CMS-2540-10 Cost Report

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

CMS-2540-10_Cost_Report.xlsx

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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Overview

S
S2-I
S2-II
S3-I
S-3 II&III
S3-IV
S3-V
S4
S5
S6
S7
S8
A
A6
A7
A8
A81
A82
BI
B1
BII
B2
C
DI
DII&III
D1
EI
EII
E1
G
GP2
G1
G2
G3
H
H1-I
H1-II
H2-I
H2-II
H3
H4
H5
I1
I2
I3
I4
I5
J1-I
J1-II
J2
J3
J4
K
K1
K2
K3
K4-I
K4-II
K5-I
K5-II
K5-III
K6
O
O1
O2
O3
O4
O5
O6I
O6II
O7
O8

Sheet 1: S
DRAFT






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











FORM APPROVED
payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).











OMB NO. 0938-0463
SKILLED NURSING FACILITY AND SKILLED NURSING





PROVIDER CCN:

PERIOD :
WORKSHEET S
FACILITY HEALTH CARE COMPLEX COST REPORT








FROM ______________
PARTS I, II & III
CERTIFICATION AND SETTLEMENT SUMMARY








TO ________________












































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 A
B TITLE XIX







1
2
3
1 SKILLED NURSING FACILITY










1
2 NURSING FACILITY










2
3 I C F / IID










3
4 SNF - BASED HHA










4
5 SNF - BASED RHC










5
6 SNF - BASED FQHC










6
7 SNF - BASED CMHC










7
100 TOTAL










100
The above amounts represent "due to" or "due from" the applicable Program for the element of the above complex indicated.


























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.












Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that












any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed,












forwarded, or retained. If you have questions or concerns regarding where to submit your documents , please contact 1-800-MEDICARE.






































































































































































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


























Rev.











41-303

Sheet 2: S2-I
4190 (Cont.)




FORM CMS-2540-10





DRAFT
SKILLED NURSING FACILITY AND SKILLED NURSING





PROVIDER CCN:
PERIOD :
WORKSHEET S-2


FACILITY HEALTH CARE COMPLEX







FROM ______________
PART I


IDENTIFICATION DATA







TO ________________


































Skilled Nursing Facility and Skilled Nursing Facility Complex Address:













1 Street:


P.O. Box:






1
2 City:


State:
ZIP Code




2
3 County:


CBSA Code:
Urban / Rural:




3















SNF and SNF - Based Component Identification:
























Payment System










Provider Date
(P, O or N)




Component


Component Name
CCN Certified V XVIII XIX



0


1
2 3 4 5 6

4 S N F










4
5 Nursing Facility










5
6 I C F/IID










6
7 SNF-Based HHA










7
8 SNF-Based RHC










8
9 SNF-Based FQHC










9
10 SNF-Based CMHC










10
11 SNF-Based OLTC










11
12 SNF-Based HOSPICE










12
13 OTHER (specify)










13
14 Cost Reporting Period (mm/dd/yyyy)

From:
To:





14
15 Type of Control (see instructions)










15















Type of Freestanding Skilled Nursing Facility






Y / N





16 Is this a distinct part skilled nursing facility that meets the requirements set forth in 42 CFR section 483.5?










16
17 Is this a composite distinct part skilled nursing facility that meets the requirements set forth in 42 CFR section 483.5?










17
18 Are there any costs included in Worksheet A that resulted from transactions with related










18

organizations as defined in CMS Pub. 15-1, chapter 10? If yes, complete Worksheet A-8-1.



























Miscellaneous Cost Reporting Information













19 Is this a low Medicare utilization cost report, enter "Y" for yes or "N" for no.










19
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)










19.01















Depreciation - Enter the amount of depreciation reported in this SNF for the method indicated on lines 20 - 22.













20 Straight Line










20
21 Declining Balance










21
22 Sum of the Year's Digits










22
23 Sum of line 20 through 22










23
24 If depreciation is funded, enter the balance as of the end of the period.










24
25 Were there any disposal of capital assets during the cost reporting period? (Y/N)










25
26 Was accelerated depreciation claimed on any assets in the current or any prior cost reporting period? (Y/N)










26
27 Did you cease to participate in the Medicare program at end of the period to which this cost report applies? (Y?N)










27
28 Was there a substantial decrease in health insurance proportion of allowable cost from prior cost reports? (Y/N)










28







































































































































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




























41-304











Rev.
11-12




FORM CMS-2540-10





4190 (Cont.)
SKILLED NURSING FACILITY AND SKILLED NURSING





PROVIDER CCN:
PERIOD
WORKSHEET S-2


FACILITY HEALTH CARE COMPLEX







FROM_____________
PART I


IDENTIFICATION DATA







TO_____________



















If this facility contains a public or non-public provider that qualifies for an exemption from the application of the lower of








Part Part


costs or charges, enter "Y" for each component and type of service that qualifies for the exemption.








A B Other

29 Skilled Nursing Facility










29
30 Nursing Facility










30
31 I C F/IID










31
32 SNF-Based HHA










32
33 SNF-Based RHC










33
34 SNF-Based FQHC










34
35 SNF-Based CMHC










35
36 SNF-Based OLTC










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)










37
38 Are you legally required to carry malpractice insurance? (Y/N)










38
39 Is the malpractice a "claims-made" or "occurrence" policy? If the policy is "claims-made," enter 1. If the policy is "occurrence", enter 2.










39






















Premiums Paid Losses Self insurance

41 List malpractice premiums and paid losses:










41























Y / N





42 Are malpractice premiums and paid losses reported in other than the Administrative and General cost center?










42

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?










43
44 If line 43 = "Y", and there are costs for the home office, enter the applicable home office chain number in column 1.










44















If this facility is part of a chain organization, enter the name and address of the home office on the lines below.













45 Name:




Contractor Name:

Contractor Number:

45
46 Street:
P.O. Box:








46
47 City
State
ZIP Code






47
























































































































































































































































































































































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




























Rev. 4











41-305

Sheet 3: S2-II
4190 (Cont.)


FORM CMS-2540-10




11-12
SKILLED NURSING FACILITY AND SKILLED NURSING


PROVIDER CCN:
PERIOD :
WORKSHEET S-2
FACILITY HEALTH CARE COMPLEX




FROM ______________
PART II
REIMBURSEMENT QUESTIONNAIRE




TO ________________














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 Date
Provider Organization and Operation






1 2
1 Has the provider changed ownership immediately prior to the beginning of the cost reporting period?







1

If column 1 is "Y", enter the date of the change in column 2. (see instructions)


























Y/N Date V/I







1 2 3
2 Has the provider terminated participation in the Medicare Program? If column 1 is "Y",







2

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







3

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)


























Y/N Type Date
Financial Data and Reports





1 2 3
4 Column 1: Were the financial statements prepared by a Certified Public Accountant? (Y/N)







4

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







5

statements? If column 1 is "Y", submit reconciliation.



























Y/N Y/N
Approved Educational Activities






1 2
6 Column 1: Were costs claimed for nursing school? (Y/N)







6

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)







7
8 Were approvals and/or renewals obtained during the cost reporting period for nursing school and/or







8

allied health program? (Y/N) (see instructions)




























Y/N
Bad Debts







1
9 Is the provider seeking reimbursement for bad debts? (Y/N) (see instructions)







9
10 If line 9 is "Y", did the provider's bad debt collection policy change during this cost reporting period? If "Y", submit copy.







10
11 If line 9 is "Y", are patient deductibles and/or coinsurance waived? If "Y", see instructions.







11











Bed Complement









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







12

















Y/N Date Y/N Date






Part A Part A Part B Part B
PS&R Report Data




1 2 3 4
13 Was the cost report prepared using the PS&R only?







13

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







14

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







15

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.







16
17 If line 13 or 14 is "Y", were adjustments made to PS&R data for Other?







17

Describe the other adjustments:________________________________








18 Was the cost report prepared only using the provider's records? If "Y", see instructions.







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

Sheet 4: S3-I
DRAFT




FORM CMS-2540-10






4190 (Cont.)
SKILLED NURSING FACILITY AND






PROVIDER CCN:
PERIOD :
WORKSHEET S-3

SKILLED NURSING FACILITY HEALTH CARE COMPLEX








FROM ______________
PART I

STATISTICAL DATA








TO ________________



































Number Bed

Inpatient Days / Visits



Discharges




of Days Title Title Title

Title Title Title



Component Beds Available V XVIII XIX Other Total V XVIII XIX Other Total


1 2 3 4 5 6 7 8 9 10 11 12
1 Skilled Nursing Facility











1
2 Nursing Facility











2
3 ICF / IID











3
4 Home Health Agency











4
5 Other Long Term Care











5
6 SNF-Based CMHC











6
7 Hospice











7
8 Total (sum of lines 1-7)











8

























































Full Time


Average Length of Stay Admissions Equivalent



Title Title Title
Title Title Title

Employees Nonpaid

Component
V XVIII XIX Total V XVIII XIX Other Total on Payroll Workers



13 14 15 16 17 18 19 20 21 22 23
1 Skilled Nursing Facility











1
2 Nursing Facility











2
3 ICF / IID











3
4 Home Health Agency











4
5 Other Long Term Care











5
6 SNF-Based CMHC











6








































































































































































































































































































































































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




























Rev.












41-307

Sheet 5: S-3 II&III
4190 (Cont.)
FORM CMS-2540-10



DRAFT
SNF WAGE INDEX INFORMATION
PROVIDER CCN:
PERIOD :
WORKSHEET S-3




FROM ______________
PARTS II & III




TO ________________










PART II - DIRECT SALARIES









Reclass. Adjusted Paid Hours Average



of Salaries Salaries Related Hourly Wage


Amount from Wkst. ( col. 1 ± to Salary ( col. 3 ÷


Reported A-6 col. 2 ) in col. 3 col. 4 )


1 2 3 4 5
SALARIES






1 Total salary (see instructions)




1
2 Physician salaries-Part A




2
3 Physician salaries-Part B




3
4 Home office personnel




4
5 Sum of lines 2 through 4




5
6 Revised wages (line 1 minus line 5)




6
7 Other Long Term Care




7
8 Home Health Agency




8
9 CMHC




9
10 Hospice




10
11 Other excluded areas




11
12 Subtotal excluded salary (sum of lines 7 through 11)




12
13 Total adjusted salaries (line 6 minus line 12)




13
OTHER WAGES AND RELATED COSTS






14 Contract Labor: Patient Related & Mgmt.




14
15 Contract Labor: Physician services-Part A




15
16 Home office salaries & wage related costs




16
WAGE RELATED COSTS






17 Wage related costs core (see Pt. IV)




17
18 Wage related costs other (see Pt. IV)




18
19 Wage related costs (excluded units)




19
20 Physicians Part A - WRC




20
21 Physicians Part B - WRC




21
22 Total adjusted wage related cost (see instructions)




22
















PART III - OVERHEAD COST - DIRECT SALARIES









Reclass. Adjusted Paid Hours Average



of Salaries Salaries Related Hourly Wage


Amount from ( col. 1 ± to Salary ( col. 3 ÷


Reported Wkst. A-6 col. 2 ) in col. 3 col. 4 )


1 2 3 4 5
1 Employee Benefits




1
2 Administrative & General




2
3 Plant Operation, Maintenance & Repairs




3
4 Laundry & Linen Service




4
5 Housekeeping




5
6 Dietary




6
7 Nursing Administration




7
8 Central Services and Supply




8
9 Pharmacy




9
10 Medical Records & Medical Records Library




10
11 Social Service




11
12 Nursing and Allied Health Ed. Act.




12
13 Other General Service (specify _______________)




13
14 Total (sum lines 1 through 13)




14
























































































































































FORM CMS-2540-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4105.2 & 4105.3)














41-308





Rev.

Sheet 6: S3-IV
DRAFT
FORM CMS-2540-10

4190 (Cont.)
SNF WAGE RELATED COSTS

PROVIDER CCN: PERIOD : WORKSHEET S-3




FROM ______________ PART IV




TO ________________
Part A - Core List



Amount





Reported
RETIREMENT COST





1 401k Employer Contributions



1
2 Tax Sheltered Annuity (TSA) Employer Contribution



2
3 Qualified and Non-Qualified Pension Plan Cost



3
4 Prior Year Pension Service Cost



4
PLAN ADMINISTRATIVE COSTS (Paid to External Organizations)





5 401K/TSA Plan Administration fees



5
6 Legal/Accounting/Management Fees-Pension Plan



6
7 Employee Managed Care Program Administration Fees



7
HEALTH AND INSURANCE COST





8 Health Insurance (Purchased or Self Funded)



8
9 Prescription Drug Plan



9
10 Dental, Hearing and Vision Plan



10
11 Life Insurance (If employee is owner or beneficiary)



11
12 Accidental Insurance (If employee is owner or beneficiary)



12
13 Disability Insurance (If employee is owner or beneficiary)



13
14 Long-Term Care Insurance (If employee is owner or beneficiary)



14
15 Workers' Compensation Insurance



15
16 Retirement Health Care Cost (Only current year, not the extraordinary



16

accrual required by FASB 106 Non cumulative portion)




TAXES




17 FICA - Employers Portion Only



17
18 Medicare Taxes - Employers Portion Only



18
19 Unemployment Insurance



19
20 State or Federal Unemployment Taxes



20
OTHER





21 Executive Deferred Compensation



21
22 Day Care Cost and Allowances



22
23 Tuition Reimbursement



23
24 Total Wage Related cost (sum of lines 1 -23)



24
Part B Other than Core Related Cost



Amount





Reported
25 Other Wage Related Costs (specify)_________________________________________



25




























































































































































































































































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












Rev.




41-309

Sheet 7: S3-V
4190 (Cont.)
FORM CMS-2540-10



DRAFT
SNF REPORTING OF DIRECT CARE
PROVIDER CCN:
PERIOD :
WORKSHEET S-3
EXPENDITURES


FROM ______________
PART V




TO ________________






Adjusted Paid Hours Average




Salaries Related Hourly Wage


Amount Fringe ( col. 1 + to Salary ( col. 3 ÷


Reported Benefits col. 2 ) in col. 3 col. 4 )

OCCUPATIONAL CATEGORY 1 2 3 4 5
Direct Salaries







Nursing Occupations





1 Registered Nurses (RNs)




1
2 Licensed Practical Nurses (LPNs)




2
3 Certified Nursing Assistants/Nursing Assistants/Aides




3
4 Total Nursing (sum of lines 1 through 3)




4
5 Physical Therapists




5
6 Physical Therapy Assistants




6
7 Physical Therapy Aides




7
8 Occupational Therapists




8
9 Occupational Therapy Assistants




9
10 Occupational Therapy Aides




10
11 Speech Therapists




11
12 Respiratory Therapists




12
13 Other Medical Staff




13
Contract Labor







Nursing Occupations





14 Registered Nurses (RNs)




14
15 Licensed Practical Nurses (LPNs)




15
16 Certified Nursing Assistants/Nursing Assistants/Aides




16
17 Total Nursing (sum of lines 14 through 16)




17
18 Physical Therapists




18
19 Physical Therapy Assistants




19
20 Physical Therapy Aides




20
21 Occupational Therapists




21
22 Occupational Therapy Assistants




22
23 Occupational Therapy Aides




23
24 Speech Therapists




24
25 Respiratory Therapists




25
26 Other Medical Staff




26








































































































































































































































































































FORM CMS-2540-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4105.5)














41-309.1





Rev.











































































































































































































This page intentionally left blank.



Sheet 8: S4
4190 (Cont.)

FORM CMS-2540-10





11-12
SNF-BASED HOME HEALTH AGENCY


PROVIDER CCN:
PERIOD :
WORKSHEET S-4

STATISTICAL DATA




FROM ______________







HHA CCN:
TO ________________




































HOME HEALTH AGENCY STATISTICAL DATA









1 County







1
















Title V Title XVIII Title XIX Other Total
DESCRIPTION



1 2 3 4 5
2 Home Health Aide Hours







2
3 Unduplicated Census Count (see instructions)







3





























Staff Contract Total
HOME HEALTH AGENCY - NUMBER OF EMPLOYEES (FULL TIME EQUIVALENT)





1 2 3
4 Enter the number of hours in your normal work week







4
5 Administrator and Assistant Administrator(s)







5
6 Directors and Assistant Director(s)







6
7 Other Administrative Personnel







7
8 Direct Nursing Service







8
9 Nursing Supervisor







9
10 Physical Therapy Service







10
11 Physical Therapy Supervisor







11
12 Occupational Therapy Service







12
13 Occupational Therapy Supervisor







13
14 Speech Pathology Service







14
15 Speech Pathology Supervisor







15
16 Medical Social Service







16
17 Medical Social Service Supervisor







17
18 Home Health Aide







18
19 Home Health Aide Supervisor







19
20 Other (specify)







20











HOME HEALTH AGENCY CBSA CODES









21 Enter in column 1 the number of CBSAs where you provided services during the cost reporting period.







21
22 List those CBSA code(s) in column 1 serviced during this cost reporting period (line 22 contains the first code).







22
















Full Episodes

Total





Without With LUPA PEP only ( cols. 1





Outliers Outliers Episodes Episodes through 4 )
PPS ACTIVITY DATA



1 2 3 4 5
23 Skilled Nursing Visits







23
24 Skilled Nursing Visit Charges







24
25 Physical Therapy Visits







25
26 Physical Therapy Visit Charges







26
27 Occupational Therapy Visits







27
28 Occupational Therapy Visit Charges







28
29 Speech Pathology Visits







29
30 Speech Pathology Visit Charges







30
31 Medical Social Service Visits







31
32 Medical Social Service Visit Charges







32
33 Home Health Aide Visits







33
34 Home Health Aide Visit Charges







34
35 Total Visits (sum of lines 23, 25, 27, 29, 31, and 33)







35
36 Other Charges







36
37 Total Charges (sum of lines 24, 26, 28, 30, 32, 34 and 36)







37
38 Total Number of Episodes (standard/non outlier)







38
39 Total Number of Outlier Episodes







39
40 Total Non-Routine Medical Supply Charges







40
















































































































































































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




















41-310








Rev. 4

Sheet 9: S5
DRAFT





FORM CMS-2540-10









4190 (Cont.)
SNF-BASED RHC/FQHC STATISTICAL DATA








PROVIDER CCN:

PERIOD :

WORKSHEET S-5














FROM ______________














RHC/FQHC CCN:

TO ________________






























































Check applicable box: [ ] RHC

[ ] FQHC


















































Clinic Address and Identification:

















1 Street:











County:


1
2 City:







State:


Zip Code:


2
3 Designation (for FQHC's only) - "U" for urban or "R" for rural















3



















Source of Federal funds:












Grant Award Date
4 Community Health Center (Section 330(d), PHS Act)















4
5 Migrant Health Center (Section 329(d), PHS Act)















5
6 Health Services for the Homeless (Section 340(d), PHS Act)















6
7 Appalachian Regional Commission















7
8 Look - Alikes















8
9 Other (specify)















9

































1

2
10 Does this facility operate as other than an RHC or FQHC? Enter "Y" for yes or "N" for no in column 1.















10

If yes, indicate the number of other operations in column 2.



































Facility hours of operations (1)





















Sunday Monday Tuesday Wednesday Thursday Friday Saturday


Type of Operation
from to from to from to from to from to from to from to


0
1 2 3 4 5 6 7 8 9 10 11 12 13 14
11 Clinic















11



















(1) Enter clinic/center 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

2
12 Have you received an approval for an exception to the productivity standard?















12
13 Is this a consolidated cost report in accordance with CMS Pub. 100-04, Chapter 9, §30.8? Enter "Y" for yes or "N" for no in column 1.















13

If yes, enter in column 2 the number of RHC/FQHC's included in this report. List the names of all RHC/FQHC's and numbers below.
















14 RHC/FQHC Name:









CCN Number:




14



































































































































































































































































































































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



































Rev.
















41-311

Sheet 10: S6
4190 (Cont.)

FORM CMS-2540-10



DRAFT
SNF-BASED COMMUNITY



PROVIDER CCN: PERIOD : WORKSHEET S-6
MENTAL HEALTH CENTER AND OTHER OUTPATIENT




FROM ______________

REHABILITATION FACILITIES STATISTICAL DATA



COMPONENT CCN: TO ________________





























Check applicable box: [ ] CMHC [ ] CORF [ ] OPT [ ] OOT [ ] OSP




















Enter the number of hours in your normal workweek ________
























NUMBER OF EMPLOYEES (FULL TIME EQUIVALENT)














Total





Staff Contract ( col. 1 + col. 2 )





1 2 3
1 Administrator and Assistant Administrator(s)





1
2 Director(s) and Assistant Director(s)





2
3 Other Administrative Personnel





3
4 Direct Nursing Service





4
5 Nursing Supervisor





5
6 Physical Therapy Service





6
7 Physical Therapy Supervisor





7
8 Occupational Therapy Service





8
9 Occupational Therapy Supervisor





9
10 Speech Pathology Service





10
11 Speech Pathology Supervisor





11
12 Medical Social Service





12
13 Medical Social Service Supervisor





13
14 Respiratory Therapy Service





14
15 Respiratory Therapy Supervisor





15
16 Psychiatric/Psychological Service





16
17 Psychiatric/Psychological Service Supervisor





17
18 Other (specify)





18
19 Other (specify)





19


























































































































































































































































































































































































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
















41-312






Rev.

Sheet 11: S7
DRAFT

FORM CMS-2540-10



4190 (Cont.)
PROSPECTIVE PAYMENT FOR SNF



PROVIDER CCN: PERIOD : WORKSHEET S-7

STATISTICAL DATA




FROM ______________








TO ________________























GROUP




Days


1




2

1 RUX





1
2 RUL





2
3 RVX





3
4 RVL





4
5 RHX





5
6 RHL





6
7 RMX





7
8 RML





8
9 RLX





9
10 RUC





10
11 RUB





11
12 RUA





12
13 RVC





13
14 RVB





14
15 RVA





15
16 RHC





16
17 RHB





17
18 RHA





18
19 RMC





19
20 RMB





20
21 RMA





21
22 RLB





22
23 RLA





23
24 ES3





24
25 ES2





25
26 ES1





26
27 HE2





27
28 HE1





28
29 HD2





29
30 HD1





30
31 HC2





31
32 HC1





32
33 HB2





33
34 HB1





34
35 LE2





35
36 LE1





36
37 LD2





37
38 LD1





38
39 LC2





39
40 LC1





40
41 LB2





41
42 LB1





42
43 CE2





43
44 CE1





44
45 CD2





45
46 CD1





46
47 CC2





47
48 CC1





48
49 CB2





49
50 CB1





50








































































































































































































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


















Rev. 7






41-313










4190 (Cont.)

FORM CMS-2540-10



DRAFT
PROSPECTIVE PAYMENT FOR SNF



PROVIDER CCN: PERIOD: WORKSHEET S-7

STATISTICAL DATA




FROM ________








TO ___________























GROUP




Days


1




2

51 CA2





51
52 CA1





52
53 SE3





53
54 SE2





54
55 SE1





55
56 SSC





56
57 SSB





57
58 SSA





58
59 IB2





59
60 IB1





60
61 IA2





61
62 IA1





62
63 BB2





63
64 BB1





64
65 BA2





65
66 BA1





66
67 PE2





67
68 PE1





68
69 PD2





69
70 PD1





70
71 PC2





71
72 PC1





72
73 PB2





73
74 PB1





74
75 PA2





75
76 PA1





76
99 AAA





99
100 Total





100




















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 Y/N






1 2 3

101 Staffing





101
102 Recruitment





102
103 Retention of employees





103
104 Training





104
105 Other (Specify)





105
106 Total SNF revenue (Wkst. G-2, Pt. I, line 1, col. 3)





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. 7

Sheet 12: S8
DRAFT
FORM CMS-2540-10




4190 (Cont.)
SNF-BASED HOSPICE IDENTIFICATION DATA

PROVIDER CCN:
PERIOD :
WORKSHEET S - 8





FROM ______________





HOSPICE CCN:
TO ________________
PARTS I, II, III & IV



























PART I - ENROLLMENT DAYS FOR COST REPORTING PERIODS BEGINNING BEFORE OCTOBER 1, 2014









Unduplicated Days









Title XVIII Title XIX
Total




Skilled Nursing Nursing All ( sum of


Title XVIII Title XIX Facility Facility Other col. 1, 2 & 5 )


1 2 3 4 5 6
1 Hospice Continuous Home Care





1
2 Hospice Routine Home Care





2
3 Hospice Inpatient Respite Care





3
4 Hospice General Inpatient Care





4
5 Total Hospice Days





5


















PART II - CENSUS DATA FOR COST REPORTING PERIODS BEGINNING BEFORE OCTOBER 1, 2014











Title XVIII Title XIX
Total




Skilled Nursing All ( sum of


Title XVIII Title XIX Nursing facility Facility Other col. 1, 2 & 5 )


1 2 3 4 5 6
6 Number of patients receiving hospice care





6
7 Total number of unduplicated Continuous Care hours billable to Medicare





7
8 Average length of stay (line 5 / line 6)





8
9 Unduplicated census count





9


















PART III - ENROLLMENT DAYS BASED ON LEVEL OF CARE FOR COST REPORTING PERIODS BEGINNING ON OR AFTER OCTOBER 1, 2014











Unduplicated Days







Total







(sum of




Title XVIII Title XIX Other cols. 1 through 3)




1 2 3 4
10 Hospice Continuous Home Care





10
11 Hospice Routine Home Care





11
12 Hospice Inpatient Respite Care





12
13 Hospice General Inpatient Care





13
14 Total Hospice Days





14



























PART IV - CONTRACTED STATISTICAL DATA FOR COST REPORTING PERIODS BEGINNING ON OR AFTER OCTOBER 1, 2014














Total







(sum of




Title XVIII Title XIX Other cols. 1 through 3)




1 2 3 4
15 Hospice Inpatient Respite Care





15
16 Hospice General Inpatient Care





16


















NOTE: Parts I and II, columns 1 and 2 also include the days reported in columns 3 and 4 .

























