amount is due "Provider to Program," show the amount and date on which the
provider agrees to the amount of repayment, even though total repayment is not accomplished until a later date.

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4156)

Rev. 4

41-381

4190 (Cont.)

FORM CMS-2540-10

ANALYSIS OF PROVIDER - BASED HOSPICE COSTS

11-12
PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

HOSPICE CCN :

COST CENTER DESCRIPTIONS
GENERAL SERVICE COST CENTERS
1 Capital Related Costs-Bldg and Fixt.
2 Capital Related Costs-Movable Equip.
3 Plant Operation and Maintenance
4 Transportation - Staff
5 Volunteer Service Coordination
6 Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
11 Nursing Care-Continuous Home Care
12 Physical Therapy
13 Occupational Therapy
14 Speech/ Language Pathology
15 Medical Social Services
16 Spiritual Counseling
17 Dietary Counseling
18 Counseling - Other
19 Home Health Aide and Homemaker
20 HH Aide & Homemaker-Cont. Home Care
21 Other
OTHER HOSPICE SERVICE COSTS
22 Drugs, Biological and Infusion Therapy
23 Analgesics
24 Sedatives / Hypnotics
25 Other - Specify
26 Durable Medical Equipment/Oxygen
27 Patient Transportation
28 Imaging Services
29 Labs and Diagnostics
30 Medical Supplies
31 Outpatient Services (including E/R Dept.)
32 Radiation Therapy
33 Chemotherapy
34 Other
HOSPICE NONREIMBURSABLE SERVICE
35 Bereavement Program Costs
36 Volunteer Program Costs
37 Fundraising
38 Other Program Costs
39 Total (sum of lines 1 through 38)

SALARIES
( from
Wkst. K-1 )
1

EMPLOYEE
BENEFITS
( from
Wkst. K-2 )
2

TRANSPORTATION
( see instruc. )
3

CONTRACTED
SERVICES
( from
Wkst. K-3 )
4

OTHER
5

TOTAL
( cols. 1
through 5 )
6

RECLASSIFICATION
7

SUBTOTAL
( col. 6
± col. 7 )
8

ADJUSTMENTS
9

WORKSHEET K

TOTAL
( col. 8
± col. 9 )
10
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4157)

41-382

Rev. 4

11-12

FORM CMS-2540-10

HOSPICE COMPENSATION ANALYSIS
SALARIES AND WAGES

4190 (Cont.)
PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

HOSPICE CCN :

COST CENTER DESCRIPTIONS
GENERAL SERVICE COST CENTERS
1 Capital Related Costs-Bldg and Fixt.
2 Capital Related Costs-Movable Equip.
3 Plant Operation and Maintenance
4 Transportation - Staff
5 Volunteer Service Coordination
6 Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
11 Nursing Care-Continuous Home Care
12 Physical Therapy
13 Occupational Therapy
14 Speech/ Language Pathology
15 Medical Social Services
16 Spiritual Counseling
17 Dietary Counseling
18 Counseling - Other
19 Home Health Aide and Homemaker
20 HH Aide & Homemaker-Cont. Home Care
21 Other
OTHER HOSPICE SERVICE COSTS
22 Drugs, Biological and Infusion Therapy
23 Analgesics
24 Sedatives / Hypnotics
25 Other - Specify
26 Durable Medical Equipment/Oxygen
27 Patient Transportation
28 Imaging Services
29 Labs and Diagnostics
30 Medical Supplies
31 Outpatient Services (including E/R Dept.)
32 Radiation Therapy
33 Chemotherapy
34 Other
HOSPICE NONREIMBURSABLE SERVICE
35 Bereavement Program Costs
36 Volunteer Program Costs
37 Fundraising
38 Other Program Costs
39 Total (sum of lines 1 through 38)

ADMINISTRATOR
1

DIRECTOR
2

SOCIAL
SERVICES
3

SUPERVISORS
4

NURSES
5

TOTAL
THERAPISTS
6

AIDES
7

ALL OTHER
8

WORKSHEET K-1

TOTAL (1)
9
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39

(1) Transfer the amount in column 9 to Wkst. K, col. 1

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4158)

Rev. 4

41-383

4190 (Cont.)

