Crosswalk

Revisions to Form CMS-2552-10 HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX COST REPORT

The revisions to the Form CMS-2552-10 are two-fold:

1. New worksheets for the hospital-based federally qualified health center (FQHC) to comply with §10501(i)(3)(A) of the Patient Protection and Affordable Care Act (ACA), codified in section 1834(o) of the Act, requiring FQHCs to maintain separate statistical records for proper determination of costs payable under the Medicare program.

2. New worksheets for the hospital-based hospice to collect data to facilitate payment reform mandated by §3132 of the ACA.

The overall burden to providers is estimated to remain unchanged as the proposed worksheets supersede worksheets currently in the cost report.

Changes

Issue #	Instructions Page #	Form Page #	Section	Old Package Form CMS‑2552‑10	New Package Form CMS‑2552‑10	Reason for the Change / Application of the instructions and accompanying worksheets	Burden Effect
1	40-73	40-521	4010	S-8	S-8	Effective for cost reporting periods beginning on and after October 1, 2014, hospital-based FQHCs will no longer complete the Worksheet S-8.	N/A
2	40-74 - 40-76.2	40-522	4011.1 - 4011.4	S-9, Parts I and II	S-9, Parts I, II, III and IV	Effective for cost reporting periods beginning on or after October 1, 2015, hospital-based hospices will no longer complete Parts I and II, but will complete Parts III and IV.	N/A
3	40-73.1 - 40-73.5	40-523.1 - 40-523.3	4010.1 -4010.4	S-8	S-11, Parts I, II, and III	The statistics reported on this worksheet pertain to hospital-based FQHCs that meet the requirements set forth in 42 CFR 413.65(n). These worksheets supersede Worksheet S-8 for FQHCs only and are effective for cost reporting periods beginning on or after October 1, 2014.	N/A
4	40-280 - 40-288	40-659 - 40-663	4066 - 4070	M-1, M-2, M-3, M-4, and M-5	M-1, M-2, M-3, M-4, and M-5	Changes to worksheet include: Minor changes to reiterate that these forms no longer apply to hospital-based FQHCs. Minor changes to forms and instructions to comply with the regulations at 42 CFR 413.78(a), to ensure that no separate GME payment is calculated for the hospital-based RHC or FQHC.	N/A

Issue #	Instructions Page #	Form Page #	Section	Old Package Form CMS‑2552‑10	New Package Form CMS‑2552‑10	Reason for the Change / Application of the instructions and accompanying worksheets	Burden Effect
5	40-290 - 40-299	40-665 - 40-669	4071 -4071.4	M-1, M-2, M-3, M-4, and M-5	N-1, N-2, N-3, N-4, and N-5	New worksheets and instructions for the hospital-based FQHC for cost reporting periods beginning on or after October 1, 2014.	N/A
6	40-300 - 40-313	40-670 - 40-682	4072 - 4072.5	K; K-1; K-2; K-3; K-4, Part I & II; K-5, Parts I, II, & III; and K-6	O; O-1; O-2; O-3; O-4; O-5; O-6, Parts I & II; O-7; and O-8	The forms and instructions are revised in accordance with the statutory requirement for hospice payment reform in §3132 of the ACA. These forms replace the Worksheet K series forms and are effective for cost reporting periods beginning on or after October 1, 2015.	N/A

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