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pdfCHAPTER 32
HOME HEALTH AGENCY COST REPORT
FORM CMS-1728-94
Section
General. .............................................................................................................3200
Rounding Standards for Fractional Computations............................................3201
Recommended Sequence for Completing Form CMS-1728-94. ......................3202
Worksheet S - Home Health Agency Cost Report............................................3203
Part I - Certification by Officer or Administrator of Provider(s)................3203.1
Part II - Settlement Summary. ....................................................................3203.2
Worksheet S-2 - Home Health Agency Complex Identification Data. .............3204
Worksheet S-2-1 - Home Health Agency Reimbursement Questionnaire. ........3204.1
Worksheet S-3 - Home Health Agency Statistical Data. .................................3205
Worksheet A - Reclassification and Adjustment of Trial
Balance of Expenses. .....................................................................................3206
Worksheet A-1 - Compensation Analysis - Salaries and Wages ......................3207
Worksheet A-2 - Compensation Analysis - Employee
Benefits (Payroll Related). .............................................................................3208
Worksheet A-3 - Compensation Analysis - Contracted
Services/Purchased Services… ......................................................................3209
Worksheet A-4 - Reclassifications....................................................................3210
Worksheet A-5 - Adjustments to Expenses. .....................................................3211
Worksheet A-6 - Statement of Costs of Services from
Related Organizations. ...................................................................................3212
Worksheet A-7 - Analysis of Changes in Capital Asset Balance. ....................3213
Worksheet B - Cost Allocation - General Service Costs
and Worksheet B-1 - Cost Allocation - Statistical Basis. ..............................3214
Worksheet C - Apportionment of Patient Service Costs ..................................3215
Part I - Aggregate Agency Cost Per Visit Computation ................................3215.1
Part II - Computation of the Aggregate Medicare Cost and the
Aggregate of the Medicare Limitation ........................................................3215.2
Part III - Supplies and Drugs Cost Computation ...........................................3215.3
Part IV - Comparison of the Lesser of the Aggregate Medicare Cost, the
Aggregate of the Medicare Per Visit Limitation and the Aggregate Per
Beneficiary Cost Limitation......................................................................3215.4
Part V - Outpatient Therapy Reduction Computation ...................................3215.5
Worksheet D - Calculation of Reimbursement Settlement Part A and Part B Services. ............................................................................3216
Part I - Computation of Lesser of Reasonable Cost or
Customary Charges. ..................................................................................3216.1
Part II - Computation of Reimbursement Settlement .................................3216.2
Worksheet D-1 - Analysis of Payments to Home Health Agencies for
Services Rendered to Program Beneficiaries. ................................................3217
Worksheets F, F-1, and F-2 - Financial Statements. .........................................3218
Worksheet A-8-3 - Reasonable Cost Determination for Therapy Services
Furnished by Outside Suppliers .....................................................................3219
Part I - General Information........................................................................3219.1
Part II - Salary Equivalency Computation. .................................................3219.2
Part III - Travel Allowance and Travel Expense Computation HHA Services. .........................................................................................3219.3
Part IV - Overtime Computation.................................................................3219.4
Part V - Computation of Therapy Limitation and Excess
Cost Adjustment.......................................................................................3219.5
Rev.
32-1
CHAPTER 32
HOME HEALTH AGENCY COST REPORT
FORM CMS-1728-94
Section
Removed and reserved ......................................................................................3220
Removed and reserved ......................................................................................3221
Removed and reserved ......................................................................................3221.1
Removed and reserved ......................................................................................3221.2
Removed and reserved ......................................................................................3221.3
Removed and reserved ......................................................................................3222
Removed and reserved ......................................................................................3222.1
Removed and reserved ......................................................................................3222.2
Removed and reserved ......................................................................................3222.3
Removed and reserved ......................................................................................3223
Removed and reserved ......................................................................................3223.1
Removed and reserved ......................................................................................3223.2
Removed and reserved ......................................................................................3224
Worksheet CM-1 - Allocation of General Service Costs
to HHA-Based CMHC Cost Centers. .............................................................3225
Part I - Allocation of General Service Costs to HHA-Based CMHC
Cost Centers. ............................................................................................3225.1
Part II - Computation of Unit Cost Multiplier for Allocation of
HHA-Based CMHC Administrative and General Costs ..........................3225.2
Part III - Allocation of General Service Costs to HHA-Based CMHC
Cost Centers - Statistical Basis ................................................................3225.3
Worksheet CM-2 - Computation of HHA-Based CMHC Costs .......................3226
Part I - Apportionment of HHA-Based CMHC Cost Centers. ....................3226.1
Part II - Apportionment of Cost of HHA-Based CMHC Services
Furnished by Shared HHA Departments .................................................3226.2
Part III - Total HHA-Based CMHC Costs. .................................................3226.3
Worksheet CM-3 - Calculation of Reimbursement
Settlement - HHA-Based CMHC Services ....................................................3227
Part I - Computation of Lesser of Reasonable Cost or Customary
Charges. ...................................................................................................3227.1
Part II - Computation of HHA-Based CMHC Reimbursement
Settlement ................................................................................................3227.2
Worksheet CM-4 - Analysis of Payments to HHA-Based CMHC for
Services Rendered to Program Beneficiaries. ...............................................3228
Removed and reserved ......................................................................................3229
Removed and reserved. .....................................................................................3229.1
Removed and reserved ......................................................................................3229.2
Removed and reserved ......................................................................................3229.3
32-2
Rev.
CHAPTER 32
HOME HEALTH AGENCY COST REPORT
FORM CMS-1728-94
Section
Removed and reserved ......................................................................................3230
Removed and reserved ......................................................................................3230.1
Removed and reserved ......................................................................................3230.2
Removed and reserved ......................................................................................3230.3
Removed and reserved ......................................................................................3231
Removed and reserved. .....................................................................................3231.1
Removed and reserved ......................................................................................3231.2
Removed and reserved ......................................................................................3231.3
Removed and reserved ......................................................................................3232
Removed and reserved. .....................................................................................3232.1
Removed and reserved ......................................................................................3232.2
Removed and reserved ......................................................................................3232.3
Worksheet S-4 - HHA-Based RHC/FQHC Statistical Data ..............................3233
Worksheet RF-1 - Analysis of HHA-Based RHC/FQHC Costs .......................3234
Worksheet RF-2 - Allocation of Overhead to HHA-Based RHC/FQHC
Services .......................................................................................................3235
Visits and Productivity...................................................................................3235.1
Determination of Total Allowable Costs Applicable to HHA-Based
RHC/FQHC Services ...................................................................................3235.2
Worksheet RF-3 - Calculation of Reimbursement Settlement
for HHA-Based RHC/FQHC Services ...........................................................3236
Determination of Rate for HHA-Based RHC/FQHC Services ...................3236.1
Calculation of HHA-Based RHC/FQHC Settlement ..................................3236.2
Worksheet RF-4 - Computation of HHA-Based RHC/FQHC
Pneumococcal and Influenza Vaccine Cost .................................................3237
Worksheet RF-5 - Analysis of Payments to HHA-Based RHC/FQHC
for Services Rendered to Program Beneficiaries ...........................................3238
Worksheet S-5 - HHA-Based Hospice Identification Data ...............................3239
Part I - Enrollment Days for Cost Reporting Periods Beginning Before
October 1, 2014 ....................................................................................3239.1
Part II - Census Data for Cost Reporting Periods Beginning Before
October 1, 2014 ......................................................................................3239.2
Part III - Enrollment Days for Cost Reporting Periods Beginning On or
After October 1, 2014 .............................................................................3239.3
Part IV - Contracted Statistical Data for Cost Reporting Periods
Beginning On or After October 1, 2014..................................................3239.4
Worksheet K - Analysis of Hospice Costs ........................................................3240
Worksheet K-1 - Hospice - Compensation Analysis - Salaries
and Wages ......................................................................................................3241
Worksheet K-2 - Hospice - Compensation Analysis - Employee
Benefits (Payroll Related). .............................................................................3242
Worksheet K-3 - Hospice - Compensation Analysis - Contracted
Services/Purchased Services ..........................................................................3243
Worksheet K-4, Part I - Hospice Cost Allocation - General
Service Costs and Worksheet K-4, Part II - Hospice Cost
Allocation - Statistical Basis ..........................................................................3244
Rev.
32-3
CHAPTER 32
HOME HEALTH AGENCY COST REPORT
FORM CMS-1728-94
Section
Worksheet K-5 - Allocation of General Service Costs to
Hospice Cost Centers .....................................................................................3245
Part I - Allocation of General Service Costs to Hospice
Cost Centers ..............................................................................................3245.1
Part II - Allocation of General Service Costs to Hospice
Cost Centers - Statistical Basis .................................................................3245.2
Part III - Apportionment of Hospice Shared Services .................................3245.3
Worksheet K-6 - Calculation of Hospice Per Diem Cost .................................3246
Worksheet O - Analysis of HHA-Based Hospice Costs ....................................3247
Worksheet O-1 - Analysis of HHA-Based Hospice Costs for
Hospice Continuous Home Care ...................................................................3248
Worksheet O-2 - Analysis of HHA-Based Hospice Costs for
Hospice Routine Home Care .........................................................................3248
Worksheet O-3 - Analysis of HHA-Based Hospice Costs for
Hospice Inpatient Respite Care .....................................................................3248
Worksheet O-4 - Analysis of HHA-Based Hospice Costs for
Hospice General Inpatient Care ....................................................................3248
Worksheet O-5 - Cost Allocation - Determination of HHA-Based
Hospice Net Expenses for Allocation.............................................................3249
Worksheet O-6, Part I - Cost Allocation - HHA-Based Hospice General
Service Costs and Worksheet O-6, Part II - Cost Allocation - HHA-Based
Hospice General Service Costs Statistical Basis ............................................3250
Worksheet O-7 - Apportionment of HHA-Based Hospice Shared Service
Costs by Level of Care ...................................................................................3251
Worksheet O-8 - Calculation of HHA-Based Hospice Per Diem Cost .............3252
Form CMS-1728-94 Worksheets ......................................................................3290
Electronic Reporting Specifications for Form CMS-1728-94 ..........................3295
Rev.
32-4
DRAFT
3200.
FORM CMS-1728-94
3200
GENERAL
The Paperwork Reduction Act of 1995 establishes the requirement that the private sector be
informed as to why information is collected and what the information is used for by the
government. In accordance with §1815(a), 1833(e), and 1861(v)(1)(A) of the Act, providers of
service participating in the Medicare program are required to submit annual information to
achieve settlement of costs for health care services rendered to Medicare beneficiaries. In
addition, 42 CFR 413.20 requires cost reports from providers on an annual basis. All home
health agencies (HHAs) must complete Form CMS-1728-94 in accordance with cost report
filing requirements contained in 42 CFR 413.24. The information reported must conform to the
requirements and principles set forth in the Provider Reimbursement Manual (CMS Pub. 15-1).
The instructions contained in this chapter are effective for cost reporting periods ending on or
after December 31, 1994.
For cost reporting periods ending on or after March 31, 2000, home health agencies (HHAs)
must submit cost reports currently required under the Medicare regulations in a standardized
electronic cost reporting (ECR) format. (See 42 CFR Part 413.24 (f)(4).)
NOTE:
This form is not used by HHAs that are hospital-based or SNF-based. Instead, they
use Form CMS-2552 and Form CMS-2540, respectively.
HHAs, as the term is used in this chapter, refers to institutions meeting the requirements of
§1861(o) of the Act. Refer to Medicare Benefit Policy Manual (CMS Pub.) 100-02, chapter 7
and CMS Pub. 15-1 for further definition of terms.
The cost data reported must be based on the step down method of cost finding (see 42 CFR
413.24(d) (1)) and on the accrual basis of accounting. However, where governmental
institutions operate on a cash basis of accounting, cost data developed on such basis of
accounting are acceptable, subject to appropriate treatment of capital expenditures.
Small HHAs, as defined in 42 CFR 413.24(d), will not have to complete certain identified
worksheets of Form CMS-1728-94, e.g., Worksheets A-1, A-2, and A-3.
An HHA may be considered a small HHA if:
1. The HHA received less than $35,000 in Medicare reimbursement for the immediately
preceding cost reporting period, and
Rev.
32-5
3200 (Cont.)
FORM CMS-1728-94
DRAFT
2. This reimbursement represented less than 50 percent of the total operating cost of the
agency.
Supplemental worksheets are provided on an as needed basis depending on the needs of the
HHA. Not all supplemental worksheets are needed by all HHAs. The following conditions are
examples of situations for which supplemental worksheets are needed:
•
Reimbursement is claimed for a HHA-based comprehensive outpatient rehabilitation
facility (CORF), HHA-based rural health clinic (RHC), HHA-based Federally
qualified health center (FQHC), or community mental health center (CMHC); or
•
The HHA has physical therapy services furnished by outside suppliers.
HHAs are required to use the stepdown method of cost finding. (See CMS Pub. 15-1, §2308.)
However, an HHA that is considered small may use a simplified version of the stepdown method
for HHA cost allocations. (See 42 CFR 413.24(d).)
In completing the worksheets, reductions in expenses must always be shown in parentheses ( ).
32-6
Rev.
DRAFT
3201.
FORM CMS-1728-94
3202
ROUNDING STANDARDS FOR FRACTIONAL COMPUTATIONS
Throughout the Medicare cost report, required computations result in the use of fractions. The
following rounding standards must be employed for such computation.
1.
Round to 2 decimal places
a. Percentages
b. Averages
c. Full time equivalent employees
d. Per diems, hourly rates
2.
Round to 5 decimal places
a. Sequestration (e.g., 2.092 percent is expressed as .02092)
3.
Round to 6 decimal places
a. Ratios (e.g., unit cost multipliers, cost/charge ratios)
If a residual exists as a result of computing costs using a fraction, adjust the residual in the
largest amount resulting from the computation. For example, in cost finding, a unit cost
multiplier is applied to the statistics in determining costs. After rounding each computation, the
sum of the allocation may be more or less than the total cost being allocated. Adjust this residual
to the largest amount resulting from the allocation so that the sum of the allocated amounts
equals the amount being allocated.
3202.
RECOMMENDED SEQUENCE FOR COMPLETING FORM CMS-1728-94
All providers using Form CMS-1728-94 must adhere to the following sequence of completion.
If worksheets are not completed because they are not applicable, do not include blank
worksheets in the assembly of the cost report.
Step
Worksheet
Instructions
1
S-2
Read §3204.
worksheet.
Complete
2
S-2-1
Read §3204.1
worksheet.
Complete entire
3
S-3
Read §3205.
worksheet.
Complete entire
4
A-1, A-2, A-3
Read §§3207-3209. Complete all
worksheets unless you are a small
HHA. (See 42 CFR 413.24 (d) and
§3200.)
5
A
Read §3206. Complete columns 1
through 6, lines 1-29.
6
A-4
Read §3210.
applicable.
7
A
Read §3206. Complete columns 7
and 8, lines 1-29.
Rev.
entire
Complete,
if
32-7
3202 (Cont.)
FORM CMS-1728-94
DRAFT
Step
Worksheet
Instructions
8
A-6
Read §3212. Complete Part A. If
the answer to Part A is "Yes,"
complete Parts B and C.
9
A-7
Read §3213.
worksheet.
Complete
entire
10
Supp. A-8-3
Read §3219.
Complete
worksheet, if applicable.
entire
11
A-5
Read §3211.
worksheet.
entire
12
A
Read §3206. Complete columns 9
and 10, lines 1-29.
13
B and B-1
Read §3214.
worksheets.
Complete
entire
14
C
Read §3215.
worksheet.
Complete
entire
15
D
Read §3216.
through 27.
Complete lines 1
16
D-1
Read §3217.
through 4.
Complete lines 1
17
D
Read §3216.
through 31.
Complete lines 1
18
F, F-1, F-2
Read
§3218.
worksheets.
32-8
Complete
Complete
all
Rev.
DRAFT
Step
FORM CMS-1728-94
Worksheet
3202 (Cont.)
Instructions
CMHC
19
Supp. CM-1, Pt I
Read §3225.1. Complete column 0,
lines 1-12.
20
Supp. CM-1, Pt III
Read §3225.3. Fully complete.
21
Supp. CM-1, Pt I
Read §3225.3. Complete columns 16, lines 1-12.
22
Supp. CM-1, Pt II
Read §3225.2. Fully complete.
23
Supp. CM-1, Pt I
Read §3225.3. Fully complete.
24
Supp. CM-2
Read §3226.
worksheet.
25
Supp. CM-3
Read §3227. Complete lines 1-24
26
Supp. CM-4
Read §3228. Complete lines 1-7.
27
Supp. CM-3
Read §3227. Complete lines 25-28
Rev.
Complete
entire
32-9
3202 (Cont.)
Step
FORM CMS-1728-94
Worksheet
DRAFT
Instructions
RHC/FQHC
28
S-4
Read §3233.
worksheet.
Complete
entire
29
RF-1
Read §3234.
worksheet.
Complete
entire
30
RF-2
Read §3235.
worksheet.
Complete
entire
31
RF-4
Read §3237.
worksheet.
Complete
entire
32
RF-5
Read §3238.
worksheet.
Complete
entire
33
RF-3
Read §3236.
worksheet.
Complete
entire
Complete
entire
HOSPICE
34
S-5
Read §3239.
worksheet.
35
K-1, K-2, K-3
Read §§3241-3243.
worksheets.
36
K
Read §3240.
worksheet.
37
K-4, Parts I and II
Read §3244. Complete entire
worksheets.
38
K-5, Parts I - III
Read §§3245-3245.3. Complete
entire worksheets.
39
K-6
Read §3246. Complete entire
worksheet.
32-10
Complete all
Complete
entire
Rev.
DRAFT
Step
FORM CMS-1728-94
Worksheet
3202 (Cont.)
Instructions
HOSPICE
Step
Worksheet
Instructions
40
O-1, O-2, O-3, O-4
Read §3248.
worksheets.
41
O
Read §3247
worksheet.
Complete
entire
42
O-5
Read §.3249
worksheet.
Complete
entire
43
O-6, Parts I and II
Read §3250
worksheets.
Complete
entire
44
O-7
Read §3251
worksheet.
Complete
entire
45
O-8
Read §3252
worksheet.
Complete
entire
46
S
Read §3203.
Complete Part II
entirely. Then complete Part I.
Rev.
Complete
all
32-10.1
3203
FORM CMS-1728-94
3203.
DRAFT
WORKSHEET S - HOME HEALTH AGENCY COST REPORT
The contractor indicates in the appropriate box whether this is the initial cost report (first cost
report filed for the provider), final report due to termination, or if this is a reopening. If it is a
reopening, indicate the number of times the cost report has been reopened.
3203.1 Part I - Certification by Officer or Administrator of Provider(s). -- This certification is
read, prepared, and signed after the cost report has been completed in its entirety. The cost
report is not accepted by the contractor unless it contains an original signature.
3203.2 Part II - Settlement Summary.--Enter the balance due to or from for each component of
the complex. Transfer the settlement amounts as follows:
o
o
o
o
Home health agency from Worksheet D, Part II, line 29 (Part A from column 1 and Part B
from column 2).
HHA-based CORF from Worksheet J-3, line 24.
HHA-based CMHC from Worksheet CM-3, line 26.
HHA-based RHC or FQHC from Worksheet RF-3, line 26. Specify the provider type.
3204.
WORKSHEET S-2 - HOME HEALTH AGENCY COMPLEX IDENTIFICATION
DATA
The information required on this worksheet is needed to properly identify the provider.
Line 1.--Enter the street address and P.O. Box (if applicable) of the HHA.
Line 1.01.--Enter the city, state, and zip code of the HHA.
Lines 2 through 6.--On the appropriate lines and columns indicated, enter the component name,
CMS certification number (CCN), and certification date of the HHA and its various components,
if any.
Line 2.--This is an institution which meets the requirements of §§1861(o) and 1891 of the Act
and participates in the Medicare program.
Line 3.--This is a distinct part CORF that has been issued a CORF CCN and meets the
requirements of §1861(cc) of the Act. If you have more than one HHA-based CORF, subscript
this line and report the required information for each CORF.
Line 3.50.--This is a distinct part Hospice that has been issued a Hospice CCN and meets the
requirements of §1861(dd) of the Act. If you have more than one HHA-based Hospice, subscript
this line and report the required information for each Hospice.
Line 4.--This is a distinct part CMHC that has been issued a CMHC CCN and meets the
requirements of §1861(ff) of the Act. If you have more than one HHA-based CMHC, subscript
this line and report the required information for each CMHC.
Line 5.--This is a distinct part RHC that has been issued a RHC CCN and meets the requirements
of §1861(aa) of the Act. If you have more than one HHA-based RHC, subscript this line and
report the required information for each RHC.
32-10.2
Rev.
DRAFT
FORM CMS-1728-94
3204 (Cont.)
Line 6.--This is a distinct part FQHC that has been issued a FQHC CCN and meets the
requirements of §1861(aa) of the Act. If you have more than one HHA-based FQHC, subscript
this line and report the required information for each FQHC. Only the primary FQHC is
identified on this line when filing a consolidated cost report. Effective for cost reporting periods
beginning on or after October 1, 2014, HHA-based FQHCs will no longer complete this line and
will be required to complete the form CMS-224-14.
Line 7.--Enter the inclusive dates covered by this cost report. In accordance with 42 CFR
413.24(f), you are required to submit periodic reports of your operations which generally cover a
consecutive 12 month period of your operations. (See CMS Pub. 15-2, §§102.1-102.3 for
situations where you may file a short period cost report.)
Cost reports are due on or before the last day of the fifth month following the close of the period
covered by the report. A 30 day extension of the due date may be granted by the contractor only
when a provider’s operations are significantly adversely affected due to extraordinary
circumstances over which the provider has no control. (See 42 CFR 413.24 (f) (2) (ii).)
When you voluntarily or involuntarily cease to participate in the health insurance program or
experience a change of ownership, a cost report is due no later than 150 days following the
effective date of the termination of your agreement or change of ownership. There are no
provisions for an extension of the cost report due date for termination or change of ownership.
Line 8.--Enter the type of ownership or auspices under which the HHA is conducted.
1 = voluntary non-profit, church
2 = voluntary non-profit, other
3 = proprietary, sole proprietor
4 = proprietary, partnership
5 = proprietary, corporation
6 = private non-profit
7 = governmental & private combined
8 = governmental, federal
9 = governmental, state
10 = governmental, city
11 = governmental, city-county
12 = governmental, county
13 = governmental, health district
•
Combined Governmental and Private.--This is an HHA administered jointly by a private
organization and a governmental agency, supported by tax funds, public funds, earnings,
and contributions, which provides nursing and therapeutic services.
•
Governmental Agency.--This is an HHA administered by a state, county, city, or other
local unit of government and having as a major responsibility prevention of disease and
community education. It must offer nursing care of the sick in their homes.
•
Voluntary Non-Profit.--This is an HHA which is governed by a community-based board
of directors and is usually financed by earnings and contributions. The primary function
is the care of the sick in their homes. Some voluntary agencies are operated under church
auspices.
•
Private Not-for-Profit.--This is an HHA that is a privately developed and governed nonprofit organization which provides care of the sick in the home. This agency must
qualify as a tax exempt organization under title 26 USC 5018 of the Internal Revenue
Code.
•
Proprietary Organization.--This is an HHA that is owned and operated by nongovernmental interests and is not a non-profit organization.
Rev.
32-11
3204 (Cont.)
FORM CMS-1728-94
DRAFT
Line 9.--Indicate whether this is a low or no Medicare utilization cost report. Enter an “L” for
low Medicare utilization or “N” for no Medicare utilization. If “L” is selected you must meet
your contractor’s criteria for filing a low Medicare utilization cost report. (See 42 CFR 413.24
(h).)
Lines 10 through 12.--Enter on the appropriate lines the amount of depreciation claimed under
each method of depreciation used by the HHA during the cost reporting period.
Line 13.--Enter the sum of lines 10 through 12.
depreciation included in costs on Worksheet A.
This amount must equal the amount of
Line 14.--Were there any disposals of capital assets during the cost reporting period? Enter "Y"
for yes or "N" for no.
Line 15.--Was accelerated depreciation claimed on any asset in the current or any prior cost
reporting period? Enter "Y" for yes or "N" for no.
Line 16.--Was accelerated depreciation claimed on assets acquired on or after August 1, 1970?
(See CMS Pub. 15-1, Chapter 1.) Enter "Y" for yes or "N" for no.
Line 17.--If depreciation is funded, enter the fund balance at the end of the cost reporting period.
Line 18.--Did the provider cease to participate in the Medicare program at the end of the period
to which this cost report applies? (See CMS Pub. 15-1, chapter 1.) Enter "Y" for yes or "N" for
no.
Line 19.--Was there a substantial decrease in the health insurance proportion of allowable costs
from prior cost reporting periods? (See CMS Pub. 15-1, chapter 1.) Enter "Y" for yes or "N" for
no.
Line 20.--Does the provider qualify as a small HHA (as explained in 42 CFR 413.24 (d))? Enter
"Y" for yes or "N" for no.
Line 21.--Does the HHA qualify as a nominal charge provider (as explained in 42 CFR 409.3)?
Enter "Y" for yes or "N" for no.
Line 22.--Does the HHA contract with outside suppliers for physical therapy services? (See
CMS Pub. 15-1, chapter 14.) Enter "Y" for yes or "N" for no.
Line 22.01.--Does the HHA contract with outside suppliers for occupational therapy services?
Enter "Y" for yes or "N" for no.
Line 22.02.--Does the HHA contract with outside suppliers for speech therapy services? Enter
"Y" for yes or "N" for no.
Lines 23 through 25.--If the facility is a non-public provider that qualifies for an exemption from
the application of the lower of cost or charges (as explained in 42 CFR 413.13(f)) indicate the
component and services that qualify for this exemption with a "Y".
Line 26.--If the HHA componentized (or fragmented) its administrative and general (A&G)
service costs, enter 1 for option one and 2 for option two. Do not respond if A&G services are
not fragmented. (See §3214 for an explanation of the A&G componentization options.)
Line 27.01-27.03.--Enter the amount of malpractice insurance premiums, paid losses and/or self
insurance premiums, respectively.
32-12
Rev.
DRAFT
FORM CMS-1728-94
3204.1
Line 28.--If malpractice premiums are reported in other than the A&G cost center, enter Y (yes)
or N (no). If yes, submit a supporting schedule listing the cost centers and amounts contained
therein.
Line 29-29.03.--If this provider is part of a chain organization, enter “Y” for yes and enter the
home office name, home office number, address of the home office, and contractor name and
identifying number of the contractor who receives the home office cost statement; otherwise,
enter “N” for no. 32-12 Rev.
3204.1. WORKSHEET S-2-1
QUESTIONNAIRE
-
HOME
HEALTH
AGENCY
REIMBURSEMENT
This worksheet collects organizational, financial and statistical information previously reported
on Form CMS-339. Where instructions for this worksheet direct the HHA to submit
documentation/information, mail or otherwise transmit the requested documentation to the
contractor with submission of the electronic cost report (ECR). The contractor has the right
under §§1815(a) and 1883(e) of the Act to request any missing documentation.
NOTE: The responses on all lines are “yes” or “no” unless otherwise indicated. When the
instructions require documentation, indicate on the documentation the Worksheet S-2-1 line
number the documentation supports.
Line 1.--Indicate whether the HHA has changed ownership immediately prior to the beginning of
the cost reporting period. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”,
enter the date the change of ownership occurred in column 2. Also, submit the name and
address of the new owner and a copy of the sales agreement with the cost report.
Line 2.--Indicate whether the HHA has terminated participation in the Medicare program. Enter
“Y” for yes or “N” for no in column 1. If column 1 is “Y”, enter the date of termination in
column 2, and “V” for voluntary or “I” for involuntary in column 3.
Line 3.--Indicate whether the HHA is involved in business transactions, including management
contracts, with individuals or entities (e.g., chain home offices, drug or medical supply
companies) that are related to the HHA or its officers, medical staff, management personnel, or
members of the board of directors through ownership, control, or family and other similar
relationships. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a list of
the individuals, the organizations involved, and a description of the transactions with the cost
report.
NOTE: A related party transaction occurs when services, facilities, or supplies are furnished to
the provider by organizations related to the provider through common ownership or control.
(See Pub. 15-1, chapter 10 and 42 CFR 413.17.)
Line 4.--Indicate in column 1 whether the financial statements were prepared by a certified
public accountant; enter “Y” for yes or “N” for no. If column 1 is yes, indicate the type of
financial statements in column 2 by entering “A” for audited, “C” for compiled, or “R” for
reviewed. Submit a complete copy of the financial statements (i.e., the independent public
accountant’s opinion, the statements themselves, and the footnotes) with the cost report. If the
financial statements are not available for submission with the cost report enter the date they will
be available in column 3.
Rev.
32-12.1
3204.1 (Cont.)
FORM CMS-1728-94
DRAFT
If column 1 is no, submit a copy of the internally prepared financial statements, and written
statements of significant accounting policy and procedure changes affecting Medicare
reimbursement which occurred during the cost reporting period. You may submit the changed
accounting or administrative procedures manual in lieu of written statements.
Line 5.--Indicate whether the total expenses and total revenues reported on the cost report differ
from those on the filed financial statements. Enter “Y” for yes or “N” for no in column 1. If you
answer “Y” in column 1, submit reconciliation with the cost report.
Line 6.--Indicate whether you are seeking reimbursement for bad debts resulting from Medicare
deductible and/or coinsurance amounts which are uncollectible from Medicare beneficiaries.
(See 42 CFR 413.89(e) and CMS Pub. 15-1, chapter 3, §§306 - 324 for the criteria for an
allowable bad debt.) Enter “Y” for yes or “N” for no in column 1. If you answer “Y” in column
1, submit a completed Exhibit 1 or internal schedule duplicating the documentation requested on
Exhibit 1 to support the bad debts claimed.
Exhibit 1 displayed at the end of this section requires the following documentation:
Columns 1, 2, 3,
Service (From beneficiary’s bill.
the filed bad debt.
4.--Patient Names, Health Insurance Claim (HIC) Number, and Dates of
To)--The documentation required for these columns is derived from the
Furnish the patient’s name, HIC number and dates of service that correlate to
(See CMS Pub. 15-1, chapter 3, §314 and 42 CFR 413.89.)
Columns 5 & 6.--Indigency/Welfare Recipient--If the patient included in column 1 has been
deemed indigent, place a check in column 5. If the patient in column 1 has a valid Medicaid
number, include this number in column 6. See the criteria in CMS Pub. 15-1, chapter 3, §§312
and 322 and 42 CFR 413.89 for guidance on the billing requirements for indigent and welfare
recipients.
Columns 7 & 8.--Date First Bill Sent to Beneficiary & Date Collection Efforts Ceased--This
information should be obtained from the HHA’s files and should correlate with the beneficiary
name, HIC number, and dates of service shown in columns 1, 2, 3 and 4 of this exhibit. The date
in column 8 represents the date that the unpaid account is deemed worthless, whereby all
collection efforts, both internal and by an outside entity, ceased and there is no likelihood of
recovery of the unpaid account. (See CFR 413.89(f), and CMS Pub. 15-1, chapter 3, §§308, 310,
and 314.)
Column 9.--Medicare Remittance Advice Dates--Enter in this column the remittance advice dates
that correlate with the beneficiary name, HIC number, and dates of service shown in columns 1,
2, 3 and 4 of this exhibit.
32-12.2
Rev.
DRAFT
FORM CMS-1728-94
3204.1 (Cont.)
Columns 10 & 11.--Deductibles & Coinsurance--Record in these columns the beneficiary’s
unpaid deductible and coinsurance amounts that relate to covered services.
Column 12.--Total Medicare Bad Debts--Calculate the total bad debts by summing up the
amounts on all lines of columns 10 and 11. This “total” must agree with the bad debts claimed
on the cost report. Attach additional supporting schedules, if necessary, for bad debt recoveries.
Line 7.--Indicate whether your bad debt collection policy changed during the cost reporting
period. Enter “Y” for yes or “N” for no in column 1. If you answer “Y” in column 1, submit a
copy of the revised policy with the cost report.
Line 8.--Indicate whether patient coinsurance amounts were waived. Enter “Y” for yes or “N”
for no in column 1. If you answer “Y” in column 1, ensure that they are not included on the bad
debt listings (i.e., Exhibit 1 or your internal schedules) submitted with the cost report.
Line 9.--Indicate whether the cost report was prepared using the Provider Statistical &
Reimbursement (PS&R) Report only. Enter “Y” for yes or “N” for no in column 1. If column 1
is “Y” enter the paid through date of the PS&R in column 2. Also, submit a crosswalk between
revenue codes and charges found on the PS&R to the cost center groupings on the cost report.
This crosswalk will reflect a cost center to revenue code match only.
Line 10.--Indicate whether the cost report was prepared using the PS&R for totals and provider
records for allocation. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y” enter
the paid through date of the PS&R used to prepare this cost report in column 2. Also, submit a
detailed crosswalk between revenue codes, departments and charges on the PS&R to the cost
center groupings on the cost report. This crosswalk must show dollars by cost center and
include which revenue codes were allocated to each cost center. The total revenue on the cost
report must match the total charges on the PS&R (as appropriately adjusted for unpaid claims,
etc.) to use this method. Supporting work papers must accompany this crosswalk to provide
sufficient documentation as to the accuracy of the provider records. If the contractor does not
find the documentation sufficient, the PS&R will be used in its entirety.
Line 11.--If you entered “Y” on either line 9 or 10, indicate whether adjustments were made to
the PS&R data for additional claims that have been billed but not included on the PS&R used to
file this cost report. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, include a
schedule which supports any claims not included on the PS&R. This schedule should include
totals consistent with the breakdowns on the PS&R, and should reflect claims that are
unprocessed or unpaid as of the cut-off date of the PS&R used to file the cost report.
Line 12.--If you entered “Y” on either line 9 or 10, column 1, indicate whether adjustments were
made to the PS&R data for corrections of other PS&R information. Enter “Y” for yes or “N”
for no in column 1. If column 1 is “Y”, submit a detailed explanation and documentation which
provides an audit trail from the PS&R to the cost report.
Line 13.--If you entered “Y” on either line 9 or 10, column 1, indicate whether other adjustments
were made to the PS&R data. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”,
include a description of the other adjustments and documentation which provides an audit trail
from the PS&R to the cost report.
Line 14.--Indicate whether the cost report was prepared using HHA records only. Enter “Y” for
yes or “N” for no in column 1. If column 1 is “Y”, submit detailed documentation of the system
used to support the data reported on the cost report. If detail documentation was previously
supplied, submit only necessary updated documentation with the cost report.
Rev.
32-12.3
3204.1 (Cont.)
FORM CMS-1728-94
DRAFT
The minimum requirements are:
•
Internal records supporting program utilization statistics, charges, prevailing rates
and payment information broken into each Medicare bill type in a manner
consistent with the PS&R report.
•
A reconciliation of remittance totals to the provider’s internal records.
•
The name of the system used and system maintainer (vendor or HHA). If the HHA
maintained the system, include date of last software update.
NOTE: Additional information may be supplied such as narrative documentation, internal flow
charts, or outside vendor informational material to further describe and validate the reliability
of your system.
Line 15.--Enter the first name, last name and the title/position held by the cost report preparer in
columns 1, 2, and 3, respectively.
Line 16.--Enter the employer/company name of the cost report preparer.
Line 17.--Enter the telephone number and email address of the cost report preparer in columns 1
and 2, respectively.
32-12.4
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DRAFT
FORM CMS-1728-94
EXHIBIT 1
LISTING OF MEDICARE BAD DEBTS AND APPROPRIATE SUPPORTING DATA
HHA Name ____________________
HHA CCN ______________________
FYE _________________________
3204.1 (Cont.)