FORM CMS-2540-10

HOSPICE COMPENSATION ANALYSIS
EMPLOYEE BENEFITS (PAYROLL RELATED)

11-12
PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

HOSPICE CCN :

COST CENTER DESCRIPTIONS
GENERAL SERVICE COST CENTERS
1 Capital Related Costs-Bldg and Fixt.
2 Capital Related Costs-Movable Equip.
3 Plant Operation and Maintenance
4 Transportation - Staff
5 Volunteer Service Coordination
6 Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
11 Nursing Care-Continuous Home Care
12 Physical Therapy
13 Occupational Therapy
14 Speech/ Language Pathology
15 Medical Social Services
16 Spiritual Counseling
17 Dietary Counseling
18 Counseling - Other
19 Home Health Aide and Homemaker
20 HH Aide & Homemaker-Cont. Home Care
21 Other
OTHER HOSPICE SERVICE COSTS
22 Drugs, Biological and Infusion Therapy
23 Analgesics
24 Sedatives / Hypnotics
25 Other - Specify
26 Durable Medical Equipment/Oxygen
27 Patient Transportation
28 Imaging Services
29 Labs and Diagnostics
30 Medical Supplies
31 Outpatient Services (including E/R Dept.)
32 Radiation Therapy
33 Chemotherapy
34 Other
HOSPICE NONREIMBURSABLE SERVICE
35 Bereavement Program Costs
36 Volunteer Program Costs
37 Fundraising
38 Other Program Costs
39 Total (sum of lines 1 through 38)

ADMINISTRATOR
1

DIRECTOR
2

SOCIAL
SERVICES
3

SUPERVISORS
4

NURSES
5

TOTAL
THERAPISTS
6

AIDES
7

ALL OTHER
8

WORKSHEET K-2

TOTAL (1)
9
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39

(1) Transfer the amounts in column 9 to Wkst. K, col. 2

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4159)

41-384

Rev. 4

11-12

FORM CMS-2540-10

HOSPICE COMPENSATION ANALYSIS
CONTRATED SERVICES / PURCHASED SERVICES

4190 (Cont.)
PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

HOSPICE CCN :

COST CENTER DESCRIPTIONS
GENERAL SERVICE COST CENTERS
1 Capital Related Costs-Bldg and Fixt.
2 Capital Related Costs-Movable Equip.
3 Plant Operation and Maintenance
4 Transportation - Staff
5 Volunteer Service Coordination
6 Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
11 Nursing Care-Continuous Home Care
12 Physical Therapy
13 Occupational Therapy
14 Speech/ Language Pathology
15 Medical Social Services
16 Spiritual Counseling
17 Dietary Counseling
18 Counseling - Other
19 Home Health Aide and Homemaker
20 HH Aide & Homemaker-Cont. Home Care
21 Other
OTHER HOSPICE SERVICE COSTS
22 Drugs, Biological and Infusion Therapy
23 Analgesics
24 Sedatives / Hypnotics
25 Other - Specify
26 Durable Medical Equipment/Oxygen
27 Patient Transportation
28 Imaging Services
29 Labs and Diagnostics
30 Medical Supplies
31 Outpatient Services (including E/R Dept.)
32 Radiation Therapy
33 Chemotherapy
34 Other
HOSPICE NONREIMBURSABLE SERVICE
35 Bereavement Program Costs
36 Volunteer Program Costs
37 Fundraising
38 Other Program Costs
39 Total (sum of lines 1 through 38)

ADMINIS
TRATOR
1

DIRECTOR
2

SOCIAL
SERVICES
3

SUPERVISORS
4

NURSES
5

TOTAL
THERAPISTS
6

AIDES
7

ALL OTHER
8

WORKSHEET K-3

TOTAL (1)
9
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39

(1) Transfer the amounts in column 9 to Wkst. K, col. 4

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4160)

Rev. 4

41-385

4190 (Cont.)

FORM CMS-2540-10

COST ALLOCATION - HOSPICE
GENERAL SERVICE COST

11-12
PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

HOSPICE CCN :

