Form CMS-2552-10 COST REPORT WORKSHEET

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Overview

S
S2I
S2II
S3I
S3II &III
S3IV
S3V
S4
S5
S6
S7
S8
S9
S10
S-11PI
S-11PII
S-11PIII
A
A6
A7I, II &III
A8
A81
A82
A83
BI
BII
B1
B2
CI
CII
DI
DII
DIII
DIV
DV
D1I
D1II
D1III
D2
D3
D4I
D4II
D4III
D5I
D5II
D5III
D5IV
EA
EB
E1
E1II
E2
E3I
E3II
E3III
E3IV
E3V
E3VI
E3VII
E4
G
G1
G2
G3
H
H1I
H1II
H2I
H2II
H3
H4
H5
I1
I2
I3
I4
I5
J1I
J1II
J2I
J2II
J3
J4
K
K1
K2
K3
K41
K4II
K5I
K5II
K5III
K6
L
L1I
L1II
L1III
M1
M2
M3
M4
M5
N1
N2
N3
N4
N5
O
O1
O2
O3
O4
O5
O6I
O6II
O7
O8

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Sheet 1: S

DRAFT						FORM CMS-2552-10					4090 (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. 0938-0050
HOSPITAL AND HOSPITAL HEALTH CARE						PROVIDER CCN:		PERIOD		WORKSHEET S
COMPLEX COST REPORT CERTIFICATION								FROM __________		PARTS I, II & III
AND SETTLEMENT SUMMARY						______________		TO _____________
PART I - COST REPORT STATUS
Provider use only				1.	[ ] Electronically filed cost report				Date:	Time:
				2.	[ ] Manually submitted cost report
				3.	[ ] If this is an amended report enter the number of times the provider resubmitted this cost report
				4	[ ] Medicare Utilization. Enter "F" for full or "L" for low.
Contractor		5. [ ] Cost Report Status				6. Date Received:_________			10. NPR Date:__________
use only		(1) As Submitted				7. Contractor No.:________			11. Contractor's Vendor Code: ___________
		(2) Settled without audit				8. [ ] Initial Report for this Provider CCN			12. [ ] If line 5, column 1 is 4: Enter number of
		(3) Settled with audit				9. [ ] Final Report for this Provider CCN			times reopened = 0-9.
		(4) Reopened
		(5) Amended
PART II - CERTIFICATION
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL,
CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN
THIS REPORT WERE PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE
ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.
		CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)
	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 Number(s)}for the cost reporting period beginning ______________ and ending ______________ and 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.
						(Signed)	______________________________________________
							Officer or Administrator of Provider(s)
							______________________________________________
							Title
							______________________________________________
							Date
PART III - SETTLEMENT SUMMARY
							TITLE XVIII
						TITLE V	PART A	PART B	HIT	TITLE XIX
						1	2	3	4	5
1	HOSPITAL										1
2	SUBPROVIDER - IPF										2
3	SUBPROVIDER - IRF										3
4	SUBPROVIDER (OTHER)										4
5	SWING BED - SNF										5
6	SWING BED - NF										6
7	SNF										7
8	NF, ICF/IID										8
9	HOME HEALTH AGENCY										9
10	HOSPITAL-BASED - RHC										10
11	HOSPITAL-BASED - FQHC										11
	OUTPATIENT REHABILITATION
12	PROVIDER (Specify)										12
200	TOTAL										200
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 0938-0050. The time required to complete this information collection is estimated 673 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-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTIONS 4003.1-4003.3)
Rev.											40-503

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Sheet 2: S2I

4090 (Cont.)			FORM CMS-2552-10							DRAFT
HOSPITAL AND HOSPITAL HEALTH CARE					PROVIDER CCN:	PERIOD		WORKSHEET S-2																							.													.
COMPLEX IDENTIFICATION DATA						FROM __________		PART I
					______________	TO _____________
Hospital and Hospital Health Care Complex Address:
1	Street:	P.O. Box:								1
2	City:	State:	Zip Code:	County:						2
Hospital and Hospital-Based Component Identification:
		Component	CCN	CBSA	Provider	Date		Payment System (P, T, O, or N)
	Component	Name	Number	Number	Type	Certified	V	XVIII	XIX
	0	1	2	3	4	5	6	7	8
3	Hospital									3
4	Subprovider- IPF									4
5	Subprovider- IRF									5
6	Subprovider- (Other)									6
7	Swing Beds-SNF									7
8	Swing Beds-NF									8
9	Hospital-Based SNF									9
10	Hospital-Based NF									10
11	Hospital-Based OLTC									11
12	Hospital-Based HHA									12
13	Separately Certified ASC									13
14	Hospital-Based Hospice									14
15	Hospital-Based Health Clinic-RHC									15
16	Hospital-Based Health Clinic-FQHC									16
17	Hospital-Based (CMHC, CORF and OPT)									17
18	Renal Dialysis									18
19	Other									19
20	Cost Reporting Period (mm/dd/yyyy)	From:_______________	To: ______________							20
21	Type of control (see instructions)									21
Inpatient PPS Information								1	2
22	Does this facility qualify and is it currently receiving payments for disproportionate share hospital adjustment, in accordance with 42 CFR 412.106?									22
	In column 1, enter "Y" for yes or "N" for no. Is this facility subject to 42 CFR 412.106 (c )(2) (Pickle amendment hospital)? In column 2, enter "Y" for yes or "N" for no.
22.01	Did this hospital receive interim uncompensated care payments for this cost reporting period? Enter in column 1, "Y" for yes or "N" for no for the portion of the cost reporting period occurring prior to October 1.									22.01
	Enter in column 2 "Y" for yes or "N" for no for the portion of the cost reporting period occurring on or after October 1. (see instructions)
23	Which method is used to determine Medicaid days on lines 24 and/or 25 below? In column 1, enter 1 if date of admission, 2 if census days, or 3 if date of discharge.									23
	Is the method of identifying the days in this cost reporting period different from the method used in the prior cost reporting period? In column 2, enter "Y" for yes or "N" for no.
				In-State	In-State	Out-of State	Out-of State	Medicaid	Other
				Medicaid	Medicaid eligible	Medicaid	Medicaid eligible	HMO	Medicaid
				paid days	unpaid days	paid days	unpaid days	days	days
				1	2	3	4	5	6
24	If this provider is an IPPS hospital, enter the in-state Medicaid paid days in col. 1, in-state Medicaid									24
	eligible unpaid days in col. 2, out-of-state Medicaid paid days in col. 3, out-of-state Medicaid eligible unpaid days
	in col. 4, Medicaid HMO paid and eligible but unpaid days in col. 5, and other Medicaid days in col. 6.
25	If this provider is an IRF, enter the in-state Medicaid paid days in col. 1, in-state Medicaid eligible unpaid									25
	days in col. 2, out-of-state Medicaid paid days in col. 3, out-of state Medicaid eligible unpaid days
	in col. 4 Medicaid HMO paid and eligible but unpaid days in col. 5.
26	Enter your standard geographic classification (not wage) status at the beginning of the cost reporting period. Enter "1" for urban or "2" for rural.									26
27	Enter your standard geographic classification (not wage) status at the end of the cost reporting period. Enter in column 1, "1" for urban or "2" for rural.									27
	If applicable enter the effective date of the geographic reclassification in column 2.
35	If this is a sole community hospital (SCH), enter the number of periods SCH status in effect in the cost reporting period.									35
36	Enter applicable beginning and ending dates of SCH status. Subscript line 36 for number of periods in excess of one and enter subsequent dates.					Beginning:_______________		Ending: ______________		36
37	If this is a Medicare dependent hospital (MDH), enter the number of periods MDH status in effect in the cost reporting period.									37
38	Enter applicable beginning and ending dates of MDH status. Subscript line 38 for number of periods in excess of one and enter subsequent dates.					Beginning:_______________		Ending: ______________		38
39	Does this facility qualify for the inpatient hospital payment adjustment for low volume hospitals in accordance with 42 CFR 412.101(b)(2)(ii)? Enter in column 1 “Y” for yes or “N” for no.									39
	Does the facility meet the mileage requirements in accordance with 42 CFR 412.101(b)(2)(ii)?  Enter in column 2 "Y" for yes or "N" for no.  (see instructions)
FORM CMS-2552-10 (03-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4004.1)
40-504										Rev.
DRAFT			FORM CMS-2552-10							4090 (Cont.)
HOSPITAL AND HOSPITAL HEALTH CARE					PROVIDER CCN:	PERIOD		WORKSHEET S-2
COMPLEX IDENTIFICATION DATA						FROM __________		PART I (CONT.)
					______________	TO _____________
							V	XVIII	XIX
Prospective Payment System (PPS)-Capital							1	2	3
45	Does this facility qualify and receive capital payment for disproportionate share in accordance with 42 CFR 412.320? (see instructions)									45
46	Is this facility eligible for additional payment exception for extraordinary circumstances pursuant to 42 CFR 412.348(f)? If yes, complete Worksheet L, Part III and L-1, Parts I through III.									46
47	Is this a new hospital under 42 CFR 412.300 PPS capital? Enter "Y for yes or "N" for no.									47
48	Is the facility electing full federal capital payment? Enter "Y" for yes or "N" for no.									48
Teaching Hospitals							1	2	3
56	Is this a hospital involved in training residents in approved GME programs? Enter "Y" for yes or "N" for no.									56
57	If line 56 is yes, is this the first cost reporting period during which residents in approved GME programs trained at this facility? Enter "Y" for yes or "N" for no in column 1.									57
	If column 1 is "Y" did residents start training in the first month of this cost reporting period? Enter "Y" for yes or "N" for no in column 2. If column 2 is "Y", complete Worksheet E-4.
	If column 2 is "N", complete Worksheet D, Parts III & IV and D-2, Part II, if applicable.
58	If line 56 is yes, did this facility elect cost reimbursement for physicians' services as defined in CMS Pub. 15-1, section 2148?									58
	If yes, complete Worksheet D-5.
59	Are costs claimed on line 100 of Worksheet A? If yes, complete Worksheet D-2, Part I.									59
60	Are you claiming nursing school and/or allied health costs for a program that meets the provider-operated criteria under 413.85? Enter "Y" for yes or "N" for no. (see instructions)									60
					Y/N			IME	Direct GME
					1	2	3	4	5
61	Did your hospital receive FTE slots under ACA section 5503? Enter "Y" for yes or "N" for no in column 1. (see instructions)									61
								IME	Direct GME
							1	2	3
61.01	Enter the average number of unweighted primary care FTEs from the hospital's 3 most recent cost reports ending and submitted before March 23, 2010. (see instructions)									61.01
61.02	Enter the current year total unweighted primary care FTE count (excluding OB/GYN, general surgery FTEs, and primary care FTEs added under section 5503 of ACA). (see instructions)									61.02
61.03	Enter the base line FTE count for primary care and/or general surgery residents, which is used for determining compliance with the 75% test. (see instructions)									61.03
61.04	Enter the number of unweighted primary care/or surgery allopathic and/or osteopathic FTEs in the current cost reporting period.(see instructions).									61.04
61.05	Enter the difference between the baseline primary and/or general surgery FTEs and the current year's primary care and/or general surgery FTE counts (line 61.04 minus line 61.03). (see instructions)									61.05
61.06	Enter the amount of ACA §5503 award that is being used for cap relief and/or FTEs that are nonprimary care or general surgery. (see instructions)									61.06
								Unweighted	Unweighted
								IME	Direct GME
						Program Name	Program Code	FTE Count	FTE Count
						1	2	3	4
61.10	Of the FTEs in line 61.05, specify each new program specialty, if any, and the number of FTE residents for each new program. (see instructions)									61.10
	Enter in column 1 the program name, enter in column 2 the program code, enter in column 3 the IME FTE unweighted count and enter in column 4 direct
	GME FTE unweighted count.
61.20	Of the FTEs in line 61.05, specify each expanded program specialty, if any, and the number of FTE residents for each expanded program. (see instructions)									61.20
	Enter in column 1 the program name, enter in column 2 the program code, enter in column 3 the IME FTE unweighted count and enter in column 4 direct
	GME FTE unweighted count.
ACA Provisions Affecting the Health Resources and Services Administration (HRSA)
62	Enter the number of FTE residents that your hospital trained in this cost reporting period for which your hospital received HRSA PCRE funding (see instructions)									62
62.01	Enter the number of FTE residents that rotated from a Teaching Health Center (THC) into your hospital during in this cost reporting period of HRSA THC program. (see instructions)									62.01
Teaching Hospitals that Claim Residents in Non-Provider Settings
63	Has your facility trained residents in non-provider settings during this cost reporting period? Enter "Y" for yes or "N" for no. If yes, complete lines 64-67. (see instructions)									63
							Unweighted	Unweighted	Ratio
							FTEs	FTEs	(col. 1/
Section 5504 of the ACA Base Year FTE Residents in Nonprovider settings--This base year is your cost reporting period that begins on or after July 1, 2009 and before June 30, 2010.							Nonprovider Site	in Hospital	(col. 1 + col. 2))
64	Enter in column 1, if line 63 is yes, or your facility trained residents in the base year period, the number of unweighted non-primary care resident FTEs attributable to rotations occurring									64
	in all non-provider settings. Enter in column 2 the number of unweighted non-primary care resident FTEs that trained in your hospital.
	Enter in column 3 the ratio of (column 1 divided by (column 1 + column 2)). (see instructions)
							Unweighted	Unweighted	Ratio
							FTEs	FTEs	(col. 3/
				Program Name		Program Code	Nonprovider Site	in Hospital	(col. 3 + col. 4))
				1		2	3	4	5
65	Enter in column 1, if line 63 is yes, or your facility trained residents in the base year period, the program name									65
	associated with primary care FTEs for each primary care program in which you trained residents.
	Enter in column 2 the program code, enter in column 3 the number of unweighted primary care FTE residents attributable to
	rotations occurring in all non-provider settings. Enter in column 4 the number of unweighted primary care resident FTEs that
	trained in your hospital. Enter in column 5 the ratio of (column 3 divided by (column 3 + column 4)). (see instructions)
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4004.14
Rev.										40-505
4090 (Cont.)			FORM CMS-2552-10					0		DRAFT
HOSPITAL AND HOSPITAL HEALTH CARE					PROVIDER CCN:	PERIOD		WORKSHEET S-2
COMPLEX IDENTIFICATION DATA						FROM __________		PART I (CONT.)
					______________	TO _____________
							Unweighted	Unweighted	Ratio
							FTEs	FTEs	(col. 1/
							Nonprovider Site	in Hospital	(col. 1 + col. 2))
Section 5504 of the ACA Current Year FTE Residents in Nonprovider settings--Effective for cost reporting periods beginning on or after July 1, 2010							1	2	3
66	Enter in column 1 the number of unweighted non-primary care resident FTEs attributable to rotations occurring in all non-provider settings. Enter in column 2 the number of									66
	unweighted non-primary care resident FTEs that trained in your hospital. Enter in column 3 the ratio of (column 1 divided by (column 1 + column 2)). (see instructions)
							Unweighted	Unweighted	Ratio
							FTEs	FTEs	(col. 3/
				Program Name		Program Code	Nonprovider Site	in Hospital	(col. 3 + col. 4))
				1		2	3	4	5
67	Enter in column 1 the program name associated with each of your primary care programs in which you trained residents.									67
	Enter in column 2 the program code. Enter in column 3 the number of
	unweighted primary care FTE residents attributable to rotations occurring in all non-provider settings.
	Enter in column 4 the number of unweighted primary care resident FTEs that trained in your hospital.
	Enter in column 5 the ratio of (column 3 divided by (column 3 + column 4)). (see instructions)
Inpatient Psychiatric Facility PPS							1	2	3
70	Is this facility an Inpatient Psychiatric Facility (IPF), or does it contain an IPF subprovider? Enter "Y" for yes or "N" for no.									70
71	If line 70 yes:									71
	Column 1: Did the facility have an approved GME teaching program in the most recent cost report filed on or before November 15, 2004? Enter "Y" for yes or "N" for no. (see 42 CFR 412.424(d)(1)(iii)(c))
	Column 2: Did this facility train residents in a new teaching program in accordance with 42 CFR 412.424 (d)(1)(iii)(D)? Enter "Y" for yes or "N" for no.
	Column 3: If column 2 is Y, enter 1, 2 or 3 respectively in column 3. (see instructions) If this cost reporting period covers the beginning of the fourth year, enter 4
	in column 3, or if the 5th or subsequent academic years of the new teaching program in existence, enter 5. (see instructions)
Inpatient Rehabilitation Facility PPS							1	2	3
75	Is this facility an Inpatient Rehabilitation Facility (IRF), or does it contain an IRF subprovider? Enter "Y" for yes or "N" for no.									75
76	If line 75 yes:									76
	Column 1: Did the facility have an approved GME teaching program in the most recent cost reporting period ending on or before November 15, 2004? Enter "Y" for yes or "N" for no.
	Column 2: Did this facility train residents in a new teaching program in accordance with 42 CFR 412.424 (d)(1)(iii)(D)? Enter "Y" for yes or "N" for no.
	Column 3: If column 2 is Y, enter 1, 2 or 3 respectively in column 3. (see instructions) If this cost reporting period covers the beginning of the fourth year, enter 4
	in column 3, or if the 5th or subsequent academic years of the new teaching program in existence, enter 5. (see instructions)
Long Term Care Hospital PPS
80	Is this a Long Term Care Hospital (LTCH)? Enter "Y" for yes or "N" for no.									80
TEFRA Providers
85	Is this a new hospital under 42 CFR 413.40(f)(1)(i) TEFRA? Enter "Y" for yes or "N" for no.									85
86	Did this facility establish a new Other subprovider (excluded unit) under 42 CFR 413.40(f)(1)(ii)? Enter "Y" for yes or "N" for no.									86
								V	XIX
Title V and XIX Services								1	2
90	Does this facility have title V and/or XIX inpatient hospital services? Enter "Y" for yes or "N" for no in applicable column.									90
91	Is this hospital reimbursed for title V and/or XIX through the cost report either in full or in part? Enter "Y" for yes or "N" for no in the applicable column.									91
92	Are title XIX NF patients occupying title XVIII SNF beds (dual certification)? (see instructions) Enter "Y" for yes or "N" for no in the applicable column.									92
93	Does this facility operate an ICF/IID facility for purposes of title V and XIX? Enter "Y" for yes or "N" for no in the applicable column.									93
94	Does title V or title XIX reduce capital cost? Enter "Y" for yes or "N" for no in the applicable column.									94
95	If line 94 is "Y", enter the reduction percentage in the applicable column.									95
96	Does title V or title XIX reduce operating cost? Enter "Y" for yes or "N" for no in the applicable column.									96
97	If line 96 is "Y", enter the reduction percentage in the applicable column.									97
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4004.1)
40-506										Rev.
03-14			FORM CMS-2552-10							4090 (Cont.)
HOSPITAL AND HOSPITAL HEALTH CARE					PROVIDER CCN:	PERIOD		WORKSHEET S-2
COMPLEX IDENTIFICATION DATA						FROM __________		PART I (CONT.)
					______________	TO _____________
Rural Providers								1	2
105	Does this hospital qualify as a Critical Access Hospital (CAH)?									105
106	If this facility qualifies as a CAH, has it elected the all-inclusive method of payment for outpatient services? (see instructions)									106
107	If this facility qualifies as a CAH, is it eligible for cost reimbursement for I &R training programs? Enter "Y" for yes or "N" for no in column 1. (see instructions)									107
	If yes, the GME elimination would not be on Worksheet B, Part I, column 25 and the program would be cost reimbursed. If yes complete Worksheet D-2, Part II.
108	Is this a rural hospital qualifying for an exception to the CRNA fee schedule? See 42 CFR 412.113(c). Enter "Y" for yes or "N" for no.									108
						Physical	Occupational	Speech	Respiratory
109	If this hospital qualifies as a CAH or a cost provider, are therapy services provided by outside supplier? Enter "Y" for yes or "N" for no for each therapy.									109
Miscellaneous Cost Reporting Information
115	Is this an all-inclusive rate provider? Enter "Y" for yes or "N" for no in column 1. If yes, enter the method used (A, B, or E only) in column 2.									115
	If column 2 is "E", enter in column 3 either "93" percent for short term hospital or "98" percent for long term care (includes psychiatric, rehabilitation and long term hospitals
	providers) based on the definition in CMS 15-1 §2208.1.
116	Is this facility classified as a referral center? Enter "Y" for yes or "N" for no.									116
117	Is this facility legally-required to carry malpractice insurance? Enter "Y" for yes or "N" for no.									117
118	Is the malpractice insurance a claims-made or occurrence policy? Enter 1 if the policy is claim- made. Enter 2 if the policy is occurrence.									118
118.01	List amounts of malpractice premiums and paid losses:						Premiums	Paid losses	Self insurance	118.01
118.02	Are malpractice premiums and paid losses reported in a cost center other than the Administrative and General? If yes, submit supporting schedule listing cost centers and amounts contained therein.									118.02
119	What is the liability limit for the malpractice insurance policy? Enter in column 1 the monetary limit per lawsuit. Enter in column 2 the monetary limit per policy year.									119
120	Is this a SCH or EACH that qualifies for the Outpatient Hold Harmless provision in ACA §3121 and applicable amendments? (see instructions) Enter in column 1 "Y" for yes or "N" for no. Is this a									120
	rural hospital with <100 beds that qualifies for the Outpatient Hold Harmless provision in ACA §3121 and applicable amendments? (see instructions) Enter in column 2 "Y" for yes or "N" for no.
121	Did this facility incur and report costs for high cost implantable devices charged to patients? Enter "Y" for yes or "N" for no.									121
Transplant Center Information
125	Does this facility operate a transplant center? Enter "Y" for yes or "N" for no. If yes, enter certification date(s) (mm/dd/yyyy) below.									125
126	If this is a Medicare certified kidney transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.									126
127	If this is a Medicare certified heart transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.									127
128	If this is a Medicare certified liver transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.									128
129	If this is a Medicare certified lung transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.									129
130	If this is a Medicare certified pancreas transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.									130
131	If this is a Medicare certified intestinal transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.									131
132	If this is a Medicare certified islet transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.									132
133	If this is a Medicare certified other transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.									133
134	If this is an organ procurement organization (OPO), enter the OPO number in column 1 and termination date, if applicable, in column 2.									134
FORM CMS-2552-10 (03-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4004.1)
Rev. 5										40-507
4090 (Cont.)			FORM CMS-2552-10							03-14
HOSPITAL AND HOSPITAL HEALTH CARE					PROVIDER CCN:	PERIOD		WORKSHEET S-2
COMPLEX IDENTIFICATION DATA						FROM __________		PART I (CONT.)
					______________	TO _____________
All Providers
								1	2
140	Are there any related organization or home office costs as defined in CMS Pub. 15-1, chapter 10? Enter "Y" for yes or "N" for no in column 1.									140
	If yes, and home office costs are claimed, enter in column 2 the home office chain number. (see instructions)
If this facility is part of a chain organization, enter on lines 141 through 143 the name and address of the home office and enter the home office contractor name and contractor number.
141	Name:			Contractor's Name: ___________________			Contractor's Number: __________			141
142	Street:		P. O. Box:							142
143	City:		State:	Zip Code:						143
144	Are provider based physicians' costs included in Worksheet A?									144
145	If costs for renal services are claimed on Worksheet A, line 74 are they costs for inpatient services only? Enter "Y" for yes or "N" for no.									145
146	Has the cost allocation methodology changed from the previously filed cost report? Enter "Y" for yes or "N" for no in column 1. (See CMS Pub. 15-2, section 4020)									146
	If yes, enter the approval date (mm/dd/yyyy) in column 2.
147	Was there a change in the statistical basis? Enter "Y" for yes or "N" for no.									147
148	Was there a change in the order of allocation? Enter "Y" for yes or "N" for no.									148
149	Was there a change to the simplified cost finding method? Enter "Y" for yes or "N" for no.									149
Does this facility contain a provider that qualifies for an exemption from the application of the lower of costs or charges?						Title XVIII
Enter "Y" for yes or "N" for no for each component for Part A and Part B. (See 42 CFR 413.13)						Part A	Part B	Title V	Title XIX
						1	2	3	4
155	Hospital									155
156	Subprovider - IPF									156
157	Subprovider - IRF									157
158	Subprovider - Other									158
159	SNF									159
160	HHA									160
161	CMHC									161
Multicampus
165	Is this hospital part of a multicampus hospital that has one or more campuses in different CBSAs? Enter "Y" for yes or "N" for no.									165
166	If line 165 is yes, for each campus enter the name in column 0, county in column 1, state in column 2, ZIP in column 3, CBSA in column 4, FTE/Campus in column 5.									166
		Name			County	State	Zip Code	CBSA	FTE/Campus
		0			1	2	3	4	5
Health Information Technology (HIT) incentive in the American Recovery and Reinvestment Act
167	Is this provider a meaningful user under §1886 (n)? Enter "Y" for yes or "N" for no.									167
168	If this provider is a CAH (line 105 is "Y") and is a meaningful user (line 167 is "Y"), enter the reasonable cost incurred for the HIT assets. (see instructions)									168
169	If this provider is a meaningful user (line 167 is "Y") and is not a CAH (line 105 is "N"), enter the transition factor. (see instructions)									169
170	Enter in columns 1 and 2 the EHR beginning date and ending date for the reporting period respectively (mm/dd/yyyy)									170
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4004.1)
40-508										Rev. 5

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Sheet 3: S2II

10-12			FORM CMS-2552-10						4090 (Cont.)
HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX				PROVIDER CCN:	PERIOD		WORKSHEET S-2
REIMBURSEMENT QUESTIONNAIRE					FROM __________		Part II
				______________	TO _____________
General Instruction:		Enter Y for all YES responses. Enter N for all NO responses.
		Enter all dates in the mm/dd/yyyy format.
COMPLETED BY ALL HOSPITALS
						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 yes, 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?								2
	If yes, enter in column 2 the date of termination and in column 3, "V" for voluntary or "I" for involuntary.
3	Is the provider involved in business transactions, including management contracts, with individuals or entities								3
	(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?								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 statements?								5
	If yes, submit reconciliation.
							Y/N	Y/N
Approved Educational Activities							1	2
6	Column 1: Are costs claimed for nursing school?								6
	Column 2: If yes, is the provider is the legal operator of the program?
7	Are costs claimed for allied health programs? If yes, see instructions.								7
8	Were nursing school and/or allied health programs approved and/or renewed during the cost reporting period?								8
	If yes, see instructions.
9	Are costs claimed for Intern-Resident programs claimed on the current cost report? If yes, see instructions.								9
10	Was an Intern-Resident program initiated or renewed in the current cost reporting period? If yes, see instructions.								10
11	Are GME costs directly assigned to cost centers other than I & R in an Approved Teaching Program on Worksheet A?								11
	If yes, see instructions.
Bad Debts								Y/N
12	Is the provider seeking reimbursement for bad debts? If yes, see instructions.								12
13	If line 12 is yes, did the provider's bad debt collection policy change during this cost reporting period? If yes, submit copy.								13
14	If line 12 is yes, were patient deductibles and/or co-payments waived? If yes, see instructions.								14
Bed Complement
15	Did total beds available change from the prior cost reporting period? If yes, see instructions.								15
					Part A		Part B
					Y/N	Date	Y/N	Date
PS&R Report Data					1	2	3	4
16	Was the cost report prepared using the PS&R Report only? If either column 1 or 3 is yes, enter the								16
	paid-through date of the PS&R Report used in columns 2 and 4. (see instructions)
17	Was the cost report prepared using the PS&R Report for totals and the provider's records for allocation?								17
	If either column 1 or 3 is yes, enter the paid-through date in columns 2 and 4. (see instructions)
18	If line 16 or 17 is yes, were adjustments made to PS&R Report data for additional claims that have been								18
	billed but are not included on the PS&R Report used to file the cost report? If yes, see instructions.
19	If line 16 or 17 is yes, were adjustments made to PS&R Report data for corrections of other								19
	PS&R Report information? If yes, see instructions.
20	If line 16 or 17 is yes, were adjustments made to PS&R Report data for Other?								20
	Describe the other adjustments:		_________________________________
21	Was the cost report prepared only using the provider's records? If yes, see instructions.								21
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTIONS 4004.2)
Rev. 3									40-509
4090 (Cont.)			FORM CMS-2552-10						10-12
HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX				PROVIDER CCN:	PERIOD		WORKSHEET S-2
REIMBURSEMENT QUESTIONNAIRE					FROM __________		Part II (CONT.)
				______________	TO _____________
General Instruction:		Enter Y for all YES responses. Enter N for all NO responses.
		Enter all dates in the mm/dd/yyyy format.
COMPLETED BY COST REIMBURSED AND TEFRA HOSPITALS ONLY (EXCEPT CHILDRENS HOSPITALS)
Capital Related Cost
22	Have assets been relifed for Medicare purposes? If yes, see instructions.								22
23	Have changes occurred in the Medicare depreciation expense due to appraisals made during the cost reporting period?								23
	If yes, see instructions.
24	Were new leases and/or amendments to existing leases entered into during this cost reporting period? If yes, see instructions.								24
25	Have there been new capitalized leases entered into during the cost reporting period? If yes, see instructions.								25
26	Were assets subject to Sec.2314 of DEFRA acquired during the cost reporting period? If yes, see instructions.								26
27	Has the provider's capitalization policy changed during the cost reporting period? If yes, see instructions.								27
Interest Expense
28	Were new loans, mortgage agreements or letters of credit entered into during the cost reporting period? If yes, see instructions.								28
29	Did the provider have a funded depreciation account and/or bond funds (Debt Service Reserve Fund) treated as a funded depreciation								29
	account? If yes, see instructions.
30	Has existing debt been replaced prior to its scheduled maturity with new debt? If yes, see instructions.								30
31	Has debt been recalled before scheduled maturity without issuance of new debt? If yes, see instructions.								31
Purchased Services
32	Have changes or new agreements occurred in patient care services furnished through contractual arrangements with suppliers of services?								32
	If yes, see instructions.
33	If line 32 is yes, were the requirements of Sec. 2135.2 applied pertaining to competitive bidding?								33
	If no, see instructions.
Provider-Based Physicians
34	Are services furnished at the provider facility under an arrangement with provider-based physicians? If "Y" see instructions.								34
35	If line 34 is yes, were there new agreements or amended existing agreements with the provider-based physicians during the cost								35
	reporting period? If yes, see instructions.
							Y/N	Date
Home Office Costs							1	2
36	Are home office costs claimed on the cost report?								36
37	If line 36 is yes, has a home office cost statement been prepared by the home office? If yes, see instructions.								37
38	If line 36 is yes , was the fiscal year end of the home office different from that of the provider?								38
	If yes, enter in column 2 the fiscal year end of the home office.
39	If line 36 is yes, did the provider render services to other chain components? If yes, see instructions.								39
40	If line 36 is yes, did the provider render services to the home office? If yes, see instructions.								40
Cost Report Preparer Contact Information
41	First name:		Last name:			Title:			41
42	Employer:								42
43	Phone number:			E-mail Address:					43
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTIONS 4004.2)
40-510									Rev. 3

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Sheet 4: S3I

09-14							FORM CMS-2552-10										4090 (Cont.)
HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX											PROVIDER CCN:		PERIOD		WORKSHEET S-3
STATISTICAL DATA													FROM __________		PART I
											______________		TO _____________
						Inpatient Days / Outpatient Visits / Trips				Full Time Equivalents			Discharges
		Worksheet
		A							Total	Total	Employees					Total
		Line	No. of	Bed Days	CAH		Title	Title	All	Interns &	On	Nonpaid		Title	Title	All
	Component	No.	Beds	Available	Hours	Title V	XVIII	XIX	Patients	Residents	Payroll	Workers	Title V	XVIII	XIX	Patients
		1	2	3	4	5	6	7	8	9	10	11	12	13	14	15
1	Hospital Adults & Peds. (columns 5,																1
	6, 7 and 8 exclude Swing Bed, Observation Bed
	and Hospice days) (see instructions for col.
	2 for the portion of LDP room available beds)
2	HMO and other (see instructions)																2
3	HMO IPF Subprovider																3
4	HMO IRF Subprovider																4
5	Hospital Adults & Peds. Swing Bed SNF																5
6	Hospital Adults & Peds. Swing Bed NF																6
7	Total Adults and Peds. (exclude																7
	observation beds) (see instructions)
8	Intensive Care Unit																8
9	Coronary Care Unit																9
10	Burn Intensive Care Unit																10
11	Surgical Intensive Care Unit																11
12	Other Special Care																12
13	Nursery																13
14	Total (see instructions)																14
15	CAH visits																15
16	Subprovider - IPF																16
17	Subprovider - IRF																17
18	Subprovider - Other																18
19	Skilled Nursing Facility																19
20	Nursing Facility																20
21	Other Long Term Care																21
22	Home Health Agency																22
23	ASC (Distinct Part)																23
24	Hospice (Distinct Part)																24
24.10	Hospice (non-distinct part)																24.10
25	CMHC																25
26	RHC/FQHC (specify)																26
27	Total (sum of lines 14-26)																27
28	Observation Bed Days																28
29	Ambulance Trips																29
30	Employee discount days (see instructions)																30
31	Employee discount days -IRF																31
32	Labor & delivery (see instructions)																32
32.01	Total ancillary labor & delivery room																32.01
	outpatient days (see instructions)
33	LTCH non-covered days																33
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4005.1)
Rev. 6																	40-511

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Sheet 5: S3II &III

4090 (Cont.)			FORM CMS-2552-10					09-14
HOSPITAL WAGE INDEX INFORMATION			PROVIDER CCN:		PERIOD		WORKSHEET S-3
					FROM __________		PART II
			______________		TO _____________
Part II - Wage Data
		Worksheet		Reclassification	Adjusted	Paid Hours	Average
		A		of Salaries	Salaries	Related	Hourly Wage
		Line	Amount	(from	(column 2 ±	to Salaries	(column 4 ÷
		Number	Reported	Worksheet A-6)	column 3)	in column 4	column 5)
		1	2	3	4	5	6
	SALARIES
1	Total salaries (see instructions)							1
2	Non-physician anesthetist Part A							2
3	Non-physician anesthetist Part B							3
4	Physician-Part A - Administrative							4
4.01	Physician-Part A - Teaching							4.01
5	Physician-Part B							5
6	Non-physician-Part B							6
7	Interns & residents (in an approved program)							7
7.01	Contracted interns & residents (in an approved program)							7.01
8	Home office personnel							8
9	SNF							9
10	Excluded area salaries (see instructions)							10
	OTHER WAGES AND RELATED COSTS
11	Contract labor : Direct Patient Care							11
12	Contract labor: Top level management and other management and administrative services							12
13	Contract labor: Physician-Part A - Administrative							13
14	Home office salaries & wage-related costs							14
15	Home office: Physician Part A - Administrative							15
16	Home office & Contract Physicians Part A - Teaching							16
	WAGE-RELATED COSTS
17	Wage-related costs (core) (see instructions)							17
18	Wage-related costs (other) (see instructions)							18
19	Excluded areas							19
20	Non-physician anesthetist Part A							20
21	Non-physician anesthetist Part B							21
22	Physician Part A - Administrative							22
22.01	Physician Part A - Teaching							22.01
23	Physician Part B							23
24	Wage-related costs (RHC/FQHC)							24
25	Interns & residents (in an approved program)							25
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4005.2 - 4005.3)
40-512								Rev. 6
09-13			FORM CMS-2552-10					4090 (Cont.)
HOSPITAL WAGE INDEX INFORMATION			PROVIDER CCN:		PERIOD		WORKSHEET S-3
					FROM __________		PART II & III
			______________		TO _____________
Part II - Wage Data
		Worksheet		Reclassification	Adjusted	Paid Hours	Average
		A		of Salaries	Salaries	Related	Hourly Wage
		Line	Amount	(from	(column 2 ±	to Salaries	(column 4 ÷
		Number	Reported	Worksheet A-6)	column 3)	in column 4	column 5)
		1	2	3	4	5	6
	OVERHEAD COSTS - DIRECT SALARIES
26	Employee Benefits Department	4						26
27	Administrative & General	5						27
28	Administrative & General under contract (see instructions)							28
29	Maintenance & Repairs	6						29
30	Operation of Plant	7						30
31	Laundry & Linen Service	8						31
32	Housekeeping	9						32
33	Housekeeping under contract (see instructions)							33
34	Dietary	10						34
35	Dietary under contract (see instructions)							35
36	Cafeteria	11						36
37	Maintenance of Personnel	12						37
38	Nursing Administration	13						38
39	Central Services and Supply	14						39
40	Pharmacy	15						40
41	Medical Records & Medical Records Library	16						41
42	Social Service	17						42
43	Other General Service	18						43
Part III - Hospital Wage Index Summary
1	Net salaries (see instructions)							1
2	Excluded area salaries (see instructions)							2
3	Subtotal salaries (line 1 minus line 2)							3
4	Subtotal other wages and related costs (see instructions)							4
5	Subtotal wage-related costs (see instructions)							5
6	Total (sum of lines 3 through 5)							6
7	Total overhead cost (see instructions)							7
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4005.2 - 4005.3)
Rev. 4								40-513

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Sheet 6: S3IV

4090 (Cont.)		FORM CMS-2552-10				09-13
HOSPITAL WAGE RELATED COSTS			PROVIDER CCN:	PERIOD	WORKSHEET S-3,
				FROM __________	PART IV
			______________	TO _____________
Part IV - Wage Related Cost
Part A - Core List
					Amount
					Reported
	RETIREMENT COST
1	401k Employer Contributions					1
2	Tax Sheltered Annuity (TSA) Employer Contribution					2
3	Nonqualified Defined Benefit Plan Cost (see instructions)					3
4	Qualified Defined Benefit Plan Cost (see instructions)					4
	PLAN ADMINISTRATIVE COSTS (Paid to External Organization):
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	Accident 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 accrual required by FASB 106. Non cumulative portion)					16
	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 (Other Than Retirement Cost Reported on lines 1 through 4 above)(see instructions)					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
25	Other Wage Related Costs (specify)_________________________________________					25
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4005.4)
40-514						Rev. 4

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Sheet 7: S3V

10-12		FORM CMS-2552-10				4090 (Cont.)
HOSPITAL CONTRACT LABOR AND BENEFIT COST			PROVIDER CCN:	PERIOD:	WORKSHEET S-3,
				FROM __________	PART V
			______________	TO _____________
Part V - Contract Labor and Benefit Cost
Hospital and Hospital-Based Component Identification:
				Contract	Benefit
	Component			Labor	Cost
	0			1	2
1	Total facility contract labor and benefit cost					1
2	Hospital					2
3	Subprovider- IPF					3
4	Subprovider- IRF					4
5	Subprovider- (Other)					5
6	Swing Beds-SNF					6
7	Swing Beds-NF					7
8	Hospital-Based SNF					8
9	Hospital-Based NF					9
10	Hospital-Based OLTC					10
11	Hospital-Based HHA					11
12	Separately Certified ASC					12
13	Hospital-Based Hospice					13
14	Hospital-Based Health Clinic RHC					14
15	Hospital-Based Health Clinic FQHC					15
16	Hospital-Based-CMHC					16
17	Renal Dialysis					17
18	Other					18
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4005.5)
Rev. 3						40-515

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Sheet 8: S4

4090 (Cont.)					FORM CMS-2552-10							10-12
HOSPITAL-BASED HOME HEALTH AGENCY						PROVIDER CCN:		PERIOD:		WORKSHEET S-4																{APP4}IALLWAYS~/PCOPB1~Q/PGQ/1
STATISTICAL DATA						______________		FROM __________
						HHA CCN:		TO _____________
						______________
	HOME HEALTH AGENCY STATISTICAL DATA							County: __________________
							Title V	Title XVIII	Title XIX	Other	Total
	Description						1	2	3	4	5
1	Home Health Aide Hours											1
2	Unduplicated Census Count (see instructions)											2
	HOME HEALTH AGENCY - NUMBER OF EMPLOYEES
									Number of Employees
	Enter the number of hours in								(Full Time Equivalent)
	your normal work week _______								Staff	Contract	Total
									1	2	3
3	Administrator and Assistant Administrator(s)											3
4	Director(s) and Assistant Director(s)											4
5	Other Administrative Personnel											5
6	Direct Nursing Service											6
7	Nursing Supervisor											7
8	Physical Therapy Service											8
9	Physical Therapy Supervisor											9
10	Occupational Therapy Service											10
11	Occupational Therapy Supervisor											11
12	Speech Pathology Service											12
13	Speech Pathology Supervisor											13
14	Medical Social Service											14
15	Medical Social Service Supervisor											15
16	Home Health Aide											16
17	Home Health Aide Supervisor											17
18	Other (specify)											18
	HOME HEALTH AGENCY CBSA CODES
19	Enter the number of CBSAs where you provided services during the cost reporting period.											19
20	List those CBSA code(s) serviced during this cost reporting period (line 20 contains the first code).											20
	PPS ACTIVITY
							Full Episodes				Total
							Without	With	LUPA	PEP only	(columns 1
							Outliers	Outliers	Episodes	Episodes	through 4)
							1	2	3	4	5
21	Skilled Nursing Visits											21
22	Skilled Nursing Visit Charges											22
23	Physical Therapy Visits											23
24	Physical Therapy Visit Charges											24
25	Occupational Therapy Visits											25
26	Occupational Therapy Visit Charges											26
27	Speech Pathology Visits											27
28	Speech Pathology Visit Charges											28
29	Medical Social Service Visits											29
30	Medical Social Service Visit Charges											30
31	Home Health Aide Visits											31
32	Home Health Aide Visit Charges											32
33	Total visits (sum of lines 21, 23, 25, 27, 29, and 31)											33
34	Other Charges											34
35	Total Charges (sum of lines 22, 24, 26, 28, 30, 32, and 34)											35
36	Total Number of Episodes (standard/non-outlier)											36
37	Total Number of Outlier Episodes											37
38	Total Non-Routine Medical Supply Charges											38
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4006)
40-516												Rev. 3

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Sheet 9: S5

09-13			FORM CMS-2552-10						4090 (Cont.)
HOSPITAL RENAL DIALYSIS DEPARTMENT				PROVIDER CCN:		PERIOD:		WORKSHEET S-5																																																																																																	{APP4}IALLWAYS~/PCOPB1~Q/PGQ/1
STATISTICAL DATA						FROM ___________
				______________		TO ______________
	RENAL DIALYSIS STATISTICS
			Outpatient		Training		Home
					Hemo-	CAPD	Hemo-	CAPD
		DESCRIPTION	Regular	High Flux	dialysis	CCPD	dialysis	CCPD
			1	2	3	4	5	6
1	Number of patients in program at								1
	end of cost reporting period
2	Number of times per week patient								2
	receives dialysis
3	Average patient dialysis time including setup								3
4	CAPD exchanges per day								4
5	Number of days in year dialysis furnished								5
6	Number of stations								6
7	Treatment capacity per day per station								7
8	Utilization (see instructions)								8
9	Average times dialyzers re-used								9
10	Percentage of patients re-using dialyzers								10
	ESRD PPS						1	2
10.01	Is the dialysis facility approved as a low-volume facility for this cost reporting period?								10.01
	Enter "Y" for yes or "N" for no. (see instructions)
10.02	Did your facility elect 100% PPS effective January 1, 2011? Enter "Y" for yes or "N" for no.								10.02
	(See instructions for "new" providers.)
10.03	If you responded "N" to line 10.02, enter in column 1 the year of transition for periods prior to January 1 and								10.03
	enter in column 2 the year of transition for periods after December 31. (see instructions)
	TRANSPLANT INFORMATION
11	Number of patients on transplant list								11
12	Number of patients transplanted during the cost reporting period								12
	EPOETIN
13	Net costs of Epoetin furnished to all maintenance dialysis patients by the provider								13
14	Epoetin amount from Worksheet A for home dialysis program								14
15	Number of EPO units furnished relating to the renal dialysis department								15
16	Number of EPO units furnished relating to the home dialysis department								16
	ARANESP
17	Net costs of ARANESP furnished to all maintenance dialysis patients by the provider								17
18	ARANESP amount from Worksheet A for home dialysis program								18
19	Number of ARANESP units furnished relating to the renal dialysis department								19
20	Number of ARANESP units furnished relating to the home dialysis department								20
	PHYSICIAN PAYMENT METHOD (Enter "X" for applicable method(s))
21	MCP_________		INITIAL METHOD__________						21
					Net Cost of	Net Cost of	Number of ESA	Number of ESA
			ESA		ESAs for	ESAs for	Units - Renal	Units - Home
			Description		Renal Patients	Home Patients	Dialysis Dept.	Dialysis Dept.
	Erythropoiesis-Stimulating Agents (ESA) Statistics:		1		2	3	4	5
22	Enter in column 1 the ESA description. Enter in column 2 the net								22
	costs of ESAs furnished to all renal dialysis patients.
	Enter in column 3 the net cost of ESAs furnished to all home
	dialysis program patients. Enter in column 4 the number of
	ESA units furnished to patients in the renal dialysis department.
	Enter in column 5 the number of units furnished
	to patients in the home dialysis program. (see instructions)
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4007)
Rev. 4									40-517

