Download:
pdf |
pdfCHAPTER 43
HOSPICE FACILITY COST REPORT
FORM CMS-1984-14
TABLE OF CONTENTS
Section
General ................................................................................................................................ 4300
Rounding Standards for Fractional Computations .............................................................. 4301
Definitions ........................................................................................................................... 4302
Acronyms and Abbreviations ............................................................................................. 4303
Recommended Sequence for Completing Form CMS-1984-14 ......................................... 4304
Sequence of Assembly ........................................................................................................ 4305
Worksheet S - Hospice Cost and Data Report .................................................................... 4306
Worksheet S-1 - Hospice Identification Data ..................................................................... 4307
Part I - Identification Data ............................................................................................ 4307.1
Part II - Statistical Data ................................................................................................. 4307.2
Part III - Contracted Statistical Data ............................................................................. 4307.3
Worksheet S-2 – Hospice Reimbursement Questionnaire .................................................. 4308
Worksheet A - Reclassification and Adjustment of Trial Balance of Expenses ................. 4310
Worksheets A-1, A-2, A-3, and A-4 - Reclassification and Adjustment of Trial
Balance of Expenses ..................................................................................................... 4311
Worksheet A-1 - Continuous Home Care ..................................................................... 4311
Worksheet A-2 - Routine Home Care ........................................................................... 4311
Worksheet A-3 - Inpatient Respite Care ....................................................................... 4311
Worksheet A-4 - General Inpatient ............................................................................... 4311
Worksheet A-6 - Reclassifications....................................................................................... 4316
Worksheet A-8 - Adjustments to Expenses ......................................................................... 4318
Worksheet A-8-1 - Statement of Costs of Services from Related Organizations
and Home Office Costs ................................................................................................. 4319
Part I - Costs Incurred and Adjustments Required as a Result of Transactions
with Related Organizations or Claimed Home Office Costs .................................. 4319.1
Part II - Interrelationship to Related Organizations and/or Home Office ...................... 4319.2
Worksheet B - Cost Allocation - General Service Costs and Worksheet B-1 - Cost
Allocation Statistical Basis ........................................................................................... 4320
Worksheet C - Calculation of Per Diem Cost ..................................................................... 4330
Worksheet F - Balance Sheet .............................................................................................. 4350
Worksheet F-1 - Statement of Changes in Fund Balances ................................................. 4351
Worksheet F-2 - Statement of Revenues and Operating Expenses ..................................... 4352
Part I - Revenues ........................................................................................................... 4352.1
Part II - Operating Expenses .......................................................................................... 4352.2
Form CMS-1984-14 Worksheets ........................................................................................ 4390
Electronic Reporting Specifications for Form CMS-1984-14 ............................................ 4395
Rev. 1
43-1
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid
OMB control number for this information collection is 0938-0758 (Expires XX/XX/XXXX). The time required to complete this information collection is estimated 188 hours
per response, including the time to review instructions, search existing resources, gather the data needed, and complete and review the information collection. If you have any
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Report Clearance
Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send applications, claims, payments, medical records or any documents containing sensitive
information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB
control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact
1-800-MEDICARE.
This page is intentionally left blank.
08-14
4300.
FORM CMS-1984-14
4300
GENERAL
The Paperwork Reduction Act of 1995 establishes the requirement that the private sector be told
why information is collected and how it will be used by the government. In accordance with
42 CFR 418.310, hospices must provide reports and keep records as the Secretary determines
necessary to administer the program. Also, 42 CFR 413.20 requires providers participating in
the Medicare program to submit information for health care services rendered to Medicare
beneficiaries through annual cost reports. The data submitted on the cost reports supports
management of Federal programs. The information reported on Form CMS-1984-14, must
conform to the requirements and principles set forth in CMS Pub. 15-1, Provider Reimbursement
Manual, Part 1, as well as those set forth in CMS Pub. 100-02, Medicare Benefit Policy Manual,
chapter 9; and CMS Pub. 100-04, Medicare Claims Processing Manual, chapter 11. These
instructions are effective for cost reporting periods beginning on or after October 1, 2014.
Providers receiving Medicare reimbursement must provide adequate cost data based on financial
and statistical records that can be verified by qualified auditors. The cost data must be based on
the accrual basis of accounting. Under the accrual basis of accounting, revenue is recorded in the
period earned regardless of when it is collected, and expenditures for expense and asset items are
recorded in the period incurred regardless of when paid. See 42 CFR 413.24(b)(2). However,
where governmental institutions operate on a cash basis of accounting, cost data developed on
such basis of accounting is acceptable subject to appropriate treatment of capital expenditures.
An electronic cost report (ECR) and supporting documentation must be submitted to the
Medicare administrative contractor (MAC), hereafter referred to as contractor. Providers
meeting the conditions set forth in the CMS Pub. 15-2, Provider Reimbursement Manual, Part 2,
chapter 1, §110 are permitted to file less than a full cost report.
Form CMS-1984-14 must be used by all freestanding hospices for cost reporting periods
beginning on or after October 1, 2014. Cost reports are due on or before the last day of the fifth
month following the close of the period covered by the report. The only provision for an
extension of the cost report due date is identified in 42 CFR 413.24(f)(2)(ii).
NOTE: This form is to be used by freestanding hospices only. Hospices that are considered
provider-based for cost reporting purposes must use the following: hospital based hospices must
use Form CMS-2552, skilled nursing facility (SNF) based hospices must use Form CMS-2540,
and home health agency based hospices must use Form CMS-1728.
Rev. 1
43-3
4301
FORM CMS-1984-14
08-14
The public reporting and recordkeeping burden for this cost report is estimated to average 188
hours per response. This includes time for reviewing instructions, gathering data, maintaining
records, and completing the forms. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing the burden, to:
Centers for Medicare and Medicaid Services
PRA Reports Clearance Officer
7500 Security Boulevard
Mail Stop C4-26-05
Baltimore, Md. 21244-1850
4301.
ROUNDING STANDARDS FOR FRACTIONAL COMPUTATIONS
Throughout the Medicare cost report, where computations result in fractions, use the following
rounding standards:
1. Round to 2 decimal places:
• percentages
• averages, standard work week, and payment rates
• full time equivalent employees
• per diem
• hourly rates
2. Round to 6 decimal places:
• ratios (e.g., unit cost multipliers)
When costs computed using a fraction or decimal result in the sum of the parts not equal to the
whole, adjust the greatest computed amount so the sum of the computed amounts equals the
whole. Should the computed amounts include multiple occurrences of the same greatest amount,
adjust the first occurrence of the greatest amount.
43-4
Rev. 1
08-14
4302.
FORM CMS-1984-14
4303
DEFINITIONS
A freestanding hospice, refers to a hospice that is not part of any other type of participating
provider meeting the requirements of §1861(dd) of the Social Security Act. Refer to the
CMS Pub. 15-1; CMS Pub. 100-02, chapter 9; and CMS Pub. 100-04, chapter 11, for further
definitions of terms.
When referring to patients in the Form CMS-1984 and the cost reporting instructions, the term
“Medicare” refers to Medicare patients currently under a valid Medicare hospice election.
Medicare patients not covered under a valid Medicare hospice election are classified as Other.
4303.
ACRONYMS AND ABBREVIATIONS
Acronyms and abbreviations used throughout the Medicare cost report and instructions are
summarized below.
A&G
ALOS
CAP REL
CBSA
CCN
CFR
CHC
CMS Pub.
CNA
COL
ECR
GIP
HCRIS
IRC
LOC
LPN
LVN
MAC
NF
NPR
OTC
PS&R Report
RHC
RN
SNF
WKST
Rev. 1
-
Administrative and General
Average Length of Stay
Capital-Related
Core Based Statistical Area
CMS Certification Number (formerly known as provider number)
Code of Federal Regulations
Continuous Home Care
Centers for Medicare & Medicaid Services Publication
Certified Nursing Assistant
Column
Electronic Cost Report
General Inpatient Care
Healthcare Cost Report Information System
Inpatient Respite Care
Level of Care
Licensed Practical Nurse
Licensed Vocational Nurse
Medicare Administrative Contractor
Nursing Facility
Notice of Program Reimbursement
Over-the-counter
Provider Statistical and Reimbursement Report
Routine Home Care
Registered Nurse
Skilled Nursing Facility
Worksheet
43-5
4304
FORM CMS-1984-14
4304.
RECOMMENDED SEQUENCE FOR COMPLETING FORM CMS-1984-14
Step
No.
Worksheet
Instructions
1
S
Read §4306. Complete entire worksheet.
2
S-1
Read §4307. Complete entire worksheet.
3
S-2
Read §4308. Complete columns 1 through 3.
4
A-1, A-2, A-3, A-4
Read §4311. Complete columns 1 through 3.
5
A
Read §4310. Complete columns 1 through 3.
6
A-6
Read §4316. Complete, if applicable.
7
A-8
Read §4318. Complete all lines.
8
A-8-1
Read §4319. Complete, if applicable.
9
A-1, A-2, A-3, A-4
Read §4311. Complete columns 4 through 7.
10
A
Read §4310. Complete columns 4 through 7.
11
B and B-1
Read §4320. Complete both worksheets entirely.
12
C
Read §4330. Complete entire worksheet.
13
F
Read §4350. Complete entire worksheet.
14
F-1
Read §4351. Complete entire worksheet.
15
F-2
Read §4352. Complete entire worksheet.
43-6
08-14
Rev. 1
08-14
4305.
FORM CMS-1984-14
4306
SEQUENCE OF ASSEMBLY
Submit the cost report worksheets in the order indicated below when using Form CMS-1984-14.
Include only applicable, completed worksheets. Do not include blank worksheets.
4306.
Worksheet
Part
S
S-1
S-2
A-1 through A-4
A
A-6
A-8
A-8-1
B
B-1
C
F
F-1
F-2
I & II
WORKSHEET S - HOSPICE COST AND DATA REPORT
4306.1 Part I - Cost Report Status.--This section is completed by the provider or contractor as
indicated on the worksheet.
Provider use only.--The provider completes lines 1 through 4.
Line 1.--Indicate if the cost report is an electronic submission by entering “Y” for yes or “N” for
no in column 1, line 1. If yes, enter the electronic file creation date and time in columns 2 and 3,
respectively. The date and time are archived in the ECR as an identifier for the file. This file is
your original submission and must not be modified. If no, line 2 must be completed.
Line 2.--Indicate if the cost report is a manual submission by entering “Y” for yes or “N” for no
on line 2. Line 2 is only completed by providers filing low utilization cost reports in accordance
with CMS Pub. 15-2, chapter 1, §110 or providers demonstrating financial hardship in
accordance with §133.
Rev. 1
43-7
4306.1 (Cont.)
FORM CMS-1984-14
08-14
Line 3.--If this is an amended cost report, enter the number of times the cost report has been
amended.
Line 4.--Enter an “F” if this is full cost report or an “L” for a low Medicare utilization cost
report. Providers must obtain contractor approval prior to submitting a low Medicare utilization
cost report. (See CMS Pub. 15-2, chapter 1, §110.)
Contractor use only.--The contractor completes lines 5 through 12.
Line 5.--Enter the Healthcare Cost Report Information System (HCRIS) cost report status code
that corresponds to the filing status of the cost report. Valid codes are: 1=As submitted or
5=Amended. Codes 2 through 4 are reserved for future use.
Line 6.--Enter the date (mm/dd/yyyy) the accepted cost report was received.
Line 7.--Enter the contractor number.
Lines 8 and 9.--If this is the very first cost report for this provider CMS certification number
(CCN), enter “Y” for yes on line 8. If this is the final (terminating) cost report for this provider
CCN, enter “Y” for yes on line 9. If the cost report is neither a first nor a final cost report for
this provider CCN, enter “N” for no on both lines.
Line 10.--Reserved.
Line 11.--Enter the software vendor code of the cost report software used by the contractor.
Enter “3” for KPMG or “4” for HFS.
Line 12.--Reserved.
4306.2 Part II - Certification.--This certification is read, completed, and signed by an officer or
administrator of the provider after the cost report has been completed in its entirety.
43-8
Rev. 1
08-14
4307.
FORM CMS-1984-14
4307.1
WORKSHEET S-1 - HOSPICE IDENTIFICATION DATA
4307.1 Part I - Identification Data.--The information required on this worksheet is needed to
properly identify the provider.
Lines 1 through 4.--Enter the name, address, city, state, ZIP code, and county of the hospice.
Line 5.--Enter the provider CCN.
Line 6.--Enter the date the hospice began operation. Enter the date of State licensure if the
hospice is located in a State that requires a State hospice license for operation.
Line 7.--Enter the date(s) the hospice was certified for Medicare (title XVIII) and, if applicable,
Medicaid (title XIX).
Line 8.--Enter the inclusive dates covered by this cost report.
In accordance with
42 CFR 413.24(f), providers are required to submit periodic reports of operations, which
generally cover a consecutive 12-month period. (See CMS Pub. 15-2, chapter 1, §§102.1
through 102.3 for situations when a provider may file a cost report for a period other than a
12-month period.)
Line 9.--Indicate whether the provider is legally required to carry malpractice insurance. Enter
“Y” for yes or “N” for no.
Line 10.--If line 9 is yes, indicate whether the malpractice insurance is a claims-made or
occurrence policy. Enter 1 if the malpractice insurance is a claims-made policy. Enter 2 if the
malpractice insurance is an occurrence policy.
Line 11.--Enter the amounts of malpractice premiums paid in column 1, the total amount of paid
losses in column 2, and the total amount of self-insurance in column 3.
Malpractice insurance premiums are money paid by the provider to a commercial insurer to
protect the provider against potential negligence claims made by their
patients/clients. Malpractice paid losses is money paid by the healthcare provider to compensate
a patient/client for professional negligence. Malpractice self-insurance is money paid by the
provider where the healthcare provider acts as its own insurance company (either as a sole or
part-owner) to financially protect itself against professional negligence. Often providers will
manage their own funds or purchase a policy referred to as captive insurance, which provides
insurance coverage they need but could not obtain economically through the mainstream
insurance market.
Rev. 1
43-9
4307.1 (Cont.)