COST CENTER DESCRIPTIONS
GENERAL SERVICE COST CENTERS
1 Capital Related Costs-Bldg and Fixt.
2 Capital Related Costs-Movable Equip.
3 Plant Operation and Maintenance
4 Transportation - Staff
5 Volunteer Service Coordination
6 Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
11 Nursing Care-Continuous Home Care
12 Physical Therapy
13 Occupational Therapy
14 Speech/ Language Pathology
15 Medical Social Services
16 Spiritual Counseling
17 Dietary Counseling
18 Counseling - Other
19 Home Health Aide and Homemaker
20 HH Aide & Homemaker-Cont. Home Care
21 Other
OTHER HOSPICE SERVICE COSTS
22 Drugs, Biological and Infusion Therapy
23 Analgesics
24 Sedatives / Hypnotics
25 Other - Specify
26 Durable Medical Equipment/Oxygen
27 Patient Transportation
28 Imaging Services
29 Labs and Diagnostics
30 Medical Supplies
31 Outpatient Services (including E/R Dept.)
32 Radiation Therapy
33 Chemotherapy
34 Other
HOSPICE NONREIMBURSABLE SERVICE
35 Bereavement Program Costs
36 Volunteer Program Costs
37 Fundraising
38 Other Program Costs
39 Total (sum of lines 1 through 38)

NET EXPENSES
FOR COST
ALLOC. (1)
( from
Wkst. K, col. 10 )
0

CAPITAL RELATED COST
BUILDS. &
MOVABLE
FIXTURES
EQUIPMENT
1
2

PLANT
OPERATION
& MAINT.
3

TRANSPORTATION
4

VOLUNTEER
SERVICE
COORDINATOR
5

SUBTOTAL
( cols. 0
through 5 )
5A

ADMINISTRATIVE &
GENERAL
6

WORKSHEET K-4
PART I

TOTAL
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4161)

41-386

Rev. 4

11-12

FORM CMS-2540-10

COST ALLOCATION - HOSPICE
STATISTICAL BASIS

4190 (Cont.)
PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

HOSPICE CCN :

COST CENTER DESCRIPTIONS
GENERAL SERVICE COST CENTERS
1 Capital Related Costs-Bldg and Fixt.
2 Capital Related Costs-Movable Equip.
3 Plant Operation and Maintenance
4 Transportation - Staff
5 Volunteer Service Coordination
6 Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
11 Nursing Care-Continuous Home Care
12 Physical Therapy
13 Occupational Therapy
14 Speech/ Language Pathology
15 Medical Social Services
16 Spiritual Counseling
17 Dietary Counseling
18 Counseling - Other
19 Home Health Aide and Homemaker
20 HH Aide & Homemaker-Cont. Home Care
21 Other
OTHER HOSPICE SERVICE COSTS
22 Drugs, Biological and Infusion Therapy
23 Analgesics
24 Sedatives / Hypnotics
25 Other - Specify
26 Durable Medical Equipment/Oxygen
27 Patient Transportation
28 Imaging Services
29 Labs and Diagnostics
30 Medical Supplies
31 Outpatient Services (including E/R Dept.)
32 Radiation Therapy
33 Chemotherapy
34 Other
HOSPICE NONREIMBURSABLE SERVICE
35 Bereavement Program Costs
36 Volunteer Program Costs
37 Fundraising
38 Other Program Costs
39 Cost to be allocated (per Wkst. K-4, Pt. I)
40 Unit Cost Multiplier

CAPITAL RELATED COST
MOVABLE
BUILDS.
EQUIPMENT
& FIXTURES
( Dollar Value or
( Square Feet )
Square Feet )
1
2

PLANT
OPERATION
& MAINT.
( Square Feet )
3

TRANSPORTATION
( Mileage )
4

VOLUNTEER
SERVICE
COORDINATOR
( Hours )
5

RECONCILIATION
6A

ADMINISTRATIVE &
GENERAL
( Accumulated
Cost )
6

WORKSHEET K-4
PART II

TOTAL
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4161)

Rev. 4

41-387

4190 (Cont.)

FORM CMS-2540-10

ALLOCATION OF GENERAL SERVICE
COSTS TO HOSPICE COST CENTERS

PROVIDER CCN:
HOSPICE CCN :

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

HOSPICE COST CENTER (1)
Administrative and General
Inpatient - General Care
Inpatient - Respite Care
Physician Services
Nursing Care
Nursing Care- Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services - Direct
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemakers
HH Aide & Homemaker - Cont. Home Care
Other
Drugs, Biologicals and Infusion
Analgesics
Sedative/Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (incl. E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1 through 33)
Unit Cost Multiplier

From
Wkst. K-4,
Pt. I,
col. 7,
line 6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38

HOSPICE
TRIAL
BALANCE
0

CAPITAL RELATED
BLDGS. &
MOVABLE
FIXTURES
EQUIPMENT
1
2

11-12
PERIOD :
FROM ______________
TO ________________

EMPLOYEE
BENEFITS
3

WORKSHEET K-5,
PART I

SUBTOTAL
( cols. 0
through 3 )
3A

ADMINISTRATIVE &
GENERAL
4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

(1) Columns 0 through 16, line 34 must agree with the corresponding columns of Wkst. B, Part I, line 83.