Prepared By __________________________________
Date Prepared ________________________________
Dates of Service
Indigency / Welfare
Recipient
(Check if applicable)
Patient
Name
HIC. No.
From
To
Yes
Medicaid
Number
1
2
3
4
5
6
Date First
Bill Sent to
Beneficiary
Date
Collection
Efforts
Ceased
Medicare
Remittance
Advice Dates
Deductible*
Co-Insurance*
Total Medicare
Bad Debts
7
8
9
10
11
12
*These amounts must not be claimed unless the HHA or HHA-based entity bills for these services with the intention of payment.
See instructions for columns 5 and 6 - Indigency/Welfare Recipient, for possible exception.
Rev.
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FORM CMS-1728-94
DRAFT
This page is reserved for future use.
32-12.6
Rev.
DRAFT
3205.
FORM CMS-1728-94
3205
WORKSHEET S-3 - HOME HEALTH AGENCY STATISTICAL DATA
In accordance with 42 CFR 413.20(a), 42 CFR 413.24(a), and 42 CFR 413.24(c), you are
required to maintain statistical records for proper determination of costs payable under the
Medicare program. The statistics required on this worksheet pertain to a HHA. The data to be
maintained, depending on the services provided by the agency, includes the number of program
visits, total number of agency visits, number of program home health aide hours, total agency
home health aide hours, program unduplicated census count and total unduplicated census count,
program patient count, and total agency patient count. In addition, FTE data are required by
employee staff, contracted staff, and total staff.
HHA Visits.--A visit is an episode of personal contact with the beneficiary by staff of the HHA
or others under arrangements with the HHA for the purpose of providing Medicare-type services.
A Medicare-type service is a service which satisfies the definition of a home health service in
CMS Pub. 100-02, chapter 7, §§40 and 50, CMS Pub. 100-04, chapter 10, and 42 CFR 409.40.
In preparing the cost report, recognize only the costs associated with Medicare-type like-kind
visits in reimbursable cost centers. Medicare like-kind visits generally fall under the definition
of Medicare visits as described in 42 CFR 409.45 (b) through (g). In counting like-kind visits, it
is critical that non-Medicare visits are of the same type as those that would be covered by
Medicare. This insures that costs of services are comparable across insurers and that providers
are reimbursed equitably for home health services provided. A visit is initiated with the delivery
of Medicare-type home health service and ends at the conclusion of delivery of Medicare-type
home health services. (See 42 CFR 409.48(c).) Use lines 1 through 7 to identify the number of
service visits and corresponding number of patients. The patient count in columns 2, 4, and 6
includes each individual who received each type of service. The sum of the patient count in
columns 2 and 4 may not equal the amount in column 6 for each line. Also, the total of all of the
lines may not equal line 10, unduplicated census count, since many patients receive more than
one type of service. Beneficiaries who experience multiple spells of illnesses (multiple visits
and/or multiple discharges and admissions) within a cost reporting period must be counted only
once in the unduplicated census count.
Part I - Statistical Data.-Columns 1 and 2.--Enter data pertaining to Title XVIII patients only. Enter in column 1 the Title
XVIII visits for each discipline for services rendered through September 30, 2000 for reporting
periods which overlap October 1, 2000. For reporting periods which begin on or after October 1,
2000 enter in column 1 all visits rendered during the entire cost reporting period. Enter in
column 2 the patient count applicable to the Title XVIII visits in column 1 for each line
description. See CMS Pub. 100-02, chapter 7, §70.2 for patient count determination. Enter the
sum of lines 1 through 7 in column 1 on line 8 (total visits). The sum of lines 1 through 7 in
column 2 do not equal the unduplicated census count on line 10 because a beneficiary could be
receiving more than one type of service.
Columns 3 and 4.--Enter data pertaining to all other patients for the entire reporting period.
Enter in column 3 the count of all the agency visits except Title XVIII visits for each discipline.
Enter in column 4 the total agency patient count, except Title XVIII, applicable to the agency
visits entered in column 3. Enter the sum of lines 1 through 7 in column 3 on line 8 (total visits).
The sum of lines 1 through 7 in column 4 may not equal the unduplicated census count on line
10 because a patient could be receiving more than one type of service.
Columns 5 and 6.--The amounts entered in column 5 are the sum of columns 1 and 3 for each
discipline for cost reporting periods ending on or before September 30, 2000. For reporting
periods which overlap October 1, 2000, enter in column 5 the total visits rendered during the
entire reporting period. For reporting periods which overlap October 1, 2000, the amounts
entered in column 5 may not equal the sum of columns 1 and 3 for each discipline. For reporting
periods beginning on or after October 1, 2000, column 5 will again equal the sum of columns 1
and 3. The amounts entered in column 6 may not be the sum of columns 2 and 4 for each
discipline. The unduplicated census count
Rev.
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3205 (Cont.)
FORM CMS-1728-94
DRAFT
on line 10, column 6, may not necessarily equal the sum of the unduplicated census count, line
10, columns 2 and 4.
For example, if a patient receives both covered services and noncovered services, he or she is
counted once as Title XVIII (for covered services), once as other (for noncovered services), and
only once as total.
Lines 1 through 6.--These lines identify the type of home health services rendered to patients.
The entries reflect the number of visits furnished and the number of patients receiving a
particular type of service.
Line 7.--Enter in columns 3 and 5 the total of all other visits. Enter in columns 4 and 6 the
patient count applicable to visits furnished by the agency but which are not reimbursable by Title
XVIII.
Line 8.--Enter the sum of lines 1 through 7 for all columns as appropriate.
Line 9.--Enter the number of hours applicable to home health aide services.
Line 10, 10.01 and 10.02.--Enter on line 10 in the appropriate column the unduplicated count of
all patients receiving home visits or other care provided by employees of the agency or under
contracted services for the entire the reporting period. Enter on line 10.01 in the appropriate
column the unduplicated count of all patients receiving home visits or other care provided prior
to October 1, 2000 by employees of the agency or under contracted services during the reporting
period. Enter on line 10.02 in the appropriate column the unduplicated count of all patients
receiving home visits or other care provided on or after October 1, 2000 by employees of the
agency or under contracted services during the reporting period. Beneficiaries who receive
services before and after October 1, 2000 must be included in both unduplicated census counts
before and after October 1, 2000. The sum of lines 10.01 and 10.02 may not necessarily equal
line 10. For cost reporting periods beginning on or after October 1, 2000, do not subscript line
10 as all unduplicated census count data is entered on line 10. Count each individual only once.
However, because a patient may be covered under more than one health insurance program, the
total census count may not equal the sum of the Title XVIII and all other census counts. For
purposes of calculating the unduplicated census count, if a beneficiary has received health care in
more than one MSA, you must prorate the unduplicated census count based on the ratio of visits
provided in an MSA to the total visits furnished to the beneficiary so as to not exceed a total of
(1). For example, if an HHA furnishes 100 visits to an individual beneficiary in one MSA during
the cost reporting period and the same individual received a total of 400 visits (the other 300
visits were furnished in other MSAs during the cost reporting period), the reporting HHA would
count the beneficiary as a .25 (100 divided by 400) in the unduplicated census count for
Medicare patients for the cost reporting period. Round the result to two decimal places, e.g.,
.2543 is rounded to .25. A provider is also to query the beneficiary to determine if he or she
has received health care from another provider during the year, i.e., Maryland versus
Florida for beneficiaries with seasonal residence.
Part II - Employment Data (Full Time Equivalent).-Lines 11 through 27--Lines 11 through 27 provide statistical data related to the human resources
of the HHA. The human resources statistics are required for each of the job categories specified
in lines 11 through 25. Enter any additional categories needed on lines 26 and 27.
Enter the number of hours in your normal work week.
Report in column 1 the full time equivalent (FTE) employees on the HHA’s payroll. These are
staff for which an IRS Form W-2 is used.
Report in column 2 the FTE contracted and consultant staff of the HHA. Compute staff FTEs for
column 1 as follows. Total all hours for which employees worked and divide by 2080 hours.
32-14
Rev.
DRAFT
FORM CMS-1728-94
3205 (Cont.)
Round to two decimal places, e.g., .04447 is rounded to .04. Compute contract FTEs for column
2 as follows. Add all hours for which contracted and consultant staff worked and divide by 2080
hours.
If employees are paid for unused vacation, unused sick leave, etc., exclude these paid hours from
the numerator in the calculations.
Part III - Metropolitan Statistical Area (MSA) or Core Based Statistical Area (CBSA) Code
Data.-Line 28.--Enter the total number of MSAs and/or CBSAs where Medicare covered services were
provided during the cost reporting period. MSA codes identify the geographic area at which
Medicare covered service are furnished while CBSA codes are five character numeric codes that
also identify the geographic area at which Medicare covered service are furnished. Obtain these
codes from your contractor. The number of identified MSAs/CBSAs must be between 1 and 30.
Line 29.--List all MSA/CBSA and/or Non-MSA/Non-CBSA codes where Medicare covered
home health services was provided. Enter one MSA/CBSA code on each line as necessary. If
additional lines are needed, continue subscripting with lines 29.01, 29.02 et cetera, as necessary
entering one MSA/CBSA code on each subscripted line. Obtain these codes from your
contractor. Non-MSA (rural) codes are assembled by placing the digits “99” in front of the two
digit State code, e.g., for the state of Maryland the rural MSA code is 9921. For HHA services
rendered on or after January 1, 2006, enter the 5 digit CBSA code and Non-CBSA (rural). NonCBSA codes are assembled by placing the digits “999” in front of the two digit State code, e.g.,
for the state of Maryland the Non-CBSA code is 99921. This line may only be subscripted
through line 29.29.
Part IV - PPS Activity Data - Applicable for Services Rendered on or After October 1, 2000.-In accordance with 42 CFR §413.20 and §1895 of the Social Security Act, home health agencies
are mandated to transition from a cost based reimbursement system to a prospective payment
system (PPS) effective for home health services rendered on or after October 1, 2000.
The statistics required on this worksheet pertain to home health services furnished on or after
October 1, 2000. Depending on the services provided by the HHA the data to be maintained
for each episode of care payment category for each covered discipline include aggregate
program visits, corresponding aggregate program charges, total visits, total charges, total
episodes and total outlier episodes, and total non-routine medical supply charges.
All data captured in Part IV of this worksheet must be associated only with episodes of care
which terminate during the current fiscal year for payment purposes. Similarly, when an episode
of care is initiated in one fiscal year and concludes in the subsequent fiscal year, all data required
in Part IV of this worksheet associated with that episode will appear in the fiscal year on the
PS&R in which the episode of care terminates.
HHA Visits.--See the second paragraph of this section for the definition of an HHA visit.
Episode of Care.--Under home health PPS the 60 day episode is the basic unit of payment where
the episode payment is specific to one individual beneficiary. Beneficiaries are covered for an
unlimited number of non-overlapping episodes. The duration of a full length
episode will be 60
days. An episode begins with the start of care date and must end by the 60th day from the start of
care.
Rev.
32-14.1
3205 (Cont.)
FORM CMS-1728-94
DRAFT
Less than a full Episode of Care.-When 4 or fewer visits are provided by the HHA in a 60 day episode period, the result is
a low utilization payment adjustment (LUPA). In this instance the HHA will be
reimbursed based on a standardized per visit payment.
An episode may end before the 60th day in the case of a beneficiary elected transfer, or a
discharge and readmission to the same HHA (including for an intervening inpatient stay).
This type of situation results in a partial episode payment (PEP) adjustment.
When a beneficiary experiences a significant change in condition (SCIC) and
subsequently, but within the same 60 day episode, elects to transfer to another provider, a
SCIC within a PEP occurs. Effective for episodes of care ending on or after January 1,
2008, do not complete column 5 for SCIC within PEP episodes.
A significant change in condition (SCIC) adjustment occurs when a beneficiary
experiences a significant change in condition, either improving or deteriorating, during
the 60 day episode that was not envisioned in the original plan of care. The SCIC
adjustment reflects the proportional payment adjustment for the time both prior and after
the beneficiary experienced the significant change in condition during the 60 day episode.
Effective for episodes of care ending on or after January 1, 2008, do not complete column
6 for SCIC-only episodes.
Use lines 30 through 41 to identify the number of visits and the corresponding visit charges for
each discipline for each episode payment category. Lines 42 and 44 identify the total number of
visits and the total corresponding charges, respectively, for each episode payment category. Line
45 identifies the total number of episodes completed for each episode payment category. Line 46
identifies the total number of outlier episodes completed for each episode payment category.
Outlier episodes do not apply to 1) Full Episodes without Outliers and 2) LUPA Episodes. Line
47 identifies the total medical supply charges incurred for each episode payment category.
Column 7 displays the sum total of data for columns 1 through 6. The statistics and data
required on this worksheet are obtained from the provider statistical and reimbursement (PS&R)
report and only pertain to services rendered on or after October 1, 2000.
Columns 1 through 6.--Enter data pertaining to Title XVIII patients only for services furnished
on or after October 1, 2000. Enter, as applicable, in the appropriate columns 1 through 6, lines
30 through 41, the number of aggregate program visits furnished in each episode of care payment
category for each covered discipline and the corresponding aggregate program visit charges
imposed for each covered discipline for each episode of care payment category. The visit counts
and corresponding charge data are mutually exclusive for all episode of care payment categories.
For example, visit counts and the corresponding charges that appear in column 4 (PEP only
Episodes) do not include any visit counts and corresponding charges that appear in column 5
(SCIC within a PEP) and vice versa. This is true for all episode of care payment categories in
columns 1 through 6.
Line 42.--Enter in columns 1 through 6 for each episode of care payment category, respectively,
the sum total of visits from lines 30, 32, 34, 36, 38 and 40.
Line 43. -- Enter in columns 1 through 6 for each episode of care payment category, respectively,
the sum total of other charges for all other unspecified services reimbursed under PPS.
32-14.2
Rev.
DRAFT
FORM CMS-1728-94
3205 (Cont.)
Line 44.--Enter in columns 1 through 6 for each episode of care payment category, respectively,
the sum total of visit charges from lines 31, 33, 35, 37, 39, 41 and 43.
NOTE: The standard episodes entered on line 9 and outlier episodes entered on line 46 are
mutually exclusive.
Line 45.--Enter in columns 1 and 3 through 6 for each episode of care payment category,
respectively, the total number of episodes of standard episodes of care rendered and concluded in
the provider’s fiscal year.
Line 46.--Enter in columns 2 and 4 through 6 for each episode of care payment category
identified, respectively, the total number of outlier episodes of care rendered and concluded in
the provider’s fiscal year. Outlier episodes do not apply to columns 1 and 3 (Full Episodes
without Outliers and LUPA Episodes, respectively).
Line 47. -- Enter in columns 1 through 6 for each episode of care payment category, respectively,
the total non-routine medical supply charges for services rendered and concluded in the
provider’s fiscal year.
Column 7. -- Enter on lines 30 through 47, respectively, the sum total of amounts from columns
1 through 6.
Rev.
32-14.3
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FORM CMS-1728-94
DRAFT
This page is reserved for future use.
32-14.4
Rev.
DRAFT
3206.
FORM CMS-1728-94
3206
WORKSHEET A - RECLASSIFICATION AND ADJUSTMENT OF TRIAL
BALANCE OF EXPENSES
Worksheet A provides for recording the trial balance of expense accounts from your accounting
books and records. It also provides for the necessary reclassifications and adjustments to certain
accounts prior to the cost finding calculations. Also include on Worksheets A, A-1, A-2, and A3 all expenses incurred for only those visits completed in the current reporting period when the
episode of care overlaps the cost report year end. For cost reporting periods beginning on or
after October 1, 2000, do not complete Worksheets A-1, A-2 and A-3. Enter directly on
Worksheet A the total expenses for Salaries and Wages (column 1), Employee Benefits (column
2) and Contracted/Purchased Services (column 4) in the appropriate cost center.
The cost centers on this worksheet are listed in a manner which facilitates the transfer of the
various cost center data to the cost finding worksheets. Each of the cost centers listed does not
apply to all providers using these forms. Therefore, use those cost centers applicable to your
type of HHA.
Under certain conditions, a provider may elect to use different cost centers for allocation
purposes. These conditions are stated in CMS Pub. 15-1, §2313.
Standard (i.e., preprinted) CMS line numbers and cost center descriptions cannot be changed. If
a provider needs to use additional or different cost center descriptions, it may do so by adding
additional lines to the cost report. Added cost centers must be appropriately coded. Identify the
added line as a numeric subscript of the immediately preceding line. That is, if two lines are
added between lines 2 and 3, identify them as lines 2.01 and 2.02. If additional lines are added
for general services cost centers, corresponding columns must be added to Worksheets B and B1 for cost finding.
NOTE: Cost centers appearing on Worksheet A, lines 6 through 11 may not be subscripted
beyond those which are preprinted. (See CMS Pub. 15-1, §2313.2c)
Submit the working trial balance of the facility with the cost report. A working trial balance is a
listing of the balances of the accounts in the general ledger to which adjustments are appended in
supplementary columns and is used as a basic summary for financial statements.
Cost center coding is a methodology for standardizing the meaning of cost center labels as used
by health care providers on the Medicare cost reports. The Form CMS 1728-94 provides for
preprinted cost center descriptions on Worksheet A. In addition, a space is provided for a cost
center code. The preprinted cost center labels are automatically coded by CMS approved cost
reporting software. These cost center descriptions are hereafter referred to as the standard cost
centers. One additional cost center description with general meaning has been identified. This
additional description will hereafter be referred to as a nonstandard label with an "Other..."
designation to provide for situations where no match in meaning to the standard cost centers can
be found. Refer to Worksheet A, line 23.
The use of this coding methodology allows providers to continue to use labels for cost centers
that have meaning within the individual institution. The four digit cost center codes that are
associated with each provider label in their electronic file provide standardized meaning for data
analysis. The preparer is required to compare any added or changed label to the descriptions
offered on the standard or nonstandard cost center tables. A description of cost center coding
and the table of cost center codes are in §3295, Table 5 of the electronic reporting specifications.
If the cost elements of a cost center are separately maintained on your books, you must maintain
a reconciliation of the costs per the accounting books and records to those on this worksheet.
The reconciliation is subject to review by the contractor.
Rev.
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FORM CMS-1728-94
DRAFT
Column 1.--Obtain the expenses listed from Worksheet A-1. The sum of column 1 must equal
Worksheet A-1, column 9, line 29. For cost reporting periods beginning on or after October 1,
2000, do not complete Worksheet A-1. Enter the total expenses for Salaries and Wages in the
appropriate cost center
Column 2.--Obtain the expenses listed from Worksheet A-2. The sum of column 2 must equal
Worksheet A-2, column 9, line 29. For cost reporting periods beginning on or after October 1,
2000, do not complete Worksheet A-2. Enter the total expenses for Employee Benefits in the
appropriate cost center
Column 3.--If the transportation costs, i.e., owning or renting vehicles, public transportation
expenses, or payments to employees for driving their private vehicles can be directly identified
to a particular cost center, enter those costs in the appropriate cost center. If these costs are not
identifiable to a particular cost center, enter them on line 4.
Column 4.--Obtain the expenses listed in this column from Worksheet A-3. The sum of column 4
must equal Worksheet A-3, column 9, line 29. For cost reporting periods beginning on or after
October 1, 2000, do not complete Worksheet A-3.
Enter the total expenses for
Contracted/Purchased Services in the appropriate cost center.
Column 5.--Enter on the applicable lines in column 5 all agency costs which have not been
reported in columns 1 through 4.
Column 6.--Add the amounts in columns 1 through 5 for each cost center and enter the totals in
column 6.
Column 7.--Enter any reclassifications among the cost center expenses in column 6 which are
needed to effect proper cost allocation.
Worksheet A-4 reflects the reclassifications affecting the cost center expenses. This worksheet
need not be completed by all providers, but is completed only to the extent reclassifications are
needed and appropriate in the particular provider’s circumstances. Show reductions to expenses
in parentheses ( ).
The net total of the entries in column 7 must equal zero on line 29.
Column 8.--Adjust the amounts entered in column 6 by the amounts entered in column 7
(increase or decrease) and extend the net balances to column 8. The total of column 8 must
equal the total of column 6 on line 29.
Column 9.--Enter on the appropriate lines the amounts of any adjustments to expenses indicated
on Worksheet A-5, column 2. The amount on Worksheet A, column 9, line 29 must equal the
amount on Worksheet A-5, column 2, line 21.
Column 10.--Adjust the amounts in column 8 by the amounts in column 9 (increase or decrease)
and extend the net balances to column 10.
Transfer the amounts in column 10, lines 1 through 29, to the corresponding lines on Worksheet
B, column 0.
Line Descriptions
Lines 1 and 2.--These cost centers include depreciation, leases and rentals for the use of facilities
and/or equipment, interest incurred in acquiring land or depreciable assets used for patient care,
insurance on depreciable assets used for patient care, and taxes on land or depreciable assets used
for patient care.
32-16
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FORM CMS-1728-94
3206 (Cont.)
Line 3.--Enter the direct expenses incurred in the operation and maintenance of the plant and
equipment, maintaining general cleanliness and sanitation of the plant, and protecting employees,
visitors, and agency property.
Line 4.--Enter all of the cost of transportation except those costs previously directly assigned in
column 3. This cost is allocated during the cost finding process.
Line 5.--Use this cost center to record the expenses of several costs which benefit the entire
facility. Examples include fiscal services, legal services, accounting, data processing, taxes, and
malpractice costs. If the option to componentize A&G costs into more than one cost center is
elected, eliminate line 5. Componentized A&G lines must begin with subscripted line 5.01 and
continue in sequential order (e.g., 5.01 A&G shared costs).
Line 6.--Skilled nursing care is a service that must be provided by or under the supervision of a
registered nurse. The complexity of the service, as well as the condition of the patient, are
factors to be considered when determining whether skilled nursing services are required.
Additionally, the skilled nursing services must be required under the plan of treatment.
Line 7.--Enter the direct costs of physical therapy services by or under the direction of a
registered physical therapist as prescribed by a physician. The therapist provides evaluation,
treatment planning, instruction, and consultation.
Line 8.--These services include (1) teaching of compensatory techniques to permit an individual
with a physical impairment or limitation to engage in daily activities; (2) evaluation of an
individual's level of independent functioning; (3) selection and teaching of task-oriented
therapeutic activities to restore sensory-integrative function; and (4) assessment of an
individual's vocational potential, except when the assessment is related solely to vocational
rehabilitation.
Line 9.--These are services for the diagnosis and treatment of speech and language disorders that
create difficulties in communication.
Line 10.--These services include (1) assessment of the social and emotional factors related to the
individual's illness, need for care, response to treatment, and adjustment to care furnished by the
facility; (2) casework services to assist in resolving social or emotional problems that may have
an adverse effect on the beneficiary's ability to respond to treatment; and (3) assessment of the
relationship of the individual's medical and nursing requirements to his or her home situation,
financial resources, and the community resources available upon discharge from facility care.
Line 11.--Enter the cost of home health aide services. The primary function of a home health
aide is the personal care of a patient. The services of a home health aide are given under the
supervision of a registered professional nurse and, if appropriate, a physical, speech, or
occupational therapist. The assignment of a home health aide to a case must be made in
accordance with a written plan of treatment established by a physician which indicates the
patient's need for personal care services. The specific personal care services to be provided by
the home health aide must be determined by a registered professional nurse and not by the home
health aide.
Line 12.--The cost of medical supplies reported in this cost center are those costs which are
directly identifiable supplies furnished to individual patients and for which a separate charge is
made. These supplies are generally specified in the patient's plan of treatment and furnished
under the specific direction of the patient's physician.
Medical supplies which are not reported on this line are those minor medical and surgical
supplies which would not be expected to be specifically identified in the plan of treatment or for
which a separate charge is not made. These supplies (e.g., cotton balls, alcohol prep) are items
that are frequently furnished to patients in small quantities (even though in certain situations,
these items may be used in greater quantity) and are reported in the administrative and general
(A&G) cost center.
Rev.
32-17
3206 (Cont.)
FORM CMS-1728-94
DRAFT
Line 13.--Enter the costs of vaccines and the cost of administering the vaccines. Also enter the
cost and administration of pneumococcal and influenza vaccines to Medicare beneficiaries
receiving services on or after January 1, 1998 in an HHA-based RHC and/or an HHA-based
FQHC. A visit by an HHA nurse for the sole purpose of administering a vaccine is not covered
as an HHA visit under the home health benefit, even though the patient may be an eligible home
health beneficiary receiving services under a home health plan of treatment. Section 1862(a) (1)
(B) of the Act excludes Medicare coverage of vaccines and their administration other than the
Part B coverage contained in §1861 of the Act.
If the vaccine is administered in the course of an otherwise covered home health visit, the visit
would be covered as usual, but the cost and charges for the vaccine and its administration must
be excluded from the cost and charges of the visit. The HHA would be entitled to separate
payment for the vaccine and its administration under the Part B vaccine benefit.
Some of the expenses includable in this cost center would be the costs of syringes, cotton balls,
bandages, etc., but the cost of travel is not permissible as a cost of administering vaccines, nor is
the travel cost includable in the A&G cost center. The travel cost is non-reimbursable. Attach a
schedule detailing the methodology employed to develop the administration of these vaccines.
These vaccines are reimbursable under Part B only.
In accordance with Change Request 4240, dated March 17, 2006, effective for services rendered
on or after July 1, 2006, the cost of administering pneumococcal, influenza, and hepatitis B
vaccines is reimbursed under the outpatient prospective payment system (OPPS), but the actual
cost of the pneumococcal, influenza, and hepatitis B vaccines will remain cost reimbursed. For
cost reporting periods ending on or after July 1, 2006, enter on this line the vaccine cost
(exclusive of the cost to administer these vaccines) incurred for pneumococcal, influenza, and
hepatitis B vaccines. Continue to include the cost of osteoporosis vaccines and the cost of
administering the osteoporosis vaccines on this line.
Line 13.20.--Enter the cost incurred to administer pneumococcal, influenza, and hepatitis B
vaccines. Use cost center code 1320 in accordance with table 5 of the electronic reporting
specifications for the appropriate cost center code.
Line 14.--Enter the direct expenses incurred in renting or selling durable medical equipment
(DME) items to the patient for the purpose of carrying out the plan of treatment. Also, include
all the direct expenses incurred by you in requisitioning and issuing the DME to patients.
Line 15.--Enter the cost of home dialysis aide services furnished in connection with a home
dialysis program.
Line 16.--These are services for the assessment, diagnostic evaluation, treatment, management,
and monitoring of patients with deficiencies or abnormalities of cardiopulmonary function.
Line 23.--Enter the direct costs of all other non-reimbursable services. Enter the direct costs
associated with TeleMedicine on line 23.20. See table 5 of the electronic reporting specifications
for the appropriate cost center code.
Line 24.--Enter the direct costs of the HHA-based CORF.
Line 25.--Enter the direct costs associated with the HHA-based hospice.
Line 26.--Enter the direct costs associated with the HHA-based CMHC.
Line 27.--Enter the direct costs associated with the HHA-based RHC. *
32-18
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FORM CMS-1728-94
3207
Line 28.--Enter the direct costs associated with the HHA-based FQHC. *
Line 29.--Enter the total of lines 1 through 28.
*
For cost reporting periods overlapping the January 1, 1998 effective date for the new
RF worksheet series, enter the direct costs associated with the HHA-based RHC and/or
FQHC as applicable for the entire cost reporting period. The A worksheet series will reflect
costs for the entire cost reporting period, not just the costs for services rendered exclusively
before or exclusively after the effective date.
3207.
WORKSHEET A-1 - COMPENSATION ANALYSIS - SALARIES AND WAGES
A small HHA, as defined in 42 CFR 413.24(d), does not have to complete Worksheet A-1.
Enter all salaries and wages for the HHA on this worksheet for the actual work performed within
the specific area or cost center in accordance with the column headings. For example, if the
administrator also performs skilled nursing care which accounts for 25 percent of that person’s
time, then enter 75 percent of the administrator’s salary on line 5 (A&G) and 25 percent of the
administrator’s salary enter on line 6 (skilled nursing care).
The records necessary to determine the split in salary between two or more cost centers must be
maintained by the HHA and must adequately substantiate the method used to split the salary.
These records must be available for audit by the contractor and the contractor can accept or
reject the method used to determine the split in salary. When approval of a method has been
requested in writing and this approval has been received prior to the beginning of a cost reporting
period, the approved method remains in effect for the requested period and all subsequent
periods until you request in writing to change to another method or until the contractor
determines that the method is no longer valid due to changes in your operations.
Definitions
Salary.--This is gross salary paid to the employee before taxes and other items are withheld,
including deferred compensation, overtime, incentive pay, and bonuses. (See CMS Pub. 15-1,
Chapter 21.)
Administrators (Column 1).-Possible Titles:
President, Chief Executive Officer
Duties: This position is the highest occupational level in the agency. This individual is the
chief management official in the agency. The administrator develops and guides the
organization by taking responsibility for planning, organizing, implementing, and evaluating.
The administrator is responsible for the application and implementation of established policies.
The administrator may act as a liaison among the governing body, the medical staff, and any
departments. The administrator provides for personnel policies and practices that adequately
support sound patient care and maintains accurate and complete personnel records. The
administrator implements the control and effective utilization of the physical and financial
resources of the provider.
Directors (Column 2).-Possible Titles:
Duties:
of
Rev.
Medical Director, Director of Nursing, or Executive Director
The medical director is responsible for helping to establish and assure that the quality
32-19
3207 (Cont.)
FORM CMS-1728-94
DRAFT
medical care is appraised and maintained. This individual advises the chief executive officer on
medical and administrative problems and investigates and studies new developments in medical
practices and techniques.
The nursing director is responsible for establishing the objectives for the department of nursing.
This individual administers the department of nursing and directs and delegates management of
professional and ancillary nursing personnel.
Supervisors (Column 4).--Employees in this classification are primarily involved in the direction,
supervision, and coordination of HHA activities.
When a supervisor performs two or more functions, e.g., supervision of nurses and home health
aides, the salaries and wages must be split in proportion with the percent of the supervisor’s time
spent in each cost center providing the HHA maintains the proper records (continuous time
records) to support the split. If continuous time records are not maintained by the HHA, enter
the entire salary of the supervisor on line 5 (A&G) and allocate to all cost centers through
stepdown. However, if the supervisor’s salary is all lumped in one cost center, e.g., skilled
nursing care, and the supervisor’s title coincides with this cost center, e.g., nursing supervisor, no
adjustment is required.
Therapists (Column 6).--Include in column 6, on the line indicated, the cost attributable to the
following services:
Physical therapy
Occupational therapy
Speech pathology
Medical social services
-
line 7
line 8
line 9
line 10
Physical therapy is the provision of physical or corrective treatment of bodily or mental
conditions by the use of physical, chemical, and other properties of heat, light, water, electricity,
sound, massage, and therapeutic exercise by or under the direction of a registered physical
therapist as prescribed by a physician. The physical therapist provides evaluation, treatment
planning, instruction, and consultation. Activities include, but are not limited to, the following:
application of muscle tests and other evaluative procedures; formulation and provision of
therapeutic exercise and other treatment programs upon physician referral or prescription;
instructing and counseling patients, relatives, or other personnel; and consultation with other
health workers concerning a patient’s total treatment program.
Occupational therapy is the application of purposeful, goal-oriented activity in the evaluation,
diagnosis, and/or treatment of persons whose function is impaired by physical illness or injury,
emotional disorder, congenital or developmental disability, or the aging process, in order to
achieve optimum functioning, to prevent disability, and to maintain health. Specific
occupational therapy services include, but are not limited to, education and training in activities
of daily living (ADL); the design, fabrication, and application of splints; sensorimotor activities;
the use of specifically designed crafts; guidance in the selection and use of adaptive equipment;
therapeutic activities to enhance functional performance; prevocational evaluation and training;
and consultation concerning the adaptation of physical environments for the handicapped. These
services are provided to individuals in their place of residence by or under the direction of an
occupational therapist as prescribed by a physician.
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FORM CMS-1728-94
3207 (Cont.)
Speech-language pathology is the provision of services to persons with impaired functional
communications skills by or under the direction of a qualified speech-language pathologist as
prescribed by a physician. This includes the evaluation and management of any existing
disorders of the communication process centering entirely, or in part, on the reception and
production of speech and language related to organic and/or nonorganic factors. Professional
services provided by this cost center are grouped into a minimum of three major areas: (1)
diagnostic assessment and evaluation, including clinical appraisal of speech, voice, and language
competencies, through standardized and other tasks, to determine need for and types of
rehabilitation required; (2) rehabilitative treatment, including planning and conducting treatment
programs on an individual basis, to develop, restore, or improve communicative efficiency of
persons disabled in the process of speech, voice, and/or language; and (3) continuing
evaluation/periodic reevaluation, including both standardized and informal procedures, to
monitor progress and verify current status. Additional activities include, but are not limited to,
the following: preparation of written diagnostic, evaluative, and special reports; provision of
extensive counseling and guidance to communicatively-handicapped individuals and their
families; and consultation with other health care practitioners concerning a patient’s total
treatment program.
Medical social services is the provision of counseling and assessment activities which contribute
meaningfully to the treatment of a patient’s condition. These services must be under the
direction of a physician and must be given by or under the supervision of a qualified medical or
psychiatric social worker. Such services include, but are not limited to, the following:
assessment of the social and emotional factors related to the patient’s illness, the patient’s need
for care, the patient’s response to treatment, and the patient’s adjustment to care; appropriate
action to obtain case work services to assist in resolving problems in these areas; and assessment
of the relationship of the patient’s medical and nursing requirements to the patient’s home
situation, the patient’s financial resources, and the community resources available to the patient.
Aides (Column 7).--Included in this classification are specially trained personnel employed for
providing personal care services to patients. These employees are subject to Federal wage and
hour laws.
The reason for the home health aide services must be to provide hands-on, personal care services
under the supervision of a registered professional nurse, and, if appropriate, a physical, speech,
or occupational therapist or other qualified person.
This function is performed by specially trained personnel who assist individuals in carrying out
physicians instructions and established plan of care. Additional services include, but are not
limited to, assisting the patient with activities of daily living (helping patient to bathe, to get in
and out of bed, to care for hair and teeth); to exercise; to take medications specially ordered by a
physician which are ordinarily self-administered; and assisting the patient with necessary selfhelp skills.
Total (Column 9).--Add the amounts of each cost center, columns 1 through 8, and enter the total
in column 9. Transfer these totals to Worksheet A, column 1, lines as applicable. To facilitate
transferring amounts from Worksheet A-1 to Worksheet A, the same cost centers with
corresponding line numbers are listed on both worksheets. Not all of the cost centers are
applicable to all agencies. Therefore, use only those cost centers applicable to your HHA.
Rev.
32-21
3208
3208.
FORM CMS-1728-94
DRAFT
WORKSHEET A-2 - COMPENSATION ANALYSIS - EMPLOYEE BENEFITS
(PAYROLL RELATED)
A small HHA, as discussed in 42 CFR 413.24(d), does not have to complete Worksheet A-2. If
Worksheet A-2 is not required, enter the employee benefit amounts in the appropriate cost center
on Worksheet A, column 2.
Enter all payroll-related employee benefits for the HHA on this worksheet. See CMS Pub. 15-1,
chapter 21, for a definition of fringe benefits. Use the same basis as that used for reporting
salaries and wages on Worksheet A-1. Therefore, using the same example as given for
Worksheet A-1, enter 75 percent of the administrator’s payroll-related fringe benefits on line 5
(A&G) and enter 25 percent of the administrator’s payroll-related fringe benefits on line 6
(skilled nursing care).