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Sheet 10: S6

4090 (Cont.)			FORM CMS-2552-10				09-13
HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND				PROVIDER CCN:	PERIOD:	WORKSHEET S-6																								.
OTHER OUTPATIENT REHABILITATION				_______________	FROM ___________
PROVIDER STATISTICAL DATA				COMPONENT CCN:	TO ______________
				_______________
COMMUNITY MENTAL HEALTH & OTHER OUTPATIENT REHABILITATION PROVIDER- NUMBER OF EMPLOYEES (FULL TIME EQUIVALENT)
Check		[ ] CMHC	[ ] OOT
applicable		[ ] CORF	[ ] OSP
box:		[ ] OPT
Enter the number of hours in your normal workweek ________
						Total
				Staff	Contract	(column 1 + column 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
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4008)
40-518							Rev. 4

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Sheet 11: S7

10-12						FORM CMS-2552-10					4090 (Cont.)
PROSPECTIVE PAYMENT FOR SNF								PROVIDER CCN:	PERIOD:	WORKSHEET S-7
STATISTICAL DATA									FROM ____________
								________________	TO ______________
									Y/N	Date
									1	2
1	If this facility contains a hospital-based SNF, were all patients under managed care or was there no Medicare										1
	utilization? Enter "Y" for yes and do not complete the rest of this worksheet.
2	Does this hospital have an agreement under either section 1883 or section 1913 for swing beds? Enter "Y" for										2
	yes or "N" for no in column 1. If yes, enter the agreement date (mm/dd/yyyy) in column 2.
								SNF	Swing Bed SNF	TOTAL
				Group				Days	Days	(sum of col. 2 + 3)
				1				2	3	4
3	RUX										3
4	RUL										4
5	RVX										5
6	RVL										6
7	RHX										7
8	RHL										8
9	RMX										9
10	RML										10
11	RLX										11
12	RUC										12
13	RUB										13
14	RUA										14
15	RVC										15
16	RVB										16
17	RVA										17
18	RHC										18
19	RHB										19
20	RHA										20
21	RMC										21
22	RMB										22
23	RMA										23
24	RLB										24
25	RLA										25
26	ES3										26
27	ES2										27
28	ES1										28
29	HE2										29
30	HE1										30
31	HD2										31
32	HD1										32
33	HC2										33
34	HC1										34
35	HB2										35
36	HB1										36
37	LE2										37
38	LE1										38
39	LD2										39
40	LD1										40
41	LC2										41
42	LC1										42
43	LB2										43
44	LB1										44
45	CE2										45
46	CE1										46
47	CD2										47
48	CD1										48
49	CC2										49
50	CC1										50
51	CB2										51
52	CB1										52
53	CA2										53
54	CA1										54
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4009)
Rev. 3											40-519
4090 (Cont.)						FORM CMS-2552-10					10-12
PROSPECTIVE PAYMENT FOR SNF								PROVIDER CCN:	PERIOD:	WORKSHEET S-7
STATISTICAL DATA									FROM ____________	(CONT.)
								________________	TO ______________
								SNF	Swing Bed SNF	TOTAL
				Group				Days	Days	(sum of col. 2 + 3)
				1				2	3	4
55	SE3										55
56	SE2										56
57	SE1										57
58	SSC										58
59	SSB										59
60	SSA										60
61	IB2										61
62	IB1										62
63	IA2										63
64	IA1										64
65	BB2										65
66	BB1										66
67	BA2										67
68	BA1										68
69	PE2										69
70	PE1										70
71	PD2										71
72	PD1										72
73	PC2										73
74	PC1										74
75	PB2										75
76	PB1										76
77	PA2										77
78	PA1										78
199	AAA										199
200	TOTAL										200
SNF SERVICES
									CBSA at	CBSA on/after
									Beginning of	October 1 of the
									Cost Reporting	Cost Reporting
									Period	Period (if applicable)
									1	2
201	Enter in column 1 the SNF CBSA code, or 5 character non-CBSA code if a rural facility, in effect at the beginning										201
	of the cost reporting period.
	Enter in column 2 the code in effect on or after October 1 of the cost reporting period (if applicable).
A notice published in the Federal Register Volume 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 202 through 207: Enter in column 1 the amount of the 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 7, column 3. In column 3, enter "Y" or "N" for no if the spending
reflects increases associated with direct patient care and related expenses for each category. (see instructions)
										Associated with
										Direct Patient Care
								Expenses	Percentage	and Related Expenses?
								1	2	3
202	Staffing										202
203	Recruitment										203
204	Retention of employees										204
205	Training										205
206	Other (Specify)										206
207	Total SNF revenue (Worksheet G-2, Part I, line 7, column 3)										207
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4009)
40-520											Rev. 3

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Sheet 12: S8

DRAFT		FORM CMS-2552-10																4090 (Cont.)
HOSPITAL-BASED RHC/FQHC STATISTICAL DATA									PROVIDER CCN:				PERIOD:			WORKSHEET S-8
									________________				FROM ___________
									COMPONENT CCN:				TO __________
									________________
Check			[ ] Hospital-based RHC
applicable box:			[ ] Hospital-based FQHC
Clinic Address and Identification:
1	Street:																	1
2	City:			State:			Zip Code:				County:							2
3	HOSPITAL-BASED FQHCs ONLY: Designation - Enter "R" for rural or "U" for urban																	3
Source of Federal Funds:
												Grant Award				Date
												1				2
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 a hospital-based 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 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 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 as defined in CMS Pub. 100-04, chapter 9, section 30.8? Enter "Y" for yes or "N" for no in column 1.																	13
	If yes, enter in column 2 the number of providers included in this report. List the names of all providers and numbers below.
14	RHC/FQHC name: _______________________________________________										CCN number: ________________							14
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4010)
Rev.																		40-521

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Sheet 13: S9

4090 (Cont.)			FORM CMS-2552-10					DRAFT
HOSPITAL-BASED HOSPICE IDENTIFICATION DATA					PROVIDER CCN:	PERIOD:	WORKSHEET S-9
					________________	FROM __________	PARTS I THROUGH IV
					HOSPICE CCN:	TO __________
					________________
PART I - ENROLLMENT DAYS FOR COST REPORTING PERIODS BEGINNING BEFORE OCTOBER 1, 2015
			Unduplicated Days
				Title XVIII	Title XIX		Total
				Skilled Nursing	Nursing	All	(sum of
		Title XVIII	Title XIX	Facility	Facility	Other	cols. 1, 2 and 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, 2015
				Title XVIII	Title XIX		Total
				Skilled Nursing	Nursing	All	(sum of
		Title XVIII	Title XIX	Facility	Facility	Other	cols. 1, 2 and 5)
		1	2	3	4	5	6
6	Number of Patients Receiving							6
	Hospice Care
7	Total Number of Unduplicated Contin-							7
	uous Care Hours Billable to Medicare
8	Average Length of Stay (line 5/line 6)							8
9	Unduplicated Census Count							9
PART III - ENROLLMENT DAYS FOR COST REPORTING PERIODS BEGINNING ON OR AFTER OCTOBER 1, 2015
				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 ENDING ON OR AFTER OCTOBER 1, 2015
							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-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4011)
40-522								Rev.

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Sheet 14: S10

09-13			FORM CMS-2552-10				4090 (Cont.)
HOSPITAL UNCOMPENSATED AND INDIGENT				PROVIDER CCN:	PERIOD:	WORKSHEET S-10
CARE DATA					FROM ___________
				________________	TO ______________
Uncompensated and indigent care cost computation
1	Cost to charge ratio (Worksheet C, Part I line 202 column 3 divided by line 202 column 8)						1
Medicaid (see instructions for each line)
2	Net revenue from Medicaid						2
3	Did you receive DSH or supplemental payments from Medicaid?						3
4	If line 3 is yes, does line 2 include all DSH or supplemental payments from Medicaid?						4
5	If line 4 is no, enter DSH or supplemental payments from Medicaid						5
6	Medicaid charges						6
7	Medicaid cost (line 1 times line 6)						7
8	Difference between net revenue and costs for Medicaid program (line 7 minus lines 2 and 5).						8
	If line 7 is less than the sum of lines 2 and 5, then enter zero.
State Children's Health Insurance Program (SCHIP) (see instructions for each line)
9	Net revenue from stand-alone SCHIP						9
10	Stand-alone SCHIP charges						10
11	Stand-alone SCHIP cost (line 1 times line 10)						11
12	Difference between net revenue and costs for stand-alone SCHIP (line 11 minus line 9).						12
	If line 11 is less than line 9, then enter zero.
Other state or local government indigent care program (see instructions for each line)
13	Net revenue from state or local indigent care program (not included on lines 2, 5 or 9)						13
14	Charges for patients covered under state or local indigent care program (not included in lines 6 or 10)						14
15	State or local indigent care program cost (line 1 times line 14)						15
16	Difference between net revenue and costs for state or local indigent care program (line 15 minus line 13)						16
	If line 15 is less than line 13, then enter zero.
Uncompensated care (see instructions for each line)
17	Private grants, donations, or endowment income restricted to funding charity care						17
18	Government grants, appropriations or transfers for support of hospital operations						18
19	Total unreimbursed cost for Medicaid, SCHIP and state and local indigent care programs (sum of lines 8, 12 and 16)						19
				Uninsured	Insured	Total
				patients	patients	(col. 1 + col. 2)
				1	2	3
20	Total initial obligation of patients approved for charity care (at full charges excluding						20
	non-reimbursable cost centers) for the entire facility
21	Cost of initial obligation of patients approved for charity care (line 1 times line 20)						21
22	Partial payment by patients approved for charity care						22
23	Cost of charity care (line 21 minus line 22)						23
24	Does the amount in line 20, column 2 include charges for patient days beyond a length of stay limit imposed on patients covered						24
	by Medicaid or other indigent care program?
25	If line 24 is yes, enter charges for patient days beyond an indigent care program's length of stay limit (see instructions)						25
26	Total bad debt expense for the entire hospital complex (see instructions)						26
27	Medicare bad debts for the entire hospital complex (see instructions)						27
28	Non-Medicare and non-reimbursable Medicare bad debt expense (line 26 minus line 27)						28
29	Cost of non-Medicare and non-reimbursable Medicare bad debt expense (line 1 times line 28)						29
30	Cost of uncompensated care (line 23 column 3 plus line 29)						30
31	Total unreimbursed and uncompensated care cost (line 19 plus line 30)						31
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4012)
Rev. 4							40-523

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Sheet 15: S-11PI

4090 (Cont.)			FORM CMS-2552-10						DRAFT
HOSPITAL-BASED FQHC IDENTIFICATION DATA						PROVIDER CCN:	PERIOD:	WORKSHEET S-11,
						______________	FROM: ___________	PART I
						COMPONENT CCN:	TO: ___________
						______________
PART I - HOSPITAL-BASED FQHC IDENTIFICATION DATA
					Type of control	Date	V/I	Date of
					(see instructions)	Decertified	Decertification	CHOW
	1				2	3	4	5
1	Site Name:								1
2	Street:	P.O. Box:							2
3	City:	State:	Zip Code:	County:	Designation - Enter "R" for rural or "U" for urban:				3
4	Is this hospital-based FQHC part of an entity that owns, leases or controls multiple FQHCs? Enter "Y" for yes or "N" for no. If yes,								4
	enter the entity's information below.
5	Name of Entity:								5
6	Street:	P.O. Box:		HRSA Award Number:					6
7	City:	State:		Zip Code:					7
						1	2	3
Consolidated Cost Report						Y/N	Date Requested	Date Approved
8	Is this hospital-based FQHC filing a consolidated cost report per CMS Pub. 100-04, chapter 9, §30.8? Enter "Y" for yes or "N" for no in column 1.								8
	(see instructions) If yes, complete line 9. If no, leave line 9 blank.
					CCN	CBSA	Date Requested	Date Approved
	1				2	3	4	5
9	Site Name:								9
Hospital-Based FQHC Operations						1	2	3
10	What type of organization is this hospital-based FQHC? If you operate as more than one sub-type of an organization, enter any or all of the applicable alpha								10
	characters in column 2. (see instructions)
11	Did this hospital-based FQHC receive a grant under §330 of the PHS Act during this cost reporting period? If this is a consolidated cost report, did the hospital-based FQHC reported								11
	on line 1, column 2 receive a grant under §330 of the PHS Act during this cost reporting period? Enter "Y" for yes or "N" for no. (complete line 12)
12	If the response to line 11 is yes, indicate in column 1, the type of HRSA grant that was awarded (see instructions). Enter the date of the grant award in								12
	column 2 and enter the grant award number in column 3. If you received more than one grant subscript this line accordingly.
Medical Malpractice
13	Did this hospital-based FQHC submit an initial deeming or annual redeeming application for medical malpractice coverage under the FTCA with HRSA? Enter "Y" for								13
	yes or "N" for no in column 1. If column 1 is yes, enter the effective date of coverage in column 2.
Interns and Residents
14	Did this hospital-based FQHC receive a Teaching Health Center development grant authorized under Part C of Title VII of the PHS Act from HRSA? Enter "Y" for								14
	yes or "N" for no in column 1. If yes, enter in column 2 the number of FTE residents that your hospital-based FQHC trained and received funding through your
	THC grant in this cost reporting period.
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4010.1 )
40-523.1									Rev.

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Sheet 16: S-11PII

DRAFT				FORM CMS-2552-10						4090 (Cont.)
HOSPITAL-BASED FQHC IDENTIFICATION DATA							PROVIDER CCN:	PERIOD:	WORKSHEET S-11,
							______________	FROM ___________	PART II
							COMPONENT CCN:	TO ___________
							______________
							SUBCOMPONENT CCN:
							______________
PART II - HOSPITAL-BASED FQHC CONSOLIDATED COST REPORT PARTICIPANT IDENTIFICATION DATA
					Date	Type of control	Date	V/I	Date of
					Certified	(see instructions)	Decertified	Decertification	CHOW
	1				2	3	4	5	6
1	Site Name:									1
2	Street:	P.O. Box:								2
3	City:	State:	Zip Code:	County:		Designation - Enter "R" for rural or "U" for urban:				3
Hospital-Based FQHC Operations							1	2	3
4	What type of organization is this hospital-based FQHC? If you operate as more than one sub-type of an organization, enter any or all of									4
	the applicable alpha characters in column 2. (see instructions)
5	Did this hospital-based FQHC receive a grant under §330 of the PHS Act during this cost reporting period? Enter "Y" for yes or "N" for no. (complete line 6)									5
6	If the response to line 5 is yes, indicate in column 1, the type of HRSA grant that was awarded (see instructions). Enter the date of the grant award in									6
	column 2 and enter the grant award number in column 3. If you received more than one grant subscript this line accordingly.
Medical Malpractice
7	Did this hospital-based FQHC submit an initial deeming or annual redeeming application for medical malpractice coverage under the FTCA with HRSA?									7
	Enter "Y" for yes or "N" for no in column 1. If column 1 is yes, enter the effective date of coverage in column 2.
Interns and Residents
8	Did this hospital-based FQHC receive a Teaching Health Center development grant authorized under Part C of Title VII of the PHS Act from HRSA?									8
	Enter "Y" for yes or "N" for no in column 1. If yes, enter in column 2 the number of FTE residents that your FQHC trained and received funding through
	your THC grant in this cost reporting period.
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4010.2)
Rev.										40-523.2

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Sheet 17: S-11PIII

4090 (Cont.)			FORM CMS-2552-10					DRAFT
HOSPITAL-BASED FQHC IDENTIFICATION DATA			PROVIDER CCN:		PERIOD:		WORKSHEET S-11,
			___________		FROM ___________		PART III
			COMPONENT CCN:		TO ___________
			______________
PART III - HOSPITAL-BASED FQHC STATISTICAL DATA
							Total
			COMPONENT		Title	Title	All
			CCN	Title V	XVIII	XIX	Patients
			0	1	2	3	4
1	Medical Visits							1
2	Total Medical Visits							2
3	Mental Health Visits							3
4	Total Mental Health Visits							4
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4010.3)
40-523.3								Rev.

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Sheet 18: A

4090 (Cont.)				FORM CMS-2552-10						09-13
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES					PROVIDER CCN:		PERIOD:		WORKSHEET A
							FROM ____________
					________________		TO _______________
							RECLASSIFIED		NET EXPENSES
		COST CENTER DESCRIPTIONS			TOTAL	RECLASSIFI-	TRIAL BALANCE		FOR ALLOCATION
		(omit cents)	SALARIES	OTHER	(col. 1 + col. 2)	CATIONS	(col. 3 ± col. 4)	ADJUSTMENTS	(col. 5 ± col. 6)
			1	2	3	4	5	6	7
		GENERAL SERVICE COST CENTERS
1	00100	Capital Related Costs-Buildings and Fixtures								1
2	00200	Capital Related Costs-Movable Equipment								2
3	00300	Other Capital Related Costs							-0-	3
4	00400	Employee Benefits Department								4
5	00500	Administrative and General								5
6	00600	Maintenance and Repairs								6
7	00700	Operation of Plant								7
8	00800	Laundry and Linen Service								8
9	00900	Housekeeping								9
10	01000	Dietary								10
11	01100	Cafeteria								11
12	01200	Maintenance of Personnel								12
13	01300	Nursing Administration								13
14	01400	Central Services and Supply								14
15	01500	Pharmacy								15
16	01600	Medical Records & Medical Records Library								16
17	01700	Social Service								17
18		Other General Service (specify)								18
19	01900	Nonphysician Anesthetists								19
20	02000	Nursing School								20
21	02100	Intern & Res. Service-Salary & Fringes (Approved)								21
22	02200	Intern & Res. Other Program Costs (Approved)								22
23	02300	Paramedical Ed. Program (specify)								23
		INPATIENT ROUTINE SERVICE COST CENTERS
30	03000	Adults and Pediatrics (General Routine Care)								30
31	03100	Intensive Care Unit								31
32	03200	Coronary Care Unit								32
33	03300	Burn Intensive Care Unit								33
34	03400	Surgical Intensive Care Unit								34
35		Other Special Care (specify)								35
40	04000	Subprovider - IPF								40
41	04100	Subprovider - IRF								41
42	04200	Subprovider (specify)								42
43	04300	Nursery								43
44	04400	Skilled Nursing Facility								44
45	04500	Nursing Facility								45
46	04600	Other Long Term Care								46
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4013)
40-524										Rev. 4
10-12				FORM CMS-2552-10						4090 (Cont.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES					PROVIDER CCN:		PERIOD:		WORKSHEET A
							FROM ____________
					________________		TO _______________
							RECLASSIFIED		NET EXPENSES
		COST CENTER DESCRIPTIONS			TOTAL	RECLASSIFI-	TRIAL BALANCE		FOR ALLOCATION
		(omit cents)	SALARIES	OTHER	(col. 1 + col. 2)	CATIONS	(col. 3 ± col. 4)	ADJUSTMENTS	(col. 5 ± col. 6)
			1	2	3	4	5	6	7
		ANCILLARY SERVICE COST CENTERS
50	05000	Operating Room								50
51	05100	Recovery Room								51
52	05200	Labor Room and Delivery Room								52
53	05300	Anesthesiology								53
54	05400	Radiology-Diagnostic								54
55	05500	Radiology-Therapeutic								55
56	05600	Radioisotope								56
57	05700	Computed Tomography (CT) Scan								57
58	05800	Magnetic Resonance Imaging (MRI)								58
59	05900	Cardiac Catheterization								59
60	06000	Laboratory								60
61	06100	PBP Clinical Laboratory Services-Program Only								61
62	06200	Whole Blood & Packed Red Blood Cells								62
63	06300	Blood Storing, Processing, & Trans.								63
64	06400	Intravenous Therapy								64
65	06500	Respiratory Therapy								65
66	06600	Physical Therapy								66
67	06700	Occupational Therapy								67
68	06800	Speech Pathology								68
69	06900	Electrocardiology								69
70	07000	Electroencephalography								70
71	07100	Medical Supplies Charged to Patients								71
72	07200	Implantable Devices Charged to Patients								72
73	07300	Drugs Charged to Patients								73
74	07400	Renal Dialysis								74
75	07500	ASC (Non-Distinct Part)								75
76		Other Ancillary (specify)								76
		OUTPATIENT SERVICE COST CENTERS
88	08800	Rural Health Clinic (RHC)								88
89	08900	Federally Qualified Health Center (FQHC)								89
90	09000	Clinic								90
91	09100	Emergency								91
92	09200	Observation Beds								92
93		Other Outpatient Service (specify)								93
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4013)
Rev. 3										40-525
4090 (Cont.)				FORM CMS-2552-10						10-12
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES					PROVIDER CCN:		PERIOD:		WORKSHEET A
							FROM ____________
					________________		TO _______________
							RECLASSIFIED		NET EXPENSES
		COST CENTER DESCRIPTIONS			TOTAL	RECLASSIFI-	TRIAL BALANCE		FOR ALLOCATION
		(omit cents)	SALARIES	OTHER	(col. 1 + col. 2)	CATIONS	(col. 3 ± col. 4)	ADJUSTMENTS	(col. 5 ± col. 6)
			1	2	3	4	5	6	7
		OTHER REIMBURSABLE COST CENTERS
94	09400	Home Program Dialysis								94
95	09500	Ambulance Services								95
96	09600	Durable Medical Equipment-Rented								96
97	09700	Durable Medical Equipment-Sold								97
98		Other Reimbursable (specify)								98
99		Outpatient Rehabilitation Provider (specify)								99
100	10000	Intern-Resident Service (not appvd. tchng. prgm.)								100
101	10100	Home Health Agency								101
		SPECIAL PURPOSE COST CENTERS
105	10500	Kidney Acquisition								105
106	10600	Heart Acquisition								106
107	10700	Liver Acquisition								107
108	10800	Lung Acquisition								108
109	10900	Pancreas Acquisition								109
110	11000	Intestinal Acquisition								110
111	11100	Islet Acquisition								111
112		Other Organ Acquisition (specify)								112
113	11300	Interest Expense							- 0 -	113
114	11400	Utilization Review-SNF							- 0 -	114
115	11500	Ambulatory Surgical Center (Distinct Part)								115
116	11600	Hospice								116
117		Other Special Purpose (specify)								117
118		SUBTOTALS (sum of lines 1-117)								118
		NONREIMBURSABLE COST CENTERS
190	19000	Gift, Flower, Coffee Shop, & Canteen								190
191	19100	Research								191
192	19200	Physicians' Private Offices								192
193	19300	Nonpaid Workers								193
194		Other Nonreimbursable (specify)								194
200		TOTAL (sum of lines 118-199)				- 0 -				200
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4013)
40-526										Rev. 3

---

Sheet 19: A6

10-12				FORM CMS-2552-10								4090 (Cont.)
RECLASSIFICATIONS							PROVIDER CCN:	PERIOD:		WORKSHEET A-6
								FROM ____________
							________________	TO _______________
				INCREASES				DECREASES			Wkst.
		CODE									A-7
	EXPLANATION OF RECLASSIFICATION(S)	(1)	COST CENTER	LINE #	SALARY	OTHER	COST CENTER	LINE #	SALARY	OTHER	Ref.
		1	2	3	4	5	6	7	8	9	10
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
500	Total reclassifications (sum of columns 4 and 5											500
	must equal sum of columns 8 and 9)
(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
Transfer the amounts in columns 4, 5, 8, and 9 to Worksheet A, column 4, lines as appropriate.
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4014)
Rev. 3												40-527

---

Sheet 20: A7I, II &III

4090 (Cont.)				FORM CMS-2552-10						10-12
RECONCILIATION OF CAPITAL COSTS CENTERS					PROVIDER CCN:		PERIOD:		WORKSHEET A-7,
							FROM ____________		PARTS I, II & III
					________________		TO _______________
PART I - ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCES
				Acquisitions			Disposals		Fully
			Beginning				and	Ending	Depreciated
	Description		Balances	Purchases	Donation	Total	Retirements	Balance	Assets
			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	HIT-designated Assets									7
8	Subtotal (sum of lines 1-7)									8
9	Reconciling Items									9
10	Total (line 7 minus line 9)									10
PART II - RECONCILIATION OF AMOUNTS FROM WORKSHEET A, COLUMN 2, LINES 1 AND 2
			SUMMARY OF CAPITAL
								Other Capital-	Total (1)
						Insurance	Taxes	Related Costs	(sum of
	Description		Depreciation	Lease	Interest	(see instructions)	(see instructions)	(see instructions)	cols. 9 through 14)
*			9	10	11	12	13	14	15
1	Capital Related Costs-Buildings and Fixtures									1
2	Capital Related Costs-Movable Equipment									2
3	Total (sum of lines 1-2)									3
(1)	The amount in columns 9 through 14 must equal the amount on Worksheet A, column 2, lines 1 and 2. Enter in each column the appropriate amounts including any directly assigned cost that may have been included in Worksheet A,
	column 2, lines 1 and 2.
*	All lines numbers are to be consistent with Worksheet A line numbers for capital cost centers.
PART III - RECONCILIATION OF CAPITAL COSTS CENTERS
		COMPUTATION OF RATIOS				ALLOCATION OF OTHER CAPITAL
				Gross Assets					Total
			Capitalized	for Ratio	Ratio			Other Capital-	(sum of
	Description	Gross Assets	Leases	(col. 1 - col. 2)	(see instructions)	Insurance	Taxes	Related Costs	cols. 5 through 7)
*		1	2	3	4	5	6	7	8
1	Capital Related Costs-Buildings and Fixtures									1
2	Capital Related Costs-Movable Equipment									2
3	Total (sum of lines 1-2)				1.000000					3
			SUMMARY OF CAPITAL
								Other Capital-	Total (2)
						Insurance	Taxes	Related Costs	(sum of
	Description		Depreciation	Lease	Interest	(see instructions)	(see instructions)	(see instructions)	cols. 9 through 14)
*			9	10	11	12	13	14	15
1	Capital Related Costs-Buildings and Fixtures									1
2	Capital Related Costs-Movable Equipment									2
3	Total (sum of lines 1-2)									3
(2)	The amounts on lines 1 and 2 must equal the corresponding amounts on Worksheet A, column 7, lines 1 and 2. Columns 9 through 14 should include related
	Worksheet A-6 reclassifications, Worksheet A-8 adjustments, and Worksheet A-8-1 related organizations and home office costs. (See instructions.)
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4015)
40-528										Rev. 3

---

Sheet 21: A8

09-13		FORM CMS-2552-10						4090 (Cont.)
ADJUSTMENTS TO EXPENSES		PROVIDER CCN:		PERIOD:		WORKSHEET A-8
				FROM ____________
		________________		TO _______________
				EXPENSE CLASSIFICATION ON
	DESCRIPTION (1)			WORKSHEET A TO/FROM WHICH			Wkst.
				THE AMOUNT IS TO BE ADJUSTED			A-7
		BASIS/CODE (2)	AMOUNT	COST CENTER		LINE #	Ref.
		1	2	3		4	5
1	Investment income - buildings and fixtures (chapter 2)			Buildings and Fixtures		1		1
2	Investment income - movable equipment (chapter 2)			Movable Equipment		2		2
3	Investment income - other (chapter 2)							3
4	Trade, quantity, and time discounts (chapter 8)							4
5	Refunds and rebates of expenses (chapter 8)							5
6	Rental of provider space by suppliers (chapter 8)							6
7	Telephone services (pay stations excluded) (chapter 21)							7
8	Television and radio service (chapter 21)							8
9	Parking lot (chapter 21)							9
10	Provider-based physician adjustment	Worksheet A-8-2						10
11	Sale of scrap, waste, etc. (chapter 23)							11
12	Related organization transactions (chapter 10)	Worksheet A-8-1						12
13	Laundry and linen service							13
14	Cafeteria-employees and guests							14
15	Rental of quarters to employee and others							15
16	Sale of medical and surgical							16
	supplies to other than patients
17	Sale of drugs to other than patients							17
18	Sale of medical records and abstracts							18
19	Nursing school (tuition, fees, books, etc.)							19
20	Vending machines							20
21	Income from imposition of interest,							21
	finance or penalty charges (chapter 21)
22	Interest expense on Medicare overpayments and							22
	borrowings to repay Medicare overpayments
23	Adjustment for respiratory therapy							23
	costs in excess of limitation (chapter 14)	Worksheet A-8-3		Respiratory Therapy		65
24	Adjustment for physical therapy costs							24
	in excess of limitation (chapter 14)	Worksheet A-8-3		Physical Therapy		66
25	Utilization review - physicians' compensation (chapter 21)			Utilization Review - SNF		114		25
26	Depreciation - buildings and fixtures			Buildings and Fixtures		1		26
27	Depreciation - movable equipment			Movable Equipment		2		27
28	Non-physician Anesthetist			Nonphysician Anesthetist		19		28
29	Physicians' assistant							29
30	Adjustment for occupational therapy costs							30
	in excess of limitation (chapter 14)	Worksheet A-8-3		Occupational Therapy		67
30.99	Hospice (non-distinct) (see instructions)			Adults and Pediatrics		30		30.99
31	Adjustment for speech pathology costs							31
	in excess of limitation (chapter 14)	Worksheet A-8-3		Speech Pathology		68
32	CAH HIT Adjustment for Depreciation							32
33	Other adjustments (specify) (3)							33
50	TOTAL (sum of lines 1 thru 49)							50
	(Transfer to Worksheet A, column 6, line 200)
(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
(3)	Additional adjustments may be made on lines 33 thru 49 and subscripts thereof.
	Note: See instructions for column 5 referencing to Worksheet A-7.
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4016)
Rev. 4								40-529

---

Sheet 22: A81

4090 (Cont.)			FORM CMS-2552-10					09-13
STATEMENT OF COSTS OF SERVICES				PROVIDER CCN:	PERIOD:	WORKSHEET A-8-1
FROM RELATED ORGANIZATIONS AND					FROM ____________
HOME OFFICE COSTS				________________	TO _______________
A.	COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS
	OR CLAIMED HOME OFFICE COSTS:
					Amount	Net
				Amount of	included in	Adjustments	Wkst.
				Allowable	Wkst. A	(col. 4 minus	A-7
	Line No.	Cost Center	Expense Items	Cost	column 5	col. 5) *	Ref.
	1	2	3	4	5	6	7
1								1
2								2
3								3
4								4
5	TOTALS (sum of lines 1-4) Transfer column 6, line 5 to Worksheet							5
	A-8, column 2, line 12.
* The amounts on lines 1 through 4 (and subscripts as appropriate) are transferred in detail to Worksheet A, column 6, lines as appropriate.
Positive amounts increase cost and negative amounts decrease cost. For related organization or home office cost which have not
been posted to Worksheet A, columns 1 and/or 2, the amount allowable should be indicated in column 4 of this part.
B.	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 B 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) and/or Home Office
			Percentage		Percentage
	Symbol		of		of	Type of
	(1)	Name	Ownership	Name	Ownership	Business
	1	2	3	4	5	6
6								6
7								7
8								8
9								9
10								10
	(1) Use the following symbols to indicate interrelationship to related organizations:
		A. Individual has financial interest (stockholder, partner, etc.) in both related
		organization and in provider.
		B. Corporation, partnership, or other organization has financial interest in provider.
		C. Provider has financial interest in corporation, partnership, or other organization.
		D. Director, officer, administrator, or key person of provider or relative of such
		person has financial interest in related organization.
		E. Individual is director, officer, administrator, or key person of provider and
		related organization.
		F. Director, officer, administrator, or key person of related organization or relative
		of such person has financial interest in provider.
		G. Other (financial or non-financial) specify __________________________________________________
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4017)
40-530								Rev. 4

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Sheet 23: A82

10-12				FORM CMS-2552-10						4090 (Cont.)
PROVIDER-BASED PHYSICIANS ADJUSTMENTS					PROVIDER CCN:		PERIOD:		WORKSHEET A-8-2
							FROM ____________
					________________		TO _______________
		Cost Center/					Physician/		5 Percent of
	Wkst. A	Physician	Total	Professional	Provider	RCE	Provider	Unadjusted	Unadjusted
	Line #	Identifier	Remuneration	Component	Component	Amount	Component Hours	RCE Limit	RCE 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
200	TOTAL									200
			Cost of	Provider	Physician	Provider
		Cost Center/	Memberships	Component	Cost of	Component
	Wkst. A	Physician	& Continuing	Share of	Malpractice	Share of	Adjusted	RCE
	Line #	Identifier	Education	col. 12	Insurance	col. 14	RCE 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
200	TOTAL									200
FORM CMS-2552-10 (10-2012)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4018)
Rev. 3										40-531

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Sheet 24: A83

4090 (Cont.)			FORM CMS-2552-10					10-12
REASONABLE COST DETERMINATION FOR THERAPY SERVICES					PROVIDER CCN:	PERIOD:	WORKSHEET A-8-3,
FURNISHED BY OUTSIDE SUPPLIERS						FROM ____________	PARTS I & II
					________________	TO _______________
Check applicable box:		[ ] Occupational [ ] Physical [ ] Respiratory [ ] Speech Pathology
PART I - GENERAL INFORMATION
1	Total number of weeks worked (excluding aides) (see instructions)							1
2	Line 1 multiplied by 15 hours per week							2
3	Number of unduplicated days in which supervisor or therapist was on provider site (see instructions)							3
4	Number of unduplicated days in which therapy assistant was on provider site but neither supervisor nor therapist was on provider site (see instructions)							4
5	Number of unduplicated offsite visits - supervisors or therapists (see instructions)							5
6	Number of unduplicated offsite visits - therapy assistants (include only visits made by therapy assistant and on which							6
	supervisor and/or therapist was not present during the visit(s)) (see instructions)
7	Standard travel expense rate							7
8	Optional travel expense rate per mile							8
			Supervisors	Therapists	Assistants	Aides	Trainees
			1	2	3	4	5
9	Total hours worked							9
10	AHSEA (see instructions)							10
11	Standard travel allowance (columns 1 and 2, one-half of column 2,							11
	line 10; column 3, one-half of column 3, line 10)
12	Number of travel hours (see instructions)							12
13	Number of miles driven (see instructions)							13
PART II - SALARY EQUIVALENCY COMPUTATION
14	Supervisors (column 1, line 9 times column 1, line 10)							14
15	Therapists (column 2, line 9 times column 2, line 10)							15
16	Assistants (column 3, line 9 times column 3, line10)							16
17	Subtotal allowance amount (sum of lines 14 and 15 for respiratory therapy or lines 14-16 for all others)							17
18	Aides (column 4, line 9 times column 4, line 10)							18
19	Trainees (column 5, line 9 times column 9, line 10)							19
20	Total allowance amount (sum of lines 17-19 for respiratory therapy or lines 17 and 18 for all others)							20
	If the sum of columns 1 and 2 for respiratory therapy or columns 1 through 3 for physical therapy, speech pathology or occupational therapy, line 9, is greater than line 2,
	make no entries on lines 21 and 22 and enter on line 23 the amount from line 20. Otherwise complete lines 21 through 23.
21	Weighted average rate excluding aides and trainees (line 17 divided by sum of columns 1 and 2, line 9 for respiratory therapy or columns 1 through 3, line 9 for all others)							21
22	Weighted allowance excluding aides and trainees (line 2 times line 21)							22
23	Total salary equivalency (see instructions)							23
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4019)
40-532								Rev. 3
10-12			FORM CMS-2552-10					4090 (Cont.)
REASONABLE COST DETERMINATION FOR THERAPY SERVICES					PROVIDER CCN:	PERIOD:	WORKSHEET A-8-3,
FURNISHED BY OUTSIDE SUPPLIERS						FROM ____________	PARTS III & IV
					________________	TO _______________
Check applicable box:		[ ] Occupational [ ] Physical [ ] Respiratory [ ] Speech Pathology
PART III - STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - PROVIDER SITE
Standard Travel Allowance
24	Therapists (line 3 times column 2, line 11)							24
25	Assistants (line 4 times column 3, line 11)							25
26	Subtotal (line 24 for respiratory therapy or sum of lines 24 and 25 for all others)							26
27	Standard travel expense (line 7 times line 3 for respiratory therapy or sum of lines 3 and 4 for all others)							27
28	Total standard travel allowance and standard travel expense at the provider site (sum of lines 26 and 27)							28
Optional Travel Allowance and Optional Travel Expense
29	Therapists (column 2, line 10 times the sum of columns 1 and 2, line 12 )							29
30	Assistants (column 3, line 10 times column 3, line 12)							30
31	Subtotal (line 29 for respiratory therapy or sum of lines 29 and 30 for all others)							31
32	Optional travel expense (line 8 times columns 1 and 2, line 13 for respiratory therapy or sum of columns 1-3, line 13 for all others)							32
33	Standard travel allowance and standard travel expense (line 28)							33
34	Optional travel allowance and standard travel expense (sum of lines 27 and 31)							34
35	Optional travel allowance and optional travel expense (sum of lines 31 and 32)							35
PART IV - STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - SERVICES OUTSIDE PROVIDER SITE
Standard Travel Expense
36	Therapists (line 5 times column 2, line 11)							36
37	Assistants (line 6 times column 3, line 11)							37
38	Subtotal (sum of lines 36 and 37)							38
39	Standard travel expense (line 7 times the sum of lines 5 and 6)							39
Optional Travel Allowance and Optional Travel Expense
40	Therapists (sum of columns 1 and 2, line 9 times column 2, line 10)							40
41	Assistants (column 3, line 9 times column 3, line 10)							41
42	Subtotal (sum of lines 40 and 41)							42
43	Optional travel expense (line 8 times the sum of columns 1-3, line 13)							43
Total Travel Allowance and Travel Expense - Offsite Services: Complete one of the following
three lines 44, 45, or 46, as appropriate.
44	Standard travel allowance and standard travel expense (sum of lines 38 and 39) (see instructions)							44
45	Optional travel allowance and standard travel expense (sum of lines 39 and 42) (see instructions)							45
46	Optional travel allowance and optional travel expense (sum of lines 42 and 43) (see instructions)							46
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4019)
Rev. 3								40-533
4090 (Cont.)			FORM CMS-2552-10					10-12
REASONABLE COST DETERMINATION FOR THERAPY SERVICES					PROVIDER CCN:	PERIOD:	WORKSHEET A-8-3,
FURNISHED BY OUTSIDE SUPPLIERS						FROM ____________	PARTS V-VI
					________________	TO _______________
Check applicable box:		[ ] Occupational [ ] Physical [ ] Respiratory [ ] Speech Pathology
PART V - OVERTIME COMPUTATION
			Therapists	Assistants	Aides	Trainees	Total
			1	2	3	4	5
47	Overtime hours worked during reporting period (if column 5,							47
	line 47, is zero or equal to or greater than 2,080, do not complete
	lines 48-55 and enter zero in each column of line 56)
48	Overtime rate (see instructions)							48
49	Total overtime (including base and overtime allowance) (multiply							49
	line 47 times line 48)
CALCULATION OF LIMIT
50	Percentage of overtime hours by category (divide the hours in each							50
	column on line 47 by the total overtime worked in column 5, line 47)
51	Allocation of provider's standard work year for one full-time							51
	employee times the percentages on line 50) (see instructions)
DETERMINATION OF OVERTIME ALLOWANCE
52	Adjusted hourly salary equivalency amount (see instructions)							52
53	Overtime cost limitation (line 51 times line 52)							53
54	Maximum overtime cost (enter the lesser of line 49 or line 53)							54
55	Portion of overtime already included in hourly computation at the AHSEA (multiply							55
	line 47 times line 52)
56	Overtime allowance (line 54 minus line 55 - if negative enter zero) ( Enter in column 5 the							56
	sum of columns 1, 3, and 4 for respiratory therapy and columns 1 through 3 for all others.)
PART VI - COMPUTATION OF THERAPY LIMITATION AND EXCESS COST ADJUSTMENT
57	Salary equivalency amount (from line 23)							57
58	Travel allowance and expense - provider site (from lines 33, 34, or 35))							58
59	Travel allowance and expense - Offsite services (from lines 44, 45, or 46)							59
60	Overtime allowance (from column 5, line 56)							60
61	Equipment cost (see instructions)							61
62	Supplies (see instructions)							62
63	Total allowance (sum of lines 57-62)							63
64	Total cost of outside supplier services (from provider records)							64
65	Excess over limitation (line 64 minus line 63; if negative, enter zero)							65
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4019)
40-534								Rev. 3