FORM CMS-1984-14
08-14
Line 12.--Indicate whether malpractice premiums paid, paid losses, or self-insurance are reported
in a cost center other than the A&G cost center. Enter “Y” for yes or “N” for no. If yes, submit
supporting schedule listing cost centers and amounts.
Line 13.--Indicate whether this cost report includes home office costs. (See CMS Pub. 15-1,
chapter 21, §2150ff.) Enter “Y” for yes or “N” for no in column 1. If yes, enter the chain home
office number in column 2, complete lines 14 through 18, and complete Worksheet A-8-1.
Lines 14 through 18.--If line 13 is yes, enter the name and address of the home office on lines 14
through 16, the home office contractor name on line 17, and the home office contractor number
on line 18.
Line 19.--Indicate the type of control under which the hospice operates.
following choices:
1
2
3
4
5
6
7
= Voluntary Nonprofit, Church
= Voluntary Nonprofit, Other
= Proprietary, Individual
= Proprietary, Corporation
= Proprietary, Partnership
= Proprietary, Other
= Governmental, Federal
8
9
10
11
12
13
Select from the
= Governmental, City-County
= Governmental, County
= Governmental, State
= Governmental, Hospital District
= Governmental, City
= Governmental, Other
Line 20.--Enter the number of CBSAs in which Medicare covered services were provided during
the cost reporting period.
Line 21.--List the code for each CBSA in which Medicare covered hospices services were
provided during the cost reporting period. Enter the first CBSA on line 21 and subscript line 21
as necessary to report additional CBSAs.
43-10
Rev. 1
08-14
4307.2
FORM CMS-1984-14
4307.2
Part II - Statistical Data.--This section collects unduplicated days data.
Lines 30 through 33.--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 -- continuous home care (CHC),
routine home care (RHC), inpatient respite care (IRC), or general inpatient care (GIP). 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 IRC day on line 32 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.
For the purposes of the Medicare and Medicaid hospice programs, a patient electing hospice care
can receive only one of the following four levels of care per day:
Continuous Home Care Day.--A CHC 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 CHC day.
Do not count days by dividing the total hours by 24.
Routine Home Care Day.--An RHC day is a day on which the hospice patient is at
home and not receiving CHC.
Inpatient Respite Care Day--An IRC 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.
General Inpatient Care Day.--A GIP 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 that cannot be managed in other settings.
Line 34.--Enter the total unduplicated days (sum of lines 30 through 33) in each column as
applicable.
Rev. 1
43-11
4307.3
FORM CMS-1984-14
08-14
4307.3 Part III - Contracted Statistical Data.--This section collects unduplicated days data for
inpatient services at a contracted facility. The days reported in Part III are a subset of the days
reported in Part II.
Lines 40 and 41.--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 IRC or GIP 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.
4308.
WORKSHEET S-2 - HOSPICE REIMBURSEMENT QUESTIONNAIRE
This worksheet collects organizational, financial and statistical information previously reported
on Form CMS-339. Where instructions for this worksheet direct the provider to submit
documentation/information, mail or otherwise transmit the requested documentation to the
contractor with submission of the 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 line
number the documentation supports.
Line 1.--Indicate whether the hospice 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 yes, enter the date
the change of ownership occurred in column 2. Also, submit documentation identifying the
name and address of the new owner and a copy of the sales agreement with the cost report.
Line 2.--Indicate whether the hospice has terminated participation in the Medicare program.
Enter “Y” for yes or “N” for no in column 1. If yes, enter the date of termination in column 2,
and “V” for voluntary or “I” for involuntary in column 3.
Line 3.--Indicate whether the hospice 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 provider 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. If yes, submit a list of the individuals, the
organizations involved, and a description of the transactions with the cost report. (See
CMS Pub. 15-1, chapter 10 and 42 CFR 413.17.)
43-12
Rev. 1
08-14
FORM CMS-1984-14
4308 (Cont.)
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 in column 3 the
date the financial statements will be available.
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 that occurred during the cost reporting period. The changed accounting or
administrative procedures manuals may be submitted 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 financial statements. Enter “Y” for yes or “N” for no in column 1. If yes,
submit a schedule reconciling the financial statements with the cost report.
Line 6.--Indicate whether the cost report was prepared using only the Provider Statistical &
Reimbursement (PS&R) report by entering “Y” for yes or “N” for no in column 1. If yes, enter
the paid-through date of the PS&R report in column 2. Submit a crosswalk matching revenue
codes and charges found on the PS&R report to the cost center groupings on the cost report.
Line 7.--Indicate whether the cost report was prepared using the PS&R report for totals and
provider records for allocation by entering “Y” for yes or “N” for no in column 1. If yes, enter
the paid-through date of the PS&R report used to prepare this cost report in column 2. Submit a
detailed crosswalk matching revenue codes, departments and charges on the PS&R report to the
cost center groupings on the cost report. This crosswalk must show dollars by cost center and
identify 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 report (as appropriately adjusted for unpaid
claims, etc.) to use this method. Workpapers must accompany this crosswalk to support the
accuracy of the provider records. If the contractor does not find the documentation sufficient,
the PS&R report will be used in its entirety.
Line 8.--If either line 6 or 7, column 1 is yes, indicate whether adjustments were made to the
PS&R report data for additional claims that have been billed but not included on the PS&R
report. Enter “Y” for yes or “N” for no. If yes, include a schedule supporting any claims not
included on the PS&R report. On the schedule, include totals consistent with the breakdowns on
the PS&R report, and list claims that are unprocessed or unpaid as of the paid-through date of the
PS&R report.
Rev. 1
43-13
4308 (Cont.)
FORM CMS-1984-14
08-14
Line 9.--If either line 6 or 7, column 1 is yes, indicate whether adjustments were made to the
PS&R report data for corrections of other PS&R report information. Enter “Y” for yes or “N”
for no. If yes, submit a detailed explanation and supporting documentation reconciling the
PS&R report to the cost report.
Line 10.--If either line 6 or 7, column 1 is yes, indicate whether other adjustments were made to
the PS&R report data. Enter “Y” for yes or “N” for no. If yes, enter a description of the
adjustments in the space provided and submit documentation reconciling the PS&R report to the
cost report.
Line 11.--Indicate whether the cost report was prepared using only provider records. Enter “Y”
for yes or “N” for no. If yes, submit detailed documentation of the system used to support the
data reported on the cost report. If detailed documentation was previously supplied, submit only
necessary updated documentation with the cost report.
The minimum documentation 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 provider). If the
provider maintained the system, include date of last software update.
NOTE: Additional documentation may be supplied such as narratives, internal flow charts, or
outside vendor informational material to further describe and validate the reliability of the
system.
Line 12.--Enter the first name, last name and the title/position held by the cost report preparer in
columns 1, 2, and 3, respectively.
Line 13.--Enter the employer or company name of the cost report preparer.
Line 14.--Enter the telephone number and email address of the cost report preparer in columns 1
and 2, respectively.
43-14
Rev. 1
08-14
4310.
FORM CMS-1984-14
4310
WORKSHEET A - RECLASSIFICATION AND ADJUSTMENT OF TRIAL
BALANCE OF EXPENSES
Worksheet A provides for recording the trial balance of expense accounts from the hospice
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.
If the cost elements of a cost center are separately maintained on the accounting books, reconcile
the costs from the accounting books and records with those reported on this worksheet. The
reconciliation is subject to review by the contractor.
Standard (i.e., preprinted) CMS line numbers and cost center descriptions cannot be changed. If
additional or different cost center descriptions are needed, add (subscript) additional lines to the
cost report. Where an added cost center description bears a logical relationship to a standard line
description, the added label must be inserted immediately after the related standard line. The
added line is identified as a numeric subscript of the immediately preceding line. For example, if
two lines are added between lines 7 and 8, identify them as lines 7.01 and 7.02. If additional
lines are added for general service cost centers, add corresponding columns for cost finding.
Cost center coding is a method for standardizing cost center labels used by health care providers
on the Medicare cost report. Form CMS 1984-14 provides for preprinted cost center descriptions
on Worksheet A. In addition, a space is provided for a cost center code. The standard cost
center labels are automatically coded by CMS approved cost reporting software. The CMS
approved cost reporting software also accommodates cost centers that are frequently used by
health care providers but not included as standard cost centers, hereafter referred to as the
nonstandard cost centers. Table 5 provides a description of cost center coding and the table of
cost center codes (see §4395).
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 the ECR provide standardized meaning for data analysis. Providers
are required to compare any added or changed label to the descriptions offered on the standard
and nonstandard cost center tables.
Rev. 1
43-15
4310 (Cont.)
FORM CMS-1984-14
08-14
COLUMN DESCRIPTIONS
Column 1.--Salaries are the gross salaries paid to employees before taxes and other items are
withheld. Salaries include deferred compensation, overtime, incentive pay, and bonuses. (See
CMS Pub. 15-1, chapter 21.) Enter salaries from the hospice accounting books and records
and/or trial balance. 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 A-1, A-2, A-3 and A-4.
Column 2.--Enter all costs other than salaries from the hospice accounting books and records
and/or trial balance. 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 A-1, A-2, A-3 and A-4.
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 cost center, enter the net amount of reclassifications from Worksheet A-6.
The net total of the entries in column 4 must equal zero on line 100.
Column 5.--For each cost center, enter the total of the amount in column 3 plus or minus the
amount in column 4. The total on column 5, line 100 must equal the total on column 3, line 100.
Column 6.--For each cost center, enter the net of any increase and decrease amounts from
Worksheet A-8. The total on Worksheet A, column 6, line 100 must equal Worksheet A-8,
column 2, line 50.
43-16
Rev. 1
08-14
FORM CMS-1984-14
4310 (Cont.)
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 B 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. 1
From Worksheet A, Column 7,
Line Number and
Cost Center Description
Cap Rel Costs-Bldg & Fixt
Cap Rel Costs-Mvble Equip
Employee Benefits
Administrative & General
Plant Operation and 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 and Board
Other Nonreimbursable
To Worksheet B,
Column 0:
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
43-17
4310 (Cont.)
FORM CMS-1984-14
08-14
LINE DESCRIPTIONS
The Worksheet A 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 B and B-1 using the same line
numbers as Worksheet A.
The direct patient care service cost centers appear on
Worksheets A-1, A-2, A-3, and A-4 using the same line numbers as Worksheet A.
GENERAL SERVICE COST CENTERS
General service cost centers include expenses incurred in operating the facility as a whole that
are not directly associated with furnishing patient care such as, but not limited to 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 - Capital Related Costs-Buildings & Fixtures and Capital Related Costs-Movable
Equipment.--These cost centers include the capital-related costs for buildings and fixtures and
the capital-related costs for movable equipment including 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. 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 lease payments for repairs and/or maintenance; 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 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 - Employee Benefits.--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).
Line 4 - Administrative and General.--The administrative and general (A&G) cost center
includes a wide variety of provider administrative costs that benefit the entire facility. Examples
include fiscal services, legal services, accounting, data processing, taxes, and malpractice costs.
Marketing and advertising costs that are not related to patient care, fundraising costs, and other
nonreimbursable costs are not included here, but are reported in the appropriate nonreimbursable
cost center.
43-18
Rev. 1
07-15
FORM CMS-1984-14
4310 (Cont.)
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.
Line 5 - Plant Operation and Maintenance.--This cost center includes expenses incurred in the
operation and maintenance of the plant and equipment, maintaining general cleanliness and
sanitation of plant, and protecting the employees, visitors, and agency property.
Plant operation and maintenance costs 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 building, 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, sidewalk, fenced areas,
fencing, external recreation areas and parking facilities, is part of this cost center. The costs of
maintaining the safety and well-being of personnel, visitors and the provider’s facilities are also
included in this cost center.
Line 6 - Laundry and 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. 2
43-19
4310 (Cont.)
FORM CMS-1984-14
07-15
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 OTC),
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 B to accumulate in-facility costs not separately identified as IRC,
GIP, 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 IRC, GIP or residential care). The
amounts allocated to this cost center on Worksheet B are allocated to IRC, GIP, 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.
43-20
Rev. 2
08-14
FORM CMS-1984-14
4310 (Cont.)
DIRECT PATIENT CARE SERVICE COST CENTERS
Direct patient care service costs are reported by LOC on Worksheets A-1, A-2, A-3 and A-4.
For each cost center on Worksheet A, enter the sum of the amounts from Worksheets A-1, A-2,
A-3, and A-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 (IRC or GIP) 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 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.
Rev. 1
43-21
4310 (Cont.)
FORM CMS-1984-14
08-14
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.
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.
43-22
Rev. 1
08-14
FORM CMS-1984-14
4310 (Cont.)
Line 37 - Hospice Aide and 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 durable
medical equipment (DME) and oxygen, as defined in 42 CFR 410.38 and 42 CFR 418.202(f),
furnished to individual RHC or CHC 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 RHC and
CHC 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 GIP LOC is transferred to RHC LOC and transported to their home,
the transportation cost associated with the transfer must be included in the RHC LOC.
Line 40 - Imaging Services.--This cost center includes the costs of imaging services.
Line 41 - Labs and Diagnostics.--This cost center includes the costs of laboratory and diagnostic
tests.
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.
Rev. 1
43-23
4310 (Cont.)
FORM CMS-1984-14
08-14
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 and 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 B and B-1.
Lines 54 through 59.--Reserved for future use.
NONREIMBURSABLE COST CENTERS
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.
43-24
Rev. 1
08-14
FORM CMS-1984-14
4310 (Cont.)
Line 64 - Palliative Care Program.--This cost center includes costs of palliative care provided to
non-hospice patients. This includes physician services.
Line 65 - Other Physician Services.--This cost center includes costs of other physician services
that are provided outside of a palliative care program to non-hospice patients.
Line 66 - Residential Care.--This cost center includes the 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 RHC and/or CHC LOC
worksheet.
Lines 67 - Advertising.--This cost center includes costs of nonallowable community education,
business development, marketing and advertising (see CMS Pub. 15-1, chapter 21, §2136).
Lines 68 - Telehealth/Telemonitoring.--This cost center includes 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.--This cost center includes costs of thrift stores.
Line 70 - Nursing Facility Room and Board.--This cost center includes 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.
Rev. 1
43-25
4311
4311.