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
















Rev.






41-315

Sheet 13: A
4190 (Cont.)


FORM CMS-2540-10




DRAFT
RECLASSIFICATION AND ADJUSTMENT



PROVIDER CCN:
PERIOD:
WORKSHEET A

OF TRIAL BALANCE OF EXPENSES





FROM ______________










TO _________________









RECLASSI- RECLASSIFIED ADJUSTMENTS NET EXPENSES







FICATIONS TRIAL TO EXPENSES FOR COST



Cost Center Description

TOTAL Increase/Decrease BALANCE Increase/Decrease ALLOCATION




SALARIES OTHER ( col. 1 + col. 2 ) ( from Wkst. A-6 ) ( col. 3 +/- col. 4 ) ( from Wkst. A-8 ) ( col. 5 +/- col. 6 )

A B C 1 2 3 4 5 6 7 A
GENERAL SERVICE COST CENTERS










1 0100 Capital-Related Costs - Buildings & Fixtures






1
2 0200 Capital-Related Costs - Moveable Equipment






2
3 0300 Employee Benefits






3
4 0400 Administrative and General






4
5 0500 Plant Operation, Maintenance and Repairs






5
6 0600 Laundry and Linen Service






6
7 0700 Housekeeping






7
8 0800 Dietary






8
9 0900 Nursing Administration






9
10 1000 Central Services and Supply






10
11 1100 Pharmacy






11
12 1200 Medical Records and Library






12
13 1300 Social Service






13
14 1400 Nursing and Allied Health Education






14
15
Other General Service Cost






15
INPATIENT ROUTINE SERVICE COST CENTERS










30 3000 Skilled Nursing Facility






30
31 3100 Nursing Facility






31
32 3200 ICF/IID






32
33 3300 Other Long Term Care






33
ANCILLARY SERVICE COST CENTERS










40 4000 Radiology






40
41 4100 Laboratory






41
42 4200 Intravenous Therapy






42
43 4300 Oxygen (Inhalation) Therapy






43
44 4400 Physical Therapy






44
45 4500 Occupational Therapy






45
46 4600 Speech Pathology






46
47 4700 Electrocardiology






47
























































































































































































































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






















41-316








Rev.












09-11


FORM CMS-2540-10




4190 (Cont.)
RECLASSIFICATION AND ADJUSTMENT



PROVIDER CCN:
PERIOD :
WORKSHEET A (Cont.)

OF TRIAL BALANCE OF EXPENSES





FROM ______________










TO ________________









RECLASSI- RECLASSIFIED ADJUSTMENTS NET EXPENSES







FICATIONS TRIAL TO EXPENSES FOR COST






TOTAL Increase/Decrease BALANCE Increase /Decrease ALLOCATION



Cost Center Description SALARIES OTHER ( col. 1 + col. 2 ) ( from Wkst. A-6 ) ( col. 3 +/- col. 4 ) ( from Wkst. A-8 ) ( col. 5 +/- col. 6 )

A B C 1 2 3 4 5 6 7

48 4800 Medical Supplies Charged to Patients






48
49 4900 Drugs Charged to Patients






49
50 5000 Dental Care - Title XIX only






50
51 5100 Support Surfaces






51
52
Other Ancillary Service Cost






52
OUTPATIENT SERVICE COST CENTERS










60 6000 Clinic






60
61 6100 Rural Health Clinic (RHC)






61
62 6200 FQHC






62
63
Other Outpatient Service Cost






63
OTHER REIMBURSABLE COST CENTERS










70 7000 Home Health Agency Cost






70
71 7100 Ambulance






71
72
Outpatient Rehabilitation (specify)






72
73 7300 CMHC






73
74
Other Reimbursable Cost






74
SPECIAL PURPOSE COST CENTERS










80 8000 Malpractice Premiums & Paid Losses





-0- 80
81 8100 Interest Expense





- 0 - 81
82 8200 Utilization Review





- 0 - 82
83 8300 Hospice






83
84
Other Special Purpose Cost






84
89
SUBTOTALS (sum of lines 1 through 84)






89
NON REIMBURSABLE COST CENTERS










90 9000 Gift, Flower, Coffee Shops and Canteen






90
91 9100 Barber and Beauty Shop






91
92 9200 Physicians' Private Offices






92
93 9300 Nonpaid Workers






93
94 9400 Patients' Laundry






94
95
Other Nonreimbursable Cost






95
100
TOTAL






100











































































































































































































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






















Rev. 2








41-317

Sheet 14: A6
4190 (Cont.)


FORM CMS-2540-10





09-11
RECLASSIFICATIONS





PROVIDER CCN: PERIOD :
WORKSHEET A-6








FROM ______________










TO ________________




























CODE
I N C R E A S E


D E C R E A S E




(1) COST CENTER LN NO. SALARY NON SALARY COST CENTER LN NO. SALARY NON SALARY

EXPLANATION OF RECLASSIFICATION(S) 1 2 3 4 5 6 7 8 9
1









1
2









2
3









3
4









4
5









5
6









6
7









7
8









8
9









9
10









10
11









11
12









12
13









13
14









14
15









15
16









16
17









17
18









18
19









19
20









20
21









21
22









22
23









23
24









24
25









25
26









26
27









27
28









28
29









29
30









30
31









31
32









32
33









33
34









34
35









35
100 TOTAL RECLASSIFICATIONS (Sum of columns 4 and 5 must equal








100

sum of columns 8 and 9 (2)





















(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

Sheet 15: A7
05-11

FORM CMS-2540-10



4190 (Cont.)
ANALYSIS OF CHANGES IN


PROVIDER CCN:
PERIOD :
WORKSHEET A-7
CAPITAL ASSET BALANCES




FROM ______________







TO ________________


























Acquisitions
Disposals
Fully


Beginning


and Ending Depreciated


Balances Purchases Donation Total Retirements Balance Assets

Description 1 2 3 4 5 6 7
1 Land






1
2 Land Improvements






2
3 Buildings and Fixtures






3
4 Building Improvements






4
5 Fixed Equipment






5
6 Movable Equipment






6
7 Subtotal (sum of lines 1-6)






7
8 Reconciling Items






8
9 Total (line 7 minus line 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

Sheet 16: A8
4190 (Cont.)
FORM CMS-2540-10




05-11
ADJUSTMENTS TO EXPENSES

PROVIDER CCN: PERIOD :
WORKSHEET A-8





FROM ______________





TO ________________





Basis
Expense Classification on Wkst. A





for
to/from which the amount is to be adjusted




Description (1) Adjustment (2) Amount
Cost Center
Line No.

0 1 2
3
4
1 Investment income on restricted funds





1

(Chapter 2)






2 Trade, quantity and time discounts





2

on purchases (Chapter 8)






3 Refunds and rebates of expenses





3

Chapter 8)






4 Rental of provider space by suppliers





4

Chapter 8)






5 Telephone services (pay stations





5

excluded) (Chapter 21)






6 Television and radio service





6

(Chapter 21)






7 Parking lot (Chapter 21)





7









8 Remuneration applicable to provider- Worksheet




8

based physician adjustment A-8-2





9 Home office costs (Chapter 21)





9









10 Sale of scrap, waste, etc.





10

(Chapter23)






11 Nonallowable costs related to certain





11

Capital expenditures (Chapter 24)






12 Adjustment resulting from transactions Worksheet




12

with related organizations (Chapter 10) A-8-1





13 Laundry and Linen service





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,





20

finance or penalty charges (Chapter 21)






21 Interest expense on Medicare overpayments





21

and borrowings to repay Medicare overpayments






22 Utilization review--physicians'

Utilization Review- SNF

82 22

compensation (Chapter 21)






23 Depreciation--buildings and fixtures

Capital Related Cost- Building

1 23









24 Depreciation--movable equipment

Capital Related Cost-Movable

2 24









25 Other Adjustment





25









100 TOTAL (sum of lines 1 through 99)





100

(transfer to Wkst. A, col. 6, line 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

Sheet 17: A81
DRAFT

FORM CMS-2540-10


4190 (Cont.)
STATEMENT OF COSTS OF SERVICES


PROVIDER CCN: PERIOD : WORKSHEET A-8-1
FROM RELATED ORGANIZATIONS AND



FROM ______________

HOME OFFICE COSTS



TO ________________

















PART I - COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED






ORGANIZATIONS OR CLAIMED HOME OFFICE COSTS










Amount Amount Adjustments




Allowable Included in ( col. 4 minus

Line No. Cost Center Expense Items In Cost Wkst. A., col. 5 col. 5 )

1 2 3 4 5 6
1





1
2





2
3





3
4





4
5





5
6





6
7





7
8





8
9





9
10 TOTALS (sum of lines 1-9)




10

(Transfer column 6, line 10 to Wkst. A-8, col. 3, line 12)





























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.



















Related Organization(s)




Percentage
Percentage


(1)
of
of Type of

Symbol Name Ownership Name Ownership Business

1 2 3 4 5 6
1





1
2





2
3





3
4





4
5





5
6





6
7





7
8





8
9





9
10





10








(1) Use the followings symbols to indicate interrelationship to related organizations:







A. Individual has financial interest (stockholder, partner, etc.)

E. Individual is director, officer, administrator or key person of provider



in both related organization and in provider.

and related organization.



B. Corporation, partnership or other organization has financial

F. Director, officer, administrator or key person of related organization



interest in provider.

or relative of such person has financial interest in provider.



C. Provider has financial interest in corporation, partnership,

G. Other (financial or non-financial) specify ______________________



or other organization.

_____________________________________________________



D. Director, officer, administrator or key person of provider or






organization.




















































































































































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














Rev.





41-321

Sheet 18: A82
4190 (Cont.)
FORM CMS-2540-10





DRAFT
PROVIDER - BASED PHYSICIAN ADJUSTMENTS



PROVIDER CCN:
PERIOD :
WORKSHEET A-8-2







FROM ______________









TO ________________































Physician /




Cost Center /



Provider
5 Percent of

Wkst. A Physician Total Professional Provider R C E Component Unadjusted Unadjusted

Line No. Identifier Remuneration Component Component Amount Hours R C E Limit R C E Limit

1 2 3 4 5 6 7 8 9
1








1
2








2
3








3
4








4
5








5
6








6
7








7
8








8
9








9
10








10
11








11
100
TOTAL






100


























































Cost of Provider Physician Provider





Cost Center / Memberships Component Cost of Component




Wkst. A Physician & Continuing Share of Malpractice Share of Adjusted R C E


Line No. Identifier Education Col. 12 Insurance Col. 14 R C E Limit Disallowance Adjustment

10 11 12 13 14 15 16 17 18
1








1
2








2
3








3
4








4
5








5
6








6
7








7
8








8
9








9
10








10
11








11
100
TOTAL






100




































































































































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




















41-322








Rev.

Sheet 19: BI
DRAFT



FORM CMS-2540-10




4190 (Cont.)
COST ALLOCATION - GENERAL SERVICE COSTS




PROVIDER CCN:
PERIOD :
WORKSHEET B








FROM ______________
PART I








TO ________________







NET EXPENSES










FOR COST CAP. REL CAP. REL
SUBTOTAL ADMINIS-





ALLOCATION BUILDINGS MOVABLE EMPLOYEE ( sum of TRATIVE





( from Wkst. A, col. 7 ) & FIXTURES EQUIPMENT BENEFITS cols. 0 - 3 ) & GENERAL


Cost Center Description

0 1 2 3 3 A 4
GENERAL SERVICE COST CENTERS










1 Capital-Related Costs - Buildings & Fixtures








1
2 Capital-Related Costs - Moveable Equipment








2
3 Employee Benefits








3
4 Administrative and General








4
5 Plant Operation, Maintenance and Repairs








5
6 Laundry and Linen Service








6
7 Housekeeping








7
8 Dietary








8
9 Nursing Administration








9
10 Central Services and Supply








10
11 Pharmacy








11
12 Medical Records and Library








12
13 Social Service








13
14 Nursing and Allied Health Education








14
15 Other General Service Cost








15
INPATIENT ROUTINE SERVICE COST CENTERS










30 Skilled Nursing Facility








30
31 Nursing Facility








31
32 ICF/IID








32
33 Other Long Term Care








33
ANCILLARY SERVICE COST CENTERS










40 Radiology








40
41 Laboratory








41
42 Intravenous Therapy








42
43 Oxygen (Inhalation) Therapy








43
44 Physical Therapy








44
45 Occupational Therapy








45
46 Speech Pathology








46
47 Electrocardiology








47
48 Medical Supplies Charged to Patients








48
49 Drugs Charged to Patients








49
50 Dental Care - Title XIX only








50
51 Support Surfaces








51
52 Other Ancillary Service Cost








52




























































































































































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






















Rev.









41-323












4190 (Cont.)



FORM CMS-2540-10




DRAFT
COST ALLOCATION - GENERAL SERVICE COSTS




PROVIDER CCN:
PERIOD:
WORKSHEET B








FROM ________________
PART I








TO ________________







NET EXPENSES










FOR COST CAP. REL CAP. REL
SUBTOTAL ADMINIS-





ALLOCATION BUILDINGS MOVABLE EMPLOYEE ( sum of TRATIVE





( from Wkst. A, col. 7 ) & FIXTURES EQUIPMENT BENEFITS cols. 0 - 3 ) & GENERAL


Cost Center Description

0 1 2 3 3 A 4
OUTPATIENT SERVICE COST CENTERS










60 Clinic








60
61 Rural Health Clinic (RHC)








61
62 FQHC








62
63 Other Outpatient Service Cost








63
OTHER REIMBURSABLE COST CENTERS










70 Home Health Agency Cost








70
71 Ambulance








71
72 Outpatient Rehabilitation (specify)








72
73 CMHC








73
74 Other Reimbursable Cost








74
SPECIAL PURPOSE COST CENTERS










83 Hospice








83
84 Other Special Purpose Cost








84
89 Subtotals








89
NON REIMBURSABLE COST CENTERS










90 Gift, Flower, Coffee Shops and Canteen








90
91 Barber and Beauty Shop








91
92 Physicians' Private Offices








92
93 Nonpaid Workers








93
94 Patients' Laundry








94
95 Other Nonreimbursable Cost








95
98 Cross Foot Adjustments








98
99 Negative Cost Center








99
100 Total








100




















































































































































































































































































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






















41-324









Rev.












DRAFT



FORM CMS-2540-10




4190 (Cont.)
COST ALLOCATION - GENERAL SERVICE COSTS




PROVIDER CCN:
PERIOD:
WORKSHEET B








FROM ________________
PART I








TO ________________


















PLANT OPER. LAUNDRY

NURSING CENTRAL





MAINTENANCE & LINEN HOUSE
ADMINIS- SERVICES





& REPAIRS SERVICE KEEPING DIETARY TRATION & SUPPLY PHARMACY


Cost Center Description
5 6 7 8 9 10 11
GENERAL SERVICE COST CENTERS










1 Capital-Related Costs - Buildings & Fixtures








1
2 Capital-Related Costs - Moveable Equipment








2
3 Employee Benefits








3
4 Administrative and General








4
5 Plant Operation, Maintenance and Repairs








5
6 Laundry and Linen Service








6
7 Housekeeping








7
8 Dietary








8
9 Nursing Administration








9
10 Central Services and Supply








10
11 Pharmacy








11
12 Medical Records and Library








12
13 Social Service








13
14 Nursing and Allied Health Education








14
15 Other General Service Cost








15
INPATIENT ROUTINE SERVICE COST CENTERS










30 Skilled Nursing Facility








30
31 Nursing Facility








31
32 ICF/IID








32
33 Other Long Term Care








33
ANCILLARY SERVICE COST CENTERS










40 Radiology








40
41 Laboratory








41
42 Intravenous Therapy








42
43 Oxygen (Inhalation) Therapy








43
44 Physical Therapy








44
45 Occupational Therapy








45
46 Speech Pathology








46
47 Electrocardiology








47
48 Medical Supplies Charged to Patients








48
49 Drugs Charged to Patients








49
50 Dental Care - Title XIX only








50
51 Support Surfaces








51
52 Other Ancillary Service Cost








52




























































































































































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






















Rev.









41-325












4190 (Cont.)



FORM CMS-2540-10




DRAFT
COST ALLOCATION - GENERAL SERVICE COSTS




PROVIDER CCN:
PERIOD:
WORKSHEET B








FROM ________________
PART I








TO ________________


















PLANT OPER. LAUNDRY

NURSING CENTRAL





MAINTENANCE & LINEN HOUSE
ADMINIS- SERVICES





& REPAIRS SERVICE KEEPING DIETARY TRATION & SUPPLY PHARMACY


Cost Center Description
5 6 7 8 9 10 11
OUTPATIENT SERVICE COST CENTERS










60 Clinic








60
61 Rural Health Clinic (RHC)








61
62 FQHC








62
63 Other Outpatient Service Cost








63
OTHER REIMBURSABLE COST CENTERS










70 Home Health Agency Cost








70
71 Ambulance








71
72 Outpatient Rehabilitation (specify)








72
73 CMHC








73
74 Other Reimbursable Cost








74
SPECIAL PURPOSE COST CENTERS










83 Hospice








83
84 Other Special Purpose Cost








84
89 Subtotals








89
NON REIMBURSABLE COST CENTERS










90 Gift, Flower, Coffee Shops and Canteen








90
91 Barber and Beauty Shop








91
92 Physicians' Private Offices








92
93 Nonpaid Workers








93
94 Patients' Laundry








94
95 Other Nonreimbursable Cost








95
98 Cross Foot Adjustments








98
99 Negative Cost Center








99
100 Total








100




















































































































































































































































































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






















41-326









Rev.












DRAFT



FORM CMS-2540-10




4190 (Cont.)
COST ALLOCATION - GENERAL SERVICE COSTS




PROVIDER CCN:
PERIOD:
WORKSHEET B








FROM ________________
PART I








TO ________________








NURSING & OTHER







MEDICAL
ALLIED GENERAL
POST





RECORDS SOCIAL HEALTH SERVICE
STEP-DOWN





& LIBRARY SERVICE EDUCATION COST SUBTOTAL ADJUSTMENTS TOTAL


Cost Center Description
12 13 14 15 16 17 18
GENERAL SERVICE COST CENTERS










1 Capital-Related Costs - Buildings & Fixtures








1
2 Capital-Related Costs - Moveable Equipment








2
3 Employee Benefits








3
4 Administrative and General








4
5 Plant Operation, Maintenance and Repairs








5
6 Laundry and Linen Service








6
7 Housekeeping








7
8 Dietary








8
9 Nursing Administration








9
10 Central Services and Supply








10
11 Pharmacy








11
12 Medical Records and Library








12
13 Social Service








13
14 Nursing and Allied Health Education








14
15 Other General Service Cost








15
INPATIENT ROUTINE SERVICE COST CENTERS










30 Skilled Nursing Facility








30
31 Nursing Facility








31
32 ICF/IID








32
33 Other Long Term Care








33
ANCILLARY SERVICE COST CENTERS










40 Radiology








40
41 Laboratory








41
42 Intravenous Therapy








42
43 Oxygen (Inhalation) Therapy








43
44 Physical Therapy








44
45 Occupational Therapy








45
46 Speech Pathology








46
47 Electrocardiology








47
48 Medical Supplies Charged to Patients








48
49 Drugs Charged to Patients








49
50 Dental Care - Title XIX only








50
51 Support Surfaces








51
52 Other Ancillary Service Cost








52




























































































































































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






















Rev.









41-327












4190 (Cont.)



FORM CMS-2540-10




DRAFT
COST ALLOCATION - GENERAL SERVICE COSTS




PROVIDER CCN:
PERIOD:
WORKSHEET B








FROM ________________
PART I








TO ________________








NURSING & OTHER







MEDICAL
ALLIED GENERAL
POST





RECORDS SOCIAL HEALTH SERVICE
STEP-DOWN





& LIBRARY SERVICE EDUCATION COST SUBTOTAL ADJUSTMENTS TOTAL


Cost Center Description
12 13 14 15 16 17 18
OUTPATIENT SERVICE COST CENTERS










60 Clinic








60
61 Rural Health Clinic (RHC)








61
62 FQHC








62
63 Other Outpatient Service Cost








63
OTHER REIMBURSABLE COST CENTERS










70 Home Health Agency Cost








70
71 Ambulance








71
72 Outpatient Rehabilitation (specify)








72
73 CMHC








73
74 Other Reimbursable Cost








74
SPECIAL PURPOSE COST CENTERS










83 Hospice








83
84 Other Special Purpose Cost








84
89 Subtotals








89
NON REIMBURSABLE COST CENTERS










90 Gift, Flower, Coffee Shops and Canteen








90
91 Barber and Beauty Shop








91
92 Physicians' Private Offices








92
93 Nonpaid Workers








93
94 Patients' Laundry








94
95 Other Nonreimbursable Cost








95
98 Cross Foot Adjustments








98
99 Negative Cost Center








99
100 Total








100




















































































































































































































































































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






















41-328









Rev.

Sheet 20: B1
DRAFT



FORM CMS-2540-10




4190 (Cont.)
COST ALLOCATION - STATISTICAL BASIS




PROVIDER CCN:
PERIOD :
WORKSHEET B - 1








FROM ______________










TO ________________







CAP. REL. CAP. REL.

ADMINIS-






BUILDINGS MOVABLE EMPLOYEE
TRATIVE






& FIXTURES EQUIPMENT BENEFITS
& GENERAL






( Square ( Dollar Value or ( Gross RECONCIL- ( Accumulated


Cost Center Description


Feet ) Square Feet ) Salaries ) IATION Cost )





0 1 2 3 4 A 4
GENERAL SERVICE COST CENTERS










1 Capital-Related Costs - Buildings & Fixtures








1
2 Capital-Related Costs - Moveable Equipment








2
3 Employee Benefits








3
4 Administrative and General








4
5 Plant Operation, Maintenance and Repairs








5
6 Laundry and Linen Service








6
7 Housekeeping








7
8 Dietary








8
9 Nursing Administration








9
10 Central Services and Supply








10
11 Pharmacy








11
12 Medical Records and Library








12
13 Social Service








13
14 Nursing and Allied Health Education








14
15 Other General Service Cost








15
INPATIENT ROUTINE SERVICE COST CENTERS










30 Skilled Nursing Facility








30
31 Nursing Facility








31
32 ICF/IID








32
33 Other Long Term Care








33
ANCILLARY SERVICE COST CENTERS










40 Radiology








40
41 Laboratory








41
42 Intravenous Therapy








42
43 Oxygen (Inhalation) Therapy








43
44 Physical Therapy








44
45 Occupational Therapy








45
46 Speech Pathology








46
47 Electrocardiology








47
48 Medical Supplies Charged to Patients








48
49 Drugs Charged to Patients








49
50 Dental Care - Title XIX only








50
51 Support Surfaces








51
52 Other Ancillary Service Cost








52
















































































































































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






















Rev.









41-329












4190 (Cont.)



FORM CMS-2540-10




DRAFT
COST ALLOCATION - STATISTICAL BASIS




PROVIDER CCN:
PERIOD:
WORKSHEET B - 1








FROM ________________










TO ________________







CAP. REL. CAP. REL.