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Sheet 25: BI

09-13				FORM CMS-2552-10						4090 (Cont.)	4090 (Cont.)					FORM CMS-2552-10							09-13	09-14					FORM CMS-2552-10						4090 (Cont.)
COST ALLOCATION - GENERAL SERVICE COSTS					PROVIDER CCN:		PERIOD:		WORKSHEET B,		COST ALLOCATION - GENERAL SERVICE COSTS					PROVIDER CCN:			PERIOD:			WORKSHEET B,		COST ALLOCATION - GENERAL SERVICE COSTS						PROVIDER CCN:		PERIOD:		WORKSHEET B,
							FROM ____________		PART I										FROM ____________			PART I										FROM ____________		PART I
					________________		TO _______________									________________			TO _______________											________________		TO _______________
		NET EXPENSES	CAPITAL																														INTERN &
		FOR COST	RELATED COSTS																								NON-		INTERNS &	INTERNS &			RESIDENT
		ALLOCATION			EMPLOYEE		ADMINIS-	MAIN-					LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL					OTHER	PHYSICIAN		RESIDENTS	RESIDENTS	PARAMEDICAL		COST & POST
	COST CENTER DESCRIPTIONS	(from Wkst.	BLDGS. &	MOVABLE	BENEFITS	SUBTOTAL	TRATIVE &	TENANCE &	OPERATION			COST CENTER DESCRIPTIONS	& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL			COST CENTER DESCRIPTIONS	GENERAL	ANES-	NURSING	SALARY AND	PROGRAM	EDUCATION		STEPDOWN
		A col. 7)	FIXTURES	EQUIPMENT	DEPARTMENT	(cols. 0-4)	GENERAL	REPAIRS	OF PLANT				SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE				SERVICE	THETISTS	SCHOOL	FRINGES	COSTS	(SPECIFY)	SUBTOTAL	ADJUSTMENTS	TOTAL
		0	1	2	4	4A	5	6	7				8	9	10	11	12	13	14	15	16	17				18	19	20	21	22	23	24	25	26
	GENERAL SERVICE COST CENTERS											GENERAL SERVICE COST CENTERS													GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Buildings and Fixtures									1	1	Capital Related Costs-Buildings and Fixtures											1	1	Capital Related Costs-Buildings and Fixtures										1
2	Capital Related Costs-Movable Equipment									2	2	Capital Related Costs-Movable Equipment											2	2	Capital Related Costs-Movable Equipment										2
4	Employee Benefits Department									4	4	Employee Benefits Department											4	4	Employee Benefits Department										4
5	Administrative and General									5	5	Administrative and General											5	5	Administrative and General										5
6	Maintenance and Repairs									6	6	Maintenance and Repairs											6	6	Maintenance and Repairs										6
7	Operation of Plant									7	7	Operation of Plant											7	7	Operation of Plant										7
8	Laundry and Linen Service									8	8	Laundry and Linen Service											8	8	Laundry and Linen Service										8
9	Housekeeping									9	9	Housekeeping											9	9	Housekeeping										9
10	Dietary									10	10	Dietary											10	10	Dietary										10
11	Cafeteria									11	11	Cafeteria											11	11	Cafeteria										11
12	Maintenance of Personnel									12	12	Maintenance of Personnel											12	12	Maintenance of Personnel										12
13	Nursing Administration									13	13	Nursing Administration											13	13	Nursing Administration										13
14	Central Services and Supply									14	14	Central Services and Supply											14	14	Central Services and Supply										14
15	Pharmacy									15	15	Pharmacy											15	15	Pharmacy										15
16	Medical Records & Medical Records Library									16	16	Medical Records & Medical Records Library											16	16	Medical Records & Medical Records Library										16
17	Social Service									17	17	Social Service											17	17	Social Service										17
18	Other General Service (specify)									18	18	Other General Service (specify)											18	18	Other General Service (specify)										18
19	Nonphysician Anesthetists									19	19	Nonphysician Anesthetists											19	19	Nonphysician Anesthetists										19
20	Nursing School									20	20	Nursing School											20	20	Nursing School										20
21	Intern & Res. Service-Salary & Fringes (Approved)									21	21	Intern & Res. Service-Salary & Fringes (Approved)											21	21	Intern & Res. Service-Salary & Fringes (Approved)										21
22	Intern & Res. Other Program Costs (Approved)									22	22	Intern & Res. Other Program Costs (Approved)											22	22	Intern & Res. Other Program Costs (Approved)										22
23	Paramedical Education Program (specify)									23	23	Paramedical Education Program (specify)											23	23	Paramedical Education Program (specify)										23
	INPATIENT ROUTINE SERVICE COST CENTERS											INPATIENT ROUTINE SERVICE COST CENTERS													INPATIENT ROUTINE SERVICE COST CENTERS
30	Adults and Pediatrics (General Routine Care)									30	30	Adults and Pediatrics (General Routine Care)											30	30	Adults and Pediatrics (General Routine Care)										30
31	Intensive Care Unit									31	31	Intensive Care Unit											31	31	Intensive Care Unit										31
32	Coronary Care Unit									32	32	Coronary Care Unit											32	32	Coronary Care Unit										32
33	Burn Intensive Care Unit									33	33	Burn Intensive Care Unit											33	33	Burn Intensive Care Unit										33
34	Surgical Intensive Care Unit									34	34	Surgical Intensive Care Unit											34	34	Surgical Intensive Care Unit										34
35	Other Special Care Unit (specify)									35	35	Other Special Care Unit (specify)											35	35	Other Special Care Unit (specify)										35
40	Subprovider IPF									40	40	Subprovider IPF											40	40	Subprovider IPF										40
41	Subprovider IRF									41	41	Subprovider IRF											41	41	Subprovider IRF										41
42	Subprovider (specify)									42	42	Subprovider (specify)											42	42	Subprovider (specify)										42
43	Nursery									43	43	Nursery											43	43	Nursery										43
44	Skilled Nursing Facility									44	44	Skilled Nursing Facility											44	44	Skilled Nursing Facility										44
45	Nursing Facility									45	45	Nursing Facility											45	45	Nursing Facility										45
46	Other Long Term Care									46	46	Other Long Term Care											46	46	Other Long Term Care										46
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)											FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)													FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)
Rev. 4										40-535	40-538												Rev. 4	Rev. 6											40-541
4090 (Cont.)				FORM CMS-2552-10						09-13	10-12					FORM CMS-2552-10							4090 (Cont.)	4090 (Cont.)					FORM CMS-2552-10						09-14
COST ALLOCATION - GENERAL SERVICE COSTS					PROVIDER CCN:		PERIOD:		WORKSHEET B,		COST ALLOCATION - GENERAL SERVICE COSTS					PROVIDER CCN:			PERIOD:			WORKSHEET B,		COST ALLOCATION - GENERAL SERVICE COSTS						PROVIDER CCN:		PERIOD:		WORKSHEET B,
							FROM ____________		PART I										FROM ____________			PART I										FROM ____________		PART I
					________________		TO _______________									________________			TO _______________											________________		TO _______________
		NET EXPENSES	CAPITAL																														INTERN &
		FOR COST	RELATED COSTS																								NON-		INTERNS &	INTERNS &			RESIDENT
		ALLOCATION			EMPLOYEE		ADMINIS-	MAIN-					LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL					OTHER	PHYSICIAN		RESIDENTS	RESIDENTS	PARAMEDICAL		COST & POST
	COST CENTER DESCRIPTIONS	(from Wkst.	BLDGS. &	MOVABLE	BENEFITS	SUBTOTAL	TRATIVE &	TENANCE &	OPERATION			COST CENTER DESCRIPTIONS	& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL			COST CENTER DESCRIPTIONS	GENERAL	ANES-	NURSING	SALARY AND	PROGRAM	EDUCATION		STEPDOWN
		A col. 7)	FIXTURES	EQUIPMENT	DEPARTMENT	(cols. 0-4)	GENERAL	REPAIRS	OF PLANT				SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE				SERVICE	THETISTS	SCHOOL	FRINGES	COSTS	(SPECIFY)	SUBTOTAL	ADJUSTMENTS	TOTAL
		0	1	2	4	4A	5	6	7				8	9	10	11	12	13	14	15	16	17				18	19	20	21	22	23	24	25	26
	ANCILLARY SERVICE COST CENTERS											ANCILLARY SERVICE COST CENTERS													ANCILLARY SERVICE COST CENTERS
50	Operating Room									50	50	Operating Room											50	50	Operating Room										50
51	Recovery Room									51	51	Recovery Room											51	51	Recovery Room										51
52	Labor Room and Delivery Room									52	52	Labor Room and Delivery Room											52	52	Labor Room and Delivery Room										52
53	Anesthesiology									53	53	Anesthesiology											53	53	Anesthesiology										53
54	Radiology-Diagnostic									54	54	Radiology-Diagnostic											54	54	Radiology-Diagnostic										54
55	Radiology-Therapeutic									55	55	Radiology-Therapeutic											55	55	Radiology-Therapeutic										55
56	Radioisotope									56	56	Radioisotope											56	56	Radioisotope										56
57	Computed Tomography (CT) Scan									57	57	Computed Tomography (CT) Scan											57	57	Computed Tomography (CT) Scan										57
58	Magnetic Resonance Imaging (MRI)									58	58	Magnetic Resonance Imaging (MRI)											58	58	Magnetic Resonance Imaging (MRI)										58
59	Cardiac Catheterization									59	59	Cardiac Catheterization											59	59	Cardiac Catheterization										59
60	Laboratory									60	60	Laboratory											60	60	Laboratory										60
61	PBP Clinical Laboratory Services-Program Only									61	61	PBP Clinical Laboratory Services-Program Only											61	61	PBP Clinical Laboratory Services-Program Only										61
62	Whole Blood & Packed Red Blood Cells									62	62	Whole Blood & Packed Red Blood Cells											62	62	Whole Blood & Packed Red Blood Cells										62
63	Blood Storing, Processing, & Trans.									63	63	Blood Storing, Processing, & Trans.											63	63	Blood Storing, Processing, & Trans.										63
64	Intravenous Therapy									64	64	Intravenous Therapy											64	64	Intravenous Therapy										64
65	Respiratory Therapy									65	65	Respiratory Therapy											65	65	Respiratory Therapy										65
66	Physical Therapy									66	66	Physical Therapy											66	66	Physical Therapy										66
67	Occupational Therapy									67	67	Occupational Therapy											67	67	Occupational Therapy										67
68	Speech Pathology									68	68	Speech Pathology											68	68	Speech Pathology										68
69	Electrocardiology									69	69	Electrocardiology											69	69	Electrocardiology										69
70	Electroencephalography									70	70	Electroencephalography											70	70	Electroencephalography										70
71	Medical Supplies Charged to Patients									71	71	Medical Supplies Charged to Patients											71	71	Medical Supplies Charged to Patients										71
72	Implantable Devices Charged to Patients									72	72	Implantable Devices Charged to Patients											72	72	Implantable Devices Charged to Patients										72
73	Drugs Charged to Patients									73	73	Drugs Charged to Patients											73	73	Drugs Charged to Patients										73
74	Renal Dialysis									74	74	Renal Dialysis											74	74	Renal Dialysis										74
75	ASC (Non-Distinct Part)									75	75	ASC (Non-Distinct Part)											75	75	ASC (Non-Distinct Part)										75
76	Other Ancillary (specify)									76	76	Other Ancillary (specify)											76	76	Other Ancillary (specify)										76
	OUTPATIENT SERVICE COST CENTERS											OUTPATIENT SERVICE COST CENTERS													OUTPATIENT SERVICE COST CENTERS
88	Rural Health Clinic (RHC)									88	88	Rural Health Clinic (RHC)											88	88	Rural Health Clinic (RHC)										88
89	Federally Qualified Health Center (FQHC)									89	89	Federally Qualified Health Center (FQHC)											89	89	Federally Qualified Health Center (FQHC)										89
90	Clinic									90	90	Clinic											90	90	Clinic										90
91	Emergency									91	91	Emergency											91	91	Emergency										91
92	Observation Beds									92	92	Observation Beds											92	92	Observation Beds										92
93	Other Outpatient Service (specify)									93	93	Other Outpatient Service (specify)											93	93	Other Outpatient Service (specify)										93
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)											FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)													FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)
40-536										Rev. 4	Rev. 3												40-539	40-542											Rev. 6
09-13				FORM CMS-2552-10						4090 (Cont.)	4090 (Cont.)					FORM CMS-2552-10							10-12	10-12					FORM CMS-2552-10						4090 (Cont.)
COST ALLOCATION - GENERAL SERVICE COSTS					PROVIDER CCN:		PERIOD:		WORKSHEET B,		COST ALLOCATION - GENERAL SERVICE COSTS					PROVIDER CCN:			PERIOD:			WORKSHEET B,		COST ALLOCATION - GENERAL SERVICE COSTS						PROVIDER CCN:		PERIOD:		WORKSHEET B,
							FROM ____________		PART I										FROM ____________			PART I										FROM ____________		PART I
					________________		TO _______________									________________			TO _______________											________________		TO _______________
		NET EXPENSES	CAPITAL																														INTERN &
		FOR COST	RELATED COSTS																								NON-		INTERNS &	INTERNS &			RESIDENT
		ALLOCATION			EMPLOYEE		ADMINIS-	MAIN-					LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL					OTHER	PHYSICIAN		RESIDENTS	RESIDENTS	PARAMEDICAL		COST & POST
	COST CENTER DESCRIPTIONS	(from Wkst.	BLDGS. &	MOVABLE	BENEFITS	SUBTOTAL	TRATIVE &	TENANCE &	OPERATION			COST CENTER DESCRIPTIONS	& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL			COST CENTER DESCRIPTIONS	GENERAL	ANES-	NURSING	SALARY AND	PROGRAM	EDUCATION		STEPDOWN
		A col. 7)	FIXTURES	EQUIPMENT	DEPARTMENT	(cols. 0-4)	GENERAL	REPAIRS	OF PLANT				SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE				SERVICE	THETISTS	SCHOOL	FRINGES	COSTS	(SPECIFY)	SUBTOTAL	ADJUSTMENTS	TOTAL
		0	1	2	4	4A	5	6	7				8	9	10	11	12	13	14	15	16	17				18	19	20	21	22	23	24	25	26
	OTHER REIMBURSABLE COST CENTERS											OTHER REIMBURSABLE COST CENTERS													OTHER REIMBURSABLE COST CENTERS
94	Home Program Dialysis									94	94	Home Program Dialysis											94	94	Home Program Dialysis										94
95	Ambulance Services									95	95	Ambulance Services											95	95	Ambulance Services										95
96	Durable Medical Equipment-Rented									96	96	Durable Medical Equipment-Rented											96	96	Durable Medical Equipment-Rented										96
97	Durable Medical Equipment-Sold									97	97	Durable Medical Equipment-Sold											97	97	Durable Medical Equipment-Sold										97
98	Other Reimbursable (specify)									98	98	Other Reimbursable (specify)											98	98	Other Reimbursable (specify)										98
99	Outpatient Rehabilitation Provider (specify)									99	99	Outpatient Rehabilitation Provider (specify)											99	99	Outpatient Rehabilitation Provider (specify)										99
100	Intern-Resident Service (not appvd. tchng. prgm.)									100	100	Intern-Resident Service (not appvd. tchng. prgm.)											100	100	Intern-Resident Service (not appvd. tchng. prgm.)										100
101	Home Health Agency									101	101	Home Health Agency											101	101	Home Health Agency										101
	SPECIAL PURPOSE COST CENTERS											SPECIAL PURPOSE COST CENTERS													SPECIAL PURPOSE COST CENTERS
105	Kidney Acquisition									105	105	Kidney Acquisition											105	105	Kidney Acquisition										105
106	Heart Acquisition									106	106	Heart Acquisition											106	106	Heart Acquisition										106
107	Liver Acquisition									107	107	Liver Acquisition											107	107	Liver Acquisition										107
108	Lung Acquisition									108	108	Lung Acquisition											108	108	Lung Acquisition										108
109	Pancreas Acquisition									109	109	Pancreas Acquisition											109	109	Pancreas Acquisition										109
110	Intestinal Acquisition									110	110	Intestinal Acquisition											110	110	Intestinal Acquisition										110
111	Islet Acquisition									111	111	Islet Acquisition											111	111	Islet Acquisition										111
112	Other Organ Acquisition (specify)									112	112	Other Organ Acquisition (specify)											112	112	Other Organ Acquisition (specify)										112
115	Ambulatory Surgical Center (Distinct Part)									115	115	Ambulatory Surgical Center (Distinct Part)											115	115	Ambulatory Surgical Center (Distinct Part)										115
116	Hospice									116	116	Hospice											116	116	Hospice										116
117	Other Special Purpose (specify)									117	117	Other Special Purpose (specify)											117	117	Other Special Purpose (specify)										117
118	SUBTOTALS (sum of lines 1-117)									118	118	SUBTOTALS (sum of lines 1-117)											118	118	SUBTOTALS (sum of lines 1-117)										118
	NONREIMBURSABLE COST CENTERS											NONREIMBURSABLE COST CENTERS													NONREIMBURSABLE COST CENTERS
190	Gift, Flower, Coffee Shop, & Canteen									190	190	Gift, Flower, Coffee Shop, & Canteen											190	190	Gift, Flower, Coffee Shop, & Canteen										190
191	Research									191	191	Research											191	191	Research										191
192	Physicians' Private Offices									192	192	Physicians' Private Offices											192	192	Physicians' Private Offices										192
193	Nonpaid Workers									193	193	Nonpaid Workers											193	193	Nonpaid Workers										193
194	Other Nonreimbursable (specify)									194	194	Other Nonreimbursable (specify)											194	194	Other Nonreimbursable (specify)										194
200	Cross Foot Adjustments									200	200	Cross Foot Adjustments											200	200	Cross Foot Adjustments										200
201	Negative Cost Centers									201	201	Negative Cost Centers											201	201	Negative Cost Centers										201
202	TOTAL (sum lines 118-201)									202	202	TOTAL (sum lines 118-201)											202	202	TOTAL (sum lines 118-201)										202
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)											FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)													FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)
Rev. 4										40-537	40-540												Rev. 3	Rev. 4											40-543

---

Sheet 26: BII

4090 (Cont.)				FORM CMS-2552-10						09-13	09-13					FORM CMS-2552-10							4090 (Cont.)	4090 (Cont.)				FORM CMS-2552-10							09-13
ALLOCATION OF CAPITAL-RELATED COSTS					PROVIDER CCN:		PERIOD:		WORKSHEET B,		ALLOCATION OF CAPITAL-RELATED COSTS					PROVIDER CCN:			PERIOD:			WORKSHEET B,		ALLOCATION OF CAPITAL-RELATED COSTS						PROVIDER CCN:		PERIOD:		WORKSHEET B,
							FROM ____________		PART II										FROM ____________			PART II										FROM ____________		PART II
					________________		TO _______________									________________			TO _______________											________________		TO _______________
		DIRECTLY	CAPITAL																														INTERN &
		ASSIGNED	RELATED COSTS																								NON-		INTERNS &	INTERNS &			RESIDENT
		NEW CAPITAL			SUBTOTAL	EMPLOYEE	ADMINIS-	MAIN-					LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL					OTHER	PHYSICIAN		RESIDENTS	RESIDENTS	PARAMEDICAL		COST & POST
	COST CENTER DESCRIPTIONS	RELATED	BLDGS. &	MOVABLE	(sum of	BENEFITS	TRATIVE &	TENANCE &	OPERATION			COST CENTER DESCRIPTIONS	& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL			COST CENTER DESCRIPTIONS	GENERAL	ANES-	NURSING	SALARY AND	PROGRAM	EDUCATION		STEPDOWN
		COSTS	FIXTURES	EQUIPMENT	(cols. 0-2)	DEPARTMENT	GENERAL	REPAIRS	OF PLANT				SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE				SERVICE	THETISTS	SCHOOL	FRINGES	COSTS	(SPECIFY)	SUBTOTAL	ADJUSTMENTS	TOTAL
		0	1	2	2A	4	5	6	7				8	9	10	11	12	13	14	15	16	17				18	19	20	21	22	23	24	25	26
	GENERAL SERVICE COST CENTERS											GENERAL SERVICE COST CENTERS													GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Buildings and Fixtures									1	1	Capital Related Costs-Buildings and Fixtures											1	1	Capital Related Costs-Buildings and Fixtures										1
2	Capital Related Costs-Movable Equipment									2	2	Capital Related Costs-Movable Equipment											2	2	Capital Related Costs-Movable Equipment										2
4	Employee Benefits Department									4	4	Employee Benefits Department											4	4	Employee Benefits Department										4
5	Administrative and General									5	5	Administrative and General											5	5	Administrative and General										5
6	Maintenance and Repairs									6	6	Maintenance and Repairs											6	6	Maintenance and Repairs										6
7	Operation of Plant									7	7	Operation of Plant											7	7	Operation of Plant										7
8	Laundry and Linen Service									8	8	Laundry and Linen Service											8	8	Laundry and Linen Service										8
9	Housekeeping									9	9	Housekeeping											9	9	Housekeeping										9
10	Dietary									10	10	Dietary											10	10	Dietary										10
11	Cafeteria									11	11	Cafeteria											11	11	Cafeteria										11
12	Maintenance of Personnel									12	12	Maintenance of Personnel											12	12	Maintenance of Personnel										12
13	Nursing Administration									13	13	Nursing Administration											13	13	Nursing Administration										13
14	Central Services and Supply									14	14	Central Services and Supply											14	14	Central Services and Supply										14
15	Pharmacy									15	15	Pharmacy											15	15	Pharmacy										15
16	Medical Records & Medical Records Library									16	16	Medical Records & Medical Records Library											16	16	Medical Records & Medical Records Library										16
17	Social Service									17	17	Social Service											17	17	Social Service										17
18	Other General Service (specify)									18	18	Other General Service (specify)											18	18	Other General Service (specify)										18
19	Nonphysician Anesthetists									19	19	Nonphysician Anesthetists											19	19	Nonphysician Anesthetists										19
20	Nursing School									20	20	Nursing School											20	20	Nursing School										20
21	Intern & Res. Service-Salary & Fringes (Approved)									21	21	Intern & Res. Service-Salary & Fringes (Approved)											21	21	Intern & Res. Service-Salary & Fringes (Approved)										21
22	Intern & Res. Other Program Costs (Approved)									22	22	Intern & Res. Other Program Costs (Approved)											22	22	Intern & Res. Other Program Costs (Approved)										22
23	Paramedical Education Program (specify)									23	23	Paramedical Education Program (specify)											23	23	Paramedical Education Program (specify)										23
	INPATIENT ROUTINE SERVICE COST CENTERS											INPATIENT ROUTINE SERVICE COST CENTERS													INPATIENT ROUTINE SERVICE COST CENTERS
30	Adults and Pediatrics (General Routine Care)									30	30	Adults and Pediatrics (General Routine Care)											30	30	Adults and Pediatrics (General Routine Care)										30
31	Intensive Care Unit									31	31	Intensive Care Unit											31	31	Intensive Care Unit										31
32	Coronary Care Unit									32	32	Coronary Care Unit											32	32	Coronary Care Unit										32
33	Burn Intensive Care Unit									33	33	Burn Intensive Care Unit											33	33	Burn Intensive Care Unit										33
34	Surgical Intensive Care Unit									34	34	Surgical Intensive Care Unit											34	34	Surgical Intensive Care Unit										34
35	Other Special Care Unit (specify)									35	35	Other Special Care Unit (specify)											35	35	Other Special Care Unit (specify)										35
40	Subprovider IPF									40	40	Subprovider IPF											40	40	Subprovider IPF										40
41	Subprovider IRF									41	41	Subprovider IRF											41	41	Subprovider IRF										41
42	Subprovider (specify)									42	42	Subprovider (specify)											42	42	Subprovider (specify)										42
43	Nursery									43	43	Nursery											43	43	Nursery										43
44	Skilled Nursing Facility									44	44	Skilled Nursing Facility											44	44	Skilled Nursing Facility										44
45	Nursing Facility									45	45	Nursing Facility											45	45	Nursing Facility										45
46	Other Long Term Care									46	46	Other Long Term Care											46	46	Other Long Term Care										46
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)											FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)													FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)
40-544										Rev. 4	Rev. 4												40-547	40-550											Rev. 4
09-13				FORM CMS-2552-10						4090 (Cont.)	4090 (Cont.)					FORM CMS-2552-10							09-13	10-12				FORM CMS-2552-10							4090 (Cont.)
ALLOCATION OF CAPITAL-RELATED COSTS					PROVIDER CCN:		PERIOD:		WORKSHEET B,		ALLOCATION OF CAPITAL-RELATED COSTS					PROVIDER CCN:			PERIOD:			WORKSHEET B,		ALLOCATION OF CAPITAL-RELATED COSTS						PROVIDER CCN:		PERIOD:		WORKSHEET B,
							FROM ____________		PART II										FROM ____________			PART II										FROM ____________		PART II
					________________		TO _______________									________________			TO _______________											________________		TO _______________
		DIRECTLY	CAPITAL																														INTERN &
		ASSIGNED	RELATED COSTS																								NON-		INTERNS &	INTERNS &			RESIDENT
		NEW CAPITAL			SUBTOTAL	EMPLOYEE	ADMINIS-	MAIN-					LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL					OTHER	PHYSICIAN		RESIDENTS	RESIDENTS	PARAMEDICAL		COST & POST
	COST CENTER DESCRIPTIONS	RELATED	BLDGS. &	MOVABLE	(sum of	BENEFITS	TRATIVE &	TENANCE &	OPERATION			COST CENTER DESCRIPTIONS	& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL			COST CENTER DESCRIPTIONS	GENERAL	ANES-	NURSING	SALARY AND	PROGRAM	EDUCATION		STEPDOWN
		COSTS	FIXTURES	EQUIPMENT	(cols. 0-2)	DEPARTMENT	GENERAL	REPAIRS	OF PLANT				SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE				SERVICE	THETISTS	SCHOOL	FRINGES	COSTS	(SPECIFY)	SUBTOTAL	ADJUSTMENTS	TOTAL
		0	1	2	2A	4	5	6	7				8	9	10	11	12	13	14	15	16	17				18	19	20	21	22	23	24	25	26
	ANCILLARY SERVICE COST CENTERS											ANCILLARY SERVICE COST CENTERS													ANCILLARY SERVICE COST CENTERS
50	Operating Room									50	50	Operating Room											50	50	Operating Room										50
51	Recovery Room									51	51	Recovery Room											51	51	Recovery Room										51
52	Labor Room and Delivery Room									52	52	Labor Room and Delivery Room											52	52	Labor Room and Delivery Room										52
53	Anesthesiology									53	53	Anesthesiology											53	53	Anesthesiology										53
54	Radiology-Diagnostic									54	54	Radiology-Diagnostic											54	54	Radiology-Diagnostic										54
55	Radiology-Therapeutic									55	55	Radiology-Therapeutic											55	55	Radiology-Therapeutic										55
56	Radioisotope									56	56	Radioisotope											56	56	Radioisotope										56
57	Computed Tomography (CT) Scan									57	57	Computed Tomography (CT) Scan											57	57	Computed Tomography (CT) Scan										57
58	Magnetic Resonance Imaging (MRI)									58	58	Magnetic Resonance Imaging (MRI)											58	58	Magnetic Resonance Imaging (MRI)										58
59	Cardiac Catheterization									59	59	Cardiac Catheterization											59	59	Cardiac Catheterization										59
60	Laboratory									60	60	Laboratory											60	60	Laboratory										60
61	PBP Clinical Laboratory Services-Program Only									61	61	PBP Clinical Laboratory Services-Program Only											61	61	PBP Clinical Laboratory Services-Program Only										61
62	Whole Blood & Packed Red Blood Cells									62	62	Whole Blood & Packed Red Blood Cells											62	62	Whole Blood & Packed Red Blood Cells										62
63	Blood Storing, Processing, & Trans.									63	63	Blood Storing, Processing, & Trans.											63	63	Blood Storing, Processing, & Trans.										63
64	Intravenous Therapy									64	64	Intravenous Therapy											64	64	Intravenous Therapy										64
65	Respiratory Therapy									65	65	Respiratory Therapy											65	65	Respiratory Therapy										65
66	Physical Therapy									66	66	Physical Therapy											66	66	Physical Therapy										66
67	Occupational Therapy									67	67	Occupational Therapy											67	67	Occupational Therapy										67
68	Speech Pathology									68	68	Speech Pathology											68	68	Speech Pathology										68
69	Electrocardiology									69	69	Electrocardiology											69	69	Electrocardiology										69
70	Electroencephalography									70	70	Electroencephalography											70	70	Electroencephalography										70
71	Medical Supplies Charged to Patients									71	71	Medical Supplies Charged to Patients											71	71	Medical Supplies Charged to Patients										71
72	Implantable Devices Charged to Patients									72	72	Implantable Devices Charged to Patients											72	72	Implantable Devices Charged to Patients										72
73	Drugs Charged to Patients									73	73	Drugs Charged to Patients											73	73	Drugs Charged to Patients										73
74	Renal Dialysis									74	74	Renal Dialysis											74	74	Renal Dialysis										74
75	ASC (Non-Distinct Part)									75	75	ASC (Non-Distinct Part)											75	75	ASC (Non-Distinct Part)										75
76	Other Ancillary (specify)									76	76	Other Ancillary (specify)											76	76	Other Ancillary (specify)										76
	OUTPATIENT SERVICE COST CENTERS											OUTPATIENT SERVICE COST CENTERS													OUTPATIENT SERVICE COST CENTERS
88	Rural Health Clinic (RHC)									88	88	Rural Health Clinic (RHC)											88	88	Rural Health Clinic (RHC)										88
89	Federally Qualified Health Center (FQHC)									89	89	Federally Qualified Health Center (FQHC)											89	89	Federally Qualified Health Center (FQHC)										89
90	Clinic									90	90	Clinic											90	90	Clinic										90
91	Emergency									91	91	Emergency											91	91	Emergency										91
92	Observation Beds									92	92	Observation Beds											92	92	Observation Beds										92
93	Other Outpatient Service (specify)									93	93	Other Outpatient Service (specify)											93	93	Other Outpatient Service (specify)										93
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)											FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)													FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)
Rev. 4										40-545	40-548												Rev. 4	Rev. 3											40-551
4090 (Cont.)				FORM CMS-2552-10						09-13	09-13					FORM CMS-2552-10							4090 (Cont.)	4090 (Cont.)				FORM CMS-2552-10							10-12
ALLOCATION OF CAPITAL-RELATED COSTS					PROVIDER CCN:		PERIOD:		WORKSHEET B,		ALLOCATION OF CAPITAL-RELATED COSTS					PROVIDER CCN:			PERIOD:			WORKSHEET B,		ALLOCATION OF CAPITAL-RELATED COSTS						PROVIDER CCN:		PERIOD:		WORKSHEET B,
							FROM ____________		PART II										FROM ____________			PART II										FROM ____________		PART II
					________________		TO _______________									________________			TO _______________											________________		TO _______________
		DIRECTLY	CAPITAL																														INTERN &
		ASSIGNED	RELATED COSTS																								NON-		INTERNS &	INTERNS &			RESIDENT
		NEW CAPITAL			SUBTOTAL	EMPLOYEE	ADMINIS-	MAIN-					LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL					OTHER	PHYSICIAN		RESIDENTS	RESIDENTS	PARAMEDICAL		COST & POST
	COST CENTER DESCRIPTIONS	RELATED	BLDGS. &	MOVABLE	(sum of	BENEFITS	TRATIVE &	TENANCE &	OPERATION			COST CENTER DESCRIPTIONS	& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL			COST CENTER DESCRIPTIONS	GENERAL	ANES-	NURSING	SALARY AND	PROGRAM	EDUCATION		STEPDOWN
		COSTS	FIXTURES	EQUIPMENT	(cols. 0-2)	DEPARTMENT	GENERAL	REPAIRS	OF PLANT				SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE				SERVICE	THETISTS	SCHOOL	FRINGES	COSTS	(SPECIFY)	SUBTOTAL	ADJUSTMENTS	TOTAL
		0	1	2	2A	4	5	6	7				8	9	10	11	12	13	14	15	16	17				18	19	20	21	22	23	24	25	26
	OTHER REIMBURSABLE COST CENTERS											OTHER REIMBURSABLE COST CENTERS													OTHER REIMBURSABLE COST CENTERS
94	Home Program Dialysis									94	94	Home Program Dialysis											94	94	Home Program Dialysis										94
95	Ambulance Services									95	95	Ambulance Services											95	95	Ambulance Services										95
96	Durable Medical Equipment-Rented									96	96	Durable Medical Equipment-Rented											96	96	Durable Medical Equipment-Rented										96
97	Durable Medical Equipment-Sold									97	97	Durable Medical Equipment-Sold											97	97	Durable Medical Equipment-Sold										97
98	Other Reimbursable (specify)									98	98	Other Reimbursable (specify)											98	98	Other Reimbursable (specify)										98
99	Outpatient Rehabilitation Provider (specify)									99	99	Outpatient Rehabilitation Provider (specify)											99	99	Outpatient Rehabilitation Provider (specify)										99
100	Intern-Resident Service (not appvd. tchng. prgm.)									100	100	Intern-Resident Service (not appvd. tchng. prgm.)											100	100	Intern-Resident Service (not appvd. tchng. prgm.)										100
101	Home Health Agency									101	101	Home Health Agency											101	101	Home Health Agency										101
	SPECIAL PURPOSE COST CENTERS											SPECIAL PURPOSE COST CENTERS													SPECIAL PURPOSE COST CENTERS
105	Kidney Acquisition									105	105	Kidney Acquisition											105	105	Kidney Acquisition										105
106	Heart Acquisition									106	106	Heart Acquisition											106	106	Heart Acquisition										106
107	Liver Acquisition									107	107	Liver Acquisition											107	107	Liver Acquisition										107
108	Lung Acquisition									108	108	Lung Acquisition											108	108	Lung Acquisition										108
109	Pancreas Acquisition									109	109	Pancreas Acquisition											109	109	Pancreas Acquisition										109
110	Intestinal Acquisition									110	110	Intestinal Acquisition											110	110	Intestinal Acquisition										110
111	Islet Acquisition									111	111	Islet Acquisition											111	111	Islet Acquisition										111
112	Other Organ Acquisition (specify)									112	112	Other Organ Acquisition (specify)											112	112	Other Organ Acquisition (specify)										112
115	Ambulatory Surgical Center (Distinct Part)									115	115	Ambulatory Surgical Center (Distinct Part)											115	115	Ambulatory Surgical Center (Distinct Part)										115
116	Hospice									116	116	Hospice											116	116	Hospice										116
117	Other Special Purpose (specify)									117	117	Other Special Purpose (specify)											117	117	Other Special Purpose (specify)										117
118	SUBTOTALS (sum of lines 1-117)									118	118	SUBTOTALS (sum of lines 1-117)											118	118	SUBTOTALS (sum of lines 1-117)										118
	NONREIMBURSABLE COST CENTERS											NONREIMBURSABLE COST CENTERS													NONREIMBURSABLE COST CENTERS
190	Gift, Flower, Coffee Shop, & Canteen									190	190	Gift, Flower, Coffee Shop, & Canteen											190	190	Gift, Flower, Coffee Shop, & Canteen										190
191	Research									191	191	Research											191	191	Research										191
192	Physicians' Private Offices									192	192	Physicians' Private Offices											192	192	Physicians' Private Offices										192
193	Nonpaid Workers									193	193	Nonpaid Workers											193	193	Nonpaid Workers										193
194	Other Nonreimbursable (specify)									194	194	Other Nonreimbursable (specify)											194	194	Other Nonreimbursable (specify)										194
200	Cross Foot Adjustments									200	200	Cross Foot Adjustments											200	200	Cross Foot Adjustments										200
201	Negative Cost Centers									201	201	Negative Cost Centers											201	201	Negative Cost Centers										201
202	TOTAL (sum lines 118-201)									202	202	TOTAL (sum lines 118-201)											202	202	TOTAL (sum lines 118-201)										202
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)											FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)													FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)
40-546										Rev. 4	Rev. 4												40-549	40-552											Rev. 3

---

Sheet 27: B1

09-13				FORM CMS-2552-10						4090 (Cont.)	4090 (Cont.)					FORM CMS-2552-10							09-13	09-14				FORM CMS-2552-10							4090 (Cont.)
COST ALLOCATION - STATISTICAL BASIS					PROVIDER CCN:		PERIOD:		WORKSHEET B-1		COST ALLOCATION - STATISTICAL BASIS							PROVIDER CCN:		PERIOD:		WORKSHEET B-1		COST ALLOCATION - STATISTICAL BASIS						PROVIDER CCN:		PERIOD:		WORKSHEET B-1
							FROM ____________													FROM ____________												FROM ____________
					________________		TO _______________											________________		TO _______________										________________		TO _______________
			CAPITAL RELATED COST		EMPLOYEE		ADMINIS-	MAIN-					LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL						NON-		INTERNS & RESIDENTS		PARA-		INTERN &
			BLDGS. &	MOVABLE	BENEFITS		TRATIVE &	TENANCE &	OPERATION				& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL				OTHER	PHYSICIAN	NURSING	SALARY AND	PROGRAM	MEDICAL		RESIDENT
			FIXTURES	EQUIPMENT	DEPARTMENT		GENERAL	REPAIRS	OF PLANT				SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE				GENERAL	ANES-	SCHOOL	FRINGES	COSTS	EDUCATION		COST & POST
	COST CENTER DESCRIPTIONS		(SQUARE	(DOLLAR	(GROSS	RECONCIL-	(ACCUM.	(SQUARE	(SQUARE			COST CENTER DESCRIPTIONS	(POUNDS OF	(HOURS OF	(MEALS	(MEALS	(NUMBER	(DIRECT	(COSTED	(COSTED	(TIME	(TIME			COST CENTER DESCRIPTIONS	SERVICE	THETISTS	(ASSIGNED	(ASSIGNED	(ASSIGNED	(ASSIGNED		STEPDOWN
			FEET)	VALUE)	SALARIES)	IATION	COST)	FEET)	FEET)				LAUNDRY)	SERVICE)	SERVED)	SERVED)	HOUSED)	NURS. HRS)	REQUIS.)	REQUIS.)	SPENT)	SPENT)				(SPECIFY)	(ASGND TIME)	TIME)	TIME)	TIME)	TIME)	SUBTOTAL	ADJUSTMENTS	TOTAL
			1	2	4	5A	5	6	7				8	9	10	11	12	13	14	15	16	17				18	19	20	21	22	23	24	25	26
	GENERAL SERVICE COST CENTERS											GENERAL SERVICE COST CENTERS													GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Buildings and Fixtures									1	1	Capital Related Costs-Buildings and Fixtures											1	1	Capital Related Costs-Buildings and Fixtures										1
2	Capital Related Costs-Movable Equipment									2	2	Capital Related Costs-Movable Equipment											2	2	Capital Related Costs-Movable Equipment										2
4	Employee Benefits Department									4	4	Employee Benefits Department											4	4	Employee Benefits Department										4
5	Administrative and General									5	5	Administrative and General											5	5	Administrative and General										5
6	Maintenance and Repairs									6	6	Maintenance and Repairs											6	6	Maintenance and Repairs										6
7	Operation of Plant									7	7	Operation of Plant											7	7	Operation of Plant										7
8	Laundry and Linen Service									8	8	Laundry and Linen Service											8	8	Laundry and Linen Service										8
9	Housekeeping									9	9	Housekeeping											9	9	Housekeeping										9
10	Dietary									10	10	Dietary											10	10	Dietary										10
11	Cafeteria									11	11	Cafeteria											11	11	Cafeteria										11
12	Maintenance of Personnel									12	12	Maintenance of Personnel											12	12	Maintenance of Personnel										12
13	Nursing Administration									13	13	Nursing Administration											13	13	Nursing Administration										13
14	Central Services and Supply									14	14	Central Services and Supply											14	14	Central Services and Supply										14
15	Pharmacy									15	15	Pharmacy											15	15	Pharmacy										15
16	Medical Records & Medical Records Library									16	16	Medical Records & Medical Records Library											16	16	Medical Records & Medical Records Library										16
17	Social Service									17	17	Social Service											17	17	Social Service										17
18	Other General Service (specify)									18	18	Other General Service (specify)											18	18	Other General Service (specify)										18
19	Nonphysician Anesthetists									19	19	Nonphysician Anesthetists											19	19	Nonphysician Anesthetists										19
20	Nursing School									20	20	Nursing School											20	20	Nursing School										20
21	Intern & Res. Service-Salary & Fringes (Approved)									21	21	Intern & Res. Service-Salary & Fringes (Approved)											21	21	Intern & Res. Service-Salary & Fringes (Approved)										21
22	Intern & Res. Other Program Costs (Approved)									22	22	Intern & Res. Other Program Costs (Approved)											22	22	Intern & Res. Other Program Costs (Approved)										22
23	Paramedical Education Program (specify)									23	23	Paramedical Education Program (specify)											23	23	Paramedical Education Program (specify)										23
	INPATIENT ROUTINE SERVICE COST CENTERS											INPATIENT ROUTINE SERVICE COST CENTERS													INPATIENT ROUTINE SERVICE COST CENTERS
30	Adults and Pediatrics (General Routine Care)									30	30	Adults and Pediatrics (General Routine Care)											30	30	Adults and Pediatrics (General Routine Care)										30
31	Intensive Care Unit									31	31	Intensive Care Unit											31	31	Intensive Care Unit										31
32	Coronary Care Unit									32	32	Coronary Care Unit											32	32	Coronary Care Unit										32
33	Burn Intensive Care Unit									33	33	Burn Intensive Care Unit											33	33	Burn Intensive Care Unit										33
34	Surgical Intensive Care Unit									34	34	Surgical Intensive Care Unit											34	34	Surgical Intensive Care Unit										34
35	Other Special Care Unit (specify)									35	35	Other Special Care Unit (specify)											35	35	Other Special Care Unit (specify)										35
40	Subprovider IPF									40	40	Subprovider IPF											40	40	Subprovider IPF										40
41	Subprovider IRF									41	41	Subprovider IRF											41	41	Subprovider IRF										41
42	Subprovider (specify)									42	42	Subprovider (specify)											42	42	Subprovider (specify)										42
43	Nursery									43	43	Nursery											43	43	Nursery										43
44	Skilled Nursing Facility									44	44	Skilled Nursing Facility											44	44	Skilled Nursing Facility										44
45	Nursing Facility									45	45	Nursing Facility											45	45	Nursing Facility										45
46	Other Long Term Care									46	46	Other Long Term Care											46	46	Other Long Term Care										46
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)											FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)													FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)
Rev. 4										40-553	40-556												Rev. 4	Rev. 6											40-559
4090 (Cont.)				FORM CMS-2552-10						09-13	10-12					FORM CMS-2552-10							4090 (Cont.)	4090 (Cont.)				FORM CMS-2552-10							09-14
COST ALLOCATION - STATISTICAL BASIS					PROVIDER CCN:		PERIOD:		WORKSHEET B-1		COST ALLOCATION - STATISTICAL BASIS							PROVIDER CCN:		PERIOD:		WORKSHEET B-1		COST ALLOCATION - STATISTICAL BASIS						PROVIDER CCN:		PERIOD:		WORKSHEET B-1
							FROM ____________													FROM ____________												FROM ____________
					________________		TO _______________											________________		TO _______________										________________		TO _______________
			CAPITAL RELATED COST		EMPLOYEE		ADMINIS-	MAIN-					LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL						NON-		INTERNS & RESIDENTS		PARA-		INTERN &
			BLDGS. &	MOVABLE	BENEFITS		TRATIVE &	TENANCE &	OPERATION				& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL				OTHER	PHYSICIAN	NURSING	SALARY AND	PROGRAM	MEDICAL		RESIDENT
			FIXTURES	EQUIPMENT	DEPARTMENT		GENERAL	REPAIRS	OF PLANT				SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE				GENERAL	ANES-	SCHOOL	FRINGES	COSTS	EDUCATION		COST & POST
	COST CENTER DESCRIPTIONS		(SQUARE	(DOLLAR	(GROSS	RECONCIL-	(ACCUM.	(SQUARE	(SQUARE			COST CENTER DESCRIPTIONS	(POUNDS OF	(HOURS OF	(MEALS	(MEALS	(NUMBER	(DIRECT	(COSTED	(COSTED	(TIME	(TIME			COST CENTER DESCRIPTIONS	SERVICE	THETISTS	(ASSIGNED	(ASSIGNED	(ASSIGNED	(ASSIGNED		STEPDOWN
			FEET)	VALUE)	SALARIES)	IATION	COST)	FEET)	FEET)				LAUNDRY)	SERVICE)	SERVED)	SERVED)	HOUSED)	NURS. HRS)	REQUIS.)	REQUIS.)	SPENT)	SPENT)				(SPECIFY)	(ASGND TIME)	TIME)	TIME)	TIME)	TIME)	SUBTOTAL	ADJUSTMENTS	TOTAL
			1	2	4	5A	5	6	7				8	9	10	11	12	13	14	15	16	17				18	19	20	21	22	23	24	25	26
	ANCILLARY SERVICE COST CENTERS											ANCILLARY SERVICE COST CENTERS													ANCILLARY SERVICE COST CENTERS
50	Operating Room									50	50	Operating Room											50	50	Operating Room										50
51	Recovery Room									51	51	Recovery Room											51	51	Recovery Room										51
52	Labor Room and Delivery Room									52	52	Labor Room and Delivery Room											52	52	Labor Room and Delivery Room										52
53	Anesthesiology									53	53	Anesthesiology											53	53	Anesthesiology										53
54	Radiology-Diagnostic									54	54	Radiology-Diagnostic											54	54	Radiology-Diagnostic										54
55	Radiology-Therapeutic									55	55	Radiology-Therapeutic											55	55	Radiology-Therapeutic										55
56	Radioisotope									56	56	Radioisotope											56	56	Radioisotope										56
57	Computed Tomography (CT) Scan									57	57	Computed Tomography (CT) Scan											57	57	Computed Tomography (CT) Scan										57
58	Magnetic Resonance Imaging (MRI)									58	58	Magnetic Resonance Imaging (MRI)											58	58	Magnetic Resonance Imaging (MRI)										58
59	Cardiac Catheterization									59	59	Cardiac Catheterization											59	59	Cardiac Catheterization										59
60	Laboratory									60	60	Laboratory											60	60	Laboratory										60
61	PBP Clinical Laboratory Services-Program Only									61	61	PBP Clinical Laboratory Services-Program Only											61	61	PBP Clinical Laboratory Services-Program Only										61
62	Whole Blood & Packed Red Blood Cells									62	62	Whole Blood & Packed Red Blood Cells											62	62	Whole Blood & Packed Red Blood Cells										62
63	Blood Storing, Processing, & Trans.									63	63	Blood Storing, Processing, & Trans.											63	63	Blood Storing, Processing, & Trans.										63
64	Intravenous Therapy									64	64	Intravenous Therapy											64	64	Intravenous Therapy										64
65	Respiratory Therapy									65	65	Respiratory Therapy											65	65	Respiratory Therapy										65
66	Physical Therapy									66	66	Physical Therapy											66	66	Physical Therapy										66
67	Occupational Therapy									67	67	Occupational Therapy											67	67	Occupational Therapy										67
68	Speech Pathology									68	68	Speech Pathology											68	68	Speech Pathology										68
69	Electrocardiology									69	69	Electrocardiology											69	69	Electrocardiology										69
70	Electroencephalography									70	70	Electroencephalography											70	70	Electroencephalography										70
71	Medical Supplies Charged to Patients									71	71	Medical Supplies Charged to Patients											71	71	Medical Supplies Charged to Patients										71
72	Implantable Devices Charged to Patients									72	72	Implantable Devices Charged to Patients											72	72	Implantable Devices Charged to Patients										72
73	Drugs Charged to Patients									73	73	Drugs Charged to Patients											73	73	Drugs Charged to Patients										73
74	Renal Dialysis									74	74	Renal Dialysis											74	74	Renal Dialysis										74
75	ASC (Non-Distinct Part)									75	75	ASC (Non-Distinct Part)											75	75	ASC (Non-Distinct Part)										75
76	Other Ancillary (specify)									76	76	Other Ancillary (specify)											76	76	Other Ancillary (specify)										76
	OUTPATIENT SERVICE COST CENTERS											OUTPATIENT SERVICE COST CENTERS													OUTPATIENT SERVICE COST CENTERS
88	Rural Health Clinic (RHC)									88	88	Rural Health Clinic (RHC)											88	88	Rural Health Clinic (RHC)										88
89	Federally Qualified Health Center (FQHC)									89	89	Federally Qualified Health Center (FQHC)											89	89	Federally Qualified Health Center (FQHC)										89
90	Clinic									90	90	Clinic											90	90	Clinic										90
91	Emergency									91	91	Emergency											91	91	Emergency										91
92	Observation Beds									92	92	Observation Beds											92	92	Observation Beds										92
93	Other Outpatient Service (specify)									93	93	Other Outpatient Service (specify)											93	93	Other Outpatient Service (specify)										93
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)											FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)													FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)
40-554										Rev. 4	Rev. 3												40-557	40-560											Rev. 6
09-13				FORM CMS-2552-10						4090 (Cont.)	4090 (Cont.)					FORM CMS-2552-10							10-12	09-13				FORM CMS-2552-10							4090 (Cont.)
COST ALLOCATION - STATISTICAL BASIS					PROVIDER CCN:		PERIOD:		WORKSHEET B-1		COST ALLOCATION - STATISTICAL BASIS							PROVIDER CCN:		PERIOD:		WORKSHEET B-1		COST ALLOCATION - STATISTICAL BASIS						PROVIDER CCN:		PERIOD:		WORKSHEET B-1
							FROM ____________													FROM ____________												FROM ____________
					________________		TO _______________											________________		TO _______________										________________		TO _______________
			CAPITAL RELATED COST		EMPLOYEE		ADMINIS-	MAIN-					LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL						NON-		INTERNS & RESIDENTS		PARA-		INTERN &
			BLDGS. &	MOVABLE	BENEFITS		TRATIVE &	TENANCE &	OPERATION				& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL				OTHER	PHYSICIAN	NURSING	SALARY AND	PROGRAM	MEDICAL		RESIDENT
			FIXTURES	EQUIPMENT	DEPARTMENT		GENERAL	REPAIRS	OF PLANT				SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE				GENERAL	ANES-	SCHOOL	FRINGES	COSTS	EDUCATION		COST & POST
	COST CENTER DESCRIPTIONS		(SQUARE	(DOLLAR	(GROSS	RECONCIL-	(ACCUM.	(SQUARE	(SQUARE			COST CENTER DESCRIPTIONS	(POUNDS OF	(HOURS OF	(MEALS	(MEALS	(NUMBER	(DIRECT	(COSTED	(COSTED	(TIME	(TIME			COST CENTER DESCRIPTIONS	SERVICE	THETISTS	(ASSIGNED	(ASSIGNED	(ASSIGNED	(ASSIGNED		STEPDOWN
			FEET)	VALUE)	SALARIES)	IATION	COST)	FEET)	FEET)				LAUNDRY)	SERVICE)	SERVED)	SERVED)	HOUSED)	NURS. HRS)	REQUIS.)	REQUIS.)	SPENT)	SPENT)				(SPECIFY)	(ASGND TIME)	TIME)	TIME)	TIME)	TIME)	SUBTOTAL	ADJUSTMENTS	TOTAL
			1	2	4	5A	5	6	7				8	9	10	11	12	13	14	15	16	17				18	19	20	21	22	23	24	25	26
	OTHER REIMBURSABLE COST CENTERS											OTHER REIMBURSABLE COST CENTERS													OTHER REIMBURSABLE COST CENTERS
94	Home Program Dialysis									94	94	Home Program Dialysis											94	94	Home Program Dialysis										94
95	Ambulance Services									95	95	Ambulance Services											95	95	Ambulance Services										95
96	Durable Medical Equipment-Rented									96	96	Durable Medical Equipment-Rented											96	96	Durable Medical Equipment-Rented										96
97	Durable Medical Equipment-Sold									97	97	Durable Medical Equipment-Sold											97	97	Durable Medical Equipment-Sold										97
98	Other Reimbursable (specify)									98	98	Other Reimbursable (specify)											98	98	Other Reimbursable (specify)										98
99	Outpatient Rehabilitation Provider (specify)									99	99	Outpatient Rehabilitation Provider (specify)											99	99	Outpatient Rehabilitation Provider (specify)										99
100	Intern-Resident Service (not appvd. tchng. prgm.)									100	100	Intern-Resident Service (not appvd. tchng. prgm.)											100	100	Intern-Resident Service (not appvd. tchng. prgm.)										100
101	Home Health Agency									101	101	Home Health Agency											101	101	Home Health Agency										101
	SPECIAL PURPOSE COST CENTERS											SPECIAL PURPOSE COST CENTERS													SPECIAL PURPOSE COST CENTERS
105	Kidney Acquisition									105	105	Kidney Acquisition											105	105	Kidney Acquisition										105
106	Heart Acquisition									106	106	Heart Acquisition											106	106	Heart Acquisition										106
107	Liver Acquisition									107	107	Liver Acquisition											107	107	Liver Acquisition										107
108	Lung Acquisition									108	108	Lung Acquisition											108	108	Lung Acquisition										108
109	Pancreas Acquisition									109	109	Pancreas Acquisition											109	109	Pancreas Acquisition										109
110	Intestinal Acquisition									110	110	Intestinal Acquisition											110	110	Intestinal Acquisition										110
111	Islet Acquisition									111	111	Islet Acquisition											111	111	Islet Acquisition										111
112	Other Organ Acquisition (specify)									112	112	Other Organ Acquisition (specify)											112	112	Other Organ Acquisition (specify)										112
115	Ambulatory Surgical Center (Distinct Part)									115	115	Ambulatory Surgical Center (Distinct Part)											115	115	Ambulatory Surgical Center (Distinct Part)										115
116	Hospice									116	116	Hospice											116	116	Hospice										116
117	Other Special Purpose (specify)									117	117	Other Special Purpose (specify)											117	117	Other Special Purpose (specify)										117
118	SUBTOTALS (sum of lines 1-117)									118	118	SUBTOTALS (sum of lines 1-117)											118	118	SUBTOTALS (sum of lines 1-117)										118
	NONREIMBURSABLE COST CENTERS											NONREIMBURSABLE COST CENTERS													NONREIMBURSABLE COST CENTERS
190	Gift, Flower, Coffee Shop, & Canteen									190	190	Gift, Flower, Coffee Shop, & Canteen											190	190	Gift, Flower, Coffee Shop, & Canteen										190
191	Research									191	191	Research											191	191	Research										191
192	Physicians' Private Offices									192	192	Physicians' Private Offices											192	192	Physicians' Private Offices										192
193	Nonpaid Workers									193	193	Nonpaid Workers											193	193	Nonpaid Workers										193
194	Other Nonreimbursable (specify)									194	194	Other Nonreimbursable (specify)											194	194	Other Nonreimbursable (specify)										194
200	Cross foot adjustments									200	200	Cross foot adjustments											200	200	Cross foot adjustments										200
201	Negative cost centers									201	201	Negative cost centers											201	201	Negative cost centers										201
202	Cost to be allocated (per Worksheet B, Part I)									202	202	Cost to be allocated (per Worksheet B, Part I)											202	202	Cost to be allocated (per Worksheet B, Part I)										202
203	Unit cost multiplier (Worksheet B, Part I)									203	203	Unit cost multiplier (Worksheet B, Part I)											203	203	Unit cost multiplier (Worksheet B, Part I)										203
204	Cost to be allocated (per Worksheet B, Part II)									204	204	Cost to be allocated (per Worksheet B, Part II)											204	204	Cost to be allocated (per Worksheet B, Part II)										204
205	Unit cost multiplier (Worksheet B, Part II)									205	205	Unit cost multiplier (Worksheet B, Part II)											205	205	Unit cost multiplier (Worksheet B, Part II)										205
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)											FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)													FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)
Rev. 4										40-555	40-558												Rev. 3	Rev. 4											40-561