Payroll-related employee benefits must be reported in the cost center that the applicable
employee’s compensation is reported. This assignment can be performed on an actual basis or
upon the following basis:
o
FICA - actual expense by cost center;
o
Pension and retirement and health insurance (nonunion) (gross salaries of participating
individuals by cost center);
o
Union health and welfare (gross salaries of participating union members by cost
center); and
o
All other payroll-related benefits (gross salaries by cost center). Include non payrollrelated employee benefits in the A&G cost center, e.g., cost for personal education, recreation
activities, and day care.
Add the amounts of each cost center, columns 1 through 8, and enter the total in column 9.
Transfer these totals to Worksheet A, column 2, corresponding lines. To facilitate transferring
amounts from Worksheet A-2 to Worksheet A, the same cost centers with corresponding line
numbers are listed on both worksheets.
32-22
Rev.
01-95
3209.
FORM CMS-1728-94
3209
WORKSHEET A-3 - COMPENSATION ANALYSIS - CONTRACTED SERVICES/
PURCHASED SERVICES
A small HHA, as defined in 42 CFR 413.24(d), does not have to complete Worksheet A-3.
All other agencies must enter on this worksheet all contracted and/or purchased services for the
HHA. Enter the contracted/purchased cost on the appropriate cost center line within the column
heading which best describes the type of services purchased. For example, where physical
therapy services are purchased, enter the contract cost of the therapist in column 6, line 7. If a
contracted/purchased service covers more than one cost center, then the amount applicable to
each cost center is included on each affected cost center line. Add the amounts of each cost
center, columns 1 through 8, and enter the total in column 9. Transfer these totals to Worksheet
A, column 4, corresponding lines. To facilitate transferring amounts from Worksheet A-3 to
Worksheet A, the same cost centers with corresponding line numbers are listed on both
worksheets.
Rev. 1
32-23
3210
3210.
FORM CMS-1728-94
01-95
WORKSHEET A-4 - RECLASSIFICATIONS
This worksheet provides for the reclassification of expense accounts to effect proper cost
allocation under cost finding. The following are some examples of costs which may need to be
reclassified.
A. Licenses and Taxes (Other Than Income Taxes).--This expense consists of the
business license expense and tax expense incidental to the operation of the agency. Such
expenses are normally included in the A&G cost centers.
Licenses and taxes applicable to buildings and fixtures must be reclassified to the capital related
- buildings and fixtures account (Worksheet A, line 1). Any licenses and taxes which cannot be
identified to a specific cost center and are incidental to the general overall operation of the
agency must be included in the A&G account (Worksheet A, line 5).
B. Interest.--Interest expense related to loans for agency working capital is includable in
A&G (Worksheet A, line 5). Interest expense attributable to mortgages on buildings is
includable in capital related - buildings and fixtures (Worksheet A, line 1). Interest related to
loans for movable equipment is includable in capital related - movable equipment (Worksheet A,
line 2).
C. Insurance - Malpractice.--Malpractice insurance may be reclassified to cost centers,
other than A&G, only if the insurance policy specifically identifies the premium for each cost
center involved.
D. Services Under Arrangements.--Where a provider purchases services (e.g., physical
therapy) under arrangements for Medicare patients, but does not purchase such services under
arrangements for non-Medicare patients, the providers’ books reflect only the cost of the
Medicare services. However, if the provider does not use the grossing up technique for purposes
of allocating overhead, and if the provider incurs related direct costs applicable to all patients,
Medicare and non-Medicare (e.g., paramedics or aides who assist a physical therapist in
performing physical therapy services), reclassify such related costs from the HHA reimbursable
service cost center and allocate them as part of administrative and general expense.
E. Leases.--This expense consists of all rental costs of buildings and equipment incidental
to the operation of the HHA. Leases applicable to buildings or movable equipment must be
reclassified to the capital related account. Any lease which cannot be identified to a special cost
center and is incidental to the general overall operation of the agency must be included in the
A&G account (Worksheet A, line 5).
32-24
Rev. 1
DRAFT
3211.
FORM CMS-1728-94
3211
WORKSHEET A-5 - ADJUSTMENTS TO EXPENSES
In accordance with 42 CFR 413.9(c) (3), if the provider’s operating costs include amounts not
related to patient care, these amounts are not reimbursable under the program. If operating costs
include amounts flowing from the provision of luxury items or services (i.e., those items or
services substantially in excess of or more expensive than those generally considered necessary
for the provision of needed health services), such amounts are not allowable.
This worksheet provides for the adjustments to the expenses listed on Worksheet A, column 8.
These adjustments, which are required under the Medicare principles of reimbursement, are to be
made on the basis of cost or amount received (revenue) only if the costs (including direct costs
and all applicable overhead) cannot be determined. If the total direct and indirect cost can be
determined, enter the cost. Submit with the cost report a copy of any workpapers used to
compute a cost adjustment. Once an adjustment to an expense is made on the basis of cost, you
may not determine the required adjustment to the expense on the basis of revenue in future cost
reporting periods. Enter the following symbols in column 1 to indicate the basis for adjustment:
"A" for cost, "B" for amount received. Line descriptions indicate the more common activities
which affect allowable costs or result in costs incurred for reasons other than patient care and,
thus, require adjustments.
Types of items entered on Worksheet A-5 are: (1) those needed to adjust expenses to reflect
actual expenses incurred; (2) those items which constitute recovery of expenses through sales,
charges, fees, etc.; (3) those items needed to adjust expenses in accordance with the Medicare
principles of reimbursement; and (4) those items which are provided for separately in the cost
apportionment process.
When an adjustment to an expense affects several cost centers, record the adjustment to each cost
center on a different line.
Line Descriptions
Line 1--Enter funds received from miscellaneous sources not specifically listed on this schedule.
Line 4--Enter allowable home office costs which have been allocated to the provider. Use
additional lines to the extent that various provider cost centers are affected. (See CMS Pub.
15-1, chapter 21.)
Line 5--Enter the amount from Worksheet A-6, Part B, column 6, line 4. Note that Worksheet
A-6, Part B, lines 1 through 3, represent the detail of the various cost centers to be adjusted on
Worksheet A.
Line 6--Enter the amount received from the sale of medical records and abstracts and offset the
amount against the A&G cost centers.
Line 7--Enter the cash received from imposition of interest, finance, or penalty charges on
overdue receivables. This income must be used to offset the allowable A&G costs. (See CMS
Pub. 15-1, chapter 21.)
Line 10--Where an HHA purchases physical therapy services furnished by an outside supplier,
Worksheet A-8-3 must be completed to compute the reasonable cost determination. Enter any
adjustment (excess cost over limitation) from Worksheet A-8-3, Part V, line 49 for physical
therapy services furnished prior to April 10, 1998 and on or after April 10, 1998.
Line 10.1--Where an HHA purchases occupational therapy services furnished on or after April
10, 1998 by an outside supplier, Worksheet A-8-3 must be completed to compute the reasonable
cost determination. Enter any adjustment (excess cost over limitation) from Worksheet A-8-3,
Part V, line 49.
Rev.
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3212
FORM CMS-1728-94
DRAFT
Line 10.2--Where an HHA purchases speech pathology services furnished on or after April 10
1998 by an outside supplier, Worksheet A-8-3 must be complete to compute the reasonable cost
determination. Enter any adjustment (excess cost over limitation) from Worksheet A-8-3, Part
V, line 49.
Line 11--Enter interest expense imposed by the contractor on Medicare overpayments to the
provider. Also, enter the interest expense on loans incurred to repay Medicare overpayments to
the provider.
Line 12--Enter the expense incurred for political and lobbying activities be identified and
disallowed. For prior cost reporting periods, policy does not require identification, but does
require disallowance of any identified portion in accordance with CMS Pub. 15-1, §§2139 2139.3
Lines 13 through 20--Enter any additional adjustments that are required under the Medicare
principles of reimbursement that affects proper cost allocation of expenses. For example, the
total costs incurred by an HHA pursuant to a contract, on behalf of the agency, are unallowable
costs if (1) the contract is entered into a period exceeding 5 years, or (2) the amount payable by
the HHA under the contract is based on a percentage of the agency's reimbursement, or claim for
reimbursement, for services furnished by the agency.
Label the lines to indicate the nature of the required adjustments. (See CMS Pub. 15-1, §2117.)
3212
WORKSHEET A-6 STATEMENT OF COSTS OF SERVICES FROM RELATED
ORGANIZATIONS
In accordance with 42 CFR 413.17, costs applicable to services, facilities, and supplies furnished
to the provider by organizations related by common ownership or control are includable in the
allowable costs at the cost to the related organization except for the exceptions outlined in 42
CFR 413.17(d). This worksheet provides for the computation of any needed adjustments to costs
applicable to services, facilities, and supplies furnished to the HHA by related organizations. In
addition, certain information concerning the related organizations with which the provider has
transacted business must be shown. (See CMS Pub. 15-1, §1004.)
Part A--This must be completed by all providers. If the answer to Part A is "Yes," Parts B and C
must also be completed.
Part B--Costs applicable to services, facilities, and supplies furnished to the provider by
organizations related to the provider by common ownership or control are includable in the
allowable costs of the provider at the related organizations. However, such costs must not
exceed the amount a prudent and cost conscious buyer would pay for the comparable services,
facilities, or supplies that are purchased elsewhere.
Part C--This part shows the interrelationship of the provider to organizations, furnishing services,
facilities, or supplies to the provider. The requested data relative to all individuals, partnerships,
corporations, or other organizations having either a related interest to the provider, a common
ownership with the provider, or control over the provider as defined in CMS Pub. 15-1, §1004,
must be shown in columns 1 through 6, as appropriate.
Complete only those columns that are pertinent to the type of relationship indicated.
Column 1--Enter the appropriate symbol that describes the interrelationship of the provider to the
related organization.
Rev.
32-26
DRAFT
FORM CMS-1728-94
3213
Column 2.--If the symbol A, D, E, F, or G is entered in column 1, enter the name of the related
individual in column 2. If the symbol B or C is entered in column 1, enter the name of the
related organization.
Column 3.--Enter the address of the individual or organization listed in column 2.
Column 4.--If the individual in column 2 or the provider has a financial interest in the related
organization, enter the percent of ownership in such organization.
Column 5.--If the individual in column 2 or the organization in column 2 has a financial interest
in the provider, enter the percent of ownership in the provider.
Column 6.--Enter the type of business in which the related organization engages (e.g., medical
drugs and/or supplies, laundry and linen service).
3213.
WORKSHEET A-7 - ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCE
Columns 1 and 6.--Enter the balance recorded in your books at the beginning of your cost
reporting period (column 1) and at the end of your cost reporting period (column 6).
Columns 2 through 4.--Enter the cost of capital assets acquired by purchase in column 2. In
column 3, enter the fair market value, at date acquired, for donated assets. Enter the sum of
columns 2 and 3 in column 4.
Column 5.--Enter the cost or other basis of all capital assets sold, traded or transferred, retired, or
disposed of in any manner during your cost reporting period.
The sum of columns 1 and 4 minus column 5 equals column 6.
Rev.
32-27
3214
3214.
FORM CMS-1728-94
DRAFT
WORKSHEET B - COST ALLOCATION - GENERAL SERVICE COSTS AND
WORKSHEET B-1 - COST ALLOCATION - STATISTICAL BASIS
Worksheet B provides for the allocation of the expenses of each general service cost center to
those cost centers which receive the services. The cost centers serviced by the general service
cost centers include all cost centers within the provider organization, i.e., other general service
cost centers, reimbursable cost centers, nonreimbursable cost centers, and special purpose cost
centers. Obtain the total direct expenses from Worksheet A, column 10. To facilitate
transferring amounts from Worksheet A to Worksheet B, the same cost centers with
corresponding line numbers (lines 1 through 29) are listed on both worksheets.
Worksheet B-1 provides for the proration of the statistical data needed to equitably allocate the
expenses of the general service cost centers on Worksheet B.
To facilitate the allocation process, the general format of Worksheets B and B-1 are identical.
The column and line numbers for each general service cost center are identical on the two
worksheets. In addition, the line numbers for each general, reimbursable, nonreimbursable, and
special purpose cost centers are identical on the two worksheets. The cost centers and line
numbers are also consistent with Worksheets A, A-1, A-2, and A-3. If the provider has
subscripted any lines on these A worksheets, the provider must subscript the same lines on the B
worksheets.
NOTE: General service columns 1 through 5 and subscripts thereof must be consistent on
Worksheets B and B-1; CM-1, Parts I and III; and K-5, Parts I and II.
The statistical bases shown at the top of each column on Worksheet B-1 are the recommended
bases of allocation of the cost centers indicated. If a different basis of allocation is used, the
provider must indicate the basis of allocation actually used at the top of the column.
Most cost centers are allocated on different statistical bases. However, for those cost centers
where the basis is the same (e.g., square feet), the total statistical base over which the costs are to
be allocated will differ because of the prior elimination of cost centers that have been closed.
Close the general service cost centers in accordance with 42 CFR 413.24(d)(1) which states, in
part, that the cost of nonrevenue-producing cost centers serving the greatest number of other
centers, while receiving benefits from the least number of centers, is apportioned first. This is
further clarified in CMS Pub. 15-1, §2306.1 which also clarifies the order of allocation for
stepdown purposes. Consequently, first close those cost centers that render the most services to
and receive the least services from other cost centers. The cost centers are listed in this sequence
from left to right on the worksheet. However, the circumstances of an agency may be such that a
more accurate result is obtained by allocating to certain cost centers in a sequence different from
that followed on these worksheets.
NOTE: A change in order of allocation and/or allocation statistics is appropriate for the current
fiscal year cost if received by the contractor, in writing, within 90 days prior to the end
of that fiscal year. The contractor has 60 days to make a decision or the change is
automatically accepted. The change must be shown to more accurately allocate the
overhead or, if it is accurate, should be changed due to simplification of maintaining
the statistics. If a change in statistics is made, the provider must maintain both sets of
statistics until an approval is made. If both sets are not maintained and the request is
denied, the provider will revert back to the previously approved methodology. The
provider must include with the request all supporting documentation and a thorough
explanation of why the alternative approach should be used. (See CMS Pub. 15-1,
§2313.)
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3214 (Cont.)
EXCEPTION: A small HHA, as defined in 42 CFR 413.24(d), does not have to request written
permission to use the procedures outlined for small HHAs below.
If the amount of any cost center on Worksheet A, column 10, has a credit balance, show this
amount as a credit balance on Worksheet B, column 0. Allocate the costs from the applicable
overhead cost centers in the normal manner to the cost center showing a credit balance. After
receiving costs from the applicable overhead cost centers, if a general service cost center has a
credit balance at the point it is allocated; do not allocate the general service cost center. Rather,
enter the credit balance on the first line of the column and on line 29. This enables column 6,
line 29, to crossfoot to columns 0 and 4A, line 29. After receiving costs from the applicable
overhead cost centers, if a revenue producing cost center has a credit balance on Worksheet B,
column 6, do not carry forward a credit balance to any worksheet.
On Worksheet B-1, enter on the first line in the column of the cost center the total statistics
applicable to the cost center being allocated (e.g., in column 1, capital-related - buildings and
fixtures, enter on line 1 the total square feet of the building on which depreciation was taken).
Use accumulated cost for allocating administrative and general expenses.
Such statistical base does not include any statistics related to services furnished under
arrangements except where both Medicare and non-Medicare costs of arranged for services are
recorded in your records.
For all cost centers (below the cost center being allocated) to which the service rendered is being
allocated, enter that portion of the total statistical base applicable to each. The total sum of the
statistical base applied to each cost center receiving the services rendered must equal the total
statistics entered on the first line.
Enter on Worksheet B-1, line 30, the total expenses of the cost center to be allocated. Obtain this
amount from Worksheet B from the same column and line number of the same column. In the
case of capital-related costs - buildings and fixtures, this amount is on Worksheet B, column 1,
line 1.
Divide the amount entered on line 30 by the total statistical base entered in the same column on
the first line. Enter the resulting unit cost multiplier on line 31. Round the unit cost multiplier to
at least the nearest six decimal places.
Multiply the unit cost multiplier by that portion of the total statistical base applicable to each cost
center receiving the services rendered. Enter the result of each computation on Worksheet B in
the corresponding column and line.
After the unit cost multiplier has been applied to all the cost centers receiving costs, the total
expenses (line 30) of all of the cost centers receiving the allocation on Worksheet B must equal
the amount entered on the first line of the cost center being allocated.
The preceding procedures must be performed for each general service cost center. Each cost
center must be completed on both Worksheets B and B-1 before proceeding to the next cost
center.
After all the costs of the general service cost centers have been allocated on Worksheet B, enter
in column 6 the sum of the expenses on lines 6 through 28. The total expenses entered in column
6, line 29, should equal the total expenses entered in column 0, line 29.
Rev.
32-29
3214 (Cont.)
FORM CMS-1728-94
DRAFT
Transfer the amounts in column 6 to Worksheet C, column 2, as follows:
From Worksheet B
Column 6
Line 6
7
8
9
10
11
12
13
To Worksheet C
Column 2
Line 1
2
3
4
5
6
15
16
Column Descriptions
Column 1--Depreciation on buildings and fixtures and expenses pertaining to buildings and
fixtures such as insurance, interest, rent, and real estate taxes are combined in this cost center to
facilitate cost allocation. Allocate all expenses to the cost centers on the basis of square feet of
area occupied. The square footage may be weighted if the person who occupies a certain area of
space spends their time in more than one function. For example, if a person spends 10 percent of
time in one function, 20 percent in another function, and 70 percent in still another function, the
square footage may be weighted according to the percentages of 10 percent, 20 percent, and 70
percent to the applicable functions.
If an HHA occupies more than one building (e.g., several branch offices), it may allocate the
depreciation and related expenses by building, using a supportive worksheet showing the detail
allocation and transferring the accumulated costs by cost center to Worksheet B, column 1.
Column 2--Allocate all expenses (e.g., interest, personal property tax) for movable equipment to
the appropriate cost centers on the basis of square feet of area occupied or dollar value.
Column 4--The cost of vehicles owned or rented by the agency and all other transportation costs
which were not directly assigned to another cost center on Worksheet A, column 3, is included in
this cost center. Allocate this expense to the cost centers to which it applies on the basis of miles
applicable to each cost center.
This basis of allocation is not mandatory and a provider may use weighted trips rather than actual
miles as a basis of allocation for transportation costs which are not directly assigned. However,
an HHA must request the use of the alternative method in accordance with CMS Pub. 15-1,
§2313. The HHA must maintain adequate records to substantiate the use of this allocation.
Column 5--The A&G expenses are allocated on the basis of accumulated costs after
reclassifications and adjustments. Therefore, obtain the amounts to be entered on Worksheet B1, column 5, from Worksheet B, columns 0 through 4.
A negative cost center balance in the statistics for allocating A&G expenses causes an improper
distribution of this overhead cost center. Negative balances are excluded from the allocation
statistics when A&G expenses are allocated on the basis of accumulated cost.
A&G costs applicable to contracted services may be excluded from the total cost (Worksheet B,
column 0) for purposes of determining the basis of allocation (Worksheet B-1, column 5) of the
A&G costs. This procedure may be followed when the HHA contracts for services to be
performed for the HHA and the contract identifies the A&G costs applicable to the purchased
services.
32-30
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FORM CMS-1728-94
3214 (Cont.)
The contracted A&G costs must be added back to the applicable cost center after allocation of
the HHA A&G cost before the reimbursable costs are transferred to Worksheet C. A separate
worksheet must be included to display the breakout of the contracted A&G costs from the
applicable cost centers before allocation and the adding back of these costs after allocation.
Contractor approval does not have to be secured in order to use the above described method of
cost finding for A&G.
Worksheet B-1, Column 5A--Enter the costs attributable to the difference between the total
accumulated cost reported on Worksheet B, column 4A, line 29 and the accumulated cost
reported on Worksheet B-1, column 5, line 5. Enter any amounts reported on Worksheet B,
column 4A for (1) any service provided under arrangements to program patients that is not
grossed up and (2) negative balances. Including these costs in the statistics for allocating
administrative and general expenses causes an improper distribution of overhead. In addition,
report on line 5 the administrative and general costs reported on Worksheet B, column 5, line 5
since these costs are not included on Worksheet B-1, column 5 as an accumulated cost statistic.
For fragmented or componentized A&G cost centers, the accumulated cost center line number
must match the reconciliation column number. Include in the column number the alpha
character "A", i.e., if the accumulated cost center for A&G is line 5 (A&G), the reconciliation
column designation must be 5A.
Worksheet B-1, Column 5--The administrative and general expenses are allocated on the basis of
accumulated costs. Therefore, the amount entered on Worksheet B-l, column 5, line 5, is the
difference between the amounts entered on Worksheet B, column 4A and Worksheet B-1,
column 5A. A negative cost center balance in the statistics for allocating administrative and
general expenses causes an improper distribution of this overhead cost center. Exclude negative
balances from the allocation statistics.
Rev.
32-30.1
3214 (Cont.)
FORM CMS-1728-94
DRAFT
This page is reserved for future use.
32-30.2
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DRAFT
FORM CMS-1728-94
3214 (Cont.)
HHAs may establish multiple A&G cost centers (referred to as componentized or fragmented) by
using one of two possible methodologies. The rationale for allocating the shared A&G service
cost center first is that shared A&G cost centers service all other cost centers, while 100 percent
of HHA A&G reimbursable and 100 percent of HHA A&G nonreimbursable only service their
respective cost centers. That is consistent with 42 CFR 413.24(d)(1), which states, in part, that
“the cost of nonrevenue-producing cost centers serving the greatest number of other centers,
while receiving benefits from the least number of centers, is apportioned first.” Under the first
methodology (also referred to as option 1), the HHA must classify all A&G costs as either A&G
shared costs, A&G reimbursable costs, or A&G nonreimbursable costs. That is, 100 percent of
the componentized A&G costs relate exclusively to either the HHA reimbursable or HHA
nonreimbursable cost centers. The remaining costs are classified as A&G shared costs. The
componentized A&G costs are allocated through cost finding to their respective cost centers in
aggregate. First, allocate A&G shared costs to all applicable cost centers, including to the A&G
reimbursable and A&G nonreimbursable cost centers on the basis of accumulated costs. Then
allocate HHA A&G reimbursable costs to all applicable HHA reimbursable cost centers (not
including special purpose cost centers) on the basis of accumulated costs and allocate HHA
A&G nonreimbursable costs to all applicable HHA nonreimbursable cost centers on the basis of
accumulated costs. Only A&G shared costs will be allocated to the special purpose cost centers.
Accordingly, the total A&G costs in the CORF, Hospice, CMHC, RHC, and FQHC worksheets
must equal the corresponding A&G shared costs on Worksheet B. The following three A&G
cost center categories will be created: (1) A&G shared costs, (2) 100 percent HHA reimbursable
costs, and (3) 100 percent HHA nonreimbursable costs, in this order only. Do not allocate A&G
reimbursable costs to the A&G nonreimbursable cost center. Calculate the accumulated cost
statistics as follows:
A&G Cost Center
Sum of Worksheet B
Transfer to Worksheet B-1
A&G Shared Costs
A&G Reimb. Costs
A&G Nonreimb. Costs
Col. 0-4, lines 5.02-28
Col. 0-5.01, lines 6-14
Col. 0-5.01, lines 15-23
Col. 5.01, lines 5.02-28
Col. 5.02, lines 6-14
Col. 5.03, lines 15-23
Under the second methodology (also referred to as option 2), unique A&G cost centers may be
created (see CMS Pub. 15-1, §2313.1) to further refine the allocation process. The statistical
basis upon which to allocate fragmented A&G costs must represent, as accurately as possible, the
consumption or usage of A&G services by the benefiting cost centers. HHAs wishing to use an
alternative allocation methodology (i.e., a change in allocation basis or the sequence of cost
center allocation) must do so in accordance with CMS Pub. 15-1, §2313.
The fragmentation of A&G costs may constitute a direct assignment of A&G costs and as such
must follow the policy established under §2307 of CMS Pub. 15-1.
Column Descriptions for Small HHAs
Small home health agencies, as defined in 42 CFR 413.24(d), may use the following procedures
for completing Worksheet B. Certain alterations must be made to the worksheets to
accommodate these procedures and not all of the columns are used. Worksheet B-1 is not used
in these procedures.
Column 0.--Enter the costs on each line from the corresponding line on Worksheet A, column
10.
Column 1.--Disregard the column title. Enter on line 5 the sum of lines 1 through 5 of column 0.
Enter on lines 6 through 28 the amounts from column 0 for the corresponding lines. Divide the
total on line 5 by the total of lines 6 through 28. This results in the unit cost multiplier (UCM).
Round the UCM to six places.
Column 2.--Multiply the cost on each of the lines 6 through 28 in column 1 by the UCM and
enter the result in column 2 for each line.
Rev.
32-31
3215
FORM CMS-1728-94
DRAFT
Columns 3, 4, and 5.--Not needed.
Column 6.--For lines 6 through 28, add the amounts on each line in columns 1 and 2, and enter
the result for each line.
3215.
WORKSHEET C - APPORTIONMENT OF PATIENT SERVICE COSTS
This worksheet provides for the apportionment of home health patient service costs to Title
XVIII only.
NOTE: Certain services may be rendered by an HHA that are not covered under the home
health provision of §1832(a)(2)(A) of the Act. These services are covered under a
different provision, i.e., §1832(a)(2)(B) of the Act. Under §1832(a)(2)(B) of the Act,
any provider may render the services authorized under that section. An HHA is a
provider. Therefore, an HHA may render medical and other health services. These
services are reimbursed in accordance with §1833(a)(2)(B) of the Act. If a beneficiary
receives any of these services, the beneficiary is liable for coinsurance, i.e., 20 percent
of reasonable charges. The reimbursement for these services is subject to the lesser of
reasonable cost or customary charges (LCC), and such reimbursement cannot exceed
80 percent of the reasonable cost of these services. These services are considered as
Medicare services reimbursable under Title XVIII of the Act and are includable as
Medicare visits for statistical purposes. However, the costs associated with the visits
are not subject to the cost per visit limit. (See 42 CFR 413.30.) The provider must
maintain auditable records of the number of visits, charges, deductibles and
coinsurance applicable to those visits. A separate reimbursement computation and a
separate LCC computation is required.
These services are reimbursable under Part B only and will be entered in lines 15 and
16, columns 7 and 10 and lines 25 through 27, columns 3 through 8.
Payment on Basis of Location of Service.--Section 4604 of the Balanced Budget Act (BBA) of
1997, appends §1891(g) of the Social Security Act, effective for cost reporting periods beginning
on or after October 1, 1997, requiring home health agencies to submit claims for payment for
home health services under Title XVIII on the basis of the geographic location at which the
service is furnished. This requires home health agencies to make Medicare program cost
limitation comparisons based on the geographic location (MSA/CBSA) or Non-MSA/NonCBSA) of services furnished to program beneficiaries. To accomplish this, Worksheet C, Part I,
the aggregate cost per visit computation is completed one time for the entire home health agency.
Worksheet C, Part II, computes the aggregate Medicare cost and the aggregate Medicare cost per
visit limitation. Worksheet C, Part II is performed once for each MSA/CBSA and/or NonMSA/Non-CBSA where Medicare covered services were furnished during the cost reporting
period. Section 4601 of BBA 1997 (See §3215.4) requires HHA net cost of covered services to
be based on the lesser of the aggregate Medicare cost, the aggregate of the Medicare cost per
visit limitation or the aggregate per beneficiary cost limitation.
3215.1 Part I - Aggregate Agency Cost Per Visit Computation.--This part provides for the
computation of the average home health agency cost per visit used to derive each MSA/CBSA's
total allowable cost attributable to Medicare patient care visits. Complete this part once for the
entire home health agency. This computation is required by 42 CFR 413.30 and 42 CFR 413.53.
Column Descriptions for Cost Per Visit Computation
Column 2.--Enter in column 2 the amount for each discipline from Worksheet B, column 6, lines
as indicated.
Column 3.--Enter the total agency visits from statistical data (Worksheet S-3, column 5, lines 1.
through 6) for each type of discipline on lines 1 through 6.
32-32
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FORM CMS-1728-94
3215.2
Column 4.--Compute the average cost per visit for each type of discipline. Divide the number of
visits (column 3) into the cost (column 2) for each discipline.
3215.2 Part II - Computation of the Aggregate Medicare Cost and the Aggregate of the
Medicare Limitation.--This part provides for the computation of the cost of Medicare patient care
visits and the corresponding reasonable cost limitation for Medicare services provided in the
MSA/CBSA/CBSA identified. Complete this part one time for each MSA/CBSA where
Medicare beneficiary visits were provided during the cost reporting period. Lines 1 through 6
and column 11 are subscripted to isolate pre October 1, 2000 costs to facilitate the application of
the lesser of aggregate costs or aggregate visit limits. Effective for cost reporting periods
beginning on or after October 1, 2000, do not complete lines 8 through 14 as all HHAs are
reimbursed under PPS and no longer subject to per visit cost limitations; but continue to
complete lines 1 through 7.
Column 4.--Transfer the average cost per visit from Worksheet C, Part I, column 4, lines as
indicated. The average cost per visit for each discipline is identical for all MSAs/CBSAs.
Columns 5 and 8.--To determine the Medicare Part A cost of services, multiply the number of
covered Part A visits made to beneficiaries prior to October 1, 2000 (column 5, lines 1 through 6,
excluding subscripts) from your records by the average cost per visit amount in column 4 for
each discipline. Enter the product in column 8.
Columns 6 and 9.--To determine the Medicare Part B cost of services not subject to deductibles
and coinsurance, multiply the number of visits made to Part B beneficiaries prior to October 1,
2000 (column 6, lines 1 through 6, excluding subscripts) from your records by the average cost
per visit amount in column 4 for each discipline. Enter the product in column 9.
Columns 5 and 6, lines 1.01, 2.01, 3.01, 4.01, 5.01, 6.01.--Enter in column 5 the Medicare Part A
visits furnished to program beneficiaries on or after October 1, 2000, for episodes completed
during the fiscal year. Multiply the number of covered Part A visits from your records by the
average cost per visit amount in column 4 for each discipline. Enter the product in column 8.
Enter in column 6 the Medicare Part B visits not subject to deductibles and coinsurance
furnished to program beneficiaries on or after October 1, 2000, for episodes completed during
the fiscal year. Multiply the number of visits made to Part B beneficiaries by the average cost
per visit amount in column 4 for each discipline. Enter the product in column 9.
NOTE: For cost reporting periods which overlap October 1, 2000, the sum of Worksheets C,
Part II, columns 5 and 6, lines 1.01, 2.01, 3.01, 4.01, 5.01 and 6.01, respectively, must
equal the corresponding amounts on Worksheet S-3, Part IV, column 7, lines 30, 32,
34, 36, 38 and 40, respectively. For cost reporting periods which begin on or after
October 1, 2000, the sum of Worksheets C, Part II, columns 5 and 6, lines 1 through 6,
respectively, must equal the corresponding amounts on Worksheet S-3, Part IV,
column 7, lines 30, 32, 34, 36, 38 and 40.
Columns 7 and 10.--DO NOT USE THESE COLUMNS. See §3215.5.
NOTE: For reporting periods overlapping October 1, 2000, the sum of all Worksheets C, Part
II, Medicare program visits, sum of lines 1-6 (excluding subscripts) for columns 5 and
6 must be equal to or less than the sum of the visits shown on Worksheet S-3, Part I,
column 1, lines 1 through 6.
Column 11.--Enter the total Medicare cost for each discipline (sum of columns 8 and 9) for visits
rendered prior to October 1, 2000. Add the amounts on lines 1 through 6 (exclusive of
subscripts). Enter this total on line 7. Enter in column 11.01 the total Medicare cost for each
discipline (sum of columns 8 and 9, lines 1.01, 2.01, 3.01, 4.01, 5.01, 6.01) for visits rendered on
or after October 1, 2000. Enter this total on line 7.
Rev.
32-33
3215.3
FORM CMS-1728-94
DRAFT
Column Descriptions for Cost Limitation Computation
Column 4.--Enter the Medicare limitation (see §1861(v)(1)(L) of the Act) for the applicable
MSA for each discipline on lines 8 through 13. The contractor furnishes these limits to the
provider.
Columns 5 and 8.--To determine the Medicare limitation cost for Part A cost of services,
multiply the number of covered Part A visits made to beneficiaries prior to October 1, 2000
(column 5) from your records by the Medicare cost limit amount in column 4 for each discipline.
Enter the product in column 8.
Columns 6 and 9.--To determine the Medicare limitation cost for Part B cost of services,
multiply the number of visits made to Part B beneficiaries not subject to deductibles and
coinsurance prior to October 1, 2000 (column 6) from your records by the Medicare cost limit
amount in column 4 for each discipline. Enter the product in column 9.
NOTE: Column 5, line 7 may not equal column 5, line 14; Column 6, line 7 may not equal
Column 6, line 14. Columns 5 and 6, respectively, lines 1-6 (excluding subscripts)
must equal columns 5 and 6, lines 8-13.
Columns 7 and 10.--DO NOT USE THESE COLUMNS. See §3215.5.
Column 11.--Enter the total Medicare limitation cost for each discipline (sum of columns 8 and
9). Add the amounts on lines 8 through 13. Enter this total on line 14.
3215.3 Part III - Supplies and Drugs Cost Computation.--Certain items covered by Medicare
and furnished by an HHA are not included in the visit for apportionment purposes. Since an
average cost per visit and the cost limit per visit do not apply to these items, the ratio of total cost
to total charges is developed and applied to Medicare charges to arrive at the Medicare cost for
these items. Enteral/parenteral nutrition therapy (EPNT) items which are considered prosthetic
devices furnished by an HHA on or after March 14, 1986, are reimbursed on a reasonable charge
basis through billings submitted to the Part B specialty carrier. (As a prosthetic device, such
items are reimbursable under Part B only.) Charges for these items must be included in the total
charges, but excluded from Title XVIII charge statistics in the apportionment of medical supply
costs on Worksheet C, Part III, line 15. Lines 15 and 16 are subscripted to isolate pre 10/1/2000
costs to facilitate the flow of these costs to Worksheet D in order to apply LCC.
NOTE: For services furnished on or after January 1, 1989, the HHA Part A reimbursement for
DME, prosthetics, and orthotics was changed from cost reimbursement to a fee
schedule reimbursement.
Additionally, certain items furnished by an HHA on or after January 1, 1990, are not
considered as DME. This includes medical supplies such as catheters, catheter
supplies, ostomy bags, and supplies relating to ostomy care.
Lines 15 and 16.--Enter in column 2 the total applicable costs for the entire cost reporting period
for each line item from Worksheet B, column 6, lines 12 and 13, respectively (the costs entered
on lines 15 and 15.01 must be equal; the costs entered on lines 16 and 16.01 must be equal).
Enter in column 3 the total charges for the entire cost reporting period for each line (the charges
entered on lines 15 and 15.01 must be equal; the charges entered on lines 16 and 16.01 must be
equal). The language in the two preceding parentheticals is only applicable for cost reporting
periods which overlap October 1, 2000. For cost reporting periods ending on or after July 1,
2006, enter in column 2 the total charges for services rendered on lines 15, 16, and 16.20,
respectively. Enter in column 4 the ratio of costs (column 2) to charges (column 3) for each line.
Line 15.--Enter in columns 5, 6, and 7 the charges for medical supplies not paid on a fee
schedule for services rendered prior to October 1, 2000. For cost reporting periods beginning on
or after October 1, 2000, continue to capture medical supply charges in columns 5, 6, and 7 for
32-34
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3215.3 (Cont.)
statistical purposes (has no reimbursement impact) as all medical supplies are covered under the
PPS benefit for this period.
Line 15.01.--For cost reporting periods that overlap October 1, 2000, enter in columns 5, 6, and 7
the charges for medical supplies not paid on a fee schedule for services rendered from October 1,
2000 through the fiscal year end. For reporting periods that begin on or after October 1, 2000,
eliminate line 15.01 and record all charges and resulting cost data on line 15.