ADMINIS-






BUILDINGS MOVABLE EMPLOYEE
TRATIVE






& FIXTURES EQUIPMENT BENEFITS
& GENERAL






( Square ( Dollar Value or ( Gross RECONCIL- ( Accumulated


Cost Center Description


Feet ) Square Feet ) Salaries ) IATION Cost )





0 1 2 3 4 A 4
OUTPATIENT SERVICE COST CENTERS










60 Clinic








60
61 Rural Health Clinic (RHC)








61
62 FQHC








62
63 Other Outpatient Service Cost








63
OTHER REIMBURSABLE COST CENTERS










70 Home Health Agency Cost








70
71 Ambulance








71
72 Outpatient Rehabilitation (specify)








72
73 CMHC








73
74 Other Reimbursable Cost








74
SPECIAL PURPOSE COST CENTERS










83 Hospice








83
84 Other Special Purpose Cost








84
89 Subtotals








89
NON REIMBURSABLE COST CENTERS










90 Gift, Flower, Coffee Shops and Canteen








90
91 Barber and Beauty Shop








91
92 Physicians' Private Offices








92
93 Nonpaid Workers








93
94 Patients' Laundry








94
95 Other Nonreimbursable Cost








95
98 Cross Foot Adjustments








98
99 Negative Cost Center








99
102 Cost to be allocated (Per Wkst. B, Pt I.)








102
103 Unit Cost Multiplier (Wkst. B, Pt I.)








103
104 Cost to be allocated (Per Wkst. B, Pt. II)








104
105 Unit Cost Multiplier (Wkst B, Pt. II)








105




































































































































































































































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






















41-330









Rev.












DRAFT



FORM CMS-2540-10




4190 (Cont.)
COST ALLOCATION - STATISTICAL BASIS




PROVIDER CCN:
PERIOD:
WORKSHEET B - 1








FROM ________________










TO ________________





PLANT OPER. LAUNDRY

NURSING CENTRAL





MAINTENANCE & LINEN HOUSE
ADMINIS- SERVICES





& REPAIRS SERVICE KEEPING DIETARY TRATION & SUPPLY PHARMACY




( Square ( Pounds of ( Hours of ( Meals ( Direct ( Costed ( Costed


Cost Center Description
Feet ) Laundry ) Service ) Served ) Nursing Hrs. ) Requisitions ) Requisitions )




5 6 7 8 9 10 11
GENERAL SERVICE COST CENTERS










1 Capital-Related Costs - Buildings & Fixtures








1
2 Capital-Related Costs - Moveable Equipment








2
3 Employee Benefits








3
4 Administrative and General








4
5 Plant Operation, Maintenance and Repairs








5
6 Laundry and Linen Service








6
7 Housekeeping








7
8 Dietary








8
9 Nursing Administration








9
10 Central Services and Supply








10
11 Pharmacy








11
12 Medical Records and Library








12
13 Social Service








13
14 Nursing and Allied Health Education








14
15 Other General Service Cost








15
INPATIENT ROUTINE SERVICE COST CENTERS










30 Skilled Nursing Facility








30
31 Nursing Facility








31
32 ICF/IID








32
33 Other Long Term Care








33
ANCILLARY SERVICE COST CENTERS










40 Radiology








40
41 Laboratory








41
42 Intravenous Therapy








42
43 Oxygen (Inhalation) Therapy








43
44 Physical Therapy








44
45 Occupational Therapy








45
46 Speech Pathology








46
47 Electrocardiology








47
48 Medical Supplies Charged to Patients








48
49 Drugs Charged to Patients








49
50 Dental Care - Title XIX only








50
51 Support Surfaces








51
52 Other Ancillary Service Cost








52
















































































































































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






















Rev.









41-331












4190 (Cont.)



FORM CMS-2540-10




DRAFT
COST ALLOCATION - STATISTICAL BASIS




PROVIDER CCN:
PERIOD:
WORKSHEET B - 1








FROM ________________










TO ________________





PLANT OPER. LAUNDRY

NURSING CENTRAL





MAINTENANCE & LINEN HOUSE
ADMINIS- SERVICES





& REPAIRS SERVICE KEEPING DIETARY TRATION & SUPPLY PHARMACY




( Square ( Pounds of ( Hours of ( Meals ( Direct ( Costed ( Costed


Cost Center Description
Feet ) Laundry ) Service ) Served ) Nursing Hrs. ) Requisitions ) Requisitions )




5 6 7 8 9 10 11
OUTPATIENT SERVICE COST CENTERS










60 Clinic








60
61 Rural Health Clinic (RHC)








61
62 FQHC








62
63 Other Outpatient Service Cost








63
OTHER REIMBURSABLE COST CENTERS










70 Home Health Agency Cost








70
71 Ambulance








71
72 Outpatient Rehabilitation (specify)








72
73 CMHC








73
74 Other Reimbursable Cost








74
SPECIAL PURPOSE COST CENTERS










83 Hospice








83
84 Other Special Purpose Cost








84
89 Subtotals








89
NON REIMBURSABLE COST CENTERS










90 Gift, Flower, Coffee Shops and Canteen








90
91 Barber and Beauty Shop








91
92 Physicians' Private Offices








92
93 Nonpaid Workers








93
94 Patients' Laundry








94
95 Other Nonreimbursable Cost








95
98 Cross Foot Adjustments








98
99 Negative Cost Center








99
102 Cost to be allocated (Per Wkst. B, Pt I.)








102
103 Unit Cost Multiplier (Wkst. B, Pt I.)








103
104 Cost to be allocated (Per Wkst. B, Pt. II)








104
105 Unit Cost Multiplier (Wkst B, Pt. II)








105




































































































































































































































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






















41-332









Rev.












DRAFT



FORM CMS-2540-10




4190 (Cont.)
COST ALLOCATION - STATISTICAL BASIS




PROVIDER CCN:
PERIOD:
WORKSHEET B - 1








FROM ________________










TO ________________





MEDICAL
NURSING &








RECORDS SOCIAL ALLIED OTHER







& LIBRARY SERVICE HEALTH GENERAL
POST





( Time ( Time EDUCATION SERVICE
STEP-DOWN



Cost Center Description
Spent ) Spent ) ( Assigned Time ) COST SUBTOTAL ADJUSTMENTS TOTAL




12 13 14 15 16 17 18
GENERAL SERVICE COST CENTERS










1 Capital-Related Costs - Buildings & Fixtures








1
2 Capital-Related Costs - Moveable Equipment








2
3 Employee Benefits








3
4 Administrative and General








4
5 Plant Operation, Maintenance and Repairs








5
6 Laundry and Linen Service








6
7 Housekeeping








7
8 Dietary








8
9 Nursing Administration








9
10 Central Services and Supply








10
11 Pharmacy








11
12 Medical Records and Library








12
13 Social Service








13
14 Nursing and Allied Health Education








14
15 Other General Service Cost








15
INPATIENT ROUTINE SERVICE COST CENTERS










30 Skilled Nursing Facility








30
31 Nursing Facility








31
32 ICF/IID








32
33 Other Long Term Care








33
ANCILLARY SERVICE COST CENTERS










40 Radiology








40
41 Laboratory








41
42 Intravenous Therapy








42
43 Oxygen (Inhalation) Therapy








43
44 Physical Therapy








44
45 Occupational Therapy








45
46 Speech Pathology








46
47 Electrocardiology








47
48 Medical Supplies Charged to Patients








48
49 Drugs Charged to Patients








49
50 Dental Care - Title XIX only








50
51 Support Surfaces








51
52 Other Ancillary Service Cost








52
















































































































































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






















Rev.









41-333












4190 (Cont.)



FORM CMS-2540-10




DRAFT
COST ALLOCATION - STATISTICAL BASIS




PROVIDER CCN:
PERIOD:
WORKSHEET B - 1








FROM ________________










TO ________________





MEDICAL
NURSING &








RECORDS SOCIAL ALLIED GENERAL







& LIBRARY SERVICE HEALTH EDU SERVICE
POST





( Time ( Time EDUCATION COST
STEP-DOWN



Cost Center Description
Spent ) Spent ) ( Assigned Time ) COST SUBTOTAL ADJUSTMENTS TOTAL




12 13 14 15 16 17 18
OUTPATIENT SERVICE COST CENTERS










60 Clinic








60
61 Rural Health Clinic (RHC)








61
62 FQHC








62
63 Other Outpatient Service Cost








63
OTHER REIMBURSABLE COST CENTERS










70 Home Health Agency Cost








70
71 Ambulance








71
72 Outpatient Rehabilitation (specify)








72
73 CMHC








73
74 Other Reimbursable Cost








74
SPECIAL PURPOSE COST CENTERS










83 Hospice








83
84 Other Special Purpose Cost








84
89 Subtotals








89
NON REIMBURSABLE COST CENTERS










90 Gift, Flower, Coffee Shops and Canteen








90
91 Barber and Beauty Shop








91
92 Physicians' Private Offices








92
93 Nonpaid Workers








93
94 Patients' Laundry








94
95 Other Nonreimbursable Cost








95
98 Cross Foot Adjustments








98
99 Negative Cost Center








99
102 Cost to be allocated (Per Wkst. B, Pt I.)








102
103 Unit Cost Multiplier (Wkst. B, Pt I.)








103
104 Cost to be allocated (Per Wkst. B, Pt. II)








104
105 Unit Cost Multiplier (Wkst B, Pt. II)








105




































































































































































































































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






















41-334









Rev.

Sheet 21: BII
DRAFT



FORM CMS-2540-10




4190 (Cont.)
ALLOCATION OF CAPITAL - RELATED COSTS




PROVIDER CCN:
PERIOD :
WORKSHEET B








FROM ______________
PART II








TO ________________






DIRECTLY










ASSIGNED CAP. REL CAP. REL.

ADMINIS- PLANT OPER.




CAPITAL BUILDINGS MOVABLE
EMPLOYEE TRATIVE MAINTENANCE




RELATED COSTS & FIXTURES EQUIPMENT SUBTOTAL BENEFITS & GENERAL & REPAIRS


Cost Center Description
0 1 2 2 A 3 4 5
GENERAL SERVICE COST CENTERS










1 Capital-Related Costs - Buildings & Fixtures








1
2 Capital-Related Costs - Moveable Equipment








2
3 Employee Benefits








3
4 Administrative and General








4
5 Plant Operation, Maintenance and Repairs








5
6 Laundry and Linen Service








6
7 Housekeeping








7
8 Dietary








8
9 Nursing Administration








9
10 Central Services and Supply








10
11 Pharmacy








11
12 Medical Records and Library








12
13 Social Service








13
14 Nursing and Allied Health Education








14
15 Other General Service Cost








15
INPATIENT ROUTINE SERVICE COST CENTERS










30 Skilled Nursing Facility








30
31 Nursing Facility








31
32 ICF/IID








32
33 Other Long Term Care








33
ANCILLARY SERVICE COST CENTERS










40 Radiology








40
41 Laboratory








41
42 Intravenous Therapy








42
43 Oxygen (Inhalation) Therapy








43
44 Physical Therapy








44
45 Occupational Therapy








45
46 Speech Pathology








46
47 Electrocardiology








47
48 Medical Supplies Charged to Patients








48
49 Drugs Charged to Patients








49
50 Dental Care - Title XIX only








50
51 Support Surfaces








51
52 Other Ancillary Service Cost








52




























































































































































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






















Rev.









41-335












4190 (Cont.)



FORM CMS-2540-10




DRAFT
ALLOCATION OF CAPITAL - RELATED COSTS




PROVIDER CCN:
PERIOD:
WORKSHEET B








FROM ________________
PART II








TO ________________






DIRECTLY










ASSIGNED CAP. REL CAP. REL.

ADMINIS- PLANT OPER.




CAPITAL BUILDINGS MOVABLE
EMPLOYEE TRATIVE MAINTENANCE




RELATED COSTS & FIXTURES EQUIPMENT SUBTOTAL BENEFITS & GENERAL & REPAIRS


Cost Center Description
0 1 2 2 A 3 4 5
OUTPATIENT SERVICE COST CENTERS










60 Clinic








60
61 Rural Health Clinic (RHC)








61
62 FQHC








62
63 Other Outpatient Service Cost








63
OTHER REIMBURSABLE COST CENTERS










70 Home Health Agency Cost








70
71 Ambulance








71
72 Outpatient Rehabilitation (specify)








72
73 CMHC








73
74 Other Reimbursable Cost








74
SPECIAL PURPOSE COST CENTERS










83 Hospice








83
84 Other Special Purpose Cost








84
89 Subtotals








89
NON REIMBURSABLE COST CENTERS










90 Gift, Flower, Coffee Shops and Canteen








90
91 Barber and Beauty Shop








91
92 Physicians' Private Offices








92
93 Nonpaid Workers








93
94 Patients' Laundry








94
95 Other Nonreimbursable Cost








95
98 Cross Foot Adjustments








98
99 Negative Cost Center








99
100 Total








100




















































































































































































































































































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






















41-336









Rev.












DRAFT



FORM CMS-2540-10




4190 (Cont.)
ALLOCATION OF CAPITAL - RELATED COSTS




PROVIDER CCN:
PERIOD:
WORKSHEET B








FROM ________________
PART II








TO ________________



















LAUNDRY

NURSING CENTRAL






& LINEN HOUSE
ADMINIS- SERVICES






SERVICE KEEPING DIETARY TRATION & SUPPLY PHARMACY


Cost Center Description

6 7 8 9 10 11
GENERAL SERVICE COST CENTERS










1 Capital-Related Costs - Buildings & Fixtures








1
2 Capital-Related Costs - Moveable Equipment








2
3 Employee Benefits








3
4 Administrative and General








4
5 Plant Operation, Maintenance and Repairs








5
6 Laundry and Linen Service








6
7 Housekeeping








7
8 Dietary








8
9 Nursing Administration








9
10 Central Services and Supply








10
11 Pharmacy








11
12 Medical Records and Library








12
13 Social Service








13
14 Nursing and Allied Health Education








14
15 Other General Service Cost








15
INPATIENT ROUTINE SERVICE COST CENTERS










30 Skilled Nursing Facility








30
31 Nursing Facility








31
32 ICF/IID








32
33 Other Long Term Care








33
ANCILLARY SERVICE COST CENTERS










40 Radiology








40
41 Laboratory








41
42 Intravenous Therapy








42
43 Oxygen (Inhalation) Therapy








43
44 Physical Therapy








44
45 Occupational Therapy








45
46 Speech Pathology








46
47 Electrocardiology








47
48 Medical Supplies Charged to Patients








48
49 Drugs Charged to Patients








49
50 Dental Care - Title XIX only








50
51 Support Surfaces








51
52 Other Ancillary Service Cost








52




























































































































































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






















Rev.









41-337












4190 (Cont.)



FORM CMS-2540-10




DRAFT
ALLOCATION OF CAPITAL - RELATED COSTS




PROVIDER CCN:
PERIOD:
WORKSHEET B








FROM ________________
PART II








TO ________________



















LAUNDRY

NURSING CENTRAL






& LINEN HOUSE
ADMINIS- SERVICES






SERVICE KEEPING DIETARY TRATION & SUPPLY PHARMACY


Cost Center Description

6 7 8 9 10 11
OUTPATIENT SERVICE COST CENTERS










60 Clinic








60
61 Rural Health Clinic (RHC)








61
62 FQHC








62
63 Other Outpatient Service Cost








63
OTHER REIMBURSABLE COST CENTERS










70 Home Health Agency Cost








70
71 Ambulance








71
72 Outpatient Rehabilitation (specify)








72
73 CMHC








73
74 Other Reimbursable Cost








74
SPECIAL PURPOSE COST CENTERS










83 Hospice








83
84 Other Special Purpose Cost








84
89 Subtotals








89
NON REIMBURSABLE COST CENTERS










90 Gift, Flower, Coffee Shops and Canteen








90
91 Barber and Beauty Shop








91
92 Physicians' Private Offices








92
93 Nonpaid Workers








93
94 Patients' Laundry








94
95 Other Nonreimbursable Cost








95
98 Cross Foot Adjustments








98
99 Negative Cost Center








99
100 Total








100




















































































































































































































































































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






















41-338









Rev.












DRAFT



FORM CMS-2540-10




4190 (Cont.)
ALLOCATION OF CAPITAL - RELATED COSTS




PROVIDER CCN:
PERIOD:
WORKSHEET B








FROM ________________
PART II








TO ________________








NURSING & OTHER







MEDICAL
ALLIED GENERAL
POST





RECORDS SOCIAL HEALTH SERVICE
STEP-DOWN





& LIBRARY SERVICE EDUCATION COST SUBTOTAL ADJUSTMENTS TOTAL


Cost Center Description
12 13 14 15 16 17 18
GENERAL SERVICE COST CENTERS










1 Capital-Related Costs - Buildings & Fixtures








1
2 Capital-Related Costs - Moveable Equipment








2
3 Employee Benefits








3
4 Administrative and General








4
5 Plant Operation, Maintenance and Repairs








5
6 Laundry and Linen Service








6
7 Housekeeping








7
8 Dietary








8
9 Nursing Administration








9
10 Central Services and Supply








10
11 Pharmacy








11
12 Medical Records and Library








12
13 Social Service








13
14 Nursing and Allied Health Education








14
15 Other General Service Cost








15
INPATIENT ROUTINE SERVICE COST CENTERS










30 Skilled Nursing Facility








30
31 Nursing Facility








31
32 ICF/IID








32
33 Other Long Term Care








33
ANCILLARY SERVICE COST CENTERS










40 Radiology








40
41 Laboratory








41
42 Intravenous Therapy








42
43 Oxygen (Inhalation) Therapy








43
44 Physical Therapy








44
45 Occupational Therapy








45
46 Speech Pathology








46
47 Electrocardiology








47
48 Medical Supplies Charged to Patients








48
49 Drugs Charged to Patients








49
50 Dental Care - Title XIX only








50
51 Support Surfaces








51
52 Other Ancillary Service Cost








52




























































































































































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






















Rev.









41-339












4190 (Cont.)



FORM CMS-2540-10




DRAFT
ALLOCATION OF CAPITAL - RELATED COSTS




PROVIDER CCN:
PERIOD:
WORKSHEET B








FROM ________________
PART II








TO ________________








NURSING & OTHER







MEDICAL
ALLIED GENERAL
POST





RECORDS SOCIAL HEALTH SERVICE
STEP-DOWN





& LIBRARY SERVICE EDUCATION COST SUBTOTAL ADJUSTMENTS TOTAL


Cost Center Description
12 13 14 15 16 17 18
OUTPATIENT SERVICE COST CENTERS










60 Clinic








60
61 Rural Health Clinic (RHC)








61
62 FQHC








62
63 Other Outpatient Service Cost








63
OTHER REIMBURSABLE COST CENTERS










70 Home Health Agency Cost








70
71 Ambulance








71
72 Outpatient Rehabilitation (specify)








72
73 CMHC








73
74 Other Reimbursable Cost








74
SPECIAL PURPOSE COST CENTERS










83 Hospice








83
84 Other Special Purpose Cost








84
89 Subtotals








89
NON REIMBURSABLE COST CENTERS










90 Gift, Flower, Coffee Shops and Canteen








90
91 Barber and Beauty Shop








91
92 Physicians' Private Offices








92
93 Nonpaid Workers








93
94 Patients' Laundry








94
95 Other Nonreimbursable Cost








95
98 Cross Foot Adjustments








98
99 Negative Cost Center








99
100 Total








100




















































































































































































































































































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






















41-340









Rev.

Sheet 22: B2
DRAFT
FORM CMS-2540-10



4190 (Cont.)
POST STEP DOWN ADJUSTMENTS

PROVIDER CCN: PERIOD :
WORKSHEET B-2




FROM ______________






TO ________________






















Worksheet B


Description Part No. Line No. Amount

1 2 3 4
1





1
2





2
3





3
4





4
5





5
6





6
7





7
8





8
9





9
10





10
11





11
12





12
13





13
14





14
15





15
16





16
17





17
18





18
19





19
20





20
21





21
22





22
23





23
24





24
25





25
26





26
27





27
28





28
29





29
30





30
31





31
32





32
33





33
34





34
35





35
36





36
37





37
38





38
39





39
40





40
41





41
42





42
43





43
44





44
45





45
46





46
47





47
48





48
49





49
50





50
























































































































































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














Rev.





41-341

Sheet 23: C
4190 (Cont.)
FORM CMS-2540-10



DRAFT
RATIO OF COST TO CHARGES
PROVIDER CCN:
PERIOD :
WORKSHEET C
FOR ANCILLARY AND OUTPATIENT


FROM ______________


COST CENTERS


TO ________________






























Total
Ratio




( from Wkst. B, Total ( col. 1 divided




Pt. I, col. 18 ) Charges by col. 2 )

Cost Center Description

1 2 3
ANCILLARY SERVICE COST CENTERS






40 Radiology




40
41 Laboratory




41
42 Intravenous Therapy




42
43 Oxygen (Inhalation) Therapy




43
44 Physical Therapy




44
45 Occupational Therapy




45
46 Speech Pathology




46
47 Electrocardiology




47
48 Medical Supplies Charged to Patients




48
49 Drugs Charged to Patients




49
50 Dental Care - Title XIX only




50
51 Support Surfaces




51
52 Other Ancillary Service Cost




52
OUTPATIENT SERVICE COST CENTERS






60 Clinic




60
61 Rural Health Clinic (RHC)




61
62 FQHC




62
63 Other Outpatient Service Cost




63
71 Ambulance




71
100 Total




100
















































































































































































































































































































































































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














41-342





Rev.

Sheet 24: DI
DRAFT


FORM CMS-2540-10




4190 (Cont.)
APPORTIONMENT OF ANCILLARY AND



PROVIDER CCN:
PERIOD :
WORKSHEET D
OUTPATIENT COST





FROM ______________
PART I







TO ________________

























Check applicable box: [ ] Title V (1) [ ] Title XVIII [ ] Title XIX ( 1 )






Check applicable box: [ ] SNF [ ] NF [ ] ICF / IID [ ] Other ______________________
[ ] PPS - Must also complete Part II
























PART I - CALCULATION OF ANCILLARY AND OUTPATIENT COST














Ratio of









Cost to Health Care Healthcare





Charges Program Charges Program Cost





( from Wkst. C,

Part A Part B





col. 3 ) Part A Part B ( col. 1 x col. 2 ) ( col. 1 x col. 3 )


Cost Center Description

1 2 3 4 5
ANCILLARY SERVICE COST CENTERS









40 Radiology







40
41 Laboratory







41
42 Intravenous Therapy







42
43 Oxygen (Inhalation) Therapy







43
44 Physical Therapy







44
45 Occupational Therapy







45
46 Speech Pathology







46
47 Electrocardiology







47
48 Medical Supplies Charged to Patients







48
49 Drugs Charged to Patients







49
50 Dental Care - Title XIX only







50
51 Support Surfaces







51
52 Other Ancillary Service Cost







52
OUTPATIENT COST CENTERS









60 Clinic







60
61 Rural Health Clinic (RHC)







61
62 FQHC







62
63 Other Outpatient Service Cost







63
71 Ambulance (2)







71
100 Total (sum of lines 40 - 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 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4124)




















Rev.








41-343

Sheet 25: DII&III
4190 (Cont.)

FORM CMS-2540-10




DRAFT
APPORTIONMENT OF ANCILLARY AND


PROVIDER CCN:
PERIOD :
WORKSHEET D
OUTPATIENT COST




FROM ______________
PARTS II & III






TO ________________






















TITLE XVIII ONLY




























PART II - APPORTIONMENT OF VACCINE COST








1 Drugs charged to patients - ratio of cost to charges (from Wkst. C, col. 3, line 49)






1
2 Program vaccine charges ( From your records or the PS&R report)






2
3 Program costs (line 1 x line 2) (Title XVIII, PPS providers, transfer this amount to Wkst. E, Pt. I, line 1)






3




















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














Ratio of Nursing
Part A





Nursing & & Allied Health Program Nursing & Allied




Total Cost Allied Health Costs to Total Part A Cost Health Costs for




( from Wkst. B, ( from Wkst. B, Costs - Part A ( from Wkst. D., Pass Through




Pt. I, col. 18 ) Pt. I, col. 14 ) ( col. 2 / col. 1 ) Pt. I, col. 4 ) ( col. 3 x col. 4 )


Cost Center Description
1 2 3 4 5
ANCILLARY SERVICE COST CENTERS








40 Radiology






40
41 Laboratory






41
42 Intravenous Therapy






42
43 Oxygen (Inhalation) Therapy






43
44 Physical Therapy






44
45 Occupational Therapy






45
46 Speech Pathology






46
47 Electrocardiology






47
48 Medical Supplies Charged to Patients






48
49 Drugs Charged to Patients






49
50 Dental Care - Title XIX only






50
51 Support Surfaces






51
52 Other Ancillary Service Cost






52
100 Total (sum of lines 40 - 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.