---

Sheet 28: B2

4090 (Cont.)		FORM CMS-2552-10				09-13
POST STEPDOWN ADJUSTMENTS		PROVIDER CCN:	PERIOD:		WORKSHEET B-2																								.
			FROM ____________
		________________	TO _______________
			WORKSHEET
	DESCRIPTION		PART	LINE NO.	AMOUNT
	1		2	3	4
1	Adjustment for EPO costs in Renal Dialysis cost center		1	74		1
2	Adjustment for EPO costs in Home Program Dialysis cost center		1	94		2
3	Adjustment for ARANESP costs in Renal Dialysis cost center		1	74		3
4	Adjustment for ARANESP costs in Home Program Dialysis cost center		1	94		4
5	Adjustment for ESA costs in Renal Dialysis cost center (see instructions)		1	74		5
6	Adjustment for ESA costs in Home Program Dialysis cost center (see instructions)		1	94		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
51						51
52						52
53						53
54						54
55						55
56						56
57						57
58						58
59						59
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4022)
40-562						Rev. 4

---

Sheet 29: CI

10-12					FORM CMS-2552-10								4090 (Cont.)
COMPUTATION OF RATIO OF COSTS TO CHARGES								PROVIDER CCN:		PERIOD:		WORKSHEET C
										FROM ____________		PART I
								________________		TO _______________
		Total Cost		Costs			Charges
		(from Wkst.	Therapy		RCE				Total		TEFRA	PPS
	COST CENTER DESCRIPTIONS	B, Part I,	Limit	Total	Dis-	Total			(column 6	Cost or	Inpatient	Inpatient
		col. 26)	Adj.	Costs	allowance	Costs	Inpatient	Outpatient	+ column 7)	Other Ratio	Ratio	Ratio
		1	2	3	4	5	6	7	8	9	10	11
	INPATIENT ROUTINE SERVICE COST CENTERS
30	Adults and Pediatrics (General Routine Care)												30
31	Intensive Care Unit												31
32	Coronary Care Unit												32
33	Burn Intensive Care Unit												33
34	Surgical Intensive Care Unit												34
35	Other Special Care (specify)												35
40	Subprovider IPF												40
41	Subprovider IRF												41
42	Subprovider (Specify)												42
43	Nursery												43
44	Skilled Nursing Facility												44
45	Nursing Facility												45
46	Other Long Term Care												46
	ANCILLARY SERVICE COST CENTERS
50	Operating Room												50
51	Recovery Room												51
52	Labor Room and Delivery Room												52
53	Anesthesiology												53
54	Radiology-Diagnostic												54
55	Radiology-Therapeutic												55
56	Radioisotope												56
57	Computed Tomography (CT) Scan												57
58	Magnetic Resonance Imaging (MRI)												58
59	Cardiac Catheterization												59
60	Laboratory												60
61	PBP Clinical Laboratory Services-Prgm. Only												61
62	Whole Blood & Packed Red Blood Cells												62
63	Blood Storing, Processing, & Trans.												63
64	Intravenous Therapy												64
65	Respiratory Therapy												65
66	Physical Therapy												66
67	Occupational Therapy												67
68	Speech Pathology												68
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4023)
Rev. 3													40-563
4090 (Cont.)					FORM CMS-2552-10								10-12
COMPUTATION OF RATIO OF COSTS TO CHARGES								PROVIDER CCN:		PERIOD:		WORKSHEET C
										FROM ____________		PART I
								________________		TO _______________
		Total Cost		Costs			Charges
		(from Wkst.	Therapy		RCE				Total		TEFRA	PPS
	COST CENTER DESCRIPTIONS	B, Part I,	Limit	Total	Dis-	Total			(column 6	Cost or	Inpatient	Inpatient
		col. 26)	Adj.	Costs	allowance	Costs	Inpatient	Outpatient	+ column 7)	Other Ratio	Ratio	Ratio
		1	2	3	4	5	6	7	8	9	10	11
69	Electrocardiology												69
70	Electroencephalography												70
71	Medical Supplies Charged to Patients												71
72	Implantable Devices Charged to Patients												72
73	Drugs Charged to Patients												73
74	Renal Dialysis												74
75	ASC (Non-Distinct Part)												75
76	Other Ancillary (specify)												76
	OUTPATIENT SERVICE COST CENTERS
88	Rural Health Clinic (RHC)												88
89	Federally Qualified Health Center (FQHC)												89
90	Clinic												90
91	Emergency												91
92	Observation Beds (see instructions)												92
93	Other Outpatient Service (specify)												93
	OTHER REIMBURSABLE COST CENTERS
94	Home Program Dialysis												94
95	Ambulance Services												95
96	Durable Medical Equipment-Rented												96
97	Durable Medical Equipment-Sold												97
98	Other Reimbursable (specify)												98
99	Outpatient Rehabilitation Provider (specify)												99
100	Intern-Resident Service (not appvd. tchng. prgm.)												100
101	Home Health Agency												101
	SPECIAL PURPOSE COST CENTERS
105	Kidney Acquisition												105
106	Heart Acquisition												106
107	Liver Acquisition												107
108	Lung Acquisition												108
109	Pancreas Acquisition												109
110	Intestinal Acquisition												110
111	Islet Acquisition												111
112	Other Organ Acquisition (specify)												112
115	Ambulatory Surgical Center (Distinct Part)												115
116	Hospice												116
117	Other Special Purpose (specify)												117
200	Subtotal (see instructions)												200
201	Less Observation Beds												201
202	Total (see instructions)												202
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4023)
40-564													Rev. 3

---

Sheet 30: CII

10-12				FORM CMS-2552-10							4090 (Cont.)
CALCULATION OF OUTPATIENT SERVICE COST TO			[ ] Title V			PROVIDER CCN:		PERIOD:		WORKSHEET C,
CHARGE RATIOS NET OF REDUCTIONS FOR MEDICAID ONLY			[ ] Title XIX					FROM ____________		PART II
						________________		TO _______________
				Capital Cost	Operating Cost			Cost Net of	Total
			Total Cost	(Wkst B,	Net of		Operating Cost	Capital and	Charges	Outpatient Cost
	Cost Center Descriptions		(Wkst. B,	Part II,	Capital Cost	Capital	Reduction	Operating Cost	(Worksheet C,	to Charge Ratio
			Part I, col. 26)	col. 26)	(col. 1 - col. 2)	Reduction	Amount	Reduction	Part I, column 8)	(col. 6 ÷ col. 7)
			1	2	3	4	5	6	7	8
	ANCILLARY SERVICE COST CENTERS
50	Operating Room										50
51	Recovery Room										51
52	Labor Room and Delivery Room										52
53	Anesthesiology										53
54	Radiology-Diagnostic										54
55	Radiology-Therapeutic										55
56	Radioisotope										56
57	Computed Tomography (CT) Scan										57
58	Magnetic Resonance Imaging (MRI)										58
59	Cardiac Catherization										59
60	Laboratory										60
61	PBP Clinical Laboratory Services-Prgm. Only										61
62	Whole Blood & Packed Red Blood Cells										62
63	Blood Storing, Processing, & Trans.										63
64	Intravenous Therapy										64
65	Respiratory Therapy										65
66	Physical Therapy										66
67	Occupational Therapy										67
68	Speech Pathology										68
69	Electrocardiology										69
70	Electroencephalography										70
71	Medical Supplies Charged to Patients										71
72	Implantable Devices Charged to Patients										72
73	Drugs Charged to Patients										73
74	Renal Dialysis										74
75	ASC (Non-Distinct Part)										75
76	Other Ancillary (specify)										76
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4023 & 4023.2)
Rev. 3											40-565
4090 (Cont.)				FORM CMS-2552-10							10-12
CALCULATION OF OUTPATIENT SERVICE COST TO			[ ] Title V			PROVIDER CCN:		PERIOD:		WORKSHEET C.
CHARGE RATIOS NET OF REDUCTIONS FOR MEDICAID ONLY			[ ] Title XIX					FROM ____________		PART II (CONT.)
						________________		TO _______________
				Capital Cost	Operating Cost			Cost Net of	Total
			Total Cost	(Wkst B,	Net of		Operating Cost	Capital and	Charges	Outpatient Cost
	Cost Center Descriptions		(Wkst. B,	Part II,	Capital Cost	Capital	Reduction	Operating Cost	(Worksheet C,	to Charge Ratio
			Part I, col. 26)	col. 26)	(col. 1 - col. 2)	Reduction	Amount	Reduction	Part I, column 8)	(col. 6 ÷ col. 7)
			1	2	3	4	5	6	7	8
	OUTPATIENT SERVICE COST CENTERS
88	Rural Health Clinic (RHC)										88
89	Federally Qualified Health Center (FQHC)										89
90	Clinic										90
91	Emergency										91
92	Observation Beds (see instructions)										92
93	Other Outpatient Service (specify)										93
	OTHER REIMBURSABLE COST CENTERS
94	Home Program Dialysis										94
95	Ambulance Services										95
96	Durable Medical Equipment-Rented										96
97	Durable Medical Equipment-Sold										97
98	Other Reimbursable (specify)										98
99	Outpatient Rehabilitation Provider (specify)										99
100	Intern-Resident Service (not appvd. tchng. prgm.)										100
101	Home Health Agency										101
105	Kidney Acquisition										105
106	Heart Acquisition										106
107	Liver Acquisition										107
108	Lung Acquisition										108
109	Pancreas Acquisition										109
110	Intestinal Acquisition										110
111	Islet Acquisition										111
112	Other Organ Acquisition (specify)										112
115	Ambulatory Surgical Center (Distinct Part)										115
116	Hospice										116
117	Other Special Purpose (specify)										117
200	Subtotal (sum of lines 50 thru 199)										200
201	Less Observation Beds										201
202	Total (line 200 minus line 201)										202
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4023 & 4023.2)
40-566											Rev. 3

---

Sheet 31: DI

10-12				FORM CMS-2552-10						4090 (Cont.)
APPORTIONMENT OF INPATIENT ROUTINE					PROVIDER CCN:		PERIOD:		WORKSHEET D,
SERVICE CAPITAL COSTS							FROM ____________		PART I
					________________		TO _______________
Check		[ ] Title V	[ ] PPS
applicable		[ ] Title XVIII, Part A	[ ] TEFRA
boxes:		[ ] Title XIX
					Reduced				Inpatient
			Capital		Capital				Program
			Related Cost		Related		Per		Capital
			(from Wkst.	Swing	Cost	Total	Diem	Inpatient	Cost
			B, Part II,	Bed	(col. 1 minus	Patient	(col. 3 ÷	Program	(col. 5
			col. 26)	Adjustment	col. 2)	Days	col. 4)	Days	x col. 6)
(A)	Cost Center Description		1	2	3	4	5	6	7
	INPATIENT ROUTNE SERVICE COST CENTERS
	Adults & Pediatrics
30	(General Routine Care)									30
31	Intensive Care Unit									31
32	Coronary Care Unit									32
33	Burn Intensive Care Unit									33
34	Surgical Intensive Care Unit									34
35	Other Special Care Unit (specify)									35
40	Subprovider IPF									40
41	Subprovider IRF									41
42	Subprovider (Other)									42
43	Nursery									43
44	Skilled Nursing Facility									44
45	Nursing Facility									45
200	Total (lines 30-199)									200
(A) Worksheet A line numbers
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4024 - 4024.1)
Rev. 3										40-567

---

Sheet 32: DII

4090 (Cont.)			FORM CMS-2552-10					10-12
APPORTIONMENT OF INPATIENT ANCILLARY			PROVIDER CCN: ______________		PERIOD:		WORKSHEET D,
SERVICE CAPITAL COSTS					FROM ____________		PART II
			COMPONENT CCN: ____________		TO _______________
Check		[ ] Title V		[ ] Hospital	[ ] Subprovider (Other)		[ ] PPS
applicable		[ ] Title XVIII, Part A		[ ] IPF			[ ] TEFRA
boxes:		[ ] Title XIX		[ ] IRF
			Capital
			Related Cost		Ratio of Cost		Capital
			(from Wkst.	Total Charges	to Charges	Inpatient	Costs
			B, Part II,	(from Wkst. C,	(col .1 ÷	Program	(column 3 x
			col. 26)	Part I, col. 8)	col. 2)	Charges	column 4)
(A)	Cost Center Description		1	2	3	4	5
	ANCILLARY SERVICE COST CENTERS
50	Operating Room							50
51	Recovery Room							51
52	Labor Room and Delivery Room							52
53	Anesthesiology							53
54	Radiology-Diagnostic							54
55	Radiology-Therapeutic							55
56	Radioisotope							56
57	Computed Tomography (CT) Scan							57
58	Magnetic Resonance Imaging (MRI)							58
59	Cardiac Catheterization							60
60	Laboratory							60
61	PBP Clinical Laboratory Services-Prgm. Only							61
62	Whole Blood & Packed Red Blood Cells							62
63	Blood Storing, Processing, & Transfusing							63
64	Intravenous Therapy							64
65	Respiratory Therapy							65
66	Physical Therapy							66
67	Occupational Therapy							67
68	Speech Pathology							68
69	Electrocardiology							69
70	Electroencephalography							70
71	Medical Supplies Charged to Patients							71
72	Implantable Devices Charged to Patients							72
73	Drugs Charged to Patients							73
74	Renal Dialysis							74
75	ASC (Non-Distinct Part)							75
76	Other Ancillary (specify)							76
88	Rural Health Clinic (RHC)							88
89	Federally Qualified Health Center (FQHC)							89
90	Clinic							90
91	Emergency							91
92	Observation Beds							92
93	Other Outpatient Service (specify)							93
	OTHER REIMBURSABLE COST CENTERS
94	Home Program Dialysis							94
95	Ambulance Services							95
96	Durable Medical Equipment-Rented							96
97	Durable Medical Equipment-Sold							97
98	Other Reimbursable (specify)							98
200	Total (sum of lines 50 through 199)							200
(A) Worksheet A line numbers
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4024.2)
40-568								Rev. 3

---

Sheet 33: DIII

09-14

FORM CMS-2552-10

4090 (Cont.)

APPORTIONMENT OF INPATIENT ROUTINE

PROVIDER CCN:

PERIOD:

WORKSHEET D,

SERVICE OTHER PASS THROUGH COSTS

FROM ____________

PART III

________________

TO _______________

Check

[ ] Title V

[ ] PPS

applicable

[ ] Title XVIII, Part A

[ ] TEFRA

boxes:

[ ] Title XIX

[ ] Other

All

Swing-Bed

Inpatient

Other

Adjustment

Total Costs

Per

Program

Medical

Amount

(sum of cols.

Total

Diem

Inpatient

Pass-Through

Nursing

Allied Health

Education

(see

1 through 3,

Patient

(col. 5 ÷

Program

Cost

School

Cost

Cost

instructions)

minus col. 4)

Days

col. 6)

Days

(col. 7 x col. 8)

(A)

Cost Center Description

1

2

3

4

5

6

7

8

9

INPATIENT ROUTINE SERVICE COST CENTERS

Adults & Pediatrics

30

(General Routine Care)

30

31

Intensive Care Unit

31

32

Coronary Care Unit

32

33

Burn Intensive Care Unit

33

34

Surgical Intensive Care Unit

34

35

Other Special Care Unit (specify)

35

40

Subprovider IPF

40

41

Subprovider IRF

41

42

Subprovider (Other)

42

43

Nursery

43

44

Skilled Nursing Facility

44

45

Nursing Facility

45

200

Total (sum of lines 30-199)

200

(A) Worksheet A line numbers

FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4024.3)

Rev. 6

40-569

---

Sheet 34: DIV

4090 (Cont.)					FORM CMS-2552-10						DRAFT
APPORTIONMENT OF INPATIENT/OUTPATIENT ANCILLARY						PROVIDER CCN: ______________		PERIOD:		WORKSHEET D,
SERVICE OTHER PASS THROUGH COSTS								FROM ____________		PART IV
						COMPONENT CCN: ____________		TO _______________
Check		[ ] Title V			[ ] Hospital	[ ] Subprovider (Other)		[ ] ICF/IID	[ ] PPS
applicable		[ ] Title XVIII, Part A			[ ] IPF	[ ] SNF			[ ] TEFRA
boxes:		[ ] Title XIX			[ ] IRF	[ ] NF			[ ] Other
								All		Total
					Non			Other		Outpatient
					Physician			Medical	Total cost	Cost
					Anesthetist	Nursing	Allied	Education	(sum of col 1	(sum of col. 2,
					Cost	School	Health	Cost	through col. 4)	3 and 4)
(A)	Cost Center Description				1	2	3	4	5	6
	ANCILLARY SERVICE COST CENTERS
50	Operating Room										50
51	Recovery Room										51
52	Labor room and Delivery Room										52
53	Anesthesiology										53
54	Radiology-Diagnostic										54
55	Radiology-Therapeutic										55
56	Radioisotope										56
57	Computed Tomography (CT) Scan										57
58	Magnetic Resonance Imaging (MRI)										58
59	Cardiac Catheterization										59
60	Laboratory										60
61	PBP Clinical Laboratory Serv.-Prgm. Only										61
62	Whole Blood & Packed Red Blood Cells										62
63	Blood Storing, Processing, & Transfusing										63
64	Intravenous Therapy										64
65	Respiratory Therapy										65
66	Physical Therapy										66
67	Occupational Therapy										67
68	Speech Pathology										68
69	Electrocardiology										69
70	Electroencephalography										70
71	Medical Supplies Charged To Patients										71
72	Implantable Devices Charged to Patients										72
73	Drugs Charged to Patients										73
74	Renal Dialysis										74
75	ASC (Non-Distinct Part)										75
76	Other Ancillary (specify)										76
	OUTPATIENT SERVICE COST CENTERS
88	Rural Health Clinic (RHC)										88
89	Federally Qualified Health Center (FQHC)										89
90	Clinic										90
91	Emergency										91
92	Observation Beds										92
93	Other Outpatient Service (specify)										93
	OTHER REIMBURSABLE COST CENTERS
94	Home Program Dialysis										94
95	Ambulance Services										95
96	Durable Medical Equipment-Rented										96
97	Durable Medical Equipment-Sold										97
98	Other Reimbursable (specify)										98
200	Total (sum of lines 50 through 199)										200
(A) Worksheet A line numbers
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4024.4)
40-570											Rev.
DRAFT					FORM CMS-2552-10						4090 (Cont.)
APPORTIONMENT OF INPATIENT/OUTPATIENT ANCILLARY						PROVIDER CCN: ______________		PERIOD:		WORKSHEET D,
SERVICE OTHER PASS THROUGH COSTS								FROM ____________		PART IV (Cont.)
						COMPONENT CCN: ____________		TO _______________
Check		[ ] Title V			[ ] Hospital	[ ] Subprovider (Other)		[ ] ICF/IID	[ ] PPS
applicable		[ ] Title XVIII, Part A			[ ] IPF	[ ] SNF			[ ] TEFRA
boxes:		[ ] Title XIX			[ ] IRF	[ ] NF			[ ] Other
								Inpatient		Outpatient
						Outpatient		Program		Program
				Total	Ratio	Ratio		Pass-		Pass-
				Charges	of Cost	of Cost	Inpatient	Through	Outpatient	Through
				(from Wkst. C,	to Charges	to Charges	Program	Costs	Program	Costs
				Part I, col. 8)	(col. 5 ÷ col. 7)	(col. 6 ÷ col. 7)	Charges	(col. 8 x col. 10)	Charges	(col. 9 x col. 12)
(A)	Cost Center Description			7	8	9	10	11	12	13
	ANCILLARY SERVICE COST CENTERS
50	Operating Room										50
51	Recovery Room										51
52	Delivery Room and Labor Room										52
53	Anesthesiology										53
54	Radiology-Diagnostic										54
55	Radiology-Therapeutic										55
56	Radioisotope										56
57	Computed Tomography (CT) Scan										57
58	Magnetic Resonance Imaging (MRI)										58
59	Cardiac Catheterization										59
60	Laboratory										60
61	PBP Clinical Laboratory Serv.-Prgm. Only										61
62	Whole Blood & Packed Red Blood Cells										62
63	Blood Storing, Processing, & Transfusing										63
64	Intravenous Therapy										64
65	Respiratory Therapy										65
66	Physical Therapy										66
67	Occupational Therapy										67
68	Speech Pathology										68
69	Electrocardiology										69
70	Electroencephalography										70
71	Medical Supplies Charged To Patients										71
72	Implantable Devices Charged to Patients										72
73	Drugs Charged to Patients										73
74	Renal Dialysis										74
75	ASC (Non-Distinct Part)										75
76	Other Ancillary (specify)										76
	OUTPATIENT SERVICE COST CENTERS
88	Rural Health Clinic (RHC)										88
89	Federally Qualified Health Center (FQHC)										89
90	Clinic										90
91	Emergency										91
92	Observation Beds										92
93	Other Outpatient Service (specify)										93
	OTHER REIMBURSABLE COST CENTERS
94	Home Program Dialysis										94
95	Ambulance Services										95
96	Durable Medical Equipment-Rented										96
97	Durable Medical Equipment-Sold										97
98	Other Reimbursable (specify)										98
200	Total (sum of lines 50 through 199)										200
(A) Worksheet A line numbers
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4024.4)
Rev.											40-571

---

Sheet 35: DV

4090 (Cont.)				FORM CMS-2552-10						DRAFT
APPORTIONMENT OF MEDICAL AND OTHER					PROVIDER CCN: ______________		PERIOD:		WORKSHEET D,
HEALTH SERVICES COSTS							FROM ____________		PART V
					COMPONENT CCN: ____________		TO _______________
Check		[ ] Title V - O/P		[ ] Hospital	[ ] Subprovider (Other)		[ ] Swing Bed SNF
applicable		[ ] Title XVIII, Part B		[ ] IPF	[ ] SNF		[ ] Swing Bed NF
boxes:		[ ] Title XIX - O/P		[ ] IRF	[ ] NF		[ ] ICF/IID
PART V - APPORTIONMENT OF MEDICAL AND OTHER HEALTH SERVICES COSTS
				Program Charges			Program Cost
			Cost		Cost	Cost		Cost	Cost
			to		Reimbursed	Reimbursed		Reimbursed	Reimbursed
			Charge	PPS	Services	Services Not	PPS	Services	Services Not
			Ratio from	Reimbursed	Subject to	Subject to	Services	Subject to	Subject to
			Worksheet C,	Services	Ded. & Coins.	Ded. & Coins.	(see	Ded. & Coins.	Ded. & Coins.
			Part I, col. 9	(see inst.)	(see inst.)	(see inst.)	(see inst.)	(see inst.)	(see inst.)
(A)	Cost Center Description		1	2	3	4	5	6	7
	ANCILLARY SERVICE COST CENTERS
50	Operating Room									50
51	Recovery Room									51
52	Labor & Delivery Room									52
53	Anesthesiology									53
54	Radiology-Diagnostic									54
55	Radiology-Therapeutic									55
56	Radioisotope									56
57	Computed Tomography (CT) Scan									57
58	Magnetic Resonance Imaging (MRI)									58
59	Cardiac Catheterization									59
60	Laboratory									60
61	PBP Clinical Laboratory Serv.-Prgm. Only									61
62	Whole Blood & Packed Red Blood Cells									62
63	Blood Storing, Processing, & Transfusing									63
64	Intravenous Therapy									64
65	Respiratory Therapy									65
66	Physical Therapy									66
67	Occupational Therapy									67
68	Speech Pathology									68
69	Electrocardiology									69
70	Electroencephalography									70
71	Medical Supplies Charged To Patients									71
72	Implantable Devices Charged to Patients									72
73	Drugs Charged to Patients									73
74	Renal Dialysis									74
75	ASC (Non-Distinct Part)									75
76	Other Ancillary (specify)									76
	OUTPATIENT SERVICE COST CENTERS
88	Rural Health Clinic (RHC)									88
89	Federally Qualified Health Center (FQHC)									89
90	Clinic									90
91	Emergency									91
92	Observation Bed									92
93	Other Outpatient Service (specify)									93
	OTHER REIMBURSABLE COST CENTERS
94	Home Program Dialysis									94
95	Ambulance									95
96	Durable Medical Equipment-Rented									96
97	Durable Medical Equipment-Sold									97
98	Other Reimbursable Cost Center									98
200	Subtotal (see instructions)									200
201	Less PBP Clinic Lab. Services-Program									201
	Only Charges
202	Net Charges (line 200 - line 201 )									202
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4024.5)
40-572										Rev.

---

Sheet 36: D1I

DRAFT			FORM CMS-2552-10				4090 (Cont.)
COMPUTATION OF INPATIENT				PROVIDER CCN.: ______________	PERIOD:	WORKSHEET D-1,
OPERATING COST					FROM ____________	PART I
				COMPONENT CCN.: ____________	TO _______________
Check		[ ] Title V - I/P	[ ] Hospital	[ ] Subprovider (other)	[ ] ICF/IID	[ ] PPS
applicable		[ ] Title XVIII, Part A	[ ] IPF	[ ] SNF		[ ] TEFRA
boxes:		[ ] Title XIX - I/P	[ ] IRF			[ ] Other
PART I - ALL PROVIDER COMPONENTS
			INPATIENT DAYS
1	Inpatient days (including private room days and swing-bed days, excluding newborn)						1
2	Inpatient days (including private room days, excluding swing-bed and newborn days)						2
3	Private room days (excluding swing-bed and observation bed days). If you have only private room days, do not complete this line.						3
4	Semi-private room days (excluding swing-bed and observation bed days)						4
5	Total swing-bed SNF type inpatient days (including private room days) through December 31 of the cost reporting period						5
6	Total swing-bed SNF type inpatient days (including private room days) after December 31 of the cost reporting period (if						6
	calendar year, enter 0 on this line)
7	Total swing-bed NF type inpatient days (including private room days) through December 31 of the cost reporting period						7
8	Total swing-bed NF type inpatient days (including private room days) after December 31 of the cost reporting period (if						8
	calendar year, enter 0 on this line)
9	Total inpatient days including private room days applicable to the Program (excluding swing-bed and newborn days)						9
10	Swing-bed SNF type inpatient days applicable to title XVIII only (including private room days) through December 31 of the						10
	cost reporting period (see instructions).
11	Swing-bed SNF type inpatient days applicable to title XVIII only (including private room days) after December 31 of the						11
	cost reporting period (if calendar year, enter 0 on this line)
12	Swing-bed NF type inpatient days applicable to titles V or XIX only (including private room days) through December 31 of						12
	the cost reporting period.
13	Swing-bed NF type inpatient days applicable to titles V or XIX only (including private room days) after December 31 of the						13
	cost reporting period (if calendar year, enter 0 on this line)
14	Medically necessary private room days applicable to the Program (excluding swing-bed days)						14
15	Total nursery days (title V or XIX only)						15
16	Nursery days (title V or XIX only)						16
			SWING BED ADJUSTMENT
17	Medicare rate for swing-bed SNF services applicable to services through December 31 of the cost reporting period						17
18	Medicare rate for swing-bed SNF services applicable to services after December 31 of the cost reporting period						18
19	Medicaid rate for swing-bed NF services applicable to services through December 31 of the cost reporting period						19
20	Medicaid rate for swing-bed NF services applicable to services after December 31 of the cost reporting period						20
21	Total general inpatient routine service cost (see instructions)						21
22	Swing-bed cost applicable to SNF type services through December 31 of the cost reporting period (line 5 x line 17)						22
23	Swing-bed cost applicable to SNF type services after December 31 of the cost reporting period (line 6 x line 18)						23
24	Swing-bed cost applicable to NF type services through December 31 of the cost reporting period (line 7 x line 19)						24
25	Swing-bed cost applicable to NF type services after December 31 of the cost reporting period (line 8 x line 20)						25
26	Total swing-bed cost (see instructions)						26
27	General inpatient routine service cost net of swing-bed cost (line 21 minus line 26)						27
			PRIVATE ROOM DIFFERENTIAL ADJUSTMENT
28	General inpatient routine service charges (excluding swing-bed and observation bed charges)						28
29	Private room charges (excluding swing-bed charges)						29
30	Semi-private room charges (excluding swing-bed charges)						30
31	General inpatient routine service cost/charge ratio (line 27 ÷ line 28)						31
32	Average private room per diem charge (line 29 ÷ line 3)						32
33	Average semi-private room per diem charge (line 30 ÷ line 4)						33
34	Average per diem private room charge differential (line 32 minus line 33) (see instructions)						34
35	Average per diem private room cost differential (line 34 x line 31)						35
36	Private room cost differential adjustment (line 3 x line 35)						36
37	General inpatient routine service cost net of swing-bed cost and private room cost differential (line 27 minus line 36)						37
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4025.1)
Rev.							40-573

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Sheet 37: D1II

4090 (Cont.)				FORM CMS-2552-10				DRAFT
COMPUTATION OF INPATIENT				PROVIDER CCN: ______________		PERIOD:	WORKSHEET D-1,
OPERATING COST						FROM ____________	PART II
				COMPONENT CCN: ____________		TO _______________
Check		[ ] Title V - I/P		[ ] Hospital	[ ]Subprovider (other)		[ ] PPS
applicable		[ ] Title XVIII, Part A		[ ] IPF			[ ] TEFRA
boxes:		[ ] Title XIX - I/P		[ ] IRF			[ ] Other
PART II - HOSPITAL AND SUBPROVIDERS ONLY
			PROGRAM INPATIENT OPERATING COST BEFORE
			PASS-THROUGH COST ADJUSTMENTS				1
38	Adjusted general inpatient routine service cost per diem (see instructions)							38
39	Program general inpatient routine service cost (line 9 x line 38)							39
40	Medically necessary private room cost applicable to the Program (line 14 x line 35)							40
41	Total Program general inpatient routine service cost (line 39 + line 40)							41
					Average
			Total	Total	Per Diem	Program	Program Cost
			Inpatient Cost	Inpatient Days	(col. 1 ÷ col. 2)	Days	(col. 3 x col. 4)
			1	2	3	4	5
42	Nursery (title V & XIX only)							42
	Intensive Care Type Inpatient
	Hospital Units
43	Intensive Care Unit							43
44	Coronary Care Unit							44
45	Burn Intensive Care Unit							45
46	Surgical Intensive Care Unit							46
47	Other Special Care Unit (specify)							47
							1
48	Program inpatient ancillary service cost (Worksheet D-3, column 3, line 200)							48
49	Total Program inpatient costs (sum of lines 41 through 48) (see instructions)							49
			PASS-THROUGH COST ADJUSTMENTS
50	Pass through costs applicable to Program inpatient routine services (from Worksheet D, sum of Parts I and III)							50
51	Pass through costs applicable to Program inpatient ancillary services (from Worksheet D, sum of Parts II and IV)							51
52	Total Program excludable cost (sum of lines 50 and 51)							52
53	Total Program inpatient operating cost excluding capital related, nonphysician anesthetist, and medical education costs							53
	(line 49 minus line 52)
			TARGET AMOUNT AND LIMIT COMPUTATION
54	Program discharges							54
55	Target amount per discharge							55
56	Target amount (line 54 x line 55)							56
57	Difference between adjusted inpatient operating cost and target amount (line 56 minus line 53)							57
58	Bonus payment (see instructions)							58
59	Lesser of line 53 ÷ line 54 or line 55 from the cost reporting period ending 1996, updated and compounded by the market basket							59
60	Lesser of line 53 ÷ line 54 or line 55 from prior year cost report, updated by the market basket							60
61	If line 53 ÷ line 54 is less than the lower of lines 55, 59 or 60 enter the lesser of 50% of the amount by which operating costs							61
	(line 53) are less than expected costs (lines 54 x 60), or 1 % of the target amount (line 56), otherwise enter zero.
	(see instructions)
62	Relief payment (see instructions)							62
63	Allowable Inpatient cost plus incentive payment (see instructions)							63
			PROGRAM INPATIENT ROUTINE SWING BED COST
64	Medicare swing-bed SNF inpatient routine costs through December 31 of the cost reporting period (see instructions)							64
	(title XVIII only)
65	Medicare swing-bed SNF inpatient routine costs after December 31 of the cost reporting period (see instructions)							65
	(title XVIII only)
66	Total Medicare swing-bed SNF inpatient routine costs (line 64 plus line 65) (Title XVIII only. For CAH, see instructions.)							66
67	Title V or XIX swing-bed NF inpatient routine costs through December 31 of the cost reporting period (line 12 x line 19)							67
68	Title V or XIX swing-bed NF inpatient routine costs after December 31 of the cost reporting period (line 13 x line 20)							68
69	Total title V or XIX swing-bed NF inpatient routine costs (line 67 + line 68)							69
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4025.2)
40-574								Rev.

---

Sheet 38: D1III

DRAFT				FORM CMS-2552-10				4090 (Cont.)
COMPUTATION OF INPATIENT				PROVIDER CCN: ______________		PERIOD:	WORKSHEET D-1,
OPERATING COST						FROM ____________	PARTS III & IV
				COMPONENT CCN: ____________		TO _______________
Check		[ ] Title V - I/P		[ ] Hospital	[ ] Subprovider (other)	[ ] ICF/IID	[ ] PPS
applicable		[ ] Title XVIII, Part A		[ ] IPF	[ ] SNF		[ ] TEFRA
boxes:		[ ] Title XIX - I/P		[ ] IRF	[ ] NF		[ ] Other
PART III - SKILLED NURSING FACILITY, OTHER NURSING FACILITY, AND ICF/IID ONLY
70	Skilled nursing facility/other nursing facility/ICF/IID routine service cost (line 37)							70
71	Adjusted general inpatient routine service cost per diem (line 70 ÷ line 2)							71
72	Program routine service cost (line 9 x line 71)							72
73	Medically necessary private room cost applicable to Program (line 14 x line 35)							73
74	Total Program general inpatient routine service costs (line 72 + line 73)							74
75	Capital-related cost allocated to inpatient routine service costs (from Worksheet B, Parts II, column 26, line 45)							75
76	Per diem capital-related costs (line 75 ÷ line 2)							76
77	Program capital-related costs (line 9 x line 76)							77
78	Inpatient routine service cost (line 74 minus line 77)							78
79	Aggregate charges to beneficiaries for excess costs (from provider records)							79
80	Total Program routine service costs for comparison to the cost limitation (line 78 minus line 79)							80
81	Inpatient routine service cost per diem limitation							81
82	Inpatient routine service cost limitation (line 9 x line 81)							82
83	Reasonable inpatient routine service costs (see instructions)							83
84	Program inpatient ancillary services (see instructions)							84
85	Utilization review - physician compensation (see instructions)							85
86	Total Program inpatient operating costs (sum of lines 83 through 85)							86
PART IV - COMPUTATION OF OBSERVATION BED PASS-THROUGH COST
87	Total observation bed days (see instructions)							87
88	Adjusted general inpatient routine cost per diem (line 27 ÷ line 2)							88
89	Observation bed cost (line 87 x line 88) (see instructions)							89
		COMPUTATION OF OBSERVATION BED PASS THROUGH COST
						Total	Observation Bed
				Routine		Observation	Pass-Through Cost
				Cost	column 1 ÷	Bed Cost	(col. 3 x col. 4)
			Cost	(from line 27)	column 2	(from line 89)	(see instructions)
			1	2	3	4	5
90	Capital-related cost							90
91	Nursing School cost							91
92	Allied Health cost							92
93	All other Medical Education							93
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4025.3 - 4025.4)
Rev.								40-575

---

Sheet 39: D2

4090 (Cont.)			FORM CMS-2552-10					DRAFT	DRAFT				FORM CMS-2552-10				4090 (Cont.)
APPORTIONMENT OF COST OF					PROVIDER CCN:	PERIOD:	WORKSHEET D-2,		APPORTIONMENT OF COST OF					PROVIDER CCN:	PERIOD:	WORKSHEET D-2,
SERVICES RENDERED BY						FROM ____________	PARTS I-III		SERVICES RENDERED BY						FROM ____________	PARTS I-III (Cont.)
INTERNS AND RESIDENTS					________________	TO _______________			INTERNS AND RESIDENTS					________________	TO _______________
PART I - NOT IN APPROVED TEACHING PROGRAM									PART I - NOT IN APPROVED TEACHING PROGRAM
					Percent of	Expense	Total Inpatient Days			Average Cost		Health Care Program Inpatient Days		Title V	Title XVIII	Title XIX
		Cost Centers			Assigned Time	Allocation	All Patients			Per Day	Title V	Title XVIII, Part B	Title XIX	(col. 4 x col. 5)	(col. 4 x col. 6)	(col. 4 x col. 7)
					1	2	3			4	5	6	7	8	9	10
1	Total cost of services rendered				100.00			1	1								1
	Hospital Inpatient Routine Services:
2		Adults & pediatrics (general routine care)						2	2								2
3		Intensive care unit						3	3								3
4		Coronary care unit						4	4								4
5		Burn Intensive Care Unit						5	5								5
6		Surgical Intensive Care Unit						6	6								6
7		Other Special Care (specify)						7	7								7
8		Nursery						8	8								8
9	Subtotal (sum of lines 2 through 8)							9	9								9
10	IPF - Inpatient routine service							10	10								10
11	IRF - Inpatient routine service							11	11								11
12	Subprovider (Other) - Inpatient routine service							12	12								12
13	Skilled Nursing Facility							13	13								13
14	Nursing Facility							14	14								14
15	Other Long Term Care							15	15								15
16	Home Health Agency							16	16								16
17	Outpatient Rehabilitation Providers							17	17								17
18	Ambulatory Surgical Center							18	18								18
19	Hospice							19	19								19
20	Subtotal (sum of lines 9 through 19)							20	20								20
							Total Charges			Ratio of Cost		Titles V and XIX Outpatient and			Titles V and XIX Outpatient and
							(from Worksheet C,			to Charges		Title XVIII Part B Charges			Title XVIII Part B Cost
							Part I, column 8,			(column 2 ÷	Title	Title XVIII	Title	Title	Title XVIII	Title
	Hospital Outpatient Services:						lines 88 through 93)			column 3)	V	Part B	XIX	V	Part B	XIX
21		Rural Health Clinic (RHC)						21	21								21
22		Federally Qualified Health Center (FQHC)						22	22								22
23		Clinic						23	23								23
24		Emergency						24	24								24
25		Observation beds						25	25								25
26		Other Outpatient Service (specify)						26	26								26
27	Subtotal (sum of lines 21 through 26)							27	27								27
28	Total (sum of lines 20 and 27)				100.00			28	28								28
PART II - IN AN APPROVED TEACHING PROGRAM (TITLE XVIII, PART B INPATIENT ROUTINE COSTS ONLY)									PART II - IN AN APPROVED TEACHING PROGRAM (TITLE XVIII, PART B INPATIENT ROUTINE COSTS ONLY)
					Expenses Allocated						Average Cost		Expenses
					to cost centers		Net Cost			Total	Per Day	Title XVIII	Applicable
					on Worksheet B, Part I	Swing Bed	(column 1 plus			Inpatient Days -	(column 3 ÷	Part B	to Title XVIII
					columns 21 and 22	Amount	column 2)			All Patients	column 4)	Inpatient Days	(col. 5 x col. 6)
	Hospital Inpatient Routine Services:				1	2	3			4	5	6	7
29		Adults & Pediatrics (general routine care)						29	29								29
30		Swing Bed - SNF						30	30								30
31		Swing Bed - NF						31	31								31
32		Intensive care unit						32	32								32
33		Coronary care unit						33	33								33
34		Burn Intensive Care Unit						34	34								34
35		Surgical Intensive Care Unit						35	35								35
36		Other Special Care (specify)						36	36								36
37	Subtotal (sum of lines 28, and 29 through 36)							37	37								37
38	IPF - Inpatient routine service							38	38								38
39	IRF - Inpatient routine service							39	39								39
40	Subprovider (Other)- Inpatient routine service							40	40								40
41	Skilled Nursing Facility							41	41								41
42	Total (sum of lines 37 through 41)							42	42								42
PART III - SUMMARY FOR TITLE XVIII (TO BE COMPLETED ONLY IF BOTH PARTS I AND II ARE USED)									PART III - SUMMARY FOR TITLE XVIII (TO BE COMPLETED ONLY IF BOTH PARTS I AND II ARE USED)
						Not In Approved Teaching Program				In Approved Teaching Program		Total Title XVIII Costs
						(from Part I)	Amount			(from Part II, col. 7)	Amount	(to Wkst. E, Part B)	(col. 2 + col. 4)
	Hospital					1	2			3	4	5	6
43	Inpatient					column 9, line 9		43	43	line 37							43
44	Outpatient					column 9, line 27		44	44								44
45	Total Hospital (sum of lines 43 and 44)							45	45			line 2					45
46	IPF - Inpatient routine service					column 9, line 10		46	46	line 38		line 2					46
47	IRF - Inpatient routine service					column 9, line 11		47	47	line 39		line 2					47
48	Subprovider (Other)- Inpatient routine service					column 9, line 12		48	48	line 40		line 2					48
49	Skilled Nursing Facility					column 9, line 13		49	49	line 41		line 2					49
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4026)									FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4026)
40-576								Rev.	Rev.								40-577

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Sheet 40: D3

4090 (Cont.)			FORM CMS-2552-10				DRAFT
INPATIENT ANCILLARY SERVICE				PROVIDER CCN:	PERIOD:	WORKSHEET D-3
COST APPORTIONMENT				________________	FROM ____________
				COMPONENT CCN:	TO _______________
				________________
Check		[ ] Title V	[ ] Hospital	[ ] Subprovider (other)	[ ] Swing-Bed SNF	[ ] PPS
applicable		[ ] Title XVIII, Part A	[ ] IPF	[ ] SNF	[ ] Swing-Bed NF	[ ] TEFRA
boxes:		[ ] Title XIX	[ ] IRF	[ ] NF	[ ] ICF/IID	[ ] Other
				Ratio of Cost	Inpatient	Inpatient Program Costs
	COST CENTER DESCRIPTION			to Charges	Program Charges	(col. 1 x col. 2)
(A)				1	2	3
	INPATIENT ROUTINE SERVICE COST CENTERS
30	Adults and Pediatrics (General Routine Care)						30
31	Intensive Care Unit						31
32	Coronary Care Unit						32
33	Burn Intensive Care Unit						33
34	Surgical Intensive Care Unit						34
35	Other Special Care (specify)						35
40	Subprovider IPF						40
41	Subprovider IRF						41
42	Subprovider (Specify)						42
43	Nursery						43
	ANCILLARY SERVICE COST CENTERS
50	Operating Room						50
51	Recovery Room						51
52	Labor Room and Delivery Room						52
53	Anesthesiology						53
54	Radiology-Diagnostic						54
55	Radiology-Therapeutic						55
56	Radioisotope						56
57	Computed Tomography (CT) Scan						57
58	Magnetic Resonance Imaging (MRI)						58
59	Cardiac Catheterization						59
60	Laboratory						60
61	PBP Clinical Laboratory Services-Prgm. Only						61
62	Whole Blood & Packed Red Blood Cells						62
63	Blood Storing, Processing, & Trans.						63
64	Intravenous Therapy						64
65	Respiratory Therapy						65
66	Physical Therapy						66
67	Occupational Therapy						67
68	Speech Pathology						68
69	Electrocardiology						69
70	Electroencephalography						70
71	Medical Supplies Charged to Patients						71
72	Implantable Devices Charged to Patients						72
73	Drugs Charged to Patients						73
74	Renal Dialysis						74
75	ASC (Non-Distinct Part)						75
76	Other Ancillary (specify)						76
	OUTPATIENT SERVICE COST CENTERS
88	Rural Health Clinic (RHC)						88
89	Federally Qualified Health Center (FQHC)						89
90	Clinic						90
91	Emergency						91
92	Observation Beds (see instructions)						92
93	Other Outpatient Service (specify)						93
	OTHER REIMBURSABLE COST CENTERS
94	Home Program Dialysis						94
95	Ambulance Services						95
96	Durable Medical Equipment-Rented						96
97	Durable Medical Equipment-Sold						97
98	Other Reimbursable (specify)						98
200	Total (sum of lines 50-94 and 96-98)						200
201	Less PBP Clinic Laboratory Services-Program only charges (line 61)						201
202	Net Charges (line 200 minus line 201)						202
(A) Worksheet A line numbers
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4027)
40-578							Rev.