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4162)

41-388

Rev. 4

11-12

FORM CMS-2540-10

ALLOCATION OF GENERAL SERVICE
COSTS TO HOSPICE COST CENTERS

4190 (Cont.)

PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

HOSPICE CCN :

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

HOSPICE COST CENTER (1)
Administrative and General
Inpatient - General Care
Inpatient - Respite Care
Physician Services
Nursing Care
Nursing Care- Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services - Direct
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemakers
HH Aide & Homemaker - Cont. Home Care
Other
Drugs, Biologicals and Infusion
Analgesics
Sedative/Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (incl. E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1 through 33)
Unit Cost Multiplier

PLANT
OPERATION
MAINTENANCE
& REPAIRS
5

LAUNDRY
& LINEN
SERVICE
6

HOUSEKEEPING
7

DIETARY
8

NURSING
ADMINISTRATION
9

WORKSHEET K-5
Part I

CENTRAL
SERVICES &
SUPPLY
10

PHARMACY
11
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

(1) Columns 0 through 16, line 34 must agree with the corresponding columns of Wkst. B, Part I, line 83.

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4162)

Rev. 4

41-389

4190 (Cont.)

FORM CMS-2540-10

ALLOCATION OF GENERAL SERVICE
COSTS TO HOSPICE COST CENTERS

11-12

PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

HOSPICE CCN :

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

HOSPICE COST CENTER (1)
Administrative and General
Inpatient - General Care
Inpatient - Respite Care
Physician Services
Nursing Care
Nursing Care- Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services - Direct
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemakers
HH Aide & Homemaker - Cont. Home Care
Other
Drugs, Biologicals and Infusion
Analgesics
Sedative/Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (incl. E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1 through 33)
Unit Cost Multiplier

MEDICAL
RECORDS &
LIBRARY
12

SOCIAL
SERVICE
13

NURSING &
ALLIED
HEALTH
EDUCATION
14

OTHER
GENERAL
SERVICE
15

SUBTOTAL
( sum of cols.
3A through 15 )
16

WORKSHEET K-5
Part I

ALLOCATED
HOSPICE A & G
( see Pt. II )
17

TOTAL
HOSPICE
COSTS
18
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

(1) Columns 0 through 16, line 34 must agree with the corresponding columns of Wkst. B, Part I, line 83.

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4162)

41-390

Rev. 4

11-12
ALLOCATION OF GENERAL SERVICE COSTS
TO HOSPICE COST CENTERS - STATISTICAL BASIS

FORM CMS-2540-10

4190 (Cont.)

PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

HOSPICE CCN :

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36

HOSPICE COST CENTER (1)
Administrative and General
Inpatient - General Care
Inpatient - Respite Care
Physician Services
Nursing Care
Nursing Care- Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services - Direct
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemakers
HH Aide & Homemaker - Cont. Home Care
Other
Drugs, Biologicals and Infusion
Analgesics
Sedative/Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (incl. E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1 through 33)
Total cost to be allocated
Unit Cost Multiplier

CAPITAL
RELATED
BLDGS. &
FIXTURES
( Square Feet )
1

CAPITAL
RELATED
MOVABLE
EQUIPMENT
( Dollar Value )
2

EMPLOYEE
BENEFITS
( Gross Salaries )
3

WORKSHEET K-5,
PART II

RECONCILIATION
4A

ADMINISTRATIVE &
GENERAL
( Accumulated
Cost )
4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4162)

Rev. 4

41-391

4190 (Cont.)