Sheet 26: D1
DRAFT


FORM CMS-2540-10


4190 (Cont.)
COMPUTATION OF INPATIENT



PROVIDER CCN: PERIOD : WORKSHEET D-1
ROUTINE COSTS




FROM ______________ PARTS I & II






TO ________________




















Check applicable box: [ ] Title V [ ] Title XVIII [ ] Title XIX




Check applicable box: [ ] SNF [ ] NF [ ] ICF / IID





















PART I - CALCULATION OF INPATIENT ROUTINE COSTS







INPATIENT DAYS







1 Inpatient days including private room days





1
2 Private room days





2
3 Inpatient days including private room days applicable to the Program





3
4 Medically necessary private room days applicable to the Program





4
5 Total general inpatient routine service cost





5
PRIVATE ROOM DIFFERENTIAL ADJUSTMENT







6 General inpatient routine service charges





6
7 General inpatient routine service cost/charge ratio (line 5 divided by line 6)





7
8 Enter private room charges from your records





8
9 Average private room per diem charge (private room charges on line 8 divided by private room days on line 2)





9
10 Enter semi-private room charges from your records





10
11 Average semi-private room per diem charge (semi-private room charges on line 10 divided by semi-private room days)





11
12 Average per diem private room charge differential (line 9 minus line 11)





12
13 Average per diem private room cost differential (line 7 times line 12 )





13
14 Private room cost differential adjustment (line 2 times line 13)





14
15 General inpatient routine service cost net of private room cost differential (line 5 minus line 14)





15
PROGRAM INPATIENT ROUTINE SERVICE COSTS







16 Adjusted general inpatient service cost per diem (line 15 divided by line 11)





16
17 Program routine service cost (line 3 times line 16)





17
18 Medically necessary private room cost applicable to program (line 4 times line 13)





18
19 Total program general inpatient routine service cost (line 17 plus line 18)





19
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





20

line 32 for ICF/IID)






21 Per diem capital related costs (line 20 divided by line 1)





21
22 Program capital related cost (line 3 times line 21)





22
23 Inpatient routine service cost (line 19 minus line 22)





23
24 Aggregate charges to beneficiaries for excess costs (from provider records)





24
25 Total program routine service costs for comparison to the cost limitation (line 23 minus line 24)





25
26 Enter the per diem limitation (1)





26
27 Inpatient routine service cost limitation (line 3 times the per diem limitation line 26) (1)





27
28 Reimbursable inpatient routine service costs (line 22 plus the lesser of line 25 or line 27)





28

(Transfer to Wkst. E, Pt. II, line 4) (see instructions)
























PART II - CALCULATION OF INPATIENT NURSING & ALLIED HEALTH COSTS FOR PPS PASS-THROUGH







1 Total inpatient days





1
2 Program inpatient days (see instructions)





2
3 Total nursing & allied health costs (see instructions)





3
4 Nursing & allied health ratio (line 2 divided by line 1)





4
5 Program nursing & allied health costs for pass-through (line 3 times line 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 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4125)
















Rev.






41-345

Sheet 27: EI
4190 (Cont.)

FORM CMS-2540-10


DRAFT
CALCULATION OF


PROVIDER CCN: PERIOD : WORKSHEET E
REIMBURSEMENT SETTLEMENT



FROM ______________ PART I
FOR TITLE XVIII



TO ________________
















PART A - INPATIENT SERVICE PPS PROVIDER COMPUTATION OF REIMBURSEMENT






1 Inpatient PPS amount (see instructions)




1
2 Nursing and Allied Health Education Activities (pass through payments)




2
3 Subtotal (sum of lines 1 and 2)




3
4 Primary payer amounts




4
5 Coinsurance




5
6 Reimbursable bad debts (from your records)




6
7 Reimbursable bad debts for dual eligible beneficiaries (see instructions)




7
8 Adjusted reimbursable bad debts (see instructions)




8
9 Recovery of bad debts - for statistical records only




9
10 Utilization review




10
11 Subtotal (see instructions)




11
12 Interim payments (see instructions)




12
13 Tentative adjustment




13
14 Other adjustment (see instructions)




14
14.99 Sequestration amount (see instructions)




14.99
15 Balance due provider/program (see instructions)




15

(Indicate overpayment in parentheses)





16 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2




16
















PART B - ANCILLARY SERVICE COMPUTATION OF REIMBURSEMENT LESSER OF COST OR CHARGES - TITLE XVIII ONLY






17 Ancillary services Part B




17
18 Vaccine cost (from Wkst. D, Pt. II, line 3)




18
19 Total reasonable costs (sum of lines 17 and 18)




19
20 Medicare Part B ancillary charges (see instructions)




20
21 Cost of covered services (lesser of line 19 or line 20)




21
22 Primary payer amounts




22
23 Coinsurance and deductibles




23
24 Reimbursable bad debts (from your records)




24
24.01 Reimbursable bad debts for dual eligible beneficiaries (see instructions)




24.01
24.02 Adjusted reimbursable bad debts (see instructions)




24.02
25 Subtotal (sum of lines 21 and 24.02, minus lines 22 and 23)




25
26 Interim payments (see instructions)




26
27 Tentative adjustment




27
28 Other Adjustments (Specify ______________) (see instructions)




28
28.99 Sequestration amount (see instructions)




28.99
29 Balance due provider/program (see instructions)




29

(indicate overpayments in parentheses)





30 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2




30







































































































































































































































































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














41-346





Rev.

Sheet 28: EII
DRAFT

FORM CMS-2540-10



4190 (Cont.)
CALCULATION OF



PROVIDER CCN: PERIOD : WORKSHEET E
REIMBURSEMENT SETTLEMENT




FROM ______________ PART II
FOR TITLE V and TITLE XIX ONLY




TO ________________



















Check applicable box: [ ] Title V [ ] Title XIX





Check applicable box: [ ] SNF [ ] NF [ ] ICF / IID





















COMPUTATION OF NET COST OF COVERED SERVICES







1 Inpatient ancillary services (see instructions)





1
2 Nursing & Allied Health Cost (from Wkst. D-1, Pt. II, line 5)





2
3 Outpatient services





3
4 Inpatient routine services (see instructions)





4
5 Utilization review - physicians' compensation (from provider records)





5
6 Cost of covered services (sum of lines 1 - 5)





6
7 Differential in charges between semiprivate accommodations and less





7

than semiprivate accommodations






8 Subtotal (line 6 minus line 7)





8
9 Primary payer amounts





9
10 Total reasonable cost (line 8 minus line 9)





10
REASONABLE CHARGES







11 Inpatient ancillary service charges





11
12 Outpatient service charges





12
13 Inpatient routine service charges





13
14 Differential in charges between semiprivate accommodations and less





14

than semiprivate accommodations






15 Total reasonable charges





15
CUSTOMARY CHARGES







16 Aggregate amount actually collected from patients liable for payment for





16

services on a charge basis






17 Amounts that would have been realized from patients liable for payment for services





17

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)





18
19 Total customary charges (see instructions)





19
COMPUTATION OF REIMBURSEMENT SETTLEMENT







20 Cost of covered services (see instructions)





20
21 Deductibles





21
22 Subtotal (line 20 minus line 21)





22
23 Coinsurance





23
24 Subtotal (line 22 minus line 23)





24
25 Reimbursable bad debts (from your records)





25
26 Subtotal (sum of lines 24 and 25)





26
27 Unrefunded charges to beneficiaries for excess costs erroneously collected





27

based on correction of cost limit






28 Recovery of excess depreciation resulting from provider termination or a decrease





28

in program utilization






29 Other adjustments (Specify ______________) (see instructions)





29
30 Amounts applicable to prior cost reporting periods resulting from disposition of





30

depreciable assets (if minus, enter amount in parentheses)






31 Subtotal (line 26 plus or minus lines 29, and 30, minus lines 27 and 28)





31
32 Interim payments





32
33 Balance due provider/program (line 31 minus line 32)





33

(indicate overpayments in parentheses) (see instructions)





















































































































































































































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
















Rev.






41-347

Sheet 29: E1
4190 (Cont.)
FORM CMS-2540-10




DRAFT
ANALYSIS OF PAYMENTS TO PROVIDERS



PROVIDER CCN: PERIOD : WORKSHEET E-1
FOR SERVICES RENDERED




FROM ______________






TO ________________





Inpatient Part A Part B




mm/dd/yyyy Amount mm/dd/yyyy Amount

Description

1 2 3 4
1 Total interim payments paid to provider





1
2 Interim payments payable on individual bills, either submitted





2

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





3.01

adjustment amount based on subsequent revision of Program .02



3.02

the interim rate for the cost reporting period to .03



3.03

Also show date of each payment. Provider .04



3.04

If none, write "NONE," or enter a zero. (1)
.05



3.05



.50



3.50


Provider .51



3.51


to .52



3.52


Program .53



3.53



.54



3.54

SUBTOTAL (sum of lines 3.01 - 3.49 minus sum of lines 3.50 - 3.98)
.99



3.99
4 TOTAL INTERIM PAYMENTS (sum of lines 1, 2 & 3.99)





4

(Transfer to Wkst. E, Pt. I, line 12 for Part A, and line 26 for Part B.)
















TO BE COMPLETED BY CONTRACTOR






5 List separately each tentative settlement Program .01



5.01

payment after desk review. Also show to .02



5.02

date of each payment. Provider .03



5.03

If none, write "NONE," or enter a zero. (1) Provider .50



5.50


to .51



5.51


Program .52



5.52

SUBTOTAL (sum of lines 5.01 - 5.49 minus sum of lines 5.50 - 5.98)
.99



5.99
6 Determine net settlement amount (balance Program to Provider .01



6.01

due) based on the cost report (1) Provider to Program .02



6.02
7 TOTAL MEDICARE PROGRAM LIABILITY (see instructions)





7
8 Name of Contractor
Contractor Number


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.

Sheet 30: G
05-11
FORM CMS-2540-10


4190 (Cont.)
BALANCE SHEET

PROVIDER CCN: PERIOD : WORKSHEET G
(If you are nonproprietary and do not maintain fund-type


FROM ______________

accounting records, complete the "General Fund" column only.)


TO ________________


















Specific




General Purpose Endowment Plant


Fund Fund Fund Fund

Assets 1 2 3 4
CURRENT ASSETS





1 Cash on hand and in banks



1
2 Temporary investments



2
3 Notes receivable



3
4 Accounts receivable



4
5 Other receivables



5
6 Less: allowances for uncollectible notes ( ) ( ) ( ) ( ) 6

and accounts receivable




7 Inventory



7
8 Prepaid expenses



8
9 Other current assets



9
10 Due from other funds



10
11 TOTAL CURRENT ASSETS



11

(sum of lines 1 - 10)




FIXED ASSETS





12 Land



12
13 Land improvements



13
14 Less: Accumulated depreciation ( ) ( ) ( ) ( ) 14
15 Buildings



15
16 Less Accumulated depreciation ( ) ( ) ( ) ( ) 16
17 Leasehold improvements



17
18 Less: Accumulated Amortization ( ) ( ) ( ) ( ) 18
19 Fixed equipment



19
20 Less: Accumulated depreciation ( ) ( ) ( ) ( ) 20
21 Automobiles and trucks



21
22 Less: Accumulated depreciation ( ) ( ) ( ) ( ) 22
23 Major movable equipment



23
24 Less: Accumulated depreciation ( ) ( ) ( ) ( ) 24
25 Minor equipment - Depreciable



25
26 Minor equipment nondepreciable



26
27 Other fixed assets



27
28 TOTAL FIXED ASSETS



28

(sum of lines 12 - 27)




OTHER ASSETS





29 Investments



29
30 Deposits on leases



30
31 Due from owners/officers



31
32 Other assets



32
33 TOTAL OTHER ASSETS



33

(sum of lines 29 - 32)




34 TOTAL ASSETS



34

(sum of lines 11, 28 and 33)











( ) = 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

Sheet 31: GP2
4190 (Cont.)
FORM CMS-2540-10


05-11
BALANCE SHEET

PROVIDER CCN: PERIOD : WORKSHEET G
(If you are nonproprietary and do not maintain fund-type


FROM ______________

accounting records, complete the "General Fund" column only.)


TO ________________


















Specific




General Purpose Endowment Plant

Liabilities and Fund Fund Fund Fund Fund

Balances 1 2 3 4
CURRENT LIABILITIES





35 Accounts payable



35
36 Salaries, wages & fees payable



36
37 Payroll taxes payable



37
38 Notes & loans payable (short term)



38
39 Deferred income



39
40 Accelerated payments



40
41 Due to other funds



41
42 Other current liabilities



42
43 TOTAL CURRENT LIABILITIES



43

(sum of lines 35 - 42)




LONG TERM LIABILITIES





44 Mortgage payable



44
45 Notes payable



45
46 Unsecured loans



46
47 Loans from owners:



47
48 Other long term liabilities



48
49 Other (specify)



49
50 TOTAL LONG TERM LIABILITIES



50

(sum of lines 44 - 49)




51 TOTAL LIABILITIES



51

(sum of lines 43 and 50)




CAPITAL ACCOUNTS





52 General fund balance



52
53 Specific purpose fund



53
54 Donor created - endowment fund



54

balance - restricted




55 Donor created - endowment fund



55

balance - unrestricted




56 Governing body created - endowment



56

fund balance




57 Plant fund balance - invested in plant



57
58 Plant fund balance - reserve for



58

plant improvement, replacement and





expansion




59 TOTAL FUND BALANCES



59

(sum of lines 52 thru 58)




60 TOTAL LIABILITIES AND



60

FUND BALANCES





(sum of lines 51 and 59)











( ) = 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

Sheet 32: G1
DRAFT
FORM CMS-2540-10






4190 (Cont.)
STATEMENT OF CHANGES IN FUND BALANCES



PROVIDER CCN:
PERIOD :
WORKSHEET G - 1







FROM ______________









TO ________________























General Fund
Special Purpose Fund
Endowment Fund
Plant Fund



1 2 3 4 5 6 7 8
1 Fund balances at beginning of period







1
2 Net income (loss) (from Wkst. G-3, line 31)







2
3 Total (sum of line 1 and line 2)







3
4 Additions (credit adjustments)







4
5








5
6








6
7








7
8








8
9








9
10 Total additions (sum of lines 5 - 9)







10
11 Subtotal (line 3 plus line 10)







11
12 Deductions (debit adjustments)







12
13








13
14








14
15








15
16








16
17








17
18 Total deductions (sum of lines 13 - 17)







18
19 Fund balance at end of period per balance sheet (line 11 - line 18)







19










































































































































































































































































































































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




















Rev.








41-351

Sheet 33: G2
4190 (Cont.)
FORM CMS-2540-10


DRAFT
STATEMENT OF PATIENT REVENUES

PROVIDER CCN: PERIOD : WORKSHEET G - 2
AND OPERATING EXPENSES


FROM ______________ PARTS I & II




TO ________________














PART I - PATIENT REVENUES








INPATIENT OUTPATIENT TOTAL

Revenue Center
1 2 3
General Inpatient Routine Care Services





1 Skilled nursing facility



1
2 Nursing facility



2
3 ICF / IID



3
4 Other long term care



4
5 Total general inpatient care services



5

(sum of lines 1 - 4)




All Other Care Service





6 Ancillary services



6
7 Clinic



7
8 Home health agency



8
9 Ambulance



9
10 RHC/FQHC



10
11 CMHC



11
12 Hospice



12
13 Other (specify)



13
14 Total patient revenues (sum of lines 5 - 13)



14

(transfer to Wkst. G-3, col. 3, line 1 )


















PART II - OPERATING EXPENSES





1 Operating Expenses (per Wkst. A, col. 3, line 100)



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 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4140)












41-352




Rev.

Sheet 34: G3
DRAFT
FORM CMS-2540-10


4190 (Cont.)
STATEMENT OF REVENUES

PROVIDER CCN: PERIOD : WORKSHEET G-3
AND EXPENSES


FROM ______________





TO ________________















1 Total patient revenues (from Wkst. G-2, Pt. I, col. 3, line 14)



1
2 Less: contractual allowances and discounts on patients accounts



2
3 Net patient revenues (line 1 minus line 2)



3
4 Less: total operating expenses (form Wkst. G-2, Pt. II, line 15)



4
5 Net income from service to patients (line 3 minus 4)



5

Other income:




6 Contributions, donations, bequests, etc.



6
7 Income from investments



7
8 Revenues from communications (telephone and internet service)



8
9 Revenue from television and radio service



9
10 Purchase discounts



10
11 Rebates and refunds of expenses



11
12 Parking lot receipts



12
13 Revenue from laundry and linen service



13
14 Revenue from meals sold to employees and guests



14
15 Revenue from rental of living quarters



15
16 Revenue from sale of medical and surgical supplies to other than patients



16
17 Revenue from sale of drugs to other than patients



17
18 Revenue from sale of medical records and abstracts



18
19 Tuition (fees, sale of textbooks, uniforms, etc.)



19
20 Revenue from gifts, flower, coffee shops, canteen



20
21 Rental of vending machines



21
22 Rental of skilled nursing space



22
23 Governmental appropriations



23
24 Other miscellaneous revenue (specify ______________)



24
25 Total other income (sum of lines 6 - 24)



25
26 Total (line 5 plus line 25)



26
27 Other expenses (specify ________________)



27
28




28
29




29
30 Total other expenses (sum of lines 27 - 29)



30
31 Net income (or loss) for the period (line 26 minus line 30)



31
























































































































































































































































































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












Rev.




41-353

Sheet 35: H
4190 (Cont.)



FORM CMS-2540-10





DRAFT
ANALYSIS OF SNF-BASED





PROVIDER CCN:
PERIOD :
WORKSHEET H
HOME HEALTH AGENCY COSTS







FROM ______________









HHA CCN:
TO ________________



















TRANSPOR-





NET




TATION CONTRACTED/
TOTAL
RECLASSIFIED
EXPENSES FOR



EMPLOYEE ( see PURCHASED OTHER ( sum of cols. RECLASSIFI- TRIAL BALANCE ADJUST- ALLOCATION


SALARIES BENEFITS instructions ) SERVICES COSTS 1 thru 5 ) CATIONS ( col. 6 + col. 7 ) MENTS ( col. 8 + col. 9 )

COST CENTER DESCRIPTIONS 1 2 3 4 5 6 7 8 9 10
GENERAL SERVICE COST CENTERS











1 Capital Related - Bldgs. and Fixtures









1
2 Capital Related - Movable Equipment









2
3 Plant Operation & Maintenance









3
4 Transportation (see instructions)









4
5 Administrative and General









5
HHA REIMBURSABLE SERVICES










6 Skilled Nursing Care









6
7 Physical Therapy









7
8 Occupational Therapy









8
9 Speech Pathology









9
10 Medical Social Services









10
11 Home Health Aide









11
12 Supplies (see instructions)









12
13 Drugs









13
14 DME









14
15 Telemedicine









15
HHA NONREIMBURSABLE SERVICES










16 Home Dialysis Aide Services









16
17 Respiratory Therapy









17
18 Private Duty Nursing









18
19 Clinic









19
20 Health Promotion Activities









20
21 Day Care Program









21
22 Home Delivered Meals Program









22
23 Homemaker Service









23
24 All Others









24
25 Total (sum of lines 1-24)









25













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








































































































































































































































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
























41-354










Rev.

Sheet 36: H1-I
11-12

FORM CMS-2540-10





4190 (Cont.)
COST ALLOCATION - HHA GENERAL SERVICE COST



PROVIDER CCN:
PERIOD :
WORKSHEET H-1







FROM ______________
PART I





HHA CCN:
TO ________________















NET EXPENSES CAPITAL







FOR COST RELATED COSTS







ALLOCATION

PLANT

ADMINIS-



( from Wkst. H, BLDGS. & MOVABLE OPERATION & TRANS- SUBTOTAL TRATIVE TOTAL


col. 10 ) FIXTURES EQUIPMENT MAINTENANCE PORTATION ( cols. 0 through 4 ) & GENERAL ( cols. 4A + 5 )


0 1 2 3 4 4A 5 6
GENERAL SERVICE COST CENTERS









1 Capital Related - Bldgs. and Fixtures







1
2 Capital Related - Movable Equipment







2
3 Plant Operation & Maintenance







3
4 Transportation (see instructions)







4
5 Administrative and General







5
HHA REIMBURSABLE SERVICES









6 Skilled Nursing Care







6
7 Physical Therapy







7
8 Occupational Therapy







8
9 Speech Pathology







9
10 Medical Social Services







10
11 Home Health Aide







11
12 Supplies







12
13 Drugs







13
14 DME







14
15 Telemedicine







15
HHA NONREIMBURSABLE SERVICES









16 Home Dialysis Aide Services







16
17 Respiratory Therapy







17
18 Private Duty Nursing







18
19 Clinic







19
20 Health Promotion Activities







20
21 Day Care Program







21
22 Home Delivered Meals Program







22
23 Homemaker Service







23
24 All Others







24
25 Total (sum of lines 1-24)







25






































































































































































































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




















Rev. 4








41-355

Sheet 37: H1-II
4190 (Cont.)

FORM CMS-2540-10





11-12
COST ALLOCATION - HHA STATISTICAL BASIS



PROVIDER CCN:
PERIOD :
WORKSHEET H-1,







FROM ______________
PART II





HHA CCN:
TO ________________
















CAPITAL








RELATED COSTS PLANT

ADMINIS-




BLDGS. & MOVABLE OPERATION &

TRATIVE



NET EXPENSES FIXTURES EQUIPMENT MAINTENANCE TRANS-
& GENERAL



FOR COST ( Square ( Dollar Value ( Square PORTATION RECONCIL- ( Accumulated



ALLOCATION Feet ) or Square Feet ) Feet ) ( Mileage ) IATION Cost ) TOTAL


0 1 2 3 4 5A 5 6
GENERAL SERVICE COST CENTERS









1 Capital Related - Bldgs. and Fixtures







1
2 Capital Related - Movable Equipment







2
3 Plant Operation & Maintenance







3
4 Transportation (see instructions)







4
5 Administrative and General







5
HHA REIMBURSABLE SERVICES









6 Skilled Nursing Care







6
7 Physical Therapy







7
8 Occupational Therapy







8
9 Speech Pathology







9
10 Medical Social Services







10
11 Home Health Aide







11
12 Supplies







12
13 Drugs







13
14 DME







14
15 Telemedicine







15
HHA NONREIMBURSABLE SERVICES









16 Home Dialysis Aide Services







16
17 Respiratory Therapy







17
18 Private Duty Nursing







18
19 Clinic







19
20 Health Promotion Activities







20
21 Day Care Program







21
22 Home Delivered Meals Program







22
23 Homemaker Service







23
24 All Others







24
25 Total (sum of lines 1-24)







25
26 Cost to be allocated







26
27 Unit Cost Multiplier







27





































































































































































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




















41-356








Rev. 4

Sheet 38: H2-I
11-12


FORM CMS-2540-10





4190 (Cont.) 4190 (Cont.)
FORM CMS-2540-10





11-12 11-12
FORM CMS-2540-10





4190 (Cont.)
ALLOCATION OF GENERAL SERVICE




PROVIDER CCN:
PERIOD:
WORKSHEET H-2,
ALLOCATION OF GENERAL SERVICE


PROVIDER CCN:
PERIOD:
WORKSHEET H-2,
ALLOCATION OF GENERAL SERVICE


PROVIDER CCN:
PERIOD :
WORKSHEET H-2,
COSTS TO HHA COST CENTERS






FROM __________________
PART I
COSTS TO HHA COST CENTERS




FROM __________________
PART I
COSTS TO HHA COST CENTERS




FROM ______________
PART I






HHA CCN:
TO ________________






HHA CCN:
TO ________________






HHA CCN:
TO ________________




































From
CAPITAL























Wkst. HHA RELATED COSTS


















NURSING
SUBTOTAL

ALLOCATED



H-1, TRIAL
SUBTOTAL ADMINIS-
LAUNDRY




NURSING CENTRAL
MEDICAL



AND ALLIED OTHER ( sum of POST
HHA



Pt. I, BALANCE BLDGS. & MOVABLE EMPLOYEE ( cols. 0 TRATIVE & OPERATION & LINEN


HOUSE ADMINIS- SERVICES &
RECORDS & SOCIAL


HEALTH GENERAL cols. 3A STEPDOWN SUBTOTAL A&G TOTAL


col. 6, (1) FIXTURES EQUIPMENT BENEFITS through 3 ) GENERAL OF PLANT SERVICE


KEEPING DIETARY TRATION SUPPLY PHARMACY LIBRARY SERVICE


EDUCATION SERVICE through 15 ) ADJUSTMENTS ( cols. 16 ± 17 ) ( see Pt. II ) HHA COSTS

HHA COST CENTER line 0 1 2 3 3A 4 5 6

HHA COST CENTER 7 8 9 10 11 12 13

HHA COST CENTER 14 15 16 17 18 19 20
1 Administrative and General 5







1 1 Administrative and General






1 1 Administrative and General






1
2 Skilled Nursing Care 6







2 2 Skilled Nursing Care






2 2 Skilled Nursing Care






2
3 Physical Therapy 7







3 3 Physical Therapy






3 3 Physical Therapy






3
4 Occupational Therapy 8







4 4 Occupational Therapy






4 4 Occupational Therapy






4
5 Speech Pathology 9







5 5 Speech Pathology






5 5 Speech Pathology






5
6 Medical Social Services 10







6 6 Medical Social Services






6 6 Medical Social Services






6
7 Home Health Aide 11







7 7 Home Health Aide






7 7 Home Health Aide






7
8 Supplies 12







8 8 Supplies






8 8 Supplies






8
9 Drugs 13







9 9 Drugs






9 9 Drugs






9
10 DME 14







10 10 DME






10 10 DME






10
11 Telemedicine 15







11 11 Telemedicine






11 11 Telemedicine






11
12 Home Dialysis Aide Services 16







12 12 Home Dialysis Aide Services






12 12 Home Dialysis Aide Services






12
13 Respiratory Therapy 17







13 13 Respiratory Therapy






13 13 Respiratory Therapy






13
14 Private Duty Nursing 18







14 14 Private Duty Nursing






14 14 Private Duty Nursing






14
15 Clinic 19







15 15 Clinic






15 15 Clinic






15
16 Health Promotion Activities 20







16 16 Health Promotion Activities






16 16 Health Promotion Activities






16
17 Day Care Program 21







17 17 Day Care Program






17 17 Day Care Program






17
18 Home Delivered Meals Program 22







18 18 Home Delivered Meals Program






18 18 Home Delivered Meals Program






18
19 Homemaker Service 23







19 19 Homemaker Service






19 19 Homemaker Service






19
20 All Others 24







20 20 All Others






20 20 All Others






20
21 Totals (sum of lines 1-20) (2)








21 21 Totals (sum of lines 1-20) (2)






21 21 Totals (sum of lines 1-20) (2)






21
22 Unit Cost Multiplier: column 18, line 1








22 22 Unit Cost Multiplier: column 18, line 1






22 22 Unit Cost Multiplier: column 18, line 1






22

divided by the sum of column 18,










divided by the sum of column 18,








divided by the sum of column 18,








line 21, minus column 18, line 1,










line 21, minus column 18, line 1,








line 21, minus column 18, line 1,








rounded to 6 decimal places.










rounded to 6 decimal places.








rounded to 6 decimal places.







































(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.