Line 16.--Enter in column 6 the charges for pneumococcal vaccine and its administration,
influenza vaccine and its administration, and hepatitis B vaccine and its administration for
services rendered prior to April 1, 2001. Enter in column 7 the charge for covered osteoporosis
drugs for services rendered prior to October 1, 2000.
For services rendered on or after April 1, 2001 through December 31, 2002, do not enter any
amounts in column 6 as pneumococcal vaccine and its administration, influenza vaccine and its
administration, and hepatitis B vaccine and its administration are reimbursed under OPPS, but
continue to enter in column 7 the charge for covered osteoporosis drugs as they remain cost
reimbursed. (See §1833(m)(5) of the Act.)
Effective for services rendered on or after January 1, 2003 through June 30, 2006, pneumococcal
vaccines and its administration and influenza vaccine and its administration are cost reimbursed
not subject to deductibles and coinsurance. For services rendered on and after January 1, 2003
through June 30, 2006, enter in column 6 program charges for hepatitis vaccines and its
administration (OPPS reimbursed). Enter in column 6.01 program charges for pneumococcal
vaccines and its administration and influenza vaccine and its administration. Continue to enter in
column 7 the program charges for covered injectable osteoporosis drugs as they remain cost
reimbursed.
Effective for cost reporting periods ending on or after July 1, 2006 (see section 3206, line 13),
line 16 represents pneumococcal, influenza, and hepatitis B vaccines, and osteoporosis drugs, but
not the administration of these vaccines. See the chart below for proper placement of charges.
Line 16.01.--For reporting periods which overlap April 1, 2001, enter in column 6 the charges
for pneumococcal vaccine and its administration and influenza vaccine and its administration.
For hepatitis B vaccine and its administration rendered on or after April 1, 2001 through
December 31, 2002, enter the charges in column 6. Enter in column 7 the charges for covered
osteoporosis drugs rendered on or after April 1, 2001 through the fiscal year end. (See
§1833(m)(5) of the Act.) For reporting periods that begin on or after April 1, 2001, eliminate
line 16.01 and record all charge and resulting cost data on line 16. Osteoporosis drugs will
continue to be reimbursed on a cost basis for services rendered on and after April 1, 2001 and
will use line 16 to record applicable data.
Line 16.20.--Effective for cost reporting periods ending on or after July 1, 2006 (see section
3206, line 13), line 16.20 represents the administration of pneumococcal, influenza, and hepatitis
B vaccines. See the chart below for proper placement of charges.
Effective for cost reporting periods ending on or after July 1, 2006, enter vaccine charges
according to the chart below:
Vaccines Charges
Column 6
Line 16
Rev.
Enter charges for 7/1/2006 &
subsequent hepatitis B vaccines.
Column 7
Enter charges for the full fiscal year
for osteoporosis drugs.
32-34.1
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FORM CMS-1728-94
DRAFT
Vaccines Charges (Continued)
Column 6
Line 16
Column 7
Enter charges for the full fiscal year
for pneumococcal and influenza vaccines.
Do not enter charges for pre 7/1/2006
hepatitis B vaccines.
Line 16.20
Enter charges for pre 7/1/2006
pneumococcal and influenza vaccine
drugs administration.
This location is shaded as the
administration of the osteoporosis
is included in the skilled nursing visit.
Do not enter charges for the full fiscal
Year for hepatitis B vaccine administration.
Do not enter charges for 7/1/2006 &
subsequent pneumococcal and influenza
vaccine administration.
For fiscal years beginning on or after
7/1/2006 enter 0 (zero).
Column 8.--To determine the Medicare Part A cost, multiply the Medicare charges (column 5)
by the ratio (column 4) for each line item. Enter the product in column 8.
Column 9-9.01.--To determine the Medicare Part B cost, multiply the Medicare charges (column
6) by the ratio (column 4) for each line item. Enter the product in column 9. If applicable,
multiply the Medicare charges (column 6.01) by the ratio (column 4) for each line item. Do not
subscript column 9 for cost reporting periods ending after June 30, 2006.
Column 10.--To determine the Medicare Part B cost (subject to deductibles and coinsurance),
multiply the Medicare charges (column 7) by the ratio (column 4). Enter the product in column
10.
3215.4 Part IV - Comparison of the Lesser of the Aggregate Medicare Cost, the Aggregate of
the Medicare Per Visit Limitation and the Aggregate Per Beneficiary Cost Limitation.--This part
provides for the comparison of the reasonable cost limitation applied to each home health
agency's total allowable cost attributable to Medicare patient care visits. This comparison is
required by 42 CFR 413.30 and 42 CFR 413.53. For cost reporting periods beginning on or after
October 1, 1997, §1861(v)(1)(L) of the Social Security Act is amended by §4601 of BBA 1997,
requiring home health
agency net cost of covered services to be based on the lesser of the aggregate Medicare cost, the
aggregate of the Medicare cost per visit limitation or the aggregate per beneficiary cost
limitation. The per beneficiary cost limitation is derived by totaling the application of each
CBSA/non-CBSA’s unduplicated census count (two decimal places) (see §3205) to the perbeneficiary cost limitation for the corresponding CBSA/non-CBSA. To accomplish this, the sum
of all Worksheets C, Part II amounts in column 11, line 7, plus the applicable cost of medical
supplies is compared with the sum of all Worksheets C, Part II amounts in column 11, line 14
plus the applicable cost of medical supplies and with the amount in column 6, line 24.
Line 17.--Enter in columns 3, 4, and 6, respectively, the sum of the amounts from each
Worksheet C, Part II, columns 8, 9, and 11 (exclusive of subscripts), respectively, lines 1-6
(exclusive of subscripts).
32-34.2
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FORM CMS-1728-94
3215.5
Line 18.--Enter in columns 3 and 4, respectively, the cost of medical supplies from Part III,
columns 8 and 9, respectively, line 15 (excluding subscripted lines). Enter in column 6 the sum
of columns 3 and 4.
Line 19.--Enter the sum of lines 17 and 18 for columns 3 and 4. Enter in column 6 the sum of
columns 3 and 4.
Effective for cost reporting periods beginning on or after October 1, 2000, do not complete lines
20 through 24 as all HHAs are reimbursed under PPS and no longer subject to cost per visit
limitations or annual beneficiary limitations.
Line 20.--Enter in columns 3, 4 and 6, respectively, the sum the amounts from each Worksheet
C, Part II, columns 8, 9 and 11, respectively, line 14.
Line 21.--Enter in columns 3 and 4, respectively, the cost of medical supplies from Part III,
columns 8 and 9, respectively, line 15 (excluding subscripted lines). Enter in column 6 the sum
of columns 3 and 4.
Line 22.--Enter the sum of lines 20 and 21 for columns 3 and 4. Enter in column 6 the sum of
columns 3 and 4.
Line 23 and applicable subscripts.--For each MSA/non-MSA enter the following:
Column 0.--Enter the MSA/non-MSA code from Worksheet S-3, Part III, line 29, the
corresponding subscripts thereof.
Column 1.--Enter the corresponding Medicare program (Title XVIII) unduplicated census
count (two decimal places) from your records associated with services rendered prior to
October 1, 2000. (See §3205.)
Column 2.--Enter the applicable per beneficiary annual limitation. Obtain this amount from
your contractor.
Column 6.--For each MSA/non-MSA determine the beneficiary cost limitation by
multiplying the unduplicated census count (column 1) by the per beneficiary annual cost
limitation (column 2). Enter the result in column 6.
Line 24.--In columns 1 (two decimal places) and 6, respectively, enter the sum of lines 23
through 23.24. Enter in column 3 the result of column 3, line 19 divided by column 6, line 19
multiplied by column 6, line 24. Enter in column 4 the result of column 4, line 19 divided by
column 6, line 19 multiplied by column 6, line 24. (The sum of columns 3 and 4 must equal
column 6.)
NOTE: The Medicare (Title XVIII) unduplicated census count (Worksheet S-3, Part I, column
2, line 10.01 (Pre 10/1/2000 Unduplicated Census Count)) must be equal to or greater
than the sum of the unduplicated census count for all MSAs (Worksheet C, Part IV,
column 1, line 24).
3215.5 Part V - Outpatient Therapy Reduction Computation.--This section computes the
reduction in the reasonable costs of outpatient physical therapy services (which includes
outpatient speech language pathology) and outpatient occupational therapy provided under
arrangement for beneficiaries who are not homebound and are not covered by a physician’s plan
of care as required by §1834(k) of the Act and enacted by §4541 of BBA 1997. The amount of
the reduction is 10 percent for services rendered on or after January 1, 1998. For outpatient
therapy services rendered on or after January 1, 1999, §4541 of BBA 1997 mandates a fee
schedule payment basis for
Rev.
32-34.3
3215.5 (Cont.)
FORM CMS-1728-94
DRAFT
outpatient physical therapy, outpatient occupational therapy, and outpatient speech pathology.
Therefore, any outpatient therapy services furnished on or after January 1, 1999 must not be
included in this section due to the application of a fee schedule for these services, but the
corresponding visits must be recorded in column 5.01. These outpatient therapy services are
reimbursed the lesser of the fee scheduled amount or the statutory limitation which is applied on
a beneficiary specific basis through the Medicare claims system. This requires no provider input
on the cost report. Columns 7 (visits) and 10 (costs) of Worksheet C, Part II represent data
subject to deductible and coinsurance which should never have been subject to per visit cost
limitations. This section (Worksheet C, Part V) was introduced in transmittal 6 (November
1998) to separately compile such visit and cost data not subject to deductible and coinsurance.
As such, columns 7 and 10 of Worksheet C, Part II should not be used. Instead, such data should
be captured in this section.
Column 2.--Enter in column 2 the average cost per visit amount for each discipline from
Worksheet C, Part I, column 4, lines as indicated.
Columns 3 and 4.--To determine the Medicare Part B cost of services subject to deductibles and
coinsurance, multiply the number of covered Part B visits made before January 1, 1998 by nonhomebound program beneficiaries to rehabilitation facilities under arrangement (column 3) from
your records by the average cost per visit amount in column 2 for each discipline. Enter the
result in column 4.
Columns 5, 5.01, 5.02 and 6.--Enter in column 5 the number of Medicare covered Part B visits
from your records made by non-homebound (not covered by a physician’s plan of care) program
beneficiaries to rehabilitation facilities under arrangement for services furnished January 1, 1998
thru December 31, 1998 only. Enter in column 5.01 the number of Medicare covered Part B
visits from your records made by non-homebound program beneficiaries to rehabilitation
facilities under arrangement for services furnished from January 1, 1999 through September 30,
2000. Outpatient therapy service visits rendered between January 1, 1999 and September 30,
2000 are reimbursed based on a fee schedule as described above. Determine the Medicare cost
of services subject to deductibles and coinsurance by multiplying the amount in column 5 by the
average cost per visit amount in column 2 for each discipline. Enter the result in column 6.
Enter in column 5.02 the number of Medicare covered Part B visits from your records made by
non-homebound program beneficiaries to rehabilitation facilities under arrangement for services
furnished on or after October 1, 2000. Outpatient therapy services furnished to non-homebound
program beneficiaries not covered by a physician’s plan of care on or after October 1, 2000 are
reimbursed under outpatient PPS. The non-homebound visits captured in columns 5.01 and 5.02
are for statistical purposes only and do not impact the settlement.
Column 7.--Compute the reasonable cost reduction by multiplying the cost of Medicare services
in column 6 by 90 percent (.90). This is the application of the 10 percent reasonable cost
reduction. Enter the result in column 7.
Column 8.--Compute the reasonable costs net of the reduction by adding column 7 to column 4.
Enter the result in column 8.
Line 28.--For columns 3 through 8, respectively, enter the sum of lines 25 through 27.
NOTE:For cost reporting periods beginning on or after October 1, 2000, the following lines
and/or columns revert back to the standard lines or columns (eliminate the subscript(s)): lines 11.01, 2-2.01, 3-3.01, 4-4.01, 5-5.01, 6-6.01, respectively, revert to lines 1, 2, 3, 4, 5, 6,
respectively; column 11-11.01, lines 1-6 reverts to column 11, lines 1-6; line 15-15.01 reverts to
line 15; line 16-16.01 reverts to line 16.
32-34.4
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3216.
FORM CMS-1728-94
3216.1
WORKSHEET D - CALCULATION OF REIMBURSEMENT SETTLEMENT PART A AND PART B SERVICES
This worksheet applies to Title XVIII only and provides for the reimbursement calculation of
Part A and Part B. This computation is required by 42 CFR 413.9, 42 CFR 413.13, and 42 CFR
413.30.
Worksheet D consists of the following two parts:
Part I
-
Computation of the Lesser of Reasonable Cost or Customary Charges. This
part provides for the computation of the lesser of reasonable cost as defined
in 42 CFR 413.13(b) or customary charges as defined in 42 CFR
413.13(e)(1).
Part II
-
Computation of Reimbursement Settlement.
3216.1 Part I - Computation of the Lesser of Reasonable Cost or Customary Charges.-Providers are paid the lesser of the reasonable cost of services furnished to beneficiaries or the
customary charges for the same services. This part provides for the computation of the lesser of
reasonable cost as defined in 42 CFR 413.13(b) or customary charges as defined in the 42 CFR
413.13(e).
NOTE: Nominal charge providers are not subject to the lesser of cost or charges (LCC).
Therefore, a nominal charge provider only completes lines 1, 2, 3, and 11 of Part I.
Transfer the resulting cost to line 12 of Part II.
Line Descriptions
Line 1--Reporting periods beginning prior to October 1, 2000, enter the cost of services from
Worksheet C, Parts III, IV and V based on the following table. If the amount in column 6, line
19 is less than the amount in column 6, line 22, and the amount in column 6, line 24, transfer the
aggregate Medicare cost. For cost reporting periods beginning on or after October 1, 2000, do
not transfer any costs to line 1, column 1 of this worksheet. For cost reporting periods beginning
on or after October 1, 2000, transfer the cost of osteoporosis drugs from Worksheet C, Part III,
column 10, line 16 to column 3 of this worksheet.
For services rendered on or after January 1, 2003, do not transfer the cost of hepatitis vaccines
from Worksheet C, Part III, column 9, line 16, as they are OPPS reimbursed; however, transfer
the cost of pneumococcal and influenza vaccines from Worksheet C, Part III, column 9.01, line
16 to column 2 of this worksheet, and the cost of osteoporosis drugs from Worksheet C, Part III,
column 10, line 16 to column 3 of this worksheet.
For cost reporting periods ending after July 1, 2006 (see §3206, line 13), transfer the cost of
pneumococcal, influenza, and hepatitis vaccines from Worksheet C, Part III, column 9, line 16,
to column 2 of this worksheet, and the cost of osteoporosis drugs from Worksheet C, Part III,
column 10, line 16 to column 3 of this worksheet. Also transfer the administration of
pneumococcal, influenza, and hepatitis B vaccines from Worksheet C, Part III, column 9, line
16.20, to column 2, for the portion of the reporting period before July 1, 2006.
To Worksheet D, Line 1
Rev.
From Worksheet C
Col. 1, Part A
Part IV, col. 3, line 19
Col. 2, Part B
Part III, sum of col. 9 line 16 (excluding subscripted
lines), and Part IV, col. 4, line 19
Col. 3, Part B
Part III, sum of col. 10, lines 15 (excluding
subscripted lines), 16 and 16.01, and Part V, col. 8,
line 28
32-35
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FORM CMS-1728-94
DRAFT
If the amount in column 6, line 22 is less than the amount in column 6, line 19, and the amount in
column 6, line 24, transfer (aggregate Medicare limitation):
To Worksheet D, Line 1
From Worksheet C
Col. 1, Part A
Part IV, col. 3, line 22
Col. 2, Part B
Part III, sum of col. 9, line 16 (excluding
subscripted lines), and Part IV, col. 4, line 22
Col. 3, Part B
Part III, sum of col. 10, lines 15 (excluding
subscripted lines), 16 and 16.01, and Part V, col. 8,
line 28
If column 6, line 24 is less than the amount in column 6, line 19, and the amount in column 6,
line 22, transfer (aggregate agency beneficiary limitation):
To Worksheet D, Line 1
From Worksheet C
Col. 1, Part A
Part IV, col. 3, line 24
Col. 2, Part B
Part III, sum of col. 9, line 16 (excluding subscripted
lines), and Part IV, col. 4, line 24
Col. 3, Part B
Part III, sum of col. 10, lines 15 (excluding
subscripted lines), 16 and 16.01, and Part V, col. 8,
line 28
Line 2.--Do not complete this line.
Line 3.--In each column, enter the amount on line 1 plus the amount on line 2.
Line 4.--In columns 1, 2 and 3, enter from your records the charges for the applicable Medicare
services rendered prior to October 1, 2000. Also, in columns 2 and 3, enter from your records
the charges for the applicable Medicare covered drugs (see §3215.3) rendered prior to October 1,
2000. In column 3, also enter the Medicare charges applicable to all RHCs and FQHCs,
respectively, for services furnished prior to January 1, 1998.
Line 4.01.--In column 2, enter from your records only the charges for applicable Medicare
covered pneumococcal and influenza vaccines (see §3215.3) rendered on or after January 1,
2003 (from Worksheet C, line 16, column 6.01). In column 3, enter from your records only the
charges for applicable Medicare covered osteoporosis drugs (see §3215.3) rendered on or after
October 1, 2000 (from Worksheet C, line 16, column 7). For all other services rendered on or
after October 1, 2000, do not enter any charges in columns 1 and 2.
Effective for cost reporting periods ending after June 30, 2006, in column 2, enter the charges for
Medicare covered pneumococcal, influenza, and hepatitis B vaccines (from Worksheet C, Part
III, lines 16 and 16.20, column 6). In column 3, enter the charges for Medicare covered
osteoporosis drugs (from Worksheet C, Part III, lines 16, column 7).
Lines 5 through 8.--These lines provide for the accumulation of charges which relate to the
reasonable cost on line 3.
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3216.1 (Cont.)
Do not include on these lines (1) the portion of charges applicable to the excess costs of luxury
items or services (see CMS Pub. 15-1, §2104.3) and (2) provider charges to beneficiaries for
excess costs as described in CMS Pub. 15-1, §2570. When provider operating costs include
amounts that flow from the provision of luxury items or services, such amounts are not allowable
in computing reimbursable costs.
Lines 5, 6, 7, and 8.--These lines provide for the reduction of Medicare charges where the
provider does not actually impose such charges (in the case of most patients liable for payment
for services on a charge basis) or fails to make reasonable efforts to collect such charges from
those patients. Enter on line 8 the product of multiplying the ratio on line 7 by line 4 for each
column. For column 3, lines 5 and 6, prorate, based on the ratio derived in line 4, all amounts
applicable to RHC/FQHCs. Providers which do impose these charges and make reasonable
efforts to collect the charges from patients liable for payment for services on a charge basis are
not required to complete lines 5, 6, and 7, but enter on line 8 the amount from line 4 for column 1
(excluding subscripted lines) and enter on line 8, columns 2 and 3 the sum of the amounts from
lines 4 and 4.01. (See 42 CFR 413.13(b).) In no instance may the customary charges on line 8
exceed the actual charges on line 4.
Line 9.--Enter in each applicable column on line 9 the excess of total customary charges (line 8)
over the total reasonable cost (line 3). In situations when in any column the total charges on line
8 are less than the total cost on line 3 of the applicable column, enter zero (0) on line 9.
Line 10.--Enter in each applicable column on line 10 the excess of total reasonable cost (line 3)
over total customary charges (line 8). In situations when in any column the total cost on line 3 is
less than the customary charges on line 8 of the applicable column, enter zero (0) on line 10.
Line 11.--Enter the amounts paid or payable by workers' compensation and other primary payers
where program liability is secondary to that of the primary payer. Primary payer amounts
relating to services paid under PPS are included on this line, which may result in line 12 being
negative. There are several situations under which Medicare payment is secondary to a primary
payer. Prorate, based on the ratio derived in line 4 (including subscripts), all amounts applicable
to RHC/FQHCs. Some of the most frequent situations in which the
Medicare program in a secondary payer include:
1.
2.
3.
4.
5.
6.
Workers' compensation,
No fault coverage,
General liability coverage,
Working aged provisions,
Disability provisions, and
Working ESRD beneficiary provisions.
Generally, when payment by the primary payer satisfies the total liability of the program
beneficiary, for cost reporting purposes only, the services are considered to be nonprogram
services. (The primary payment satisfies the beneficiary's liability when the provider accepts
that payment as payment in full. The provider notes this on no-pay bills submitted in these
situations.) The patient visits and charges are included in total patient visits and charges, but are
not included in program patient visits and charges. In this situation, no primary payer payment is
entered on line 11.
However, when the payment by the primary payer does not satisfy the beneficiary's obligation,
the program pays the lesser of (a) the amount it would otherwise pay (without regard to the
primary payer payment or deductible and coinsurance) less the primary payer payment or (b) the
amount it would otherwise pay (without regard to primary payer payment or deductibles and
coinsurance) less applicable deductible and coinsurance. Primary payer payment is credited
toward the beneficiary's deductible and coinsurance and are not entered on line 11.
Rev.
32-37
3216.2
FORM CMS-1728-94
DRAFT
When the primary payment does not satisfy the beneficiary's liability, include the covered visits
and charges in program visits and charges, and include the total visits and charges in total visits
and charges for cost apportionment purposes. Enter the primary payer payment on line 11 to the
extent that primary payer payment is not credited toward the beneficiary's deductible and
coinsurance. Primary payer payments that are credited toward the beneficiary's deductible and
coinsurance are not entered on line 11. The primary payer rules are more fully explained in 42
CFR 411.
3216.2
Part II - Computation of Reimbursement Settlement.--
NOTE: For Part II, where applicable and not specifically instructed to do so, prorate, based on
the ratio derived in Part I, line 4, all amounts applicable to RHCs and FQHCs,
respectively.
Line 12.--Enter in column 1 the amount on line 3, column 1, minus the amount on line 11,
column 1. Enter in column 2 the sum of the amounts on line 3, columns 2 and 3, minus the sum
of the amounts on line 11, columns 2 and 3.
Lines 12.01 through 12.14.--Under PPS enter only payment amounts associated with episodes
completed in the current cost reporting period. Payments for episodes of care which overlap
fiscal years must be recorded in the fiscal year in which the episode was completed. Enter in
columns 1 and 2 for lines 12.01 through 12.06, as applicable, the appropriate PPS payment for
each episode of care payment category indicated on the worksheet. Enter in columns 1 and 2 for
lines 12.07 through 12.10, as applicable, the appropriate PPS outlier payment for each episode of
care payment category indicated on the worksheet. Enter in columns 1 and 2, line 12.11 the sum
total of other payments. Enter in columns 1 and 2, lines 12.12 through 12.14, the gross payments
for DME, oxygen, and prosthetics and orthotics payments, respectively associated with home
health PPS services (bill types 32 and 33 only).
For lines 12.12 through 12.14 do not include any amounts associated with services billed on bill
type 34. Obtain these amounts from your records or PS&R report.
Line 13.--Enter in column 2 the applicable Part B deductibles billed to Medicare patients.
Exclude coinsurance amounts. Include any amounts of deductibles satisfied by primary payer
payments. Prorate, based on the ratio derived in line 4, all amounts applicable to RHCs/FQHCs,
respectively.
Do not enter deductibles for DME, oxygen, and prosthetics and orthotics.
Line 15.--If there is an excess of reasonable cost over customary charges, enter the Part A excess
(line 10, column 1) in column 1 and the Part B excess (sum of line 10, columns 2 and 3) in
column 2. If you are a nominal charge provider (response of “Y” to S-2, line 21), enter zero on
this line.
Line 17.--Enter in column 2 all coinsurance billable to Medicare beneficiaries including amounts
satisfied by primary payer payments. Coinsurance is applicable for services reimbursable under
§1832(a)(2) of the Act and is entered in column 2. Prorate, based on the ratio derived in line 4,
all amounts applicable to RHCs/FQHCs, respectively. Do not enter coinsurance for DME,
oxygen, and prosthetics and orthotics.
NOTE: If the component qualifies as a nominal charge provider, enter 20 percent of costs
subject to coinsurance on this line. Compute this amount by subtracting Part B deductibles on
line 13 and Part B primary payment amounts in column 3, line 11 from Part B costs subject to
coinsurance in column 3, line 1. Multiply the resulting amount by 20 percent and enter it on this
line.
Line 19.--Enter the reimbursable bad debts, net of recoveries, in the appropriate columns.
Columns 1 and 2 are shaded as HHAs cannot generate bad debts.
32-38
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FORM CMS-1728-94
3216.2 (Cont.)
Line 20.--Do not complete this line.
Line 21.--For column 1, enter the sum of lines 18 and 19, column 1. For column 2, enter the sum
of lines 18, 19, and 20, column 2.
Line 22.--Enter the program's share of any net depreciation adjustment applicable to prior years
resulting from the gain or loss on the disposition of depreciable assets. (See CMS Pub. 15-1,
§132.) Enter the amount of any excess depreciation taken as a negative amount.
NOTE: Effective for changes in ownership that occur on or after December 1, 1997, §4404 of
BBA 1997 amends §1861(v)(1)(O) of the Act which states, in part, that “...a provider
of services which has undergone a change of ownership, such regulations provide that
the valuation of the asset after such change of ownership shall be the historical cost of
the asset, as recognized under this title, less depreciation allowed, to the owner of
record....” That is, no gain or loss is recognized for such transactions on or after
December 1, 1997.
Line 23.--Enter the program's share of any recovery of excess depreciation applicable to prior
years resulting from provider termination or a decrease in Medicare utilization. Submit the
workpapers which have developed this amount. (See CMS Pub. 15-1, §136ff.)
Line 24.--Where a provider's cost limit is raised as a result of its request for review, amounts
which were erroneously collected on the basis of the initial cost limit are required to be refunded
to the beneficiary. Enter any amounts which are not refunded either because they are less than
$5 collected from a beneficiary or because the provider is unable to locate the beneficiary. (See
CMS Pub. 15-1, §2577.)
Line 25.--Enter in each column the amount on line 21, plus line 22 minus the sum of lines 23 and
24.
Rev.
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FORM CMS-1728-94
DRAFT
This page is reserved for future use.
32-38.2
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FORM CMS-1728-94
3217
Line 25.50.--Enter any other adjustments. For example, enter an adjustment resulting from
changing the recording of vacation pay from cash basis to accrual basis. (See CMS Pub. 15-1,
§2146.4.) For purposes of reimbursing costs associated with the Outcome and Assessment
Information Set (OASIS) as required by Program Memorandum A-00-03 (cost reporting periods
beginning in Federal fiscal year 2000 only), report on this line, in column 1, the result of
multiplying the Medicare unduplicated census count on Worksheet S-3, column 2, line 10
(excluding subscripts), times $10, minus the interim OASIS payment made to the provider on
April 1, 2000. Do not include this interim OASIS payment on Worksheet D-1, but rather attach
documentation supporting the payment(s). (For contractor use only during final settlement.)
Line 26.--Enter the sequestration adjustment amount from the PS&R report.
Line 27.--Enter the amount on line 25 plus line 25.50 and subscripts minus line 26.
Line 28.--Enter the interim payment from Worksheet D-1, line 4. For contractor final settlement,
report on line 28.5 the amount from Worksheet D-1, line 5.99.
Line 29.--Enter the balance due the provider or the program by entering the result of line 27
minus line 28. Indicate overpayments by parentheses ( ). Transfer the amount in column 1 to
Worksheet S, Part II, line 1, and column 1. Transfer the amount in column 2 to Worksheet S,
Part II, line 1, and column 2.
Line 30.--Enter the Medicare reimbursement effect of protested items. The reimbursement effect
of the nonallowable items is estimated by applying reasonable methodology which closely
approximates the actual effect of the item as if it had been determined through the normal cost
finding process. (See §115.2.) A schedule showing the supporting details and computations for
this line must be attached.
Line 31.--Do not use this line.
3217.
WORKSHEET D-1 - ANALYSIS OF PAYMENTS TO HOME HEALTH
AGENCIES FOR SERVICES RENDERED TO PROGRAM BENEFICIARIES
Complete this worksheet for Medicare interim payments only. (See 42 CFR 413.64.)
The column headings designate two categories of payments:
Category 1 - Part A
Category 2 - Part B
Complete the identifying information on lines 1 through 4. The remainder of the worksheet is
completed by your contractor .
NOTE: DO NOT reduce any interim payments by recoveries as a result of medical review
adjustments where the recoveries were based on a sample percent applied to the
universe of claims reviewed and the Provider Statistical and Reimbursement Report
(PS&R) was not also adjusted.
Line Descriptions
Line 1.--Enter the total Medicare interim payments paid to the HHA for all covered services
rendered prior to October 1, 2000. Additionally, for services rendered on or after October 1,
2000, enter the total Medicare interim payments paid to the HHA for applicable covered
osteoporosis drugs and any
Rev.
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FORM CMS-1728-94
DRAFT
other vaccines paid on a cost reimbursement basis. The amount entered reflects the sum of all
interim payments paid on individual bills (net of adjustment bills) for services rendered in this
cost reporting period and includes amounts withheld from the HHA's interim payments due to an
offset against overpayments to the HHA applicable to prior cost reporting periods. It does not
include any retroactive lump sum adjustment amounts based on a subsequent revision of the
interim rate, or tentative or net settlement amounts; nor does it include interim amounts; nor does
it include interim payments payable. If the HHA is reimbursed under the periodic interim
payment method of reimbursement, enter the periodic interim payments received for this cost
reporting period. Do not include payments received for services reimbursed on a fee schedule
basis.
Also enter in columns 2 and 4, as applicable for HHA services furnished on or after
October 1, 2000, the total Medicare PPS payments and the total Medicare PPS outlier payments
paid to the HHA for all episode payment categories for related episodes completed during the
current cost reporting period. The amounts entered reflect the sum of all interim PPS payments
paid on individual claims (net of adjustments) for episodes completed in the current cost
reporting period. Enter gross payments for total DME, oxygen, and prosthetics and orthotics,
associated with home health PPS services only (bill types 32 and 33). Do not include any
payment information associated with services recorded on bill type 34.
Line 2.--Enter the total Medicare interim payments payable on individual bills. Since the cost in
the cost report is on an accrual basis, this line represents the amount of services rendered in the
cost reporting period but not paid as of the end of the cost reporting period and does not include
payments reported on line 1.
Line 3.--Enter the amount of each retroactive lump sum adjustment and the applicable date.
Line 4.--Enter the total amount of the interim payments (sum of lines 1, 2, and 3.99). Transfer
these totals to the appropriate column on Worksheet D, Part II, line 28.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET D-1. THE REMAINDER OF
THE WORKSHEET IS COMPLETED BY YOUR CONTRACTOR.
Line 5.--List separately each tentative settlement payment after desk review together with the
date of payment. If the cost report is reopened after the Notice of Program Reimbursement
(NPR) has been issued, all settlement payments prior to the current reopening settlement are
reported on line 5.
Line 6.--Enter the net settlement amount from Worksheet D, Part II, line 29, transferring the Part
A amount to column 2 and Part B amount to column 4.
NOTE: On lines 3, 5, and 6, when 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.
Line 7.--Enter the total Medicare program liability. Enter the sum of the amounts on lines 4,
5.99, and 6.01 or 6.02 in columns 2 and 4, as appropriate. Enter amounts due the program in
parentheses ( ).
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FORM CMS-1728-94
3218
WORKSHEETS F, F-1, AND F-2 - FINANCIAL STATEMENTS
These worksheets are prepared from your accounting books and records. Additional worksheets
may be submitted if necessary.
Complete all worksheets in the "F" series. Worksheets F and F-2 are completed by all providers
maintaining fund-type accounting records. Providers not maintaining fund-type accounting
records should only complete the General Fund columns of these worksheet. Cost reports
received with incomplete "F" worksheets are returned to the provider for completion and the
provider is considered as having failed to file a cost report.
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3219.
FORM CMS-1728-94
DRAFT
WORKSHEET A-8-3 - REASONABLE COST DETERMINATION FOR THERAPY
SERVICES FURNISHED BY OUTSIDE SUPPLIERS
This worksheet provides for the computation of any needed adjustments to costs applicable to
physical therapy, occupational therapy, and speech pathology services furnished by outside
suppliers. The information required on this worksheet provides, in the aggregate, all data for
therapy services furnished by all outside suppliers in determining the reasonableness of therapy
costs. (See CMS Pub. 15-1, chapter 14.)
Complete this worksheet for cost reporting periods beginning prior to October 1, 2000 for
physical therapy, occupational therapy, or speech pathology services rendered prior to October 1,
2000. Do not complete this worksheet for cost reporting periods beginning on or after October 1,
2000.
NOTE: If you furnish physical therapy services under arrangement with outside suppliers,
complete a separate worksheet A-8-3 for physical therapy services rendered before
April 10, 1998 and a separate worksheet A-8-3 for physical therapy services rendered
on or after April 10, 1998. In additional to physical therapy services, if you furnish
either occupational therapy and/or speech pathology services on or after April 10,
1998, under arrangement with outside suppliers, complete a separate worksheet for
each discipline. For physical therapy, occupational therapy, and speech pathology
services that overlap April 10, 1998, prorate, based on total charges, any statistics and
costs for purposes of calculating standards, allowances, or the actual reasonable cost
determination, e.g., overtime hours. (See 42 CFR §413.106.)
Complete this worksheet once for each type of therapy service furnished by an outside supplier.
If you contract with an outside supplier for therapy services, the potential for limitation and the
amount of payment you receive depends on several factors:
o
An initial test to determine whether these services are categorized as intermittent part
time or full time services;
o
The location where the services are rendered, i.e., HHA home visit;
o
For HHA services, whether detailed time and mileage records are maintained by the
contractor and HHA;
o
Add-ons for supervisory functions, aides, overtime, equipment, and supplies; and
o
Contractor determinations of reasonableness of rates charged by the supplier compared
with the going rates in the area.
3219.1 Part I - General Information.--This part provides for furnishing certain information
concerning therapy services furnished by outside suppliers.
Line 1.--For services performed at the patient’s residence, count only those weeks during which
services were rendered by supervisors, therapists, or assistants to patients of the HHA. (See
CMS Pub. 15-1, chapter 14.)
Line 2.--Multiply the amount on line 1 by 15 hours per week. This calculation is used to
determine whether services are full time or intermittent part time.
Line 3.--Enter the number of unduplicated HHA visits made by the supervisor or therapist. Only
count one visit when both the supervisor and therapist were present during the same visit.
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3219.2
Line 4.--Enter the number of unduplicated HHA visits made by the therapy assistant. Do not
include in the count the visits when either the supervisor or therapist were present during the
same visit.
Line 5.--Enter the standard travel expense rate applicable. (See CMS Pub. 15-1, chapter 14.)
Line 6.--Enter the optional travel expense rate applicable. (See CMS Pub. 15-1, chapter 14.)
Use this rate only for home health patient services for which time records are available.
Line 7.--Enter in the appropriate columns the total number of hours worked for therapy
supervisors, therapists, therapy assistants, and aides furnished by outside suppliers.
Line 8.--Enter in each column the appropriate adjusted hourly salary equivalency amount
(AHSEA). This amount is the prevailing hourly salary rate plus the fringe benefit and expense
factor described in CMS Pub. 15-1, chapter 14. This amount is determined on a periodic basis
for appropriate geographical areas and is published as an exhibit at the end of CMS Pub. 15-1,
chapter 14. Use the appropriate exhibit for the period of this cost report.