FORM CMS-1984-14
08-14
WORKSHEETS A-1, A-2, A-3 AND A-4 - RECLASSIFICATION AND
ADJUSTMENT OF TRIAL BALANCE OF EXPENSES
Worksheet A-1 - Continuous Home Care
Worksheet A-2 - Routine Home Care
Worksheet A-3 - Inpatient Respite Care
Worksheet A-4 - General Inpatient Care
Worksheets A-1, A-2, A-3 and A-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 A in order to facilitate the transfer of direct patient care costs to Worksheet A. 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 A.
Column 1.--Enter salaries from the hospice accounting books and records and/or trial balance.
Column 2.--Enter all costs other than salaries from the hospice accounting books and records
and/or trial balance.
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 cost center, enter the net Worksheet A-6 increase and decrease amounts
that can be identified by LOC. The total of the entries in column 4 may not equal zero on
line 100.
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 cost center, enter the net Worksheet A-8 increase and decrease amounts
that can be identified by LOC.
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, line 100 to Worksheet B, column 0 as
follows:
From column 7, line 100 of:
Worksheet A-1
Worksheet A-2
Worksheet A-3
Worksheet A-4
43-26
To Worksheet B, column 0:
Line 50
Line 51
Line 52
Line 53
Rev. 1
07-15
4316.
FORM CMS-1984-14
4316
WORKSHEET A-6 - RECLASSIFICATIONS
This worksheet provides for the reclassification of costs to effect proper cost allocation under
cost finding. For example:
•
Reclassification of employee benefits expenses (e.g., personnel department,
employee health service, hospitalization insurance, workers compensation,
employee group insurance, social security taxes, unemployment taxes, annuity
premiums, past service benefits, and pensions) included in the A & G cost center.
•
Reclassification from Worksheet A-4 (GIP) to Worksheet A-3 (IRC) of any IRC
RN expenses included in the registered nurse cost center on Worksheet A-4.
Column 1.--Identify each reclassification adjustment by assigning an alpha character (e.g., A, B,
C) in column 1. Do not use numeric designations.
Columns 2, 3, 4, and 4.01.--For each increase reclassification, enter the amount of the
reclassification related to salary costs in column 4, and/or the amount of the reclassification
related to other costs in column 4.01; the Worksheet A cost center line number reference in
column 3; and the corresponding cost center description in column 2.
Columns 5, 6, 7, and 7.01.--For each decrease reclassification, enter the amount of the
reclassification related to salary costs in column 7, and/or the amount of the reclassification
related to other costs in column 7.01; the Worksheet A cost center line number reference in
column 6; and the corresponding cost center description in column 5.
Column 8.--Enter the LOC worksheet indicator using 1, 2, 3 or 4 when a reclassification affects a
direct patient care service cost center (lines 25 through 46). If a reclassification affects more
than one LOC, report each entry as a separate line to properly identify each LOC
worksheet. The indicators are defined as follows:
LOC Worksheet
Worksheet A-1
Worksheet A-2
Worksheet A-3
Worksheet A-4
LOC Worksheet Indicator
1
2
3
4
For line 100, the sum of all increases in columns 4 and 4.01 must equal the sum of all decreases
in columns 7 and 7.01. Submit (with the cost report) copies of workpapers used to compute the
reclassifications.
Rev. 2
43-27
4318
4318.
FORM CMS-1984-14
07-15
WORKSHEET A-8 - ADJUSTMENTS TO EXPENSES
In accordance with 42 CFR 413.9(c)(3), where operating costs include amounts not related to
patient care, specifically not reimbursable under the program, or 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 in support of those
listed on Worksheet A, column 6. These adjustments, required under Medicare principles of
reimbursement, are made on the basis of cost or, only if the cost (including direct cost and all
applicable overhead) cannot be determined, amount received (revenue). If the total direct and
indirect cost can be determined, enter the cost. Adjustments to expenses based on cost cannot be
based on revenue in subsequent cost reporting periods. Submit documentation used to compute a
cost adjustment with the cost report. Adjustments entered on this worksheet are to:
•
•
•
•
reflect actual expenses incurred,
record the recovery of expenses through sales, charges, or fees,
adjust expenses in accordance with the Medicare principles of reimbursement, and
adjust expenses for those items provided for separately in the cost apportionment
process.
When an adjustment to an expense affects more than one cost center or more than one LOC,
record the adjustment to each cost center or LOC on a separate line.
Column 1.--Enter the basis for each adjustment using "A" for cost or "B" for revenue.
Columns 2, 3, and 4.--For each adjustment, enter the amount in column 2, enter the Worksheet A
cost center line number reference in column 4, and enter the corresponding cost center
description in column 3.
Column 5.--For each adjustment, enter the LOC worksheet indicator (defined in §4316) using 1,
2, 3 or 4 when an adjustment affects a direct patient care service cost center (lines 25 through
46).
Line 1.--Enter the investment income applied against interest expense. (See CMS Pub. 15-1,
chapter 2, §202.2.)
Line 2.--Enter the patient telephones adjustment on this line or establish a nonreimbursable cost
center. When line 2 is used, the adjustment must be based on cost. Revenue cannot be used.
43-28
Rev. 2
08-14
FORM CMS-1984-14
4318 (Cont.)
Line 3.--Enter the amount from Worksheet A-8-1, column 6, line 10.
Line 4.--Enter the amount received from the sale of meals to employees and guests.
Line 5.--Enter the amounts received from imposition of interest, finance, or penalty charges on
overdue receivables. This income must be used to offset allowable A&G costs. (See
CMS Pub. 15-1, chapter 21, §2110.2.)
Line 6.--Enter the amount of bad debts included on the trial balance.
Line 7.--Include items patients purchased from the hospice, the cost of which is included in any
of the cost centers on Worksheet A such as laundry and linen service.
Lines 8 and 9.--When depreciation expense computed in accordance with the Medicare
principles of reimbursement differs from depreciation expenses per the hospice’s books, enter
the difference on line 8 and/or line 9. (See CMS Pub. 15-1, chapter 1.)
Line 10.--Enter the Medicaid room and board payments, for dual-eligible beneficiaries, that are
redirected by the State from the nursing home to the hospice.
Line 11 through 49.--Enter any additional adjustments required under the Medicare principles of
reimbursement. A description must be entered in the description column to indicate the nature of
the adjustment.
Line 50.--Enter the sum of lines 1 through 49.
NOTE: Transfer amounts entered in column 2, lines 1 through 49 to the appropriate lines on
Worksheet A, column 6.
Rev. 1
43-29
4319
4319.
FORM CMS-1984-14
08-14
WORKSHEET A-8-1 - STATEMENT OF COSTS OF SERVICES FROM RELATED
ORGANIZATIONS AND HOME OFFICE COSTS
In accordance with 42 CFR 413.17 (except as provided in 42 CFR 413.17(d)), costs applicable to
services, facilities, and supplies furnished to the hospice by organizations related to the hospice
by common ownership or control are includable in the hospice’s allowable cost at the cost to the
related organization. However, such cost must not exceed the amount a prudent and cost
conscious buyer pays for comparable services, facilities, or supplies that are purchased
elsewhere.
4319.1 Part I - Costs Incurred and Adjustments Required as a Result of Transactions with
Related Organizations or Claimed Home Office Costs.--This part of the worksheet provides for
the computation of adjustments needed to properly report costs of services, facilities, and
supplies furnished to the hospice by related organizations or costs associated with the home
office.
Columns 1 and 2.--Enter in column 1 the Worksheet A cost center line number to be adjusted.
Enter the corresponding cost center description in column 2.
Column 3.--Enter the description of the related organization or home office expense.
Column 4.--Enter the allowable costs from the books and/or records of the related organization
or home office. Allowable costs are the actual costs incurred by the related organization or home
office for services, facilities, and/or supplies and exclude any markup, profit or amounts that
otherwise exceed the acquisition cost of such items.
Column 5.--Enter the amount included on Worksheet A for services, facilities, and/or supplies
acquired from related organizations or home office.
Column 6.--Enter the result of column 4 minus column 5.
Column 7.--Enter the LOC worksheet indicator (defined in §4316) using 1, 2, 3 or 4 when an
adjustment affects a direct patient care service cost center (lines 25 through 46).
4319.2 Part II - Interrelationship to Related Organizations and/or Home Office.--This part of
the worksheet identifies the interrelationship between the hospice and individuals, partnerships,
corporations, or other organizations having either a related interest to, a common ownership
with, or control over the hospice as defined in CMS Pub. 15-1, chapter 10. Complete columns 1
through 6 as applicable for each interrelationship.
43-30
Rev. 1
08-14
FORM CMS-1984-14
4319.2 (Cont.)
Column 1.--Enter the symbol that represents the interrelationship between the hospice and the
related organization or home office. Select from the following choices:
Symbol
A
B
C
D
E
F
G
Relationship
Individual has financial interest (stockholder, partner, etc.) in both related
organization and in provider
Corporation, partnership or other organization has financial interest in
provider
Provider has financial interest in corporation, partnership, or other
organization
Director, officer, administrator or key person of provider or organization
Individual is director, officer, administrator or key person of provider and
related organization
Director, officer, administrator or key person of related organization or
relative of such person has financial interest in provider
Other (financial or non-financial) -- specify
Column 2.--If the symbol entered in column 1 is A, D, E, F, or G, enter the name of the related
individual in column 2.
Column 3.--If the individual reported in column 2, or the organization reported in column 4, has
a financial interest in the hospice, enter the percentage of ownership.
Column 4.--Enter the name of each related corporation, partnership, or other organization.
Column 5.--If the hospice, or an individual reported in column 2, has a financial interest in the
organization reported in column 4, enter the percentage of ownership.
Column 6.--Enter the type of business of the related organization (e.g., medical drugs and/or
supplies, laundry and linen service).
Rev. 1
43-31
4320
4320.
FORM CMS-1984-14
08-14
WORKSHEET B - COST ALLOCATION - GENERAL SERVICE COSTS AND
WORKSHEET B-1 - COST ALLOCATION - 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. Cost finding is the process of recasting the data derived from the
accounts ordinarily kept by a provider to ascertain costs of the various types of services rendered.
It is the determination of these costs by the allocation of direct costs and proration of indirect
costs.
Worksheets B and B-1 facilitate the step-down method of cost finding. This method recognizes
that general services of the hospice are utilized by other general service, direct patient care
service, and nonreimbursable cost centers. Worksheet B provides for the equitable allocation of
general service costs based on statistical data reported on Worksheet B-1. To facilitate the
allocation process, the general format of Worksheets B is identical to that of Worksheet B-1.
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 A)
are reported by LOC on lines 50 through 53 of Worksheets B and B-1. The line numbers for
nonreimbursable cost centers are identical on Worksheets A, B and B-1.
When certain general services costs are related to in-facility days and are not separately
identifiable by LOC or service, Worksheets B and B-1 provide for the accumulation of these
costs on line 17. The amounts accumulated in this cost center are allocated based on the infacility days for IRC, GIP, 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 B-1 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.
43-32
Rev. 1
07-15
FORM CMS-1984-14
4320 (Cont.)
If the amount of any cost center on Worksheet A, column 7, has a negative balance, show this
amount as a negative balance on Worksheet B, column 0. Allocate the costs from the overhead
cost centers to applicable cost centers, including those 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 line 100 of the column, and do not allocate. This enables Worksheet B,
column 18, line 101, to cross foot to Worksheet B, column 0, line 101. After receiving costs
from overhead cost centers, LOC cost centers with negative balances on Worksheet B,
column 18, are not transferred to Worksheet C.
On Worksheet B-1, 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 Costs - Buildings and
Fixtures, enter on line 1 the total square feet of buildings on which depreciation was taken). Use
accumulated cost for allocating A&G expenses.
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 B-1, 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 B, which includes the direct expenses from Worksheet B column 0 plus allocated
costs from previously closed cost centers. Divide the amount entered on Worksheet B-1,
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.
Multiply the unit cost multiplier by that 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 B. For each column, the sum of the costs allocated (line 101) must equal the total
cost on the first line.
Rev. 2
43-33
4320 (Cont.)
FORM CMS-1984-14
07-15
After all the costs of the general service cost centers have been allocated on Worksheet B, 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 in column 18, line 101, must equal the total costs entered in
column 0, line 101.
COLUMN DESCRIPTIONS
Column 0.--For each cost center except the direct patient care cost centers (lines 25 through 46),
enter the total direct costs from Worksheet A, column 7. For the direct patient care cost centers,
enter the total direct costs as follows:
From column 7, line 100 of:
Worksheet A-1
Worksheet A-2
Worksheet A-3
Worksheet A-4
To Worksheet B, column 0:
Line 50
Line 51
Line 52
Line 53
Column 3A.--For each cost center, enter the sum of columns 0 through 3. The sum for each cost
center is the accumulated cost and, unless an adjustment is required, is the Worksheet B-1,
column 4, statistic for allocating A&G costs.
If an adjustment to the accumulated cost statistic on Worksheet B-1, column 4, is required to
properly allocate A&G costs, enter the adjustment amount on Worksheet B-1, column 4A, for
the applicable cost center. For example, when the hospice contracts for IRC or GIP services and
the contractual costs include A&G costs, the contractual costs reported on Worksheet A-3,
column 7, line 25, or Worksheet A-4, column 7, line 25, may be used to reduce the accumulated
cost statistic on Worksheet B-1, column 4A, line 52, or line 53, respectively.
For each cost center, the accumulated cost statistic on Worksheet B-1, column 4, is the difference
between the amount on Worksheet B, column 3A, and the adjustment amount on Worksheet B-1,
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 B, column 3A, line 4, to Worksheet B-1,
column 4A, line 4.
The total accumulated cost statistic for Worksheet B-1, column 4, line 4, is the difference
between the total on Worksheet B, column 3A, line 101, and the amounts in column 4A of
Worksheet B-1.
43-34
Rev. 2
07-15
FORM CMS-1984-14
4320 (Cont.)
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 B, column 18:
Line 50
Line 51
Line 52
Line 53
Rev. 2
To Worksheet C, column 3:
Line 1
Line 6
Line 11
Line 16
43-35
4330
4330.
FORM CMS-1984-14
07-15
WORKSHEET C - CALCULATION OF PER DIEM COST
Worksheet C calculates the average cost per diem by level of care and in total.