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Sheet 41: D4I

09-14				FORM CMS-2552-10				4090 (Cont.)
COMPUTATION OF ORGAN ACQUISITION COSTS AND CHARGES					PROVIDER CCN:	PERIOD:	WORKSHEET D-4,
FOR HOSPITALS WHICH ARE CERTIFIED TRANSPLANT CENTERS					________________	FROM ____________	PART I
					OPO CCN:	TO _______________
					________________
Check		[ ] HEART	[ ] LIVER	[ ] PANCREAS		[ ] ISLET
applicable box:		[ ] KIDNEY	[ ] LUNG	[ ] INTESTINE
PART I - COMPUTATION OF ORGAN ACQUISITION COSTS (INPATIENT ROUTINE AND ANCILLARY SERVICES)
			Inpatient			Organ
Computation of Inpatient			Routine Organ		Per Diem Costs	Acquisition	Cost
Routine Service Costs			Charges		(from Wkst. D-1, Part II)	Days	(col. 2 x col. 3)
Applicable to Organ Acquisition			1	D	2	3	4
1	Adults and Pediatrics			38				1
2	Intensive Care			43				2
3	Coronary Care			44				3
4	Burn Intensive Care Unit			45				4
5	Surgical Intensive Care Unit			46				5
6	Other Special Care (specify)			47				6
7	TOTAL (sum of lines 1-6)							7
					Ratio of Cost	Organ	Organ
					to Charges	Acquisition	Acquisition
Computation of Ancillary					(from	Ancillary	Ancillary
Service Costs Applicable					Wkst. C)	Charges	Costs
to Organ Acquisition				C	1	2	3
8	Operating Room			50				8
9	Recovery Room			51				9
10	Labor Room & Delivery Room			52				10
11	Anesthesiology			53				11
12	Radiology-Diagnostic			54				12
13	Radiology-Therapeutic			55				13
14	Radioisotope			56				14
15	Computed Tomography (CT) Scan			57				15
16	Magnetic Resonance Imaging (MRI)			58				16
17	Cardiac Catheterization			59				17
18	Laboratory			60				18
19	PBP Clinical Laboratory Services-Program Only			61				19
20	Whole Blood & Packed Red Blood Cells			62				20
21	Blood Storage, Processing, & Transfusing			63				21
22	IV Therapy			64				22
23	Respiratory Therapy			65				23
24	Physical Therapy			66				24
25	Occupational Therapy			67				25
26	Speech Pathology			68				26
27	Electrocardiology			69				27
28	Electroencephalography			70				28
29	Medical Supplies Charged to Patients			71				29
30	Implantable Devices Charged to Patients			72				30
31	Drugs Charged to Patients			73				31
32	Renal Dialysis			74				32
33	ASC (non-distinct part)			75				33
34	Other Ancillary (specify)			76				34
35	Rural Health Clinic (RHC)			88				35
36	Federally Qualified Health Center (FQHC)			89				36
37	Clinic			90				37
38	Emergency Room			91				38
39	Observation Beds			92				39
40	Other Outpatient Service (specify)			93				40
41	TOTAL (sum of lines 8-40)							41
	C = Worksheet C line numbers		D = Worksheet D-1 line numbers
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4028.1)
Rev. 6								40-579

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Sheet 42: D4II

4090 (Cont.)			FORM CMS-2552-10					09-14
COMPUTATION OF ORGAN ACQUISITION COSTS AND CHARGES			PROVIDER CCN:		PERIOD:		WORKSHEET D-4,
FOR HOSPITALS WHICH ARE CERTIFIED TRANSPLANT CENTERS			________________		FROM ____________		PART II
			OPO CCN:		TO _______________
			________________
Check		[ ] HEART	[ ] LIVER		[ ] PANCREAS		[ ] ISLET
applicable box:		[ ] KIDNEY	[ ] LUNG		[ ] INTESTINE																				[ ] LIVER											[ ] HEART
PART II - COMPUTATION OF ORGAN ACQUISITION COSTS (OTHER THAN INPATIENT ROUTINE AND
	ANCILLARY SERVICE COSTS)
				Average Cost			Organ
	Computation of the Cost of Inpatient			Per Day			Acquisition
	Services of Interns and Residents Not			(from Wkst. D-2,	Organ		Costs
	In Approved Teaching Program			Part I, col. 4)	Acquisition Days		(col. 1 x col. 2)
			D	1	2		3													1									2									3
42	Adults & Pediatrics (General routine care)		2					42
43	Intensive Care Unit		3					43
44	Coronary Care Unit		4					44
45	Burn Intensive Care Unit		5					45
46	Surgical Intensive Care Unit		6					46
47	Other Special Care (specify)		7					47
48	TOTAL (sum of lines 42 through 47)							48
						Ratio of Cost	Organ
	Computation of the Cost of Outpatient		Organ			to Charges	Acquisition
	Services of Interns and Residents Not		Charges			from Wkst. D-2,	Costs
	In Approved Teaching Program		(see instructions)			Part I, col. 4)	(col. 1 x col. 2)																				Ratio of Cost
			1		D	2	3
49	Rural Health Clinic (RHC)				21			49																		Supp. Wkst. D-2,
50	Federally Qualified Health Center (FQHC)				22			50												1								2										3
51	Clinic				23			51
52	Emergency				24			52
53	Observation Beds				25			53
54	Other Outpatient Service (specify)				26			54
55	TOTAL (sum of lines 49 through 54)							55
D = Worksheet D-2, Part I, line numbers
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4028.2)
40-580								Rev. 6
								\

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Sheet 43: D4III

09-14			FORM CMS-2552-10				4090 (Cont.)
COMPUTATION OF ORGAN ACQUISITION COSTS AND CHARGES				PROVIDER CCN:	PERIOD:	WORKSHEET D-4,
FOR HOSPITALS WHICH ARE CERTIFIED TRANSPLANT CENTERS				________________	FROM ____________	PARTS III & IV
				OPO CCN:	TO _______________
				________________
Check		[ ] HEART	[ ] LIVER	[ ] PANCREAS	[ ] ISLET
applicable box:		[ ] KIDNEY	[ ] LUNG	[ ] INTESTINE
PART III - SUMMARY OF COSTS AND CHARGES
			Cost		Charges
			Part A	Part B	Part A	Part B
			1	2	3	4
56	Routine and Ancillary from Part I						56
57	Interns and Residents (inpatient)						57
58	Interns and Residents (outpatient)						58
59	Direct Organ Acquisition (see instructions)						59
60	Cost of physicians' services in a teaching						60
	hospital (see instructions)
61	Total (sum of lines 56 thru 60)						61
62	Total Usable Organs (see instructions)						62
63	Medicare Usable Organs (see instructions)						63
64	Ratio of Medicare Usable Organs to Total Usable						64
	Organs (line 63 ÷ line 62)
65	Medicare Cost/Charges (see instructions)						65
66	Revenue for Organs Sold						66
67	Subtotal (line 65 minus line 66)						67
68	Organs Furnished Part B						68
69	Net Organ Acquisition Cost and Charges (see instructions)						69
PART IV - STATISTICS
				Living Related	Cadaveric	Revenue
				1	2	3
70	Organs Excised in Provider (1)						70
71	Organs Purchased from Other Transplant Hospitals (2)						71
72	Organs Purchased from Non-Transplant Hospitals						72
73	Organs Purchased from OPOs						73
74	Total (sum of lines 70 thru 73)						74
75	Organs Transplanted						75
76	Organs Sold to Other Hospitals						76
77	Organs Sold to OPOs						77
78	Organs Sold to Transplant Hospitals						78
79	Organs Sold to Military or VA Hospitals						79
80	Organs Sold Outside the U.S.						80
81	Organs Sent Outside the U.S. (no revenue received)						81
82	Organs Used for Research						82
83	Unusable/Discarded Organs						83
84	Total (sum of lines 75 through 83 should equal line 74)						84
(1)	Organs procured outside your center by a procurement team from your center are not included in the count.
(2)	Organs procured outside your center by a procurement team from your center are included in the count.
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4028.3)
Rev. 6							40-581
																										{EDIT}{HOME}{R}{DEL}{D}

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Sheet 44: D5I

4090 (Cont.)				FORM CMS-2552-10					09-14
APPORTIONMENT OF COST FOR PHYSICIANS' SERVICES IN A TEACHING HOSPITAL						PROVIDER CCN:	PERIOD:	WORKSHEET D-5,
							FROM ____________	PART I
						________________	TO _______________
Check applicable box:		[ ] Hospital Staff [ ] Medical Staff
PART I - REASONABLE COMPENSATION EQUIVALENT COMPUTATION FOR COST REPORTING PERIODS ENDING BEFORE JUNE 30, 2014
						Physician/		5 Percent
Line	Specialty		Total	Professional	RCE	Professional	Unadjusted	of Unadjusted
No.	Description/Physician Identifier		Remuneration	Component	Amount	Component Hours	RCE Limit	RCE Limit
1	2		3	4	5	6	7	8
1	General Practitioner Family Practice								1
2	Internal Medicine								2
3	Surgery								3
4	Pediatrics								4
5	Obstetrics-Gynecology								5
6	Radiology								6
7	Psychiatry								7
8	Anesthesiology								8
9	Pathology								9
10	All Other								10
11	Total								11
			Cost of		Cost of			Adjust Cost
			Membership	Professional	Physician	Professional		of Physician's
Line	Specialty		& Continuing	Component	Malpractice	Component	Adjusted	Direct Medical &
No.	Description/Physician Identifier		Education	Share of col. 11	Insurance	Share of col. 13	RCE Limit	Surgical Services
9	10		11	12	13	14	15	16
1	General Practitioner Family Practice								1
2	Internal Medicine								2
3	Surgery								3
4	Pediatrics								4
5	Obstetrics-Gynecology								5
6	Radiology								6
7	Psychiatry								7
8	Anesthesiology								8
9	Pathology								9
10	All Other								10
11	Total (transfer the amount in column 16, line 11, to								11
	Part II, line 1, column 1 or 2, as appropriate)
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4029.1)
40-582									Rev. 6

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Sheet 45: D5II

09-14		FORM CMS-2552-10				4090 (Cont.)
APPORTIONMENT OF COST FOR PHYSICIANS' SERVICES IN A TEACHING HOSPITAL			PROVIDER CCN:	PERIOD:	WORKSHEET D-5,																								.
				FROM ____________	PART II
			________________	TO _______________
Check		[ ] Hospital	[ ] IPF
applicable box:		[ ] IRF
PART II - APPORTIONMENT OF COST FOR PHYSICIANS' SERVICES IN A TEACHING HOSPITAL FOR COST REPORTING PERIODS ENDING BEFORE JUNE 30, 2014
				Medical School	Total
			Hospital Staff	Faculty	(col 1 + col 2)
			1	2	3
1	Adjusted Cost of Physician's Direct Medical and Surgical Services					1
2	Total Inpatient Days and Outpatient Visit Days					2
3	Average Per Diem (line 1 ÷ line 2)					3
	HEALTH CARE PROGRAM REIMBURSABLE DAYS
4	Title V - Inpatient					4
5	Title V - Outpatient					5
6	Title XVIII - Part A					6
7	Title XVIII - Part B					7
8	Title XIX - Inpatient					8
9	Title XIX - Outpatient					9
10	Inpatient and Outpatient Kidney Acquisition					10
11	Inpatient and Outpatient Liver Acquisition					11
12	Inpatient and Outpatient Heart Acquisition					12
13	Inpatient and Outpatient Lung Acquisition					13
14	Inpatient and Outpatient Pancreas Acquisition					14
15	Inpatient and Outpatient Intestine Acquisition					15
16	Inpatient and Outpatient Islet Acquisition					16
17	Other Organ Acquisition					17
	HEALTH CARE PROGRAM REIMBURSABLE COST
18	Title V - Inpatient (line 3 x line 4)					18
19	Title V - Outpatient (line 3 x line 5)					19
20	Title XVIII - Part A (line 3 x line 6)					20
21	Title XVIII - Part B (line 3 x line 7)					21
22	Title XIX - Inpatient (line 3 x line 8)					22
23	Title XIX - Outpatient (line 3 x line 9)					23
24	Inpatient and Outpatient Kidney Acquisition (line 3 x line 10)					24
25	Inpatient and Outpatient Liver Acquisition (line 3 x line 11)					25
26	Inpatient and Outpatient Heart Acquisition (line 3 x line 12)					26
27	Inpatient and Outpatient Lung Acquisition (line 3 x line 13)					27
28	Inpatient and Outpatient Pancreas Acquisition (line 3 x line 14)					28
29	Inpatient and Outpatient Intestine Acquisition (line 3 x line 15)					29
30	Inpatient and Outpatient Islet Acquisition (line 3 x line 16)					30
31	Inpatient and Outpatient Other Organ Acquisition (line 3 x line 17)					31
	Transfer the amounts in column 3 as follows:
	Add lines 18 and 19, and transfer to Worksheet E-3, Part VII
	Line 20 to Worksheet E, Part A, or Worksheet E-3, Part I to IV as appropriate
	Line 21 to Worksheet E, Part B
	Add lines 22 and 23, and transfer to Worksheet E-3, Part VII, as appropriate
	Sum of lines 24 through 30 to Worksheet D-4, Part III, line 60
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4029.2)
Rev. 6						40-583

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Sheet 46: D5III

4090 (Cont.)					FORM CMS-2552-10					09-14
APPORTIONMENT OF COST FOR PHYSICIANS' SERVICES IN A TEACHING HOSPITAL							PROVIDER CCN:	PERIOD:	WORKSHEET D-5,
								FROM ____________	PART III
							________________	TO _______________
PART III - REASONABLE COMPENSATION EQUIVALENT COMPUTATION FOR COST REPORTING PERIODS ENDING ON OR AFTER JUNE 30, 2014
		Cost Center / Physician Identifier					Physician/		5 Percent
	Wkst. A			Total	Professional	RCE	Professional	Unadjusted	of Unadjusted
	Line #			Remuneration	Component	Amount	Component Hours	RCE Limit	RCE Limit
	1	2		3	4	5	6	7	8
1										1
2										2
3										3
4										4
5										5
6										6
7										7
8										8
9										9
10										10
200		Total								200
		Cost Center / Physician Identifier		Cost of		Cost of			Adjust Cost
				Membership	Professional	Physician	Professional		of Physician's
	Wkst. A			& Continuing	Component	Malpractice	Component	Adjusted	Direct Medical &
	Line #			Education	Share of Column 11	Insurance	Share of Column 13	RCE Limit	Surgical Services
	9	10		11	12	13	14	15	16
1										1
2										2
3										3
4										4
5										5
6										6
7										7
8										8
9										9
10										10
200		Total (transfer the amount in column 16, line 200, to Part IV, line 1)								200
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4029.3)
40-583.1										Rev. 6

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Sheet 47: D5IV

09-14				FORM CMS-2552-10				4090 (Cont.)
APPORTIONMENT OF COST FOR PHYSICIANS' SERVICES IN A TEACHING HOSPITAL					PROVIDER CCN:	PERIOD:	WORKSHEET D-5,
						FROM ____________	PART IV
					________________	TO _______________
Check applicable box:		[ ] Hospital	[ ] IPF	[ ] IRF
PART IV - APPORTIONMENT OF COST FOR PHYSICIANS' SERVICES IN A TEACHING HOSPITAL FOR COST REPORTING PERIODS ENDING ON OR AFTER JUNE 30, 2014
1	Adjusted cost of physicians' direct medical and surgical services							1
2	Total inpatient days and outpatient visit days							2
3	Average per diem (line 1 ÷ line 2)							3
	HEALTH CARE PROGRAM REIMBURSABLE DAYS
4	Title V - Inpatient							4
5	Title V - Outpatient							5
6	Title XVIII - Part A							6
7	Title XVIII - Part B							7
8	Title XIX - Inpatient							8
9	Title XIX - Outpatient							9
10	Inpatient and outpatient kidney acquisition							10
11	Inpatient and outpatient liver acquisition							11
12	Inpatient and outpatient heart acquisition							12
13	Inpatient and outpatient lung acquisition							13
14	Inpatient and outpatient pancreas acquisition							14
15	Inpatient and outpatient intestine acquisition							15
16	Inpatient and autpatient islet acquisition							16
17								17
	HEALTH CARE PROGRAM REIMBURSABLE COST
18	Title V - Inpatient (line 3 x line 4)							18
19	Title V - Outpatient (line 3 x line 5)							19
20	Title XVIII - Part A (line 3 x line 6)							20
21	Title XVIII - Part B (line 3 x line 7)							21
22	Title XIX - Inpatient (line 3 x line 8)							22
23	Title XIX - Outpatient (line 3 x line 9)							23
24	Inpatient and outpatient kidney acquisition (line 3 x line 10)							24
25	Inpatient and outpatient liver acquisition (line 3 x line 11)							25
26	Inpatient and outpatient heart acquisition (line 3 x line 12)							26
27	Inpatient and outpatient lung acquisition (line 3 x line 13)							27
28	Inpatient and outpatient pancreas acquisition (line 3 x line 14)							28
29	Inpatient and outpatient intestine acquisition (line 3 x line 15)							29
30	Inpatient and outpatient islet acquisition (line 3 x line 16)							30
31								31
	Transfer amounts as follows:
	Add lines 18 and 19, and transfer to Worksheet E-3, Part VII, line 20 (title V hospital or component)
	Line 20 to Worksheet E, Part A, line 56 (Medicare IPPS); Worksheet E-3, Part I, line 3 (TEFRA); Worksheet E-3, Part II, line 15 (IPF);
	Worksheet E-3, Part III, line 16 (IRF); Worksheet E-3, Part IV, line 6 (LTCH); or, Worksheet E-3, Part V, line 17 (Cost reimbursement)
	Line 21 to Worksheet E, Part B , line 23 (Medicare Part B Medical and Other Health Services)
	Add lines 22 and 23, and transfer to Worksheet E-3, Part VII, line 20 (title XIX hospital or component)
	Sum of lines 24 through 30 to Worksheet D-4, Part III, line 60
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4029.4)
Rev. 6								40-583.2

---

Sheet 48: EA

4090 (Cont.)				FORM CMS-2552-10				09-14
CALCULATION OF REIMBURSEMENT					PROVIDER CCN:	PERIOD:	WORKSHEET E,
SETTLEMENT					________________	FROM ___________	PART A
					COMPONENT CCN:	TO ______________
					________________
PART A - INPATIENT HOSPITAL SERVICES UNDER PPS
1	DRG amounts other than outlier payments							1
1.01	DRG amounts other than outlier payments for discharges occurring prior to October 1, 2013 (see instructions)							1.01
1.02	DRG amounts other than outlier payments for discharges occurring on or after October 1, 2013 (see instructions)							1.02
1.03	DRG for federal specific operating payment for Model 4 BPCI (see instructions)							1.03
2	Outlier payments for discharges (see instructions)							2
2.01	Outlier reconciliation amount							2.01
2.02	Outlier payment for discharges for Model 4 BPCI (see instructions)							2.02
3	Managed care simulated payments							3
4	Bed days available divided by number of days in the cost reporting period (see instructions)							4
	Indirect Medical Education Adjustment Calculation for Hospitals
5	FTE count for allopathic and osteopathic programs for the most recent cost reporting period ending on or							5
	before 12/31/1996 (see instructions)
6	FTE count for allopathic and osteopathic programs which meet the criteria for an add-on to the cap for new programs in							6
	in accordance with 42 CFR 413.79(e)
7	MMA Section 422 reduction amount to the IME cap as specified under 42 CFR §412.105(f)(1)(iv)(B)(1)							7
7.01	ACA Section 5503 reduction amount to the IME cap as specified under 42 CFR §412.105(f)(1)(iv)(B)(2)							7.01
	If the cost report straddles July 1, 2011 then see instructions.
8	Adjustment (increase or decrease) to the FTE count for allopathic and osteopathic programs for affiliated programs in accordance							8
	with 42 CFR 413.75(b), 413.79(c)(2)(iv) and Vol. 64 Federal Register, May 12, 1998, page 26340 and Vol. 67 Federal Register,
	page 50069, August 1, 2002.
8.01	The amount of increase if the hospital was awarded FTE cap slots under section 5503 of the ACA.							8.01
	If the cost report straddles July 1, 2011, see instructions.
8.02	The amount of increase if the hospital was awarded FTE cap slots from a closed teaching hospital under							8.02
	section 5506 of ACA. (see instructions)
9	Sum of lines 5 plus 6 minus lines (7 and 7.01) plus/minus line 8 plus lines (8.01 and 8.02) (see instructions)							9
10	FTE count for allopathic and osteopathic programs in the current year from your records							10
11	FTE count for residents in dental and podiatric programs							11
12	Current year allowable FTE (see instructions)							12
13	Total allowable FTE count for the prior year							13
14	Total allowable FTE count for the penultimate year if that year ended on or after September 30, 1997, otherwise enter zero.							14
15	Sum of lines 12 through 14 divided by 3							15
16	Adjustment for residents in initial years of the program							16
17	Adjustment for residents displaced by program or hospital closure							17
18	Adjusted rolling average FTE count							18
19	Current year resident to bed ratio (line 18 divided by line 4)							19
20	Prior year resident to bed ratio (see instructions)							20
21	Enter the lesser of lines 19 or 20 (see instructions)							21
22	IME payment adjustment (see instructions)							22
	Indirect Medical Education Adjustment for the Add-on for Section 422 of the MMA
23	Number of additional allopathic and osteopathic IME FTE resident cap slots under 42 Sec. 412.105 (f)(1)(iv)(C ).							23
24	IME FTE resident count over cap (see instructions)							24
25	If the amount on line 24 is greater than -0-, then enter the lower of line 23 or line 24 (see instructions)							25
26	Resident to bed ratio (divide line 25 by line 4)							26
27	IME payments adjustment factor (see instructions)							27
28	IME add-on adjustment amount (see instructions)							28
29	Total IME payment (sum of lines 22 and 28)							29
	Disproportionate Share Adjustment
30	Percentage of SSI recipient patient days to Medicare Part A patient days (see instructions)							30
31	Percentage of Medicaid patient days to total patient days (see instructions)							31
32	Sum of lines 30 and 31							32
33	Allowable disproportionate share percentage (see instructions)							33
34	Disproportionate share adjustment (see instructions)							34
	Uncompensated Care Adjustment					Prior to October 1	On or after October 1
35	Total uncompensated care amount (see instructions)							35
35.01	Factor 3 (see instructions)							35.01
35.02	Hospital uncompensated care payment (If line 34 is zero, enter zero on this line) (see instructions)							35.02
35.03	Pro rata share of the hospital uncompensated care payment amount (see instructions)							35.03
36	Total uncompensated care (sum of columns 1 and 2 on line 35.03)							36
FORM CMS-2552-10 (03-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4030.1)
40-584								Rev. 6
09-14				FORM CMS-2552-10				4090 (Cont.)
CALCULATION OF REIMBURSEMENT					PROVIDER CCN:	PERIOD:	WORKSHEET E,
SETTLEMENT					________________	FROM ___________	PART A (Cont.)
					COMPONENT CCN:	TO ______________
					________________
PART A - INPATIENT HOSPITAL SERVICES UNDER PPS
	Additional payment for high percentage of ESRD beneficiary discharges
40	Total Medicare discharges, excluding discharges for MS-DRGs 652, 682, 683, 684 and 685 (see instructions)							40
41	Total ESRD Medicare discharges excluding MS-DRGs 652, 682, 683, 684 an 685 (see instructions)							41
41.01	Total ESRD Medicare covered and paid discharges excluding MS-DRGs 652, 682, 683, 684, and 685 (see instructions)							41.01
42	Divide line 41 by line 40 (if less than 10%, you do not qualify for adjustment)							42
43	Total Medicare ESRD inpatient days excluding MS-DRGs 652, 682, 683, 684 and 685 (see instructions)							43
44	Ratio of average length of stay to one week (line 43 divided by line 41.01 divided by 7 days)							44
45	Average weekly cost for dialysis treatments (see instructions)							45
46	Total additional payment (line 45 times line 44 times line 41.01)							46
47	Subtotal (see instructions)							47
48	Hospital specific payments (to be completed by SCH and MDH, small rural hospitals only (see instructions)							48
49	Total payment for inpatient operating costs SCH and MDH only (see instructions)							49
50	Payment for inpatient program capital (from Worksheet L, Parts I, II, as applicable)							50
51	Exception payment for inpatient program capital (Worksheet L, Part III) (see instructions)							51
52	Direct graduate medical education payment (from Worksheet E-4, line 49) (see instructions).							52
53	Nursing and allied health managed care payment							53
54	Special add-on payments for new technologies							54
55	Net organ acquisition cost (Worksheet D-4 Part III, col. 1, line 69)							55
56	Cost of physicians' services in a teaching hospital (see instructions)							56
57	Routine service other pass through costs (from Wkst D, Part III, column 9, lines 30 through 35).							57
58	Ancillary service other pass through costs (from Worksheet D, Part IV, col. 11, line 200)							58
59	Total (sum of amounts on lines 49 through 58)							59
60	Primary payer payments							60
61	Total amount payable for program beneficiaries (line 59 minus line 60)							61
62	Deductibles billed to program beneficiaries							62
63	Coinsurance billed to program beneficiaries							63
64	Allowable bad debts (see instructions)							64
65	Adjusted reimbursable bad debts (see instructions)							65
66	Allowable bad debts for dual eligible beneficiaries (see instructions)							66
67	Subtotal (line 61 plus line 65 minus lines 62 and 63)							67
68	Credits received from manufacturers for replaced devices applicable to MS-DRG (see instructions)							68
69	Outlier payments reconciliation (sum of lines 93, 95 and 96) (for SCH see instructions)							69
70	Other adjustments (specify) (see instructions)							70
70.92	Bundled Model 1 discount amount							70.92
70.93	HVBP payment adjustment (see instructions)							70.93
70.94	Hospital readmissions reduction adjustment (see instructions)							70.94
70.95	Recovery of accelerated depreciation							70.95
70.96	Low volume adjustment for federal fiscal year (yyyy)							70.96
70.97	Low volume adjustment for federal fiscal year (yyyy)							70.97
71	Amount due provider (see instructions)							71
71.01	Sequestration adjustment (see instructions)							71.01
72	Interim payments							72
73	Tentative settlement (for contractor use only)							73
74	Balance due provider (Program) line 71 minus lines 71.01, 72 and 73							74
75	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2							75
	TO BE COMPLETED BY CONTRACTOR
90	Operating outlier amount from Worksheet E, Part A line 2 (see instructions).							90
91	Capital outlier from Worksheet L, Part I, line 2							91
92	Operating outlier reconciliation adjustment amount (see instructions)							92
93	Capital outlier reconciliation adjustment amount (see instructions)							93
94	The rate used to calculate the fime value of money (see instructions)							94
95	Time value of money for operating expenses (see instructions)							95
96	Time value of money for capital related expenses (see instructions)							96
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4030.1)
Rev. 6								40-585

---

Sheet 49: EB

4090 (Cont.)			FORM CMS-2552-10				09-14
CALCULATION OF				PROVIDER CCN:	PERIOD:	WORKSHEET E,
REIMBURSEMENT SETTLEMENT				________________	FROM ____________	PART B
				COMPONENT CCN:	TO _______________
				________________
Check applicable box:		[ ] Hospital [ ] IPF [ ] IRF [ ] Subprovider (Other) [ ] SNF
PART B - MEDICAL AND OTHER HEALTH SERVICES
1	Medical and other services (see instructions)						1
2	Medical and other services reimbursed under OPPS (see instructions).						2
3	PPS payments						3
4	Outlier payment (see instructions)						4
5	Enter the hospital specific payment to cost ratio (see instructions)						5
6	Line 2 times line 5						6
7	Sum of line 3 and line 4 divided by line 6						7
8	Transitional corridor payment (see instructions)						8
9	Ancillary service other pass through costs from Worksheet D, Part IV, column 13, line 200						9
10	Organ acquisition						10
11	Total cost (sum of lines 1 and 10) (see instructions)						11
	COMPUTATION OF LESSER OF COST OR CHARGES
	Reasonable charges
12	Ancillary service charges						12
13	Organ acquisition charges (from Worksheet D-4, Part III, line 69, col. 4)						13
14	Total reasonable charges (sum of lines 12 and 13)						14
	Customary charges
15	Aggregate amount actually collected from patients liable for payment for services on a charge basis						15
16	Amounts that would have been realized from patients liable for payment for services on a charge						16
	basis had such payment been made in accordance with 42 CFR §413.13(e)
17	Ratio of line 15 to line 16 (not to exceed 1.000000)						17
18	Total customary charges (see instructions)						18
19	Excess of customary charges over reasonable cost (complete only if line 18 exceeds line 11) (see instructions)						19
20	Excess of reasonable cost over customary charges (complete only if line 11 exceeds line 18) (see instructions)						20
21	Lesser of cost or charges (line 11 minus line 20) (for CAH, see instructions)						21
22	Interns and residents (see instructions)						22
23	Cost of physicians' services in a teaching hospital (see instructions)						23
24	Total prospective payment (sum of lines 3, 4, 8 and 9)						24
	COMPUTATION OF REIMBURSEMENT SETTLEMENT
25	Deductibles and coinsurance (see instructions)						25
26	Deductibles and Coinsurance relating to amount on line 24 (see instructions)						26
27	Subtotal [(lines 21 and 24 - the sum of lines 25 and 26) plus the sum of lines 22 and 23] (see instructions)						27
28	Direct graduate medical education payments (from Worksheet E-4, line 50)						28
29	ESRD direct medical education costs (from Worksheet E-4, line 36)						29
30	Subtotal (sum of lines 27 through 29)						30
31	Primary payer payments						31
32	Subtotal (line 30 minus line 31)						32
	ALLOWABLE BAD DEBTS (EXCLUDE BAD DEBTS FOR PROFESSIONAL SERVICES)
33	Composite rate ESRD (from Worksheet I-5, line 11)						33
34	Allowable bad debts (see instructions)						34
35	Adjusted reimbursable bad debts (see instructions)						35
36	Allowable bad debts for dual eligible beneficiaries (see instructions)						36
37	Subtotal (see instructions)						37
38	MSP-LCC reconciliation amount from PS&R						38
39	Other adjustments (specify) (see instructions)						39
39.98	Partial or full credits received from manufacturers for replaced devices (see instructions)						39.98
39.99	Recovery of Accelerated depreciation						39.99
40	Subtotal (see instructions)						40
40.01	Sequestration adjustment (see instructions)						40.01
41	Interim payments						41
42	Tentative settlement (for contractors use only)						42
43	Balance due provider/program (see instructions)						43
44	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2						44
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4030.2)
40-586							Rev. 6
10-12			FORM CMS-2552-10				4090 (Cont.)
CALCULATION OF				PROVIDER CCN:	PERIOD:	WORKSHEET E,
REIMBURSEMENT SETTLEMENT				________________	FROM ____________	PART B (Cont.)
				COMPONENT CCN:	TO _______________
				________________
Check applicable box		[ ] Hospital [ ] IPF [ ] IRF [ ] Subprovider(Other) [ ] SNF
PART B - MEDICAL AND OTHER HEALTH SERVICES
	TO BE COMPLETED BY CONTRACTOR
90	Original outlier amount (see instructions)						90
91	Outlier reconciliation adjustment amount (see instructions)						91
92	The rate used to calculate the Time Value of Money						92
93	Time Value of Money (see instructions)						93
94	Total (sum of lines 91 and 93)						94
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4030.2)
Rev. 3							40-587

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Sheet 50: E1

4090 (Cont.)				FORM CMS-2552-10					10-12
ANALYSIS OF PAYMENTS TO PROVIDERS			PROVIDER CCN:			PERIOD:		WORKSHEET E-1,
FOR SERVICES RENDERED			________________			FROM ____________		PART I
			COMPONENT CCN:			TO _______________
			________________
Check		[ ] Hospital [ ] Subprovider (Other)			Inpatient
applicable		[ ] IPF [ ] SNF			Part A		Part B
box:		[ ] IRF [ ] Swing-Bed SNF			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 or to be submitted to the intermediary								2
	for services rendered in the cost reporting period. If none, write "NONE" or enter a zero
3	List separately each retroactive			.01					3.01
	lump sum adjustment amount based			.02					3.02
	on subsequent revision of the		Program to	.03					3.03
	interim rate for the cost reporting period.		Provider	.04					3.04
	Also show date of each payment.			.05					3.05
	If none, write "NONE" or enter a zero. (1)			.50					3.50
				.51					3.51
			Provider 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. E or Wkst. E-3, line
	and column as appropriate)
	TO BE COMPLETED BY CONTRACTOR
5	List separately each tentative settlement		Program to	.01					5.01
	payment after desk review. Also show		Provider	.02					5.02
	date of each payment.			.03					5.03
	If none, write "NONE" or enter a zero. (1)			.50					5.50
			Provider 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	Determined 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		NPR Date (Month/Day/Year)		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-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4031)
40-588									Rev. 3

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Sheet 51: E1II

09-13				FORM CMS-2552-10				4090 (Cont.)
CALCULATION OF REIMBURSEMENT					PROVIDER CCN:	PERIOD:	WORKSHEET E-1,
SETTLEMENT FOR HIT					________________	FROM ____________	PART II
					COMPONENT CCN:	TO _______________
					________________
Check			[ ] Hospital	[ ] CAH
Applicable box:
TO BE COMPLETED BY CONTRACTOR FOR NONSTANDAD COST REPORTS
HEALTH INFORMATION TECHNOLOGY DATA COLLECTION AND CALCULATION
1	Total hospital discharges as defined in ARRA §4102 from Wkst S-3, Part I, column 15, line 14							1
2	Medicare days from Wkst S-3, Part I, column 6, sum of lines 1, 8-12							2
3	Medicare HMO days from Wkst S-3, Part I, column 6, line 2							3
4	Total inpatient days from S-3, Part I, column 8, sum of lines 1, 8-12							4
5	Total hospital charges from Wkst C, Part I, column 8, line 200							5
6	Total hospital charity care charges from Wkst S-10, column 3, line 20							6
7	CAH only - The reasonable cost incurred for the purchase of certified HIT technology from Worksheet S-2, Part I line 168							7
8	Calculation of the HIT incentive payment (see instructions)							8
9	Sequestration adjustment amount (see instructions)							9
10	Calculation of the HIT incentive payment after sequestration (see instructions)							10
INPATIENT HOSPITAL SERVICES UNDER PPS & CAH
30	Initial/interim HIT payment(s).							30
31	Initial/interim HIT payment adjustments (see instructions)							31
32	Balance due provider (line 8 (or line 10) minus line 30 and line 31) (see instructions)							32
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4031.1)
Rev. 4								40-589

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Sheet 52: E2

4090(Cont.)			FORM CMS-2552-10				09-13
CALCULATION OF REIMBURSEMENT				PROVIDER CCN:	PERIOD:	WORKSHEET E-2
SETTLEMENT - SWING BEDS				________________	FROM ____________
				COMPONENT CCN:	TO _______________
				________________
Check		[ ] Title V	[ ] Swing Bed - SNF
applicable		[ ] Title XVIII	[ ] Swing Bed - NF
boxes:		[ ] Title XIX
					PART A	PART B
	COMPUTATION OF NET COST OF COVERED SERVICES				1	2
1	Inpatient routine services - swing bed-SNF (see instructions)						1
2	Inpatient routine services - swing bed-NF (see instructions)						2
3	Ancillary services (from Wkst. D-3, column 3, line 200 for Part A, and sum of Wkst. D, Part V,						3
	columns 5 and 7, line 202 for Part B) (For CAH, see instructions)
4	Per diem cost for interns and residents not in approved teaching program (see instructions)						4
5	Program days						5
6	Interns and residents not in approved teaching program (see instructions)						6
7	Utilization review - physician compensation - SNF optional method only						7
8	Subtotal (sum of lines 1 through 3 plus lines 6 and 7)						8
9	Primary payer payments (see instructions)						9
10	Subtotal (line 8 minus line 9)						10
11	Deductibles billed to program patients (exclude amounts applicable to physician professional						11
	services)
12	Subtotal (line 10 minus line 11)						12
13	Coinsurance billed to program patients (from provider records) (exclude coinsurance for						13
	physician professional services)
14	80% of Part B costs (line 12 x 80%)						14
15	Subtotal (enter the lesser of line 12 minus line 13, or line 14)						15
16	Other adjustments (specify) (see instructions)						16
17	Allowable bad debts (see instructions)						17
17.01	Adjusted reimbursable bad debts (see instructions)						17.01
18	Allowable bad debts for dual eligible beneficiaries (see instructions)						18
19	Total (see instructions)						19
19.01	Sequestration adjustment (see instructions)						19.01
20	Interim payments						20
21	Tentative settlement (for contractor use only)						21
22	Balance due provider/program line 19 minus lines 19.01, 20 and 21						22
23	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2,						23
	section 115.2
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4032)
40-590							Rev. 4

---

Sheet 53: E3I

09-14		FORM CMS-2552-10				4090 (Cont.)
CALCULATION OF REIMBURSEMENT SETTLEMENT			PROVIDER CCN:	PERIOD:	WORKSHEET E-3,
				FROM ____________	PART I
				TO _______________
			________________
PART I - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER - TEFRA
1	Inpatient hospital services (see instructions)					1
2	Organ acquisition					2
3	Cost of physicians' services in a teaching hospital (see instructions)					3
4	Subtotal (sum of lines 1 thru 3)					4
5	Primary payer payments					5
6	Subtotal (line 4 less line 5).					6
7	Deductibles					7
8	Subtotal (line 6 minus line 7)					8
9	Coinsurance					9
10	Subtotal (line 8 minus line 9)					10
11	Allowable bad debts (exclude bad debts for professional services) (see instructions)					11
12	Adjusted reimbursable bad debts (see instructions)					12
13	Allowable bad debts for dual eligible beneficiaries (see instructions)					13
14	Subtotal (sum of lines 10 and 12)					14
15	Direct graduate medical education payments (from Worksheet E-4, line 49)					15
16	Other pass through costs (see instructions). DO NOT USE THIS LINE.					16
17	Other adjustments (specify) (see instructions)					17
18	Total amount payable to the provider (see instructions)					18
18.01	Sequestration adjustment (see instructions)					18.01
19	Interim payments					19
20	Tentative settlement (for contractor use only)					20
21	Balance due provider/program line 18 minus lines 18.01, 19 and 20					21
22	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2					22
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.1)
Rev. 6						40-591

---

Sheet 54: E3II

4090 (Cont.)		FORM CMS-2552-10				09-14
CALCULATION OF REIMBURSEMENT SETTLEMENT			PROVIDER CCN:	PERIOD:	WORKSHEET E-3,
			________________	FROM __________	PART II
			COMPONENT CCN:	TO _____________
			________________
Check		[ ] Hospital
applicable		[ ] Subprovider IPF
box:
PART II - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER IPF PPS
1	Net Federal IPF PPS payment (excluding outlier, ECT, and medical education payments)					1
2	Net IPF PPS Outlier payment					2
3	Net IPF PPS ECT payment					3
4	Unweighted intern and resident FTE count in the most recent cost report filed on or before November 15, 2004 (see instructions)					4
4.01	Cap increases for the unweighted intern and resident FTE count for residents that were displaced by program or hospital closure,					4.01
	that would not be counted without a temporary cap adjustment under §412.424(d)(1)(iii)(F)(1) or (2) (see instructions)
5	New teaching program adjustment (see instructions)					5
6	Current year unweighted FTE count of I&R excluding FTEs in the new program growth period					6
	of a "new teaching program (see isntructions)
7	Current year unweighted I&R FTE count for residents within the new program growth period					7
	of a "new teaching program (see isntructions)
8	Intern and resident count for IPF PPS medical education adjustment (see instructions)					8
9	Average daily census (see instructions)					9
10	Teaching Adjustment Factor {((1 + (line 8/line 9)) raised to the power of .5150 -1}.					10
11	Teaching Adjustment (line 1 multiplied by line 10).					11
12	Adjusted Net IPF PPS Payments (sum of lines 1, 2, 3 and 11)					12
13	Nursing and allied health managed care payment (see instruction)					13
14	Organ acquisition DO NOT USE THIS LINE					14
15	Cost of physicians' services in a teaching hospital (see instructions)					15
16	Subtotal (see instructions)					16
17	Primary payer payments					17
18	Subtotal (line 16 less line 17).					18
19	Deductibles					19
20	Subtotal (line 18 minus line 19)					20
21	Coinsurance					21
22	Subtotal (line 20 minus line 21)					22
23	Allowable bad debts (exclude bad debts for professional services) (see instructions)					23
24	Adjusted reimbursable bad debts (see instructions)					24
25	Allowable bad debts for dual eligible beneficiaries (see instructions)					25
26	Subtotal (sum of lines 22 and 24)					26
27	Direct graduate medical education payments (from Worksheet E-4, line 49) (For freestanding IPF only)					27
28	Other pass through costs (see instructions)					28
29	Outlier payments reconciliation					29
30	Other adjustments (specify) (see instructions)					30
31	Total amount payable to the provider (see instructions)					31
31.01	Sequestration adjustment (see instructions)					31.01
32	Interim payments					32
33	Tentative settlement (for contractor use only)					33
34	Balance due provider/program line 31 minus lines 31.01, 32 and 33					34
35	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2					35
	TO BE COMPLETED BY CONTRACTOR
50	Original outlier amount from Worksheet E-3, Part II, line 2 (see instructions)					50
51	Outlier reconciliation adjustment amount (see instructions)					51
52	The rate used to calculate the Time Value of Money (see instructions)					52
53	Time Value of Money (see instructions)					53
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.2)
40-592						Rev. 6