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










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








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








































Rev. 4









41-357 41-358







Rev. 4 Rev. 4







41-359

Sheet 39: H2-II
4190 (Cont.)


FORM CMS-2540-10





11-12 11-12
FORM CMS-2540-10





4190 (Cont.) 4190 (Cont.)
FORM CMS-2540-10





11-12
ALLOCATION OF GENERAL SERVICE




PROVIDER CCN:
PERIOD :
WORKSHEET H-2,
ALLOCATION OF GENERAL SERVICE


PROVIDER CCN:
PERIOD :
WORKSHEET H-2,
ALLOCATION OF GENERAL SERVICE


PROVIDER CCN:
PERIOD :
WORKSHEET H-2,
COSTS TO HHA COST CENTERS






FROM ______________
PART II
COSTS TO HHA COST CENTERS




FROM ______________
PART II
COSTS TO HHA COST CENTERS




FROM ______________
PART II
STATISTICAL BASIS




HHA CCN:
TO ________________


STATISTICAL BASIS


HHA CCN:
TO ________________


STATISTICAL BASIS


HHA CCN:
TO ________________






































CAPITAL















NURSING










RELATED COSTS


ADMINIS-
LAUNDRY




NURSING CENTRAL
MEDICAL



AND ALLIED










BLDGS. & MOVABLE EMPLOYEE
TRATIVE & OPERATION & LINEN


HOUSE- ADMINIS- SERVICES &
RECORDS & SOCIAL


HEALTH OTHER SUBTOTAL








FIXTURES EQUIPMENT BENEFITS
GENERAL OF PLANT SERVICE


KEEPING DIETARY TRATION SUPPLY PHARMACY LIBRARY SERVICE


EDUCATION GENERAL ( sum of POST
ALLOCATED





( Square ( Dollar Value ( Gross RECONCIL- ( Accumulated ( Square ( Pounds of


( Hours of ( Meals ( Direct ( Costed ( Costed ( Time ( Time


( Assigned SERVICE cols. 3A STEPDOWN SUBTOTAL HHA A&G TOTAL




Feet ) or Square Feet ) Salaries ) IATION Cost ) Feet ) Laundry )


Service ) Served ) Nursing Hrs. ) Requis. ) Requis. ) Spent ) Spent )


Time ) ( SPECIFY ) through 15 ) ADJUSTMENTS ( cols. 16 ± 17 ) ( see Pt. II ) HHA COSTS

HHA COST CENTER

1 2 3 4A 4 5 6

HHA COST CENTER 7 8 9 10 11 12 13

HHA COST CENTER 14 15 16 17 18 19 20
1 Administrative and General








1 1 Administrative and General






1 1 Administrative and General






1
2 Skilled Nursing Care








2 2 Skilled Nursing Care






2 2 Skilled Nursing Care






2
3 Physical Therapy








3 3 Physical Therapy






3 3 Physical Therapy






3
4 Occupational Therapy








4 4 Occupational Therapy






4 4 Occupational Therapy






4
5 Speech Pathology








5 5 Speech Pathology






5 5 Speech Pathology






5
6 Medical Social Services








6 6 Medical Social Services






6 6 Medical Social Services






6
7 Home Health Aide








7 7 Home Health Aide






7 7 Home Health Aide






7
8 Supplies








8 8 Supplies






8 8 Supplies






8
9 Drugs








9 9 Drugs






9 9 Drugs






9
10 DME








10 10 DME






10 10 DME






10
11 Telemedicine








11 11 Telemedicine






11 11 Telemedicine






11
12 Home Dialysis Aide Services








12 12 Home Dialysis Aide Services






12 12 Home Dialysis Aide Services






12
13 Respiratory Therapy








13 13 Respiratory Therapy






13 13 Respiratory Therapy






13
14 Private Duty Nursing








14 14 Private Duty Nursing






14 14 Private Duty Nursing






14
15 Clinic








15 15 Clinic






15 15 Clinic






15
16 Health Promotion Activities








16 16 Health Promotion Activities






16 16 Health Promotion Activities






16
17 Day Care Program








17 17 Day Care Program






17 17 Day Care Program






17
18 Home Delivered Meals Program








18 18 Home Delivered Meals Program






18 18 Home Delivered Meals Program






18
19 Homemaker Service








19 19 Homemaker Service






19 19 Homemaker Service






19
20 All Others








20 20 All Others






20 20 All Others






20
21 Totals (sum of lines 1-20)








21 21 Totals (sum of lines 1-20)






21 21 Totals (sum of lines 1-20)






21
22 Total cost to be allocated








22 22 Total cost to be allocated






22 22 Total cost to be allocated






22
23 Unit Cost Multiplier








23 23 Unit Cost Multiplier






23 23 Unit Cost Multiplier






23































































































































































































































































































































































































































































































































































































































































































































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










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








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








































41-360









Rev. 4 Rev. 4







41-361 41-362







Rev. 4

Sheet 40: H3
DRAFT





FORM CMS-2540-10






4190 (Cont.)
APPORTIONMENT OF PATIENT SERVICE COSTS







PROVIDER CCN:
PERIOD :
WORKSHEET H-3,












FROM ______________
Parts I & II










HHA CCN:
TO ________________




















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
Average
Program Visits

Cost of Services




Wkst. Costs Ancillary HHA
Cost
Part B

Part B
Total


H-2, ( from Costs Costs
Per Visit
Not Subject Subject
Not Subject Subject Program Cost


Pt. I, Wkst. H-2. ( from ( col. 1 + Total ( col. 3
to Deductibles to Deductibles
to Deductibles to Deductibles ( sum of


col. 20, Pt. I ) Pt. II ) col 2 ) Visits ÷ col. 4 ) Part A & Coinsurance & Coinsurance Part A & Coinsurance & Coinsurance cols. 9-10 )

Patient Services line - 1 2 3 4 5 6 7 8 9 10 11 12
1 Skilled Nursing Care 2











1
2 Physical Therapy 3











2
3 Occupational Therapy 4











3
4 Speech Pathology 5











4
5 Medical Social Services 6











5
6 Home Health Aide 7











6
7 Total (sum of lines 1-6)












7
















Patient Services by CBSA











Program Visits














Part B














Not Subject Subject











CBSA
to Deductibles to Deductibles











No. (1) Part A & Coinsurance & Coinsurance











1 2 3 4
8 Skilled Nursing Care












8
9 Physical Therapy












9
10 Occupational Therapy












10
11 Speech Pathology












11
12 Medical Social Services












12
13 Home Health Aide












13
14 Total (sum of lines 8-13)












14
















Supplies and Drugs Cost


Facility




Program Covered Charges

Cost of Services

Computations


Costs Shared
Total

Part B

Part B




From ( from Ancillary Total Charges

Not Subject Subject
Not Subject Subject



Wkst. H-2, Wkst. Costs HHA ( from Ratio
to to
to to



Pt. I, H-2, ( from Cost HHA ( col. 3
Deductibles & Deductibles &
Deductibles & Deductibles &



col. 20, Pt. I ) Pt. II ) ( cols. 1 + 2 ) records ) ÷ col. 4 ) Part A Coinsurance Coinsurance Part A Coinsurance Coinsurance

Other Patient Services
line - 1 2 3 4 5 6 7 8 9 10 11
15 Cost of Medical Supplies
8










15
16 Cost of Drugs
9










16
















PART II - APPORTIONMENT OF COST OF HHA SERVICES FURNISHED BY SHARED SKILLED NURSING FACILITY DEPARTMENTS





















From Cost to Charge
Total HHA Charges
HHA Shared Ancillary Costs
Transfer to







Wkst. C, Ratio
( from provider records )
( col. 1 x col. 2 )
Pt. 1 -







col. 3, line - 1
2
3
4
1 Physical Therapy




44





col. 2, line 2 1
2 Occupational Therapy




45





col. 2, line 3 2
3 Speech Pathology




46





col. 2, line 4 3
4 Cost of Medical Supplies




48





col. 2, line 15 4
5 Cost of Drugs




49





col. 2, line 16 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.













41-363

Sheet 41: H4
4190 (Cont.)


FORM CMS-2540-10


DRAFT
CALCULATION OF SNF-BASED HHA



PROVIDER CCN: PERIOD : WORKSHEET H-4,
REIMBURSEMENT SETTLEMENT




FROM ______________ Parts I & II





HHA CCN: TO ________________




















Check applicable box: [ ] Title V [ ] Title XVIII
[ ] Title XIX











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













Part B






Not Subject to Subject to






Deductibles Deductibles





Part A & Coinsurance & Coinsurance

Description


1 2 3
Reasonable Cost of Part A & Part B Services







1 Reasonable cost of services (see instructions)





1
2 Total charges





2
Customary Charges







3 Amount actually collected from patients liable for payment





3

for services on a charge basis (from your records)






4 Amount that would have been realized from patients liable





4

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)





5
6 Total customary charges (see instructions)





6
7 Excess of total customary charges over total reasonable





7

cost (complete only if line 6 exceeds line 1)






8 Excess of reasonable cost over customary charges





8

(complete only if line 1 exceeds line 6)






9 Primary payer amounts





9


















PART II - COMPUTATION OF SNF-BASED HHA REIMBURSEMENT SETTLEMENT













Part A Services Part B Services

Description



1 2
10 Total reasonable cost (see instructions)





10
11 Total PPS Reimbursement - Full Episodes without Outliers





11
12 Total PPS Reimbursement - Full Episodes with Outliers





12
13 Total PPS Reimbursement - LUPA Episodes





13
14 Total PPS Reimbursement - PEP Episodes





14
15 Total PPS Outlier Reimbursement - Full Episodes with Outliers





15
16 Total PPS Outlier Reimbursement - PEP Episodes





16
17 Total Other Payments





17
18 DME Payments





18
19 Oxygen Payments





19
20 Prosthetic and Orthotic Payments





20
21 Part B deductibles billed to Medicare patients (exclude coinsurance)





21
22 Subtotal (sum of lines 10 through 20 minus line 21)





22
23 Excess reasonable cost (from line 8)





23
24 Subtotal (line 22 minus line 23)





24
25 Coinsurance billed to program patients (from your records)





25
26 Net cost (line 24 minus line 25)





26
27 Reimbursable bad debts (from your records)





27
28 Reimbursable bad debts for dual eligible beneficiaries (see instructions)





28
29 Total costs - current cost reporting period (line 26 plus line 27)





29
30 Other adjustments (see instructions) (specify)





30
30.99 Sequestration amount (see instructions)





30.99
31 Subtotal (see instructions)





31
32 Interim payments (see instructions)





32
33 Tentative settlement (for contractor use only)





33
34 Balance due provider/program (see instructions)





34
35 Protested amounts (nonallowable cost report items) in accordance with





35

CMS Pub. 15-2, section 115.2






















































































































































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
















41-364






Rev.

Sheet 42: H5
DRAFT
FORM CMS-2540-10




4190 (Cont.)
ANALYSIS OF PAYMENTS TO SNF-BASED



PROVIDER CCN: PERIOD : WORKSHEET H-5
HHA FOR SERVICES




FROM ______________

RENDERED TO PROGRAM BENEFICIARIES



HHA CCN: TO ________________














Part A Part B




mm/dd/yyyy Amount mm/dd/yyyy Amount

Description

1 2 3 4
1 Total interim payments paid to provider





1
2 Interim payments payable on individual bills, either submitted





2

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





3.01

adjustment amount based on subsequent revision of Program .02



3.02

the interim rate for the cost reporting period to .03



3.03

Also show date of each payment. Provider .04



3.04

If none, write "NONE," or enter a zero. (1)
.05



3.05



.50



3.50

Provider .51



3.51


to .52



3.52

Program .53



3.53



.54



3.54

SUBTOTAL (sum of lines 3.01 - 3.49 minus sum of lines 3.50 - 3.98)
.99



3.99
4 TOTAL INTERIM PAYMENTS (sum of lines 1, 2, and 3.99)





4

(Transfer to Wkst. H-4, Part II, column as appropriate, line 32)
















TO BE COMPLETED BY CONTRACTOR






5 List separately each tentative settlement Program .01



5.01

payment after desk review. Also show to .02



5.02

date of each payment. Provider .03



5.03

If none, write "NONE," or enter a zero. (1) Provider .50



5.50


to .51



5.51


Program .52



5.52

SUBTOTAL (sum of lines 5.01 - 5.49 minus sum of lines 5.50 - 5.98)
.99



5.99
6 Determine net settlement amount (balance Program to Provider .01



6.01

due) based on the cost report (1) Provider to Program .02



6.02
7 TOTAL MEDICARE PROGRAM LIABILITY (see instructions)





7
8 Name of Contractor
Contractor Number



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 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4146)
















Rev.






41-365

Sheet 43: I1
4190 (Cont.)


FORM CMS-2540-10




DRAFT
ANALYSIS OF SNF-BASED RHC/FQHC COSTS



PROVIDER CCN:
PERIOD :
WORKSHEET I-1







FROM ______________







RHC/FQHC CCN:
TO ________________

























Check applicable box: [ ] RHC [ ] FQHC
























RECLASSIFIED
NET EXPENSES







TRIAL
FOR



COMPEN- OTHER TOTAL RECLASSIFI- BALANCE
ALLOCATION



SATION COSTS ( col. 1 + col. 2 ) CATIONS ( col. 3 +/- col. 4 ) ADJUSTMENTS ( col. 5 +/- col.6 )



1 2 3 4 5 6 7
HEALTH CARE STAFF COSTS









1 Physician







1
2 Physician Assistant







2
3 Nurse Practitioner







3
4 Visiting Nurse







4
5 Other Nurse







5
6 Clinical Psychologist







6
7 Clinical Social Worker







7
8 Laboratory Technician







8
9 Other health care staff costs







9
10 Subtotal (sum of lines 1 - 9)







10
COSTS UNDER AGREEMENT









11 Physician Services Under Agreement







11
12 Physician Supervision Under Agreement







12
13 Other costs under agreement







13
14 Subtotal (sum of lines 11 - 13)







14
OTHER HEALTH CARE COSTS









15 Medical Supplies







15
16 Transportation (Health Care Staff)







16
17 Depreciation - Medical Equipment







17
18 Professional Liability Insurance







18
19 Other health care costs







19
21 Subtotal (sum of lines 15 - 19)







21
22 Total cost of health care services







22

(sum of lines 10, 14, and 21)








COSTS OTHER THAN RHC / FQHC SERVICES









23 Pharmacy







23
24 Dental







24
25 Optometry







25
26 All other non reimbursable costs







26
28 Total nonreimbursable costs (sum of lines 23 - 26)







28
RHC/FQHC OVERHEAD









29 RHC/FQHC costs







29
30 Administrative costs







30
31 Total RHC/FQHC overhead (sum of lines 29-30)







31
32 Total RHC/FQHC costs (sum of lines 22, 28 and 31)







32











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











































































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




















41-366








Rev.

Sheet 44: I2
DRAFT


FORM CMS-2540-10




4190 (Cont. )
ALLOCATION OF OVERHEAD



PROVIDER CCN:
PERIOD :
WORKSHEET I-2
TO SNF-BASED RHC/FQHC SERVICES





FROM ______________







RHC/FQHC CCN:
TO ________________

























Check applicable box: [ ] RHC [ ] FQHC

















PART I - VISITS AND PRODUCTIVITY














Number
Productivity Minimum Greater of





of FTE Total Standard Visits Column 2 or





Personnel Visits (1) ( col. 1 x col. 3 ) Column 4





1 2 3 4 5
1 Physicians




4200

1
2 Physician Assistants




2100

2
3 Nurse Practitioners




2100

3
4 Subtotal (sum of lines 1 - 3)







4
5 Visiting Nurse







5
6 Clinical Psychologist







6
7 Clinical Social Worker







7
8 Medical Nutrition Therapist (FQHC only)







8
9 Diabetes Self Management Training (FQHC only)







9
10 Total FTEs and visits (sum of lines 4 - 9)







10
11 Physician Services Under Agreements







11






















PART II - DETERMINATION OF TOTAL ALLOWABLE COST APPLICABLE TO SNF-BASED RHC / FQHC SERVICES









12 Total costs of health care services (from Wkst. I-1, col. 7, line 22)







12
13 Total nonreimbursable costs (from Wkst I-1, col 7, line 28)







13
14 Cost of all services - excluding overhead (sum of lines 12 and 13)







14
15 Ratio of RHC/FQHC services (line 12 divided by line 14)







15
16 Total RHC/FQHC overhead (from Wkst. I-1, col. 7, line 31)







16
17 Parent provider overhead allocated to RHC/FQHC (see instructions)







17
18 Total overhead (sum of lines 16 and 17)







18
19 Overhead applicable to RHC/FQHC services (lines 15 X line 18)







19
20 Total allowable cost of RHC/FQHC services (sum of lines 12 and 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 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4149)




















Rev.








41-367

Sheet 45: I3
4190 (Cont.)


FORM CMS-2540-10


DRAFT
CALCULATION OF REIMBURSEMENT



PROVIDER CCN: PERIOD : WORKSHEET I-3
SETTLEMENT FOR SNF-BASED RHC/FQHC SERVICES




FROM ______________






RHC/FQHC CCN: TO ________________




















Check applicable box: [ ] Title V [ ] Title XVIII [ ] Title XIX




Check applicable box: [ ] RHC
[ ] FQHC





















PART I - DETERMINATION OF RATE FOR SNF-BASED RHC/FQHC SERVICES







1 Total allowable cost of RHC/FQHC services (from Wkst. I-2, Pt. II, line 20)





1
2 Cost of vaccines and their administration (from Wkst. I-4, line 15)





2
3 Total allowable cost excluding vaccine (line 1 minus line 2)





3
4 Total FTEs and visits (from Wkkst. I-2, col. 5, line 10)





4
5 Physicians' visits under agreement (from Wkst. I-2, col. 5, line 11)





5
6 Total adjusted visits (line 4 plus line 5)





6
7 Adjusted cost per visit (line 3 divided by line 6)





7









CALCULATION OF LIMIT




Prior to On or after
Lines 8 through 14: Fiscal year RHC/FQHC use columns 1 and 2.




January 1 January 1
Lines 8 through 14: Calendar year RHC/FQHC use column 2 only.




1 2
8 Rate per visit limit (from your contractor)





8
9 Rate for Program covered visits (see instructions)





9


















PART II - CALCULATION OF SETTLEMENT FOR SNF-BASED RHC/FQHC SERVICES







10 Program covered visits excluding mental health services (from contractor records)





10
11 Program cost excluding costs for mental health services (line 9 x line 10)





11
12 Program covered visits for mental health services (from contractor records)





12
13 Program covered cost for mental health services (line 9 x line 12)





13
14 Limit adjustment for mental health services (see instructions)





14
15 Total Program cost (sum of line 11 cols. 1 and 2, plus line 14 cols. 1 and 2)





15
15.01 Total Program charges (see instructions) (from contractor records)





15.01
15.02 Total Program preventive charges (see instructions) (from provider records)





15.02
15.03 Total Program preventive costs ((line 15.02/line 15.01) times line 15)





15.03
15.04 Total Program non-preventive costs ((line 15 minus lines 15.03 and 17) times .80)





15.04
15.05 Total Program cost (see instructions)





15.05
16 Primary payer amounts





16
17 Less: Beneficiary deductible for RHC only (see instructions) (from contractor records)





17
18 Less: Beneficiary coinsurance for RHC/FQHC services (see instructions) (from contractor records)





18
19 Net Program cost excluding vaccines (see instructions)





19
20 Program cost of vaccines and their administration (from Wkst. I -4, line 16)





20
21 Total reimbursable Program cost (line 19 plus 20)





21
22 Reimbursable bad debts





22
22.01 Adjusted reimbursable bad debts (see instructions)





22.01
23 Reimbursable bad debts for dual eligible beneficiaries (see instructions)





23
24 Other adjustments





24
25 Net reimbursable amount (see instructions)





25
25.01 Sequestration amount (see instructions)





25.01
26 Interim payments (from Wkst. I-5, line 4)





26
27 Tentative settlement (for contractor use only)





27
28 Balance due RHC/FQHC/Program (see instructions)





28
29 Protested amounts (nonallowable cost report items) in accordance with CMS Publ. 15-2, § 115.2





29
























































































































































































































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
















41-368






Rev.

Sheet 46: I4
DRAFT


FORM CMS-2540-10


4190 (Cont.)
COMPUTATION OF SNF-BASED RHC/FQHC PNEUMOCOCCAL



PROVIDER CCN: PERIOD : WORKSHEET I-4
AND INFLUENZA VACCINE COST




FROM ______________






RHC/FQHC CCN: TO ________________




















Check applicable box: [ ] Title V [ ] Title XVIII [ ] Title XIX




Check applicable box: [ ] RHC
[ ] FQHC





















CALCULATION OF COST




PNEUMOCOCCAL INFLUENZA






1 2
1 Health care staff cost (from Wkst. I-1, col. 7, line 10)





1
2 Ratio of pneumococcal and influenza vaccine staff time to total health care staff time





2
3 Pneumococcal and influenza vaccine health care staff cost (line 1 x line 2)





3
4 Medical supplies cost - pneumococcal and influenza vaccine (from your records)





4
5 Direct cost of pneumococcal and influenza vaccine (sum of lines 3 and 4)





5
6 Total direct cost of the RHC/FQHC (from Wkst. I-1, col. 7, line 22)





6
7 Total overhead (from Wkst. I-2, line 19)





7
8 Ratio of pneumococcal and influenza vaccine direct cost to total direct cost (line 5 divided by line 6)





8
9 Overhead cost - pneumococcal and influenza vaccine (line 7 x line 8)





9
10 Total pneumococcal and influenza vaccine cost and its (their) administration (sum of lines 5 and 9)





10
11 Total number of pneumococcal and influenza vaccine injections (from your records)





11
12 Cost per pneumococcal and influenza vaccine injection (line 10 divided by line 11)





12
13 Number of pneumococcal and influenza vaccine injections administered to Medicare beneficiaries





13
14 Medicare cost of pneumococcal and influenza vaccine and their administration (line 12 x line 13)





14
15 Total cost of pneumococcal and influenza vaccine and its (their) administration (sum of





15

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





16

cols. 1 and 2, line 14) (transfer to Wkst. I-3, line 20)





















































































































































































































































































































































































































































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
















Rev.