Line1.--Enter in column 3, the total CHC cost from Worksheet B, column 18, line 50.
Line 2.--Enter in column 3, the total CHC days from Worksheet S-1, column 4, line 30.
Line 3.--Enter in column 3, the average CHC cost per diem by dividing column 3, line 1, by
column 3, line 2.
Line 4.--Enter in column 1, the title XVIII - Medicare CHC days from Worksheet S-1, column 1,
line 30. Enter in column 2, the title XIX - Medicaid CHC days from Worksheet S-1, column 2,
line 30.
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 RHC cost from Worksheet B, column 18, line 51.
Line 7.--Enter in column 3, the total RHC days from Worksheet S-1, column 4, line 31.
Line 8.--Enter in column 3, the average RHC cost per diem by dividing column 3, line 6, by
column 3, line 7.
Line 9.--Enter in column 1, the title XVIII - Medicare RHC days from Worksheet S-1, column 1,
line 31. Enter in column 2, the title XIX - Medicaid RHC days from Worksheet S-1, column 2,
line 31.
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 IRC cost from Worksheet B, column 18, line 52.
43-36
Rev. 2
08-14
FORM CMS-1984-14
4330 (Cont.)
Line 12.--Enter in column 3 the total IRC days from Worksheet S-1, column 4, line 32.
Line 13.--Enter in column 3 the average IRC cost per diem by dividing column 3, line 11 by
column 3, line 12.
Line 14.--Enter in column 1 the Title XVIII - Medicare IRC days from Worksheet S-1,
column 1, line 32. Enter in column 3 the Title XIX - Medicaid IRC days from Worksheet S-1,
column 2, line 32.
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 GIP cost from Worksheet B, column 18, line 53.
Line 17.--Enter in column 3 the total GIP days from Worksheet S-1, column 4, line 33.
Line 18.--Enter in column 3 the average GIP cost per diem by column 3, line 16 by column 3,
line 17.
Line 19.--Enter in column 1, the Title XVIII - Medicare GIP days from Worksheet S-1,
column 1, line 33. Enter in column 3, the Title XIX - Medicaid GIP days from Worksheet S-1,
column 2, line 33.
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-1, column 4, line 34.
Line 23.--Enter the average cost per diem by dividing column 3, line 21 by column 3, line 22.
Rev. 1
43-37
4350
4350.
FORM CMS-1984-14
08-14
WORKSHEET F - BALANCE SHEET
Prepare this worksheet from the hospice accounting books and records. Where applicable, the
worksheets must be consistent with the hospice financial statements.
Line 1 - Cash on hand and in banks.--Enter the amount of cash on deposit in banks and
immediately available for use in financing activities, amounts on hand for minor disbursements
and amounts invested in savings accounts and certificates of deposit. Typical accounts would be
cash, general checking accounts, payroll checking accounts, other checking accounts, impress
cash funds, saving accounts, certificates of deposit, treasury bills and treasury notes and other
cash accounts.
Line 2 - Temporary investments.--Enter current securities evidenced by certificates of ownership
or indebtedness. Typical accounts would be marketable securities and other current investments.
Line 3 - Notes receivable.--Enter current unpaid amounts evidenced by certificates of
indebtedness.
Line 4 - Accounts receivable.--Enter unpaid inpatient and outpatient billings. Include direct
billings to patients for deductibles, co-insurance and other patient chargeable items not included
elsewhere.
Line 5 - Other receivable.--Enter other unpaid amounts due to the hospice.
Line 6 - Less: Allowance for uncollectable notes and accounts.--Enter the estimated amount of
the hospice accounts receivable which are expected to not be paid.
Line 7 - Inventory.--Enter the costs of unused hospice supplies. Perpetual inventory records may
be maintained and adjusted periodically to physical count. The extent of inventory control and
detailed record-keeping will depend upon the size and organizational complexity of the hospice.
The inventories may be valued by any generally accepted method, but the method must be
consistently applied from year to year.
Line 8 - Prepaid expenses.--Enter the costs incurred that are properly chargeable to a future
accounting period.
Line 9 - Other current assets.--Enter the balances of other current assets.
Line 10 - Total Current Assets.--Enter the sum of lines 1 through 9.
43-38
Rev. 1
08-14
FORM CMS-1984-14
4350 (Cont.)
Line 11 - Land.--Enter the cost of land as defined in CMS Pub. 15-1, chapter 1, §104.6.
Lines 12 and 13 - Land improvements.--Enter on line 12 the costs of land improvements as
defined in CMS Pub. 15-1, chapter 1, §104.7. Enter accumulated depreciation on line 13.
Lines 14 and 15 - Buildings.--Enter on line 14 the costs of the hospice buildings as defined in
CMS Pub. 15-1, chapter 1, §104.2. Enter accumulated depreciation on line 15.
Lines 16 and 17 - Leasehold improvements.--Enter on line 16 the costs of leasehold
improvements as defined in CMS Pub. 15-1, chapter 1, §104.8. Enter accumulated depreciation
on line 17.
Lines 18 and 19 - Fixed equipment.--Enter on line 18 the costs of building equipment as defined
in CMS Pub. 15-1, chapter 1, §104.3. Enter accumulated depreciation on line 19.
Lines 20 and 21 - Automobiles and trucks.--Enter on line 20 the costs of automobiles and trucks
used in hospice operations. Enter accumulated depreciation on line 21.
Lines 22 and 23 - Major movable equipment.--Enter on line 22 the costs of equipment as defined
in CMS Pub. 15-1, chapter 1, §104.4. Enter accumulated depreciation on line 23.
Lines 24 and 25 - Minor equipment-depreciable.--Enter on line 24 the costs of minor equipment
as defined in CMS Pub. 15-1, chapter 1, §104.5. Enter accumulated depreciation on line 25.
Line 26 - Total fixed assets.--Enter the sum of lines 11 through 25.
Line 27 - Investments.--Enter the cost of investments purchased with hospice funds and the fair
market value (at date of donation) of securities donated to the hospice.
Line 28 - Deposits on leases.--Enter the amount of deposits on leases including security deposits.
Line 29 - Due from owners/officers.--Enter the amount loaned to the hospice by owners and/or
officers.
Line 30 - Other assets.--Enter the amounts for assets not reported on lines 1 through 9, lines 11
through 25, or lines 27 through 29 (e.g., intangible assets such as goodwill, unamortized loan
costs and other organization costs).
Line 31 - Total other assets.--Sum of lines 27 through 30.
Line 32 - Total assets.--Sum of lines 10, 26 and 31.
Rev. 1
43-39
4350 (Cont.)
FORM CMS-1984-14
08-14
Line 33 - Accounts payable.--Enter amounts due trade creditors and others for supplies and
services purchased.
Line 34 - Salaries, wages and fees payable.--Enter the actual or estimated liabilities of salaries
and wages/fees payable.
Line 35 - Payroll taxes payable.-- Enter the actual or estimated liabilities of amounts payable for
payroll taxes withheld from salaries and wages, payroll taxes to be paid and other payroll
deductions, such as hospitalization insurance premiums.
Line 36 - Notes and loans payable (short-term).--Enter amounts payable on notes and loans as
evidenced by certificates of indebtedness due in the next 12 months.
Line 37 - Deferred income.--Enter the amount of deferred income received or accrued applicable
to services to be rendered within the next accounting period. Deferred income applicable to
accounting periods extending beyond the next accounting period is included as other current
liabilities. These amounts also reflect the effects of any timing differences between book and tax
or third-party reimbursement accounting.
Line 38 - Accelerated payments.--Enter the amounts payable for accelerated payments in
accordance with CMS Pub 15-1 §2412.
Line 39 - Other current liabilities.--Enter current liabilities not reported on lines 33 through 38.
Line 40 - Total current liabilities.--Enter the sum of lines 33 through 39.
Line 41 - Mortgage payable.--Enter the long-term financing obligation as evidenced by
certificates of indebtedness used to purchase real estate/property.
Line 42 - Notes payable.--Enter amounts payable on notes and loans as evidenced by certificates
of indebtedness due after the next 12 months.
Line 43 - Unsecured loans.--Enter amounts payable for unsecured liabilities due after the next 12
months.
Line 44 - Other long-term liabilities.--Enter the amounts payable to owners and/or officers for
loans to the hospice.
Line 45 - Other long-term liabilities.--Enter long-term liabilities not reported on lines 41 through
44.
43-40
Rev. 1
08-14
FORM CMS-1984-14
4351
Line 46 - Total long-term liabilities.--Enter the sum of lines 41 through 45.
Line 47 - Total liabilities.--Enter the sum of lines 40 and 46.
Line 48 - Fund balance.--Enter the end of period fund balance.
Line 49 - Total liabilities and fund balance.--Enter the sum of lines 47 and 48.
4351
WORKSHEET F-1 - STATEMENT OF CHANGES IN FUND BALANCES
Prepare this worksheet from the hospice accounting books and records. Where applicable, the
worksheet must be consistent with the hospice financial statements.
Column 1.--Hospices not maintaining fund-type accounting records complete the general fund
column. Hospices maintaining fund-type accounting records complete the general fund column
and applicable columns 2 through 4.
Column 2.--Hospices maintaining fund-type accounting records complete this column to report
changes in funds held for specific purposes such as research and education.
Column 3.--Hospices maintaining fund-type accounting records complete this column to report
changes in funds restricted for endowment purposes.
Column 4.--Hospices maintaining fund-type accounting records complete this column to report
changes in funds restricted for the replacement and expansion of the plant.
Line 1.--For each applicable column, the fund balance at the beginning of the period comes from
the same column on the prior year cost report Worksheet F-1, line 19.
Line 2.--In column 1, enter the amount from Worksheet F-2, line 42. This line is not completed
for columns 2, 3, and 4.
Line 3.--For each applicable column, enter the sum of lines 1 and 2.
Lines 4 through 9.--Most income is included in the net income reported on line 2. For each
applicable column, report on lines 4 through 9, those fund balance increases not included in
line 2. In column 0, enter a description for each increase entered on lines 4 through 9.
Rev. 1
43-41
4351 (Cont.)
FORM CMS-1984-14
08-14
Line 10.--For each applicable column, enter the sum of lines 4 through 9.
Line 11.--For each applicable column, enter the sum of line 3 plus line 10.
Lines 12 through 17.--Most expenses are included in the net income reported on line 2. For each
applicable column, report on lines 12 through 17, those fund balance decreases not included in
line 2. In column 0, enter a description for each decrease entered on lines 12 through 17.
Line 18.--For each applicable column, enter the sum of lines 12 through 17.
Line 19.--For each applicable column, enter the result of line 11 minus line 18. The sum of the
amounts in columns 1 through 4, line 19 must equal the amount entered on Worksheet F, line 48.
For each applicable column, the amount on line 19 is the fund balance at the beginning of the
next period and each amount is reported in line 1 of the corresponding column on the
Worksheet F-1 of the next cost reporting period.
4352
WORKSHEET F-2 - STATEMENT OF REVENUES AND OPERATING EXPENSES
This worksheet provides for reporting total revenues and total operating expenses for the
hospice. If total revenues and total expenses reported on this worksheet differ from the total
revenues and total expenses on the hospice financial statements, submit a reconciliation report
with the cost report.
4352.1
Part I - Revenues.--Enter gross revenue amounts for each payor source.
Columns 1 through 3.--Report revenues by the payor type indicated for each column.
Column 4.--Report total revenues for the hospice. For each line, the amount entered in column 4
is the sum of the amounts in columns 1, 2, and 3.
Lines 1 through 5.--For each column 1 through 3, enter the gross patient revenues from sources
as indicated on lines 1, 2, 3, 4, and 5. For column 4, enter the sum of columns 1, 2, and 3.
Line 6.--For each applicable column, enter the sum of lines 1 through 5.
43-42
Rev. 1
08-14
FORM CMS-1984-14
4352.2
Line 7.--For each column 1 through 3, enter the contractual allowances and discounts on patient
accounts. Such allowances and discounts include contractual adjustments, charity discounts,
teaching allowances, policy discounts, administrative adjustments, and other deductions from
revenue. For column 4, enter the sum of columns 1, 2, and 3.
Line 8.--For each column 1 through 3, enter the result of line 6 minus line 7. For column 4, enter
the sum of columns 1, 2, and 3.
Lines 9 through 15.--For each column 1 through 3, enter the amounts from other revenue sources
as indicated. For column 4, enter the sum of columns 1, 2, and 3.
Lines 16 through 25.--For each column 1 through 3, enter the amounts from other revenue
sources not already reported on lines 9 through 15. In column 0, enter a description for each
revenue amount entered on lines 16 through 25. For column 4, enter the sum of columns 1, 2,
and 3.
Line 26.--For each applicable column, enter the sum of lines 8 through 25.
4352.2 Part II - Operating Expenses.--Enter gross operating expenses for the cost reporting
period.
Line 27.--Enter the amount from Worksheet A, column 3, line 100.
Lines 28 through 33.--In column 1, enter the amounts of additional operating expenses not
included in line 27. In column 0, enter a description for each expense amount entered on lines 28
through 33.
Line 34.--In column 2, enter the sum of column 1, lines 28 through 33.
Lines 35 through 39.--In column 1, enter any deductions from operating expenses not accounted
for included in line 27. In column 0, enter a description for each amount entered on lines 35
through 39.
Line 40.--In column 2, enter the sum of lines 35 through 39.
Line 41.--In column 2, enter the sum of lines 27 plus line 34 minus line 40.
Line 42.--In column 2, enter the result of line 26 minus line 41.
Rev. 1
43-43
This page is intentionally left blank.
43-44
Rev. 1
07-15
FORM CMS-1984-14
4395
REPORTING SPECIFICATIONS FOR FORM CMS-1984-14
TABLE OF CONTENTS
Table
Topic
Table 1
Record Specifications
Table 2
Worksheet Indicators
Table 3
List of Data Elements with Worksheet, Line and Column Designations
Table 3A
Worksheets Requiring No Input
Table 3B
Table for Worksheet S-1
Table 3C
Lines That Cannot be Subscripted
Table 5
Cost Center Coding
Table 6
I: Level I Edits
II: Level II Edits
Rev. 2
43-201
4395 (Cont.)