---

Sheet 55: E3III

09-14		FORM CMS-2552-10				4090 (Cont.)
CALCULATION OF REIMBURSEMENT SETTLEMENT			PROVIDER CCN:	PERIOD:	WORKSHEET E-3,
			________________	FROM _________	PART III
			COMPONENT CCN:	TO ____________
			________________
Check		[ ] Hospital
applicable		[ ] Subprovider IRF
box:
PART III - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER IRF PPS
1	Net Federal PPS payment (see instructions)					1
2	Medicare SSI ratio (IRF PPS only) (see instructions)					2
3	Inpatient Rehabilitation LIP payments (see instructions)					3
4	Outlier payments					4
5	Unweighted intern and resident FTE count in the most recent cost reporting period ending					5
	on or prior to November 15, 2004 (see instructions)
5.01	Cap increases for the unweighted intern and resident FTE count for residents that were displaced by program or hospital					5.01
	closure, that would not be counted without a temporary cap adjustment under §412.424(d)(1)(iii)(F)(1) or (2)
6	New teaching program adjustment (see instructions)					6
7	Current year unweighted FTE count of I&R excluding FTEs in the new program growth period					7
	of a "new teaching program (see isntructions)
8	Current year unweighted I&R FTE count for residents within the new program growth period					8
	of a "new teaching program (see isntructions)
9	Intern and resident count for IRF PPS medical education adjustment (see instructions)					9
10	Average daily census (see instructions)					10
11	Teaching Adjustment Factor (see instructions)					11
12	Teaching Adjustment (see instructions)					12
13	Total PPS Payment (see instructions)					13
14	Nursing and allied health managed care payments (see instructions)					14
15	Organ acquisition DO NOT USE THIS LINE					15
16	Cost of physicians' services in a teaching hospital (see instructions)					16
17	Subtotal (see instructions)					17
18	Primary payer payments					18
19	Subtotal (line 17 less line 18).					19
20	Deductibles					20
21	Subtotal (line 19 minus line 20)					21
22	Coinsurance					22
23	Subtotal (line 21 minus line 22)					23
24	Allowable bad debts (exclude bad debts for professional services) (see instructions)					24
25	Adjusted reimbursable bad debts (see instructions)					25
26	Allowable bad debts for dual eligible beneficiaries (see instructions)					26
27	Subtotal (sum of lines 23 and 25)					27
28	Direct graduate medical education payments (from Worksheet E-4, line 49) (For free standing IRF only).					28
29	Other pass through costs (see instructions)					29
30	Outlier payments reconciliation					30
31	Other adjustments (specify) (see instructions)					31
32	Total amount payable to the provider (see instructions)					32
32.01	Sequestration adjustment (see instructions)					32.01
33	Interim payments					33
34	Tentative settlement (for contractor use only)					34
35	Balance due provider/program line 32 minus lines 32.01, 33 and 34					35
36	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2					36
	TO BE COMPLETED BY CONTRACTOR
50	Original outlier amount from Worksheet E-3, Part III, line 4 (see instructions)					50
51	Outlier reconciliation adjustment amount (see instructions)					51
52	The rate used to calculate the Time Value of Money (see instructions)					52
53	Time Value of Money (see instructions)					53
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.3)
Rev. 6						40-593

---

Sheet 56: E3IV

4090 (Cont.)		FORM CMS-2552-10				09-14
CALCULATION OF REIMBURSEMENT SETTLEMENT			PROVIDER CCN:	PERIOD:	WORKSHEET E-3,
				FROM ____________	PART IV
				TO _______________
			________________
PART IV - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER LTCH PPS
1	Net Federal PPS payment (see instructions)					1
2	Outlier payments					2
3	Total PPS payments (sum of lines 1 and 2)					3
4	Nursing and allied health managed care payments (see instructions)					4
5	Organ acquisition DO NOT USE THIS LINE					5
6	Cost of physicians' services in a teaching hospital (see instructions)					6
7	Subtotal (see instructions)					7
8	Primary payer payments					8
9	Subtotal (line 7 less line 8)					9
10	Deductibles					10
11	Subtotal (line 9 minus line 10)					11
12	Coinsurance					12
13	Subtotal (line 11 minus line 12)					13
14	Allowable bad debts (exclude bad debts for professional services) (see instructions)					14
15	Adjusted reimbursable bad debts (see instructions)					15
16	Allowable bad debts for dual eligible beneficiaries (see instructions)					16
17	Subtotal (sum of lines 13 and 15)					17
18	Direct graduate medical education payments (from Wkst. E-4, line 49)					18
19	Other pass through costs (see instructions)					19
20	Outlier payments reconciliation					20
21	Other adjustments (specify) (see instructions)					21
22	Total amount payable to the provider (see instructions)					22
22.01	Sequestration adjustment (see instructions)					22.01
23	Interim payments					23
24	Tentative settlement (for contractor use only)					24
25	Balance due provider/program (line 22 minus lines 22.01, 23 and 24)					25
26	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2					26
	TO BE COMPLETED BY CONTRACTOR
50	Original PPS payment and outlier amount from Wkst. E-3, Pt. IV, line 3 (see instructions)					50
51	Outlier reconciliation adjustment amount (see instructions)					51
52	The rate used to calculate the Time Value of Money (see instructions)					52
53	Time Value of Money (see instructions)					53
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.4)
40-594						Rev. 6

---

Sheet 57: E3V

09-14		FORM CMS-2552-10				4090 (Cont.)
CALCULATION OF REIMBURSEMENT SETTLEMENT			PROVIDER CCN:	PERIOD:	WORKSHEET E-3,
			________________	FROM ____________	PART V
			COMPONENT CCN:	TO _______________
			________________
PART V - CALCULATION OF REIMBURSEMENT SETTLEMENT FOR MEDICARE PART A SERVICES - COST REIMBURSEMENT
1	Inpatient services					1
2	Nursing and allied health managed care payment (see instruction)					2
3	Organ acquisition					3
4	Subtotal (sum of lines 1 thru 3)					4
5	Primary payer payments					5
6	Total cost (line 4 less line 5) (see instructions)					6
	COMPUTATION OF LESSER OF COST OR CHARGES
	Reasonable charges
7	Routine service charges					7
8	Ancillary service charges					8
9	Organ acquisition charges, net of revenue					9
10	Total reasonable charges					10
	Customary charges
11	Aggregate amount actually collected from patients liable for payment for services on a charge basis					11
12	Amounts that would have been realized from patients liable for payment for services on					12
	a charge basis had such payment been made in accordance with 42 CFR §413.13(e)
13	Ratio of line 11 to line 12 (not to exceed 1.000000)					13
14	Total customary charges (see instructions)					14
15	Excess of customary charges over reasonable cost (complete only if line 14 exceeds line 6) (see instructions)					15
16	Excess of reasonable cost over customary charges (complete only if line 6 exceeds line 14) (see instructions)					16
17	Cost of physicians' services in a teaching hospital (see instructions)					17
	COMPUTATION OF REIMBURSEMENT SETTLEMENT
18	Direct graduate medical education payments					18
19	Cost of covered services (sum of lines 6 and 17 )					19
20	Deductibles (exclude professional component)					20
21	Excess reasonable cost (from line 16)					21
22	Subtotal (line 19 minus lines 20 and 21)					22
23	Coinsurance					23
24	Subtotal (line 22 minus line 23)					24
25	Allowable bad debts (exclude bad debts for professional services) (see instructions)					25
26	Adjusted reimbursable bad debts (see instructions)					26
27	Allowable bad debts for dual eligible beneficiaries (see instructions)					27
28	Subtotal (sum of lines 24 and 25 or 26)					28
29	Other adjustments (specify) (see instructions)					29
30	Subtotal (line 28, plus or minus line 29)					30
30.01	Sequestration adjustment (see instructions)					30.01
31	Interim payments					31
32	Tentative settlement (for contractor use only)					32
33	Balance due provider/program line 30 minus lines 30.01, 31, and 32					33
34	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chatper 1, §115.2					34
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.5)
Rev. 6						40-595

---

Sheet 58: E3VI

4090 (Cont.)		FORM CMS-2552-10				09-14
CALCULATION OF REIMBURSEMENT SETTLEMENT			PROVIDER CCN:	PERIOD:	WORKSHEET E-3,
			________________	FROM ____________	PART VI
			COMPONENT CCN.:	TO _______________
			________________
PART VI - CALCULATION OF REIMBURSEMENT SETTLEMEMENT - TITLE XVIII PART A PPS SNF SERVICES
	PROSPECTIVE PAYMENT AMOUNT (SEE INSTRUCTIONS)
1	Resource Utilization Group (RUGS) payment					1
2	Routine service other pass through costs					2
3	Ancillary service other pass through costs					3
4	Subtotal (sum of lines 1 through 3)					4
	COMPUTATION OF NET COST OF COVERED SERVICES
5	Medical and other services. Do not use this line (see instructions).					5
6	Deductibles					6
7	Coinsurance					7
8	Allowable bad debts (see instructions)					8
9	Reimbursable bad debts for dual eligible beneficiaries (see instructions)					9
10	Adjusted reimbursable bad debts (see instructions)					10
11	Utilization review					11
12	Subtotal (Sum of lines 4 and 5, minus 6 & 7 plus 10 and 11) (see instructions)					12
13	Inpatient primary payer payments					13
14	Other adjustments (specify) (see instructions)					14
15	Subtotal (line 12 minus 13 ± lines 14					15
15.01	Sequestration adjustment (see instructions)					15.01
16	Interim payments					16
17	Tentative settlement (for contractor use only)					17
18	Balance due provider/program line 15 minus 15.01, 16 and 17					18
19	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2					19
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.6)
40-596						Rev. 6

---

Sheet 59: E3VII

DRAFT			FORM CMS-2552-10				4090 (Cont.)
CALCULATION OF REIMBURSEMENT SETTLEMENT				PROVIDER CCN:	PERIOD:	WORKSHEET E-3,
				________________	FROM ____________	PART VII
				COMPONENT CCN:	TO _______________
				________________
Check		[ ] Title V	[ ] Hospital	[ ] NF	[ ] PPS
applicable		[ ] Title XIX	[ ] Subprovider	[ ] ICF/IID	[ ] TEFRA
boxes:			[ ] SNF		[ ] Other
PART VII - CALCULATION OF REIMBURSEMENT - ALL OTHER HEALTH SERVICES FOR TITLES V OR XIX SERVICES
					Inpatient	Outpatient
					Title V or	Title V or
	COMPUTATION OF NET COST OF COVERED SERVICES				Title XIX	Title XIX
1	Inpatient hospital/SNF/NF services						1
2	Medical and other services						2
3	Organ acquisition (certified transplant centers only)						3
4	Subtotal (sum of lines 1, 2 and 3)						4
5	Inpatient primary payer payments						5
6	Outpatient primary payer payments						6
7	Subtotal (line 4 less sum of lines 5 and 6)						7
	COMPUTATION OF LESSER OF COST OR CHARGES
	Reasonable Charges
8	Routine service charges						8
9	Ancillary service charges						9
10	Organ acquisition charges, net of revenue						10
11	Incentive from target amount computation						11
12	Total reasonable charges (sum of lines 8 through 11)						12
	CUSTOMARY CHARGES
13	Amount actually collected from patients liable for payment for services on a charge basis						13
14	Amounts that would have been realized from patients liable for payment for services						14
	on a charge basis had such payment been made in accordance with 42 CFR §413.13(e)
15	Ratio of line 13 to line 14 (not to exceed 1.000000)						15
16	Total customary charges (see instructions)						16
17	Excess of customary charges over reasonable cost (complete only if line 16						17
	exceeds line 4) (see instructions)
18	Excess of reasonable cost over customary charges (complete only if line 4 exceeds line 16) (see instructions)						18
19	Interns and residents (see instructions)						19
20	Cost of physicians' service in a teaching hospital (see instructions)						20
21	Cost of covered services (enter the lesser of line 4 or line 16)						21
	PROSPECTIVE PAYMENT AMOUNT
22	Other than outlier payments						22
23	Outlier payments						23
24	Program capital payments						24
25	Capital exception payments (see instructions)						25
26	Routine and ancillary service other pass through costs						26
27	Subtotal (sum of lines 22 through 26)						27
28	Customary charges (title V or XIX PPS covered services only)						28
29	Titles V or XIX (sum of lines 21 and 27)						29
	COMPUTATION OF REIMBURSEMENT SETTLEMENT
30	Excess of reasonable cost (from line 18)						30
31	Subtotal (sum of lines 19 and 20, plus 29 minus lines 5 and 6)						31
32	Deductibles						32
33	Coinsurance						33
34	Allowable bad debts (see instructions)						34
35	Utilization review						35
36	Subtotal (sum of lines 31, 34 and 35 minus the sum of lines 32 and 33)						36
37	Other adjustments (specify) (see instructions)						37
38	Subtotal (line 36 ± line 37)						38
39	Direct graduate medical education payments (from Wkst. E-4)						39
40	Total amount payable to the provider (sum of lines 38 and 39)						40
41	Interim payments						41
42	Balance due provider/program (line 40 minus line 41)						42
43	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2						43
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.7)
Rev.							40-597

---

Sheet 60: E4

4090 (Cont.)		FORM CMS-2552-10				DRAFT
DIRECT GRADUATE MEDICAL EDUCATION (GME)			PROVIDER CCN:	PERIOD:	WORKSHEET E-4
& ESRD OUTPATIENT DIRECT MEDICAL				FROM ____________
EDUCATION COSTS			________________	TO _______________
Check		[ ] Title V
applicable		[ ] Title XVIII
box:		[ ] Title XIX
	COMPUTATION OF TOTAL DIRECT GME AMOUNT
1	Unweighted resident FTE count for allopathic and osteopathic programs for cost reporting periods ending on or before December 31, 1996					1
2	Unweighted FTE resident cap add-on for new programs per 42 CFR 413.79(e) (see instructions)					2
3	Amount of reduction to Direct GME cap under §422 of MMA					3
3.01	Direct GME cap reduction amount under ACA §5503 in accordance with 42 CFR §413.79 (m). (see instructions					3.01
	for cost reporting periods straddling 7/1/2011)
4	Adjustment (plus or minus) to the FTE cap for allopathic and osteopathic programs due to a Medicare GME					4
	affiliation agreement (42 CFR §413.75(b) and § 413.79 (f))
4.01	ACA §5503 increase to the direct GME FTE cap (see instructions for cost reporting periods straddling 7/1/2011)					4.01
4.02	ACA §5506 number of additional direct GME FTE cap slots (see instructions for cost reporting periods straddling 7/1/2011)					4.02
5	FTE adjusted cap (line 1 plus line 2 minus line 3 and 3.01 plus or minus line 4 plus lines 4.01 and 4.02 plus applicable subscripts					5
6	Unweighted resident FTE count for allopathic and osteopathic programs for the current year from your records (see instructions)					6
7	Enter the lesser of line 5 or line 6					7
			Primary Care	Other	Total
			1	2	3
8	Weighted FTE count for physicians in an allopathic and osteopathic program for					8
	the current year
9	If line 6 is less than 5 enter the amount from line 8, otherwise multiply line 8 times					9
	the result of line 5 divided by the amount on line 6
10	Weighted dental and podiatric resident FTE count for the current year					10
11	Total weighted FTE count					11
12	Total weighted resident FTE count for the prior cost reporting year (see instructions)					12
13	Total weighted resident FTE count for the penultimate cost reporting year (see instr.)					13
14	Rolling average FTE count (sum of lines 11 through 13 divided by 3)					14
15	Adjustment for residents in initial years of new programs					15
16	Adjustment for residents displaced by program or hospital closure					16
17	Adjusted rolling average FTE count					17
18	Per resident amount					18
19	Approved amount for resident costs					19
20	Additional unweighted allopathic and osteopathic direct GME FTE resident cap slots received under 42 §413.79(c )(4)					20
21	Direct GME FTE unweighted resident count over cap (see instructions)					21
22	Allowable additional direct GME FTE resident count (see instructions)					22
23	Enter the locality adjustment national average per resident amount (see instructions)					23
24	Multiply line 22 time line 23					24
25	Total direct GME amount (sum of lines 19 and 24)					25
	COMPUTATION OF PROGRAM PATIENT LOAD		Inpatient Part A	Managed Care
26	Inpatient days (see instructions)					26
27	Total inpatient days (see instructions)					27
28	Ratio of inpatient days to total inpatient days					28
29	Program direct GME amount					29
30	Reduction for direct GME payments for Medicare Advantage					30
31	Net Program direct GME amount					31
	DIRECT MEDICAL EDUCATION COSTS FOR ESRD COMPOSITE RATE - TITLE XVIII ONLY (NURSING SCHOOL AND
	PARAMEDICAL EDUCATION COSTS)
32	Renal dialysis direct medical education costs (from Wkst. B, Pt. I, sum of col. 20 and 23, lines 74 and 94)					32
33	Renal dialysis and home dialysis total charges (Wkst. C, Pt. I, col. 8, sum of lines 74 and 94)					33
34	Ratio of direct medical education costs to total charges (line 32 ÷ line 33)					34
35	Medicare outpatient ESRD charges (see instructions)					35
36	Medicare outpatient ESRD direct medical education costs (line 34 x line 35)					36
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4034)
40-598						Rev.
09-14		FORM CMS-2552-10				4090 (Cont.)
DIRECT GRADUATE MEDICAL EDUCATION (GME)			PROVIDER CCN:	PERIOD:	WORKSHEET E-4
& ESRD OUTPATIENT DIRECT MEDICAL				FROM ____________	(Cont.)
EDUCATION COSTS			________________	TO _______________
Check		[ ] Title V
applicable		[ ] Title XVIII
box:		[ ] Title XIX
	APPORTIONMENT OF MEDICARE REASONABLE COST OF GME
	Part A Reasonable Cost
37	Reasonable cost (see instructions)					37
38	Organ acquisition costs Wkst. D-4, Pt. III, col. 1, line 69)					38
39	Cost of physicians' services in a teaching hospital (see instructions)					39
40	Primary payer payments (see instructions)					40
41	Total Part A reasonable cost (sum of lines 37 through 39 minus line 40)					41
	Part B Reasonable Cost
42	Reasonable cost (see instructions)					42
43	Primary payer payments (see instructions)					43
44	Total Part B reasonable cost (line 42 minus line 43)					44
45	Total reasonable cost (sum of lines 41 and 44)					45
46	Ratio of Part A reasonable cost to total reasonable cost (line 41 ÷ line 45)					46
47	Ratio of Part B reasonable cost to total reasonable cost (line 44 ÷ line 45)					47
	ALLOCATION OF MEDICARE DIRECT GME COSTS BETWEEN PART A AND PART B
48	Total program GME payment (line 31)					48
49	Part A Medicare GME payment (line 46 x 48) (title XVIII only) (see instructions)					49
50	Part B Medicare GME payment (line 47 x 48) (title XVIII only) (see instructions)					50
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4034)
Rev. 6						40-599

---

Sheet 61: G

4090 (Cont.)			FORM CMS-2552-10			09-14
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
	Assets	Fund	Fund	Fund	Fund
	(Omit cents)	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	Allowances for uncollectible notes and					6
	accounts receivable
7	Inventory					7
8	Prepaid expenses					8
9	Other current assets					9
10	Due from other funds					10
11	Total current assets (sum of lines 1-10)					11
	FIXED ASSETS
12	Land					12
13	Land improvements					13
14	Accumulated depreciation					14
15	Buildings					15
16	Accumulated depreciation					16
17	Leasehold improvements					17
18	Accumulated depreciation					18
19	Fixed equipment					19
20	Accumulated depreciation					20
21	Automobiles and trucks					21
22	Accumulated depreciation					22
23	Major movable equipment					23
24	Accumulated depreciation					24
25	Minor equipment depreciable					25
26	Accumulated depreciation					26
27	HIT designated Assets					27
28	Accumulated depreciation					28
29	Minor equipment-nondepreciable					29
30	Total fixed assets (sum of lines 12-29)					30
	OTHER ASSETS
31	Investments					31
32	Deposits on leases					32
33	Due from owners/officers					33
34	Other assets					34
35	Total other assets (sum of lines 31-34)					35
36	Total assets (sum of lines 11, 30, and 35)					36
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4040)
40-600						Rev. 6
10-12		FORM CMS-2552-10				4090 (Cont.)
BALANCE SHEET			PROVIDER CCN:	PERIOD:	WORKSHEET G
(If you are nonproprietary and do not maintain fund-type				FROM ____________	(CONT.)
accounting records, complete the General Fund column only)			________________	TO _______________
			Specific
	Liabilities and Fund	General	Purpose	Endowment	Plant
	Balances	Fund	Fund	Fund	Fund
	(Omit cents)	1	2	3	4
	CURRENT LIABILITIES
37	Accounts payable					37
38	Salaries, wages, and fees payable					38
39	Payroll taxes payable					39
40	Notes and loans payable (short term)					40
41	Deferred income					41
42	Accelerated payments					42
43	Due to other funds					43
44	Other current liabilities					44
45	Total current liabilities (sum of					45
	lines 37 thru 44)
	LONG TERM LIABILITIES
46	Mortgage payable					46
47	Notes payable					47
48	Unsecured loans					48
49	Other long term liabilities					49
50	Total long term liabilities (sum of					50
	lines 46 thru 49)
51	Total liabilities (sum of lines 45 and 50)					51
	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 plant					58
	improvement, replacement, and expansion
59	Total fund balances (sum of lines 52 thru 58)					59
60	Total liabilities and fund balances (sum of					60
	lines 51 and 59)
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4040)
Rev. 3						40-601

---

Sheet 62: G1

4090 (Cont.)				FORM CMS-2552-10						10-12
STATEMENT OF CHANGES IN FUND BALANCES					PROVIDER CCN:		PERIOD:		WORKSHEET G-1
							FROM ____________
					________________		TO _______________
		GENERAL FUND		SPECIFIC 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 Worksheet G-3, line 29)									2
3	Total (sum of line 1 and line 2)									3
4	Additions (credit adjustments) (specify)									4
5										5
6										6
7										7
8										8
9										9
10	Total additions (sum of lines 4-9)									10
11	Subtotal (line 3 plus line 10)									11
12	Deductions (debit adjustments) (specify)									12
13										13
14										14
15										15
16										16
17										17
18	Total deductions (sum of lines 12-17)									18
19	Fund balance at end of period per balance									19
	sheet (line 11 minus line 18)
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4040)
40-602										Rev. 3

---

Sheet 63: G2

10-12		FORM CMS-2552-10				4090 (Cont.)
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	Hospital					1
2	Subprovider IPF					2
3	Subprovider IRF					3
4	Subprovider (Other)					4
5	Swing bed - SNF					5
6	Swing bed - NF					6
7	Skilled nursing facility					7
8	Nursing facility					8
9	Other long term care					9
10	Total general inpatient care services (sum of lines 1-9)					10
	INTENSIVE CARE TYPE INPATIENT HOSPITAL SERVICES
11	Intensive care unit					11
12	Coronary care unit					12
13	Burn intensive care unit					13
14	Surgical intensive care unit					14
15	Other special care (specify)					15
16	Total intensive care type inpatient hospital services (sum of					16
	of lines 11-15)
17	Total inpatient routine care services (sum of lines 10 and 16)					17
18	Ancillary services					18
19	Outpatient services					19
20	Rural Health Clinic (RHC)					20
21	Federally Qualified Health Center (FQHC)					21
22	Home health agency					22
23	Ambulance					23
24	Outpatient rehabilitation providers					24
25	ASC					25
26	Hospice					26
27	Other (specify)					27
28	Total patient revenues (sum of lines 17-27) (transfer column 3 to					28
	Worksheet G-3, line 1)
PART II - OPERATING EXPENSES
				1	2
29	Operating expenses (per Wkst. A, column 3, line 200)					29
30	Add (specify)					30
31						31
32						32
33						33
34						34
35						35
36	Total additions (sum of lines 30-35)					36
37	Deduct (specify)					37
38						38
39						39
40						40
41						41
42	Total deductions (sum of lines 37-41)					42
43	Total operating expenses (sum of lines 29 and 36 minus line 42) (transfer to Worksheet G-3, line 4)					43
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4040)
Rev. 3						40-603

---

Sheet 64: G3

4090 (Cont.)		FORM CMS-2552-10			10-12
STATEMENT OF REVENUES		PROVIDER CCN:	PERIOD:	WORKSHEET G-3
AND EXPENSES			FROM ____________
		________________	TO _______________
	Description
1	Total patient revenues (from Worksheet G-2, Part I, column 3, line 28)				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 (from Worksheet G-2, Part II, line 43)				4
5	Net income from service to patients (line 3 minus line 4)				5
	OTHER INCOME
6	Contributions, donations, bequests, etc				6
7	Income from investments				7
8	Revenues from telephone and other miscellaneous communication services				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, flowers, coffee shops, and canteen				20
21	Rental of vending machines				21
22	Rental of hospital space				22
23	Governmental appropriations				23
24	Other (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	Total other expenses (sum of line 27 and subscripts)				28
29	Net income (or loss) for the period (line 26 minus line 28)				29
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4040)
40-604					Rev. 3

---

Sheet 65: H

DRAFT					FORM CMS-2552-10							4090 (Cont.)
ANALYSIS OF HOSPITAL-BASED							PROVIDER CCN: ______________		PERIOD:		WORKSHEET H
HOME HEALTH AGENCY COSTS									FROM ____________
							HHA CCN: ____________		TO _______________
				TRANSPOR-	CONTRACTED/				RECLASSIFIED		NET
		SALARIES	EMPLOYEE	TATION	PURCHASED		TOTAL		TRIAL		EXPENSES FOR
	COST CENTER DESCRIPTIONS		BENEFITS	(see	SERVICES		(sum of cols.	RECLASS-	BALANCE		ALLOCATION
	(omit cents)			instructions)		OTHER COSTS	1 thru 5)	IFICATIONS	(col. 6 + col. 7)	ADJUSTMENTS	(col. 8 + col. 9)
		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
	HHA NONREIMBURSABLE SERVICES
15	Home Dialysis Aide Services											15
16	Respiratory Therapy											16
17	Private Duty Nursing											17
18	Clinic											18
19	Health Promotion Activities											19
20	Day Care Program											20
21	Home Delivered Meals Program											21
22	Homemaker Service											22
23	All Others											23
24	Total (sum of lines 1-23)											24
Column, 6 line 24 should agree with the Worksheet A, column 3, line 101, or subscript as applicable.
FORM CMS 2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4041)
Rev.												40-605

---

Sheet 66: H1I

4090 (Cont.)				FORM CMS-2552-10						DRAFT
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.	BLDGS. &	MOVABLE	OPERATION &	TRANS-	SUBTOTAL	TRATIVE	TOTAL
		H, col. 10)	FIXTURES	EQUIPMENT	MAINTENANCE	PORTATION	(cols. 0-4)	& 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 (see instructions)									12
13	Drugs									13
14	DME									14
	HHA NONREIMBURSABLE SERVICES
15	Home Dialysis Aide Services									15
16	Respiratory Therapy									16
17	Private Duty Nursing									17
18	Clinic									18
19	Health Promotion Activities									19
20	Day Care Program									20
21	Home Delivered Meals Program									21
22	Homemaker Service									22
23	All Others									23
24	Totals (sum of lines 1-23)									24
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4042)
40-606										Rev.

---

Sheet 67: H1II

09-13				FORM CMS-2552-10						4090 (Cont.)
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
				FIXTURES	EQUIPMENT	MAINTENANCE	TRANS-		& GENERAL
				(SQUARE	(DOLLAR	(SQUARE	PORTATION	RECONCIL-	(ACCUM.
				FEET)	VALUE)	FEET)	(MILEAGE)	IATION	COST)
				1	2	3	4	5a	5
	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
	HHA NONREIMBURSABLE SERVICES
15	Home Dialysis Aide Services									15
16	Respiratory Therapy									16
17	Private Duty Nursing									17
18	Clinic									18
19	Health Promotion Activities									19
20	Day Care Program									20
21	Home Delivered Meals Program									21
22	Homemaker Service									22
23	All Others									23
24	Total (sum of lines 1-23)									24
25	Cost To Be Allocated (per Worksheet H-1, Part I)									25
26	Unit Cost Multiplier									26
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4042)
Rev. 4										40-607

---

Sheet 68: H2I

4090 (Cont.)					FORM CMS-2552-10							09-13	10-12						FORM CMS-2552-10							4090 (Cont.)	4090 (Cont.)				FORM CMS-2552-10							10-12
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 I			COSTS TO HHA COST CENTERS									FROM ____________		PART I (CONT.)			COSTS TO HHA COST CENTERS							FROM ____________		PART I (CONT.)
					HHA CCN: ____________			TO _______________											HHA CCN: ____________			TO _______________									HHA CCN: ____________			TO _______________
				CAPITAL																														INTERN &
		From	HHA	RELATED COSTS																					NON-									RESIDENT		ALLOCATED
	HHA COST CENTER	Wkst. H-1	TRIAL			EMPLOYEE		ADMINIS-	MAIN-		LAUNDRY			HHA COST CENTER				MAIN-	NURSING	CENTRAL		MEDICAL		OTHER	PHYSICIAN			HHA COST CENTER		INTERNS & RESIDENTS		PARAMEDICAL	SUBTOTAL	COST & POST		HHA
	(omit cents)	Part I,	BALANCE	BLDGS. &	MOVABLE	BENEFITS	SUBTOTAL	TRATIVE &	TENANCE &	OPERATION	& LINEN			(omit cents)	HOUSE			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL	GENERAL	ANES-			(omit cents)	NURSING	SALARY AND	PROGRAM	EDUCATION	(sum of cols.	STEPDOWN	SUBTOTAL	A&G (see	TOTAL
		col. 6,	(1)	FIXTURES	EQUIPMENT	DEPARTMENT	(cols. 0-4)	GENERAL	REPAIRS	OF PLANT	SERVICE				KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE	SERVICE	THETISTS				SCHOOL	FRINGES	COSTS	(SPECIFY)	4a-23)	ADJUSTMENTS	(cols. 23 ± 24)	Part II)	HHA COSTS
		line	0	1	2	4	4A	5	6	7	8				9	10	11	12	13	14	15	16	17	18	19				20	21	22	23	24	25	26	27	28
1	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	Home Dialysis Aide Services	15										11	11	Home Dialysis Aide Services												11	11	Home Dialysis Aide Services										11
12	Respiratory Therapy	16										12	12	Respiratory Therapy												12	12	Respiratory Therapy										12
13	Private Duty Nursing	17										13	13	Private Duty Nursing												13	13	Private Duty Nursing										13
14	Clinic	18										14	14	Clinic												14	14	Clinic										14
15	Health Promotion Activities	19										15	15	Health Promotion Activities												15	15	Health Promotion Activities										15
16	Day Care Program	20										16	16	Day Care Program												16	16	Day Care Program										16
17	Home Delivered Meals Program	21										17	17	Home Delivered Meals Program												17	17	Home Delivered Meals Program										17
18	Homemaker Service	22										18	18	Homemaker Service												18	18	Homemaker Service										18
19	All Others	23										19	19	All Others												19	19	All Others										19
20	Totals (sum of lines 1-19) (2)											20	20	Totals (sum of lines 1-19) (2)												20	20	Totals (sum of lines 1-19) (2)										20
21	Unit Cost Multiplier: column 26, line 1 divided by the sum of column 26, line 20											21	21	Unit Cost Multiplier: column 26, line 1 divided by the sum of column 26, line 20												21	21	Unit Cost Multiplier: column 26, line 1 divided by the sum of column 26, line 20										21
	minus column 26, line 1, rounded to 6 decimal places.													minus column 26, line 1, rounded to 6 decimal places.														minus column 26, line 1, rounded to 6 decimal places.
(1) Column 0, line 20 must agree with Wkst. A, column 7, line 101.													(2) Columns 0 through 26, line 20 must agree with the corresponding columns of Wkst. B, Part I, line 101.														(2) Columns 0 through 26, line 20 must agree with the corresponding columns of Wkst. B, Part I, line 101.
(2) Columns 0 through 26, line 20 must agree with the corresponding columns of Wkst. B, Part I, line 101.
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4043.1)													FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4043.1)														FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4043.1)
40-608												Rev. 4	Rev. 3													40-609	40-610											Rev. 3

---

Sheet 69: H2II

09-13				FORM CMS-2552-10					4090 (Cont.)	4090 (Cont.)				FORM CMS-2552-10							09-13	10-12				FORM CMS-2552-10					4090 (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 II		COSTS TO HHA COST CENTERS								FROM ____________		PART II (CONT.)		COSTS TO HHA COST CENTERS						FROM ____________		PART II (CONT.)
STATISTICAL BASIS				HHA CCN: ____________		TO _______________				STATISTICAL BASIS						HHA CCN: ____________		TO _______________				STATISTICAL BASIS				HHA CCN: ____________		TO _______________
		CAPITAL																								NON-				PARA-
		RELATED COST		EMPLOYEE		ADMINIS-	MAIN-					LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL						PHYSICIAN		INTERNS & RESIDENTS		MEDICAL
		BLDGS. &	MOVABLE	BENEFITS		TRATIVE &	TENANCE &	OPERATION				& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &				SOCIAL	OTHER	ANES-	NURSING	SALARY &	PROGRAM	EDUCATION
	HHA COST CENTER	FIXTURES	EQUIPMENT	DEPARTMENT		GENERAL	REPAIRS	OF PLANT			HHA COST CENTER	SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY			HHA COST CENTER	SERVICE	GENERAL	THETISTS	SCHOOL	FRINGES	COSTS	(SPECIFY)
		(SQUARE	(DOLLAR	(GROSS	RECONCIL-	(ACCUM.	(SQUARE	(SQUARE				(POUNDS OF	(HOURS OF	(MEALS	(MEALS	(NUMBER	(DIRECT	(COSTED	(COSTED	(TIME				(TIME	SERVICE	(ASSIGNED	(ASSIGNED	(ASSIGNED	(ASSIGNED	(ASSIGNED
		FEET)	VALUE)	SALARIES)	IATION	COST)	FEET)	FEET)				LAUNDRY)	SERVICE)	SERVED)	SERVED)	HOUSED)	NURS. HRS)	REQUIS.)	REQUIS.)	SPENT)				SPENT)	(SPECIFY)	TIME)	TIME)	TIME)	TIME)	TIME)
		1	2	4	4A	5	6	7				8	9	10	11	12	13	14	15	16				17	18	19	20	21	22	23
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	Home Dialysis Aide Services								11	11	Home Dialysis Aide Services										11	11	Home Dialysis Aide Services								11
12	Respiratory Therapy								12	12	Respiratory Therapy										12	12	Respiratory Therapy								12
13	Private Duty Nursing								13	13	Private Duty Nursing										13	13	Private Duty Nursing								13
14	Clinic								14	14	Clinic										14	14	Clinic								14
15	Health Promotion Activities								15	15	Health Promotion Activities										15	15	Health Promotion Activities								15
16	Day Care Program								16	16	Day Care Program										16	16	Day Care Program								16
17	Home Delivered Meals Program								17	17	Home Delivered Meals Program										17	17	Home Delivered Meals Program								17
18	Homemaker Service								18	18	Homemaker Service										18	18	Homemaker Service								18
19	All Others								19	19	All Others										19	19	All Others								19
20	Totals (sum of lines 1-19)								20	20	Totals (sum of lines 1-19)										20	20	Totals (sum of lines 1-19)								20
21	Total cost to be allocated								21	21	Total cost to be allocated										21	21	Total cost to be allocated								21
22	Unit Cost Multiplier								22	22	Unit Cost Multiplier										22	22	Unit Cost Multiplier								22
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4043.2)										FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4043.2)												FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4043.2)
Rev. 4									40-611	40-612											Rev. 4	Rev. 3									40-613

---

Sheet 70: H3

4090 (Cont.)

FORM CMS-2552-10

10-12

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

Program Visits

Cost of Services

From,

Facility

Shared

Average

Part B

Part B

Wkst.

Costs

Ancillary

Total

Cost

Not

Not

Total

H-2,

(from

Costs

HHA

Per Visit

Subject to

Subject to

Subject to

Subject to

Program Cost

Patient Services

Part I,

Wkst. H-2,

(from

Costs

Total

(col. 3

Deductibles

Deductibles

Deductibles

Deductibles

(sum of

col. 28,

Part I)

Part II)

(cols. 1 + 2)

Visits

÷ col. 4)

Part A

& Coinsurance

& Coinsurance

Part A

& Coinsurance

& Coinsurance

cols. 9-10)

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

Limitation Cost Computation

Program Visits

Part B

Not Subject to

Subject to

Patient Services

CBSA

Deductibles

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

Program Covered Charges

Cost of Services

Computations

Facility

Shared

Part B

Part B

From

Costs

Ancillary

Total

Total

Not

Not

Wkst. H-2

(from

Costs

HHA

Charges

Ratio

Subject to

Subject to

Subject to

Subject to

Other Patient Services

Part I,

Wkst. H-2,

(from

Costs

(from HHA

(col. 3

Deductibles

Deductibles

Deductibles

Deductibles

col. 28,

Part I)

Part II)

(cols. 1 + 2)

Record)

÷ col. 4)

Part A

& Coinsurance

& Coinsurance

Part A

& Coinsurance

& Coinsurance

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 HOSPITAL DEPARTMENTS

Total

Cost

HHA Charges

HHA Shared

Transfer to

From Wkst. C,

to Charge

(from provider

Ancillary Costs

Part I

Part I, col. 9,

Ratio

records)

(col. 1 x col. 2)

as Indicated

line

1

2

3

4

1

Physical Therapy

66

col. 2, line 2

1

2

Occupational Therapy

67

col. 2, line 3

2

3

Speech Pathology

68

col. 2, line 4

3

4

Cost of Medical Supplies

71

col. 2, line 15

4

5

Cost of Drugs

73

col. 2, line 16

5

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4044)

40-614

Rev. 3

---

Sheet 71: H4

DRAFT		FORM CMS-2552-10				4090 (Cont.)
CALCULATION OF HHA REIMBURSEMENT			PROVIDER CCN:	PERIOD:	WORKSHEET H-4,
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 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 thru 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
31	Subtotal (line 29 plus/minus line 30)					31
31.01	Sequestration adjustment (see instructions)					31.01
32	Interim payments (see instructions)					32
33	Tentative settlement (for contractor use only)					33
34	Balance due provider/program line 31 minus lines 31.01, 32 and 33					34
35	Protested amounts (nonallowable cost report items) in accordance with CMS					35
	Pub. 15-2, section 115.2
FORM CMS-2552-12 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4045.1 - 4045.2)
Rev.						40-615

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Sheet 72: H5

4090 (Cont.)							FORM CMS-2552-10				DRAFT
ANALYSIS OF PAYMENTS TO HOSPITAL-								PROVIDER CCN:	PERIOD:	WORKSHEET H-5
BASED HHAs FOR SERVICES								________________	FROM ____________
RENDERED TO PROGRAM BENEFICIARIES								HHA CCN:	TO _______________
								________________
		Description					Part A		Part B
							mm/dd/yyyy	Amount	mm/dd/yyyy	Amount
							1	2	3	4
1	Total interim payments paid to provider										1
2	Interim payments payable on individual bills either submitted or										2
	to be submitted to the intermediary for services rendered in the
	cost reporting period. If none, write "NONE" or enter a zero.
3	List separately each retroactive lump sum					.01					3.01
	adjustment amount based on subsequent revision					.02					3.02
	of the interim rate for the cost reporting period.				Program	.03					3.03
	Also show date of each payment. If none, write				to	.04					3.04
	"NONE" or enter a zero.(1)				Provider	.05					3.05
						.50					3.50
						.51					3.51
					Provider	.52					3.52
					to	.53					3.53
					Program	.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 INTERMEDIARY
5	List separately each tentative settlement payment				Program	.01					5.01
	after desk review. Also show date of each				to	.02					5.02
	payment. If none, write "NONE" or enter				Provider	.03					5.03
	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 due)				Program
	based on the cost report (see instructions)				to	.01
					Provider						6.01
					Provider
					to	.02
					Program						6.02
7	TOTAL MEDICARE PROGRAM LIABILITY										7
	(see instructions)
8	Name of Contractor				Contractor Number			NPR Date: Month, Day, Year			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-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4046)
40-616											Rev.

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Sheet 73: I1

09-14			FORM CMS-2552-10				4090 (Cont.)
ANALYSIS OF RENAL DIALYSIS DEPARTMENT COSTS				PROVIDER CCN:	PERIOD:	WORKSHEET I-1
					FROM ____________
				________________	TO _______________
Check applicable box:		[ ] Renal Dialysis Department [ ] Home Program Dialysis
			TOTAL			FTEs per
			COSTS	BASIS	STATISTICS	2080 Hours
			1	2	3	4
1	Registered Nurses			Hours of Service			1
2	Licensed Practical Nurses			Hours of Service			2
3	Nurses Aides			Hours of Service			3
4	Technicians			Hours of Service			4
5	Social Workers			Hours of Service			5
6	Dieticians			Hours of Service			6
7	Physicians			Accumulated Cost			7
8	Non-patient Care Salary			Accumulated Cost			8
9	Subtotal (sum of lines 1-8)						9
10	Employee Benefits			Salary			10
11	Capital Related Costs-Bldgs. & Fixtures			Square Feet			11
12	Capital Related Costs-Mov. Equip.			Percentage of Time			12
13	Machine Costs & Repairs			Percentage of Time			13
14	Supplies			Requisitions			14
15	Drugs			Requisitions			15
16	Other			Accumulated Cost			16
17	Subtotal (sum of lines 9-16)*						17
18	Capital Related Costs-Bldgs. & Fixtures			Square Feet			18
19	Capital Related Costs-Mov. Equip.			Percentage of Time			19
20	Employee Benefits Department			Salary			20
21	Administrative and General			Accumulated Cost			21
22	Maint./Repairs-Operation-Housekeeping			Square Feet			22
23	Medical Education Program Costs						23
24	Central Services & Supplies			Requisitions			24
25	Pharmacy			Requisitions			25
26	Other Allocated Costs			Accumulated Cost			26
27	Subtotal (sum of lines 17-26)*						27
28	Laboratory (see instructions)			Charges			28
29	Respiratory Therapy (see instructions)			Charges			29
30	Other (see instructions)			Charges			30
31	Total costs (sum of lines 27-30)						31
	* Line 17, column 1 should agree with Worksheet A, column 7 for line 74 or line 94 as appropriate,
	and line 27, column 1 should agree with Worksheet B, Part I, column 26 for line 74 or line 94 as appropriate.
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4048)
Rev. 6							40-617
ALLOCATION METHOD
Statistics	Exception Requests
Charges	No S/W I-2 Part II
Weighted Treatments	I/P = 2
	O/P & Home = 1
	Training = 3

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Sheet 74: I2

4090 (Cont.)					FORM CMS-2552-10								09-14
ALLOCATION OF RENAL DEPARTMENT COSTS TO TREATMENT MODALITIES							PROVIDER CCN:		PERIOD:		WORKSHEET I-2
									FROM ____________
							________________		TO _______________
Check applicable box:		[ ] Renal Dialysis Department [ ] Home Program Dialysis
OUTPATIENT SERVICES
COMPOSITE PAYMENT RATE		CAPITAL AND		DIRECT PATIENT		EMPLOYEE			ROUTINE	SUBTOTAL		TOTAL
		RELATED COSTS		CARE SALARY		BENEFITS		MEDICAL	ANCILLARY	(sum of		(col. 9 +
		BUILDING	EQUIPMENT	RNs	OTHER	DEPARTMENT	DRUGS	SUPPLIES	SERVICES	cols. 1-8)	OVERHEAD	col. 10)
		1	2	3	4	5	6	7	8	9	10	11
1	Total Renal Department Costs												1
	MAINTENANCE
2	Hemodialysis												2
3	Intermittent Peritoneal												3
	TRAINING
4	Hemodialysis												4
5	Intermittent Peritoneal												5
6	CAPD												6
7	CCPD												7
	HOME
8	Hemodialysis												8
9	Intermittent Peritoneal												9
10	CAPD												10
11	CCPD												11
	OTHER BILLABLE SERVICES
12	Inpatient Dialysis												12
13	Method II Home Patient												13
14	EPO (included in Renal Department)												14
15	ARENESP (included in Renal Department)												15
16	Other												16
17	Total (sum of lines 2 through 16)												17
18	Medical Educational Program Costs												18
19	Total Renal Costs (line 17 + line 18)												19
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4049)
40-618													Rev. 6

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Sheet 75: I3

DRAFT					FORM CMS-2552-10								4090 (Cont.)
DIRECT AND INDIRECT RENAL DIALYSIS COST ALLOCATION -							PROVIDER CCN:		PERIOD:		WORKSHEET I-3
STATISTICAL BASIS									FROM ____________
							________________		TO _______________
Check applicable box:		[ ] Renal Dialysis Department [ ] Home Program Dialysis
			CAPITAL AND
			RELATED COSTS		DIRECT PATIENT		EMPLOYEE			ROUTINE
			BUILDING	EQUIPMENT	CARE SALARY		BENEFITS		MEDICAL	ANCILLARY		OVERHEAD
	COMPOSITE PAYMENT SERVICES		(SQUARE	(% OF	RNs	OTHERS	DEPARTMENT	DRUGS	SUPPLIES	SERVICES	SUB-	(ACCUM.
			FEET)	TIME)	(HOURS)	(HOURS)	(SALARY)	(REQUIST.)	(REQUIST.)	(CHARGES)	TOTAL	COST)
			1	2	3	4	5	6	7	8	9	10
1	Total Renal Department Costs												1
	MAINTENANCE
2	Hemodialysis												2
3	Intermittent Peritoneal												3
	TRAINING
4	Hemodialysis												4
5	Intermittent Peritoneal												5
6	CAPD												6
7	CCDP												7
	HOME
8	Hemodialysis												8
9	Intermittent Peritoneal												9
10	CAPD												10
11	CCDP												11
	OTHER BILLABLE SERVICES
12	Inpatient Dialysis Treatments __________												12
13	Method II Home Patient												13
14	EPO												14
15	ARENESP												15
16	Other												16
17	Total Statistical Basis												17
18	Unit Cost Multiplier (line 1 ÷ line 17)												18
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4050)
Rev.													40-619

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Sheet 76: I4

4090 (Cont.)