41-369

Sheet 47: I5
4190 (Cont. )

FORM CMS-2540-10



DRAFT
ANALYSIS OF PAYMENTS TO


PROVIDER CCN:
PERIOD : WORKSHEET I - 5
SNF-BASED RHC/FQHC FOR SERVICES RENDERED




FROM ______________





RHC/FQHC CCN:
TO ________________




















Check applicable box: [ ] RHC
[ ] FQHC


























mm/dd/yyyy Amount

Description



1 2
1 Total interim payments paid to RHC/FQHC





1
2 Interim payments payable on individual bills, either submitted





2

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


.01

3.01

adjustment amount based on subsequent revision of

Program .02

3.02

the interim rate for the cost reporting period

to .03

3.03

Also show date of each payment.

RHC/FQHC .04

3.04

If none, write "NONE," or enter a zero. (1)


.05

3.05





.50

3.50




RHC/FQHC .51

3.51




to .52

3.52




Program .53

3.53





.54

3.54

SUBTOTAL (sum of lines 3.01 - 3.49 minus sum of lines 3.50 - 3.98)


.99

3.99
4 TOTAL INTERIM PAYMENTS (sum of lines 1, 2, and 3.99)





4

(Transfer to Wkst. I-3, line 26)
















TO BE COMPLETED BY CONTRACTOR






5 List separately each tentative settlement

Program .01

5.01

payment after desk review. Also show

to .02

5.02

date of each payment.

RHC/FQHC .03

5.03

If none, write "NONE," or enter a zero. (1)

RHC/FQHC .50

5.50




to .51

5.51




Program .52

5.52

SUBTOTAL (sum of lines 5.01 - 5.49 minus sum of lines 5.50 - 5.98)


.99

5.99
6 Determine net settlement amount (balance

Program to RHC/FQHC .01

6.01

due) based on the cost report (1)

RHC/FQHC to Program .02

6.02
7 TOTAL MEDICARE PROGRAM LIABILITY (see instructions)





7
8 Name of Contractor


Contractor Number

8


















(1) On lines 3, 5, and 6, where an amount is due "RHC/FQHC to Program," show the amount and date on which the








RHC/FQHC agrees to the amount of repayment, even though total repayment is not accomplished until a later date.















































































































































































































































































































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
















41-370






Rev.

Sheet 48: J1-I
11-12

FORM CMS-2540-10




4190 (Cont.) 4190 (Cont.)

FORM CMS-2540-10




11-12 11-12

FORM CMS-2540-10




4190 (Cont.) 4190 (Cont. )

FORM CMS-2540-10




11-12
ALLOCATION OF GENERAL SERVICE COSTS


PROVIDER CCN:
PERIOD :
WORKSHEET J-1
ALLOCATION OF GENERAL SERVICE COSTS


PROVIDER CCN:
PERIOD :
WORKSHEET J-1
ALLOCATION OF GENERAL SERVICE COSTS


PROVIDER CCN:
PERIOD :
WORKSHEET J-1
ALLOCATION OF GENERAL SERVICE COSTS


PROVIDER CCN:
PERIOD :
WORKSHEET J-1
TO COST CENTERS FOR CMHC




FROM ______________
PART I
TO COST CENTERS FOR CMHC




FROM ______________
PART I
TO COST CENTERS FOR CMHC




FROM ______________
PART I
TO COST CENTERS FOR CMHC




FROM ______________
PART I




COMPONENT CCN:
TO ________________






COMPONENT CCN:
TO ________________






COMPONENT CCN:
TO ________________






COMPONENT CCN:
TO ________________





















































































NET



ADMINIS-




PLANT











NURSING &














EXPENSES CAPITAL RELATED COST

SUBTOTAL TRATIVE




OPERATION LAUNDRY

NURSING



CENTRAL
MEDICAL
ALLIED OTHER





POST
ALLOCATED TOTAL



FOR COST BUILDS. & MOVABLE EMPLOYEE ( cols. 0 &




MAINTENANCE & LINEN HOUSE -
ADMINIS-



SERVICES
RECORDS SOCIAL HEALTH GENERAL





STEP-DOWN
A & G ( sum of cols.



ALLOCATION FIXTURES EQUIPMENT BENEFITS through 3 ) GENERAL




& REPAIRS SERVICE KEEPING DIETARY TRATION



& SUPPLY PHARMACY & LIBRARY SERVICES EDUCATION SERVICE




SUBTOTAL ADJUSTMENTS SUBTOTAL ( see Pt. II ) 18 and 19 ()

COMPONENT COST CENTER
0 1 2 3 3A 4

COMPONENT COST CENTER

5 6 7 8 9

COMPONENT COST CENTER
10 11 12 13 14 15

COMPONENT COST CENTER

16 17 18 19 20
1 Administrative and General






1 1 Administrative and General






1 1 Administrative and General






1 1 Administrative and General






1
2 Skilled Nursing Care






2 2 Skilled Nursing Care






2 2 Skilled Nursing Care






2 2 Skilled Nursing Care






2
3 Physical Therapy






3 3 Physical Therapy






3 3 Physical Therapy






3 3 Physical Therapy






3
4 Occupational Therapy






4 4 Occupational Therapy






4 4 Occupational Therapy






4 4 Occupational Therapy






4
5 Speech Pathology






5 5 Speech Pathology






5 5 Speech Pathology






5 5 Speech Pathology






5
6 Medical Social Services






6 6 Medical Social Services






6 6 Medical Social Services






6 6 Medical Social Services






6
7 Respiratory Therapy






7 7 Respiratory Therapy






7 7 Respiratory Therapy






7 7 Respiratory Therapy






7
8 Psychiatric/Psychological Services






8 8 Psychiatric/Psychological Services






8 8 Psychiatric/Psychological Services






8 8 Psychiatric/Psychological Services






8
9 Individual Therapy






9 9 Individual Therapy






9 9 Individual Therapy






9 9 Individual Therapy






9
10 Group Therapy






10 10 Group Therapy






10 10 Group Therapy






10 10 Group Therapy






10
11 Individualized Activity Therapy






11 11 Individualized Activity Therapy






11 11 Individualized Activity Therapy






11 11 Individualized Activity Therapy






11
12 Family Counseling






12 12 Family Counseling






12 12 Family Counseling






12 12 Family Counseling






12
13 Diagnostic Services






13 13 Diagnostic Services






13 13 Diagnostic Services






13 13 Diagnostic Services






13
14 Appr. Patient Training & Education






14 14 Appr. Patient Training & Education






14 14 Appr. Patient Training & Education






14 14 Appr. Patient Training & Education






14
15 Prosthetic and Orthotic Devices






15 15 Prosthetic and Orthotic Devices






15 15 Prosthetic and Orthotic Devices






15 15 Prosthetic and Orthotic Devices






15
16 Drugs and Biologicals






16 16 Drugs and Biologicals






16 16 Drugs and Biologicals






16 16 Drugs and Biologicals






16
17 Medical Supplies






17 17 Medical Supplies






17 17 Medical Supplies






17 17 Medical Supplies






17
18 Medical Appliances






18 18 Medical Appliances






18 18 Medical Appliances






18 18 Medical Appliances






18
19 Durable Medical Equipment - Rented






19 19 Durable Medical Equipment - Rented






19 19 Durable Medical Equipment - Rented






19 19 Durable Medical Equipment - Rented






19
20 Durable Medical Equipment - Sold






20 20 Durable Medical Equipment - Sold






20 20 Durable Medical Equipment - Sold






20 20 Durable Medical Equipment - Sold






20
21 All Other






21 21 All Other






21 21 All Other






21 21 All Other






21
22 Totals (sum of lines 1-21) (1)






22 22 Totals (sum of lines 1-21) (1)






22 22 Totals (sum of lines 1-21) (1)






22 22 Totals (Sum of lines 1-21) (1)






22
23 Unit Cost Multiplier (see instructions)






23 23 Unit Cost Multiplier (see instructions)






23 23 Unit Cost Multiplier (see instructions)






23 23 Unit Cost Multiplier (see instructions)






23








































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








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








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








(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)








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








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








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
















































Rev. 4







41-371 41-372







Rev. 4 Rev. 4







41-373 41-374







Rev. 4

Sheet 49: J1-II
11-12

FORM CMS-2540-10




4190 (Cont.) 4190 (Cont.)

FORM CMS-2540-10




11-12 11-12

FORM CMS-2540-10




4190 (Cont.)
ALLOCATION OF GENERAL SERVICE COSTS


PROVIDER CCN:
PERIOD :
WORKSHEET J-1
ALLOCATION OF GENERAL SERVICE COSTS


PROVIDER CCN:
PERIOD :
WORKSHEET J-1
ALLOCATION OF GENERAL SERVICE COSTS


PROVIDER CCN:
PERIOD :
WORKSHEET J-1
TO COST CENTERS FOR CMHC




FROM ______________
PART II
TO COST CENTERS FOR CMHC




FROM ______________
PART II
TO COST CENTERS FOR CMHC




FROM ______________
PART II




COMPONENT CCN:
TO ________________






COMPONENT CCN:
TO ________________






COMPONENT CCN:
TO ________________


































































CAPITAL RELATED


ADMINIS-




PLANT LAUNDRY

NURSING



CENTRAL


NURSING &






MOVABLE

TRATIVE




OPERATION & LINEN HOUSE -
ADMINIS-



SERVICES
MEDICAL
ALLIED OTHER




BUILDS. EQUIPMENT EMPLOYEE
& GENERAL




MAINTENANCE SERVICE KEEPING DIETARY TRATION



& SUPPLY PHARMACY RECORDS & SOCIAL HEALTH GENERAL




& FIXTURES ( Dollar Value or BENEFITS RECONCIL- ( Accumulated




& REPAIRS ( Pounds of ( Hours of ( Meals ( Direct Nursing



( Costed ( Costed LIBRARY SERVICES EDUCATION SERVICE




( Square Feet ) Square Feet ) ( Gross Salaries ) IATION Cost )




( Square Feet ) Laundry ) Service ) Served ) Hours of Service )



Requisitions ) Requisitions ) ( Time Spent ) ( Time Spent ) ( Assigned Time ) ( )

COMPONENT COST CENTER

1 2 3 4A 4

COMPONENT COST CENTER

5 6 7 8 9

COMPONENT COST CENTER
10 11 12 13 14 15
1 Administrative and General






1 1 Administrative and General






1 1 Administrative and General






1
2 Skilled Nursing Care






2 2 Skilled Nursing Care






2 2 Skilled Nursing Care






2
3 Physical Therapy






3 3 Physical Therapy






3 3 Physical Therapy






3
4 Occupational Therapy






4 4 Occupational Therapy






4 4 Occupational Therapy






4
5 Speech Pathology






5 5 Speech Pathology






5 5 Speech Pathology






5
6 Medical Social Services






6 6 Medical Social Services






6 6 Medical Social Services






6
7 Respiratory Therapy






7 7 Respiratory Therapy






7 7 Respiratory Therapy






7
8 Psychiatric/Psychological Services






8 8 Psychiatric/Psychological Services






8 8 Psychiatric/Psychological Services






8
9 Individual Therapy






9 9 Individual Therapy






9 9 Individual Therapy






9
10 Group Therapy






10 10 Group Therapy






10 10 Group Therapy






10
11 Individualized Activity Therapy






11 11 Individualized Activity Therapy






11 11 Individualized Activity Therapy






11
12 Family Counseling






12 12 Family Counseling






12 12 Family Counseling






12
13 Diagnostic Services






13 13 Diagnostic Services






13 13 Diagnostic Services






13
14 App. Patient Training & Education






14 14 App. Patient Training & Education






14 14 App. Patient Training & Education






14
15 Prosthetic and Orthotic Devices






15 15 Prosthetic and Orthotic Devices






15 15 Prosthetic and Orthotic Devices






15
16 Drugs and Biologicals






16 16 Drugs and Biologicals






16 16 Drugs and Biologicals






16
17 Medical Supplies






17 17 Medical Supplies






17 17 Medical Supplies






17
18 Medical Appliances






18 18 Medical Appliances






18 18 Medical Appliances






18
19 Durable Medical Equipment - Rented






19 19 Durable Medical Equipment - Rented






19 19 Durable Medical Equipment - Rented






19
20 Durable Medical Equipment - Sold






20 20 Durable Medical Equipment - Sold






20 20 Durable Medical Equipment - Sold






20
21 All Other






21 21 All Other






21 21 All Other






21
22 Totals (sum of lines 1-21)






22 22 Totals (sum of lines 1-21)






22 22 Totals (sum of lines 1-21)






22
23 Total cost to be allocated






23 23 Total cost to be allocated






23 23 Total cost to be allocated






23
24 Unit Cost Multiplier






24 24 Unit Cost Multiplier






24 24 Unit Cost Multiplier






24






















































































































































































































































































































































































































































































































































































































































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








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








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






































Rev. 4







41-375 41-376







Rev. 4 Rev. 4







41-377

Sheet 50: J2
4190 (Cont.)



FORM CMS-2540-10





11-12
COMPUTATION OF CMHC





PROVIDER CCN:
PERIOD :
WORKSHEET J - 2
REHABILITATION COSTS







FROM ______________
PART I







COMPONENT CCN:
TO ________________









































PART I - APPORTIONMENT OF CMHC COST CENTERS














Total Costs
Ratio of Title V
Title XVIII
Title XIX




( from Wkst. J-1, Total Costs to
Costs
Costs
Costs



Pt. I, col. 20 ) Charges Charges Charges ( col. 3 x col. 4 ) Charges ( col. 3 x col. 6 ) Charges ( col. 3 x col. 8 )



1 2 3 4 5 6 7 8 9
1 Administrative and General









1
2 Skilled Nursing Care









2
3 Physical Therapy









3
4 Occupational Therapy









4
5 Speech Pathology









5
6 Medical Social Services









6
7 Respiratory Therapy









7
8 Psychiatric/Psychological Services









8
9 Individual Therapy









9
10 Group Therapy









10
11 Individualized Activity Therapy









11
12 Family Counseling









12
13 Diagnostic Services









13
14 App. Patient Training & Education









14
15 Prosthetic and Orthotic Devices









15
16 Drugs and Biologicals









16
17 Medical Supplies









17
18 Medical Appliances









18
19 Durable Medical Equipment - Rented









19
20 Durable Medical Equipment - Sold









20
21 All Other









21
22 Totals (sum of lines 2-21)









22











































































































































































































































































































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
























41-378










Rev. 4













DRAFT



FORM CMS-2540-10





4190 (Cont.)
COMPUTATION OF CMHC





PROVIDER CCN:
PERIOD :
WORKSHEET J - 2
REHABILITATION COSTS







FROM ______________
PART II







COMPONENT CCN:
TO ________________









































PART II - APPORTIONMENT OF COST OF CMHC SERVICES FURNISHED BY SHARED DEPARTMENTS
















Ratio of Title V
Title XVIII
Title XIX






Costs to
Costs
Costs
Costs





Charges Charges ( col. 3 x col. 4 ) Charges ( col. 3 x col. 6 ) Charges ( col. 3 x col. 8 )





3 4 5 6 7 8 9
23 Oxygen (Inhalation) Therapy









23
24 Physical Therapy









24
25 Occupational Therapy









25
26 Speech Pathology









26
27 Medical Supplies Charged to Patients









27
28 Drugs Charged to Patients









28
29 Other Costs Furnished by shared Departments









29
30 Total (sum of lines 23 through 29)









30
31 Total component cost (sum of Pt. I, line 22 and Pt. II, line 30)









31

(Transfer to Wkst. J-3)























(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. 6










41-379

Sheet 51: J3
4190 (Cont.)


FORM CMS-2540-10



DRAFT
CALCULATION OF REIMBURSEMENT SETTLEMENT



PROVIDER CCN:
PERIOD : WORKSHEET J-3
FOR SNF-BASED COMMUNITY MENTAL HEALTH CENTER





FROM ______________

SERVICES



COMPONENT CCN:
TO ________________






















Check applicable box: [ ] Title V [ ] Title XVIII [ ] Title XIX






















PROGRAM








COST
1 Cost of component services (from Wkst. J-2, Pt. II, line 31)






1
2 PPS payments received excluding outliers






2
3 Outlier payments






3
4 Primary payer payments






4
5 Total reasonable cost (see instructions)






5
CUSTOMARY CHARGES








6 Total charges for program services






6
7 Excess of customary charges over reasonable cost (see instructions)






7
8 Excess of reasonable cost over customary charges (see instructions)






8
COMPUTATION OF REIMBURSEMENT SETTLEMENT








9 Total reasonable cost (see instructions)






9
10 Part B deductible billed to program patients






10
11 Part B coinsurance billed to program patients (from provider records)






11
12 Net cost (line 9 minus lines 10 and 11)






12
13 Reimbursable bad debts (from provider records) (see instructions)






13
13.01 Adjusted reimbursable bad debts (see instructions)






13.01
14 Reimbursable bad debts for dual eligible beneficiaries (see instructions)






14
15 Net reimbursable amount (see instructions)






15
16 Other adjustments (see instructions) (specify)






16
17 Total cost (line 15 plus or minus line 16)






17
17.01 Sequestration amount (see instructions)






17.01
18 Interim payments (see instructions)






18
19 Tentative settlement (for contractor use only)






19
20 Balance due component/program (see instructions)






20
21 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2






21
























































































































































































































































































































































































































































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


















41-380







Rev.

Sheet 52: J4
DRAFT
FORM CMS-2540-10



4190 (Cont.)
ANALYSIS OF PAYMENTS TO

PROVIDER CCN:
PERIOD : WORKSHEET J - 4
SNF-BASED CMHC



FROM ______________

FOR SERVICES RENDERED

COMPONENT CCN:
TO ________________

TO PROGRAM BENEFICIARIES











mm/dd/yyyy Amount

Description


1 2
1 Total interim payments paid to CMHC




1
2 Interim payments payable on individual bills, either submitted




2

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

.01

3.01

adjustment amount based on subsequent revision of
Program .02

3.02

the interim rate for the cost reporting period
to .03

3.03

Also show date of each payment.
Provider .04

3.04

If none, write "NONE," or enter a zero. (1)

.05

3.05




.50

3.50



Provider .51

3.51



to .52

3.52



Program .53

3.53




.54

3.54

SUBTOTAL (sum of lines 3.01 - 3.49 minus sum of lines 3.50 - 3.98)

.99

3.99
4 TOTAL INTERIM PAYMENTS (sum of lines 1, 2, and 3.99)




4

(Transfer to Wkst. J-3: Pt. I, line 18)














TO BE COMPLETED BY CONTRACTOR





5 List separately each tentative
Program .01

5.01

settlement payment after desk review.
to .02

5.02



Provider .03

5.03

Also show date of each payment.
Provider .50

5.50

If none, write "NONE," or enter a zero. (1)
to .51

5.51



Program .52

5.52

SUBTOTAL (sum of lines 5.01 - 5.49 minus sum of lines 5.50 - 5.98)

.99

5.99
6 Determine net settlement amount (balance
Program to Provider .01

6.01

due) based on the cost report (1)
Provider to Program .02

6.02
7 TOTAL MEDICARE PROGRAM LIABILITY (see instructions)




7
8 Name of Contractor

Contractor Number

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 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4156)














Rev.





41-381

Sheet 53: K
4190 (Cont.)


FORM CMS-2540-10






11-12
ANALYSIS OF HOSPICE COSTS





PROVIDER CCN:
PERIOD :
WORKSHEET K









FROM ______________









HOSPICE CCN:
TO ________________




















CON-









EMPLOYEE
TRACTED








SALARIES BENEFITS TRANSPOR- SERVICES
TOTAL
SUBTOTAL
TOTAL


( from ( from TATION ( from
( cols. 1 RECLASSI- ( col. 6 ADJUST- ( col. 8


Wkst. K-1 ) Wkst. K-2 ) ( see instruct. ) Wkst. K-3 ) OTHER through 5 ) FICATION ± col. 7 ) MENTS ± col. 9 )

COST CENTER DESCRIPTIONS 1 2 3 4 5 6 7 8 9 10
GENERAL SERVICE COST CENTERS











1 Capital Related Costs-Bldg. and Fixt.








1
2 Capital Related Costs-Movable Equip.








2
3 Plant Operation and Maintenance









3
4 Transportation - Staff









4
5 Volunteer Service Coordination









5
6 Administrative and General









6
INPATIENT CARE SERVICE











7 Inpatient - General Care









7
8 Inpatient - Respite Care









8
VISITING SERVICES











9 Physician Services









9
10 Nursing Care









10
11 Nursing Care-Continuous Home Care









11
12 Physical Therapy









12
13 Occupational Therapy









13
14 Speech/ Language Pathology









14
15 Medical Social Services









15
16 Spiritual Counseling





16
17 Dietary Counseling









17
18 Counseling - Other









18
19 Home Health Aide and Homemaker









19
20 HH Aide & Homemaker-Cont. Home Care









20
21 Other









21
OTHER HOSPICE SERVICE COSTS











22 Drugs, Biological and Infusion Therapy









22
23 Analgesics









23
24 Sedatives / Hypnotics









24
25 Other - Specify









25
26 Durable Medical Equipment/Oxygen









26
27 Patient Transportation









27
28 Imaging Services









28
29 Labs and Diagnostics









29
30 Medical Supplies









30
31 Outpatient Services (including E/R Dept.)









31
32 Radiation Therapy









32
33 Chemotherapy









33
34 Other









34
HOSPICE NONREIMBURSABLE SERVICE











35 Bereavement Program Costs









35
36 Volunteer Program Costs









36
37 Fundraising









37
38 Other Program Costs









38
39 Total (sum of lines 1 through 38)









39

























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
























41-382










Rev.

Sheet 54: K1
11-12


FORM CMS-2540-10





4190 (Cont.)
HOSPICE COMPENSATION ANALYSIS




PROVIDER CCN:
PERIOD :
WORKSHEET K-1
SALARIES AND WAGES






FROM ______________








HOSPICE CCN:
TO ________________
















ADMINIS-
SOCIAL SUPER-
TOTAL





TRATOR DIRECTOR SERVICES VISORS NURSES THERAPISTS AIDES ALL OTHER TOTAL (1)

COST CENTER DESCRIPTIONS 1 2 3 4 5 6 7 8 9
GENERAL SERVICE COST CENTERS






1 Capital Related Costs-Bldg. and Fixt.






1
2 Capital Related Costs-Movable Equip.






2
3 Plant Operation and Maintenance








3
4 Transportation - Staff








4
5 Volunteer Service Coordination








5
6 Administrative and General








6
INPATIENT CARE SERVICE










7 Inpatient - General Care








7
8 Inpatient - Respite Care








8
VISITING SERVICES










9 Physician Services








9
10 Nursing Care








10
11 Nursing Care-Continuous Home Care








11
12 Physical Therapy








12
13 Occupational Therapy








13
14 Speech/ Language Pathology








14
15 Medical Social Services








15
16 Spiritual Counseling




16
17 Dietary Counseling








17
18 Counseling - Other








18
19 Home Health Aide and Homemaker








19
20 HH Aide & Homemaker-Cont. Home Care








20
21 Other








21
OTHER HOSPICE SERVICE COSTS










22 Drugs, Biological and Infusion Therapy








22
23 Analgesics








23
24 Sedatives / Hypnotics








24
25 Other - Specify








25
26 Durable Medical Equipment/Oxygen







26
27 Patient Transportation








27
28 Imaging Services








28
29 Labs and Diagnostics








29
30 Medical Supplies








30
31 Outpatient Services (including E/R Dept.)








31
32 Radiation Therapy








32
33 Chemotherapy








33
34 Other








34
HOSPICE NONREIMBURSABLE SERVICE










35 Bereavement Program Costs








35
36 Volunteer Program Costs








36
37 Fundraising








37
38 Other Program Costs








38
39 Total (sum of lines 1 through 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

Sheet 55: K2
4190 (Cont.)