Enter in column 1 the supervisory AHSEA, adjusted for administrative and supervisory
responsibilities. Determine this amount in accordance with the provisions of CMS Pub. 15-1,
§1412.5. Enter in columns 2, 3, and 4 (for therapists, assistants, and aides respectively) the
AHSEA from either the appropriate exhibit found in CMS Pub. 15-1, chapter 14 or from the
latest publication of rates. If the going hourly rate for assistants in the area is unobtainable, use
no more than 75 percent of the therapist AHSEA. The cost of services of a therapy aide or
trainee is evaluated at the hourly rate, not to exceed the hourly rate paid to your employees of
comparable classification and/or qualification, e.g., nurses’ aides. (See CMS Pub. 15-1,
§1412.2.)
Line 9.--Enter the standard travel allowance equal to one half of the AHSEA. Enter in columns 1
and 2 one half of the amount in column 2, line 8. Enter in column 3 one half of the amount in
column 3, line 8. (See CMS Pub. 15-1, §1402.4.)
Lines 10 and 11.--Enter the number of travel hours and number of miles driven, respectively, if
time records of visits are kept. (See CMS Pub. 15-1, §§1402.5 and 1412.6.)
NOTE: There is no travel allowance for aides employed by outside suppliers.
3219.2 Part II - Salary Equivalency Computation.--This part provides for the computation of
the full time or intermittent part time salary equivalency.
When you furnish therapy services from outside suppliers to Medicare patients but simply
arrange for such services for non health care program patients and do not pay the other Medicare
portion of such services, your books reflect only the cost of the health care program portion.
Where you can gross up costs and charges in accordance with provisions of CMS Pub. 15-1,
§2314, complete Part II, lines 12 through 17 and 20 in all cases and lines 18 and 19, where
appropriate. However, where you cannot gross up costs and charges, complete lines 12 through
17 and 20.
Lines 12 through 17.--To compute the total salary equivalency allowance amounts, multiply the
total hours worked (line 7) by the adjusted hourly salary equivalency amount for supervisors,
therapists, assistants, and aides.
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Lines 18 and 19.--If the sum of hours in columns 1 through 3, line 7, is less than or equal to the
product found on line 2, complete these lines. (See the exception above where you cannot gross
up costs and charges, and services are provided to program patients only.)
Line 20.--If there are no entries on lines 18 and 19, enter the amount on line 17. Otherwise, enter
the sum of the amounts on lines 16 and 19.
3219.3 Part III - Travel Allowance and Travel Expense Computation - HHA Services.--This
part provides for the computation of the standard travel allowance, the standard travel expense,
the optional travel allowance, and the optional travel expense. (See CMS Pub. 15-1, §§1402ff,
1403.1 and 1412.6.)
Lines 21 through 24.--Complete these lines for the computation of the standard travel allowance
and standard travel expense for therapy services performed in conjunction with HHA visits. Use
these lines only if you do not use the optional method of computing travel. A standard travel
allowance is recognized for each visit to a patient’s residence. If services are furnished to more
than one patient at the same location, only one standard travel allowance is permitted, regardless
of the number of patients treated.
Lines 25 through 28.--Complete the optional travel allowance and optional travel expense
computations for therapy services in conjunction with home health services only. Compute the
optional travel allowance on lines 25 through 27. Compute the optional travel expense on line
28.
Lines 29 through 31.--Choose and complete only one of the options on lines 29 through 31.
However, use lines 30 and 31 only if you maintain time records of visits. (See CMS Pub. 15-1,
§1402.5.)
3219.4 Part IV - Overtime Computation.--This part provides for the computation of an
overtime allowance when an individual employee of the outside supplier performs services for
you in excess of your standard work week. No overtime allowance is given to a therapist who
receives an additional allowance for supervisory or administrative duties. (See CMS Pub. 15-1,
§1412.4.)
Line 32.--Enter in the appropriate columns the total overtime hours worked. Where the total
hours in column 4 are either zero or equal to or greater than 2080, the overtime computation is
not applicable. Make no further entries on lines 33 through 40. Enter zero in each column of line
41. Enter the sum of the hours recorded in columns 1 through 3 in column 4.
Line 33.--Enter in the appropriate column the overtime rate (the AHSEA from line 8, column as
appropriate, multiplied by 1.5).
Line 35.--Enter the percentage of overtime hours by class of employee. Determine this amount
by dividing each column on line 32 by the total overtime hours in column 4, line 32.
Line 36.--Use this line to allocate your standard work year for one full time employee. Enter the
numbers of hours in your standard work year for one full time employee in column 4. Multiply
the standard work year in column 4 by the percentage on line 35 and enter the result in the
corresponding columns.
Line 37.--Enter in columns 1 through 3 the AHSEA from Part I, line 10, columns 2 through 4, as
appropriate.
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3219.5 Part V - Computation of Therapy Limitation and Excess Cost Adjustment.--This part
provides for the calculation of the adjustment to therapy service costs in determining the
reasonableness of therapy cost.
Lines 45 and 46--When the outside supplier provides the equipment and supplies used in
furnishing direct services to your patients, the actual cost of the equipment and supplies incurred
by the outside supplier (as specified in CMS Pub. 15-1, §1412.1) is considered an additional
allowance in computing the limitation.
Line 48--Enter the amounts paid and/or payable to the outside suppliers for therapy services
rendered during the period as reported in the cost report. This includes any payments for
supplies, equipment use, overtime, or any other expenses related to supplying therapy services
for you. For physical therapy, occupational therapy, and speech pathology services rendered to
non-homebound beneficiaries on or after January 1, 1999, prorate, based on total HHA visits, the
amounts paid and/or payable to outside suppliers, e.g., multiply the amount paid and/or payable
to outside suppliers by the ratio of visits made by non-homebound beneficiaries to CORFs
(and/or OPTs) to total HHA visits. The result is the amount of the reduction.
Line 49--Enter the excess cost over the limitation, i.e., line 48 minus line 47. Transfer this
amount to Worksheet A-5, line 10 for physical therapy services, line 10.1 for occupational
therapy services and line 10.2 for speech pathology services. If the amount is negative, enter a
zero.
3220.
3221.
3221.1
3221.2
3221.3
3222.
3222.1
3222.2
3222.3
3223.
3223.1
3223.2
3224.
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32-46
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3225.
FORM CMS-1728-94
3225.3
WORKSHEET CM-1 - ALLOCATION OF GENERAL SERVICE COSTS TO
HHA-BASED CMHC COST CENTERS
Use this worksheet only if you operate a certified HHA-based CMHC as part of your complex.
If you have more than one HHA-based CMHC, complete a separate worksheet for each.
3225.1 Part I - Allocation of General Service Costs to HHA-Based CMHC Cost Centers.-Worksheet CM-1, Part I, provides for the allocation of the expenses of each general service cost
center to those cost centers which receive the services. Obtain the total direct expenses (column
0, line 12) from Worksheet A, column 10, line 26. Obtain the cost center allocation (column 0,
lines 1 through 11) from your records. The amounts on line 12, columns 0 through 5, must agree
with the corresponding amounts on Worksheet B, columns 0 through 5, line 26. Complete the
amounts entered on lines 1 through 11, columns 1 through 8, in accordance with the instructions
contained in §3225.3.
NOTE:
There is no revenue code specifically entitled "Diagnostic Services." Therefore, use
revenue code 918 (testing) when billing for these services.
3225.2 Part II - Computation of Unit Cost Multiplier for Allocation of HHA-Based CMHC
Administrative and General Costs.--Use this part to compute the unit cost multiplier used to
allocate CMHC administrative and general costs to the revenue producing CMHC cost centers.
Line 1.--Enter the amount from Part I, column 6, line 12.
Line 2.--Enter the amount from Part I, column 6, line 1.
Line 3.--Subtract the amount on line 2 from the amount on line 1 and enter the result.
Line 4.--Divide line 2 by line 3 and enter the result. Multiply each amount in Part I, column 6,
lines 2 through 11, by the unit cost multiplier and enter the result on the corresponding line of
column 7.
3225.3 Part III - Allocation of General Service Costs to HHA-Based CMHC Cost Centers Statistical Basis.--Worksheet CM-1, Parts II and III, provide for the proration of the statistical
data needed to equitably allocate the expenses of the general service cost centers on Worksheet
CM-1, Part I. If there is a difference between the total accumulated costs reported on the Part III
statistics and the total accumulated costs calculated on Part I, use the reconciliation column on
Part III for reporting any adjustments. See §3214 for the appropriate usage of the reconciliation
columns. For componentized A&G cost centers, the accumulated cost center line must match the
reconciliation column number.
To facilitate the allocation process, the general format of Worksheet CM-1, Parts I and III, is
identical.
The statistical basis shown at the top of each column on Worksheet CM-1, Part III, is the
recommended basis of allocation of the cost center indicated.
NOTE: If you wish to change your allocation basis for a particular cost center, you must make
a written request to your contractor for approval of the change and submit reasonable
justification for such change prior to the beginning of the cost reporting period for
which the change is to apply. The effective date of the change is the beginning of the
cost reporting period for which the request has been made. (See CMS Pub. 15-1,
§2313.)
Lines 1 through 11.--On Worksheet CM-1, Part III, for all cost centers to which the general
service cost center is being allocated, enter that portion of the total statistical base applicable to
each.
Line 12.--Enter the total of lines 1 through 11 for each column. The total in each column must
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FORM CMS-1728-94
DRAFT
be the same as shown for the corresponding column on Worksheet B-1, line 26.
Line 13.--Enter the total expenses for the cost center allocated. Obtain this amount from
Worksheet B, line 26, from the same column used to enter the statistical base on Worksheet CM1, Part III (e.g., in the case of capital-related cost buildings and fixtures, this amount is on
Worksheet B, column 1, line 26).
Line 14.--Enter the unit cost multiplier which is obtained by dividing the cost entered on line 13
by the total statistic entered in the same column on line 12. Round the unit cost multiplier to six
decimal places.
Multiply the unit cost multiplier by that portion of the total statistics applicable to each cost
center receiving the services. Enter the result of each computation on Worksheet CM-1, Part I,
in the corresponding column and line.
After the unit cost multiplier has been applied to all the cost centers receiving the services, the
total cost (line 12, Part I) must equal the total cost on line 13, Part III.
Perform the preceding procedures for each general service cost center.
In column 6, Part I, enter the total of columns 4A through 5.
In column 7, Part I, for lines 2 through 11, multiply the amount in column 6 by the unit cost
multiplier on line 4, Part II, and enter the result in this column. On line 12, enter the total of the
amounts on lines 2 through 11. The total on line 12 equals the amount in column 6, line 1.
In column 8, Part I, enter on lines 2 through 11 the sum of the amounts in columns 6 and 7. The
total on line 12 equals the total in column 6, line 12.
3226.
WORKSHEET CM-2 - COMPUTATION OF HHA-BASED CMHC COSTS
Use this worksheet only if you operate an HHA-based CMHC. If you have more than one
HHA-based CMHC, complete a separate worksheet for each. Partial hospitalization services
provided by HHA-based CMHCs are reimbursed based on a Prospective Payment System (PPS).
All CMHC services rendered on or after August 1, 2000 are reimbursed based on a PPS subject
to a transitional corridor payment. Vaccines furnished by HHA-based CMHCs are reimbursed
based on outpatient PPS.
3226.1
Part I - Apportionment of HHA-Based CMHC Cost Centers.--
Column 1.--Enter on each line the total cost for the cost center as previously computed on
Worksheet CM-1, Part I, column 8. To facilitate the apportionment process, the line numbers are
the same on both worksheets.
Column 2.--Enter the charges for each cost center. Obtain the charges from your records.
Column 3.--For each cost center, enter the ratio derived by dividing the cost in column 1 by the
charges in column 2.
Column 3.01.-- For each cost center, enter the corresponding charges from your records for total
Title XVIII HHA-based CMHC services rendered during the entire cost reporting period.
Column 3.02.--For each cost center, enter the total Title XVIII HHA-based CMHC costs by
multiplying the charges in column 3.01 by the ratio in column 3.
Column 4.--For each cost center, enter the corresponding charges from your records for Title
XVIII HHA-based CMHC services rendered on or after August 1, 2000, January 1, 2002,
January 1, 2003, or January 1, 2004. For cost reporting periods beginning on or after January 1,
2004, enter zero (0).
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Column 5.--For each cost center, enter the costs on or after August 1, 2000, January 1, 2002,
January 1, 2003, or January 1, 2004, by multiplying the charges in column 4 by the ratio in
column 3.
Column 6.-- For each cost center, enter the costs associated with services rendered prior to
August 1, 2000, January 1, 2002, January 1, 2003, or January 1, 2004, by subtracting the amount
in column 5 from the amount in column 3.02.
Line 12.--Enter the totals for columns 1, 2, 3.01, 3.02, 4, 5 and 6.
3226.2 Part II - Apportionment of Cost of HHA-Based CMHC Services Furnished by Shared
HHA Departments.--Use this part only when the HHA complex maintains a separate department
for any of the cost centers listed on this worksheet, and the department provides services to
patients of the HHA’s CMHC.
Column 1.--Enter on each line the total cost for the HHA cost center as previously computed on
Worksheet B, column 6, for the corresponding cost centers only when HHA-based CHMC
services are furnished by shared HHA departments.
Column 2.--Enter the total charges for each cost center. Obtain the charges from your records.
Column 3.--For each of the cost centers listed, enter the ratio of cost to charges (column 1
divided by column 2).
Column 3.01.-- For each cost center, enter the corresponding charges from your records for total
Title XVIII HHA-based CMHC services rendered during the entire cost reporting period.
Column 3.02.--For each cost center, enter the total Title XVIII HHA-based CMHC costs by
multiplying the charges in column 3.01 by the ratio in column 3.
Column 4.--For each cost center, enter the charges from your records for Title XVIII HHA-based
CMHC services rendered on or after August 1, 2000, January 1, 2002, January 1, 2003, or
January 1, 2004. For cost reporting periods beginning on or after January 1, 2004, enter zero (0).
Column 5.--For each cost center, enter the costs on or after August 1, 2000, January 1, 2002,
January 1, 2003, or January 1, 2004 obtained by multiplying the charges in column 4 by the ratio
in column 3.
Column 6.-- For each cost center, enter the costs associated with services rendered prior to
August 1, 2000, January 1, 2002, January 1, 2003, or January 1, 2004, by subtracting the amount
in column 5 from the amount in column 3.02.
Line 16.--Enter the sum lines 13 through 15 for columns 1, 2, 3.01, 3.02, 4, 5 and 6.
3226.3
Part III - Total HHA-Based CMHC Costs.--
Columns 3.01, 3.02 and 4-6.--Enter the sum total of Part I, line 12 plus Part II, line 16 for each
column, respectively.
Column 6.--Enter the total costs from Part I, column 6, line 12 plus Part II, column 6, line 16.
Transfer this amount to Worksheet CM-3, line 1, column 1.
3227.
WORKSHEET CM-3 - CALCULATION OF REIMBURSEMENT SETTLEMENT HHA-BASED CMHC SERVICES
Submit a Worksheet CM-3 only if you operate a HHA-based CMHC. If you have more than one
HHA-based CMHC, complete a separate worksheet for each.
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3227.1
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NOTE: Column 1 is subscripted for lines 1 through 18 for cost reporting periods which overlap
August 1, 2000, January 1, 2002, January 1, 2003, or January 1, 2004, to accommodate the
transitional corridor payment calculation associated with the portion of the cost reporting period
which overlaps any of the aforementioned dates. For cost reporting periods which overlap a
transition date enter in column 1 any data applicable to CMHC services rendered prior to the
transition and enter in column 1.01 data applicable to CMHC services rendered on or after the
transition date. For cost reporting periods that do not overlap transition dates and for cost
reporting periods beginning on or after January 1, 2004, only complete column 1.
3227.1
Part I - Computation of Lesser of Reasonable Cost or Customary Charges.--
Line 1.--For cost reporting periods ending prior to August 1, 2000, enter in column 1 the
applicable cost from Worksheet CM-2, column 5, line 17. CMHCs with cost reporting periods
overlapping August 1, 2000, January 1, 2002, January 1, 2003, or January 1, 2004, enter in the
applicable column the cost of services provided prior to the applicable transition date from
Worksheet CM-2, column 6, line 17, and enter in the applicable column the cost of services
provided on or after the applicable transition date from Worksheet CM-2, column 5, line 17.
HHA-based CMHCs with cost reporting periods beginning on or after January 1, 2004, enter
zero (0) as CMHC services are reimbursed under 100% PPS.
Lines 1.01 through 1.05 are to be completed by HHA-based CMHCs for Title XVIII services
rendered on or after August 1, 2000.
Line 1.01.--Enter the gross PPS payments (includes deductible and coinsurance) received
including payments for drugs and outliers.
Line 1.02.--Enter the 1996 CMHC specific payment to cost ratio provided by your contractor.
Line 1.03.--Line 1 times line 1.02.
Line 1.04.--Line 1.01 divided by line 1.03. Express the results as a percentage to 3 decimal
places, i.e., 94.824%. If this line is equal to or greater than 100%, enter zero on line 1.05.
Line 1.05.-- Enter the transitional corridor payment amount calculated based on the following:
For services rendered August 1, 2000 through December 31, 2001:
a. If line 1.04 is => 90% but < 100% enter 80% of line 1.03 minus line 1.01.
b. If line 1.04 is => 80% but < 90% enter the result of .71 times line 1.03 minus .70 times line
1.01.
c. If line 1.04 is => 70% but < 80% enter the result of .63 times line 1.03 minus .60 times line
1.01.
d. If line 1.04 is < 70% enter 21% of line 1.03.
For services rendered January 1, 2002 through December 31, 2002:
a. If line 1.04 is => 90% but < 100% enter 70% of line 1.03 minus line 1.01.
b. If line 1.04 is => 80% but < 90% enter the result of .61 times line 1.03 minus .60 times line
1.01.
c. If line 1.04 is < 80% enter 13% of result line 1.03.
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For services rendered January 1, 2003 through December 31, 2003:
a. If line 1.04 is => 90% but < 100% enter 60% of line 1.03 minus line 1.01.
b. If line 1.04 is < 90% enter 6% of line 1.03.
Do not use lines 2 through 8, 12 and 14, columns as applicable for a) any part of the cost
reporting period on or after August 1, 2000 when the reporting period overlaps August 1, 2000;
and b) for all cost reporting periods beginning on or after August 1, 2000 as these lines are not
applicable for the previously mentioned periods.
Line 2.--For cost reporting periods ending prior to August 1, 2000, enter in column 1 the charges
from Worksheet CM-2, column 3.01, line 17. For cost reporting periods that overlap August 1,
2000, enter in column 1 the pre-transition Medicare charges. For cost reporting periods which
overlap August 1, 2000, January 1, 2002, January 1, 2003, or January 1, 2004, do not enter
charge data for services rendered on or after August 1, 2000, as services are 100 percent OPPS
reimbursed and not subject to LCC.
Lines 3 through 6.--These lines provide for the reduction of program charges when you do not
actually impose such charges (in the case of most patients liable for payment for services on a
charge basis) or when you fail to make reasonable efforts to collect such charges from the
patients. Enter on line 6 the product of line 5 times line 2. In no instance may the customary
charges on line 6 exceed the actual charges on line 2. This line is not applicable for services
rendered on or after August 1, 2000.
If you impose these charges and make reasonable efforts to collect the charges from patients
liable for payment for services on a charge basis, you are not required to complete lines 3, 4, and
5, but enter on line 6 the amount on line 2. (See 42 CFR 413.13(b).)
Line 7.--If line 6 is greater than line 1, column 1, enters the excess of customary charges over
reasonable cost. This line is not applicable for services rendered on or after August 1, 2000.
Line 8.--If line 1, column 1 is greater than line 6, enter the excess of reasonable cost over
customary charges. This line is not applicable for services rendered on or after August 1, 2000.
Line 9.--Enter the amounts paid and payable by Workers’ Compensation and other primary
payers (from your records).
3227.2
Part II - Computation of HHA-Based CMHC Reimbursement Settlement.--
Line 10.--For cost reporting periods overlapping August 1, 2000, enter in column 1 the cost of
CMHC services from Part I, line 1, column 1 minus line 9, column 1 and enter in column 1.01
the cost of CMHC services from Part I, line 1.01, column 1.01 plus line 1.05, column 1.01 minus
line 9, column 1.01.
For cost reporting periods beginning on or after August 1, 2000, enter in column 1 the cost of
CMHC services from Part I, line 1.01, and column 1, plus line 1.05, column 1 minus line 9,
column 1. Follow the same procedures for column 1.01.
Line 11.--Enter the Part B deductibles billed to HHA-based CMHC patients (from your records)
excluding any coinsurance amounts.
Line 12.--Enter excess reasonable cost from line 8. This line is not applicable for services
rendered on or after August 1, 2000 as PPS reimbursed services are not subject to LCC.
Line 13.--Enter the result of line 10 minus lines 11 and 12.
Line 14.--Enter in the applicable column 80 percent of the amount shown on line 13.
HHA-based CMHCs enter 0 (zero) for services on or after August 1, 2000 reimbursed under
OPPS.
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Line 15.--For services rendered prior to August 1, 2000, enter in the appropriate column the
actual coinsurance billed program patients from your records. For services rendered on or after
August 1, 2000, enter in the appropriate column the gross coinsurance amount billed to Medicare
beneficiaries.
Line 17.--For services rendered prior to August 1, 2000, enter reimbursable bad debts, net of
recoveries, for HHA-based CMHC services. The amount entered for services rendered on or
after August 1, 2000 must not exceed the discounted coinsurance applicable to Medicare
beneficiaries.
Line 17.01.--Enter in column 1 the result of line 17 (including negative amounts) times 88
percent for cost reporting periods that begin on or after October 1, 2012, 76 percent for cost
reporting periods that begin on or after October 1, 2013, and 65 percent for cost reporting periods
that begin on or after October 1, 2014.
Line 17.02.--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. These amounts must also be reported on line 17.
Line 18.--For services rendered prior to August 1, 2000, enter in the appropriate column the
result of line 17 plus the lesser of lines 14 or 16. For services rendered on or after August 1,
2000, enter in the appropriate column the result of line 16 plus line 17. For cost reporting
periods that begin on or after October 1, 2012, enter in column 1 the result of line 16 plus line
17.01.
Line 19.--Enter the program's share of any net depreciation adjustment applicable to prior years
resulting from the gain or loss on the disposition of depreciable assets. (See CMS Pub. 15-1,
§132ff.) Enter the amount of any excess depreciation taken in parenthesis ( ).
NOTE: Effective for changes in ownership that occur on or after December 1, 1997, §4404 of
BBA 1997 amends §1861(v)(1)(O) of the Act which states, in part, that “...a provider
of services which has undergone a change of ownership, such regulations provide that
the valuation of the asset after such change of ownership shall be the historical cost of
the asset, as recognized under this title, less depreciation allowed, to the owner of
record....” That is, no gain or loss is recognized for such transactions on or after
December 1, 1997.
Line 20.--Enter the program's share of any recovery of excess depreciation applicable to prior
years resulting from your termination or a decrease in Medicare utilization. (See CMS Pub.
15-1, §136ff.)
Line 21.--Enter any other adjustment. For example, if you change the recording of vacation pay
from the cash basis to the accrual basis, enter the adjustment. (See CMS Pub. 15-1, §2146.4.)
Specify the adjustment in the space provided.
Line 22.--Enter the total cost (sum of line 18, columns 1 and 2, minus lines 19 and 20, plus or
minus line 21).
Line 23.--For cost reporting periods that overlap or begin on or after April 1, 2013, enter the
sequestration adjustment amount as [(2 percent times (total days in the cost reporting period that
occur during the sequestration period beginning on or after April 1, 2013, divided by total days
in the entire cost reporting period, rounded to four decimal places)) times line 22].
Line 24.--Enter the amount due the HHA-based CMHC (line 22 minus line 23).
Line 25.--Enter the total interim payments from Worksheet CM-4, column 2, line 4. For
contractor final settlement, report on line 25.5 the amount from Worksheet CM-4, line 5.99.
Line 26.--Enter the balance due HHA-based CMHC/program (line 24 minus line 25) and transfer
the amount to Worksheet S, Part II, column 2, and line 3.
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Line 27.--Enter the program reimbursable effect of nonallowable cost report items which you are
disputing. Compute the reimbursement effect in accordance with CMS Pub. 15-2, §115.2.
Attach a schedule showing the supporting details and computation.
Line 28.--Do not use this line for periods beginning on or after October 1, 1997.
3228.
WORKSHEET CM-4 - ANALYSIS OF PAYMENTS TO HHA-BASED CMHC FOR
SERVICES RENDERED TO PROGRAM BENEFICIARIES
Complete this worksheet for Medicare interim payments only. (See 42 CFR 413.64.) If there is
more than one HHA-based CMHC, complete a separate worksheet for each.
Complete the identifying information on lines 1 through 4. The remainder of the worksheet is
completed by your contractor.
Line Descriptions
Line 1.--Enter the total Medicare interim payments paid to the HHA-based CMHC. The amount
entered reflects the sum of all interim payments paid on individual bills (net of adjustment bills)
for services rendered in this cost reporting period. The amount entered must include amounts
withheld from the HHA-based CMHC's interim payments due to an offset against overpayments
to the HHA-based CMHC applicable to prior cost reporting periods. It does not include any
retroactive lump sum adjustment amounts based on a subsequent revision of the interim rate or
tentative or net settlement amounts; nor does it include interim payments payable. If the
HHA-based CMHC is reimbursed under the periodic interim payment method of reimbursement,
enter the periodic interim payments received for this cost reporting period.
Line 2.--Enter the total Medicare interim payments payable on individual bills. Since the cost in
the cost report is on an accrual basis, this line represents the amount of services rendered in the
cost reporting period, but not paid as of the end of the cost reporting period, and does not include
payments reported on line 1.
Line 3.--Enter the amount of each retroactive lump sum adjustment and the applicable date.
Line 4.--Enter the total amount of the interim payments (sum of lines 1, 2, and 3.99). Transfer
these totals to Worksheet CM-3, line 25.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET CM-4. THE REMAINDER OF
THE WORKSHEET IS COMPLETED BY YOUR CONTRACTOR.
Line 5.--List separately each tentative settlement payment after desk review together with the
date of payment. If the cost report is reopened after the Notice of Program Reimbursement
(NPR) has been issued, report all settlement payments prior to the current reopening settlement
on line 5.
Line 6.--Enter the net settlement amount (balance due to the HHA-based CMHC or balance due
to the program) for the NPR, or, if this settlement is after a reopening of the NPR, for this
reopening.
NOTE: On lines 3, 5, and 6, when an amount is due HHA-based CMHC to program, show the
amount and date on which the HHA-based CMHC agrees to the amount of repayment,
even though total repayment is not accomplished until a later date.
Line 7.--Enter the sum of the amounts on lines 4 and 5.99. The amount must equal Worksheet
CM-3, line 24.
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3229.2.
3229.3.
3230.
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3230.2
3230.3
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3231.2.
3231.3.
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3233
WORKSHEET S-4 - HHA-BASED RHC/FQHC STATISTICAL DATA
COMPLETE THE S-4 AND RF SERIES WORKSHEETS FOR SERVICES RENDERED
ON OR AFTER JANUARY 1, 1998.
In accordance with 42 CFR 413.20(a), 42 CFR 413.24(a), and 42 CFR 413.24(c), you are
required to maintain statistical records for proper determination of costs payable under the
Medicare program. The statistics reported on this worksheet pertain to HHA-based rural health
clinics (RHCs) and HHA-based federally qualified health centers (FQHCs). If you have more
than one of these clinics or centers, complete a separate worksheet for each. Effective for cost
reporting periods beginning on and after October 1, 2014, FQHCs cannot file as an
HHA-based FQHC, and must file as a free standing or independent FQHC on the form
CMS-224-14.
Lines 1 and 1.01.--Enter the full address of the HHA-based RHC/FQHC.
Line 2.--For HHA-based FQHCs only, enter your appropriate designation (urban or rural). See
CMS Pub. 100-04, chapter 9, §20.6.2 for information regarding urban and rural designations. If
you are uncertain of your designation, contact your contractor. HHA-based RHCs do not
complete this line.
Lines 3 through 8.--In column 1, enter the applicable grant award number(s). In column 2, enter
the date(s) awarded.
Line 9.--Subscript line 9 as needed to list all physicians furnishing services at the HHA-based
RHC/FQHC. Enter the physician name in column 1, and the physician’s Medicare billing
number in column 2.
Line 10.--Subscript line 10 as needed to list all supervisory physicians. Enter the physician name
in column 1, and the number of hours the physician spent in supervision in column 2.
Line 11.--If the HHA-based RHC/FQHC provides other than RHC or FQHC services (e.g.,
laboratory or physician services), answer Y (yes) in column 1, then indicate the number of other
operations in column 2, and enter the type(s) of operation(s) and hour(s) on subscripts of line 12.
If the facility does not provide other services, enter N (no) on line 11, and do not complete
subscripts of line 12.
Lines 12.--Enter the starting and ending hours in the applicable columns 1 through 14 for the
days that the clinic is available to provide HHA-based RHC/FQHC services. For facilities
providing other than RHC or FQHC services, enter on subscripts of line 12, columns 1 through
14 the starting and ending hours in the applicable columns for the days that the facility is
available to provide HHA-based RHC/FQHC services.
Line 13.--If the HHA-based RHC/FQHC has been approved for an exception to the productivity
standard, enter Y (yes) or N (no).
Line 14.--If this HHA-based RHC/FQHC is filing a consolidated cost report, as defined in CMS
Pub. 100-04, chapter 9, §30.8, enter Y (yes) or N (no). If the response is yes, enter in column 2
the number of providers included in this report.
Line 15.--If the response to question 14 is yes, list all associated site names and the
corresponding CCN included in this report.
Line 16.--If this facility is claiming allowable GME costs as a result of substantial payment for
interns and residents, enter “Y” for yes or “N” for no in column 1. If yes, enter the number of
Medicare visits performed by interns and residents in column 2 and total visits performed by
interns and residents in column 3. Complete Worksheet RF-1, lines 20 and 27 as applicable.
(See 42 CFR 405.2468 (f)(2).)
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3234.
WORKSHEET RF-1 - ANALYSIS OF HHA-BASED RHC/FQHC COSTS
DRAFT
Effective for services rendered on or after January 1, 1998, use this worksheet only if you
operate a HHA-based certified rural health clinic (RHC) or federally qualified health center
(FQHC). Only those cost centers that represent services for which the facility is certified are
used. If you have more than one HHA-based RHC and/or FQHC, complete a separate
worksheet for each facility. Effective for cost reporting periods beginning on and after
October 1, 2014, FQHCs cannot file as an HHA-based FQHC, and must file as a free standing
or independent FQHC on the form CMS-224-14.
This worksheet is for the recording of direct HHA-based RHC/FQHC costs from your
accounting books and records to arrive at the identifiable agency cost. This data is required by
42 CFR 413.20. It also provides for the necessary reclassifications and adjustments to certain
accounts prior to the cost finding calculations.
Column Descriptions
Columns 1 through 6.--The expenses listed in these columns must be in accordance with your
accounting books and records. If the cost elements of a cost center are maintained separately on
your books, a reconciliation of costs per the accounting books and records to those on this
worksheet must be maintained by you and are subject to review by your contractor.
Enter on the appropriate lines in columns 1 through 6 the total expenses incurred during the
reporting period. Detail the expenses as Compensation (column 1), Employee Benefits (column
2), Contracted Services (column 3), Transportation (column 4) and Other (column 5). The sum
of columns 1 through 5 must equal column 6.
Column 7.--Enter any reclassifications among the cost center expenses listed in column 6 which
are needed to effect proper cost allocation. This column need not be completed by all providers,
but is completed only to the extent reclassifications are needed and appropriate in the particular
circumstances. (See §3210 for examples of reclassifications that may be needed.) Submit with
the cost report copies of any workpapers used to compute the reclassifications reported in this
column. Show reductions to expenses in parentheses ( ).
The net total of the entries in column 7 must equal zero on line 30.
Column 8.--Add column 6 to column 7, and extend the net balances to column 8. The total of
column 8 must equal the total of column 6 on line 30.
Column 9.--In accordance with 42 CFR 413ff, enter on the appropriate lines the amounts of any
adjustments to expenses required under the Medicare principles of reimbursement. (See §3211.)
Submit with the cost report copies of any workpapers used to compute the adjustments reported
in this column.
NOTE: The allowable cost of the services furnished by Public Health Service personnel may be
included in your clinic/center’s costs. Obtain this amount from your contractor, and include this
as an adjustment to the appropriate lines on column 9.
Column 10.--Adjust the amounts in column 8 by the amounts in column 9, and extend the net
balance to column 10. The total HHA-based RHC/FQHC costs on line 30 must equal the net
expenses for cost allocation on Worksheet A for the HHA-based RHC/FQHC cost center.
Line Descriptions
Lines 1 through 9.--Enter the costs of your health care staff.
Line 10.--Enter the sum of the amounts on lines 1 through 9.
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Line 11.--Enter the cost of physician medical services furnished under agreement.
Line 12.--Enter the expenses of physician supervisory services furnished under agreement.
Line 14.--Enter the sum of the amounts on lines 11 through 13.
Lines 15 through 20.--Enter the expenses of other health care costs.
Line 20.--If the clinic incurred all or substantially all training costs for interns and residents,
enter the total allowable direct GME cost. (See 42 CFR 405.2468 (f)(2).)
Line 21.--Enter the sum of the amounts on lines 15 through 20.
Line 22.--Enter the sum of the amounts on lines 10, 14, and 21. Transfer this amount to
Worksheet RF-2, line 10.
Lines 23 through 26.--Enter the expenses applicable to services that are not reimbursable under
the RHC/FQHC benefit.
Line 27.--If the clinic does not provide all or substantially all training costs, enter the total nonallowable direct GME cost.
Line 28.--Enter the sum of the amounts on lines 23 through 27. Transfer the total amount in
column 7 to Worksheet RF-2, line 11.
Line 29.--Enter the overhead expenses directly costed to the HHA-based RHC/FQHC. These
expenses may include rent, insurance, interest on mortgage or loans, utilities, depreciation of
buildings and fixtures, depreciation of equipment, housekeeping and maintenance expenses, and
property taxes. Submit with the cost report supporting documentation to detail and compute the
costs reported on this line.
Line 30.--Enter the expenses related to the administration and management of the HHA-based
RHC/FQHC that are directly costed to the clinic/center. These expenses may include office
salaries, depreciation of office equipment, office supplies, legal fees, accounting fees, insurance,
telephone service, fringe benefits, and payroll taxes. Submit with the cost report supporting
documentation to detail and compute the administrative costs reported on this line.
Line 31.--Enter the sum of the amounts on lines 29 and 30. Transfer the total amount in column
7 to Worksheet RF-2, line 14.
Line 32.--Enter the sum of the amounts on lines 22, 28 and 31. This is the total clinic/center
cost.
3235.
WORKSHEET RF-2 - ALLOCATION OF OVERHEAD TO HHA-BASED
RHC/FQHC SERVICES
Use this worksheet only if you operate a certified HHA-based RHC or FQHC as part of your
complex. If you have more than one HHA-based RHC and/or FQHC, complete a separate
worksheet for each facility.
3235.1 Visits and Productivity.--This section summarizes the number of visits furnished by the
health care staff and calculates the number of visits to be used in the rate determination. Lines 1
through 9 list the types of practitioners (positions) for whom visits must be counted and
reported.
Column descriptions
Column 1.--Record the number of all full time equivalent (FTE) personnel in each of the
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applicable staff positions in the clinic/center’s practice. (See CMS Pub. 100-02, chapter 13,
§70.4 for a definition of FTEs.)
Column 2.--Record the total visits actually furnished to all patients by all personnel in each of
the applicable staff positions in the reporting period. Count visits in accordance with instructions
in 42 CFR 405.2401(b) defining a visit.