FORM CMS-2552-10

DRAFT

COMPUTATION OF AVERAGE COST PER TREATMENT

PROVIDER CCN: ____________

PERIOD:

WORKSHEET I-4

FOR OUTPATIENT RENAL DIALYSIS

FROM ____________

SATELLITE CCN: ____________

TO ____________

Check applicable box:

[ ] Renal Dialysis Department [ ] Home Program Dialysis

Average Cost

Total

Average

Average

Number

Total Cost

of Program

Number

Number

Number

Program

Total

Total

Total

Average

Payment Rate

Payment Rate

of Total

(from Wkst.

Treatments

of Program

of Program

of Program

Expenses

Program

Program

Program

Payment Rate

(col. 6.01 ÷

(col. 6.02 ÷

Treatments

I-2, col. 11)

(col. 2 ÷ col. 1)

Treatments

Treatments

Treatments

(see instructions)

Payment

Payment

Payment

(col. 6 ÷ col. 4)

col. 4.01)

col. 4.02)

1

2

3

4

4.01

4.02

5

6

6.01

6.02

7

7.01

7.02

1

Maintenance - Hemodialysis

1

2

Maintenance - Peritoneal Dialysis

2

3

Training - Hemodialysis

3

4

Training - Peritoneal Dialysis

4

5

Training - Continuous Ambulatory Peritoneal Dialysis

5

6

Training - Continuous Cycling Peritoneal Dialysis

6

7

Home Program - Hemodialysis

7

8

Home Program - Peritoneal Dialysis

8

Patient Weeks

Patient Weeks

Patient Weeks

Patient Weeks

9

Home Program - Continuous Ambulatory Peritoneal Dialysis

9

10

Home Program - Continuous Cycling Peritoneal Dialysis

10

11

Totals (sum of lines 1 through 8, columns 1 and 4)

11

(sum of lines 1-10, columns 2, 5 and 6)

12

Total treatments (sum of lines 1 through 8 plus

12

(sum of lines 9 and 10 times 3))

FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4051)

40-620

Rev.

---

Sheet 77: I5

03-14		FORM CMS-2552-10				4090 (Cont.)
CALCULATION OF REIMBURSABLE			PROVIDER CCN:	PERIOD:	WORKSHEET I-5
BAD DEBTS - TITLE XVIII - PART B				FROM ____________
			________________	TO _______________
	Description
1	Total expenses related to care of program beneficiaries (see instructions)					1
				1	2
2	Total payment due (from Wkst. I-4, col. 6, line 11) (see instructions)					2
2.01	Total payment due (from Wkst. I-4, col. 6.01, line 11) (see instructions)					2.01
2.02	Total payment due(from Wkst. I-4, col. 6.02, line 11) (see instructions)					2.02
2.03	Total payment due (see instructions)					2.03
2.04	Outlier payments					2.04
3	Deductibles billed to Medicare (Part B) patients (see instructions)					3
3.01	Deductibles billed to Medicare (Part B) patients (see instructions)					3.01
3.02	Deductibles billed to Medicare (Part B) patients (see instructions)					3.02
3.03	Total deductibles billed to Medicare (Part B) patients (see instructions)					3.03
4	Coinsurance billed to Medicare (Part B) patients (see instructions)					4
4.01	Coinsurance billed to Medicare (Part B) patients (see instructions)					4.01
4.02	Coinsurance billed to Medicare (Part B) patients (see instructions)					4.02
4.03	Total coinsurance billed to Medicare (Part B) patients (see instructions)					4.03
5	Bad debts for deductibles and coinsurance, net of bad debt recoveries					5
5.01	Transition period 1 (75-25%) bad debts for deductibles and coinsurance net of bad debt recoveries for					5.01
	services rendered on or after 1/1/2011 but before 1/1/2012
5.02	Transition period 2 (50-50%) bad debts for deductibles and coinsurance net of bad debt recoveries for					5.02
	services rendered on or after 1/1/2012 but before 1/1/2013
5.03	Transition period 3 (25-75%) bad debts for deductibles and coinsurance net of bad debt recoveries for					5.03
	services rendered on or after 1/1/2013 but before 1/1/2014
5.04	100% PPS bad debts for deductibles and coinsurance net of bad debt recoveries for					5.04
	services rendered on or after 1/1/2014
5.05	Total bad debts (sum of line 5 through line 5.04)					5.05
6	Allowable bad debts (see instructions)					6
7	Reimbursable bad debts for dual eligible beneficiaries (see instructions)					7
8	Net deductibles and coinsurance billed to Medicare (Part B) patients (see instructions)					8
9	Program payment (see instructions)					9
10	Unrecovered from Medicare (Part B) patients (see instructions)					10
11	Reimbursable bad debts (see instructions) (transfer to Worksheet E, Part B, line 33)					11
PART II - CALCULATION OF FACILITY SPECIFIC COMPOSITE COST PERCENTAGE
12	Total allowable expenses (see instructions)					12
13	Total composite costs (from Wkst. I-4, col. 2, line 11)					13
14	Facility specific composite cost percentage (line 13 divided by line 12)					14
FORM CMS-2552-10 (03-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4052)
Rev. 5						40-621

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Sheet 78: J1I

4090 (Cont.)						FORM CMS-2552-10								03-14	10-12					FORM CMS-2552-10								4090 (Cont.)	4090 (Cont.)				FORM CMS-2552-10								10-12
ALLOCATION OF GENERAL SERVICE COSTS TO							PROVIDER CCN: ______________			PERIOD:		WORKSHEET J-1,			ALLOCATION OF GENERAL SERVICE COSTS TO						PROVIDER CCN: ______________			PERIOD:		WORKSHEET J-1,			ALLOCATION OF GENERAL SERVICE COSTS TO					PROVIDER CCN: ______________			PERIOD:		WORKSHEET J-1,
COMMUNITY MENTAL HEALTH CENTERS										FROM ____________		PART I			COMMUNITY MENTAL HEALTH CENTERS									FROM ____________		PART I (CONT.)			COMMUNITY MENTAL HEALTH CENTERS								FROM ____________		PART I (CONT.)
							COMPONENT CCN: ____________			TO _______________											COMPONENT CCN: ____________			TO _______________										COMPONENT CCN: ____________			TO _______________
PART I - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS															PART I - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS														PART I - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS
					NET																																INTERN &
					EXPENSES	CAPITAL														MAIN-		CENTRAL		MEDICAL			NON-								PARA-		RESIDENT		ALLOCATED
	COMPONENT COST CENTER				FOR COST	RELATED COSTS		EMPLOYEE		ADMINIS-	MAIN-		LAUNDRY			COMPONENT COST CENTER				TENANCE	NURSING	SERVICES		RECORDS		OTHER	PHYSICIAN			COMPONENT COST CENTER			INTERNS & RESIDENTS		MEDICAL	SUBTOTAL	COST & POST	SUBTOTAL	COMPONENT	TOTAL
	(omit cents)				ALLOCATION	BLDGS. &	MOVABLE	BENEFITS	SUBTOTAL	TRATIVE &	TENANCE	OPERATION	& LINEN			(omit cents)	HOUSE-			OF	ADMINIS-	&		&	SOCIAL	GENERAL	ANES-			(omit cents)		NURSING	SALARY &	PROGRAM	EDUCATION	(sum of	STEPDOWN	(sum of cols.	A&G (see	(sum of cols.
					(see instru.)	FIXTURES	EQUIPMENT	DEPARTMENT	(cols. 0-4)	GENERAL	& REPAIRS	OF PLANT	SERVICE				KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE	SERVICE	THETISTS					SCHOOL	FRINGES	COSTS	(SPECIFY)	cols. 4A-23)	ADJ.	24 ± 25)	Part II) (2)	26 ± 27)
					0	1	2	4	4A	5	6	7	8				9	10	11	12	13	14	15	16	17	18	19					20	21	22	23	24	25	26	27	28
1	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 Therapies													11	11	Individualized Activity Therapies												11	11	Individualized Activity Therapies											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	Approved Patient Training & Education													14	14	Approved Patient Training & Education												14	14	Approved 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 Others													21	21	All Others												21	21	All Others											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
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 26, line 22 must agree with the corresponding columns of Wkst. B, Part I, lines as appropriate. See instructions.															(1) Columns 0 through 26, line 22 must agree with the corresponding columns of Wkst. B, Part I, lines as appropriate. See instructions.														(1) Columns 0 through 26, line 22 must agree with the corresponding columns of Wkst. B, Part I, lines as appropriate. See instructions.
FORM CMS-2552-10 (10-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.1)															FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.1)														FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.1)
40-622														Rev. 5	Rev. 3													40-623	40-624												Rev. 3

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Sheet 79: J1II

09-13					FORM CMS-2552-10								4090 (Cont.)	4090 (Cont.)					FORM CMS-2552-10								09-13	10-12				FORM CMS-2552-10							4090 (Cont.)
ALLOCATION OF GENERAL SERVICE COSTS TO						PROVIDER CCN: ______________			PERIOD:		WORKSHEET J-1,			ALLOCATION OF GENERAL SERVICE COSTS TO						PROVIDER CCN: ______________			PERIOD:		WORKSHEET J-1,			ALLOCATION OF GENERAL SERVICE COSTS TO				PROVIDER CCN: ______________			PERIOD:		WORKSHEET J-1,
COMMUNITY MENTAL HEALTH CENTERS									FROM ____________		PART II			COMMUNITY MENTAL HEALTH CENTERS									FROM ____________		PART II (CONT.)			COMMUNITY MENTAL HEALTH CENTERS							FROM ____________		PART II (CONT.)
						COMPONENT CCN: ____________			TO _______________											COMPONENT CCN: ____________			TO _______________									COMPONENT CCN: ____________			TO _______________
PART II - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS - STATISTICAL BASIS														PART II - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS - STATISTICAL BASIS														PART II - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS - STATISTICAL BASIS
					CAPITAL														MAIN-							NON-							PARA-
					RELATED COST		EMPLOYEE		ADMINIS-	MAIN-		LAUNDRY							TENANCE	NURSING	CENTRAL		MEDICAL			PHYSICIAN					INTERNS & RESIDENTS		MEDICAL
					BLDGS &	MOVABLE	BENEFITS		TRATIVE &	TENANCE &	OPERATION	& LINEN				HOUSE-			OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL	OTHER	ANES-				NURSING	SALARY &	PROGRAM	EDUCATION
	CMHC COST CENTER				FIXTURES	EQUIPMENT	DEPARTMENT		GENERAL	REPAIRS	OF PLANT	SERVICE			CORF COST CENTER	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE	GENERAL	THETISTS			CORF COST CENTER	SCHOOL	FRINGES	COSTS	(SPECIFY)
	(omit cents)				(SQUARE	(SQUARE	(GROSS	RECONCIL-	(ACCUM.	(SQUARE	(SQUARE	(POUNDS OF			(omit cents)	(HOURS OF	(MEALS	(MEALS	(NUMBER	(DIRECT	(COSTED	(COSTED	(TIME	(TIME	SERVICE	(ASSIGNED			(omit cents)	(ASSIGNED	(ASSIGNED	(ASSIGNED	(ASSIGNED
					FEET)	FEET)	SALARIES)	IATION	COST)	FEET)	FEET)	LAUNDRY)				SERVICE)	SERVED)	SERVED)	HOUSED)	NURS. HRS)*	REQUIS.)	REQUIS.)	SPENT)	SPENT)	(SPECIFY)	TIME)				TIME)	TIME)	TIME)	TIME)
				0	1	2	4	4A	5	6	7	8				9	10	11	12	13	14	15	16	17	18	19				20	21	22	23	24	25	26	27	28
1	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 Therapies												11	11	Individualized Activity Therapies												11	11	Individualized Activity Therapies										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	Approved Patient Training & Education												14	14	Approved Patient Training & Education												14	14	Approved 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 Others												21	21	All Others												21	21	All Others										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 (see instructions)												24	24	Unit Cost Multiplier (see instructions)												24	24	Unit Cost Multiplier (see instructions)										24
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.2)														FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.2)														FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.2)
Rev. 4													40-625	40-626													Rev. 4	Rev. 3											40-627

---

Sheet 80: J2I

4090 (Cont.)				FORM CMS-2552-10							10-12
COMPUTATION OF COMMUNITY MENTAL HEALTH CENTER PROVIDER COSTS					PROVIDER CCN: ______________			PERIOD:		WORKSHEET J-2,
								FROM ____________		PART I
					COMPONENT CCN: ____________			TO _______________
PART I - APPORTIONMENT OF CMHC COST CENTERS
		(From		Ratio of		Title V		Title XVIII		Title XIX
		Wkst. J-1,	Total	Costs to	Title V	Component	Title XVIII	Component	Title XIX	Component
		Part I,	Component	Charges	Component	Costs (col. 3	Component	Costs (col. 3	Component	Costs (col. 3
		col. 28)	Charges	(col. 1 ÷ col. 2)	Charges	x col. 4)	Charges	x col. 6)	Charges	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	Approved Patient Training & Education										14
15	Prosthetic and Orthotic Devices										15
16	Drugs and Biologicals										16
17	Medical Supplies										17
18	Medical Appliances										18
19	All Others (1)										19
20	Totals (sum of lines 1-19)										20
(1)	Enter amount in column 1 from Worksheet J-1, Part I, column 28, line 21.
FORM CMS-2552-10(10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4054.1)
40-628											Rev. 3

---

Sheet 81: J2II

09-13				FORM CMS-2552-10							4090 (Cont.)
COMPUTATION OF COMMUNITY MENTAL HEALTH CENTER PROVIDER COSTS					PROVIDER CCN: ______________			PERIOD:		WORKSHEET J-2,
								FROM ____________		PART II
					COMPONENT CCN: ____________			TO _______________
PART II - APPORTIONMENT OF COST OF CMHC PROVIDER SERVICES FURNISHED BY SHARED HOSPITAL DEPARTMENTS
		(From				Title V		Title XVIII		Title XIX
		Wkst. J-1,	Total	Ratio of	Title V	Component	Title XVIII	Component	Title XIX	Component
		Part I,	Component	Costs to	Component	costs (col. 3	Component	costs (col. 3	Component	costs (col. 3
		col. 29)	Charges	Charges (1)	Charges (2)	x col. 4)	Charges (2)	x col. 6)	Charges (2)	x col. 8)
		1	2	3	4	5	6	7	8	9
21	Respiratory Therapy										21
22	Physical Therapy										22
23	Occupational Therapy										23
24	Speech Pathology										24
25	Medical Supplies Charged to Patients										25
26	Implantable Devices Charged to Patients										26
27	Drugs Charged to Patients										27
28	Total (sum of lines 21-28)										28
29	Total component costs. Add the amount from Part I, line 20										29
	and the amounts from line 28, columns 5, 7, and 9. (3)
(1)	From Worksheet C, Part I, column 9, lines as appropriate
(2)	Charges for columns 4 and 8 are obtained from your records.
(3)	Transfer the amounts on line 28, columns 5, 7, and 9, as appropriate, to Worksheet J-3, line 1.
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4054.2)
Rev. 4											40-629

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Sheet 82: J3

4090 (Cont.)			FORM CMS-2552-10				09-13
CALCULATION OF REIMBURSEMENT SETTLEMENT COMMUNITY				PROVIDER CCN:	PERIOD:	WORKSHEET J-3																								.
MENTAL HEALTH CENTER PROVIDER SERVICES				________________	FROM ____________
				COMPONENT CCN:	TO _______________
				________________
Check
applicable		[ ] Title V	[ ] Title XVIII	[ ] Title XIX
boxes:
						PROGRAM
						COST
1	Cost of component services (from Worksheet J-2, Part II, line 29)						1
2	PPS payments received excluding outliers						2
3	Outlier payments						3
4	Primary payer payments						4
5	Total reasonable cost (see instructions)						5
6	Total charges for program services						6
	CUSTOMARY CHARGES
7	Aggregate amount actually collected from patients liable for services on a charge basis						7
8	Amount that would have been realized from patients liable for payment for services on a charge						8
	basis had such payment been made in accordance with 42 CFR 413.13(e)						8
9	Ratio of line 7 to line 8 (not to exceed 1.000000) (see instructions)						9
10	Total customary charges (see instructions)						10
11	Excess of customary charges over reasonable cost (see instructions)						11
12	Excess of reasonable cost over customary charges (see instructions)						12
	COMPUTATION OF REIMBURSEMENT SETTLEMENT
13	Total reasonable cost (from line 5)						13
14	Part B deductible billed to program patients						14
15	Net cost (line 13 minus line 14)						15
16	Excess of reasonable cost over customary charges (from line 12)						16
17	Subtotal (line 15 minus line 16)						17
18	80 percent of costs (80% of line 17) (see instructions)						18
19	Actual coinsurance billed to program patients (from provider records)						19
20	Net cost less actual billed coinsurance (line 17 minus line 19)						20
21	Allowable bad debts (from provider records) (see instructions)						21
22	Adjusted reimbursable bad debts (see instructions)						22
23	Allowable bad debts for dual eligible beneficiaries (see instructions)						23
24	Net reimbursable amount (see instructions)						24
25	Other adjustments (see instructions) (specify)						25
26	Total cost (line 24 plus or minus line 25)						26
26.01	Sequestration adjustment (see instructions)						26.01
27	Interim payments (see instructions)						27
28	Tentative settlement (for contractor use only)						28
29	Balance due component/program line 26 minus lines 26.01, 27 and 28						29
30	Protested amounts (nonallowable cost report items in accordance with CMS Pub. 15-2, section 115.2)						30
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4055)
40-630							Rev. 4

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Sheet 83: J4

DRAFT				FORM CMS-2552-10					4090 (Cont.)
ANALYSIS OF PAYMENTS TO HOSPITAL-BASED COMMUNITY MENTAL HEALTH					PROVIDER CCN:		PERIOD:	WORKSHEET J-4																				.
CENTER FOR SERVICES RENDERED TO PROGRAM BENEFICIARIES					________________		FROM ____________
					COMPONENT CCN:		TO _______________
					________________
Check
applicable		[ ] Title XVIII
boxes:
							Part B
	DESCRIPTION						1	2
							mm/dd/yyyy	Amount
1	Total interim payments paid to providers								1
2	Interim payments payable on individual bills, either								2
	submitted or to be submitted to the intermediary, for
	services rendered in the cost reporting periods. If
	none, write "NONE", or enter zero.
3	List separately each retroactive					.01			3.01
	lump sum adjustment amount				Program	.02			3.02
	based on subsequent revision of				to	.03			3.03
	the interim rate for the				Provider	.04			3.04
	cost reporting period. Also show					.05			3.05
	date of each payment.					.50			3.50
	If none, write "NONE",				Provider	.51			3.51
	or enter zero (1).				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 Worksheet J-3, line 27)
	TO BE COMPLETED BY INTERMEDIARY
5	List separately each tentative				Program	.01			5.01
	settlement payment after desk review.				to	.02			5.02
	Also show date of each payment.				Provider	.03			5.03
	If none, write "NONE,"				Provider	.50			5.50
	or enter 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				Program
	(balance due) based on the cost				to
	report (see instructions). (1)				Provider	.01			6.01
					to
					Program	.02			6.02
7	Total Medicare liability (see instructions)								7
8	Name of Contractor	Contractor Number				NPR Date (Month, Day, Year)			8
(1) On lines 3, 5, and 6, where an amount is due provider to program, show the amount and date on which you agree to the amount of
	repayment, even though the total repayment is not accomplished until a later date.
FORM CMS-2552-10 (03-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4056)
Rev.									40-631

---

Sheet 84: K

4090 (Cont.)					FORM CMS-2552-10							DRAFT
ANALYSIS OF HOSPITAL-BASED						PROVIDER CCN: ______________			PERIOD:		WORKSHEET K
HOSPICE COSTS									FROM ____________
						HOSPICE CCN: ________________			TO _______________
			EMPLOYEE		CONTRACTED
		SALARIES	BENEFITS	TRANSPOR-	SERVICES				SUBTOTAL		TOTAL
	COST CENTER DESCRIPTIONS	(from	(from	TATION	(from		TOTAL	RECLASSI-	(col. 6	ADJUST-	(col. 8
		Wkst. K-1)	Wkst. K-2)	(see inst.)	Wkst. K-3)	OTHER	(cols. 1-5)	FICATION	± col. 7)	MENTS	± col. 9)
		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											25
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 thru 38)											39
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4057)
40-632												Rev.

---

Sheet 85: K1

DRAFT				FORM CMS-2552-10							4090 (Cont.)
HOSPICE COMPENSATION ANALYSIS					PROVIDER CCN: ______________			PERIOD:		WORKSHEET K-1
SALARIES AND WAGES								FROM ____________
					HOSPICE CCN: ________________			TO _______________
				MEDICAL
	COST CENTER DESCRIPTIONS	ADMINIS-		SOCIAL	SUPER-		TOTAL
	(omit cents)	TRATOR	DIRECTOR	WORKERS	VISORS	NURSES	THERAPISTS	AIDES	ALL OTHER	TOTAL (1)
		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 thru 38)										39
(1) Transfer the amount in column 9 to Wkst. K, column 1
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4058)
Rev.											40-633

---

Sheet 86: K2

4090 (Cont.)				FORM CMS-2552-10							DRAFT
HOSPICE COMPENSATION ANALYSIS EMPLOYEE					PROVIDER CCN: ______________			PERIOD:		WORKSHEET K-2
BENEFITS (PAYROLL RELATED)								FROM ____________
					HOSPICE CCN: ________________			TO _______________
				MEDICAL
	COST CENTER DESCRIPTIONS	ADMINIS-		SOCIAL	SUPER-		TOTAL
	(omit cents)	TRATOR	DIRECTOR	WORKERS	VISORS	NURSES	THERAPISTS	AIDES	ALL OTHER	TOTAL (1)
		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 thru 38)										39
(1) Transfer the amount in column 9 to Wkst. K, column 2
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4059)
40-634											Rev.

---

Sheet 87: K3

09-13				FORM CMS-2552-10							4090 (Cont.)
HOSPICE COMPENSATION ANALYSIS					PROVIDER CCN: ______________			PERIOD:		WORKSHEET K-3
CONTRACTED SERVICES/PURCHASED SERVICES								FROM ____________
					HOSPICE CCN: ________________			TO _______________
				MEDICAL
	COST CENTER DESCRIPTIONS	ADMINIS-		SOCIAL	SUPER-		TOTAL
	(omit cents)	TRATOR	DIRECTOR	WORKERS	VISORS	NURSES	THERAPISTS	AIDES	ALL OTHER	TOTAL (1)
		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 thru 38)										39
(1) Transfer the amount in column 9 to Wkst. K, column 4
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4060)
Rev. 4											40-635

---

Sheet 88: K41

4090 (Cont.)				FORM CMS-2552-10							09-13
COST ALLOCATION - HOSPICE GENERAL SERVICE COST					PROVIDER CCN: ______________			PERIOD:		WORKSHEET K-4,
								FROM ____________		PART I
					HOSPICE CCN: ________________			TO _______________
		NET					VOLUNTEER
		EXPENSES	CAPITAL RELATED COST		PLANT		SERVICES		ADMINIS-	TOTAL
	COST CENTER DESCRIPTIONS	FOR COST	BUILDINGS	MOVABLE	OPERATION	TRANS-	COORDI-	SUBTOTAL	TRATIVE &	(col. 5
		ALLOCATION	& FIXTURES	EQUIPMENT	& MAINT.	PORTATION	NATOR	(cols. 0 - 5)	GENERAL	± col. 6)
		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 thru 38)										39
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4061)
40-636											Rev. 4

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Sheet 89: K4II

09-13			FORM CMS-2552-10						4090 (Cont.)
COST ALLOCATION - HOSPICE STATISTICAL BASIS				PROVIDER CCN: ______________		PERIOD:		WORKSHEET K-4,
						FROM ____________		PART II
				HOSPICE CCN: ________________		TO _______________
		CAPITAL RELATED COST		PLANT		VOLUNTEER		ADMINIS-
		BUILDINGS	MOVABLE	OPERATION	TRANS-	SERVICES		TRATIVE &
	COST CENTER DESCRIPTIONS	& FIXTURES	EQUIPMENT	& MAINT.	PORTATION	COORDINATOR	RECONCIL-	GENERAL
		(SQ. FT.)	($ VALUE)	(SQ. FT.)	(MILEAGE)	(HOURS)	IATION	(ACC. COST)
		1	2	3	4	5	6A	6
	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								5
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, Part I)								39
40	Unit Cost Multiplier								40
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4061)
Rev. 4									40-637

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Sheet 90: K5I

4090 (Cont.)					FORM CMS-2552-10							09-13	10-12					FORM CMS-2552-10							4090 (Cont.)	4090 (Cont.)						FORM CMS-2552-10							10-12
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 (Cont.)		COSTS TO HOSPICE COST CENTERS										FROM ____________		PART I (Cont.)
						HOSPICE CCN: ________________			TO _______________										HOSPICE CCN: ________________			TO _______________											HOSPICE CCN: ________________			TO _______________
PART I - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS													PART I - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS													PART I - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS
																																			INTERN &
			From	HOSPICE	CAPITAL																								NON-				PARA-		RESIDENT		ALLOCATED	TOTAL
	HOSPICE COST CENTER		Wkst. K-4	TRIAL	RELATED COSTS		EMPLOYEE		ADMINIS-	MAIN-				HOSPICE COST CENTER	LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL				HOSPICE COST CENTER	OTHER	PHYSICIAN		INTERNS & RESIDENTS		MEDICAL		COST & POST		HOSPICE	HOSPICE
	(omit cents)		Part I,	BALANCE	BLDGS. &	MOVABLE	BENEFITS	SUBTOTAL	TRATIVE &	TENANCE &	OPERATION			(omit cents)	& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL			(omit cents)	GENERAL	ANES-	NURSING	SALARY &	PROGRAM	EDUCATION	SUBTOTAL	STEPDOWN	SUBTOTAL	A&G (see	COSTS
			col. 7,	(1)	FIXTURES	EQUIPMENT	DEPARTMENT	(cols. 0-4)	GENERAL	REPAIRS	OF PLANT				SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE				SERVICE	THETISTS	SCHOOL	FRINGES	COSTS	(SPECIFY)	(cols. 4a-23)	ADJUST.	(cols. 24 ± 25)	Part II)	(cols. 26 ± 27)
			line	0	1	2	4	4A	5	6	7				8	9	10	11	12	13	14	15	16	17				`8	19	20	21	22	23	24	25	26	27	28
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		15									10	10	Medical Social Services											10	10	Medical Social Services												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 Homemaker		19									14	14	Home Health Aide and Homemaker											14	14	Home Health Aide and Homemaker												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, Biological and Infusion Therapy		22									17	17	Drugs, Biological and Infusion Therapy											17	17	Drugs, Biological and Infusion Therapy												17
18	Analgesics		23									18	18	Analgesics											18	18	Analgesics												18
19	Sedatives / Hypnotics		24									19	19	Sedatives / Hypnotics											19	19	Sedatives / 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 (including E/R Dept.)		31									26	26	Outpatient Services (including E/R Dept.)											26	26	Outpatient Services (including 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 1-33) (2)											34	34	Totals (sum of lines 1-33) (2)											34	34	Totals (sum of lines 1-33) (2)												34
35	Unit Cost Multiplier (see instructions)											35	35	Unit Cost Multiplier (see instructions)											35	35	Unit Cost Multiplier (see instructions)												35
(1) Column 0, line 34 must agree with Wkst. A, column 7, line 116.													(1) Column 0, line 34 must agree with Wkst. A, column 7, line 116.													(1) Column 0, line 34 must agree with Wkst. A, column 7, line 116.
(2) Columns 0 through 25, line 34 must agree with the corresponding columns of Wkst. B, Part I, line 116.													(2) Columns 0 through 25, line 34 must agree with the corresponding columns of Wkst. B, Part I, line 116.													(2) Columns 0 through 25, line 34 must agree with the corresponding columns of Wkst. B, Part I, line 116.
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.1)													FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.1)													FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.1)
40-638												Rev. 4	Rev. 3												40-639	40-640													Rev. 3

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Sheet 91: K5II

09-13				FORM CMS-2552-10						4090 (Cont.)	4090 (Cont.)					FORM CMS-2552-10						09-13	10-12			FORM CMS-2552-10						4090 (Cont.)
ALLOCATION OF GENERAL SERVICE COSTS TO					PROVIDER CCN: ______________		PERIOD:		WORKSHEET K-5,		ALLOCATION OF GENERAL SERVICE COSTS TO						PROVIDER CCN: ______________		PERIOD:		WORKSHEET K-5,		ALLOCATION OF GENERAL SERVICE COSTS TO				PROVIDER CCN: ______________		PERIOD:		WORKSHEET K-5,
HOSPICE COST CENTERS STATISTICAL BASIS							FROM ____________		PART II		HOSPICE COST CENTERS STATISTICAL BASIS								FROM ____________		PART II (Cont.)		HOSPICE COST CENTERS STATISTICAL BASIS						FROM ____________		PART II (Cont.)
					HOSPICE CCN: ________________		TO _______________										HOSPICE CCN: ________________		TO _______________								HOSPICE CCN: ________________		TO _______________
PART II - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS - STATISTICAL BASIS											PART II - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS - STATISTICAL BASIS												PART II - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS - STATISTICAL BASIS
			CAPITAL																								NON-				PARA-
			RELATED COST		EMPLOYEE		ADMINIS-	MAIN-					LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL						PHYSICIAN		INTERNS & RESIDENTS		MEDICAL
			BLDGS. &	MOVABLE	BENEFITS		TRATIVE &	TENANCE &	OPERATION				& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &				SOCIAL	OTHER	ANES-	NURSING	SALARY &	PROGRAM	EDUCATION
	HOSPICE COST CENTER		FIXTURES	EQUIPMENT	DEPARTMENT		GENERAL	REPAIRS	OF PLANT			HOSPICE COST CENTER	SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY			HOSPICE COST CENTER	SERVICE	GENERAL	THETISTS	SCHOOL	FRINGES	COSTS	(SPECIFY)
			(SQUARE	(DOLLAR	(GROSS	RECONCIL-	(ACCUM.	(SQUARE	(SQUARE				(POUNDS OF	(HOURS OF	(MEALS	(MEALS	(NUMBER	(DIRECT	(COSTED	(COSTED	(TIME				(TIME	SERVICE	(ASSIGNED	(ASSIGNED	(ASSIGNED	(ASSIGNED	(ASSIGNED
			FEET)	VALUE)	SALARIES)	IATION	COST)	FEET)	FEET)				LAUNDRY)	SERVICE)	SERVED)	SERVED)	HOUSED)	NURS. HRS)	REQUIS.)	REQUIS.)	SPENT)				SPENT)	(SPECIFY)	TIME)	TIME)	TIME)	TIME)	TIME)
			1	2	4	5A	5	6	7				8	9	10	11	12	13	14	15	16				17	18	19	20	21	22	23
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									10	10	Medical Social Services										10	10	Medical Social Services								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 Homemaker									14	14	Home Health Aide and Homemaker										14	14	Home Health Aide and Homemaker								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, Biological and Infusion Therapy									17	17	Drugs, Biological and Infusion Therapy										17	17	Drugs, Biological and Infusion Therapy								17
18	Analgesics									18	18	Analgesics										18	18	Analgesics								18
19	Sedatives / Hypnotics									19	19	Sedatives / Hypnotics										19	19	Sedatives / 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 (including E/R Dept.)									26	26	Outpatient Services (including E/R Dept.)										26	26	Outpatient Services (including 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 1-33) (2)									34	34	Totals (sum of lines 1-33) (2)										34	34	Totals (sum of lines 1-33) (2)								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 (see instructions)									36	36	Unit Cost Multiplier (see instructions)										36	36	Unit Cost Multiplier (see instructions)								36
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.2)											FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.2)												FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.2)
Rev. 4										40-641	40-642											Rev. 4	Rev. 3									40-643

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Sheet 92: K5III

4090 (Cont.)		FORM CMS-2552-10					10-12
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
					Total	Hospice
			Wkst. C,		Hospice	Shared
			Part I,	Cost to	Charges	Ancillary
			col. 9,	Charge	(Provider	Costs
	COST CENTER		line	Ratio	Records)	(cols. 1 x 2)
			0	1	2	3
	ANCILLARY SERVICE COST CENTERS
1	Physical Therapy		66				1
2	Occupational Therapy		67				2
3	Speech/ Language Pathology		68				3
4	Drugs, Biological and Infusion Therapy		73				4
5	Durable Medical Equipment/Oxygen		96				5
6	Labs and Diagnostics		60				6
7	Medical Supplies		71				7
8	Outpatient Services (including E/R Dept.)		93				8
9	Radiation Therapy		55				9
10	Other		76				10
11	Totals (sum of lines 1-10)						11
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4062.3)
40-644							Rev. 3

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Sheet 93: K6

03-14			FORM CMS-2552-10				4090 (Cont.)
CALCULATION OF HOSPICE PER DIEM COST		PROVIDER CCN: ______________		PERIOD:		WORKSHEET K-6
				FROM ____________
		HOSPICE CCN: ________________		TO _______________
	COMPUTATION OF PER DIEM COST		TITLE XVIII	TITLE XIX	OTHER	TOTAL
			1	2	3	4
1	Total cost (see instructions)						1
2	Total unduplicated days (Worksheet S-9, column 6, line 5)						2
3	Average cost per diem (line 1 divided by line 2)						3
4	Unduplicated Medicare days (Worksheet S-9, column 1, line 5)						4
5	Aggregate Medicare cost (line 3 times line 4)						5
6	Unduplicated Medicaid days (Worksheet S-9, column 2, line 5)						6
7	Aggregate Medicaid cost (line 3 times line 6)						7
8	Unduplicated SNF days (Worksheet S-9, column 3, line 5)						8
9	Aggregate SNF cost (line 3 times line 8)						9
10	Unduplicated NF days (Worksheet S-9, column 4, line 5)						10
11	Aggregate NF cost (line 3 times line 10)						11
12	Other Unduplicated days (Worksheet S-9, column 5, line 5)						12
13	Aggregate cost for other days (line 3 times line 12)						13
Note: The data for the SNF and NF on lines 8 through 11 are included in the Medicare and Medicaid lines 4 through 7.
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4063)
Rev. 5							40-645

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Sheet 94: L

4090 (Cont.)				FORM CMS-2552-10				03-14
CALCULATION OF CAPITAL PAYMENT			PROVIDER CCN:		PERIOD:		WORKSHEET L
			________________		FROM ____________
			COMPONENT CCN:		TO _______________
			________________
Check		[ ] Title V		[ ] Hospital		[ ] PPS
applicable		[ ] Title XVIII, Part A		[ ] Subprovider (other)		[ ] Cost Method
boxes:		[ ] Title XIX
PART I - FULLY PROSPECTIVE METHOD
	CAPITAL FEDERAL AMOUNT
1	Capital DRG other than outlier							1
1.01	Model 4 BPCI Capital DRG other than outlier							1.01
2	Capital DRG outlier payments							2
2.01	Model 4 BPCI Capital DRG outlier payments							2.01
3	Total inpatient days divided by number of days in the cost reporting period (see instructions)							3
4	Number of interns & residents (see instructions)							4
5	Indirect medical education percentage (see instructions)							5
6	Indirect medical education adjustment (multiply line 5 by the sum of lines 1 and 1.01)							6
7	Percentage of SSI recipient patient days to Medicare Part A patient days (Worksheet E, Part A line 30) (see instructions)							7
8	Percentage of Medicaid patient days to total days (see instructions)							8
9	Sum of lines 7 and 8							9
10	Allowable disproportionate share percentage (see instructions)							10
11	Disproportionate share adjustment (line 10 times the sum of lines 1 and 1.01)							11
12	Total prospective capital payments (sum of lines 1, 1.01, 2, 2.01, 6 and 11)							12
PART II - PAYMENT UNDER REASONABLE COST
1	Program inpatient routine capital cost (see instructions)							1
2	Program inpatient ancillary capital cost (see instructions)							2
3	Total inpatient program capital cost (line 1 plus line 2)							3
4	Capital cost payment factor (see instructions)							4
5	Total inpatient program capital cost (line 3 x line 4)							5
PART III - COMPUTATION OF EXCEPTION PAYMENTS
1	Program inpatient capital costs (see instructions)							1
2	Program inpatient capital costs for extraordinary circumstances (see instructions)							2
3	Net program inpatient capital costs (line 1 minus line 2)							3
4	Applicable exception percentage (see instructions)							4
5	Capital cost for comparison to payments (line 3 x line 4)							5
6	Percentage adjustment for extraordinary circumstances (see instructions)							6
7	Adjustment to capital minimum payment level for extraordinary circumstances (line 2 x line 6)							7
8	Capital minimum payment level (line 5 plus line 7)							8
9	Current year capital payments (from Part I, line 12 as applicable)							9
10	Current year comparison of capital minimum payment level to capital payments (line 8 less line 9)							10
11	Carryover of accumulated capital minimum payment level over capital payment							11
	(from prior year Worksheet L, Part III, line 14)
12	Net comparison of capital minimum payment level to capital payments (line 10 plus line 11)							12
13	Current year exception payment (if line 12 is positive, enter the amount on this line)							13
14	Carryover of accumulated capital minimum payment level over capital payment							14
	for the following period (if line 12 is negative, enter the amount on this line)
15	Current year allowable operating and capital payment (see instructions)							15
16	Current year operating and capital costs (see instructions)							16
17	Current year exception offset amount (see instructions)							17
FORM CMS-2552-10 (03-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4064.1 - 4064.3)
40-646								Rev. 5