FORM CMS-2540-10





11-12
HOSPICE COMPENSATION ANALYSIS




PROVIDER CCN:
PERIOD :
WORKSHEET K-2
EMPLOYEE BENEFITS (PAYROLL RELATED)






FROM ______________








HOSPICE CCN:
TO ________________
















ADMINIS-
SOCIAL SUPER-
TOTAL





TRATOR DIRECTOR SERVICES VISORS NURSES THERAPISTS AIDES ALL OTHER TOTAL (1)

COST CENTER DESCRIPTIONS 1 2 3 4 5 6 7 8 9
GENERAL SERVICE COST CENTERS






1 Capital Related Costs-Bldg. and Fixt.






1
2 Capital Related Costs-Movable Equip.






2
3 Plant Operation and Maintenance








3
4 Transportation - Staff








4
5 Volunteer Service Coordination








5
6 Administrative and General








6
INPATIENT CARE SERVICE










7 Inpatient - General Care








7
8 Inpatient - Respite Care








8
VISITING SERVICES










9 Physician Services








9
10 Nursing Care








10
11 Nursing Care-Continuous Home Care








11
12 Physical Therapy








12
13 Occupational Therapy








13
14 Speech/ Language Pathology








14
15 Medical Social Services








15
16 Spiritual Counseling




16
17 Dietary Counseling








17
18 Counseling - Other








18
19 Home Health Aide and Homemaker








19
20 HH Aide & Homemaker-Cont. Home Care








20
21 Other








21
OTHER HOSPICE SERVICE COSTS










22 Drugs, Biological and Infusion Therapy








22
23 Analgesics








23
24 Sedatives / Hypnotics








24
25 Other - Specify








25
26 Durable Medical Equipment/Oxygen








26
27 Patient Transportation








27
28 Imaging Services








28
29 Labs and Diagnostics








29
30 Medical Supplies








30
31 Outpatient Services (including E/R Dept.)








31
32 Radiation Therapy








32
33 Chemotherapy








33
34 Other








34
HOSPICE NONREIMBURSABLE SERVICE










35 Bereavement Program Costs








35
36 Volunteer Program Costs








36
37 Fundraising








37
38 Other Program Costs








38
39 Total (sum of lines 1 through 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

Sheet 56: K3
11-12


FORM CMS-2540-10





4190 (Cont.)
HOSPICE COMPENSATION ANALYSIS




PROVIDER CCN:
PERIOD :
WORKSHEET K-3
CONTRATED SERVICES / PURCHASED SERVICES






FROM ______________








HOSPICE CCN:
TO ________________
















ADMINIS
SOCIAL SUPER-
TOTAL





TRATOR DIRECTOR SERVICES VISORS NURSES THERAPISTS AIDES ALL OTHER TOTAL (1)

COST CENTER DESCRIPTIONS 1 2 3 4 5 6 7 8 9
GENERAL SERVICE COST CENTERS










1 Capital Related Costs-Bldg. and Fixt.






1
2 Capital Related Costs-Movable Equip.






2
3 Plant Operation and Maintenance








3
4 Transportation - Staff








4
5 Volunteer Service Coordination








5
6 Administrative and General








6
INPATIENT CARE SERVICE










7 Inpatient - General Care








7
8 Inpatient - Respite Care








8
VISITING SERVICES










9 Physician Services








9
10 Nursing Care








10
11 Nursing Care-Continuous Home Care








11
12 Physical Therapy








12
13 Occupational Therapy








13
14 Speech/ Language Pathology








14
15 Medical Social Services








15
16 Spiritual Counseling




16
17 Dietary Counseling








17
18 Counseling - Other








18
19 Home Health Aide and Homemaker








19
20 HH Aide & Homemaker-Cont. Home Care








20
21 Other








21
OTHER HOSPICE SERVICE COSTS










22 Drugs, Biological and Infusion Therapy








22
23 Analgesics








23
24 Sedatives / Hypnotics








24
25 Other - Specify








25
26 Durable Medical Equipment/Oxygen








26
27 Patient Transportation








27
28 Imaging Services








28
29 Labs and Diagnostics








29
30 Medical Supplies








30
31 Outpatient Services (including E/R Dept.)








31
32 Radiation Therapy








32
33 Chemotherapy








33
34 Other








34
HOSPICE NONREIMBURSABLE SERVICE










35 Bereavement Program Costs








35
36 Volunteer Program Costs








36
37 Fundraising








37
38 Other Program Costs








38
39 Total (sum of lines 1 through 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

Sheet 57: K4-I
4190 (Cont.)


FORM CMS-2540-10





11-12
COST ALLOCATION - HOSPICE




PROVIDER CCN:
PERIOD :
WORKSHEET K-4
GENERAL SERVICE COST






FROM ______________
PART I






HOSPICE CCN:
TO ________________
















NET EXPENSES










FOR COST



VOLUNTEER





ALLOC. (1) CAPITAL RELATED COST
PLANT
SERVICE SUBTOTAL ADMINIS-



( from BUILDS. & MOVABLE OPERATION TRANS- COORDI- ( cols. 0 TRATIVE &



Wkst. K, col. 10 ) FIXTURES EQUIPMENT & MAINT. PORTATION NATOR through 5 ) GENERAL TOTAL

COST CENTER DESCRIPTIONS 0 1 2 3 4 5 5A 6 7
GENERAL SERVICE COST CENTERS








1 Capital Related Costs-Bldg. and Fixt.







1
2 Capital Related Costs-Movable Equip.






2
3 Plant Operation and Maintenance








3
4 Transportation - Staff








4
5 Volunteer Service Coordination








5
6 Administrative and General








6
INPATIENT CARE SERVICE










7 Inpatient - General Care








7
8 Inpatient - Respite Care








8
VISITING SERVICES










9 Physician Services








9
10 Nursing Care








10
11 Nursing Care-Continuous Home Care








11
12 Physical Therapy








12
13 Occupational Therapy








13
14 Speech/ Language Pathology








14
15 Medical Social Services








15
16 Spiritual Counseling






16
17 Dietary Counseling








17
18 Counseling - Other








18
19 Home Health Aide and Homemaker








19
20 HH Aide & Homemaker-Cont. Home Care








20
21 Other








21
OTHER HOSPICE SERVICE COSTS










22 Drugs, Biological and Infusion Therapy








22
23 Analgesics








23
24 Sedatives / Hypnotics








24
25 Other - Specify








25
26 Durable Medical Equipment/Oxygen








26
27 Patient Transportation








27
28 Imaging Services








28
29 Labs and Diagnostics








29
30 Medical Supplies








30
31 Outpatient Services (including E/R Dept.)








31
32 Radiation Therapy








32
33 Chemotherapy








33
34 Other








34
HOSPICE NONREIMBURSABLE SERVICE










35 Bereavement Program Costs








35
36 Volunteer Program Costs








36
37 Fundraising








37
38 Other Program Costs








38
39 Total (sum of lines 1 through 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

Sheet 58: K4-II
11-12


FORM CMS-2540-10





4190 (Cont.)
COST ALLOCATION - HOSPICE




PROVIDER CCN:
PERIOD :
WORKSHEET K-4
STATISTICAL BASIS






FROM ______________
PART II






HOSPICE CCN:
TO ________________

















CAPITAL RELATED COST



ADMINIS-





MOVABLE PLANT
VOLUNTEER
TRATIVE &




BUILDS. EQUIPMENT OPERATION TRANS- SERVICE
GENERAL




& FIXTURES ( Dollar Value or & MAINT. PORTATION COORDINATOR RECONCI- ( Accumulated




( Square Feet ) Square Feet ) ( Square Feet ) ( Mileage ) ( Hours ) LIATION Cost ) TOTAL

COST CENTER DESCRIPTIONS
1 2 3 4 5 6A 6 7
GENERAL SERVICE COST CENTERS








1 Capital Related Costs-Bldg. and Fixt.







1
2 Capital Related Costs-Movable Equip.






2
3 Plant Operation and Maintenance








3
4 Transportation - Staff








4
5 Volunteer Service Coordination








5
6 Administrative and General








6
INPATIENT CARE SERVICE










7 Inpatient - General Care








7
8 Inpatient - Respite Care








8
VISITING SERVICES










9 Physician Services








9
10 Nursing Care








10
11 Nursing Care-Continuous Home Care








11
12 Physical Therapy








12
13 Occupational Therapy








13
14 Speech/ Language Pathology








14
15 Medical Social Services








15
16 Spiritual Counseling






16
17 Dietary Counseling








17
18 Counseling - Other








18
19 Home Health Aide and Homemaker








19
20 HH Aide & Homemaker-Cont. Home Care








20
21 Other








21
OTHER HOSPICE SERVICE COSTS










22 Drugs, Biological and Infusion Therapy








22
23 Analgesics








23
24 Sedatives / Hypnotics








24
25 Other - Specify








25
26 Durable Medical Equipment/Oxygen








26
27 Patient Transportation








27
28 Imaging Services








28
29 Labs and Diagnostics








29
30 Medical Supplies








30
31 Outpatient Services (including E/R Dept.)








31
32 Radiation Therapy








32
33 Chemotherapy








33
34 Other








34
HOSPICE NONREIMBURSABLE SERVICE










35 Bereavement Program Costs








35
36 Volunteer Program Costs








36
37 Fundraising








37
38 Other Program Costs








38
39 Cost to be allocated (per Wkst. K-4, Pt. I)








39
40 Unit Cost Multiplier








40












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






















Rev. 4









41-387

Sheet 59: K5-I
4190 (Cont.)

FORM CMS-2540-10




11-12 11-12

FORM CMS-2540-10




4190 (Cont.) 4190 (Cont.)

FORM CMS-2540-10




11-12
ALLOCATION OF GENERAL SERVICE


PROVIDER CCN:
PERIOD :
WORKSHEET K-5,
ALLOCATION OF GENERAL SERVICE


PROVIDER CCN:
PERIOD :
WORKSHEET K-5
ALLOCATION OF GENERAL SERVICE


PROVIDER CCN:
PERIOD :
WORKSHEET K-5
COSTS TO HOSPICE COST CENTERS




FROM ______________
PART I
COSTS TO HOSPICE COST CENTERS




FROM ______________
Part I
COSTS TO HOSPICE COST CENTERS




FROM ______________
Part I




HOSPICE CCN:
TO ________________






HOSPICE CCN:
TO ________________






HOSPICE CCN:
TO ________________


































From








PLANT










NURSING &






Wkst. K-4, HOSPICE CAPITAL RELATED
SUBTOTAL ADMINIS-


OPERATION LAUNDRY

NURSING CENTRAL



MEDICAL
ALLIED OTHER SUBTOTAL ALLOCATED TOTAL


Pt. I, TRIAL BLDGS. & MOVABLE EMPLOYEE ( cols. 0 TRATIVE &


MAINTENANCE & LINEN HOUSE-
ADMINIS- SERVICES &



RECORDS & SOCIAL HEALTH GENERAL ( sum of cols. HOSPICE A & G HOSPICE


col. 7, BALANCE FIXTURES EQUIPMENT BENEFITS through 3 ) GENERAL


& REPAIRS SERVICE KEEPING DIETARY TRATION SUPPLY PHARMACY


LIBRARY SERVICE EDUCATION SERVICE 3A through 15 ) ( see Pt. II ) COSTS

HOSPICE COST CENTER (1) line - 0 1 2 3 3A 4

HOSPICE COST CENTER (1) 5 6 7 8 9 10 11

HOSPICE COST CENTER (1) 12 13 14 15 16 17 18
1 Administrative and General 6





1 1 Administrative and General






1 1 Administrative and General






1
2 Inpatient - General Care 7





2 2 Inpatient - General Care






2 2 Inpatient - General Care






2
3 Inpatient - Respite Care 8





3 3 Inpatient - Respite Care






3 3 Inpatient - Respite Care






3
4 Physician Services 9





4 4 Physician Services






4 4 Physician Services






4
5 Nursing Care 10





5 5 Nursing Care






5 5 Nursing Care






5
6 Nursing Care- Continuous Home Care 11





6 6 Nursing Care- Continuous Home Care






6 6 Nursing Care- Continuous Home Care






6
7 Physical Therapy 12





7 7 Physical Therapy






7 7 Physical Therapy






7
8 Occupational Therapy 13





8 8 Occupational Therapy






8 8 Occupational Therapy






8
9 Speech/ Language Pathology 14





9 9 Speech/ Language Pathology






9 9 Speech/ Language Pathology






9
10 Medical Social Services - Direct 15





10 10 Medical Social Services - Direct






10 10 Medical Social Services - Direct






10
11 Spiritual Counseling 16





11 11 Spiritual Counseling






11 11 Spiritual Counseling






11
12 Dietary Counseling 17





12 12 Dietary Counseling






12 12 Dietary Counseling






12
13 Counseling - Other 18





13 13 Counseling - Other






13 13 Counseling - Other






13
14 Home Health Aide and Homemakers 19





14 14 Home Health Aide and Homemakers






14 14 Home Health Aide and Homemakers






14
15 HH Aide & Homemaker - Cont. Home Care 20





15 15 HH Aide & Homemaker - Cont. Home Care






15 15 HH Aide & Homemaker - Cont. Home Care






15
16 Other 21





16 16 Other






16 16 Other






16
17 Drugs, Biologicals and Infusion 22





17 17 Drugs, Biologicals and Infusion






17 17 Drugs, Biologicals and Infusion






17
18 Analgesics 23





18 18 Analgesics






18 18 Analgesics






18
19 Sedative/Hypnotics 24





19 19 Sedative/Hypnotics






19 19 Sedative/Hypnotics






19
20 Other - Specify 25





20 20 Other - Specify






20 20 Other - Specify






20
21 Durable Medical Equipment/Oxygen 26





21 21 Durable Medical Equipment/Oxygen






21 21 Durable Medical Equipment/Oxygen






21
22 Patient Transportation 27





22 22 Patient Transportation






22 22 Patient Transportation






22
23 Imaging Services 28





23 23 Imaging Services






23 23 Imaging Services






23
24 Labs and Diagnostics 29





24 24 Labs and Diagnostics






24 24 Labs and Diagnostics






24
25 Medical Supplies 30





25 25 Medical Supplies






25 25 Medical Supplies






25
26 Outpatient Services (incl. E/R Dept.) 31





26 26 Outpatient Services (incl. E/R Dept.)






26 26 Outpatient Services (incl. E/R Dept.)






26
27 Radiation Therapy 32





27 27 Radiation Therapy






27 27 Radiation Therapy






27
28 Chemotherapy 33





28 28 Chemotherapy






28 28 Chemotherapy






28
29 Other 34





29 29 Other






29 29 Other






29
30 Bereavement Program Costs 35





30 30 Bereavement Program Costs






30 30 Bereavement Program Costs






30
31 Volunteer Program Costs 36





31 31 Volunteer Program Costs






31 31 Volunteer Program Costs






31
32 Fundraising 37





32 32 Fundraising






32 32 Fundraising






32
33 Other Program Costs 38





33 33 Other Program Costs






33 33 Other Program Costs






33
34 Totals (sum of lines 1 through 33)






34 34 Totals (sum of lines 1 through 33)






34 34 Totals (sum of lines 1 through 33)






34
35 Unit Cost Multiplier






35 35 Unit Cost Multiplier






35 35 Unit Cost Multiplier






35






























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








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








(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)








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








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






































41-388







Rev. 4 Rev. 4







41-389 41-390







Rev. 4

Sheet 60: K5-II
11-12

FORM CMS-2540-10




4190 (Cont.) 4190 (Cont.)

FORM CMS-2540-10




11-12 11-12

FORM CMS-2540-10




4190 (Cont.)
ALLOCATION OF GENERAL SERVICE COSTS


PROVIDER CCN:
PERIOD :
WORKSHEET K-5,
ALLOCATION OF GENERAL SERVICE COSTS

PROVIDER CCN:
PERIOD :
WORKSHEET K-5

ALLOCATION OF GENERAL SERVICE COSTS


PROVIDER CCN:
PERIOD :
WORKSHEET K-5

TO HOSPICE COST CENTERS - STATISTICAL BASIS




FROM ______________
PART II
TO HOSPICE COST CENTERS - STATISTICAL BASIS



FROM ______________
PART II

TO HOSPICE COST CENTERS - STATISTICAL BASIS




FROM ______________
PART II





HOSPICE CCN:
TO ________________





HOSPICE CCN:
TO ________________







HOSPICE CCN:
TO ________________






































CAPITAL CAPITAL

ADMINIS-


PLANT LAUNDRY

NURSING CENTRAL





NURSING &









RELATED RELATED

TRATIVE &


OPERATION & LINEN HOUSE
ADMINIS- SERVICES &



MEDICAL
ALLIED OTHER








BLDGS. & MOVABLE EMPLOYEE
GENERAL


MAINTENANCE SERVICE KEEPING
TRATION SUPPLY PHARMACY


RECORDS & SOCIAL HEALTH GENERAL

TOTAL





FIXTURES EQUIPMENT BENEFITS RECONCIL- ( Accumulated


& REPAIRS ( Pounds of ( Hours of DIETARY ( Direct Nursing ( Costed ( Costed


LIBRARY SERVICE EDUCATION SERVICE
ALLOCATED HOSPICE





( Square Feet ) ( Dollar Value ) ( Gross Salaries ) IATION Cost )


( Square Feet ) Laundry ) Service ) ( Meals Served ) Hours ) Requisitions ) Requisitions )


( Time Spent ) ( Time Spent ) ( Assigned Time ) ( Specify ) SUBTOTAL HOSPICE A&G COSTS


HOSPICE COST CENTER (1)

1 2 3 4a 4

HOSPICE COST CENTER (1) 5 6 7 8 9 10 11

HOSPICE COST CENTER (1) 12 13 14 15 16 17 18

1 Administrative and General






1 1 Administrative and General






1 1 Administrative and General






1
2 Inpatient - General Care






2 2 Inpatient - General Care






2 2 Inpatient - General Care






2
3 Inpatient - Respite Care






3 3 Inpatient - Respite Care






3 3 Inpatient - Respite Care






3
4 Physician Services






4 4 Physician Services






4 4 Physician Services






4
5 Nursing Care






5 5 Nursing Care






5 5 Nursing Care






5
6 Nursing Care- Continuous Home Care






6 6 Nursing Care- Continuous Home Care






6 6 Nursing Care- Continuous Home Care






6
7 Physical Therapy






7 7 Physical Therapy






7 7 Physical Therapy






7
8 Occupational Therapy






8 8 Occupational Therapy






8 8 Occupational Therapy






8
9 Speech/ Language Pathology






9 9 Speech/ Language Pathology






9 9 Speech/ Language Pathology






9
10 Medical Social Services - Direct






10 10 Medical Social Services - Direct






10 10 Medical Social Services - Direct






10
11 Spiritual Counseling






11 11 Spiritual Counseling






11 11 Spiritual Counseling






11
12 Dietary Counseling






12 12 Dietary Counseling






12 12 Dietary Counseling






12
13 Counseling - Other






13 13 Counseling - Other






13 13 Counseling - Other






13
14 Home Health Aide and Homemakers






14 14 Home Health Aide and Homemakers






14 14 Home Health Aide and Homemakers






14
15 HH Aide & Homemaker - Cont. Home Care






15 15 HH Aide & Homemaker - Cont. Home Care






15 15 HH Aide & Homemaker - Cont. Home Care






15
16 Other






16 16 Other






16 16 Other






16
17 Drugs, Biologicals and Infusion






17 17 Drugs, Biologicals and Infusion






17 17 Drugs, Biologicals and Infusion






17
18 Analgesics






18 18 Analgesics






18 18 Analgesics






18
19 Sedative/Hypnotics






19 19 Sedative/Hypnotics






19 19 Sedative/Hypnotics






19
20 Other - Specify






20 20 Other - Specify






20 20 Other - Specify






20
21 Durable Medical Equipment/Oxygen






21 21 Durable Medical Equipment/Oxygen






21 21 Durable Medical Equipment/Oxygen






21
22 Patient Transportation






22 22 Patient Transportation






22 22 Patient Transportation






22
23 Imaging Services






23 23 Imaging Services






23 23 Imaging Services






23
24 Labs and Diagnostics






24 24 Labs and Diagnostics






24 24 Labs and Diagnostics






24
25 Medical Supplies






25 25 Medical Supplies






25 25 Medical Supplies






25
26 Outpatient Services (incl. E/R Dept.)






26 26 Outpatient Services (incl. E/R Dept.)






26 26 Outpatient Services (incl. E/R Dept.)






26
27 Radiation Therapy






27 27 Radiation Therapy






27 27 Radiation Therapy






27
28 Chemotherapy






28 28 Chemotherapy






28 28 Chemotherapy






28
29 Other






29 29 Other






29 29 Other






29
30 Bereavement Program Costs






30 30 Bereavement Program Costs






30 30 Bereavement Program Costs






30
31 Volunteer Program Costs






31 31 Volunteer Program Costs






31 31 Volunteer Program Costs






31
32 Fundraising






32 32 Fundraising






32 32 Fundraising






32
33 Other Program Costs






33 33 Other Program Costs






33 33 Other Program Costs






33
34 Totals (sum of lines 1 through 33)






34 34 Totals (sum of lines 1 through 33)






34 34 Totals (sum of lines 1 through 33)






34
35 Total cost to be allocated






35 35 Total cost to be allocated






35 35 Total cost to be allocated






35
36 Unit Cost Multiplier






36 36 Unit Cost Multiplier






36 36 Unit Cost Multiplier






36





















































































































































































































































































































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








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








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








































Rev. 4







41-391 41-392







Rev. 4 Rev. 4







41-393

Sheet 61: K5-III
4190 (Cont.)
FORM CMS-2540-10


11-12
APPORTIONMENT OF HOSPICE SHARED SERVICES

PROVIDER CCN: PERIOD : WORKSHEET K-5




FROM ______________ Part III



HOSPICE CCN: TO ________________






















PART III - COMPUTATION OF TOTAL HOSPICE SHARED COSTS







Wkst. C, Cost to Total Hospice Hospice Shared


col. 3, Charge Charges Ancillary Costs

COST CENTER line: Ratio ( from provider records ) ( col. 1 x col. 2 )


0 1 2 3
ANCILLARY SERVICE COST CENTERS





1 Physical Therapy 44


1
2 Occupational Therapy 45


2
3 Speech/ Language Pathology 46


3
4 Drugs, Biologicals and Infusion 49


4
5 Labs and Diagnostics 41


5
6 Medical Supplies 48


6
7 Radiation Therapy 40


7
8 Other 52


8
9 Total (sum of lines 1-8)



9








































































































































































































































































































































































































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












41-394




Rev. 4

Sheet 62: K6
DRAFT
FORM CMS-2540-10


4190 (Cont.)
CALCULATION OF HOSPICE PER DIEM COST

PROVIDER CCN: PERIOD : WORKSHEET K-6




FROM ______________




HOSPICE CCN: TO ________________































Tittle XVIII Title XIX Other Total


1 2 3 4
1 Total cost



1

(see instructions)




2 Total unduplicated days



2

(Wkst. S-8, line 5, col. 6)




3 Average cost per diem



3

(line 1 divided by line 2)




4 Unduplicated Medicare days



4

(Wkst. S-8, line 5, col. 1)




5 Average Medicare cost



5

(line 3 times line 4)




6 Unduplicated Medicaid days



6

(Wkst. S-8, line 5, col. 2)




7 Average Medicaid cost



7

(line 3 times line 6)




8 Unduplicated SNF days



8

(Wkst. S-8, line 5, col. 3)




9 Average SNF cost



9

(line 3 times line 8)




10 Unduplicated NF days



10

(Wkst. S-8, line 5, col. 4)




11 Average NF cost



11

(line 3 times line 10)




12 Other unduplicated days



12

(Wkst. S-8, line 5, col. 5)




13 Average cost for other days



13

(line 3 times line 12)










































































































































































































































































































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












Rev.




41-395

Sheet 63: O
4190 (Cont.)