FORM CMS-1984-14
07-15
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 1 – RECORD SPECIFICATIONS
Table 1 specifies the standard record format required for the four types of records in an ECR file.
Type 1 records contain information for identifying the provider, for processing the cost report,
and for vendor validation. Type 2 records contain the line and column labels. Type 3 records
contain data necessary to calculate the hospice cost report. Table 3 provides specifications for the
layout of type 3 records. Type 4 records contain the ECR file encryption coding, records 1, 1.01,
and 1.02.
The medium for electronically submitting the cost report to a contractor is CD, flash drive, or
contractor-approved form such as electronic mail, or secured website. The file must be in IBM
format and the character set must be ASCII. Providers must seek approval from their contractor
regarding the method of submission to ensure that the method of transmission is acceptable. An
ECR file sent electronically must be a compressed or self-extracting file.
The following are requirements for all records:
1. All alpha characters must be in upper case.
2. For micro systems, the end of record indicator must be a carriage return and line feed,
in that sequence.
3. No record may exceed 60 characters.
4. The "Usage" column in all tables specifies the format of each data item as follows:
9 Numeric, greater than or equal to zero.
-9 Numeric, may be either greater than or less than zero.
9(x).9(y) Numeric, greater than zero, with x or fewer significant digits to the left of
the decimal point, a decimal point, and exactly y digits to the right of the
decimal point.
X Character.
Below is an example of a set of type 1 records with a narrative description of their meaning.
1
2
3
4
5
6
123456789012345678901234567890123456789012345678901234567890
1
1
011509201427420152735A99P00120153202014274
1
4
14:30
Record #1:
43-202
This is a cost report file submitted by CCN 011509 for the period from
October 1, 2014 (2014274) through September 30, 2015 (2015273). It is filed
on the Form CMS-1984-14. It is prepared with vendor number A99's PC based
system, version number 1. Position 38 changes with each new test case and/or
re-approval and is an alpha character. Positions 39 and 40 will remain constant
for approvals issued after the first test case. This file is prepared by the hospice
on November 16, 2015 (2015320). The electronic cost report specifications,
dated October 1, 2014 (2014274), are used to prepare this file.
Rev. 2
08-14
FORM CMS-1984-14
4395 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 1 – RECORD SPECIFICATIONS
FILE NAMING CONVENTION
Name each cost report ECR file in the following manner:
HSNNNNNN.YYLC, where
1. HS (Electronic Cost Report) is constant;
2. NNNNNN is the 6 digit CCN;
3. YY is the year in which the provider's cost reporting period ends; and
4. L is a character variable (A through Z) to enable separate identification of files from
hospices with two or more cost reporting periods ending in the same calendar year.
5. C is the number of times this original cost report is being filed.
Name each cost report PI file in the following manner:
PINNNNNN.YYLC, where
1. PI (Print Image) is constant;
2. NNNNNN is the 6 digit CCN;
3. YY is the year in which the provider's cost reporting period ends; and,
4. L is a character variable (A through Z) to enable separate identification of files from
hospices with two or more cost reporting periods ending in the same calendar year.
5. C is the number of times this original cost report is being filed.
RECORD NAME: Type 1 Records - Record Number 1
1.
2.
3.
4.
5.
6.
7.
Record Type
For Future Use
Space
Record Number
Spaces
Hospice CCN Number
Fiscal Year Beginning
Date
8. Fiscal Year Ending
Date
9. MCR Version
10. Vendor Code
11. Vendor Equipment
Rev. 1
Size
1
10
1
1
3
6
7
Usage
X
9
X
X
X
9
9
Loc.
1
2 - 11
12
13
14 - 16
17 - 22
23 - 29
7
9
30 - 36
5
3
9
X
37
38 - 40
1
X
41
Remarks
Constant “1”
Not used
Constant “1”
Field must have 6 numeric characters
YYYYDDD – Julian date; first day
covered by this cost report
YYYYDDD – Julian date; last day
covered by this cost report
Constant “5” (for Form CMS 1984-14)
To be supplied upon approval. Refer to
page 43-201.
P=PC; M=Main Frame
43-203
4395 (Cont.)
FORM CMS-1984-14
08-14
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 1 – RECORD SPECIFICATIONS
RECORD NAME: Type 1 Records - Record Number 1 (Cont.)
Size
3
Usage
X
Loc.
42 - 44
13. Creation Date
7
9
45 - 51
14. ECR Spec. Date
7
9
52 - 58
12. Version Number
Remarks
Version of extract software, e.g.,
001=1st, 002=2nd, etc. or 101=1st,
102=2nd. The version number must be
incremented by 1 with each recompile
and release to client(s).
YYYYDDD – Julian date; date on
which the file was created (extracted
from the cost report)
YYYYDDD – Julian date; date of
electronic cost report specifications
used in producing each file. Valid for
cost reporting periods beginning on or
after 2014274 (10/01/2014).
RECORD NAME: Type 1 Records - Record Numbers 2 through 99
1. Record Type
2. Spaces
3. Record Number
Size
1
10
2
Usage
9
X
9
Loc.
1
2 - 11
12 - 13
4. Spaces
5. ID Information
7
40
X
X
14 - 20
21 - 60
43-204
Remarks
Constant “1”
#2 – Reserved for future use.
#3 – Vendor information; optional
record for use by vendors.
Left
justified in positions 21 through 60.
#4 – The time that the cost report is
created. This is represented in military
time as alpha numeric. Use positions
21 through 25. Example: 2:30PM is
expressed as 14:30.
#5 to #99 – Reserved for future use.
Spaces (optional)
Left justified to position 21.
Rev. 1
07-15
FORM CMS-1984-14
4395 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 1 – RECORD SPECIFICATIONS
RECORD NAME: Type 2 Records for Labels
1. Record Type
2. Worksheet Indicator
3.
4.
5.
6.
7.
8.
Spaces
Line Number
Sub line Number
Column Number
Sub column Number
Cost Center Code
9. Labels/Headings
1. Line Labels
2. Column
Headings:
Statistical
Basis & Code
Size
1
7
Usage
9
X
Loc.
1
2-8
2
3
2
3
2
4
X
9
9
X
9
9
9 - 10
11 - 13
14 - 15
16 - 18
19 - 20
21 - 24
36
10
X
X
25 - 60
21 - 30
Remarks
Constant “2”
Alphanumeric. Refer to Table 2.
Numeric
Numeric
Alphanumeric
Numeric
Numeric. Refer to Table 5 for cost
center coding.
Alphanumeric, left justified.
Alphanumeric, left justified.
The type 2 records contain text that appears on the printed cost report. Of these, there are three
groups: (1) Worksheet A cost center names (labels); (2) column headings for step down entries;
and, (3) other text appearing in various places throughout the cost report. The standard cost
center labels/descriptions are listed below.
Worksheet A cost center labels must be furnished for every cost center with cost data anywhere in
the cost report. The line and sub line numbers for each label must be the same as the line and sub
line numbers of the corresponding cost center on Worksheet A. The columns and sub column
numbers are always set to zero.
Column headings for the General Service cost centers on Worksheets B-1 and B, are supplied
once, consisting of one to three records. The statistical basis shown on Worksheet B-1 is also
reported. The statistical basis consists of one or two records (lines 4 and 5). Statistical basis code
is supplied only to Worksheet B-1 columns and is recorded as line 5 and only for capital cost
centers, columns 1 and 2 and subscripts as applicable. The statistical code must agree with the
statistical basis indicated on lines 4 and 5, i.e., code 1 = square footage, code 2 = dollar value, and
code 3 = all others. Refer to Table 2 for the special worksheet identifier to be used with column
headings and statistical basis and to Table 3 for line and column references.
Rev. 2
43-205
4395 (Cont.)
FORM CMS-1984-14
07-15
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 1 – RECORD SPECIFICATIONS
Use the following type 2 cost center descriptions for Worksheet A standard cost center lines.
Line Description
1
CAP REL COSTS - BLDG &
FIXT
2
CAP REL COSTS - MVBLE
EQUIP
3
EMPLOYEE BENEFITS
DEPARTMENT
4
ADMINISTRATIVE &
GENERAL
5
PLANT OPERATION &
MAINTENANCE
6
LAUNDRY & LINEN SERVICE
7
HOUSEKEEPING
8
DIETARY
9
NURSING ADMINISTRATION
10
ROUTINE MEDICAL SUPPLIES
11
MEDICAL RECORDS
12
STAFF TRANSPORTATION
13
VOLUNTEER SERVICE
COORDINATION
14
PHARMACY
15
PHYSICIAN ADMINISTRATIVE
SERVICES
16
OTHER GENERAL SERVICE
(SPECIFY)
17
PATIENT/RESIDENTIAL CARE
SERVICES
25
INPATIENT CARE CONTRACTED
26
PHYSICIAN SERVICES
27
NURSE PRACTITIONER
28
REGISTERED NURSE
29
LPN/LVN
30
PHYSICAL THERAPY
43-206
Line
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
60
61
62
63
64
65
66
67
68
69
70
71
Description
OCCUPATIONAL THERAPY
SPEECH/LANGUAGE PATHOLOGY
MEDICAL SOCIAL SERVICES
SPIRITUAL COUNSELING
DIETARY COUNSELING
COUNSELING - OTHER
HOSPICE AIDE AND HOMEMAKER
SERVICES
DURABLE MEDICAL
EQUIPMENT/OXYGEN
PATIENT TRANSPORTATION
IMAGING SERVICES
LABS AND DIAGOSTICS
MEDICAL SUPPLIES - NON-ROUTINE
OUTPATIENT SERVICES
PALLIATIVE RADIATION THERAPY
PALLIATIVE CHEMOTHERAPY
OTHER PATIENT CARE SERVICES
(SPECIFY)
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
(SPECIFY)
Rev. 2
07-15
FORM CMS-1984-14
4395 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 1 – RECORD SPECIFICATIONS
Type 2 records for Worksheet B-1, columns 1 through 17, lines 1 through 5, and line 6, for
columns 1 and 2 only (capital cost center columns), are listed below. The numbers running
vertical to line 1 descriptions are the general service cost center line designations.
LINE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
1
CAP REL
CAP REL
EMPLOYEE
ADMINISPLANT
LAUNDRY
HOUSEDIETARY
NURSING
ROUTINE
MEDICAL
STAFF
VOLUNTEER
PHARMACY
PHYSICIAN
OTHER
PATIENT/
Rev. 2
2
BLDG
MVBLE
BENEFITS
TRATIVE &
OP &
& LINEN
KEEPING
3
& FIX
EQUIP
DEPARTMENT
GENERAL
MAINT
4
SQUARE
DOLLAR
GROSS
ACCUM.
SQUARE
IN-FACILSQUARE
IN-FACILDIRECT
PATIENT
PATIENT
ADMINISMEDICAL
RECORDS
TRANSSVC COOR-
TRATION
SUPPLIES
PORTATION
DINATION
HOURS OF
ADMIN
GENERAL
RESIDENT
SVCS
SERVICE
CARE SVCS
PATIENT
SPECIFY
IN-FACIL-
5
6
FEET
1
VALUE
2
SALARIES
COST
FEET
ITY DAYS
FEET
ITY DAYS
NURS. HRS.
DAYS
DAYS
MILEAGE
SERVICE
CHARGES
DAYS
BASIS
ITY DAYS
43-207
4395 (Cont.)
FORM CMS-1984-14
07-15
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 1 – RECORD SPECIFICATIONS
Examples of type 2 records are below. Either zeros or spaces may be used in the line, sub line,
column, and sub column number fields (positions 11 through 20). Spaces are preferred. (See first
two lines of the example.)* Refer to Table 6 for additional cost center code requirements.
Examples:
Worksheet A line labels with embedded cost center codes:
* 2A000000
1
0100CAP REL COSTS – BLDS & FIXT
* 2A0000000000200000000200CAP REL COSTS – MVBLE EQUIP
2A000000
4
0400ADMINISTRATIVE & GENERAL
2A000000
10
1000ROUTINE MEDICAL SUPPLIES
2A000000
11
1100MEDICAL RECORDS
Examples of column headings for Worksheet B and B-1, statistical bases used in cost allocation
on Worksheet B-1, and statistical codes used for Worksheet B-1 (line 6) are displayed below.
Examples of column headings:
2B10000*
2B10000*
2B10000*
2B10000*
2B10000*
2B10000*
43-208
1
2
3
4
5
6
1
1
1
1
1
1
CAP REL
BLDG
& FIX
(SQUARE
FEET)
1
Rev. 2
08-14
FORM CMS-1984-14
4395 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 1 – RECORD SPECIFICATIONS
RECORD NAME: Type 3 Records for Non-label Data
1.
2.
3.
4.
5.
6.
7.
8.
Record Type
Worksheet Indicator
Spaces
Line Number
Sub line Number
Column Number
Sub column Number
Field Data
a) Alpha Data
Spaces
b) Numeric Data
Rev. 1
Size
1
7
2
3
2
3
2
Usage
9
X
X
9
9
X
9
36
X
4
X
16
9
Loc.
1
2-8
9 - 10
11 - 13
14 - 15
16 - 18
19 - 20
Remarks
Constant “3”
Numeric. Refer to Table 2.
Numeric
Numeric
Alphanumeric
Numeric
21 - 56 Left justified. (Y or N for yes/no answers;
dates must use mm/dd/yyyy format –
slashes, no hyphens). Refer to Table 6 for
additional requirements for alpha data.
57 - 60 Spaces (optional).
21 - 36 Right justified. May contain embedded
decimal point.
Leading zeroes are
suppressed; trailing zeroes to the right of
the decimal point are not. (See example
below.) Positive values are presumed; no
“+” signs are allowed. Use leading minus
to specify negative values.
Express
percentages as decimal equivalents, i.e.,
8.75% is expressed as .087500. All
records with zero values are dropped.
Refer to Table 6 for additional
requirements regarding numeric data.
43-209
4395 (Cont.)
FORM CMS-1984-14
08-14
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 1 – RECORD SPECIFICATIONS
A sample of type 3 records and a number line for reference are below.
1
2
3
4
5
6
123456789012345678901234567890123456789012345678901234567890
3A000000 4 1
141353
3A000000 11 1
32061
3A000000 60 2
2047
3A000000 67 2
1650
3A000000 70 2
13726
The line numbers and LOC worksheet indicators are numeric. In several places throughout the
cost report (see list below), the line numbers and LOC worksheet indicators themselves are data.