---

Sheet 95: L1I

09-13			FORM CMS-2552-10							4090 (Cont.)	4090 (Cont.)				FORM CMS-2552-10								09-13	4090 (Cont.)				FORM CMS-2552-10							09-13
ALLOCATION OF ALLOWABLE COSTS FOR					PROVIDER CCN:		PERIOD:		WORKSHEET L-1,		ALLOCATION OF ALLOWABLE COSTS FOR							PROVIDER CCN:		PERIOD:		WORKSHEET L-1,		ALLOCATION OF ALLOWABLE COSTS FOR						PROVIDER CCN:		PERIOD:		WORKSHEET L-1,
EXTRAORDINARY CIRCUMSTANCES							FROM ____________		PART I		EXTRAORDINARY CIRCUMSTANCES									FROM ____________		PART I (Cont.)		EXTRAORDINARY CIRCUMSTANCES								FROM ____________		PART I (Cont.)
					________________		TO _______________											________________		TO _______________										________________		TO _______________
		EXTRA-	CAPITAL																														INTERN &
		ORDINARY	RELATED COSTS																								NON-		INTERNS &	INTERNS &	PARA-		RESIDENT
		CAPITAL			SUBTOTAL	EMPLOYEE	ADMINIS-	MAIN-					LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL					OTHER	PHYSICIAN		RESIDENTS	RESIDENTS	MEDICAL		COST & POST
	Cost Center Descriptions	RELATED	BLDGS. &	MOVABLE	(sum of	BENEFITS	TRATIVE &	TENANCE &	OPERATION			Cost Center Descriptions	& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL			Cost Center Descriptions	GENERAL	ANES-	NURSING	SALARY &	PROGRAM	EDUCATION		STEPDOWN
		COSTS	FIXTURES	EQUIPMENT	cols. 0-2)	DEPARTMENT	GENERAL	REPAIRS	OF PLANT				SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE				SERVICE	THETISTS	SCHOOL	FRINGES	COSTS	(SPECIFY)	SUBTOTAL	ADJUSTMENTS	TOTAL
		0	1	2	2A	4	5	6	7				8	9	10	11	12	13	14	15	16	17				18	19	20	21	22	23	24	25	26
	GENERAL SERVICE COST CENTERS											GENERAL SERVICE COST CENTERS													GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Buildings and Fixtures									1	1	Capital Related Costs-Buildings and Fixtures											1	1	Capital Related Costs-Buildings and Fixtures										1
2	Capital Related Costs-Movable Equipment									2	2	Capital Related Costs-Movable Equipment											2	2	Capital Related Costs-Movable Equipment										2
4	Employee Benefits Department									4	4	Employee Benefits Department											4	4	Employee Benefits Department										4
5	Administrative and General									5	5	Administrative and General											5	5	Administrative and General										5
6	Maintenance and Repairs									6	6	Maintenance and Repairs											6	6	Maintenance and Repairs										6
7	Operation of Plant									7	7	Operation of Plant											7	7	Operation of Plant										7
8	Laundry and Linen Service									8	8	Laundry and Linen Service											8	8	Laundry and Linen Service										8
9	Housekeeping									9	9	Housekeeping											9	9	Housekeeping										9
10	Dietary									10	10	Dietary											10	10	Dietary										10
11	Cafeteria									11	11	Cafeteria											11	11	Cafeteria										11
12	Maintenance of Personnel									12	12	Maintenance of Personnel											12	12	Maintenance of Personnel										12
13	Nursing Administration									13	13	Nursing Administration											13	13	Nursing Administration										13
14	Central Services and Supply									14	14	Central Services and Supply											14	14	Central Services and Supply										14
15	Pharmacy									15	15	Pharmacy											15	15	Pharmacy										15
16	Medical Records & Medical Records Library									16	16	Medical Records & Medical Records Library											16	16	Medical Records & Medical Records Library										16
17	Social Service									17	17	Social Service											17	17	Social Service										17
18	Other General Service (specify)									18	18	Other General Service (specify)											18	18	Other General Service (specify)										18
19	Nonphysician Anesthetists									19	19	Nonphysician Anesthetists											19	19	Nonphysician Anesthetists										19
20	Nursing School									20	20	Nursing School											20	20	Nursing School										20
21	Intern & Res. Service-Salary & Fringes (Approved)									21	21	Intern & Res. Service-Salary & Fringes (Approved)											21	21	Intern & Res. Service-Salary & Fringes (Approved)										21
22	Intern & Res. Other Program Costs (Approved)									22	22	Intern & Res. Other Program Costs (Approved)											22	22	Intern & Res. Other Program Costs (Approved)										22
23	Paramedical Ed. Program (specify)									23	23	Paramedical Ed. Program (specify)											23	23	Paramedical Ed. Program (specify)										23
	INPATIENT ROUTINE SERVICE COST CENTERS											INPATIENT ROUTINE SERVICE COST CENTERS													INPATIENT ROUTINE SERVICE COST CENTERS
30	Adults and Pediatrics (General Routine Care)									30	30	Adults and Pediatrics (General Routine Care)											30	30	Adults and Pediatrics (General Routine Care)										30
31	Intensive Care Unit									31	31	Intensive Care Unit											31	31	Intensive Care Unit										31
32	Coronary Care Unit									32	32	Coronary Care Unit											32	32	Coronary Care Unit										32
33	Burn Intensive Care Unit									33	33	Burn Intensive Care Unit											33	33	Burn Intensive Care Unit										33
34	Surgical Intensive Care Unit									34	34	Surgical Intensive Care Unit											34	34	Surgical Intensive Care Unit										34
35	Other Special Care Unit (specify)									35	35	Other Special Care Unit (specify)											35	35	Other Special Care Unit (specify)										35
40	Subprovider IPF									40	40	Subprovider IPF											40	40	Subprovider IPF										40
41	Subprovider IRF									41	41	Subprovider IRF											41	41	Subprovider IRF										41
42	Subprovider									42	42	Subprovider											42	42	Subprovider										42
43	Nursery									43	43	Nursery											43	43	Nursery										43
44	Skilled Nursing Facility									44	44	Skilled Nursing Facility											44	44	Skilled Nursing Facility										44
45	Nursing Facility									45	45	Nursing Facility											45	45	Nursing Facility										45
46	Other Long Term Care									46	46	Other Long Term Care											46	46	Other Long Term Care										46
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)											FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)													FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)
Rev. 4										40-647	40-650												Rev. 4	Rev. 4											40-653
4690 (Cont.)			FORM CMS-2552-10							09-13	10-12				FORM CMS-2552-10								4090 (Cont.)	4690 (Cont.)				FORM CMS-2552-10							09-13
ALLOCATION OF ALLOWABLE COSTS FOR					PROVIDER CCN:		PERIOD:		WORKSHEET L-1,		ALLOCATION OF ALLOWABLE COSTS FOR							PROVIDER CCN:		PERIOD:		WORKSHEET L-1,		ALLOCATION OF ALLOWABLE COSTS FOR						PROVIDER CCN:		PERIOD:		WORKSHEET L-1,
EXTRAORDINARY CIRCUMSTANCES							FROM ____________		PART I (Cont.)		EXTRAORDINARY CIRCUMSTANCES									FROM ____________		PART I (Cont.)		EXTRAORDINARY CIRCUMSTANCES								FROM ____________		PART I (Cont.)
					________________		TO _______________											________________		TO _______________										________________		TO _______________
		EXTRA-	CAPITAL																														INTERN &
		ORDINARY	RELATED COSTS																										INTERNS &	INTERNS &			RESIDENT
		CAPITAL			SUBTOTAL	EMPLOYEE	ADMINIS-	MAIN-					LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL					OTHER			RESIDENTS	RESIDENTS	PARAMEDICAL		COST & POST
	Cost Center Descriptions	RELATED	BLDGS. &	MOVABLE	(sum of	BENEFITS	TRATIVE &	TENANCE &	OPERATION			Cost Center Descriptions	& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL			Cost Center Descriptions	GENERAL	NONPHYSICIAN	NURSING	SALARY AND	PROGRAM	EDUCATION		STEPDOWN
		COSTS	FIXTURES	EQUIPMENT	cols. 0-2)	DEPARTMENT	GENERAL	REPAIRS	OF PLANT				SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE				SERVICE	ANESTHETISTS	SCHOOL	FRINGES	COSTS	(SPECIFY)	SUBTOTAL	ADJUSTMENTS	TOTAL
		0	1	2	2A	4	5	6	7				8	9	10	11	12	13	14	15	16	17				18	19	20	21	22	23	24	25	26
	ANCILLARY SERVICE COST CENTERS											ANCILLARY SERVICE COST CENTERS													ANCILLARY SERVICE COST CENTERS
50	Operating Room									50	50	Operating Room											50	50	Operating Room										50
51	Recovery Room									51	51	Recovery Room											51	51	Recovery Room										51
52	Labor Room and Delivery Room									52	52	Labor Room and Delivery Room											52	52	Labor Room and Delivery Room										52
53	Anesthesiology									53	53	Anesthesiology											53	53	Anesthesiology										53
54	Radiology-Diagnostic									54	54	Radiology-Diagnostic											54	54	Radiology-Diagnostic										54
55	Radiology-Therapeutic									55	55	Radiology-Therapeutic											55	55	Radiology-Therapeutic										55
56	Radioisotope									56	56	Radioisotope											56	56	Radioisotope										56
57	Computed Tomography (CT) Scan									57	57	Computed Tomography (CT) Scan											57	57	Computed Tomography (CT) Scan										57
58	Magnetic Resonance Imaging (MRI)									58	58	Magnetic Resonance Imaging (MRI)											58	58	Magnetic Resonance Imaging (MRI)										58
59	Cardiac Catherization									59	59	Cardiac Catherization											59	59	Cardiac Catherization										59
60	Laboratory									60	60	Laboratory											60	60	Laboratory										60
61	PBP Clinical Laboratory Service-Program Only									61	61	PBP Clinical Laboratory Service-Program Only											61	61	PBP Clinical Laboratory Service-Program Only										61
62	Whole Blood & Packed Red Blood Cells									62	62	Whole Blood & Packed Red Blood Cells											62	62	Whole Blood & Packed Red Blood Cells										62
63	Blood Storing, Processing, & Trans.									63	63	Blood Storing, Processing, & Trans.											63	63	Blood Storing, Processing, & Trans.										63
64	Intravenous Therapy									64	64	Intravenous Therapy											64	64	Intravenous Therapy										64
65	Respiratory Therapy									65	65	Respiratory Therapy											65	65	Respiratory Therapy										65
66	Physical Therapy									66	66	Physical Therapy											66	66	Physical Therapy										66
67	Occupational Therapy									67	67	Occupational Therapy											67	67	Occupational Therapy										67
68	Speech Pathology									68	68	Speech Pathology											68	68	Speech Pathology										68
69	Electrocardiology									69	69	Electrocardiology											69	69	Electrocardiology										69
70	Electroencephalography									70	70	Electroencephalography											70	70	Electroencephalography										70
71	Medical Supplies Charged to Patients									71	71	Medical Supplies Charged to Patients											71	71	Medical Supplies Charged to Patients										71
72	Implantable Devices Charged to Patients									72	72	Implantable Devices Charged to Patients											72	72	Implantable Devices Charged to Patients										72
73	Drugs Charged to Patients									73	73	Drugs Charged to Patients											73	73	Drugs Charged to Patients										73
74	Renal Dialysis									74	74	Renal Dialysis											74	74	Renal Dialysis										74
75	ASC (Non-Distinct Part)									75	75	ASC (Non-Distinct Part)											75	75	ASC (Non-Distinct Part)										75
76	Other Ancillary (specify)									76	76	Other Ancillary (specify)											76	76	Other Ancillary (specify)										76
	OUTPATIENT SERVICE COST CENTERS											OUTPATIENT SERVICE COST CENTERS													OUTPATIENT SERVICE COST CENTERS										0
88	Rural Health Clinic (RHC)									88	88	Rural Health Clinic (RHC)											88	88	Rural Health Clinic (RHC)										88
89	Federally Qualified Health Center (FQHC)									89	89	Federally Qualified Health Center (FQHC)											89	89	Federally Qualified Health Center (FQHC)										89
90	Clinic									90	90	Clinic											90	90	Clinic										90
91	Emergency									91	91	Emergency											91	91	Emergency										91
92	Observation Beds									92	92	Observation Beds											92	92	Observation Beds										92
93	Other Outpatient (specify)									93	93	Other Outpatient (specify)											93	93	Other Outpatient (specify)										93
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)											FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)													FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)
40-648										Rev. 4	Rev. 3												40-651	40-654											Rev. 4
09-13			FORM CMS-2552-10							4090 (Cont.)	4090 (Cont.)				FORM CMS-2552-10								10-12	10-12				FORM CMS-2552-10							4090 (Cont.)
ALLOCATION OF ALLOWABLE COSTS FOR					PROVIDER CCN:		PERIOD:		WORKSHEET L-1,		ALLOCATION OF ALLOWABLE COSTS FOR							PROVIDER CCN:		PERIOD:		WORKSHEET L-1,		ALLOCATION OF ALLOWABLE COSTS FOR						PROVIDER CCN:		PERIOD:		WORKSHEET L-1,
EXTRAORDINARY CIRCUMSTANCES							FROM ____________		PART I (Cont.)		EXTRAORDINARY CIRCUMSTANCES									FROM ____________		PART I (Cont.)		EXTRAORDINARY CIRCUMSTANCES								FROM ____________		PART I (Cont.)
					________________		TO _______________											________________		TO _______________										________________		TO _______________
		EXTRA-	CAPITAL																														INTERN &
		ORDINARY	RELATED COSTS																										INTERNS &	INTERNS &			RESIDENT
		CAPITAL			SUBTOTAL	EMPLOYEE	ADMINIS-	MAIN-					LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL					OTHER			RESIDENTS	RESIDENTS	PARAMEDICAL		COST & POST
	Cost Center Descriptions	RELATED	BLDGS. &	MOVABLE	(sum of	BENEFITS	TRATIVE &	TENANCE &	OPERATION			Cost Center Descriptions	& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL			Cost Center Descriptions	GENERAL	NONPHYSICIAN	NURSING	SALARY AND	PROGRAM	EDUCATION		STEPDOWN
		COSTS	FIXTURES	EQUIPMENT	cols. 0-4)	DEPARTMENT	GENERAL	REPAIRS	OF PLANT				SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE				SERVICE	ANESTHETISTS	SCHOOL	FRINGES	COSTS	(SPECIFY)	SUBTOTAL	ADJUSTMENTS	TOTAL
		0	1	2	2A	4	5	6	7				8	9	10	11	12	13	14	15	16	17				18	19	20	21	22	23	24	25	26
	OTHER REIMBURSABLE COST CENTERS											OTHER REIMBURSABLE COST CENTERS													OTHER REIMBURSABLE COST CENTERS
94	Home Program Dialysis									94	94	Home Program Dialysis											94	94	Home Program Dialysis										94
95	Ambulance Services									95	95	Ambulance Services											95	95	Ambulance Services										95
96	Durable Medical Equipment-Rented									96	96	Durable Medical Equipment-Rented											96	96	Durable Medical Equipment-Rented										96
97	Durable Medical Equipment-Sold									97	97	Durable Medical Equipment-Sold											97	97	Durable Medical Equipment-Sold										97
98	Other Reimbursable (specify)									98	98	Other Reimbursable (specify)											98	98	Other Reimbursable (specify)										98
99	Outpatient Rehabilitation Provider (specify)									99	99	Outpatient Rehabilitation Provider (specify)											99	99	Outpatient Rehabilitation Provider (specify)										99
100	Intern-Resident Service (not appvd. tchng. prgm.)									100	100	Intern-Resident Service (not appvd. tchng. prgm.)											100	100	Intern-Resident Service (not appvd. tchng. prgm.)										100
101	Home Health Agency									101	101	Home Health Agency											101	101	Home Health Agency										101
	SPECIAL PURPOSE COST CENTERS									0		SPECIAL PURPOSE COST CENTERS													SPECIAL PURPOSE COST CENTERS
105	Kidney Acquisition									105	105	Kidney Acquisition											105	105	Kidney Acquisition										105
106	Heart Acquisition									106	106	Heart Acquisition											106	106	Heart Acquisition										106
107	Liver Acquisition									107	107	Liver Acquisition											107	107	Liver Acquisition										107
108	Lung Acquisition									108	108	Lung Acquisition											108	108	Lung Acquisition										108
109	Pancreas Acquisition									109	109	Pancreas Acquisition											109	109	Pancreas Acquisition										109
110	Intestinal Acquisition									110	110	Intestinal Acquisition											110	110	Intestinal Acquisition										110
111	Islet Acquisition									111	111	Islet Acquisition											111	111	Islet Acquisition										111
112	Other Organ Acquisition (specify)									112	112	Other Organ Acquisition (specify)											112	112	Other Organ Acquisition (specify)										112
115	Ambulatory Surgical Center (Distinct Part)									115	115	Ambulatory Surgical Center (Distinct Part)											115	115	Ambulatory Surgical Center (Distinct Part)										115
116	Hospice									116	116	Hospice											116	116	Hospice										116
117	Other Special Purpose (specify)									117	117	Other Special Purpose (specify)											117	117	Other Special Purpose (specify)										117
118	SUBTOTALS (sum of lines 1-117)									118	118	SUBTOTALS (sum of lines 1-117)											118	118	SUBTOTALS (sum of lines 1-117)										118
	NONREIMBURSABLE COST CENTERS											NONREIMBURSABLE COST CENTERS													NONREIMBURSABLE COST CENTERS
190	Gift, Flower, Coffee Shop, & Canteen									190	190	Gift, Flower, Coffee Shop, & Canteen											190	190	Gift, Flower, Coffee Shop, & Canteen										190
191	Research									191	191	Research											191	191	Research										191
192	Physicians' Private Offices									192	192	Physicians' Private Offices											192	192	Physicians' Private Offices										192
193	Nonpaid Workers									193	193	Nonpaid Workers											193	193	Nonpaid Workers										193
194	Other Nonreimbursable (specify)									194	194	Other Nonreimbursable (specify)											194	194	Other Nonreimbursable (specify)										194
200	Cross Foot Adjustments									200	200	Cross Foot Adjustments											200	200	Cross Foot Adjustments										200
201	Negative Cost Centers									201	201	Negative Cost Centers											201	201	Negative Cost Centers										201
202	Total (sum of line 118 and lines190-201)									202	202	Total (sum of line 118 and lines190-201)											202	202	Total (sum of line 118 and lines190-201)										202
203	Total Statistical Basis									203	203	Total Statistical Basis											203	203	Total Statistical Basis										203
204	Unit Cost Multiplier									204	204	Unit Cost Multiplier											204	204	Unit Cost Multiplier										204
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)											FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)													FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)
Rev. 4										40-649	40-652												Rev. 3	Rev. 3											40-655

---

Sheet 96: L1II

4090 (Cont.)

FORM CMS-2552-10

10-12

COMPUTATION OF PROGRAM INPATIENT ROUTINE SERVICE

PROVIDER CCN:

PERIOD:

WORKSHEET L-1,

CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES

FROM ____________

PART II

________________

TO _______________

Check

[ ] Title V

-

-

-

-

-

-

-

-

applicable

[ ] Title XVIII, Part A

PROVIDER NO.

PERIOD

TITLE XIX

box:

[ ] Title XIX

FROM 7-1-85

HOSPITAL

Capital Cost

Reduced

for Extraordinary

Capital Cost

OO-OOO1

TO 6-30-85

TEFRA

Circumstances

for Extraordinary

Inpatient Program

-

-

-

-

-

-

-

-

-

-

-

(from Wkst. L-1,

Swing Bed

Circumstances

Total

Per Diem

Inpatient

Capital Cost

CAPITAL

REDUCED

SWING-BED

TOTAL

INPATIENT

PROGRAM

Cost Center Description

Part I, col. 26)

Adjustment

(col. 1 - col. 2)

Patient Days

(col. 3 ÷ col. 4)

Program Days

(col. 5 x col. 6)

CAPITAL

REDUCTION

CAPITAL

NONPHYSICIAN

MEDICAL

ADJUSTMENT

PATIENT

PER DIEM

PROGRAM

PASS THROUGH

(A)

1

2

3

4

5

6

7

INPATIENT ROUTINE SERVICE

COST CENTERS

30

Adults & Pediatrics (General Routine Care)

30

31

Intensive Care Unit

31

32

Coronary Care Unit

32

33

Burn Intensive Care Unit

33

34

Surgical Intensive Care Unit

34

35

Other Special Care Unit (specify)

35

40

Subprovider IPF

40

41

Subprovider IRF

41

42

Subprovider (Other)

42

43

Nursery

43

200

Total (sum of lines 30-199)

200

(A) Worksheet A line numbers

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.2)

40-656

Rev. 3

---

Sheet 97: L1III

10-12				FORM CMS-2552-10						4090 (Cont.)
COMPUTATION OF PROGRAM INPATIENT ANCILLARY SERVICE							PROVIDER CCN:	PERIOD:	WORKSHEET L-1,
CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES							________________	FROM ____________	PART III
							COMPONENT CCN:	TO _______________
							________________
Check		[ ] Hospital		[ ] Title V
applicable		[ ] Subprovider		[ ] Title XVIII, Part A
boxes:				[ ] Title XIX
					Capital Cost for
					Extraordinary				Program
					Circumstances	Total Charges	Ratio of Cost		Extraordinary
	Cost Center Description				(from Wkst. L-1,	(from Wkst. C,	to Charges	Inpatient	Capital Cost
					Part I, col. 26)	Part I, col. 6)	(col. 1 ÷ col. 2)	Program Charges	(col. 3 x col. 4)
(A)					1	2	3	4	5
	ANCILLARY SERVICE COST CENTERS
50	Operating Room									50
51	Recovery Room									51
52	Labor Room and Delivery Room									52
53	Anesthesiology									53
54	Radiology-Diagnostic									54
55	Radiology-Therapeutic									55
56	Radioisotope									56
57	Computed Tomography (CT) Scan									57
58	Magnetic Resonance Imaging (MRI)									58
59	Cardiac Catherization									59
60	Laboratory									60
61	PBP Clinical Laboratory Service-Program Only									61
62	Whole Blood & Packed Red Blood Cells									62
63	Blood Storing, Processing, & Trans.									63
64	Intravenous Therapy									64
65	Respiratory Therapy									65
66	Physical Therapy									66
67	Occupational Therapy									67
68	Speech Pathology									68
69	Electrocardiology									69
70	Electroencephalography									70
71	Medical Supplies Charged to Patients									71
72	Implantable Devices Charged to Patients									72
73	Drugs Charged to Patients									73
74	Renal Dialysis									74
75	ASC (Non-Distinct Part)									75
76	Other Ancillary (specify)									76
	(A) Worksheet A line numbers
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4065.3)
Rev. 3										40-657
4090 (Cont.)				FORM CMS-2552-10						10-12
COMPUTATION OF PROGRAM INPATIENT ANCILLARY SERVICE							PROVIDER CCN:	PERIOD:	WORKSHEET L-1,
CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES							________________	FROM ____________	PART III (CONT.)
							COMPONENT CCN:	TO _______________
							________________
Check		[ ] Hospital		[ ] Title V
applicable		[ ] Subprovider		[ ] Title XVIII, Part A
boxes:				[ ] Title XIX
					Capital Cost for
					Extraordinary				Program
					Circumstances	Total Charges	Ratio of Cost		Extraordinary
	Cost Center Description				(from Wkst. L-1,	(from Wkst. C,	to Charges	Inpatient	Capital Cost
					Part I, col. 26)	Part I, col. 6)	(col. 1 ÷ col. 2)	Program Charges	(col. 3 x col. 4)
(A)					1	2	3	4	5
	OUTPATIENT SERVICE COST CENTERS
88	Rural Health Clinic (RHC)									88
89	Federally Qualified Health Center (FQHC)									89
90	Clinic									90
91	Emergency									91
92	Observation Beds									92
93	Other Outpatient (specify)									93
	OTHER REIMBURSABLE COST CENTERS
94	Home Program Dialysis									94
95	Ambulance Services									95
96	Durable Medical Equipment-Rented									96
97	Durable Medical Equipment-Sold									97
98	Other Reimbursable (specify)									98
200	Total (sum of lines 50 through 199)									200
	(A) Worksheet A line numbers
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4065.3)
40-658										Rev. 3

---

Sheet 98: M1

DRAFT					FORM CMS-2552-10					4090 (Cont.)
ANALYSIS OF HOSPITAL-BASED RHC/FQHC COSTS							PROVIDER CCN:	PERIOD:	WORKSHEET M-1
							________________	FROM ____________
							COMPONENT CCN:	TO _______________
							________________
Check applicable box:		[ ] Hospital-based RHC [ ] Hospital-based FQHC
							RECLASSIFIED		NET EXPENSES
							TRIAL		FOR
			COMPEN-		TOTAL	RECLASS-	BALANCE		ALLOCATION
			SATION	OTHER COSTS	(col. 1 + col. 2)	IFICATIONS	(col. 3 + col. 4)	ADJUSTMENTS	(col. 5 + col. 6)
			1	2	3	4	5	6	7
	FACILITY 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 Facility 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
20	Allowable GME Costs									20
21	Subtotal (sum of lines 15-20)									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 nonreimbursable costs									26
27	Nonallowable GME costs									27
28	Total Nonreimbursable Costs (sum of lines 23-27)									28
	FACILITY OVERHEAD
29	Facility Costs									29
30	Administrative Costs									30
31	Total Facility Overhead (sum of lines 29 and 30)									31
32	Total facility costs (sum of lines 22, 28 and 31)									32
The net expenses for cost allocation on Worksheet A for the hospital-based RHC/FQHC cost center line must equal the total facility costs in column 7, line 32 of this worksheet.
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4066)
Rev.										40-659

---

Sheet 99: M2

4090 (Cont.)			FORM CMS-2552-10				DRAFT
ALLOCATION OF OVERHEAD				PROVIDER CCN:	PERIOD:	WORKSHEET M-2
TO HOSPTIAL-BASED RHC/FQHC SERVICES				________________	FROM ____________
				COMPONENT CCN:	TO _______________
				________________
Check applicable box:		[ ] Hospital-based RHC [ ] Hospital-based FQHC
VISITS AND PRODUCTIVITY
		Number			Minimum	Greater of
		of FTE	Total	Productivity	Visits (col. 1	col. 2 or
		Personnel	Visits	Standard (1)	x col. 3)	col. 4
	Positions	1	2	3	4	5
1	Physicians						1
2	Physician Assistants						2
3	Nurse Practitioners						3
4	Subtotal (sum of lines 1-3)						4
5	Visiting Nurse						5
6	Clinical Psychologist						6
7	Clinical Social Worker						7
7.01	Medical Nutrition Therapist (FQHC only)						7.01
7.02	Diabetes Self Management Training (FQHC only)						7.02
8	Total FTEs and Visits (sum of lines 4-7)						8
9	Physician Services Under Agreements						9
DETERMINATION OF ALLOWABLE COST APPLICABLE TO RHC/FQHC SERVICES
10	Total costs of health care services (from Worksheet M-1, column 7, line 22)						10
11	Total nonreimbursable costs (from Worksheet M-1, column 7, line 28)						11
12	Cost of all services (excluding overhead) (sum of lines 10 and 11)						12
13	Ratio of hospital-based RHC/FQHC services (line 10 divided by line 12)						13
14	Total hospital-based RHC/FQHC overhead (from Worksheet M-1, column 7, line 31)						14
15	Parent provider overhead allocated to facility (see instructions)						15
16	Total overhead (sum of lines 14 and 15)						16
17	Allowable Direct GME overhead (see instructions)						17
18	Enter the amount from line 16						18
19	Overhead applicable to hospital-based RHC/FQHC services (line 13 x line 18)						19
20	Total allowable cost of hospital-based RHC/FQHC services (sum of lines 10 and 19)						20
(1)	The productivity standard for physicians is 4,200 and 2,100 for physician assistants and nurse practitioners. If an exception
	to the standard has been granted (Worksheet S-8, line 12 equals "Y"), column 3, lines 1thru 3 of this worksheet should contain,
	at a minimum, one element that is different than the standard.
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4067)
40-660							Rev.

---

Sheet 100: M3

DRAFT			FORM CMS-2552-10				4090(Cont.)
CALCULATION OF REIMBURSEMENT				PROVIDER CCN:	PERIOD:	WORKSHEET M-3
SETTLEMENT FOR HOSPITAL-BASED RHC/FQHC SERVICES				________________	FROM ____________
				COMPONENT CCN:	TO _______________
				________________
Check		[ ] Hospital-based RHC	[ ] Title V	[ ] Title XIX
applicable boxes:		[ ] Hospital-based FQHC	[ ] Title XVIII
DETERMINATION OF RATE FOR HOSPITAL-BASED RHC/FQHC SERVICES
1	Total allowable cost of hospital-based RHC/FQHC services (from Worksheet M-2, line 20)						1
2	Cost of vaccines and their administration (from Worksheet M-4, line 15)						2
3	Total allowable cost excluding vaccine (line 1 minus line 2)						3
4	Total visits (from Worksheet M-2, column 5, line 8)						4
5	Physicians visits under agreement (from Worksheet M-2, column 5, line 9)						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 (1)
					Prior to	On or after
					January 1	January 1
					1	2
8	Per visit payment limit (from CMS Pub. 100-04, chapter 9, §20.6 or your contractor)						8
9	Rate for Program covered visits (see instructions)						9
CALCULATION OF SETTLEMENT
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 from mental health services (line 9 x line 12)						13
14	Limit adjustment for mental health services (see instructions)						14
15	Graduate Medical Education pass-through cost (see instructions)						15
16	Total Program cost (sum of lines 11, 14, and 15, columns 1, 2 and 3)						16
16.01	Total program charges (see instructions)(from contractor's records)						16.01
16.02	Total program preventive charges (see instructions)(from provider's records)						16.02
16.03	Total program preventive costs (see instructions)						16.03
16.04	Total program non-preventive costs (see instructions)						16.04
16.05	Total program cost (see instructions)						16.05
17	Primary payer amounts						17
18	Less: Beneficiary deductible for RHC only (see instructions) (from contractor records)						18
19	Less: Beneficiary coinsurance for RHC/FQHC services (see instructions) (from contractor records)						19
20	Net Medicare cost excluding vaccines (see instructions)						20
21	Program cost of vaccines and their administration (from Worksheet M-4, line 16)						21
22	Total reimbursable Program cost (line 20 plus line 21)						22
23	Allowable bad debts (see instructions)						23
23.01	Adjusted reimbursable bad debts (see instructions)						23.01
24	Allowable bad debts for dual eligible beneficiaries (see instructions)						24
25	Other adjustments (specify) (see instructions)						25
26	Net reimbursable amount (see instructions)						26
26.01	Sequestration adjustment (see instructions)						26.01
27	Interim payments						27
28	Tentative settlement (for contractor use only)						28
29	Balance due component/program line 26 minus lines 26.01, 27 and 28						29
30	Protested amounts (nonallowable cost report items) in accordance with CMS						30
	Pub. 15-2, chapter 1, section 115.2
(1) Lines 8 through 14: Fiscal year providers use columns 1 & 2, calendar year providers use column 2 only.
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4068)
Rev.							40-661

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Sheet 101: M4

4090(Cont.)			FORM CMS-2552-10				DRAFT
COMPUTATION OFHOSPITAL-BASED RHC/FQHC PNEUMOCOCCAL AND INFLUENZA				PROVIDER CCN:	PERIOD:	WORKSHEET M-4
VACCINE COST				________________	FROM ____________
				COMPONENT CCN:	TO ____________
				________________
Check		[ ] Hospital-based RHC	[ ] Title V	[ ] Title XIX
applicable boxes:		[ ] Hospital-based FQHC	[ ] Title XVIII
					PNEUMOCOCCAL	INFLUENZA
					1	2
1	Health care staff cost (from Worksheet M-1, column 7, line 10)						1
2	Ratio of pneumococcal and influenza vaccine staff time to total						2
	health care staff time
3	Pneumococcal and influenza vaccine health care staff cost (line 1 x line 2)						3
4	Medical supplies cost - pneumococcal and influenza vaccine						4
	(from your records)
5	Direct cost of pneumococcal and influenza vaccine (line 3 plus line 4)						5
6	Total direct cost of the hospital-based RHC/FQHC (from Worksheet M-1, column 7, line 22)						6
7	Total overhead (from Worksheet M-2, line 19)						7
8	Ratio of pneumococcal and influenza vaccine direct cost to total direct						8
	cost (line 5 divided by line 6)
9	Overhead cost - pneumococcal and influenza vaccine (line 7 x line 8)						9
10	Total pneumococcal and influenza vaccine costs and their						10
	administration costs (sum of lines 5 and 9)
11	Total number of pneumococcal and influenza vaccine injections						11
	(from your records)
12	Cost per pneumococcal and influenza vaccine injection (line 10/line 11)						12
13	Number of pneumococcal and influenza vaccine injections administered						13
	to Program beneficiaries
14	Program cost of pneumococcal and influenza vaccines and their						14
	administration costs (line 12 x line 13)
15	Total cost of pneumococcal and influenza vaccines and their administration costs (sum of columns						15
	1 and 2, line 10) (transfer this amount to Worksheet M-3, line 2)
16	Total Program cost of pneumococcal and influenza vaccines and their administration costs (sum						16
	of columns 1 and 2, line 14) (transfer this amount to Worksheet M-3, line 21)
FORM CMS 2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4069)
40-662							Rev.

---

Sheet 102: M5

DRAFT			FORM CMS-2552-10					4090 (Cont.)
ANALYSIS OF PAYMENTS TO HOSPITAL-BASED				PROVIDER CCN:		PERIOD:	WORKSHEET M-5
RHC/FQHC FOR SERVICES RENDERED				________________		FROM ____________
TO PROGRAM BENEFICIARIES				COMPONENT CCN:		TO ____________
				________________
Check applicable box:		[ ] Hospital-based RHC [ ] Hospital-based FQHC
						Part B
	DESCRIPTION					1	2
						mm/dd/yyyy	Amount
1	Total interim payments paid to hospital-based RHC/FQHC							1
2	Interim payments payable on individual bills, either							2
	submitted or to be submitted to the intermediary, for
	services rendered in the cost reporting periods. If
	none, write "NONE", or enter zero.
3	List separately each retroactive				.01			3.01
	lump sum adjustment amount			Program	.02			3.02
	based on subsequent revision of			to	.03			3.03
	the interim rate for the			Provider	.04			3.04
	cost reporting period. Also show				.05			3.05
	date of each payment.				.50			3.50
	If none, write "NONE",			Provider	.51			3.51
	or enter zero (1).			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 Worksheet M-3, line 27)
	TO BE COMPLETED BY CONTRACTOR
5	List separately each tentative			Program	.01			5.01
	settlement payment after desk review.			to	.02			5.02
	Also show date of each payment.			Provider	.03			5.03
	If none, write "NONE,"			Provider	.50			5.50
	or enter 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			Program
	(balance due) based on the cost			to
	report (see instructions). (1)			Provider	.01			6.01
				Provider
				to
				Program	.02			6.02
7	Total Medicare liability (see instructions)							7
8	Name of Contractor				Contractor Number		NPR Date (Month/Day/Year)	8
(1) On lines 3, 5, and 6, where an amount is due component to program,
	show the amount and date on which you agree to the amount of repayment,
	even though the total repayment is not accomplished until a later date.
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4070)
Rev.								40-663

---

Sheet 103: N1

4090 (Cont.)			FORM CMS-2552-10						DRAFT
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES				PROVIDER CCN:		PERIOD:		WORKSHEET N-1
FOR HOSPITAL-BASED FQHC				_________________		FROM: ___________
				COMPONENT CCN:		TO: ___________
				_________________
								NET
						RECLASSIFIED		EXPENSES FOR
	COST CENTER DESCRIPTIONS			TOTAL	RECLASSIFI-	TRIAL BALANCE		ALLOCATION
	(omit cents)	SALARIES	OTHER	(col. 1 + col. 2)	CATIONS	(col. 3 ± col. 4)	ADJUSTMENTS	(col. 5 ± col. 6)
		1	2	3	4	5	6	7
GENERAL SERVICE COST CENTERS
1	Cap Rel Costs-Bldg and Fix								1
2	Cap Rel Costs-Mvble Equip								2
3	Employee Benefits								3
4	Administrative and General								4
5	Plant Operation and Maintenance								5
6	Janitorial								6
7	Medical Records								7
8	Subtotal - Administrative Overhead								8
9	Pharmacy								9
10	Medical Supplies								10
11	Transportation								11
12	Other General Service								12
13	Subtotal - Total Overhead								13
DIRECT CARE COST CENTERS
23	Physician								23
24	Physican Services Under Agreement								24
25	Physician Assistant								25
26	Nurse Practitioner								26
27	Visiting Registered Nurse								27
28	Visiting Licensed Practical Nurse								28
29	Certified Nurse Midwife								29
30	Clinical Psychologist								30
31	Clinical Social Worker								31
32	Laboratory Technician								32
33	Reg Dietician/Cert DSMT/MNT Educator								33
34	Physical Therapist								34
35	Occupational Therapist								35
36	Other Allied Health Personnel								36
37	Subtotal - Direct Patient Care Services								37
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4071)
40-664									Rev.
DRAFT			FORM CMS-2552-10						4090 (Cont.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES				PROVIDER CCN:		PERIOD:		WORKSHEET N-1
FOR HOSPITAL-BASED FQHC				_________________
				COMPONENT CCN:		FROM ____________
				_________________		TO ____________
								NET
						RECLASSIFIED		EXPENSES FOR
	COST CENTER DESCRIPTIONS			TOTAL	RECLASSIFI-	TRIAL BALANCE		ALLOCATION
	(omit cents)	SALARIES	OTHER	(col. 1 + col. 2)	CATIONS	(col. 3 ± col. 4)	ADJUSTMENTS	(col. 5 ± col. 6)
		1	2	3	4	5	6	7
REIMBURSABLE PASS THROUGH COSTS
47	Pneumococcal Vaccines & Med Supplies								47
48	Influenza Vaccines & Med Supplies								48
49	Subtotal - Reimbursable Pass through Costs								49
OTHER FQHC SERVICES
60	Medicare Excluded Services								60
61	Diagnostic & Screening Lab Tests								61
62	Radiology - Diagnostic								62
63	Prosthetic Devices								63
64	Durable Medical Equipment								64
65	Ambulance Services								65
66	Telehealth								66
67	Other								67
68	Subtotal - Other FQHC Services								68
NONREIMBURSABLE COST CENTERS
78	Other Nonreimbursable								78
100	TOTAL (sum of lines 13, 37, 49, 68 and 78)								100
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4071)
Rev.									40-665

---

Sheet 104: N2

4090 (Cont.)					FORM CMS-2552-10										DRAFT
CALCULATION OF HOSPITAL-BASED FQHC COST PER VISIT									PROVIDER CCN:			PERIOD:		WORKSHEET N-2
									__________________			FROM: ___________
									COMPONENT CCN:			TO: ___________
									__________________
									Total Visits		Title XVIII Visits		Title XVIII Costs
			Direct Cost	Total Medical	Other Direct	General
		From	by	& Mental Health	Care Costs	Service Cost	Total Costs	Average		Mental		Mental		Mental
		Wkst. N-1,	Practitioner	Visits	(see	(see	by	Cost Per Visit	Medical Visits	Health Visits	Medical Visits	Health Visits	Medical Cost	Health Cost
		col. 7,	from Wkst. N-1	by Practitioner	instructions)	instructions)	Practitioner	by Practitioner	by Practitioner	by Practitioner	by Practitioner	by Practitioner	by Practitioner	by Practitioner
	Positions	line:	1	2	3	4	5	6	7	8	9	10	11	12
1	Physician	23													1
2	Physican Services Under Agreement	24													2
3	Physician Assistant	25													3
4	Nurse Practitioner	26													4
5	Visiting Registered Nurse	27													5
6	Visiting Licensed Practical Nurse	28													6
7	Certified Nurse Midwife	29													7
8	Clinical Psychologist	30													8
9	Clinical Social Worker	31													9
10	Reg Dietician/Cert DSMT/MNT Educator	33													10
11	Totals														11
12	Unit Cost Multiplier														12
13	Total Cost Per Visit														13
FORM CMS-2552-10 (DRAFT) INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4071.1)
40-666															Rev.

---

Sheet 105: N3

DRAFT		FORM CMS-2552-10				4090 (Cont.)
COMPUTATION OF HOSPITAL-BASED FQHC PNEUMOCOCCAL			PROVIDER CCN:	PERIOD:	WORKSHEET N-3
AND INFLUENZA VACCINE COST			________________	FROM: ____________
			COMPONENT CCN:	TO: ____________
			________________
				PNEUMOCOCCAL	INFLUENZA
				1	2
1	Health care staff cost (from Worksheet N-1, column 7, sum of lines 23, and 25 through 36)					1
2	Ratio of pneumococcal and influenza vaccine staff time to total					2
	health care staff time
3	Pneumococcal and influenza vaccine health care staff cost (line 1 x line 2)					3
4	Vaccines and related medical supplies cost (from Worksheet N-1, column 7, lines 47 and 48, respectively)					4
5	Direct cost of pneumococcal and influenza vaccine (line 3 + line 4)					5
6	Total direct cost of the hospital-based FQHC (from Worksheet N-1, column 7, line 100)					6
7	Total administrative overhead (from Worksheet N-1, column 7, line 8)					7
8	Ratio of pneumococcal and influenza vaccine direct cost to total direct					8
	cost (line 5 / line 6)
9	Overhead cost - pneumococcal and influenza vaccine (line 7 x line 8)					9
10	Total cost of pneumococcal and influenza vaccine and their					10
	administration (sum of lines 5 and 9)
11	Total number of pneumococcal and influenza vaccine injections					11
	(from your records)
12	Cost per pneumococcal and influenza vaccine injection (line 10 / line 11)					12
13	Number of pneumococcal and influenza vaccine injections administered					13
	to Medicare beneficiaries
14	Cost of pneumococcal and influenza vaccines and their					14
	administration costs furnished to Medicare beneficiaries (line 12 x line 13)
15	Total cost of pneumococcal and influenza vaccines and their administration costs.					15
	(sum of columns 1 and 2, line 10)
16	Total Medicare cost of pneumococcal and influenza vaccines and their administration costs (sum					16
	of columns 1 and 2, line 14) (transfer this amount to Worksheet N-4, line 2)
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4071.2)
Rev.						40-667

---

Sheet 106: N4

4090 (Cont.)		FORM CMS-2552-10				DRAFT
CALCULATION OF HOSPITAL-BASED FQHC REIMBURSEMENT SETTLEMENT			PROVIDER CCN:	PERIOD:	WORKSHEET N-4
			________________	FROM: ___________
			COMPONENT CCN:	TO: ___________
			________________
1	FQHC PPS Amount (see instructions)					1
2	Medicare cost of pneumococcal and influenza vaccine and administration (From Worksheet N-3, line 16)					2
3	Medicare advantage supplemental payments (for information only)					3
4	Total (sum of lines 1 through 2)					4
5	Primary payer payments					5
6	Total amount payable for program beneficiaries (line 4 minus line 5)					6
7	Coinsurance billed to program beneficiaries					7
8	Net Medicare reimbursement excluding bad debts (line 6 minus line 7)					8
9	Allowable bad debts (see instructions)					9
10	Adjusted reimbursable bad debts (see instructions)					10
11	Allowable bad debts for dual eligible beneficiaries (see instructions)					11
12	Subtotal (line 8 plus line 10)					12
13	Other adjustments (specify) (see instructions)					13
14	Amount due hospital-based FQHC prior to the sequestration adjustment (see instructions)					14
15	Sequestration adjustment (see instructions)					15
16	Amount due hospital-based FQHC after sequestration adjustment (see instructions)					16
17	Interim payments (from Worksheet N-5, column 2, line 4)					17
18	Tentative settlement (for contractor use only)					18
19	Balance due hospital-based FQHC/program (line 16 minus lines 17 and 18)					19
20	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2					20
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4071.3)
40-668						Rev.

---

Sheet 107: N5

DRAFT				FORM CMS-2552-10					4090 (Cont.)
ANALYSIS OF PAYMENTS TO HOSPITAL-BASED FQHC FOR SERVICES RENDERED					PROVIDER CCN:	PERIOD:		WORKSHEET N-5
					________________	FROM: ____________
					COMPONENT CCN:	TO: ___________
					________________
	Description						Part B
							mm/dd/yyyy	Amount
							1	2
1	Total interim payments paid to hospital-based FQHC								1
2	Interim payments payable on individual bills, either submitted or to be submitted to the contractor								2
	for services rendered in the cost reporting period. If none, write "NONE" or enter a zero
3	List separately each retroactive					.01			3.01
	lump sum adjustment amount based					.02			3.02
	on subsequent revision of the				Program to	.03			3.03
	interim rate for the cost reporting period.				Provider	.04			3.04
	Also show date of each payment.					.05			3.05
	If none, write "NONE" or enter a zero. (1)					.50			3.50
						.51			3.51
					Provider 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. N-4, line 17)
	TO BE COMPLETED BY CONTRACTOR
5	List separately each tentative settlement				Program to	.01			5.01
	payment after desk review. Also show				Provider	.02			5.02
	date of each payment.					.03			5.03
	If none, write "NONE" or enter a zero. (1)					.50			5.50
					Provider 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
(1) On lines 3, 5, and 6, where an amount is due hospital-based FQHC to program, show the amount and date on which the hospital-based FQHC agrees to the amount of repayment
even though total repayment is not accomplished until a later date.
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4071.4)
Rev.									40-669

---

Sheet 108: O

4090 (Cont.)				FORM CMS-2552-10						DRAFT
ANALYSIS OF HOSPITAL-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 and 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-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072)
40-670										Rev.
DRAFT				FORM CMS-2552-10						4090 (Cont.)
ANALYSIS OF HOSPITAL-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**								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*								71
100		Total								100
*	Transfer the amounts in column 7 to Wkst. O-5, Part I, column 0, line as appropriate.
**	See instructions. Do not transfer the amounts in column 7 to Wkst. O-5, Part I.
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072)
Rev.										40-671

---

Sheet 109: O1

4090 (Cont.)			FORM CMS-2552-10						DRAFT
ANALYSIS OF HOSPITAL-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								46
100	Total *								100
*	Transfer the amount in column 7 to Wkst. O-5, column 1, line 50
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.1)
40-672									Rev.

---

Sheet 110: O2

DRAFT			FORM CMS-2552-10						4090 (Cont.)
ANALYSIS OF HOSPITAL-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								46
100	Total *								100
*	Transfer the amount in column 7 to Wkst. O-5, column 1, line 51
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.1)
Rev.									40-673

---

Sheet 111: O3

4090 (Cont.)			FORM CMS-2552-10						DRAFT
ANALYSIS OF HOSPITAL-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								46
100	Total *								100
*	Transfer the amount in column 7 to Wkst. O-5, column 1, line 52
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.1)
40-674									Rev.

---

Sheet 112: O4

DRAFT			FORM CMS-2552-10						4090 (Cont.)
ANALYSIS OF HOSPITAL-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								46
100	Total *								100
*	Transfer the amount in column 7 to Wkst. O-5, column 1, line 53
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.1)
Rev.									40-675

---

Sheet 113: O5

4090 (Cont.)		FORM CMS-2552-10			DRAFT
COST ALLOCATION - DETERMINATION OF HOSPITAL-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 PART I	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				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				71
99	Negative Cost Center				99
100	Total				100
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4072.2)
40-676					Rev.

---

Sheet 114: O6I

DRAFT				FORM CMS-2552-10								4090 (Cont.)
COST ALLOCATION - HOSPITAL-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											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											71
99	Negative Cost Center											99
100	Total											100
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.3)
Rev.												40-677
4090 (Cont.)				FORM CMS-2552-10								DRAFT
COST ALLOCATION - HOSPITAL-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 /	TOTAL
		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-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.3)
40-678												Rev.

---

Sheet 115: O6II

DRAFT				FORM CMS-2552-10								4090 (Cont.)
COST ALLOCATION - HOSPITAL-BASED HOSPICE GENERAL SERVICE COSTS 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											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											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-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.3)
Rev.												40-679
4090 (Cont.)				FORM CMS-2552-10								DRAFT
COST ALLOCATION - HOSPITAL-BASED HOSPICE GENERAL SERVICE COSTS 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											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											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-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.3)
40-680												Rev.

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Sheet 116: O7

DRAFT					FORM CMS-2552-10							4090 (Cont.)
APPORTIONMENT OF HOSPITAL-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
		Pt. I, col. 9,	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	66										1
2	Occupational Therapy	67										2
3	Speech/ Language Pathology	68										3
4	Drugs, Biological and Infusion Therapy	73										4
5	Durable Medical Equipment/Oxygen	96										5
6	Labs and Diagnostics	60										6
7	Medical Supplies	71										7
8	Outpatient Services (including E/R Dept.)	93										8
9	Radiation Therapy	55										9
10	Other	76										10
11	Totals (sum of lines 1 through 10)											11
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4072.4)
Rev.												40-681

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Sheet 117: O8

4090 (Cont.)		FORM CMS-2552-10			DRAFT
CALCULATION OF HOSPITAL-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-9, col. 4, line 10)				2
3	Total average cost per diem (line 1 divided by line 2)				3
4	Unduplicated program days (Wkst. S-9, 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-9, col. 4, line 11)				7
8	Total average cost per diem (line 6 divided by line 7)				8
9	Unduplicated program days (Wkst. S-9, 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-9, col. 4, line 12)				12
13	Total average cost per diem (line 11 divided by line 12)				13
14	Unduplicated program days (Wkst. S-9, 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-9, col. 4, line 13)				17
18	Total average cost per diem (line 16 divided by line 17)				18
19	Unduplicated program days (Wkst. S-9, 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-9, col. 4, line 14)				22
23	Average cost per diem (line 21 divided by line 22)				23
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4072.5)
40-682					Rev.