FORM CMS-2540-10

ALLOCATION OF GENERAL SERVICE COSTS
TO HOSPICE COST CENTERS - STATISTICAL BASIS

PROVIDER CCN:
HOSPICE CCN :

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36

HOSPICE COST CENTER (1)
Administrative and General
Inpatient - General Care
Inpatient - Respite Care
Physician Services
Nursing Care
Nursing Care- Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services - Direct
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemakers
HH Aide & Homemaker - Cont. Home Care
Other
Drugs, Biologicals and Infusion
Analgesics
Sedative/Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (incl. E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1 through 33)
Total cost to be allocated
Unit Cost Multiplier

PLANT
OPERATION
MAINTENANCE
& REPAIRS
( Square Feet )
5

LAUNDRY
& LINEN
SERVICE
( Pounds of
Laundry )
6

11-12
PERIOD :
FROM ______________
TO ________________

HOUSE
KEEPING
( Hours of
Service )
7

DIETARY
( Meals Served )
8

WORKSHEET K-5
PART II

NURSING
ADMINISTRATION
( Direct Nursing
Hours )
9

CENTRAL
SERVICES &
SUPPLY
( Costed
Requisitions )
10

PHARMACY
( Costed
Requisitions )
11
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4162)

41-392

Rev. 4

11-12

FORM CMS-2540-10

ALLOCATION OF GENERAL SERVICE COSTS
TO HOSPICE COST CENTERS - STATISTICAL BASIS

4190 (Cont.)

PROVIDER CCN:

PERIOD :
FROM ______________
TO ________________

HOSPICE CCN :

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36

HOSPICE COST CENTER (1)
Administrative and General
Inpatient - General Care
Inpatient - Respite Care
Physician Services
Nursing Care
Nursing Care- Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services - Direct
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemakers
HH Aide & Homemaker - Cont. Home Care
Other
Drugs, Biologicals and Infusion
Analgesics
Sedative/Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (incl. E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1 through 33)
Total cost to be allocated
Unit Cost Multiplier

MEDICAL
RECORDS &
LIBRARY
( Time Spent )
12

SOCIAL
SERVICE
( Time Spent )
13

NURSING &
ALLIED
HEALTH
EDUCATION
( Assigned Time )
14

OTHER
GENERAL
SERVICE
( Specify )
15

SUBTOTAL
16

WORKSHEET K-5
PART II

ALLOCATED
HOSPICE A&G
17

TOTAL
HOSPICE
COSTS
18
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4162)

Rev. 4

41-393

4190 (Cont.)

FORM CMS-2540-10

APPORTIONMENT OF HOSPICE SHARED SERVICES

PROVIDER CCN:
HOSPICE CCN :

11-12
PERIOD :
FROM ______________
TO ________________

WORKSHEET K-5
Part III

PART III - COMPUTATION OF TOTAL HOSPICE SHARED COSTS

COST CENTER
ANCILLARY SERVICE COST CENTERS
1 Physical Therapy
2 Occupational Therapy
3 Speech/ Language Pathology
4 Drugs, Biologicals and Infusion
5 Labs and Diagnostics
6 Medical Supplies
7 Radiation Therapy
8 Other
9 Total (sum of lines 1-8)

Wkst. C,
col. 3,
line:
0

Cost to
Charge
Ratio
1

Total Hospice
Charges
( from provider records )
2

44
45
46
49
41
48
40
52

Hospice Shared
Ancillary Costs
( col. 1 x col. 2 )
3
1
2
3
4
5
6
7
8
9

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4162)

41-394

Rev. 4

11-12

FORM CMS-2540-10

CALCULATION OF PER DIEM COST

PROVIDER CCN:
HOSPICE CCN :

Tittle XVIII
1

Title XIX
2

4190 (Cont.)
PERIOD :
FROM ______________
TO ________________

Other
3

1 Total cost
(see instructions)
2 Total unduplicated days
(Wkst. S-8, line 5, col. 6)
3 Average cost per diem
(line 1 divided by line 2)
4 Unduplicated Medicare days
(Wkst. S-8, line 5, col. 1)
5 Average Medicare cost
(line 3 times line 4)
6 Unduplicated Medicaid days
(Wkst. S-8, line 5, col. 2)
7 Average Medicaid cost
(line 3 times line 6)
8 Unduplicated SNF days
(Wkst. S-8, line 5, col. 3)
9 Average SNF cost
(line 3 times line 8)
10 Unduplicated NF days
(Wkst. S-8, line 5, col. 4)
11 Average NF cost
(line 3 times line 10)
12 Other unduplicated days
(Wkst. S-8, line 5, col. 5)
13 Average cost for other days
(line 3 times line 12)

WORKSHEET K-6

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

FORM CMS 2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4163)

Rev. 4

41-395
File Type	application/pdf
File Modified	2014-06-18
File Created	2014-06-18