The placement of the line and sub line numbers, and LOC worksheet indicators as data must be
uniform.
Worksheet A-6, columns 3, 6 and 8
Worksheet A-8, columns 4 and 5
Worksheet A-8-1, Part I, columns 1 and 7
43-210
Rev. 1
07-15
FORM CMS-1984-14
4395 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 1 – RECORD SPECIFICATIONS
Examples of records (*) with a Worksheet A line number and LOC worksheet indicator as data
and a number line for reference are listed below.
1
2
3
4
5
6
123456789012345678901234567890123456789012345678901234567890
3A6000E0
3A6000E0
* 3A6000E0
3A6000E0
* 3A6000E0
3A6000E0
3A6000E0
6
6
6
6
6
6
6
0
1
3
4
6
7
8
CONTRACTED SERVICES
E
25.00
27723
4.00
27723
4
RECORD NAME: TYPE "3" RECORDS
1
2
3
4
5
6
123456789012345678901234567890123456789012345678901234567890
3A800000
3A800000
3A800000
* 3A800000
* 3A800000
3A810001
3A810001
3A810001
3A810001
3A810001
11
11
11
11
11
1
1
1
1
1
1
2
3
4
5
1
3
4
5
7
PATIENT TRANSPORTATION
A
-9705
39.00
1
37.00
AIDE SERVICES
23789
36702
2
RECORD NAME: TYPE 4 RECORDS
File Encryption and Date and Time Stamp
This type 4 record consists of 3 records: 1, 1.01, and 1.02. These records, created at the time the
ECR file is created and saved to an electronic medium, are used to verify the integrity of the file.
Rev. 2
43-211
4395 (Cont.)
FORM CMS-1984-14
07-15
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 2 – WORKSHEET INDICATORS
This table contains the worksheet indicators that are used for electronic cost reporting. A
worksheet indicator is provided only for those worksheets from which data are to be provided.
The worksheet indicator consists of seven characters in positions 2 through 8 of the record
identifier. The first two characters of the worksheet indicator (positions 2 and 3 of the record
identifier) always show the worksheet. The third character of the worksheet indicator (position 4
of the record identifier) is used as part of the worksheet, e.g., A81. The fourth character of the
worksheet indicator (position 5 of the record identifier) is not used. Except for Worksheet A-6 (to
handle multiple worksheets), the fifth and sixth characters of the worksheet indicator (positions 6
and 7 of the record identifier) identify worksheets required by a Federal program
(18 = title XVIII, 05 = title V, or 19 = title XIX) or worksheets required for the facility
(00 = Universal). The seventh character of the worksheet indicator (position 8 of the record
identifier) represents the worksheet part.
Worksheets That Apply to the Hospice Cost Report
Worksheet
S, Part I
S, Part II
S-1, Parts I, II, and III
S-2
A
A-1
A-2
A-3
A-4
A-6
Worksheet
Indicator
S000001
S000002
S100000 (a)
S200000
A000000
A100000
A200000
A300000
A400000
A600?A0 (b)
Worksheet
A-8
A-8-1, Part I
A-8-1, Part II
B-1 (for use in column headings)
B
B-1
C
F
F-1
F-2, Parts I and II
Worksheet
Indicator
A800000
A810001
A810002
B10000*
B000000
B100000
C000000
F000000
F100000
F200000 (a)
(a) Worksheets with Multiple Parts Using Identical Worksheet Indicator: While this worksheet
has several parts, the lines are numbered sequentially. This worksheet identifier is used with
all lines from this worksheet regardless of the worksheet part. This differs from the Table 3
presentation which still identifies each worksheet and part as they appear on the printed cost
report. This affects Worksheet S-1 and Worksheet F-2.
(b) Worksheet A-6: For Worksheet A-6, include in the worksheet identifier the reclassification
code as the 5th and 6th digits (6th and 7th in the ECR file). For example, 3A6000A0 or
3A6000B0, 3A6000C0, 3A600AA0, 3A600AB0, or 3A600AC0.
43-212
Rev. 2
07-15
FORM CMS-1984-14
4395 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 3 – LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
INTRODUCTION
This table identifies those data elements necessary to calculate a hospice cost report. It also
identifies some figures from a completed cost report. These calculated fields (e.g., Worksheet B,
column 18) are needed to verify the mathematical accuracy of the raw data elements and to isolate
differences between the file submitted by the hospice and the report produced by the contractor.
Where an adjustment is made, the record must be present in the electronic data file. For
explanations of the adjustment(s) required, refer to the cost report instructions.
Table 3 "Usage" column specifies the format of each data item as follows:
9
-9
Numeric, greater than or equal to zero.
Numeric, may be either greater than or less than zero.
9(x).9(y)
Numeric, greater than zero, with x or fewer significant digits to the left of the
decimal point, a decimal point, and exactly y digits to the right of the decimal point.
X Character.
Consistency in line numbering (and column numbering for general service cost centers) for each
cost center is essential. The sequence of some cost centers does change among worksheets.
Table 3 refers to the data elements needed from a standard cost report. When a standard line is
subscripted, the subscripted lines must be numbered sequentially with the first sub line number
displayed as "01" or "1" in field locations 14 and 15. It is unacceptable to format in series of 10,
20, or skip sub line numbers (i.e., 01, 03, except for skipping sub line numbers for prior year cost
center(s) deleted in the current period or initially created cost centers no longer in existence after
cost finding). Exceptions are specified in this manual. For "Other (specify)" lines, i.e. any other
nonstandard cost center lines, all subscripted lines should be in sequence and consecutively
numbered beginning with subscripted sub line "01". Automated systems should reorder these
numbers where the provider skips or deletes a line number in the series.
Drop all records with zero values from the file. Any record absent from a file is treated as if it
were zero.
All numeric values are presumed positive. Leading minus signs may only appear in data with
values less than zero which are specified in Table 3 with a usage of "-9".
Italic script within this table denotes adjustments which are not displayed in the print image or
hard copy of the cost report, but are contained in the ECR file.
Rev. 2
43-213
4395 (Cont.)
FORM CMS-1984-14
07-15
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 3 – LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
WORKSHEET S
Description
Line(s)
Column(s)
Field Size
Usage
1
2
3
4
1
1
1
1
1
1
1
1
X
X
9
X
5
1
1
X
6
7
8
9
11
1
1
1
1
1
10
5
1
1
1
X
X
X
X
X
Line(s)
Column(s)
Field Size
Usage
1
2
2
3
3
3
4
1
1
2
1
2
3
1
36
36
9
36
2
10
36
X
X
X
X
X
X
X
Part I: Cost Report Status
Provider Use Only
Electronic filed cost report
Manually submitted cost report
Amended report
Medicare Utilization
Contractor Use Only
Cost Report Status
Enter the cost report status code: 1 for as
submitted, or 5 amended.
Date received (mm/dd/yyyy)
Contractor Number
First cost report for this Provider CCN
Last cost report for this Provider CCN
Enter contractor’s vendor code (ADR)
WORKSHEET S-1
Description
Part I: Identification Data
Hospice name
Street address
P.O. Box
City
State
ZIP Code
County
43-214
Rev. 2
08-14
FORM CMS-1984-14
4395 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 3 – LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
WORKSHEET S-1 (Cont.)
Description
Provider CCN
Date hospice began operation (mm/dd/yyyy)
Certification date (mm/dd/yyyy) for title XVIII
Certification date (mm/dd/yyyy) for title XIX
Cost
reporting
period
beginning
date
(mm/dd/yyyy)
Cost reporting period ending date (mm/dd/yyyy)
Is this facility legally required to carry
malpractice insurance? (Y/N)
Enter 1 if the malpractice insurance is a claimsmade policy. Enter 2 if the malpractice
insurance is an occurrence policy.
Amounts of malpractice premiums, paid losses,
and self-insurance
Premiums
Paid Losses
Self-Insurance
Are malpractice premiums and paid losses
reported in a cost center other than A & G?
(Y/N)
If yes, submit supporting schedule
listing cost centers and amounts contained
therein.
Are home office costs (as defined in CMS
Pub. 15-1 §2150ff)) claimed? (Y/N) If yes,
enter the home office number in column 2. (see
instructions)
Home Office Number
Home Office Name
Street Address
P.O. Box
Rev. 1
Line(s)
Column(s) Field Size Usage
5
6
7
7
8
1
1
1
2
1
6
10
10
10
10
X
X
X
X
X
8
9
2
1
10
1
X
X
10
1
1
X
11
11
11
12
1
2
3
1
11
11
11
1
9
9
9
X
13
1
1
X
13
14
15
15
2
1
1
2
6
36
36
9
X
X
X
X
43-215
4395 (Cont.)
FORM CMS-1984-14
08-14
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 3 – LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
WORKSHEET S-1 (Cont.)
Description
Line(s)
Column(s)
Field Size
Usage
16
16
16
17
18
19
20
1
2
3
1
1
1
1
36
2
10
36
5
2
2
X
X
X
X
X
X
X
21
1
5
X
Part II – Statistical Data
Continuous Home Care
Routine Home Care
Inpatient Respite Care
General Inpatient Care
Total Hospice days
30
31
32
33
34
1-4
1-4
1-4
1-4
1-4
11
11
11
11
11
9
9
9
9
9
Part III – Contracted Statistical Data
Inpatient Respite care
General Inpatient Care
40
41
1-4
1-4
11
11
9
9
City
State
ZIP Code
Home office contractor name
Home office contractor number
Type of control (see Table 3B)
Number of CBSAs where Medicare covered
services were provided during the cost
reporting period
List each CBSA code where Medicare
covered hospice services were provided
during the cost reporting period (line 21
contains the first code)
43-216
Rev. 1
07-15
FORM CMS-1984-14
4395 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 3 – LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
WORKSHEET S-2
Description
Has the provider changed ownership immediately
prior to the beginning of the cost reporting period?
(Y/N) (see instructions)
If yes, enter the date of the change in column 2.
(mm/dd/yyyy)
Has the provider terminated participation in the
Medicare program? (Y/N)
If yes, enter in column 2 the termination date.
(mm/dd/yyyy)
If yes, enter in column 3 “V” for voluntary or “I” for
involuntary.
Is the provider involved in business transactions,
including management contracts, with individuals
or entities that were related to the provider or its
officers, medical staff, management personnel, or
members of the board of directors through
ownership, control, or family and other similar
relationships? (Y/N) (see instructions)
Were the financial statements prepared by a certified
public accountant? (Y/N)
If yes, enter in column 2 “A” for audited, “C” for
compiled, or “R” for reviewed.
Submit a complete copy of financial statements or
enter date available in column 3. (see instructions)
Are the cost report total expenses and total revenues
different from those on the filed financial
statements? (Y/N) If yes, submit reconciliation.
Was the cost report prepared using the PS&R report
only? (Y/N)
If yes, enter in column 2 the paid-through date of the
PS&R report used to prepare the cost report. (see
instructions)
Rev. 2
Line(s) Column(s)
Field Size
Usage
1
1
1
X
1
2
10
X
2
1
1
X
2
2
10
X
2
3
1
X
3
1
1
X
4
1
1
X
4
2
1
X
4
3
10
X
5
1
1
X
6
1
1
X
6
2
10
X
43-217
4395 (Cont.)
FORM CMS-1984-14
07-15
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 3 – LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
WORKSHEET S-2 (Cont.)
Description
Was the cost report prepared using the PS&R
report for totals and the provider’s records
for allocation? (Y/N)
If yes, enter in column 2 the paid-through date
of the PS&R report. (see instructions)
If line 6 or 7 is yes, were adjustments made to
the PS&R report data for additional claims
that have been billed but are not included on
the PS&R report used to file the cost report?
(Y/N). If yes, see instructions.
If line 6 or 7 is yes, were adjustments made to
the PS&R report data for corrections of
other PS&R report information? (Y/N) If
yes, see instructions.
If line 6 or 7 is yes, were adjustments made to
the PS&R report data for Other? (Y/N)
If yes, describe the other adjustments.
Was the cost report prepared only using the
provider’s records? (Y/N)
If yes, see
instructions.
Cost Report Preparer Contact Information
First Name
Last Name
Title
Employer
Telephone Number
Email Address
43-218
Line(s)
Column(s)
Field Size
Usage
7
1
1
X
7
2
10
X
8
1
1
X
9
1
1
X
10
1
1
X
10
11
0
1
36
1
X
X
12
12
12
13
14
14
1
2
3
1
1
2
36
36
36
36
36
36
X
X
X
X
X
X
Rev. 2
07-15
FORM CMS-1984-14
4395 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 3 – LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
WORKSHEET A
Description
Salaries
Other Costs
Reclassifications
Adjustments
Net Expense for Allocation
Total
Line(s)
Column(s)
Field Size
Usage
3 - 16, 25 - 39,
40 - 46, 60 - 71
1 - 16, 25 - 39,
40 - 46, 60 - 71
1 - 16, 25 - 39,
40 - 46, 60 - 71
1 - 16, 25 - 39,
40 - 46, 60 - 71
1 - 16, 25 - 39,
40 - 46, 60 - 71
100
1
11
-9
2
11
-9
4
11
-9
6
11
-9
7
11
-9
1-7
11
9
WORKSHEETS A-1 and A-2
Description
Line(s)
Column(s)
Field Size
Usage
Direct Patient Care Service Cost Centers
Total
26 - 46
100
1, 2, 4, 6
7
11
11
-9
9
Line(s)
Column(s)
Field Size
Usage
25 - 37, 39 - 46
100
1, 2, 4, 6
7
11
11
-9
9
WORKSHEETS A-3 and A-4
Description
Direct Patient Care Service Cost Centers
Total
Rev. 2
43-219
4395 (Cont.)