Column 3.--Productivity standards established by CMS are applied as a guideline that reflects the
total combined services of the staff. Apply a level of 4200 visits for each physician and a level
of 2100 visits for each nonphysician practitioner. If you were granted an exception to the
productivity standards (answered yes to question 13 of Worksheet S-4), enter the number of
productivity visits approved by the contractor on lines 1-3.
Contractors have the authority to waive the productivity guideline in cases where you have
demonstrated reasonable justification for not meeting the standard. In such cases, the contractor
could set any number of visits as reasonable (not just your actual visits) if an exception is
granted. For example, if the guideline number is 4200 visits and you have only furnished 1000
visits, the contractor need not accept the 1000 visits but could permit 2500 visits to be used in the
calculation.
Column 4.--For lines 1 through 3, enter the product of column 1 and column 3. This is the
minimum number of facility visits the personnel in each staff position are expected to furnish.
Column 5.--On line 4, enter the greater of the subtotal of the actual visits in column 2 or the
minimum visits in column 4.
On lines 5 through 7 and 9, enter the actual number of visits for each type of position.
Line Descriptions
Line 1.--Enter in column 1 the number of staff physician FTEs and in column 2 the total visits
furnished to facility patients by staff physicians working at the facility on a regular ongoing
basis. Include on this line, physician data (FTEs and visits) for services furnished to facility
patients by staff physicians working under contractual agreement with you on a regular ongoing
basis in the HHA-based RHC facility. These physicians are subject to productivity standards.
(See 42 CFR 405.2468(d)(2)(v).)
Line 7.01.--For medical nutrition therapy services performed by a registered dietitian, enter the
corresponding FTE count in column 1 and total visits performed in column 2. (See CMS Pub.
100-02, chapter 13, §210.2.4.) For FQHC only.
Line 7.02.--For diabetes self-management training performed by a registered dietitian, enter the
corresponding FTE count in column 1 and total visits performed in column 2. (See CMS Pub.
100-02, chapter 13, §210.2.4.) For FQHC only.
Line 8.--Enter the total of lines 4 through 7 (and subscripts).
Line 9.--Enter the number of visits furnished to HHA-based RHC/FQHC patients by physicians
under agreement with you who do not furnish services to patients on a regular ongoing basis in
the HHA-based RHC/FQHC. Physicians services under agreements with you are (1) all medical
services performed at your site by a physician who is not the owner or an employee of the
facility, and (2) medical services performed at a location other than your site by such a physician
for which the physician is compensated by you. While all physician services at your site are
included in HHA-based RHC/FQHC services, physician services furnished in other locations by
physicians who are not on your full time staff are paid to you only if your agreement with the
physician provides for compensation for such services.
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3235.2 Determination of Total Allowable Cost Applicable To HHA-Based RHC/FQHC
Services.--This section determines the amount of the overhead costs incurred by both the parent
provider and the facility which apply to HHA-based RHC/FQHC services.
Line 10.--Enter the cost of health care services from Worksheet RF-1, column 10, line 22 less the
amount on Worksheet RF-1, column 10, line 20.
Line 11.--Enter the total nonreimbursable costs from Worksheet RF-1, column 10, line 28.
Line 12.--Enter the sum of lines 10 and 11 for the cost of all services (excluding overhead).
Line 13.--Enter the percentage of HHA-based RHC/FQHC services. This percentage is
determined by dividing the amount on line 10 (the cost of health care services) by the amount on
line 12 (the cost of all services, excluding overhead).
Line 14.--Enter the total overhead costs incurred from Worksheet RF-1, column 10, line 31.
Line 15.--If you are claiming allowable GME cost (line 20 of Worksheet RF-1 completed), enter
the amount of GME overhead costs. To determine the amount of GME overhead, multiply the
amount of facility overhead (from line 14) by the ratio of Intern and Resident visits (from
Worksheet S-4, column 3, line 16) over total visits (from Worksheet RF-3, line 6 ). If you are
not claiming GME enter zero.
Line 16.--Enter the net overhead costs by subtracting line 15 from line 14.
Line 17.--Enter the overhead cost incurred by the HHA allocated to the HHA-based RHC/FQHC.
This amount is the difference between the total costs after allocation from the corresponding
HHA-based RHC/FQHC cost center on the B worksheet, column 6 and Worksheet B, column 0.
Line 18.--Enter the sum of lines 16 and 17 to determine the total overhead costs related to the
HHA-based RHC/FQHC.
Line 19.--Enter the overhead amount applicable to HHA-based RHC/FQHC services. It is
determined by multiplying the amount on line 13 (the ratio of HHA-based RHC/FQHC services
to total services) by the amount on line 18 (total overhead costs).
Line 20.--Enter the total allowable cost of HHA-based RHC/FQHC services. It is the sum of line
10 (cost of HHA-based RHC/FQHC health care services) and line 19 (total overhead costs).
3236.
WORKSHEET RF-3 - CALCULATION OF REIMBURSEMENT SETTLEMENT
FOR HHA-BASED RHC/FQHC SERVICES
This worksheet applies to title XVIII only and provides for the reimbursement calculation for
services rendered. Use this worksheet to determine the interim all inclusive rate of payment
and the total Medicare payment due you for the reporting period.
3236.1 Determination of Rate For HHA-Based RHC/FQHC Services.--This section calculates
the cost per visit for HHA-based RHC/FQHC services and applies the screening guideline
established by CMS on your health care staff productivity.
Line Descriptions
Line 1.--Enter the total allowable cost from Worksheet RF-2, line 20.
Line 2.--Enter the total cost of pneumococcal and influenza vaccine from Worksheet RF-4, line
15.
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Line 3.--Subtract the amount on line 2 from the amount on line 1 and enter the result.
Line 4.--Enter the greater of the minimum or actual visits by the health care staff from
Worksheet RF-2, column 5, line 8.
Line 5.--Enter the visits made by physicians under agreement from Worksheet RF-2, column 5,
line 9.
Line 6.--Enter the total adjusted visits (sum of lines 4 and 5).
Line 7.--Enter the adjusted cost per visit. This is determined by dividing the amount on line 3 by
the visits on line 6.
Lines 8 and 9.--Per visit payment limits are revised each January 1, (except calendar year 2003
updates that occurred January 1 and March 1 (see PM A-03-21)). Complete columns 1, 2 and 3,
if applicable (add column 3 for lines 8-14 if the cost reporting period overlaps 3 limit update
periods) for lines 8 and 9 to identify costs and visits affected by different payment limits during a
cost reporting period. Enter the rates and the corresponding data chronologically in the
appropriate column as they occur during the cost reporting period.
For services rendered from January 1, 2010, through December 31, 2013, the maximum rate per
visit entered on line 8 and the outpatient mental health treatment service limitation applied on
line 14 both correspond to the same time period (calendar year). Consequently, both are entered
in the same column, and no subscripting of the columns are necessary.
Line 8.--Enter your applicable per visit payment limit. Obtain this amount from your contractor.
See CMS Pub. 100-02, chapter 13, §70.1.1 for RHCs or §70.1.2 for FQHCs.
Line 9.--Enter the lesser of the amount on line 7 or line 8.
NOTE: If only one payment limit is applicable during the cost reporting period, or the cost per
visit (line 7) is less than both payment limits (line 8), complete column 2 only.
3236.2 Calculation of HHA-Based RHC/FQHC Settlement.--Use this section to determine the
total Medicare payment due you for covered HHA-based RHC/FQHC services furnished to
Medicare beneficiaries during the reporting period.
Complete columns 1 and 2 of lines 10 through 14 to identify costs and visits affected by different
payment limits during a cost reporting period.
Line Descriptions
Line 10.--Enter the number of Medicare covered visits excluding visits subject to the outpatient
mental health services limitation from the PS&R.
Line 11.--Enter the subtotal of Medicare cost. This cost is determined by multiplying the rate per
visit on line 9 by the number of visits on line 10 (the total number of covered Medicare
beneficiary visits for HHA-based RHC/FQHC services during the reporting period).
Line 12.--Enter the number of Medicare covered visits subject to the outpatient mental health
services limitation from the PS&R.
Line 13.--Enter the Medicare covered cost for outpatient mental health services by multiplying
the rate per visit on line 9 by the number of visits on line 12.
Line 14.--Enter the limit adjustment. In accordance with MIPPA 2008, §102, the outpatient
mental health treatment service limitation applies as follows: For services rendered through
December 31, 2009, the limitation is 62.50 percent; services from January 1, 2010, through
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December 31, 2011, the limitation is 68.75 percent; services from January 1, 2012, through
December 31, 2012, the limitation is 75 percent; services from January 1, 2013, through
December 31, 2013 the limitation is 81.25 percent; and services on or after January 1, 2014, the
limitation is 100 percent. This is computed by multiplying the amount on line 13 by the
corresponding outpatient mental health service limit percent. This limit applies only to
therapeutic services, not initial diagnostic services.
Line 15.--Enter the total allowable GME pass-through costs determined by dividing Medicare
visits performed by Interns and Residents (from Worksheet S-4, column 2, line 16) by the total
visits (from Worksheet S-4, column 3, line 16,) and multiply that result by the (sum of total
allowable GME cost reported on Worksheet RF-1, column 10, line 20 and allowable GME
overhead costs from Worksheet RF-2, line 15) and enter that result on this line. For cost
reporting periods that overlap January 1, 2011, prorate the result using a ratio of days before
January 1, 2011, to days on and after January 1, 2011, for the applicable columns. For cost
reporting periods beginning on or after January 1, 2011, do not use column 1; instead enter the
result in column 2.
NOTE: If there are no allowable GME pass-through costs, this line is zero.)
Line 15.5.--Enter the primary payers (from the PS&R). For cost reporting periods that overlap
January 1, 2011, prorate the result using a ratio of days before January 1, 2011, to days on and
after January 1, 2011, for the applicable columns. For cost reporting periods beginning on or
after January 1, 2011, do not use column 1; instead enter the result in column 2.
Line 16.--Enter the total Medicare cost. This is equal to the sum of the amounts on line 11,
columns 1 and 2, plus line 14, columns 1 and 2, plus line 15, column 1 minus line 15.5. For cost
reporting period that overlap January 1, 2011, enter in column 1 the sum of the amounts on lines
11, 14, and 15, column 1, minus line 15.5. Enter in column 2 the sum of the amounts on lines
11, 14, and 15, column 2, minus line 15.5. For cost reporting periods that begin on or after
January 1, 2011, enter the sum of lines 11, 14, and 15, columns 1 and 2, minus line 15.5 in
column 2.
NOTE: Section 4104 of ACA eliminates coinsurance and deductible for preventive services,
effective for dates of service on or after January 1, 2011. HHA-based RHCs and FQHCs must
provide detailed HCPCS coding for preventive services to ensure that coinsurance and deductible
are not applied. HHA-based RHCs and FQHCs must maintain this documentation to apply the
appropriate reductions on lines 16.03 and 16.04.
Line 16.01.--Enter the total program charges from the contractor’s records (PS&R). For cost
reporting periods that overlap January 1, 2011, do not complete column 1 and enter total
program charges for services rendered on or after January 1, 2011 in column 2. For cost
reporting periods beginning on or after January 1, 2011, enter total program charges in column 2.
Line 16.02.--Enter the total program preventive charges from the provider’s records. For cost
reporting periods that overlap January 1, 2011, do not complete column 1 and enter total
program preventive charges for services rendered on or after January 1, 2011 in column 2. For
cost reporting periods beginning on or after January 1, 2011, enter total program preventive
charges in column 2.
Line 16.03.--Enter the total program preventive costs. For cost reporting periods that overlap
January 1, 2011, do not complete column 1 and enter the total program preventive costs ((line
16.02 divided by line 16.01) times line 16) for services rendered on or after January 1, 2011, in
column 2. For cost reporting periods beginning on or after January 1, 2011, enter the total
program preventive costs ((line 16.02 divided by line 16.01) times line 16, column 2).
Line 16.04.--Enter the total program non-preventive costs. For cost reporting periods that
overlap January 1, 2011, do not complete column 1 and enter the total program non- preventive
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costs ((line 16 minus lines 16.03 and 17) times .80) for services rendered on or after January 1,
2011, in column 2. For cost reporting periods beginning on or after January 1, 2011, enter the
total program non- preventive costs ((line 16, column 2, minus lines 16.03 and 17, column 2)
times .80) in column 2.
Line 16.05.--Enter the total program costs. For cost reporting periods that overlap January 1,
2011, enter total program costs (line 16 times .80) for services rendered prior to January 1, 2011,
in column 1, and enter the sum of lines 16.03 and 16.04, in column 2. For cost reporting periods
beginning on or after January 1, 2011, enter the sum of lines 16.03 and 16.04, in column 2.
Line 17.--Enter the amount credited to the HHA-based RHC's Medicare patients, to satisfy their
deductible liabilities on the visits on lines 10 and 12 as recorded by the contractors from clinic
bills processed during the reporting period. HHA-based RHCs determine this amount from their
PS&R. HHA-based FQHCs enter zero on this line as deductibles do not apply.
Line 17.5--Enter the coinsurance amount applicable to the HHA-based RHC or FQHC for
program patient visits on lines 10 and 12 as recorded by the contractor from clinic bills processed
during the reporting period. This line captures data for informational and statistical purposes
only. This line does not impact the settlement calculation.
Line 18.--Enter the net Medicare cost, excluding vaccines. This is equal to the result of
subtracting the amount on line 17 from the amount on line 16. Do not complete this line for cost
reporting periods ending on or after January 1, 2011.
Line 19.--Enter the net program costs, excluding vaccines. For cost reporting periods ending
prior to January 1, 2011, enter 80% of the amount on line 18. Do not complete this line for cost
reporting periods ending on or after January 1, 2011.
Line 20.--Enter the Medicare cost of pneumococcal and influenza vaccines and their
administration from Worksheet RF-4, line 16.
Line 21.--Enter the total reimbursable Medicare cost. This is equal to the sum of the amounts on
lines 19 and 20. For cost reporting periods ending on or after January 1, 2011, enter the sum of
line 16.05, columns 1 and 2, plus line 20.
Line 22.--Enter your total reimbursable bad debts, net of recoveries, from your records.
Line 22.01.--Enter the result of line 22 (including negative amounts) times 88 percent for cost
reporting periods that begin on or after October 1, 2012, 76 percent for cost reporting periods
that begin on or after October 1, 2013, and 65 percent for cost reporting periods that begin on or
after October 1, 2014.
Line 22.02.--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. These amounts must also be reported on line 22.
Line 23.--Enter any other adjustment. For example, if you change the recording of vacation pay
from the cash basis to the accrual basis, enter the adjustment. (See CMS Pub. 15-1, §2146.4.)
Specify the adjustment in the space provided.
Line 24.--This is the sum of lines 21 and 22, plus or minus line 23. For cost reporting periods
that begin on or after October 1, 2012, enter the sum of lines 21 and 22.01, plus or minus line 23.
Line 24.01.--For cost reporting periods that overlap or begin on or after April 1, 2013, enter the
sequestration adjustment amount as [(2 percent times (total days in the cost reporting period that
occur during the sequestration period beginning on or after April 1, 2013, divided by total days
in the entire cost reporting period, rounded to four decimal places)) times line 24].
Line 25--Enter the interim payments from Worksheet RF-5, line 4. For contractor final
settlement, report on line 25.5 the amount from Worksheet RF-5, line 5.99.
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Line 26.--Enter the total amount due to/from the Medicare program (line 24 minus lines 24.01
and 25.) Transfer this amount to Worksheet S, Part II, column 2, line:
• 3.50 - 3.58 for HHA-based RHCs
• 3.60 - 3.68 for HHA-based FQHCs
3237.
WORKSHEET RF-4 - COMPUTATION OF HHA-BASED
PNEUMOCOCCAL AND INFLUENZA VACCINE COST
RHC/FQHC
The cost and administration of pneumococcal and influenza vaccines to Medicare beneficiaries is
100 percent reimbursable by Medicare. This worksheet provides for the computation of these
vaccines for services rendered on or after April 1, 2001. Use this worksheet only for vaccines
rendered to patients who, at the time of receiving the vaccine(s), are not also receiving services
under HHA PPS. If a patient simultaneously received vaccine(s) with any Medicare covered
services under HHA PPS, those vaccine costs are reimbursed through the HHA under HHA PPS,
and cannot be claimed by the HHA-based RHC or FQHC.
Effective for services rendered on or after September 1, 2009, the administration of influenza
H1N1 vaccines furnished by HHA-based RHCs and FQHCs are cost reimbursed. However, no
cost will be incurred for the H1N1 vaccine as this is provided free of charge to
providers/suppliers.
To account for the cost of administering seasonal influenza vaccines, influenza H1N1 vaccines,
and/or both vaccines administered during the same patient visit, column 2 is subscripted adding
column 2.01 (administration of only H1N1 vaccines) and 2.02 (administration of both the
seasonal influenza and H1N1 vaccines during the same patient visit). The data entered in all
columns (1, 2, and applicable subscripts) for lines 4, 11, and 13 are mutually exclusive. That is,
the vaccine costs, the total number of vaccines administered, and the total number of Medicare
covered vaccines shall be represented only one time in the appropriate column. Columns 2.01
and 2.02 will not reflect the cost of H1N1 vaccines as it is furnished at no cost to the provider.
However, the cost of seasonal influenza vaccines is required in columns 2 and 2.02, line 4.
Line 1.--Enter the health care staff cost from Worksheet RF-1, column 10, line 10.
Line 2.--Enter the ratio of the estimated percentage of time involved in administering
pneumococcal and influenza vaccine injections to the total health care staff time. Do not include
physician service under agreement time in this calculation.
Line 3.--Multiply the amount on line 1 by the amount on line 2 and enter the result.
Line 4.--Enter the cost of pneumococcal and influenza vaccine medical supplies from your
records.
Line 5.--Enter the sum of lines 3 and 4.
Line 6.--Enter the amount on Worksheet RF-1, column 10, line 22. This is your total direct cost
of the HHA-based RHC/FQHC.
Line 7.--Enter the amount from Worksheet RF-2, line 18.
Line 8.--Divide the amount on line 5 by the amount on line 6 and enter the result.
Line 9.--Multiply the amount on line 7 by the amount on line 8 and enter the result.
Line 10.--Enter the sum of the amounts on lines 5 and 9.
Rev.
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3238
FORM CMS-1728-94
DRAFT
Line 11.--Enter the total number of pneumococcal and influenza vaccine injections from your
records.
Line 12.--Enter the cost per pneumococcal and influenza vaccine injection by dividing the
amount on line 10 by the number on line 11 and entering the result.
Line 13.--Enter the number of pneumococcal and influenza vaccine injections from your records.
Line 14.--Enter the Medicare cost for vaccine injections by multiplying the amount on line 12 by
the amount on line 13.
Line 15.--Enter the total cost of pneumococcal and influenza vaccine and their administration
and the administration of H1N1 vaccines by entering the sum of the amount in column 1, line 10
and the amount in column 2 (and applicable subscripts), line 10. Transfer this amount to
Worksheet RF-3, line 2.
Line 16.--Enter the Medicare cost of pneumococcal and influenza vaccine and its (their)
administration and the administration of H1N1 vaccines. This is equal to the sum of the amount
in column 1, line 14 and column 2 (and applicable subscripts), line 14. Transfer the result to
Worksheet RF-3, line 20.
3238.
WORKSHEET RF-5 - ANALYSIS OF PAYMENTS TO HHA-BASED RHC/FQHC
FOR SERVICES RENDERED TO PROGRAM BENEFICIARIES
Complete this worksheet for Medicare interim payments only. (See 42 CFR 413.64.) If there is
more than one HHA-based RHC/FQHC, complete a separate worksheet for each.
Complete the identifying information on lines 1 through 4. The remainder of the worksheet is
completed by your contractor.
NOTE: DO NOT reduce any interim payments by recoveries as a result of medical review
adjustments where the recoveries were based on a sample percent applied to the
universe of claims reviewed, and the PS&R was not also adjusted.
Line Descriptions
Line 1.--Enter the total Medicare interim payments paid to the HHA-based RHC/FQHC. The
amount entered reflects the sum of all interim payments paid on individual bills (net of
adjustment bills) for services rendered in this cost reporting period. The amount entered must
include amounts withheld from the HHA-based RHC/FQHC’s interim payments due to an offset
against overpayments to the HHA-based RHC/FQHC applicable to prior cost reporting periods.
It does not include any retroactive lump sum adjustment amounts based on a subsequent revision
of the interim rate or tentative or net settlement amounts; nor does it include interim payments
payable. If the HHA-based RHC/FQHC is reimbursed under the periodic interim payment
method of reimbursement, enter the periodic interim payments received for this cost reporting
period.
32-72.2
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FORM CMS-1728-94
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Line 2.--Enter the total Medicare interim payments payable on individual bills. Since the cost in
the cost report is on an accrual basis, this line represents the amount of services rendered in the
cost reporting period, but not paid as of the end of the cost reporting period, and does not include
payments reported on line 1.
Line 3--Enter the amount of each retroactive lump sum adjustment and the applicable date.
Line 4--Enter the total amount of the interim payments (sum of lines 1, 2, and 3.99). Transfer
these totals to Worksheet RF-3, line 25.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET RF-5. THE REMAINDER OF
THE WORKSHEET IS COMPLETED BY YOUR CONTRACTOR.
Line 5--List separately each tentative settlement payment after desk review together with the
date of payment. If the cost report is reopened after the Notice of Program Reimbursement
(NPR) has been issued, report all settlement payments prior to the current reopening settlement
on line 5.
Line 6--Enter the net settlement amount (balance due to the provider or balance due to the
program) for the NPR, or, if this settlement is after a reopening of the NPR, for this reopening.
NOTE: On lines 3, 5, and 6, when an amount is due HHA-based RHC/FQHC to program,
show the amount and date on which the HHA-based RHC/FQHC agrees to the amount
of repayment, even though total repayment is not accomplished until a later date.
Line 7--Enter the sum of the amounts on lines 4 and 5.99. The amount must equal Worksheet
RF-3, line 24.
3239.
WORKSHEET S-5 - HHA-BASED HOSPICE IDENTIFICATION DATA
In accordance with 42 CFR 418.310 hospice providers of service participating in the Medicare
program are required to submit annual information for health care services rendered to Medicare
beneficiaries. Also, 42 CFR 413.24 requires cost reports from providers on an annual basis. The
data submitted on the cost reports supports management of Federal programs. The statistics
required on this worksheet pertain to a HHA-based hospice. Complete a separate S-5 for each
HHA-based hospice.
3239.1
2014.--
Part I - Enrollment Days For Cost Reporting Periods Beginning Before October 1,
Lines 1 through 4.--Enter on lines 1 through 4 the enrollment days applicable to each level of
care (LOC). Enrollment days are unduplicated days of care received by a hospice patient. A day
is recorded for each day a hospice patient receives one of four levels of care. Where a patient
moves from one (LOC) to another, count only one day of care for that patient for the last type of
care rendered. For line 4, an inpatient care day should be reported only where the hospice
provides or arranges to provide the inpatient care.
Line 5.--Enter the total of lines 1 through 4 for columns 1 through 4.
For the purposes of the Medicare and Medicaid hospice programs, a patient electing hospice can
receive only one of the following four types of care per day:
Rev.
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3239.2
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DRAFT
Hospice Continuous Home Care (HCHC) Day - An HCHC day is a day on which the hospice
patient is not in an inpatient facility, and receives continuous care during a period of crisis in
order to maintain the individual at home. A day consists of a minimum of 8 hours and a
maximum of 24 hours of predominantly nursing care. For each day a beneficiary received 8 or
more hours of predominantly nursing care, count the day as one HCHC day. Note: Do not
count days by dividing the total hours by 24.
Hospice Routine Home Care (HRHC) Day - An HRHC day is a day on which the hospice patient
is at home and not receiving HRHC.
Hospice Inpatient Respite Care (HIRC) Day - An HIRC day is a day on which the hospice patient
receives care in an approved inpatient facility, to provide respite for the individual’s family or
other persons caring for the individual at home.
Hospice General Inpatient Care (HGIP) Day - An HGIP day is a day on which the hospice
patient receives care in a Medicare certified hospice facility, hospital or SNF for pain control or
acute or chronic symptom management which cannot be managed in other settings.
Column Descriptions
Column 1.--Enter only the unduplicated Medicare days applicable to the four types of care.
Enter on line 5 the total unduplicated Medicare days.
Column 2.-- Enter only the unduplicated Medicare days applicable to the four types of care for
all Medicare hospice patients residing in a skilled nursing facility. Enter on line 5 the total
unduplicated days.
Column 3.-- Enter in column 3 only the days applicable to the four types of care for all nonMedicare or other hospice patients. Enter on line 5 the total unduplicated days.
Column 4.--Enter the total days for each type of care, (i.e., sum of columns 1 and 3). The
amount entered in column 4, line 5 should represent the total days provided by the hospice.
NOTE: Convert continuous home care hours into days so that column 4, line 5
reflects the actual total number of days provided by the hospice.
3239.2
Part II - Census Data for Cost Reporting Periods Beginning Before October 1, 2014.--
Line 6.--Enter on line 6 the total number of patients receiving hospice care within the cost
reporting period for the appropriate payor source. Do not include the number of patients
receiving care under subsequent election periods. (See CMS Pub. 100-02, chapter 9, §20.2.)
The total under this line should equal the actual number of patients served during the cost
reporting period for each program. Thus, if a patient’s total stay overlapped two reporting
periods, the stay should be counted once in each reporting period. The patient who initially
elects the hospice benefit, is discharged or revokes the benefit, and then elects the benefit again
within a reporting period is considered to be a new admission with a new election and is counted
twice.
A patient transferring from another hospice is considered to be a new admission and is included
in the count. If a patient entered a hospice under a payer source other than Medicare and then
subsequently elects the Medicare hospice benefit, count the patient once for each payor source.
The difference between line 6 and line 9 is that line 6 equals the actual number of patients served
during the reporting period for each program, whereas under line 9, patients are counted once,
even if their stay overlaps more than one reporting period.
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3239.2 (Cont.)
Line 7.--Enter the total Title XVIII Unduplicated Continuous Care hours billable to Medicare.
When computing the Unduplicated Continuous Care hours, count only one hour regardless of the
number of services or therapies provided simultaneously within that hour.
Line 8.-- Enter the average length of stay for the reporting period by dividing the amount on line
5 by the amount on line 6. Include only the days for which a hospice election was in effect. The
average length of stay for patients with a payor source other than Medicare and Medicaid is not
limited to the number of days under a hospice election.
The statistics for a patient who had periods of stay with the hospice under more than one
program is included in the respective columns. For example, patient A enters the hospice under
the Medicare hospice benefit, stays 90 days, revokes the election for 70 days (and thus goes back
into regular Medicare coverage), then reelects the Medicare hospice benefits for an additional 45
days, under a new benefit period and dies (patient B).
Medicare patient C was in the program on the first day of the year and died on January 29 for a
total length of stay of 29 days. Patient D was admitted with private insurance for 27 days, then
their private insurance ended and Medicaid covered an additional 92 days. Patient E, with
private insurance, received hospice care for 87 days. The average length of stay (LOS) (assuming
these are the only patients the hospice served during the cost reporting period) is computed as
follows:
Medicare Days (90 & 45 & 29)
Patient (A, B & C)
Medicare Patients
164 days
/3
----
Average LOS Medicare
Medicaid Days Patient D (92)
Medicaid Patient
Average LOS Medicaid
Other (Insurance) Days (87 & 27)
Other Payments (D & E)
2
Average LOS (Other)
All Patients (90+45+29+92+87+27)
Total number of patients
Average LOS for all patients
54.67 Days
92 Days
1
92 Days
114 Days
54 Days
370 Days
6
61.67 Days
Enter the hospice’s average length of stay, without regard to payor source, in column 4, line 8.
Line 9.--Enter the unduplicated census count of the hospice for all patients initially admitted and
filing an election statement with the hospice within a reporting period for the appropriate payor
source. Do not include the number of patients receiving care under subsequent election periods
(see CMS Pub. 100-02, chapter 9, §20.2). However, the patient who initially elects the hospice
benefit, is discharged or revokes the benefits, and elects the benefit again within the reporting
period is considered a new admission with each new election and is counted twice.
The total under this line equals the unduplicated number of patients served during the reporting
period for each program. Thus, you do not include a patient if their stay was counted in a
previous cost reporting period. If a patient enters a hospice source other than Medicare and
subsequently becomes eligible for Medicare and elects the Medicare hospice benefit, then count
that patient only once in the Medicare column, even though he/she may have had a period in
another payor source prior to the Medicare election. A patient transferring from another hospice
is considered a new admission and is included in the count.
Rev.
32-75
3239.3
FORM CMS-1728-94
DRAFT
3239.3 Part III - Enrollment Days for Cost Reporting Periods Beginning On or After
October 1, 2014.--This section collects unduplicated day’s data.
Lines 10 through 13.--Enter the enrollment days applicable to each level of care (LOC) in
columns 1 through 3. Include dually eligible (Medicare/Medicaid) beneficiaries in column 1.
Enrollment days are unduplicated days of care received by a hospice patient. Report a day for
each day a hospice patient received one of four levels of care -- HCHC, HRHC, HIRC, or HGIP.
When a patient was transferred from one LOC to another, count the day of transfer as one day of
care at the LOC billed. Report an HIRC day on line 12 only when the hospice provided or
arranged to provide the inpatient respite care.
Enter the total unduplicated days by LOC (sum of columns 1 through 3) in column 4.
Line 14.--Enter the total unduplicated days (sum of lines 10 through 13) in each column as
applicable.
3239.4 Part IV - Contracted Statistical Data for Cost Reporting Periods Beginning On or After
October 1, 2014.--This section collects unduplicated day’s data for inpatient services at a
contracted facility. The days reported in Part IV are a subset of the days reported in Part III.
Lines 15 and 16.--Enter the contracted inpatient service enrollment days applicable to each LOC
in columns 1 through 3. Include dually eligible (Medicare/Medicaid) beneficiaries in column 1.
Enrollment days are unduplicated days of care received by a hospice patient. Report a day for
each day a hospice patient received HIRC or HGIP care at a contracted facility. When a patient
was transferred from one LOC to another, count the day of transfer as one day of care at the
LOC billed. Enter the total unduplicated days by LOC (sum of columns 1 through 3) in column 4.
32-75.1
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This page is reserved for future use.
Rev.
32-75.2
3240
3240.
FORM CMS-1728-94
DRAFT
WORKSHEET K - ANALYSIS OF HOSPICE COSTS
In accordance with 42 CFR 413.20, the methods of determining costs payable under Title XVIII
involve making use of data available from the institution's basic accounts, as usually maintained
to arrive at equitable and proper payment for services. The K series worksheets must be
completed by all hospices. This worksheet provides for recording the trial balance of expense
accounts from your accounting books and records. It also provides for reclassification and
adjustments to certain accounts. The cost centers on this worksheet are listed in a manner which
facilitates the transfer of the various cost center data to the cost finding worksheets (e.g., on
Worksheets K, K-4, Parts I & II, the line numbers are consistent, and the total line is set at 34).
Not all of the cost centers listed apply to all providers using these forms. Complete a separate
worksheet K for each HHA-based hospice. Effective for cost reporting periods beginning on or
after October 1, 2014, do not complete these worksheets, but complete the O series worksheets.
Column 1.--Obtain salaries to be reported from Worksheet K-1, col. 9, lines 3-34.
Column 2.--Obtain employee benefits to be reported from Worksheet K-2 col. 9 lines 3-34.
Column 3.--If the transportation costs, i.e., owning or renting vehicles, public transportation
expenses, or payments to employees for driving their private vehicles can be directly identified
to a particular cost center, enter those costs in the appropriate cost center. If these costs are not
identified to a particular cost center enter them on line 22.
Column 4.--Obtain the contracted services to be reported from Worksheet K-3, col. 9 lines 3-34.
Column 5.--Enter in the applicable lines in column 5 all costs which have not been reported in
columns 1 through 4.
Column 6.--Add the amounts in columns 1 through 5 for each cost center and enter the total in
column 6.
Column 7.--Enter any reclassifications among cost center expenses in column 6 which are
needed to effect proper cost allocation. This column need not be completed by all providers, but
is completed only to the extent reclassifications are needed and appropriate in the particular
circumstances. Show reductions to expenses as negative amounts.
Column 8.--Adjust the amounts entered in column 6 by the amounts in column 7 (increases and
decreases) and extend the net balances to column 8. The total of column 8 must equal the total
of column 6 on line 34.
Column 9.--In accordance with 42 CFR 413ff, enter on the appropriate lines the amounts of any
adjustments to expenses required under Medicare principles of reimbursements. (See §3613.)
Column 10.--Adjust the amounts in column 8 by the amounts in column 9, (increases or
decreases) and extend the net balances to column 10.
Transfer the amounts in column 10, lines 1 through 34, to the corresponding lines on worksheet
K-4, Part I, column 0.
Line Descriptions
Lines 1 and 2 - Capital Related Cost - Buildings and Fixtures and Capital Related Cost -Movable
Equipment.--These cost centers include depreciation, leases and rentals for the use of the
facilities and/or equipment, interest incurred in acquiring land and depreciable assets used for
patient care, insurance on depreciable assets used for patient care, and taxes on land or
depreciable assets used for patient care.
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Do not include in these cost centers the following costs: costs incurred for the repair or
maintenance of equipment or facilities; amounts included in the rentals or lease or lease
payments for repair and/or maintenance agreements; interest expense incurred to borrow
working capital or for any purpose other than the acquisition of land or depreciable assets used
for patient care; general liability insurance or any other form of insurance to provide protection
other than the replacement of depreciable assets; or taxes other than those assessed on the basis
of some valuation of land or depreciable assets used for patient care.
Line 3 - Plant Operation and Maintenance.--This cost center contains the direct expenses
incurred in the operation and maintenance of the plant and equipment, maintaining general
cleanliness and sanitation of the plant, and protecting employees, visitors, and agency property.
Plant Operation and Maintenance include the maintenance and service of utility systems such as
heat, light, water, air conditioning and air treatment. This cost center also includes the cost of
maintenance and repair of buildings, parking facilities and equipment, painting, elevator
maintenance, performance of minor renovation of buildings, and equipment. The maintenance of
grounds such as landscape and paved areas, streets on the property, sidewalks, fenced areas,
fencing, external recreation areas and parking facilities are part of this cost center. The care or
cleaning of the interior physical plant, including the care of floors, walls, ceilings, partitions,
windows (inside and outside), fixtures and furnishings, and emptying of trash containers, as well
as the costs of similar services purchased from an outside organization which maintains the
safety and well-being of personnel, visitors and the provider’s facilities, are all included in this
cost center.
Line 4 - Transportation - Staff.--Enter all of the cost of transportation except those costs
previously directly assigned in column 3. This cost is allocated during the cost finding process.
Line 5 - Volunteer Service Coordination.--Enter all of the cost associated with the coordination
of service volunteers. This includes recruitment and training costs.
Line 6 - Administrative and General.--Use this cost center to record expenses of several costs
which benefit the entire facility. Examples include fiscal services, legal services, accounting,
data processing, taxes, and malpractice costs.
Line 7 - Inpatient - General Care.--This cost center includes costs applicable to patients who
receive this level of care because their condition is such that they can no longer be maintained at
home. Generally, they require pain control or management of acute and severe clinical problems
which cannot be managed in other settings. The costs incurred on this line are those direct costs
of furnishing routine and ancillary services associated with inpatient general care for which other
provisions are not made on this worksheet.
If a hospice maintains its own inpatient beds, direct patient care costs include 24-hour nursing
care within the facility, patient meals, laundry and linen services, and housekeeping. (Plant
operation and maintenance costs are recorded on line 3.)
If a hospice does not maintain its own inpatient beds:
Show any costs for furnishing direct patient care services in the Visiting Services section,
and;
Show any costs for furnishing inpatient general care services through a contract with
another facility on Worksheet K-3.