FORM CMS-2540-10



DRAFT
ANALYSIS OF SNF-BASED HOSPICE COSTS





PROVIDER CCN: PERIOD: WORKSHEET O







________________ FROM ___________








HOSPICE CCN: TO ______________








________________







SUBTOTAL









( col. 1 plus RECLASSI-
ADJUST- TOTAL



SALARIES OTHER col. 2 ) FICATIONS SUBTOTAL MENTS ( col. 5 ± col. 6 )



1 2 3 4 5 6 7
GENERAL SERVICE COST CENTERS









1 0100 Cap Rel Costs-Bldg & Fixt*






1
2 0200 Cap Rel Costs-Mvble Equip*






2
3 0300 Employee Benefits Department*






3
4 0400 Administrative & General *






4
5 0500 Plant Operation & Maintenance*






5
6 0600 Laundry & Linen Service*






6
7 0700 Housekeeping*






7
8 0800 Dietary*






8
9 0900 Nursing Administration*






9
10 1000 Routine Medical Supplies*






10
11 1100 Medical Records*






11
12 1200 Staff Transportation*






12
13 1300 Volunteer Service Coordination*






13
14 1400 Pharmacy*






14
15 1500 Physician Administrative Services*






15
16 1600 Other General Service*






16
17 1700 Patient/Residential Care Services






17
DIRECT PATIENT CARE SERVICE COST CENTERS









25 2500 Inpatient Care-Contracted**






25
26 2600 Physician Services**






26
27 2700 Nurse Practitioner**






27
28 2800 Registered Nurse**






28
29 2900 LPN/LVN**






29
30 3000 Physical Therapy**






30
31 3100 Occupational Therapy**






31
32 3200 Speech/ Language Pathology**






32
33 3300 Medical Social Services**






33
34 3400 Spiritual Counseling**






34
35 3500 Dietary Counseling**






35
36 3600 Counseling - Other**






36
37 3700 Hospice Aide and Homemaker Services**






37
38 3800 Durable Medical Equipment/Oxygen**






38
39 3900 Patient Transportation**






39











* Transfer the amounts in column 7 to Wkst. O-5, col. 1, line as appropriate.








** See instructions. Do not transfer the amounts in col. 7 to Wkst. O-5.










































































FORM CMS-2540-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164)




















41-396








Rev.
DRAFT



FORM CMS-2540-10



4190 (Cont.)
ANALYSIS OF SNF-BASED HOSPICE COSTS





PROVIDER CCN: PERIOD: WORKSHEET O







________________ FROM ___________








HOSPICE CCN: TO ______________








________________







SUBTOTAL









( col. 1 plus RECLASSI-
ADJUST- TOTAL



SALARIES OTHER col. 2 ) FICATIONS SUBTOTAL MENTS ( col. 5 ± col. 6 )



1 2 3 4 5 6 7
DIRECT PATIENT CARE SERVICE COST CENTERS (Cont.)









40 4000 Imaging Services**






40
41 4100 Labs and Diagnostics**






41
42 4200 Medical Supplies-Non-routine**






42
43 4300 Outpatient Services**






43
44 4400 Palliative Radiation Therapy**






44
45 4500 Palliative Chemotherapy**






45
46
Other Patient Care Services (specify)**






46
NONREIMBURSABLE COST CENTERS









60 6000 Bereavement Program *






60
61 6100 Volunteer Program *






61
62 6200 Fundraising*






62
63 6300 Hospice/Palliative Medicine Fellows*






63
64 6400 Palliative Care Program*






64
65 6500 Other Physician Services*






65
66 6600 Residential Care *






66
67 6700 Advertising*






67
68 6800 Telehealth/Telemonitoring*






68
69 6900 Thrift Store*






69
70 7000 Nursing Facility Room & Board*






70
71 7100 Other Nonreimbursable (specify)*






71
100
Total






100











* Transfer the amounts in column 7 to Wkst. O-5, col. 1, line as appropriate.








** See instructions. Do not transfer the amounts in col. 7 to Wkst. O-5.



































































































































































































FORM CMS-2540-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164)




















Rev.








41-397

Sheet 64: O1
4190 (Cont.)


FORM CMS-2540-10



DRAFT
ANALYSIS OF SNF-BASED HOSPICE COSTS




PROVIDER CCN: PERIOD: WORKSHEET O-1
HOSPICE CONTINUOUS HOME CARE




________________ FROM ___________







HOSPICE CCN: TO ______________







________________






SUBTOTAL








( col. 1 plus RECLASSI-
ADJUST- TOTAL


SALARIES OTHER col. 2 ) FICATIONS SUBTOTAL MENTS ( col. 5 ± col. 6 )


1 2 3 4 5 6 7
DIRECT PATIENT CARE SERVICE COST CENTERS








25 Inpatient Care - Contracted






25
26 Physician Services






26
27 Nurse Practitioner






27
28 Registered Nurse






28
29 LPN/LVN






29
30 Physical Therapy






30
31 Occupational Therapy






31
32 Speech/ Language Pathology






32
33 Medical Social Services






33
34 Spiritual Counseling






34
35 Dietary Counseling






35
36 Counseling - Other






36
37 Hospice Aide and Homemaker Services






37
38 Durable Medical Equipment/Oxygen






38
39 Patient Transportation






39
40 Imaging Services






40
41 Labs and Diagnostics






41
42 Medical Supplies-Non-routine






42
43 Outpatient Services






43
44 Palliative Radiation Therapy






44
45 Palliative Chemotherapy






45
46 Other Patient Care Svc (specify)






46
100 Total *






100










* Transfer the amount in column 7 to Wkst. O-5, column 1, line 50







































































































































































FORM CMS-2540-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164.1)


















41-398







Rev.

Sheet 65: O2
DRAFT


FORM CMS-2540-10



4190 (Cont.)
ANALYSIS OF SNF-BASED HOSPICE COSTS




PROVIDER CCN: PERIOD: WORKSHEET O-2
HOSPICE ROUTINE HOME CARE




________________ FROM ___________







HOSPICE CCN: TO ______________







________________






SUBTOTAL








( col. 1 plus RECLASSI-
ADJUST- TOTAL


SALARIES OTHER col. 2 ) FICATIONS SUBTOTAL MENTS ( col. 5 ± col. 6 )


1 2 3 4 5 6 7
DIRECT PATIENT CARE SERVICE COST CENTERS








25 Inpatient Care - Contracted






25
26 Physician Services






26
27 Nurse Practitioner






27
28 Registered Nurse






28
29 LPN/LVN






29
30 Physical Therapy






30
31 Occupational Therapy






31
32 Speech/ Language Pathology






32
33 Medical Social Services






33
34 Spiritual Counseling






34
35 Dietary Counseling






35
36 Counseling - Other






36
37 Hospice Aide and Homemaker Services






37
38 Durable Medical Equipment/Oxygen






38
39 Patient Transportation






39
40 Imaging Services






40
41 Labs and Diagnostics






41
42 Medical Supplies-Non-routine






42
43 Outpatient Services






43
44 Palliative Radiation Therapy






44
45 Palliative Chemotherapy






45
46 Other Patient Care Svc (specify)






46
100 Total *






100










* Transfer the amount in column 7 to Wkst. O-5, column 1, line 51







































































































































































FORM CMS-2540-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164.1)


















Rev.







41-399

Sheet 66: O3
4190 (Cont.)


FORM CMS-2540-10 FORM CMS-2540-10


DRAFT
ANALYSIS OF SNF-BASED HOSPICE COSTS




PROVIDER CCN: PERIOD: WORKSHEET O-3
HOSPICE INPATIENT RESPITE CARE




________________ FROM ___________







HOSPICE CCN: TO ______________







________________






SUBTOTAL








( col. 1 plus RECLASSI-
ADJUST- TOTAL


SALARIES OTHER col. 2 ) FICATIONS SUBTOTAL MENTS ( col. 5 ± col. 6 )


1 2 3 4 5 6 7
DIRECT PATIENT CARE SERVICE COST CENTERS








25 Inpatient Care - Contracted






25
26 Physician Services






26
27 Nurse Practitioner






27
28 Registered Nurse






28
29 LPN/LVN






29
30 Physical Therapy






30
31 Occupational Therapy






31
32 Speech/ Language Pathology






32
33 Medical Social Services






33
34 Spiritual Counseling






34
35 Dietary Counseling






35
36 Counseling - Other






36
37 Hospice Aide and Homemaker Services






37
38 Durable Medical Equipment/Oxygen






38
39 Patient Transportation






39
40 Imaging Services






40
41 Labs and Diagnostics






41
42 Medical Supplies-Non-routine






42
43 Outpatient Services






43
44 Palliative Radiation Therapy






44
45 Palliative Chemotherapy






45
46 Other Patient Care Svc (specify)






46
100 Total *






100










* Transfer the amount in column 7 to Wkst. O-5, column 1, line 52







































































































































































FORM CMS-2540-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164.1)


















41-400







Rev.

Sheet 67: O4
DRAFT


FORM CMS-2540-10



4190 (Cont.)
ANALYSIS OF SNF-BASED HOSPICE COSTS




PROVIDER CCN: PERIOD: WORKSHEET O-4
HOSPICE GENERAL INPATIENT CARE




________________ FROM ___________







HOSPICE CCN: TO ______________







________________






SUBTOTAL








( col. 1 plus RECLASSI-
ADJUST- TOTAL


SALARIES OTHER col. 2 ) FICATIONS SUBTOTAL MENTS ( col. 5 ± col. 6 )


1 2 3 4 5 6 7
DIRECT PATIENT CARE SERVICE COST CENTERS








25 Inpatient Care - Contracted






25
26 Physician Services






26
27 Nurse Practitioner






27
28 Registered Nurse






28
29 LPN/LVN






29
30 Physical Therapy






30
31 Occupational Therapy






31
32 Speech/ Language Pathology






32
33 Medical Social Services






33
34 Spiritual Counseling






34
35 Dietary Counseling






35
36 Counseling - Other






36
37 Hospice Aide and Homemaker Services






37
38 Durable Medical Equipment/Oxygen






38
39 Patient Transportation






39
40 Imaging Services






40
41 Labs and Diagnostics






41
42 Medical Supplies-Non-routine






42
43 Outpatient Services






43
44 Palliative Radiation Therapy






44
45 Palliative Chemotherapy






45
46 Other Patient Care Svc (specify)






46
100 Total *






100










* Transfer the amount in column 7 to Wkst. O-5, column 1, line 53







































































































































































FORM CMS-2540-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164.1)


















Rev.







41-401

Sheet 68: O5
4190 (Cont.)
FORM CMS-2540-10

DRAFT
COST ALLOCATION - DETERMINATION OF SNF-BASED HOSPICE
PROVIDER CCN: PERIOD: WORKSHEET O-5
NET EXPENSES FOR ALLOCATION
________________ FROM ___________



HOSPICE CCN: TO ______________



________________





GENERAL



HOSPICE SERVICE



DIRECT EXPENSES TOTAL


EXPENSES FROM WKST B EXPENSES


( see instructions ) ( see instructions ) ( sum of cols. 1 + 2 )

Descriptions 1 2 3
GENERAL SERVICE COST CENTERS




1 Cap Rel Costs-Bldg & Fixt


1
2 Cap Rel Costs-Mvble Equip


2
3 Employee Benefits


3
4 Administrative & General


4
5 Plant Operation and Maintenance


5
6 Laundry & Linen Service


6
7 Housekeeping


7
8 Dietary


8
9 Nursing Administration


9
10 Routine Medical Supplies


10
11 Medical Records


11
12 Staff Transportation


12
13 Volunteer Service Coordination


13
14 Pharmacy


14
15 Physician Administrative Services


15
16 Other General Service (specify)


16
17 Patient/Residential Care Services


17
LEVEL OF CARE




50 Hospice Continuous Home Care


50
51 Hospice Routine Home Care


51
52 Hospice Inpatient Respite Care


52
53 Hospice General Inpatient Care


53
NONREIMBURSABLE COST CENTERS




60 Bereavement Program


60
61 Volunteer Program


61
62 Fundraising


62
63 Hospice/Palliative Medicine Fellows


63
64 Palliative Care Program


64
65 Other Physician Services


65
66 Residential Care


66
67 Advertising


67
68 Telehealth/Telemonitoring


68
69 Thrift Store


69
70 Nursing Facility Room & Board


70
71 Other Nonreimbursable (specify)


71
99 Negative Cost Center


99
100 Total


100




































































































































FORM CMS-2540-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164.2)




41-402



Rev.

Sheet 69: O6I
DRAFT



FORM CMS-2540-10





4190 (Cont.)
COST ALLOCATION - SNF-BASED HOSPICE GENERAL SERVICE COSTS





PROVIDER CCN: ______________
PERIOD:
WORKSHEET O-6







HOSPICE CCN: ________________
FROM _____________________
PART I









TO _________________________





CAP REL CAP REL EMPLOYEE
ADMINIS- PLANT LAUNDRY HOUSE- DIETARY


TOTAL BLDG MVBLE BENEFITS
TRATIVE & OP & & LINEN KEEPING



EXPENSES & FIX EQUIP DEPARTMENT SUBTOTAL GENERAL MAINT




Descriptions 0 1 2 3 3A 4 5 6 7 8
GENERAL SERVICE COST CENTERS











1 Cap Rel Costs-Bldg & Fixt









1
2 Cap Rel Costs-Mvble Equip









2
3 Employee Benefits









3
4 Administrative & General









4
5 Plant Operation and Maintenance









5
6 Laundry & Linen Service









6
7 Housekeeping









7
8 Dietary









8
9 Nursing Administration









9
10 Routine Medical Supplies









10
11 Medical Records









11
12 Staff Transportation









12
13 Volunteer Service Coordination









13
14 Pharmacy









14
15 Physician Administrative Services









15
16 Other General Service (specify)









16
17 Patient/Residential Care Services









17
LEVEL OF CARE











50 Hospice Continuous Home Care









50
51 Hospice Routine Home Care









51
52 Hospice Inpatient Respite Care









52
53 Hospice General Inpatient Care









53
NONREIMBURSABLE COST CENTERS











60 Bereavement Program









60
61 Volunteer Program









61
62 Fundraising









62
63 Hospice/Palliative Medicine Fellows









63
64 Palliative Care Program









64
65 Other Physician Services









65
66 Residential Care









66
67 Advertising









67
68 Telehealth/Telemonitoring









68
69 Thrift Store









69
70 Nursing Facility Room & Board









70
71 Other Nonreimbursable (specify)









71
99 Negative Cost Center









99
100 Total









100

































































FORM CMS-2540-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164.3)
























Rev.










41-403
4190 (Cont.)



FORM CMS-2540-10





DRAFT
COST ALLOCATION - SNF-BASED HOSPICE GENERAL SERVICE COSTS





PROVIDER CCN: ______________
PERIOD:
WORKSHEET O-6







HOSPICE CCN: ________________
FROM _____________________
Part I









TO _________________________




NURSING ROUTINE MEDICAL STAFF VOLUNTEER PHARMACY PHYSICIAN OTHER PATIENT /



ADMINIS- MEDICAL RECORDS TRANS- SVC COOR-
ADMINISTRA- GENERAL RESIDENTIAL



TRATION SUPPLIES
PORTATION DINATION
TIVE SVCS SERVICE CARE SVCS


Descriptions 9 10 11 12 13 14 15 16 17 18
GENERAL SERVICE COST CENTERS











1 Cap Rel Costs-Bldg & Fixt









1
2 Cap Rel Costs-Mvble Equip









2
3 Employee Benefits









3
4 Administrative & General









4
5 Plant Operation and Maintenance









5
6 Laundry & Linen Service









6
7 Housekeeping









7
8 Dietary









8
9 Nursing Administration









9
10 Routine Medical Supplies









10
11 Medical Records









11
12 Staff Transportation









12
13 Volunteer Service Coordination









13
14 Pharmacy









14
15 Physician Administrative Services









15
16 Other General Service (specify)









16
17 Patient/Residential Care Services









17
LEVEL OF CARE











50 Continuous Home Care









50
51 Routine Home Care









51
52 Inpatient Respite Care









52
53 General Inpatient Care









53
NONREIMBURSABLE COST CENTERS











60 Bereavement Program









60
61 Volunteer Program









61
62 Fundraising









62
63 Hospice/Palliative Medicine Fellows









63
64 Palliative Care Program









64
65 Other Physician Services









65
66 Residential Care









66
67 Advertising









67
68 Telehealth/Telemonitoring









68
69 Thrift Store









69
70 Nursing Facility Room & Board









70
71 Other Nonreimbursable (specify)









71
99 Negative Cost Center









99
100 Total









100




















































FORM CMS-2540-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164.3)











41-404










Rev.

Sheet 70: O6II
DRAFT



FORM CMS-2540-10





4190 (Cont.)
COST ALLOCATION - SNF-BASED HOSPICE GENERAL SERVICE COST STATISTICAL BASIS





PROVIDER CCN: ______________
PERIOD:
WORKSHEET O-6







HOSPICE CCN: ________________
FROM _____________________
PART II









TO _________________________





CAP REL CAP REL EMPLOYEE
ADMINIS- PLANT LAUNDRY HOUSE- DIETARY



BLDG MVBLE BENEFITS
TRATIVE & OP & & LINEN KEEPING




& FIX EQUIP DEPARTMENT
GENERAL MAINT






( Square ( Dollar ( Gross RECONCIL- ( Accum. ( Square ( In-Facility ( Square ( In-Facility



Feet ) Value ) Salaries ) IATION Cost ) Feet ) Days ) Feet ) Days )

Cost Center Descriptions
1 2 3 4A 4 5 6 7 8
GENERAL SERVICE COST CENTERS











1 Cap Rel Costs-Bldg & Fixt









1
2 Cap Rel Costs-Mvble Equip









2
3 Employee Benefits









3
4 Administrative & General









4
5 Plant Operation and Maintenance









5
6 Laundry & Linen Service









6
7 Housekeeping









7
8 Dietary









8
9 Nursing Administration









9
10 Routine Medical Supplies









10
11 Medical Records









11
12 Staff Transportation









12
13 Volunteer Service Coordination









13
14 Pharmacy









14
15 Physician Administrative Services









15
16 Other General Service (specify)









16
17 Patient/Residential Care Services









17
LEVEL OF CARE











50 Hospice Continuous Home Care









50
51 Hospice Routine Home Care









51
52 Hospice Inpatient Respite Care









52
53 Hospice General Inpatient Care









53
NONREIMBURSABLE COST CENTERS











60 Bereavement Program









60
61 Volunteer Program









61
62 Fundraising









62
63 Hospice/Palliative Medicine Fellows









63
64 Palliative Care Program









64
65 Other Physician Services









65
66 Residential Care









66
67 Advertising









67
68 Telehealth/Telemonitoring









68
69 Thrift Store









69
70 Nursing Facility Room & Board









70
71 Other Nonreimbursable (specify)









71
99 Negative Cost Center









99
100 Total (sum of lines 1 through 99)









100
101 Cost to be allocated (per Wkst. O-6, Part I)









101
102 Unit cost multiplier









102


























FORM CMS-2540-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164.3)
























Rev.










41-405
4190 (Cont.)



FORM CMS-2540-10





DRAFT
COST ALLOCATION - SNF-BASED HOSPICE GENERAL SERVICE COST STATISTICAL BASIS





PROVIDER CCN: ______________
PERIOD:
WORKSHEET O-6







HOSPICE CCN: ________________
FROM _____________________
Part II









TO _________________________




NURSING ROUTINE MEDICAL STAFF VOLUNTEER PHARMACY PHYSICIAN OTHER PATIENT /



ADMINIS- MEDICAL RECORDS TRANS- SVC COOR-
ADMINISTRA- GENERAL RESIDENTIAL



TRATION SUPPLIES
PORTATION DINATION
TIVE SVCS SERVICE CARE SVCS



( Direct ( Patient ( Patient
( Hours of
( Patient ( Specify ( In-Facility



Nurs. Hrs. ) Days ) Days ) ( Mileage ) Service ) ( Charges ) Days ) Basis ) Days ) TOTAL

Cost Center Descriptions 9 10 11 12 13 14 15 16 17 18
GENERAL SERVICE COST CENTERS











1 Cap Rel Costs-Bldg & Fixt









1
2 Cap Rel Costs-Mvble Equip









2
3 Employee Benefits









3
4 Administrative & General









4
5 Plant Operation and Maintenance









5
6 Laundry & Linen Service









6
7 Housekeeping









7
8 Dietary









8
9 Nursing Administration









9
10 Routine Medical Supplies









10
11 Medical Records









11
12 Staff Transportation









12
13 Volunteer Service Coordination









13
14 Pharmacy









14
15 Physician Administrative Services









15
16 Other General Service (specify)









16
17 Patient/Residential Care Services









17
LEVEL OF CARE











50 Continuous Home Care









50
51 Routine Home Care









51
52 Inpatient Respite Care









52
53 General Inpatient Care









53
NONREIMBURSABLE COST CENTERS











60 Bereavement Program









60
61 Volunteer Program









61
62 Fundraising









62
63 Hospice/Palliative Medicine Fellows









63
64 Palliative Care Program









64
65 Other Physician Services









65
66 Residential Care









66
67 Advertising









67
68 Telehealth/Telemonitoring









68
69 Thrift Store









69
70 Nursing Facility Room & Board









70
71 Other Nonreimbursable (specify)









71
99 Negative Cost Center









99
100 Total (sum of lines 1 through 99)









100
101 Cost to be allocated (per Wkst. O-6, Part I)









101
102 Unit cost multiplier









102


























FORM CMS-2540-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164.3)











41-406










Rev.

Sheet 71: O7
DRAFT



FORM CMS-2540-10





4190 (Cont.)
APPORTIONMENT OF SNF-BASED HOSPICE SHARED SERVICE COSTS BY LEVEL OF CARE





PROVIDER CCN: ______________
PERIOD:
WORKSHEET O-7







HOSPICE CCN: ________________
FROM _____________________











TO _________________________

















Wkst. C, Cost to Charges by LOC (from Provider Records) Shared Service Costs by LOC


col. 3, Charge



HCHC HRHC HIRC HGIP


line Ratio HCHC HRHC HIRC HGIP ( col. 1 x col. 2 ) ( col. 1 x col. 3 ) ( col. 1 x col. 4 ) ( col. 1 x col. 5 )

Cost Center Descriptions 0 1 2 3 4 5 6 7 8 9

ANCILLARY SERVICE COST CENTERS










1 Physical Therapy 44








1
2 Occupational Therapy 45








2
3 Speech/ Language Pathology 46








3
4 Drugs, Biological and Infusion Therapy 49








4
5 Durable Medical Equipment/Oxygen 51








5
6 Labs and Diagnostics 40








6
7 Medical Supplies 48








7
8 Outpatient Services (including E/R Dept.) 63








8
9 Radiation Therapy 40








9
10 Other 52








10
11 Totals (sum of lines 1 through 10)









11

























































































































































































































































































































































































FORM CMS-2540-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164.4)











Rev.










41-407

Sheet 72: O8
4190 (Cont.)
FORM CMS-2540-10

DRAFT
CALCULATION OF SNF-BASED HOSPICE PER DIEM COST
PROVIDER CCN: PERIOD: WORKSHEET O-8


________________ FROM ___________



HOSPICE CCN: TO ______________



________________




TITLE XVIII TITLE XIX



MEDICARE MEDICAID TOTAL


1 2 3
HOSPICE CONTINUOUS HOME CARE




1 Total cost (Wkst. O-6, Part I, col 18, line 50 plus Wkst. O-7, col. 6, line 11)


1
2 Total unduplicated days (Wkst. S-8, col. 4, line 10)


2
3 Total average cost per diem (line 1 divided by line 2)


3
4 Unduplicated program days (Wkst. S-8, col. as appropriate, line 10)


4
5 Program cost (line 3 times line 4)


5
HOSPICE ROUTINE HOME CARE




6 Total cost (Wkst. O-6, Part I, col. 18, line 51 plus Wkst. O-7, col. 7, line 11)


6
7 Total unduplicated days (Wkst. S-8, col. 4, line 11)


7
8 Total average cost per diem (line 6 divided by line 7)


8
9 Unduplicated program days (Wkst. S-8, col. as appropriate, line 11)


9
10 Program cost (line 8 times line 9)


10
HOSPICE INPATIENT RESPITE CARE




11 Total cost (Wkst. O-6, Part I, col. 18, line 52 plus Wkst. O-7, col. 8, line 11)


11
12 Total unduplicated days (Wkst. S-8, col. 4, line 12)


12
13 Total average cost per diem (line 11 divided by line 12)


13
14 Unduplicated program days (Wkst. S-8, col. as appropriate, line 12)


14
15 Program cost (line 13 times line 14)


15
HOSPICE GENERAL INPATIENT CARE




16 Total cost (Wkst. O-6, Part I, col. 18, line 53 plus Wkst. O-7, col. 9, line 11)


16
17 Total unduplicated days (Wkst. S-8, col. 4, line 13)


17
18 Total average cost per diem (line 16 divided by line 17)


18
19 Unduplicated program days (Wkst. S-8, col. as appropriate, line 13)


19
20 Program cost (line 18 times line 19)


20
TOTAL HOSPICE CARE




21 Total cost (sum of line 1 + line 6 + line 11 + line 16)


21
22 Total unduplicated days (Wkst. S-8, col. 4, line 14)


22
23 Average cost per diem (line 21 divided by line 22)


23





















































































































































FORM CMS-2540-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164.5)




41-408



Rev.
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