FORM CMS-1984-14
07-15
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 3 – LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
WORKSHEETS A-6
Description
For each expense reclassification
Explanation
Code
Increases:
Adjustment A line number
Reclassification amount
Decreases:
Worksheet A line number
Reclassification amount
LOC WS indicator
Total
Line(s)
Column(s)
Field Size
Usage
1 - 99
1 - 99
0
1
36
2
X
X
1 - 99
1 - 99
3
4, 4.01
6
11
9(3).99
9
1 - 99
1 - 99
1 - 99
100
6
7, 7.01
8
4, 4.01, 7, 7.01
6
11
1
11
9(3).99
9
X
9
WORKSHEETS A-8
Description
Description of adjustment
Basis (A or B)*
Amount*
Worksheet A line number +
LOC WS indicator
Total
Line(s)
Column(s)
Field Size
Usage
11 - 49
1 - 2, 7 - 9, 11 - 49
1 - 49
1 - 2, 6, 7, 11 - 49
1 - 2, 6, 7, 11 - 49
50
0
1
2
4
5
2
36
1
11
6
1
11
X
X
-9
9(3).99
X
-9
*These include subscripts of lines 11 through 49, requiring records for columns 1 and 2. These
subscripts should occur based on Worksheet A layout.
+Do not include preprinted lines 4, 5, 8, 9, 10.
43-220
Rev. 2
07-15
FORM CMS-1984-14
4395 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 3 – LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
WORKSHEET A-8-1
Description
Part I – Costs incurred and adjustments required
as a result of transactions with a related
organizations or claimed home office costs:
Worksheet A line number
Expense item (s)
Amount allowable in cost
Amount included in Worksheet A
LOC WS indicator
Total
Part II – For each related organization:
Type of interrelationship (A through G)
If type is G, description of relationship must be
included.
Name of individual or partnership with interest
in provider and related organization(s)
Percent of ownership of provider
Name of related organization
Percent of ownership of related organization
Type of business
Line(s)
Column(s)
Field Size
Usage
1-9
1-9
1-9
1-9
1-9
10
1
3
4
5
7
4, 5
6
36
11
11
1
11
9(3).99
X
9
9
X
-9
1 - 10
1 - 10
1
0
1
36
X
X
1 - 10
2
36
X
1 - 10
1 - 10
1 - 10
1 - 10
3
4
5
6
6
36
6
36
9(3).99
X
9(3).99
X
WORKSHEET B-1 Headings*
Description
Line(s)
Column(s)
Field Size
Usage
Column heading (cost center name)
Statistical basis
1 - 3*
4, 5*
1 - 17
1 - 17
10
10
X
X
Rev. 2
43-221
4395 (Cont.)
FORM CMS-1984-14
07-15
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 3 – LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
WORKSHEET B
Description
Costs after cost finding by department
Total costs after cost finding
Line(s)
Column(s)
Field Size
Usage
50 - 53,
60 - 71, 100
101
18
11
-9
18
11
9
*Refer to Table 1 for specifications and Table 2 for the worksheet identified for column
headings. There may be up to five type 2 records (3 for cost center name and 2 for the statistical
basis) for each column. However, for any column which has less than five type 2 entries, blank
records or the word “blank” is not required to maximize each column record count.
WORKSHEET B-1
Description
For each cost allocation using accumulated
costs as the statistic, include a record
containing X.
All cost allocation statistics
Reconciliation
Total cost to be allocated
Line(s)
Column(s)
Field Size
Usage
0
4 - 17
1
X
1 - 17, 50 - 53,
60 - 71
4 - 17, 50 - 53,
60 - 71
101
1 - 17*
11
9
4A - 17A
11
-9
1 - 17+
11
9
*In each column using accumulated cost as the statistical basis for allocating costs, identify each
cost center which is to receive no allocation with a negative 1 (-1) placed in the accumulated cost
column. Providers may elect to indicate total accumulated cost as a negative amount in the
reconciliation column. However, entries must never appear in both the reconciliation column
and the accumulated column simultaneously on the same line. For those cost centers that are to
receive partial allocation of costs, provide only the cost to be excluded from the statistics as a
negative amount on the appropriate line in the reconciliation column. If A&G costs are reported
as fragmented cost centers, line 4 must be deleted and subscripts of line 4 must be used. A&G
may not appear on line 4 in addition to fragmented A&G cost centers on subscripts of line 4.
+
Include any column which uses accumulated cost as its basis for allocation.
43-222
Rev. 2
07-15
FORM CMS-1984-14
4395 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 3 – LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
WORKSHEET F
Description
Balance sheet accounts
Total Assets
Total Liabilities and Fund Balance
Line(s)
Column(s)
Field Size
Usage
1 - 9, 11 - 25,
27 - 30, 33 - 39,
41 - 45, 48
32
49
1
11
-9
1
1
11
11
-9
-9
Note: Accumulated Depreciation lines will always be positive numbers unless otherwise
specified.
WORKSHEET F-1
Description
Line(s)
Column(s)
Field Size
Usage
For hospices using fund accounting: Text
as needed for blank lines
Beginning fund balances
Additions and reductions to beginning
fund balances
4 - 9,
12 - 17
1
4 - 9,
12 - 17
0
36
X
1-4
1-4
11
11
-9
-9
Rev. 2
43-223
4395 (Cont.)
FORM CMS-1984-14
07-15
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 3 – LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
WORKSHEET F-2
Description
Part I
Continuous Home Care
Routine Home Care
Inpatient Respite Care
General Inpatient Care
Drug copay/coinsurance
Total gross patient revenue (sum of lines 1
through 5)
Less: Contractual allowances and discounts
Net patient revenue (line 6 minutes line 7)
Hospice physician services
Room and board
Palliative consults/Other phys. Services
Donations/Charitable contributions
Rebates/refunds of expenses
Income from investments
Governmental appropriations
Other (specify)
Other (specify)
Total Revenues (sum of lines 8 through 25)
Part II
Operating Expenses (per Worksheet A,
column 3, line 100)
Add (specify)
Add (specify)
Total additions (sum of lines 28 through 33)
Deduct (specify
Deduct (specify)
Total deductions (sum of lines 35 through 39)
Total operating expenses (sum of lines 27 and
34, minus line 40)
Net income /(loss) for the period
43-224
Line(s)
Column(s)
Field Size
Usage
1
2
3
4
5
6
1-4
1-4
1-4
1-4
1-4
1-4
11
11
11
11
11
11
9
9
9
9
9
9
7
8
9
10
11
12
13
14
15
16 - 25
16 - 25
26
1-4
1-4
1-4
2-4
3-4
3-4
3-4
3-4
3-4
0
3-4
1-4
11
11
11
11
11
11
11
11
11
36
11
11
9
9
9
9
9
9
9
9
9
X
9
9
27
2
11
9
28 - 33
28 - 33
34
35 - 39
35 - 39
40
41
0
1
2
0
1
2
2
36
11
11
36
11
11
11
X
9
9
X
9
9
9
42
2
11
9
Rev. 2
07-15
FORM CMS-1984-14
4395 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 3A – WORKSHEETS REQUIRING NO INPUT
No input required for Worksheet C
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 3B – TABLE FOR WORKSHEET S-1
Type of Control
1 = Voluntary, Nonprofit, Church
2 = Voluntary Nonprofit, Other
3 = Proprietary, Individual
4 = Proprietary, Corporation
5 = Proprietary, Partnership
6 = Proprietary, Other
7 = Governmental, Federal
8 = Governmental, City-County
9 = Governmental, County
10 = Governmental, State
11 = Governmental, Hospital District
12 = Governmental, City
13 = Governmental, Other
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 3C – LINES THAT CANNOT BE SUBSCRIPTED
(BEYOND THOSE PREPRINTED)
Worksheet S-1, lines 1 through 20,
30 through 34, 40 through 41
Worksheet S-2
Worksheet A, lines 17, 100
Worksheet A-1, line 25
Worksheet A-2, line 25
Worksheet A-3, line 38
Worksheet A-4, line 38
Worksheet A-6
Worksheet A-8, lines 1 through 10, 50
Rev. 2
Worksheet A-8-1, Part I, lines 1 through 8
Worksheet A-8-1, Part II, lines 1 through 10
Worksheet B, lines 50 through 53, 100
Worksheet B-1, lines 50 through 53, 100
Worksheet C
Worksheet F
Worksheet F -1, lines 1, 3, 10, 11,
18 through 19
Worksheet F-2, Part I, lines 1 through 15, 26
Worksheet F-2, Part II
43-225
4395 (Cont.)
FORM CMS-1984-14
07-15
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 5 – COST CENTER CODING
INSTRUCTIONS FOR PROGRAMMERS
Cost center coding is required because there are thousands of unique cost center names in use by
providers. Many of these names are exclusive to the reporting provider and give no hint as to the
actual function being reported. By using codes to standardize meanings, practical data analysis
becomes possible. The methodology to accomplish this must be rigidly controlled to enhance
accuracy.
For any added cost center names (the preprinted cost center labels must be pre-coded), the
preparer must be presented with the allowable choices for that line or range of lines from the lists
of standard and nonstandard descriptions. They will then select a description that best matches
their added label. The code associated with the matching description, including increments due to
choosing the same description more than once, will then be appended to the user's label by the
software.
Additional guidelines are:
•
•
•
•
•
•
•
•
43-226
Any pre-existing codes for the line must not be allowed to carry over.
All "Other . . ." lines must not be pre-coded.
The order of choice is standard first, followed by specific nonstandard, and lastly, the
nonstandard
"Other . . ." cost centers.
When the nonstandard "Other . . ." is chosen, the preparer must be prompted with "Is this
the most appropriate choice?" and offered a chance to answer yes or to select another
description.
The cost center coding process must be able to be edited for purposes of making
corrections.
A separate list showing the preparer's added cost center name on the left with the chosen
standard or nonstandard description and code on the right must be printed for review.
The number of times a description can be selected on a given report must be displayed on
the screen next to the description and this number must decrease with each usage to
show the remaining number available. The number of times a description can be
selected is shown on the standard and nonstandard cost center tables.
Standard cost center lines, descriptions, and codes are not to be changed. The acceptable
format for these are displayed in the STANDARD COST CENTER DESCRIPTIONS
AND CODES listed on page 43-229. The proper line number is the first two digits of the
cost center code. Change all "Other" nonstandard lines to the appropriate cost center
name.
Rev. 2
07-15
FORM CMS-1984-14
4395 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 5 – COST CENTER CODING
INSTRUCTIONS FOR PREPARERS
Coding of Cost Center Labels
Cost center coding is a methodology for standardizing the meaning of cost center labels as used
by hospices on the Medicare cost report. The use of this coding methodology allows the hospice
to use their labels for cost centers that have meaning within the institution.
The four digit codes are required and must be associated with each cost center label/description.
The codes provide standardized meaning for data analysis. The preparer must code all added cost
center labels/descriptions. Standard cost center labels/descriptions are automatically coded by
CMS approved cost report software.
Additional cost center descriptions have been identified through analysis of provider labels. The
meanings of these additional descriptions were sufficiently different when compared to the
standard labels to warrant their use. These additional descriptions are hereafter referred to as the
nonstandard labels. Included with the nonstandard descriptions are "Other . . ." designations to
provide for situations where no match in meaning can be found. Refer to Worksheet A, lines 16,
46 and 71. Both the standard and nonstandard cost center descriptions, along with their cost
center codes, are shown on Table 5. The "USE" column on that table indicates the number of
times that a given code can be used on one cost report. Compare your added cost center
labels/descriptions to the standard and nonstandard table and select the appropriate cost center
code. CMS approved software provides an automated process for selecting an appropriate code to
properly match with your added cost center label/description.
Rev. 2
43-227
4395 (Cont.)
FORM CMS-1984-14
07-15
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 5 – COST CENTER CODING
Additional Guidelines
Categories
You must make your selection from the proper category such as general service descriptions for
general service cost center lines, nonreimbursable descriptions for nonreimbursable cost center
lines, etc.
Cost Center Coding and Line Restrictions
Cost center codes may only be used in designated lines in accordance with the classification of the
cost center(s), i.e., lines 1 through 17, may only contain cost center codes within the general
service cost center category of both standard and nonstandard coding. For example, in the general
service cost center category for Plant Operation & Maintenance cost, line 5 and subscripts must
contain cost center codes of 0500 through 0519 and nonstandard cost center codes. This logic
must hold true for all other cost center categories, i.e., direct patient care services and nonreimbursable cost centers.
43-228
Rev. 2
07-15
FORM CMS-1984-14
4395 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 5 – COST CENTER CODING
TABLE 5 – STANDARD COST CENTER DESCRIPTIONS AND CODES
CODE
GENERAL SERVICE
COST CENTERS
Cap Rel Costs-Bldg & Fixt
Cap Rel Costs-Mvble Equip
Employee Benefits
Department
Administrative & General
Plant Operation &
Maintenance
Laundry & Linen Service
Housekeeping
Dietary
Nursing Administration
Routine Medical Supplies
Medical Records
Staff Transportation
Volunteer Service
Coordination
Pharmacy
Physician Administrative
Services
Patient/Residential Care
Services
DIRECT PATIENT CARE
SERVICE COST CENTERS
Inpatient Care-Contracted
Physician Services
Nurse Practitioner
Registered Nurse
LPN/LVN
Physical Therapy
Occupational Therapy
Speech/Language Pathology
Rev. 2
USE
0100
0200
0300
(20)
(20)
(20)
0400
0500
(01)
(20)
0600
0700
0800
0900
1000
1100
1200
1300
(20)
(20)
(20)
(20)
(20)
(20)
(20)
(20)
1400
1500
(20)
(20)
1700
(01)
2500
2600
2700
2800
2900
3000
3100
3200
(01)
(20)
(20)
(20)
(20)
(20)
(20)
(20)
CODE
DIRECT PATIENT CARE
SERVICE COST CENTERS (Cont.)
Medical Social Services
3300
Spiritual Counseling
3400
Dietary Counseling
3500
Counseling-Other
3600
Hospice Aide and
3700
Homemaker Services
Durable Medical
3800
Equipment/Oxygen
Patient Transportation
3900
Imaging Services
4000
Labs and Diagnostics
4100
Medical Supplies - Non4200
Routine
Outpatient Services
4300
Palliative Radiation Therapy
4400
Palliative Chemotherapy
4500
NONREIMBURSABLE
COST CENTERS
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
USE
(20)
(20)
(20)
(20)
(20)
(01)
(20)
(20)
(20)
(20)
(20)
(20)
(20)
6000
6100
6200
6300
(20)
(20)
(20)
(20)
6400
6500
6600
6700
6800
6900
7000
(20)
(20)
(20)
(20)
(20)
(20)
(20)
43-229
4395 (Cont.)