Rev. 13
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FORM CMS-1728-94
05-07
Line 8 - Inpatient - Respite Care.--This cost center includes costs applicable to patients who
receive this level of care on an intermittent, nonroutine, and occasional basis. The costs included
on this line are those direct costs of furnishing routine and ancillary services associated with
inpatient respite care for which other provisions are not made on this worksheet. Costs incurred
by the hospice in furnishing direct patient care services to patients receiving inpatient respite care
either directly by the hospice or under a contractual arrangement in an inpatient facility are to be
included in visiting service costs section.
For a hospice that maintains its own inpatient beds, these costs include (but are not limited to)
the costs of furnishing 24-hour nursing care within the facility, patient meals, laundry and linen
services and housekeeping. Plant operation and maintenance costs would be recorded on line 3.
For a hospice that does not maintain its own inpatient beds, but furnishes inpatient respite care
through a contractual arrangement with another facility, record contracted/purchased costs on
Worksheet K-3. Do not include any costs associated with providing direct patient care. These
costs are recorded in the visiting service costs section.
Line 9 - Physician Services.--In addition to the palliation and management of terminal illness and
related conditions, hospice physician services also include meeting the general medical needs of
the patients to the extent that these needs are not met by the attending physician. The amount
entered on this line includes costs incurred by the hospice or amounts billed through the hospice
for physicians’ direct patient care services.
Line 10 - Nursing Care.--Generally, nursing services are provided as specified in the plan of care
by or under the supervision of a registered nurse at the patient’s residence.
Line 10.20 - Nursing Care–Continuous Home Care.--Enter the continuous home care portion of
costs for nursing services provided by a registered nurse, licensed practical nurse or licensed
vocational nurse as specified in the plan of care by or under the supervision of a registered nurse
at the patient’s residence.
Line 11 - Physical Therapy.--Physical therapy is the corrective treatment of bodily or mental
conditions by the use of physical, chemical, and other properties of heat, light, water, electricity,
sound massage, and therapeutic exercise by or under the direction of a registered physical
therapist as prescribed by a physician. Therapy and speech-language pathology services may be
provided for purposes of symptom control or to enable the individual to maintain activities of
daily living and basic functional skills.
Line 12 - Occupational Therapy.--Occupational therapy is the application of purposeful goaloriented activity in the evaluation and diagnosis for the persons whose function is impaired by
physical illness or injury, emotional disorder, congenital or developmental disability, and to
maintain health. Therapy and speech-language pathology services may be provided for purposes
of symptom control or to enable the individual to maintain activities of daily living and basic
functional skills.
Line 13 - Speech/Language Pathology.--These are physician-prescribed services provided by or
under the direction of a qualified speech-language pathologist to those with functionally
impaired communications skills. This includes the evaluation and management of any existing
disorders of the communication process centering entirely, or in part, on the reception and
production of speech and language related to organic and/or nonorganic factors. Speechlanguage pathology services may be provided for purposes of symptom control or to enable the
individual to maintain activities of daily living and basic functional skills.
Line 14 - Medical Social Services.--This cost center includes only direct expenses incurred in
providing medical social services. Medical social services consist of counseling and assessment
32-78
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activities which contribute meaningfully to the treatment of a patient’s condition. These services
must be provided by a qualified social worker under the direction of a physician.
Lines 15-16 - Counseling.--Counseling services must be available to both the terminally ill
individual and family members or other persons caring for the individual at home. Counseling,
including dietary counseling, may be provided both for the purpose of training the individual's
family or other care giver to provide care, and for the purpose of helping the individual and those
caring for him or her to adjust to the individual's approaching death. This includes dietary,
spiritual, and other counseling services provided while the individual is enrolled in the hospice.
Costs associated with the provision of such counseling are accumulated in the appropriate
counseling cost center. (Costs associated with bereavement counseling are recorded on line 30.)
Line 18 - Home Health Aide and Homemaker.--Enter the cost of a home health aide and
homemaker services. Home health aide services are provided under the general supervision of a
registered professional nurse and may be provided only by individuals who have successfully
completed a home health aide training and competency evaluation program or competency
evaluation program as required in 42 CFR 484.36.
Home health aides may provide personal care services. Aides may also perform household
services to maintain a safe and sanitary environment in areas of the home used by the patient,
such as changing the bed or light cleaning and laundering essential to the comfort and cleanliness
of the patient.
Homemaker services may include assistance in personal care, maintenance of a safe and healthy
environment and services to enable the individual to carry out the plan of care.
Line 18.20 - Home Health Aide and Homemaker-Continuous Home Care.--Enter the continuous
care portion of cost for home health aide and/or homemaker services provided as specified in the
plan of care and under the supervision of a registered nurse.
Line 19 - Other.--Enter on this line any other visiting cost which cannot be appropriately
identified in the services already listed.
Line 20 - Drugs, Biological and Infusion Therapy.--Only drugs as defined in §1861(t) of the Act
and which are used primarily for the relief of pain and symptom control related to the
individual's terminal illness are covered. The amount entered on this line includes costs incurred
for drugs or biologicals provided to the patients while at home. If a pharmacist dispenses
prescriptions and provides other services to patients while the patient is both at home and in an
inpatient unit, a reasonable allocation of the pharmacist cost must be made and reported
respectively on line 20 (drugs and biologicals) and on line 7 (Inpatient General Care) or line 8
(Inpatient Respite Care) of worksheet K.
A hospice may, for example, use the number of prescriptions provided in each setting to make
that allocation, or may use any other method that results in a reasonable allocation of the
pharmacist’s cost in relation to the service rendered.
Infusion therapy may be used for palliative purposes if you determine that these services are
needed for palliation. For the purposes of a hospice, infusion therapy is considered to be the
therapeutic introduction of a fluid other than blood, such as saline solution, into a vein.
Line 20.30 - Analgesics.--Enter the cost of analgesics.
Line 20.31 - Sedatives/Hypnotics.--Enter the cost of sedatives/hypnotics.
Line 20.32 - Other Specify.--Specify the type and enter the cost of any other drugs which cannot
be appropriately identified in the drug cost center already listed.
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Line 21 - Durable Medical Equipment/Oxygen.--Durable medical equipment as defined in 42
CFR 410.38 as well as other self-help and personal comfort items related to the palliation or
management of the patient’s terminal illness are covered. Equipment is provided by the hospice
for use in the patient’s home while he or she is under hospice care.
Line 22 - Patient Transportation.--Enter all of the cost of transportation except those costs
previously directly assigned in column 3. This cost is allocated during the cost finding process.
Line 23 - Imaging Services.--Enter the cost of imaging services including MRI.
Line 24 - Labs and Diagnostics.--Enter the cost of laboratory and diagnostic tests.
Line 25 - Medical Supplies.--The cost of medical supplies reported in this cost center are those
costs which are directly identifiable supplies furnished to individual patients.
These supplies are generally specified in the patient's plan of treatment and furnished under the
specific direction of the patient's physician.
Line 26 - Outpatient Services.--Use this line for any outpatient services costs not captured
elsewhere. This cost may include the cost of an emergency room department.
Lines 27-28 - Radiation Therapy and Chemotherapy.--Radiation, chemotherapy and other
modalities may be used for palliative purposes if you determine that these services are needed for
palliation. This determination is based on the patient’s condition and your care giving
philosophy.
Line 29 - Other.--Enter any additional costs involved in providing visiting services which has not
been provided for in the previous lines.
Lines 30-33 - Non Reimbursable Costs.--Enter in the appropriate lines the applicable costs.
Bereavement program costs consist of counseling services provided to the individual’s family
after the individual’s death. In accordance with §1814 (i)(1)(A) of the Act, bereavement
counseling is a required hospice service, but it is not reimbursable.
3241.
WORKSHEET K-1 - HOSPICE - COMPENSATION ANALYSIS - SALARIES AND
WAGES
Enter all salaries and wages for the hospice on this worksheet for the actual work performed
within the specific area or cost center in accordance with the column headings. For example, if
the administrator also performs visiting services which account for 25 percent of that person's
time, then enter 75 percent of the administrator's salary on line 6 (A&G) and 25 percent of the
administrator's salary enter on line 10 (nursing care). Complete a separate worksheet K-1 for
each HHA-based hospice.
The records necessary to determine the split in salary between two or more cost centers must be
maintained by the hospice and must adequately substantiate the method used to split the salary.
These records must be available for audit by the contractor, and the contractor can accept or
reject the method used to determine the split in salary. When approval of a method has been
requested in writing and this approval has been received prior to the beginning of a cost reporting
period, the approved method remains in effect for the requested period and all subsequent
periods until you request in writing to change to another method or until the contractor
determines that the method is no longer valid due to changes in your operations.
Definitions
Salary.--This is gross salary paid to the employee before taxes and other items are withheld,
includes deferred compensation, overtime, incentive pay, and bonuses. (See CMS Pub. 15-1,
Chapter 21.)
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Administrator (Column 1).-Possible Titles:
President, Chief Executive Officer
Duties: This position is the highest occupational level in the agency. This individual is the
chief management official in the agency. The administrator develops and guides the
organization by taking responsibility for planning, organizing, implementing, and evaluating.
The administrator is responsible for the application and implementation of established policies.
The administrator may act as a liaison among the governing body, the medical staff, and any
departments. The administrator provides for personnel policies and practices that adequately
support sound patient care, and maintains accurate and complete personnel records. The
administrator implements the control and effective utilization of the physical and financial
resources of the provider.
Director (Column 2).-Possible Titles:
Medical Director, Director of Nursing, or Executive Director
Duties: The medical director is responsible for helping to establish and assure that the quality
of medical care is appraised and maintained. This individual advises the chief executive officer
on medical and administrative problems and investigates and studies new developments in
medical practices and techniques.
The nursing director is responsible for establishing the objectives for the department of nursing.
This individual administers the department of nursing and directs and delegates management of
professional and ancillary nursing personnel.
Social Worker (Column 3).--The medical social worker is an individual who has at least a
bachelor’s degree from a school accredited or approved by the council of social work education.
These services must be under the direction of a physician and must be provided by a qualified
social worker.
Supervisors (Column 4).--Employees in this classification are primarily involved in the direction,
supervision, and coordination of the hospice activities.
When a supervisor performs two or more functions, e.g., supervision of nurses and home health
aides, the salaries and wages must be split in proportion with the percent of the supervisor's time
spent in each cost center, provided the hospice maintains the proper records (continuous time
records) to support the split. If continuous time records are not maintained by the hospice, enter
the entire salary of the supervisor on line 6 (A&G) and allocate to all cost centers through
stepdown. However, if the supervisor's salary is all lumped in one cost center, e.g., nursing care,
and the supervisor's title coincides with this cost center, e.g., nursing supervisor, no adjustment is
required.
Total Therapists (Column 6).--Include in column 6, on the line indicated, the cost attributable to
the following services:
Physical therapy
Occupational therapy
Speech/language pathology -
line 11
line 12
line 13
Therapy and speech/language pathology may be provided for purposes of symptom control or to
enable the individual to maintain activities of daily living and basic functional skill.
Physical therapy is the provision of corrective treatment of bodily or mental conditions by the
use of physical, chemical, and other properties of heat, light, water, electricity, sound, massage,
and therapeutic exercise by or under the direction of a registered physical therapist as prescribed
by a physician.
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Occupational therapy is the application of purposeful, goal-oriented activity in the evaluation,
diagnosis, and/or treatment of persons whose ability to work is impaired by physical illness or
injury, emotional disorder, congenital or developmental disability, or the aging process, in order
to achieve optimum functioning, to prevent disability, and to maintain health.
Speech/language pathology provides services to persons with impaired functional
communications skills by or under the direction of a qualified speech-language pathologist as
prescribed by a physician. This includes the evaluation and management of any existing
disorders of the communication process centering entirely, or in part, on the reception and
production of speech and language related to organic and/or nonorganic factors.
Aides (Column 7).--Included in this classification are specially trained personnel employed for
providing personal care services to patients. These employees are subject to Federal wage and
hour laws. This function is performed by specially trained personnel who assist individuals in
carrying out physician instructions and established plans of care. The reason for the home health
aide services must be to provide hands-on, personal care services under the supervision of a
registered professional nurse.
Aides may provide personal care services and household services to maintain a safe and sanitary
environment in areas of the home used by the patient, such as changing the bed or light cleaning
and laundering essential to the comfort and cleanliness of the patient. Additional services
include, but are not limited to, assisting the patient with activities of daily living.
All Other (Column 8).--Employees in this classification are those not included in columns 1-7,
e.g., dietary, spiritual, and other counseling services provided while the individual is enrolled in
the hospice. Counseling Services must be available to both the terminally ill individual and the
family members or other persons caring for the individual at home. Counseling, including dietary
counseling, may be provided both for the purpose of training the individual's family or other care
giver to provide care, and for the purpose of helping the individual and those caring for him or
her to adjust to the individual's approaching death.
Total (Column 9).--Add the amounts of each cost center, columns 1 through 8, and enter the total
in column 9. Transfer these totals to Worksheet K, column 1, lines as applicable. To facilitate
transferring amounts from Worksheet K-1 to Worksheet K, the same cost centers with
corresponding line numbers are listed on both worksheets. Not all of the cost centers are
applicable to all agencies. Therefore, use only those cost centers applicable to your hospice.
3242.
WORKSHEET K-2 - HOSPICE - COMPENSATION ANALYSIS - EMPLOYEE
BENEFITS (PAYROLL RELATED)
Enter all payroll-related employee benefits for the hospice on this worksheet. See CMS Pub.
15-1, chapter 20, for a definition of fringe benefits. Use the same basis as that used for reporting
salaries and wages on Worksheet K-1. Therefore, using the same example as given for
Worksheet K-1, enter 75 percent of the administrator's payroll-related fringe benefits on line 6
(A&G) and enter 25 percent of the administrator's payroll-related fringe benefits on line 10
(nursing care). Payroll-related employee benefits must be reported in the cost center in which
the applicable employee's compensation is reported. Complete a separate worksheet K-2 for
each HHA-based hospice.
This assignment can be performed on an actual basis or the following basis:
o
FICA - actual expense by cost center;
o
Health insurance (nonunion) and pension and retirement (gross salaries of participating
individuals by cost center);
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o
Union health and welfare (gross salaries of participating union members by cost
center); and;
o
All other payroll-related benefits (gross salaries by cost center). Include non payrollrelated employee benefits in the A&G cost center, e.g., cost for personal education,
recreation activities, and day care.
Add the amounts of each cost center, columns 1 through 8, and enter the total in column 9.
Transfer these totals to Worksheet K, column 2, corresponding lines. To facilitate transferring
amounts from Worksheet K-2 to Worksheet K, the same cost centers with corresponding line
numbers are listed on both worksheets.
3243.
WORKSHEET K-3 - HOSPICE - COMPENSATION ANALYSIS - CONTRACTED
SERVICES/ PURCHASED SERVICES
The hospice may contract with another entity to provide non-core hospice services. However,
nursing care, medical social services and counseling are core hospice services and must routinely
be provided directly by hospice employees. Supplemental services may be contracted in order to
meet unusual staffing needs that cannot be anticipated and that occur so infrequently it would not
be practical to hire additional staff to fill these needs. You may also contract to obtain physician
specialty services. If contracting is used for any services, maintain professional, financial, and
administrative responsibility for the services and assure that all staff meet the regulatory
qualification requirements. Complete a separate worksheet K-3 for each hospice.
Enter on this worksheet all contracted and/or purchased services for the hospice. Enter the
contracted/purchased cost on the appropriate cost center line within the column heading which
best describes the type of services purchased. Costs associated with contracting for general
inpatient or respite care are recorded on this worksheet. For example, where physical therapy
services are purchased, enter the contract cost of the therapist in column 6, line 11. If a
contracted/purchased service covers more than one cost center, then the amount applicable to
each cost center is included on each affected cost center line. Add the amounts of each cost
center, columns 1 through 8, and enter the total in column 9. Transfer these totals to Worksheet
K, column 4, corresponding lines. To facilitate transferring amounts from Worksheet K-3 to
Worksheet K, the same cost centers with corresponding line numbers are listed on both
worksheets.
3244.
WORKSHEET K-4, PART I - HOSPICE COST ALLOCATION - GENERAL
SERVICE COSTS AND WORKSHEET K-4, PART II - HOSPICE COST
ALLOCATION - STATISTICAL BASIS
Worksheet K-4 provides for the allocation of the expenses of each hospice general service cost
center to those hospice cost centers which receive the services. The cost centers serviced by the
general service cost centers include all cost centers within the provider organization, i.e., other
general service cost centers, reimbursable cost centers, and nonreimbursable cost centers. Obtain
the total direct expenses from Worksheet K, column 10. To facilitate transferring amounts from
Worksheet K to Worksheet K-4, part I, the same cost centers with corresponding line numbers
(lines 3 through 34) are listed on both worksheets. Complete a separate worksheet K-4, part 1
and 2 for each HHA-based hospice.
Worksheet K-4, part II, provides for the proration of the statistical data needed to equitably
allocate the expenses of the general service cost centers on Worksheet K-4, part I.
To facilitate the allocation process, the general format of Worksheets K-4, part I & II are
identical. The column and line numbers for each general service cost center are identical on the
two worksheets. In addition, the line numbers for each general, reimbursable, nonreimbursable,
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and special purpose cost centers are identical on the two worksheets. The cost centers and line
numbers are also consistent with Worksheets K, K-1, K-2, and K-3.
NOTE: General service columns 1 through 5 and subscripts thereof must be consistent on
Worksheets K-4, parts I & II.
The statistical bases shown at the top of each column on Worksheet K-4, Part II are the
recommended bases of allocation of the cost centers indicated. If a different basis of allocation
is used, the provider must indicate the basis of allocation actually used at the top of the column.
Most cost centers are allocated on different statistical bases. However, for those cost centers
where the basis is the same (e.g., square feet), the total statistical base over which the costs are to
be allocated will differ because of the prior elimination of cost centers that have been closed.
Close the general service cost centers in accordance with 42 CFR 413.24(d)(1) which states, in
part, that the cost of nonrevenue-producing cost centers serving the greatest number of other
centers, while receiving benefits from the least number of centers, is apportioned first. This is
clarified in CMS Pub. 15-1, §2306.1 which further clarifies the order of allocation for stepdown
purposes. Consequently, first close those cost centers that render the most services to and receive
the least services from other cost centers. The cost centers are listed in this sequence from left to
right on the worksheet. However, the circumstances of an agency may be such that a more
accurate result is obtained by allocating to certain cost centers in a sequence different from that
followed on these worksheets.
NOTE: A change in order of allocation and/or allocation statistics is appropriate for the current
fiscal year cost if received by the contractor, in writing, within 90 days prior to the end
of that fiscal year. The contractor has 60 days to make a decision or the change is
automatically accepted. The change must be shown to more accurately allocate the
overhead or, if the allocation is accurate, to simplify maintaining the statistics. If a
change in statistics is made, the provider must maintain both sets of statistics until
approved. If both sets are not maintained and the request is denied, the provider
reverts back to the previously approved methodology. The provider must include with
the request all supporting documentation and a thorough explanation of why the
alternative approach should be used. (See CMS Pub. 15-1, §2313.)
If the amount of any cost center on Worksheet K, column 10, has a credit balance, show this
amount as a credit balance on Worksheet K-4, part I, column 0. Allocate the costs from the
applicable overhead cost centers in the normal manner to the cost center showing a credit
balance. After receiving costs from the applicable overhead cost centers, if a general service cost
center has a credit balance at the point it is allocated, do not allocate the general service cost
center. Rather, enter the credit balance on the first line of the column and on line 34. This
enables column 7, line 34, to crossfoot to columns 0 and 5A, line 34. After receiving costs from
the applicable overhead cost centers, if a revenue producing cost center has a credit balance on
Worksheet K-4, part I, column 7, do not carry forward a credit balance to any worksheet.
On Worksheet K-4, part II, enter on the first line in the column of the cost center the total
statistics applicable to the cost center being allocated (e.g., in column 1, capital-related cost buildings and fixtures, enter on line 1 the total square feet of the building on which depreciation
was taken). Use accumulated cost for allocating administrative and general expenses.
Such statistical base does not include any statistics related to services furnished under
arrangements except where both Medicare and non-Medicare costs of arranged-for services are
recorded in your records.
For all cost centers (below the cost center being allocated) to which the service rendered is being
allocated, enter that portion of the total statistical base applicable to each.
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The total sum of the statistical base applied to each cost center receiving the services rendered
must equal the total statistics entered on the first line.
Enter on Worksheet K-4, part II line 34, the total expenses of the cost center to be allocated.
Obtain this amount from Worksheet K-4, part I from the same column and line number of the
same column. In the case of capital-related costs - buildings and fixtures, this amount is on
Worksheet K-4, part I, column 1, line 1.
Divide the amount entered on line 34 by the total statistical base entered in the same column on
the first line. Enter the resulting unit cost multiplier on line 35. Round the unit cost multiplier to
at least the nearest six decimal places.
Multiply the unit cost multiplier by that portion of the total statistical base applicable to each cost
center receiving the services rendered. Enter the result of each computation on Worksheet K-4,
part I in the corresponding column and line.
After the unit cost multiplier has been applied to all the cost centers receiving costs, the total
expenses (line 34) of all of the cost centers receiving the allocation on Worksheet K-4, part I,
must equal the amount entered on the first line of the cost center being allocated.
The preceding procedures must be performed for each general service cost center. Each cost
center must be completed on both Worksheets K-4, part I & II before proceeding to the next cost
center.
After all the costs of the general service cost centers have been allocated on Worksheet K-4, part
I, enter in column 7 the sum of the expenses on lines 7 through 33. The total expenses entered in
column 7, line 34, must equal the total expenses entered in column 0, line 34.
Column Descriptions
Column 1.--Depreciation on buildings and fixtures and expenses pertaining to buildings and
fixtures such as insurance, interest, rent, and real estate taxes are combined in this cost center to
facilitate cost allocation.
Allocate all expenses to the cost centers on the basis of square feet of area occupied. The square
footage may be weighted if the person who occupies a certain area of space spends their time in
more than one function. For example, if a person spends 10 percent of time in one function, 20
percent in another function, and 70 percent in still another function, the square footage may be
weighted according to the percentages of 10 percent, 20 percent, and 70 percent to the applicable
functions.
Column 2.--Allocate all expenses (e.g., interest or personal property tax) for movable equipment
to the appropriate cost centers on the basis of square feet of area occupied or dollar value.
Column 4.--The cost of vehicles owned or rented by the agency and all other transportation costs
which were not directly assigned to another cost center on Worksheet K, column 3, is included in
this cost center. Allocate this expense to the cost centers to which it applies on the basis of miles
applicable to each cost center.
This basis of allocation is not mandatory and a provider may use weighted trips rather than actual
miles as a basis of allocation for transportation costs which are not directly assigned. However, a
hospice must request the use of the alternative method in accordance with CMS Pub. 15-1,
§2313. The hospice must maintain adequate records to substantiate the use of this allocation.
Column 6.--The A&G expenses are allocated on the basis of accumulated costs after
reclassifications and adjustments.
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Therefore, obtain the amounts to be entered on Worksheet K-4, part II, column 6, from
Worksheet K-4, part I, columns 0 through 5.
A negative cost center balance in the statistics for allocating A&G expenses causes an improper
distribution of this overhead cost center. Negative balances are excluded from the allocation
statistics when A&G expenses are allocated on the basis of accumulated cost.
A&G costs applicable to contracted services may be excluded from the total cost (Worksheet K4, part I, column 0) for purposes of determining the basis of allocation (Worksheet K-4, part II,
column 5) of the A&G costs. This procedure may be followed when the hospice contracts for
services to be performed for the hospice and the contract identifies the A&G costs applicable to
the purchased services.
The contracted A&G costs must be added back to the applicable cost center after allocation of
the hospice A&G cost before the reimbursable costs are transferred to Worksheet K-5, part I. A
separate worksheet must be included to display the breakout of the contracted A&G Costs from
the applicable cost centers before allocation and the adding back of these costs after allocation.
Contractor approval does not have to be secured in order to use the above described method of
cost finding for A&G.
Worksheet K-4, Part II, Column 6A.--Enter the costs attributable to the difference between the
total accumulated cost reported on Worksheet K-4, part I, column 5A, line 34 and the
accumulated cost reported on Worksheet K-4, part II, column 6, line 6. Enter any amounts
reported on Worksheet K-4, part I, column 5A for (1) any service provided under arrangements
to program patients that is not grossed up and (2) negative balances. Including these costs in the
statistics for allocating administrative and general expenses causes an improper distribution of
overhead.
In addition, report on line 6 the administrative and general costs reported on Worksheet K-4, Part
I, column 6, line 6 since these costs are not included on Worksheet K-4, Part II, column 6 as an
accumulated cost statistic.
Worksheet K-4, Part II, Column 6.--The administrative and general expenses are allocated on the
basis of accumulated costs. Therefore, the amount entered on Worksheet K-4, part II, column 6,
line 6, is the difference between the amounts entered on Worksheet K-4, part I, column 5A and
Worksheet K-4, part II, column 6A. A negative cost center balance in the statistics for allocating
administrative and general expenses causes an improper distribution of this overhead cost center.
Exclude negative balances from the allocation statistics.
3245.
WORKSHEET K-5 - ALLOCATION OF GENERAL SERVICE COSTS HOSPICE
COST CENTERS
Use this worksheet only if you operate a certified HHA-based Hospice as part of your complex.
If you have more than one HHA-based Hospice, complete a separate worksheet for each.
3245.1 Part I - Allocation of General Service Costs to Hospice Cost Centers.--Worksheet K-5,
part I, provides for the allocation of the expenses of each general service cost center of the HHA
to those hospice cost centers which receive the services. Worksheet K-5, parts I and II, provide
for the proration of the statistical data needed to equitably allocate the expenses of the general
service cost centers on Worksheet K-5, part I.
Obtain the total direct expenses (column 0, line 29) from Worksheet A, column 10, line 25.
Obtain the cost center allocation (column 0, lines 1 through 28) from Worksheet K-4, part I, lines
as indicated. The amounts on line 29, column 0 through column 5 must agree with the
corresponding amounts on Worksheet B, part I, column 0 through column 5, line 25. Complete
the amounts entered on lines 1 through 28, columns 1 through 4 and column 5.
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Line 30.--Enter the unit cost multiplier (column 6, line 1, divided by the sum of column 6, line
29 minus column 6, line 1, rounded to 6 decimal places). Multiply each amount in column 6,
lines 2 through 28, by the unit cost multiplier, and enter the result on the corresponding line of
column 7.
3245.2 Part II - Allocation of General Service Costs to Hospice Cost Centers -Statistical
Basis.--To facilitate the allocation process, the general format of Worksheet K-5, Parts I and II,
are identical.
The statistical basis shown at the top of each column on Worksheet K-5, Part II, is the
recommended basis of allocation of the cost center indicated.
NOTE: If you wish to change your allocation basis for a particular cost center, you must make
a written request to your contractor for approval of the change and submit reasonable
justification for such change prior to the beginning of the cost reporting period for
which the change is to apply. The effective date of the change is the beginning of the
cost reporting period for which the request has been made. (See CMS Pub. 15-1,
§2313.)
Except for non-PPS providers, unless there is a change in ownership, the hospital must
continue the same cost finding methods (including its cost finding bases) in effect in
the hospital's last cost reporting period ending on or before October 1, 1991. (See 42
CFR 412.302(d).) If there is a change in ownership, the new owners may request that
the contractor approve a change in order to be consistent with their established cost
finding practices. (See CMS Pub. 15-1, §2313.)
Lines 1 through 28.--On Worksheet K-5, Part II, for all cost centers to which the general service
cost center is being allocated, enter that portion of the total statistical base applicable to each.
Line 29.--Enter the total of lines 1 through 28 for each column. The total in each column must
be the same as shown for the corresponding column on Worksheet B-1, line 25.
Line 30.--Enter the total expenses for the cost center allocated. Obtain this amount from
Worksheet B, line 25 from the same column used to enter the statistical base on Worksheet K-5,
Part II (e.g., in the case of capital-related cost buildings and fixtures, this amount is on
Worksheet B, column 1, line 25).
Line 31.--Enter the unit cost multiplier, which is obtained by dividing the cost entered on line 30
by the total statistic entered in the same column on line 29. Round the unit cost multiplier to six
decimal places.
Multiply the unit cost multiplier by that portion of the total statistics applicable to each cost
center receiving the services. Enter the result of each computation on Worksheet K-5, Part I, in
the corresponding column and line.
After the unit cost multiplier has been applied to all the cost centers receiving the services, the
total cost (line 29, Part I) must equal the total cost on line 30, Part II.
Perform the preceding procedures for each general service cost center.
In column 6, Part I, enter the total of columns 4A through 5.
In column 7, Part I, for lines 2 through 28, multiply the amount in column 6 by the unit cost
multiplier on line 30, Part I, and enter the result in this column. On line 29, enter the total of the
amounts on lines 2 through 28. The total on line 29 equals the amount in column 6, line 1.
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In column 8, Part I, enter on lines 2 through 28 the sum of columns 6 and 7. The total on line 29
equals the total in column 6, line 29.
3245.3 Part III- Apportionment of Hospice Shared Services.--Use this part only when the
complex maintains a separate department for any of the cost centers listed on this worksheet, and
the department provides services to patients of the HHA’s hospice. This worksheet provides for
the shared therapy, drugs, or medical supplies from the HHA to the hospice.
Column Description
Column 2.--Where HHA departments provides services to the hospice, enter in column 2 the cost
for each discipline from Worksheet B, col. 6, lines as indicated.
Column 3.--Where HHA departments provide services to the hospice, enter on the appropriate
lines the total HHA charges, from the provider’s records, applicable to the HHA-based hospice.
Column 4.--Where applicable, determine the cost to charge ratio by dividing column 2 by
column 3. Enter the results in column 4.
Column 5.-- Where HHA departments provides services to the hospice, enter on the appropriate
lines the total hospice charges, from the provider’s records, applicable to the HHA-based
hospice.
Column 6.--Multiply the ratio in column 4 by the amount in column 5. Enter the result in column
6.
Line 7.--Enter the sum of column 6, lines 1 through 6.
3246.
WORKSHEET K-6 - CALCULATION OF HOSPICE PER DIEM COST
Worksheet K-6 calculates the average cost per days in providing care for a hospice patient. It is
only an average and should not be misconstrued as the absolute. If you have more than one
HHA-based Hospice, complete a separate worksheet for each.
Line 1.--Total cost from Worksheet K-5, Part I, column 8, line 29 less column 8, line 28, plus
Worksheet K-5, Part III, column 6, line 7. This line reflects the true cost without any nonhospice related costs.
Line 2.--Total unduplicated days from Worksheet S-5, line 5, col. 4.
Line 3.--Average cost per day. Divide the total cost from line 1 by the total number of days from
line 2.
Line 4.--Unduplicated Medicare days from Worksheet S-5, line 5, column 1.
Line 5.--Aggregate Medicare cost. Multiply the average cost from line 3 by the number of
unduplicated Medicare days on line 4 to arrive at the aggregate Medicare cost.
Line 6 and 7.--NOT APPLICABLE.
Line 8.--Unduplicated SNF days from Worksheet S-5, line 5, column 2.
Line 9.--Aggregate SNF cost. Multiply the average cost from line 3 by the number of
unduplicated SNF days on line 8 to arrive at the aggregate SNF cost.
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Line 10.--NOT APPLICABLE.
Line 11.--NOT APPLICABLE.
Line 12.--Other Unduplicated days from Worksheet S-5, line 5, column 3.
Line 13.--Aggregate cost for other days. Multiply the average cost from line 3 by the number of
Unduplicated Other days on line 12 to arrive at the aggregate cost for other days.
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WORKSHEET O - ANALYSIS OF HHA-BASED HOSPICE COSTS
The O series of worksheets must be completed by all HHA-based hospices effective for cost
reporting periods beginning on or after October 1, 2014. This worksheet is to record the trial
balance of expense accounts from the provider’s accounting books and records. It also provides
for reclassification and adjustments to certain accounts. The cost centers on this worksheet are
listed in a manner that facilitates the combination of the various groups of cost centers for
purposes of cost finding. Cost centers listed may not apply to every provider using these forms.
Complete only those lines that are applicable.
Column Descriptions
For columns 1, 2, 4, and 6, direct patient care service costs (lines 25 through 46) are reported by
LOC on Worksheets O-1, O-2, O-3 and O-4. For each cost center on Worksheet O, enter the
sum of the amounts from Worksheets O-1, O-2, O-3, and O-4 for salaries, other costs,
reclassifications, and adjustments, in columns 1, 2, 4, and 6, respectively.
Column 1.--Enter salaries from the provider’s accounting books and. Salaries for the direct
patient care service cost centers (lines 25 through 46) must equal the sum of amounts reported in
column 1 of Worksheets O-1, O-2, O-3, and O-4. The total salaries for column 1, line 100, must
equal the salaries reported on Worksheet A, column 1, line 25.
Column 2.--Enter all costs other than salaries from the provider’s accounting books and
records. Other costs for the direct patient care service cost centers (lines 25 through 46) must
equal the sum of amounts reported in column 2 of Worksheets O-1, O-2, O-3, and O-4. The total
other costs for column 2, line 100, must equal the other costs reported on Worksheet A, the sums
of columns 2 through 5, line 25.
Column 3.--For each cost center, enter the total of columns 1 plus 2.
Column 4.--Enter any reclassifications among cost center expenses in column 3 that are needed
to effect proper cost allocation. This column need not be completed by all providers, but is
completed to the extent reclassifications are needed or reported on Worksheet A, line 25. Show
reductions to expenses as negative amounts.
If reclassifications are needed for direct patient care service cost centers (lines 25 through 46),
enter the reclassification amounts on the appropriate Worksheets O-1, O-2, O-3, and O-4,
column 4, for each level of care.
Reclassifications for the direct patient care service cost centers (lines 25 through 46) must equal
the sum of amounts reported on the corresponding lines in column 4 of Worksheets O-1, O-2,
O-3, and O-4. The total reclassifications for column 4, line 100, must equal the reclassifications
reported on Worksheet A, column 7, line 25.
Column 5.--For each cost center, enter the total of the amount in column 3 plus or minus the
amount in column 4.
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Column 6.--In accordance with 42 CFR 413.9(c)(3), enter on the appropriate lines, the amounts
of any adjustments to expenses required under Medicare principles of reimbursements. (See
§3211). This column need not be completed by all providers, but is completed only to the extent
adjustments are needed or reported on Worksheet A, column 9, line 25. Show reductions to
expenses as negative amounts.
If adjustments are needed for direct patient care service cost centers (lines 25 through 46), enter
the adjustment amounts on the appropriate Worksheets O-1, O-2, O-3, and O-4, column 6, for
each level of care.
Adjustments for the direct patient care service cost centers (lines 25 through 46) must equal the
sum of amounts reported on the corresponding lines in column 6 of Worksheets O-1, O-2, O-3,
and O-4. The total adjustments for column 6, line 100, must equal the adjustments reported on
Worksheet A, column 9, line 25.
Column 7.--For each cost center, enter the total of the amount in column 5 plus or minus the
amount in column 6. Transfer the amounts in column 7 for cost centers marked with an
asterisk (*) to Worksheet O-5, as follows:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
60
61
62
63
64
65
66
67
68
69
70
71
Rev.
