Crosswalk

Revisions to Form CMS-2088-17 Community Mental Health Center Cost Report
The forms are revised to remove obsolete worksheets for certified outpatient physical therapy, outpatient occupational therapy and outpatient
speech pathology providers, and comprehensive outpatient rehabilitation facilities that no longer have a cost report filing requirement. In
addition, the forms are revised to incorporate data previously reported on OMB No. 0938-0301, the Provider Cost Report Reimbursement Questionnaire,
Form CMS-339.

WORKSHEET DESCRIPTION
Community Mental Health Center Cost Report Certification and
Settlement Summary
Cost Report Identification Data
Cost Report Reimbursement Questionnaire
Reclassification and Adjustment of Trial Balance of Expenses
Reclassifications
Adjustments to Expenses
Statement of Costs of Services from Related Organizations
Provider-Based Physicians Adjustments
Cost Allocations General Service Costs\
Cost Allocations - Statistical Basis
Apportionment of Patient Service Costs
Calculation of Reimbursement Settlement
Analysis of Payments for Services Rendered to Program
Beneficiaries
Statement of Revenues and Expenses
Reasonable Costs Determination for Physical Therapy Services
Furnished by Outside Suppliers
Reasonable Costs Determination for Respiratory Therapy Services
Furnished by Outside Suppliers
Reasonable Costs Determination for Therapy Services Furnished
by Outside Suppliers

OLD
S Part
II - III
S Part I and
IV
New
Worksheet
A
A-1
A-3
A-3-1
A-8-2
B
B-1
C
D

NEW

Reason

S-1 Part I and II

Changed to conform with other cost reporting
forms.
Changed format to include identification and
statistical data on one worksheet.

S-2

Incorporates the Form CMS-339

A
A-6
A-8
A-8-1
A-8-2
B
B-1
C
D

S Part I - III

S-1

D-1

N/A
Changed to conform with other cost reports.
Changed to conform with other cost reports.
Changed to conform with other cost reports.
N/A
N/A
N/A
N/A
N/A
Changed to conform with other cost reporting
forms.

New
Worksheet
A-8-3
All PARTS
A-8-4
ALL PARTS
A-8-5
ALL PARTS

F

Requested by DCCM policy group.

REMOVED

Obsolete

REMOVED

Obsolete

REMOVED

Obsolete