From Worksheet O, Column 7,
Line Number and
Cost Center Description
Cap Rel Costs-Bldg & Fixt
Cap Rel Costs-Mvble Equip
Employee Benefits Department
Administrative & General
Plant Operation & Maintenance
Laundry & Linen
Housekeeping
Dietary
Nursing Administration
Routine Medical Supplies
Medical Records
Staff Transportation
Volunteer Service Coordination
Pharmacy
Physician Administrative Services
Other General Service
Bereavement Program
Volunteer Program
Fundraising
Hospice/Palliative Medicine Fellows
Palliative Care Program
Other Physician Services
Residential Care
Advertising
Telehealth/Telemonitoring
Thrift Store
Nursing Facility Room & Board
Other Nonreimbursable
To Worksheet O-5,
Column 1:
Line 1
Line 2
Line 3
Line 4
Line 5
Line 6
Line 7
Line 8
Line 9
Line 10
Line 11
Line 12
Line 13
Line 14
Line 15
Line 16
Line 60
Line 61
Line 62
Line 63
Line 64
Line 65
Line 66
Line 67
Line 68
Line 69
Line 70
Line 71
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FORM CMS-1728-94
DRAFT
Line Descriptions
The Worksheet O cost centers are segregated into general service, direct patient care service,
and nonreimbursable categories to facilitate the transfer of costs to the various worksheets. For
example, the general service cost centers appear on Worksheets O-5, Part I, and O-5, Part II,
using the same line numbers as Worksheet O. The direct patient care service cost centers
appear on Worksheets O-1, O-2, O-3, and O-4 using the same line numbers as Worksheet O.
General service cost centers (lines 1 through 17) include expenses incurred in operating the
facility as a whole that are not directly associated with furnishing patient care such as mortgage,
rent, plant operations, administrative salaries, utilities, telephone, and computer hardware and
software costs. General service cost centers furnish services to other general service cost
centers and to reimbursable and nonreimbursable cost centers.
Lines 1 and 2 - Capl Rel Costs-Bldg & Fixt and Cap Rel Costs-Mvble Equip.--Enter in column 2,
the capital-related costs for buildings and fixtures and the capital-related costs for moveable
equipment on lines 1 and 2, respectively.
Line 3 - Employee Benefits Department.--This cost center includes the costs of the employee
benefits department. In addition, this cost center includes the fringe benefits paid to, or on
behalf of, an employee when a provider’s accounting system is not designed to accumulate the
benefits on a departmentalized or cost center basis. (See CMS Pub. 15-1, chapter 21, §2144 and
CMS Pub. 15-1, chapter 23, §2307.) Enter the employee benefits.
Line 4 - Administrative & General.--Enter in columns 1 and 2, the salary and other costs of
A&G.
If the option to subscript A&G costs into more than one cost center is elected (in accordance
with CMS Pub. 15-1, chapter 23, §2313), eliminate line 4. Begin numbering the subscripted
A&G cost centers with line 4.01 and continue in sequential order.
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Line 5 - Plant Operation & Maintenance.--This cost center includes expenses incurred in the
operation and maintenance of the plant and equipment (see §3206). Enter in columns 1 and 2,
the costs of plant operation and maintenance.
Line 6 - Laundry & Linen Service.--This cost center includes the cost of routine laundry and
linen services whether performed in-house or by outside contractors.
Line 7 - Housekeeping.--This cost center includes the cost of routine housekeeping activities such
as mopping, vacuuming, cleaning restrooms, lobbies, waiting areas and otherwise maintaining
patient and non-patient care areas.
Line 8 - Dietary.--This cost center includes the cost of preparing meals for patients. Do not
include the cost of dietary counseling in this cost center; report dietary counseling on line 35.
Line 9 - Nursing Administration.--This cost center includes the cost of overall management and
direction of the nursing services. Do not include the cost of direct nursing services reported on
lines 27 through 29. The salary cost of direct nursing services, including the salary cost of
nurses who render direct service in more than one patient care area, is directly assigned to the
various patient care cost centers in which the services were rendered. However, if the hospice
accounting system fails to specifically identify all direct nursing services to the applicable direct
patient care cost centers, then the salary cost of all direct nursing service is included in this cost
center.
Line 10 - Routine Medical Supplies.--This cost center includes the cost of supplies used in the
normal course of caring for patients, such as gloves, masks, swabs, or glycerin sticks, that
generally are not traceable to individual patients. Do not include the costs of non-routine
medical supplies that can be traced to individual patients; report non-routine medical supplies
on line 42.
Rev.
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FORM CMS-1728-94
DRAFT
Line 11 - Medical Records.--This cost center includes cost of the medical records department
where patient medical records are maintained. The general library and the medical library are
not included in this cost center but are included in the A&G cost center.
Line 12 - Staff Transportation.--This cost center includes the cost of owning or renting vehicles,
public transportation expenses, parking, tolls, or payments to employees for driving their private
vehicles to see patients or for other hospice business. Staff transportation costs do not include
patient transportation costs; report patient transportation costs on line 39.
Line 13 - Volunteer Service Coordination.--This cost center includes the cost of the overall
coordination of service volunteers including their recruitment and training costs of volunteers.
Line 14 - Pharmacy.--This cost center includes the costs of drugs (both prescription and overthe-counter), pharmacy supplies, pharmacy personnel, and pharmacy services. Do not report
the cost of palliative chemotherapy drugs on this line; report the cost of palliative chemotherapy
on line 45.
Line 15 - Physician Administrative Services.--This cost center includes the costs for physicians’
administrative and general supervisory activities that are included in the hospice payment rates.
These activities include participating in the establishment, review and updating of plans of care,
supervising care and services, conducting required face-to-face encounters for recertification,
and establishing governing policies. These activities are generally performed by the physician
serving as the medical director and the physician member of the interdisciplinary group. Nurse
practitioners may not serve as or replace the medical director or physician member of the
interdisciplinary group.
Line 17 - Patient/Residential Care Services.--Do not use this line on this worksheet. This cost
center is used on Worksheet O-5 to accumulate in-facility costs not separately identified as
HIRC, HGIP, or residential care services that are not part of a separate and distinct residential
care unit (e.g., depreciation related to in-facility areas that provide HIRC, HGIP or residential
care). The amounts allocated to this cost center on Worksheet O-5 are allocated to HIRC, HGIP
and residential care services that are not part of a separate and distinct residential care unit,
based on in-facility days. This cost center does not include any costs related to contracted
inpatient services.
When a residential care unit is separate and distinct and only used for resident care services
(such as hospice home care provided in a residential unit), costs are reported directly on line 66.
Lines 18 through 24.--Reserved for future use.
Direct patient care service costs are reported by LOC on Worksheets O-1, O-2, O-3 and O-4.
For each cost center on Worksheet O, enter the sum of the amounts from Worksheets O-1, O-2,
O-3, and O-4 for salaries, other costs, reclassifications, and adjustments in columns 1, 2, 4, and
6, respectively.
Line 25- Inpatient Care - Contracted.--This cost center includes the contractual costs paid to
another facility for use by the hospice for hospice inpatient care (HIRC or HGIP) in accordance
with 42 CFR 418.108(c). This cost center does not include the cost of any direct patient care
services or nonreimbursable services provided by hospice staff in the contracted setting. Costs
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of any services provided by hospice staff in the contracted setting are included in the appropriate
direct patient care service or nonreimbursable cost center. Costs in this cost center are excluded
from the allocation of A&G costs.
Line 26 - Physician Services.--This cost center includes the costs incurred by the hospice for
physicians, or nurse practitioners providing physician services, for direct patient care services
and general supervisory services, participation in the establishment of plans of care, supervision
of care and services, periodic review and updating of plans of care, and establishment of
governing policies by the physician member of the interdisciplinary group.
(See
42 CFR 418.304.) Reclassify the cost for the portion of time physicians spent on general
supervisory services or other hospice administrative activities to Physician Administrative
Services (line 15). This cost center must not include costs associated with palliative care or
other nonreimbursable physician services. Those nonreimbursable physician services must be
reported in the appropriate nonreimbursable cost center.
Line 27 - Nurse Practitioner.--This cost center includes the costs of nursing care provided by
nurse practitioners. Do not include costs for nurse practitioners providing physician services on
this line; report the costs for nurse practitioners providing physician services on line 26.
Line 28 - Registered Nurse.--This cost center includes the costs of nursing care provided by
registered nurses other than nurse practitioners.
Line 29 - LPN/LVN.--This cost center includes the costs of nursing care provided by licensed
practical nurses (LPN) or licensed vocational nurses (LVN). Do not include costs for certified
nursing assistant (CNA) services on this line; report the costs for CNA services on line 37.
Line 30 - Physical Therapy.--This cost center includes the costs of physical or corrective
treatment of bodily or mental conditions by the use of physical, chemical, and other properties of
heat, light, water, electricity, sound massage, and therapeutic exercise by or under the direction
of a registered physical therapist as prescribed by a physician. Physical therapy services may be
provided for purposes of symptom control or to enable the individual to maintain activities of
daily living and basic functional skills.
Line 31 - Occupational Therapy.--This cost center includes the costs of purposeful goal-oriented
activities in the evaluation, diagnosis, and/or treatment of persons whose function is impaired by
physical illness or injury, emotional disorder, congenital or developmental disability, or the
aging process, in order to achieve optimum functioning, to prevent disability, and to maintain
health. Occupational therapy services may be provided for purposes of symptom control or to
enable the individual to maintain activities of daily living and basic functional skills.
Line 32 - Speech/Language Pathology.--This cost center includes the costs of physicianprescribed services provided by or under the direction of a qualified speech/language
pathologist to those with functionally impaired communications skills. This includes the
evaluation and management of any existing disorders of the communication process centering
entirely, or in part, on the reception and production of speech and language related to organic
and/or nonorganic factors. Speech/language pathology services may be provided for purposes
of symptom control or to enable the individual to maintain activities of daily living and basic
functional skills.
Rev.
32-95
3247 (Cont.)
FORM CMS-1728-94
DRAFT
Line 33 - Medical Social Services.--This cost center includes the cost of the medical social
services defined in CMS Pub. 100-02, chapter 9, §40.1.2. Costs for nonreimbursable activities
included in this cost center must be reclassified to the appropriate nonreimbursable cost center.
Line 34 - Spiritual Counseling.--This cost centers includes the cost of spiritual counseling
services. Costs for nonreimbursable activities included in this cost center must be reclassified to
the appropriate nonreimbursable cost center.
Line 35 - Dietary Counseling.--This cost center includes the costs of dietary counseling services.
Line 36 - Counseling - Other.--This cost center include the cost of counseling services not
already identified as spiritual, dietary or bereavement counseling. Costs for nonreimbursable
activities included in this cost center must be reclassified to the appropriate nonreimbursable
cost center.
Line 37 - Hospice Aide & Homemaker Services.--This cost center includes the costs of:
•
Hospice aide services such as personal care services and household services to
maintain a safe and sanitary environment in areas of the home used by the patient;
and,
•
Homemaker services such as assistance in the maintenance of a safe and healthy
environment and services to enable the individual to carry out the plan of care.
Include the cost of CNAs that meet the criteria for an aide in this cost center.
Line 38 - Durable Medical Equipment/Oxygen.--This cost center includes the costs of DME and
oxygen, as defined in 42 CFR 410.38 and 42 CFR 418.202(f), furnished to individual HRHC or
HCHC patients. Report DME costs by the LOC the patient was receiving at the time the
DME/oxygen was delivered. If the LOC of a patient changed after delivery of the DME/Oxygen,
the hospice may report the costs proportionally between HRHC and HCHC based on patient
days.
Line 39 - Patient Transportation.--This cost center includes the costs of ambulance transports of
hospice patients, related to the terminal prognosis and occurring after the effective date of the
hospice election, that are the responsibility of the hospice. (See CMS Pub. 100-02, chapter 9,
§40.1.9.) When a patient is transferred to a new LOC, report the transportation cost to that
LOC. For example, a patient in a HGIP LOC is transferred to HRHC LOC and transported to
their home, the transportation cost associated with the transfer must be included in the HRHC
LOC.
Line 40 - Imaging Services.--This cost center includes the costs of imaging services.
Line 41 - Labs & Diagnostics.--This cost center includes the costs of laboratory and diagnostic
tests.
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Line 42 - Medical Supplies - Non-routine.--This cost center includes the costs of medical
supplies furnished to individual patients for which a separate charge would be applicable.
These supplies are specified in the patient's plan of treatment and furnished under the specific
direction of the patient's physician. Do not include the cost of routine medical supplies used in
the normal course of caring for patients, (such as gloves, masks, swabs, or glycerin sticks) on
this line; report routine medical supplies on line 10. When a provider does not track the use of
non-routine medical supplies by LOC, the provider may report the costs proportionally between
LOCs based on patient days
Line 43 - Outpatient Services.--This cost center includes the costs of outpatient services costs not
captured elsewhere. This cost can include the cost of an emergency room department visit when
related to the terminal condition.
Lines 44 and 45 - Palliative Radiation Therapy & Palliative Chemotherapy.--These cost centers
include costs of radiation, chemotherapy and other modalities used for palliative purposes based
on the patient’s condition and the hospice’s caregiving philosophy.
Lines 47 through 49.--Reserved for future use.
Lines 50 through 53.--Reserved for use on Worksheets O-6, Parts I and II.
Lines 54 through 59.--Reserved for future use.
Nonreimbursable cost centers include costs of nonreimbursable services and programs. Report
the costs applicable to nonreimbursable cost centers to which general service costs apply. If
additional lines are needed for nonreimbursable cost centers other than those shown, subscript
one or more of these lines with a numeric code. The subscripted lines must be appropriately
labeled to indicate the purpose for which they are being used. However, when the expense
(direct and all applicable overhead) attributable to any non-allowable cost area is so
insignificant as to not warrant establishment of a nonreimbursable cost center, remove the
expense on Worksheet A-8. (See CMS Pub. 15-1, chapter 23, §2328.)
Line 60 - Bereavement Program.--This cost center includes the cost of bereavement services,
defined as emotional, psychosocial, and spiritual support and services provided before and after
the death of the patient to assist with grief, loss, and adjustment (42 CFR 418.3). Bereavement
counseling is a required hospice service, but it is not reimbursable (see §1814(I)(1)(A) of the
Act).
Line 61 - Volunteer Program.--This cost center includes costs of volunteer programs. (See
CMS Pub. 15-1, chapter 7.)
Line 62 - Fundraising.--This cost centers include costs of fundraising. (See CMS Pub. 15-1,
chapter 21, §2136.)
Line 63 - Hospice/Palliative Medicine Fellows.--This cost center includes costs of hospice and
palliative medicine fellows.
Line 64 - Palliative Care Program.--Enter in columns 1 and 2, the salary and other costs of
palliative care provided to non-hospice patients. This includes physician services.
Rev.
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FORM CMS-1728-94
DRAFT
Line 65 - Other Physician Services.--Enter in columns 1 and 2, the salary and other costs of
other physician services that are provided outside of a palliative care program to non-hospice
patients.
Line 66 - Residential Care.--Enter in columns 1 and 2, the salary and other costs of residential
care for patients living in the hospice, but who are not receiving inpatient hospice services.
Patients living in the hospice are considered residents, where the hospice is their home. These
patients are liable for their room and board charges; however, the outpatient hospice care
services provided must be recorded in the direct patient care cost centers on the appropriate
HRHC and/or HCHC LOC worksheet.
Lines 67 - Advertising.--Enter in columns 1 and 2, the salary and other costs of nonallowable
community education, business development, marketing and advertising (see CMS Pub. 15-1,
chapter 21, §2136).
Lines 68 - Telehealth/Telemonitoring.--Enter in columns 1 and 2, the salary and other costs of
telehealth/ telemonitoring services. These costs are nonreimbursable since a hospice is not an
approved originating site (see 42 CFR 410.78(b)(3)).
Lines 69 - Thrift Store.--Enter in columns 1 and 2, the salary and other costs of thrift stores.
Line 70 - Nursing Facility Room & Board.--Enter the costs incurred by a hospice for dually
eligible beneficiaries residing in a nursing facility (NF) when room and board is paid by the
State to the hospice. The full amount paid to the NF by the hospice must be included on this line
and offset by the State payment via an adjustment on Worksheet A-8. The residual cost is the net
cost incurred.
For example, a dually eligible beneficiary is residing in a NF and has elected the Medicare
hospice benefit. The NF charges $100 per day for room and board. The State pays the hospice
$95 for the NF room and board. The hospice has a written agreement with the NF that requires
full room and board payment of $100 per day. The hospice receives $95 per day, but pays the
NF $100 per day, thereby incurring a net cost of $5 per day.
Lines 72 through 99.--Reserved for future use.
32-98
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3248.
FORM CMS-1728-94
3248
WORKSHEETS O-1, O-2, O-3, AND O-4 - ANALYSIS OF HHA-BASED HOSPICE
COSTS
Worksheet O-1 - Analysis of HHA-Based Hospice Costs for Hospice Continuous Home Care
Worksheet O-2 - Analysis of HHA-Based Hospice Costs for Hospice Routine Home Care
Worksheet O-3 - Analysis of HHA-Based Hospice Costs for Hospice Inpatient Respite Care
Worksheet O-4 - Analysis of HHA-Based Hospice Costs for Hospice General Inpatient Care
Worksheets O-1, O-2, O-3, and O-4 provide for recording the direct patient care costs by LOC,
including reclassifications and adjustments. The general format of these worksheets is identical
to Worksheet O in order to facilitate the transfer of direct patient care costs to Worksheet O.
For each cost center, the sums of the amounts reported in columns 1, 2, 4, and 6 of these
worksheets are transferred to the corresponding columns on Worksheet O.
Column 1.--For each LOC worksheet, enter salaries from the provider’s accounting books and
records.
Column 2.--For each LOC worksheet, enter all costs other than salaries from the provider’s
accounting books and records.
Column 3.--For each cost center, add the amounts in columns 1 and 2 and enter the total in
column 3.
Column 4.--For each LOC worksheet enter any reclassification of direct patient care service
costs needed to effect proper cost allocation. For each line, the sum of the reclassification
entries on Worksheets O-1, O-2, O-3, and O-4, column 4, must equal the amount on the
corresponding line on Worksheet O, column 4.
Column 5.--For each cost center, enter the total of the amount in column 3 plus or minus the
amount in column 4.
Column 6.--For each LOC worksheet, enter any adjustments for direct patient care service costs
(lines 25 through 46) required under Medicare principles of reimbursements. (See §3212.) Show
reductions to expenses as negative amounts. For each line, the sum of the adjustment entries on
Worksheets O-1, O-2, O-3 and O-4, column 6, must equal the amount on the corresponding line
of Worksheet O, column 6.
Column 7.--For each cost center, enter the total of the amount in column 5 plus or minus the
amount in column 6. For each LOC worksheet, transfer the amount on line 100 to the
corresponding LOC line on Worksheet O-5, column 1, as follows:
From line 100 of:
Worksheet O-1
Worksheet O-2
Worksheet O-3
Worksheet O-4
Rev.
To Worksheet O-5, column 1, line:
50
51
52
53
32-99
3249
3249.
FORM CMS-1728-94
DRAFT
WORKSHEET O-5 - COST ALLOCATION - DETERMINATION OF HHA-BASED
HOSPICE NET EXPENSES FOR ALLOCATION
Worksheet O-5 determines total expenses of each general service cost center for proper
allocation of general service costs to each LOC and to nonreimbursable cost centers. This
worksheet combines the direct general services costs reported on Worksheet O, lines 1 through
17 with the overhead allocation of the HHA general services costs reported on Worksheet B, line
25, columns 1 through 5.
Column Descriptions
Column 1.--For each general service and nonreimbursable cost center, transfer the amount from
the corresponding cost center on Worksheet O, column 7. For each LOC line, transfer amounts
as follows:
From column 7,
Line:
line 100 of:
50
Worksheet O-1
51
Worksheet O-2
52
Worksheet O-3
53
Worksheet O-4
The total on line 100 of column 1 must equal the amount on Worksheet A, column 10, line 25.
Column 2.--For each general service cost center, transfers the amount from the corresponding
column on Worksheet B, line 25 as follows:
Line:
1
2
3
4
5
6
7
8
From Worksheet B,
line 25, column(s):
1
2
N/A
5
3
N/A
N/A
N/A
Line:
9
10
11
12
13
14
15
16
From Worksheet B,
line 25, column(s):
N/A
N/A
N/A
4
N/A
N/A
N/A
N/A
Column 3.--For each line, enter the sum of columns 1 and 2. The total on line 100 of column 3
must equal the amount on Worksheet B, column 6, line 25. Transfer the amount from each cost
center to the corresponding line on Worksheet O-6, Part I, column 0.
32-100
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3250
FORM CMS 1728-94
3250
WORKSHEET O-6 - PART I - COST ALLOCATION - HHA-BASED HOSPICE
GENERAL SERVICE COSTS AND WORKSHEET O-6 - PART II - COST
ALLOCATION - HHA-BASED HOSPICE GENERAL SERVICE COSTS STATISTICAL
BASIS
In accordance with 42 CFR 413.24, cost data must be based on an approved method of cost
finding and on the accrual basis of accounting except where governmental institutions operate
on a cash basis of accounting.
Worksheet O-6, Parts I and II, facilitate the step-down method of cost finding. This method
recognizes that general services of the hospice are utilized by other general service, LOC, and
nonreimbursable cost centers. Worksheet O-6, Part I provides for the equitable allocation of
general service costs based on statistical data reported on Worksheet O-6, Part II. To facilitate
the allocation process, the general format of Worksheet O-6, Part I is identical to that of
Worksheet O-6, Part II. The column and line numbers for each general service cost center are
identical on the two worksheets. The direct patient care service cost centers (lines 25 through 46
of Worksheet O) are reported by LOC on lines 50 through 53 of Worksheets O-6, Parts I and II.
The line numbers for nonreimbursable cost centers are identical on Worksheet O and
Worksheet O-6, Parts I and II.
When certain general services costs are related to in-facility days and are not separately
identifiable by LOC or service, Worksheet O-6, Parts I and II, provide for the accumulation of
these costs on line 17, Patient/Residential Care Services. The amounts accumulated in this cost
center are allocated based on the in-facility days for HIRC, HGIP, and residential care services
that are not part of a separate and distinct residential care unit. This cost center does not
include any costs related to contracted inpatient services.
The statistical basis shown at the top of each column on Worksheet O-6, Part II is the
recommended basis of allocation. The total statistic for cost centers using the same basis (e.g.,
square feet) may differ with the closing of preceding cost centers. A hospice can elect to change
the order of allocation and/or allocation statistics, as appropriate, for the current cost reporting
period if a request is submitted in accordance with CMS Pub. 15-1, chapter 23, §2313.
Close the general service cost centers in accordance with 42 CFR 413.24(d)(1) so that the cost
centers rendering the most services to and receiving the least services from other cost centers
are closed first (see CMS Pub. 15-1, chapter 23, §2306.1). If a more accurate result is obtained
by allocating costs in a sequence that differs from the recommended sequence, the hospice must
request approval in accordance with CMS Pub. 15-1, chapter 23, §2313.
If the amount of any cost center on Worksheet O-5, column 3, has a negative balance, show this
amount as a negative balance on Worksheet O-6, Part I, column 0. Allocate the costs from the
overhead cost centers in the normal manner, including to those cost centers with a negative
balance. Close a general service cost center with a negative balance by entering the negative
balance in parentheses on the first line and on lines 99 and 100 of the column, and do not
allocate. This enables Worksheet O-6, Part I, column 18, line 100 to cross foot to Worksheet O6, Part I, column 0, line 100. After receiving costs from overhead cost centers, LOC cost centers
with negative balances on Worksheet O-6, Part I, column 18, are not transferred to Worksheet
O-7.
On Worksheet O-6, Part II, enter on the first available line of each column the total statistics
applicable to the cost center being allocated (e.g., in column 1, Capital-Related Cost - Buildings
& Fixtures, enter on line 1 the total square feet of the building on which depreciation was taken).
Use accumulated cost for allocating A&G expenses.
Rev.
32-101
3250 (cont.)
FORM CMS 1728-94
DRAFT
Such statistical base, including accumulated cost for allocating A&G expenses, does not include
any statistics related to services furnished under arrangements except where:
•
Both Medicare and non-Medicare costs of arranged for services are recorded in the
hospice’s books/records; or
•
The contractor determines that the hospice is able to and does gross up the costs
and charges for services to non-Medicare patients so that both cost and charges are
recorded as if the hospice had furnished such services directly to all patients. (See
CMS Pub. 15-1, chapter 23, §2314.)
For each cost center being allocated, enter that portion of the total statistical base applicable to
each cost center receiving services. For each column, the sum of the statistics entered for cost
centers receiving services must equal the total statistical base entered on the first line.
For each column on Worksheet O-6, Part II, enter on line 101, the total expenses of the cost
center to be allocated. Obtain the total expenses from the first line of the corresponding column
on Worksheet O-6, Part I, which includes the direct expenses from Worksheet O-6, Part I,
column 0 plus the allocated costs from previously closed cost centers. Divide the amount
entered on Worksheet O-6, Part II, line 101 by the total statistical base entered in the same
column on the first line. Enter the resulting unit cost multiplier (rounded to six decimal places)
on line 102.
For each column on Worksheet O-6, Part II, multiply the unit cost multiplier on line 102 by the
portion of the total statistical base applicable to each cost center receiving services and enter the
result in the corresponding column and line on Worksheet O-6, Part I. For each column on
Worksheet O-6, Part I, the sum of the costs allocated (line 100) must equal the total cost on the
first line.
After the costs of the general service cost centers have been allocated on Worksheet O-6, Part I,
enter on each line of column 18, the sum of the costs in columns 3A through column 17 for
lines 50 through 71. The total costs entered on Worksheet O-6, Part I, column 18, line 100 must
equal the total costs entered in column 0, line 100.
Column Descriptions
Column 0.--For each line, enter the total direct costs from the corresponding line on
Worksheet O-5, column 3.
Column 3A.--For each line, enter the sum of columns 0 through 3. The sum for each line is the
accumulated cost and, unless an adjustment is required, is the Worksheet O-6, Part II, column 4
statistic for allocating A&G costs.
If an adjustment to the accumulated cost statistic on Worksheet O-6, Part II, column 4, is
required to properly allocate A&G costs, enter the adjustment amount on Worksheet O-6,
Part II, column 4A for the applicable line. For example, when the hospice contracts for HIRC or
HGIP services and the contractual costs include A&G costs, the contractual costs reported on
Worksheet O-3, column 7, line 25, or Worksheet O-4, column 7, line 25, may be used to reduce
the accumulated cost statistic on Worksheet O-6, Part II, column 4A, line 52 or line 53,
respectively.
32-102
Rev.
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FORM CMS 1728-94
3250 (Cont.)
For each line, the accumulated cost statistic on Worksheet O-6, Part II, column 4, is the
difference between the amount on Worksheet O-6, Part I, column 3A and the adjustment amount
on Worksheet O-6, Part II, column 4A. Accumulated cost for A&G is not included in the total
statistic for the A&G cost center; therefore, transfer the amount on Worksheet O-6, Part I,
column 3A, line 4, to Worksheet O-6, Part II, column 4A, line 4.
The total accumulated cost statistic for Worksheet O-6, Part II, column 4, line 4 is the difference
between the total on Worksheet O-6, Part I, column 3A, line 101 and the amounts in column 4A
of Worksheet O-6, Part II.
A negative cost center balance in the statistics for allocating A&G expenses causes an improper
distribution of this overhead cost center. Negative balances are excluded from the allocation
statistics when A&G expenses are allocated on the basis of accumulated cost.
Column 18--Transfer the amounts on lines 50 through 53 as follows:
From Worksheet O-6, Part I,
column 18:
Line 50
Line 51
Line 52
Line 53
3251.
To Worksheet O-8,
column 3:
Line 1
Line 6
Line 11
Line 16
WORKSHEET O-7 - APPORTIONMENT OF HHA-BASED HOSPICE SHARED
SERVICE COSTS BY LEVEL OF CARE
This worksheet calculates the cost of ancillary services provided by HHA departments to
HHA-based hospice patients.
Column Descriptions
Column 1.--For each cost center, enter in column 1, the cost for each discipline from Worksheet
B, column 6, lines as indicated.
Column 2.--For each cost center, enter on the appropriate lines the total HHA charges from the
provider’s records, applicable to the HHA-based hospice.
Column 3.--For each cost center, enter in column 3, the cost-to-charge ratio by dividing the
HHA cost in column 1 by the HHA charges in column 2.
Columns 4 through 7.--For each cost center, enter the charges, from the provider’s records, for
ancillary services provided by HHA ancillary departments to HHA-based hospice patients.
Enter the charges by LOC in the appropriate LOC column.
Columns 8 through 11.--For each column, calculate cost of ancillary services provided by HHA
ancillary departments to HHA-based hospice patients as follows:
Column:
8
9
10
11
Calculation:
col. 3 x col. 4
col. 3 x col. 5
col. 3 x col. 6
col. 3 x col. 7
For each column 8 through 11, enter the sum of lines 1 through 6 on line 7.
Rev.
32-103
3252
3252.
FORM CMS 1728-94
DRAFT
WORKSHEET O-8 - CALCULATION OF HHA-BASED HOSPICE PER DIEM COST
Worksheet O-8 calculates the average cost per diem by level of care and in total.
Line 1.--Enter in column 3 the total HCHC cost from Worksheet O-6, Part I, column 18, line 50,
plus Worksheet O-7, column 8, line 7.
Line 2.--Enter in column 3 the total HCHC days from Worksheet S-5, column 4, line 10.
Line 3.--Enter in column 3 the average HCHC cost per diem by dividing column 3, line 1 by
column 3, line 2.
Line 4.--Enter in column 1 the title XVIII - Medicare HCHC days from Worksheet S-5, column 1,
line 10. Enter in column 2 the title XIX - Medicaid HCHC days from Worksheet S-5, column 2,
line 10.
Line 5.--Enter in column 1 the title XVIII - Medicare program cost calculated by multiplying
column 3, line 3 by column 1, line 4. Enter in column 2 the title XIX - Medicaid program cost
calculated by multiplying column 3, line 3 by column 2, line 4.
Line 6.--Enter in column 3 the total HRHC cost from Worksheet O-6, Part I, column 18, line 51,
plus Worksheet O-7, column 9, line 7.
Line 7.--Enter in column 3 the total HRHC days from Worksheet S-5, column 4, line 11.
Line 8.--Enter in column 3 the average HRHC cost per diem by dividing column 3, line 6 by
column 3, line 7.
Line 9.--Enter in column 1 the title XVIII - Medicare HRHC days from Worksheet S-5, column 1,
line 11. Enter in column 2 the title XIX - Medicaid HRHC days from Worksheet S-5, column 2,
line 11.
Line 10.--Enter in column 1 the title XVIII - Medicare program cost calculated by multiplying
column 3, line 8 by column 1, line 9. Enter in column 2 the title XIX - Medicaid program cost
calculated by multiplying column 3, line 8 by column 2, line 9.
Line 11.--Enter in column 3 the total HIRC cost from Worksheet O-6, Part I, column 18, line 52,
plus Worksheet O-7, column 10, line 7.
Line 12.--Enter in column 3 the total HIRC days from Worksheet S-5, column 4, line 12.
Line 13.--Enter in column 3 the average HIRC cost per diem by dividing column 3, line 11 by
column 3, line 12.
Line 14.--Enter in column 1 the title XVIII - Medicare HIRC days from Worksheet S-5, column 1,
line 12. Enter in column 3 the title XIX - Medicaid HIRC days from Worksheet S-5, column 2,
line 12.
Line 15.--Enter in column 1 the title XVIII - Medicare program cost calculated by multiplying
column 3, line 13 by column 1, line 14. Enter in column 2 the title XIX - Medicaid program cost
calculated by multiplying column 3, line 13 by column 2, line 14.
Line 16.--Enter in column 3 the total HGIP cost from Worksheet O-6, Part I, column 18, line 53,
plus Worksheet O-7, column 11, line 7.
Line 17.--Enter in column 3 the total HGIP days from Worksheet S-5, column 4, line 13.
32-104
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FORM CMS 1728-94
3252 (Cont.)
Line 18.--Enter in column 3 the average HGIP cost per diem by dividing column 3, line 16 by
column 3, line 17.
Line 19.--Enter in column 1, the title XVIII - Medicare HGIP days from Worksheet S-5,
column 1, line 13. Enter in column 3, the title XIX - Medicaid HGIP days from Worksheet S-5,
column 2, line 13.
Line 20.--Enter in column 1 the title XVIII - Medicare program cost calculated by multiplying
column 3, line 18 by column 1, line 19. Enter in column 2 the title XIX - Medicaid program cost
calculated by multiplying column 3, line 18 by column 2, line 19.
Line 21.--Enter in column 3 the sum of lines 1, 6, 11 and 16.
Line 22.--Enter in column 3 total days from Worksheet S-5, column 4, line 14.
Line 23.--Enter the average cost per diem by dividing column 3, line 21 by column 3, line 22.
Rev.
32-105
3252 (Cont.)
FORM CMS 1728-94
DRAFT
This page is reserved for future use.
32-106
Rev.
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FORM CMS 1728-94
3290
FORM CMS-1728-94
The following is a listing of the FORM CMS-1728-94 worksheets and the page number location.
Rev.
Worksheets
Page(s)
Wkst. S, Parts I & II
Wkst. S-2
Wkst. S-2-1
Wkst. S-3, Parts I-III
Wkst. S-3, Part IV
Wkst. S-4
Wkst. S-5
Wkst. S-6, Parts I & II
Wkst. A
Wkst. A-1
Wkst. A-2
Wkst. A-3
Wkst. A-4
Wkst. A-5
Wkst. A-6
Wkst. A-7
Wkst. A-8-3, Parts I-III
Wkst. A-8-3, Parts IV & V
Wkst. B
Wkst. B-1
Wkst. C, Parts I & II
Wkst. C, Parts III, IV & V
Wkst. D
Wkst. D-1
Wkst. F
Wkst. F-1
Wkst. F-2
Wkst. J-1, Parts I & II
Wkst. J-1, Part III
Wkst. J-2
Wkst. J-3
Wkst. J-4
Wkst. K
Wkst. K-1
Wkst. K-2
Wkst. K-3
Wkst. K-4, Part I
Wkst. K-4, Part II
Wkst. K-5, Part I
Wkst. K-5, Part II
Wkst. K-5, Part III
Wkst. K-6
Wkst. CM-1, Parts I & II
Wkst. CM-1, Part III
Wkst. CM-2
Wkst. CM-3
Wkst. CM-4
Wkst. RH-1, Parts I & II
Wkst. RH-1, Part III
32-303
32-304
32-304.1
32-305
32-305.1
32-305.2
32-306
REMOVED
32-308
32-309
32-310
32-311
32-312
32-313
32-314
32-315
32-316
32-317
32-318
32-319
32-320
32-321
32-322
32-323
32-324
32-325
32-326
REMOVED
REMOVED
REMOVED
REMOVED
REMOVED
32-331.1
32-331.2
32-331.3
32-331.4
32-331.5
32-331.6
32-331.7
32-331.8
32-331.9
32-331.10
32-332
32-333
32-334
32-335
32-336
REMOVED
REMOVED
32-301
3290 (Cont.)
32-302
FORM CMS-1728-94
DRAFT
Worksheets
Page(s)
Wkst. RH-2
Wkst. FQ-1, Parts I & II
Wkst. FQ-1, Part III
Wkst. FQ-2
Wkst. RF-1
Wkst. RF-2
Wkst. RF-3
Wkst. RF-4 (Do not complete. See instructions.)
Wkst. RF-5
Wkst. O
Wkst. O-1
Wkst. O-2
Wkst. O-3
Wkst. O-4
Wkst. O-5
Wkst. O-6, Part I
Wkst. O-6, Part II
Wkst. O-7
Wkst. O-8
REMOVED
REMOVED
REMOVED
REMOVED
32-343
32-344
32-345
32-346
32-347
32-348 -32-349
32-350
32-351
32-352
32-353
32-354
32-355-32-356
32-357-32-358
32-359
32-360
Rev.
| File Type | application/pdf |
| File Modified | 2015-05-18 |
| File Created | 2015-05-18 |