FORM CMS-1984-14
07-15
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 5 – COST CENTER CODING
TABLE 5 – NONSTANDARD COST CENTER DESCRIPTIONS AND CODES
43-230
CODE
USE
GENERAL SERVICE COST CENTERS
Administrative & General Other
Other General Service (specify)
0450
1600
(10)
(20)
DIRECT PATIENT CARE SERVICE COST CENTERS
Other Patient Care Services (specify)
4600
(20)
NONREIMBURSABLE COST CENTERS
Other Nonreimbursable (specify)
7100
(20)
Rev. 2
08-14
FORM CMS-1984-14
4395 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 6 – EDITS
Medicare cost reports submitted electronically must meet a variety of edits. These include
mathematical accuracy edits, certain minimum file requirements, and other data edits. Any
vendor software which produces an electronic cost report file for Medicare hospices must
automate all of these edits. Failure to properly implement these edits may result in the suspension
of a vendor's system certification until corrective action is taken. The vendor's software should
provide meaningful error messages to notify the hospice of the cause of every exception. The edit
message generated by the vendor systems must contain the related 4 digit and 1 alpha character,
where indicated, reject/edit code specified below. Any file submitted by a provider containing a
Level I edit will be rejected by the contractors. Notification must be made to CMS for any
exceptions.
The edits are applied at two levels. Level I edits (1000 series reject codes) test the format of the
data to identify error conditions that must be corrected or they will result in a cost report rejection.
These edits also test for critical data elements specified in Table 3. Vendor programs must
prevent hospices from generating an electronic cost report (ECR) file when the cost report
violates any Level 1 edits. Level II edits (2000 series edit codes) identify potential
inconsistencies and missing data items. These items should be resolved at the hospice site and
supporting documentation (such as worksheets or data) should be submitted with the cost report.
The vendor requirements (above) and the edits (below) reduce both contractor processing time
and unnecessary rejections. Vendors must develop their programs to prevent their client hospices
from generating an ECR file where Level I edit conditions exist. In addition, ample warnings
should be given to the hospice where Level II edit conditions are violated.
Level I edit conditions are to be applied against title XVIII services only. However, any
inconsistencies or omissions that would cause a Level I condition for non-title XVIII services
must be resolved prior to acceptance of the cost report. [10/01/2014b]
Note: The date in brackets [ ] at the end of each edit indicates the effective date of the edit. A
date without an alpha suffix, such as [10/01/2014], indicates the edit is effective for cost reporting
periods ending on or after the date in brackets. A date followed by a "b," such as [10/01/2014b],
indicates the edit is effective for cost reporting periods beginning on or after the date in brackets.
A date followed by an "s," such as [10/01/2014s], indicates the edit is effective for services
rendered on or after the date in brackets.
Rev. 1
43-231
4395 (Cont.)
FORM CMS-1984-14
08-14
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 6 – EDITS
I. Level I Edits (Minimum File Requirements)
Edit
Condition
1000
The first digit of every record must be 1, 2, 3, or 4 (encryption code only).
[10/01/2014b]
1005
No record may exceed 60 characters.[10/01/2014b]
1010
All alpha characters must be in upper case, exclusive of the vendor information, type 1
record, record number 3 and the encryption code, type 4 record, record numbers 1,
1.01, and 1.02. [10/01/2014b]
1015
For micro systems, the end of the record indicator must be a carriage return and line
feed, in that sequence. [10/01/2014b]
1020
The hospice provider number (record #1, positions 17-22) must be valid and numeric.
[10/01/2014b]
1025
All calendar format dates must be edited for 10 character format, e.g. 10/01/2014
(MM/DD/YYYY). [10/01/2014b]
1030
All dates (record #1, positions 23 through 29, 30 through 36, 45 through 51, and 52
through 58) must be in Julian format and a possible date. [10/01/2014b]
1035
The fiscal year beginning date (record #1, positions 23 through 29) must be less than
the fiscal year ending date (record #1, positions 30 through 36). [10/01/2014b]
1036
The fiscal year ending date (record #1, positions 30 through 36) must be 28 days
greater than the fiscal year beginning date (record #1, positions 23 through 29) and the
fiscal year ending date (record #1, positions 30 through 36) must be less than 458 days
greater than the fiscal year beginning date (record #1, positions 23 through 29).
[10/01/2014b]
1040
The vendor code (record #1, positions 38 through 40) must be a valid code.
[10/01/2014b]
1045
The type 1 record #1 must be correct and the first record in the file. [10/01/2014b]
43-232
Rev. 1
07-15
FORM CMS-1984-14
4395 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 6 – EDITS
I. Level I Edits (Minimum File Requirements – Cont.)
Edit
1047
Condition
The following standard cost centers listed below must be reported on the lines as
indicated and the corresponding cost center codes may only appear on the lines as
indicated. No other cost center codes may be placed on these lines or subscripts of
these lines. [10/01/2014b]
Cost Center
Cap Rel Costs-Bldg & Fixt
Cap Rel Costs-Mvble Equip
Employee Benefits
Administrative & General
Plant Operation & Maintenance
Laundry & Linen Service
Housekeeping
Dietary
Nursing Administration
Routine Medical Supplies
Medical Records
Staff Transportation
Volunteer Service Coordination
Pharmacy
Physician Administrative Services
Patient/Residential Care Services
Inpatient Care-Contracted
Physician Services
Nurse Practitioner
Registered Nurse
LPN/LVN
Physical Therapy
Occupational Therapy
Speech/Language Pathology
Medical Social Services
Spiritual Counseling
Dietary Counseling
Rev. 2
Line
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
17
25
26
27
28
29
30
31
32
33
34
35
Code
0100 - 0119
0200 - 0219
0300 - 0319
0400
0500 - 0519
0600 - 0619
0700 - 0719
0800 - 0819
0900 - 0919
1000 - 1019
1100 - 1119
1200 - 1219
1300 - 1319
1400 - 1419
1500 - 1519
1700
2500
2600 - 2619
2700 - 2719
2800 - 2819
2900 - 2919
3000 - 3019
3100 - 3119
3200 - 3219
3300 - 3319
3400 - 3419
3500 - 3519
43-233
4395 (Cont.)
FORM CMS-1984-14
07-15
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 6 – EDITS
I. Level I Edits (Minimum File Requirements – Cont.)
Edit
Condition
1047
(Cont.)
Cost Center
Counseling - Other
Hospice Aid and Homemaker Services
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies-Non-Routine
Outpatient Services
Palliative Radiation Therapy
Palliative Chemotherapy
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
43-234
Line
36
37
38
39
40
41
42
43
44
45
60
61
62
63
64
65
66
67
68
69
70
Code
3600 - 3619
3700 - 3719
3800
3900 - 3919
4000 - 4019
4100 - 4119
4200 - 4219
4300 - 4319
4400 - 4419
4500 - 4519
6000 - 6019
6100 - 6119
6200 - 6219
6300 - 6319
6400 - 6419
6500 - 6519
6600 - 6619
6700 - 6719
6800 - 6819
6900 - 6919
7000 - 7019
Rev. 2
07-15
FORM CMS-1984-14
4395 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 6 – EDITS
I. Level I Edits (Minimum File Requirements – Cont.)
Edit
Condition
1050
All record identifiers (positions 1 through 20) must be unique. [10/01/2014b]
1055
Only a Y or N is valid for fields that require a yes/no response. [10/01/2014b]
1060
Variable columns (Worksheet B and Worksheet B-1) must have a corresponding type 2
record (Worksheet A label) with a matching line number. [10/01/2014b]
1065
All line, sub line, column, and sub column numbers (positions 11 through 13, 14
through 15, 16 through 18, and 19 through 20, respectively) must be numeric, except
that each cost center using accumulated cost as the statistical basis must have a
Worksheet B-1 reconciliation column numbered the same as the Worksheet A line
number followed by an “A” as part of the line number followed by the sub line number.
[10/01/2014b]
1070
Cost center integrity must be maintained throughout the cost report. For subscripted
lines, the relative position must be consistent throughout the cost report. [10/01/2014b]
1075
The cost center code (positions 21 through 24 in type 2 records) must be a code from
Table 5, Cost Center Coding, and each cost center code must be unique. [10/01/2014b]
1080
Every line used on Worksheets A, and B-1, must have a corresponding type 2 record.
[10/01/2014b]
1085
Fields requiring numeric data (days, charges, discharges, costs, etc.) may not contain
any alpha characters. [10/01/2014b]
1090
A numeric field cannot exceed 11 positions. [10/01/2014b]
1095
In all cases where the file includes both a total and the parts which comprise that total,
each total must equal the sum of its parts. [10/01/2014b]
1100
All dates must be possible, e.g., no "00", no "30" or "31" of February, and the date
cannot be greater than the current date. [10/01/2014b]
Rev. 2
43-235
4395 (Cont.)
FORM CMS-1984-14
07-15
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 6 – EDITS
I. Level I Edits (Minimum File Requirements – Cont.)
Edit
Condition
1000S
Worksheet S-1, Part II, lines 30 through 34, and Worksheet S-1, Part III, lines 40 and
41, all applicable columns must be equal to or greater than zero. [10/01/2014b]
1010S
Worksheet S-1, Part I, lines 1 through 6, must contain: the hospice name in column 1,
line 1; the hospice street address in column 1, line 2; the hospice city name in column 1,
line 3; the hospice 2-letter state abbreviation that corresponds to the first two positions
of the provider CCN in column 2, line 3; the hospice ZIP code (formatted as XXXXX
or XXXXX-) or the hospice ZIP+4 code (formatted as XXXXX-XXXX) in column 3,
line 3; the hospice county name in column 1, line 4; the hospice CCN in column 1,
line 5; and, the date the hospice began operations in column 1, line 6. [10/01/2014b]
1020S
The certification date entered on Worksheet S-1, Part I, column 1, line 7, must be
present and possible. The date must be before the cost reporting period ending date and
after 1/1/1966. [10/01/2014b]
1030S
The cost reporting period beginning date on Worksheet S-1, Part I, column 1, line 8,
must be on or after October 1, 2014. [10/01/2014b]
1040S
The cost reporting period beginning date on Worksheet S-1, Part I, column 1, line 8,
must precede the cost reporting ending date on Worksheet S-1, Part I, column 2, line 8.
[10/01/2014b]
1050S
Worksheet S-1, Part I, line 9, must contain a “Y” or “N” response. [10/01/2014b]
1060S
If Worksheet S-1, Part I, line 9, is “Y”, then line 10 must contain a “1” or “2”, and
line11, sum of columns 1 through 3, must be greater than zero. [10/01/2014b]
1070S
Worksheet S-1, Part I, line 13, must contain a “Y” or “N” response. [10/01/2014b]
1080S
If Worksheet S-1, Part I, column 1, line 13, is “Y”, then column 2 must have an entry.
In addition, Worksheet S-1, Part I, columns 1, 2, and 3, as applicable, lines 14 through
18, must be present and valid. [10/01/2014b]
1090S
Worksheet S-1, Part I, line 19, must have a value of 1 through 13 (see Table 3B), and
line 20 must be completed with a number of 1 through 99. [10/01/2014b]
43-236
Rev. 2
07-15
FORM CMS-1984-14
4395 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 6 – EDITS
I. Level I Edits (Minimum File Requirements – Cont.)
Edit
Condition
1095S
If Worksheet S-1, Part I, line 20, is greater than 1, then line 21 must be subscripted
accordingly. [10/01/2014b]
1100S
Worksheet S-1, Part I, line 21, and subscripts must contain valid five-digit
alphanumeric CBSA codes. [10/01/2014b]
1110S
If days are reported on Worksheet S-1, Part II, in any of columns 1 through 3, lines 30
through 33, then Worksheet F-2, columns 1 through 3, lines 1 through 4, must have
corresponding entries, and vice versa. [10/01/2014b]
1120S
If Worksheet S-1, Part II, column 4, line 30, is greater than zero, then Worksheet A-1,
column 7, line 100, must be greater than zero and vice versa. [10/01/2014b]
1130S
If Worksheet S-1, Part II, column 4, line 31, is greater than zero, then Worksheet A-2,
column 7, line 100, must be greater than zero and vice versa. [10/01/2014b]
1140S
If Worksheet S-1, Part II, column 4, line 32, is greater than zero, then Worksheet A-3,
column 7, line 100, must be greater than zero versa. [10/01/2014b]
1150S
If Worksheet S-1, Part II, column 4, line 33, is greater than zero, then Worksheet A-4,
column 7, line 100, must be greater than zero and vice versa. [10/01/2014b]
1160S
Removed and reserved.
1170S
Worksheet S-1, Part III, lines 40 and/or 41, columns 1, 2, or 3, cannot be greater than
Worksheet S-1, Part II, lines 32 and/or 33, columns 1, 2, or 3, respectively.
[10/01/2014b]
1175S
If Worksheet S-1, Part III, column 4, line 40, is greater than zero, then Worksheet A-3,
column 7, line 25, must be greater than zero, and if Worksheet S-1, Part III, column 4,
line 41, is greater than zero, then Worksheet A-4, column 7, line 25, must be greater
than zero. [10/01/2014b]
Rev. 2
43-237
4395 (Cont.)
FORM CMS-1984-14
07-15
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 6 – EDITS
I. Level I Edits (Minimum File Requirements – Cont.)
Edit
Condition
1180S
If Worksheet S-2, column 1, line 1, is “Y”, then column 2 must contain a valid date
(MM/DD/YYYY). [10/01/2014b]
1185S
If Worksheet S-2, column 1, line 2, is “Y”, then column 2 must contain a valid date
(MM/DD/YYYY) and column 3 must contain a “V” or an “I”. [10/01/2014b]
1190S
If Worksheet S-2, column 1, line 3, is "N", then Worksheet A-8-1 must not be present.
[10/01/2014b]
1195S
If Worksheet S-2, column 1, line 3, is "Y", then Worksheet A-8-1, Part I, columns 4 or
5, sum of lines 1 through 9, must not equal zero, and Worksheet A-8-1, Part II, column
1, any one of lines 1 through 10, must contain one of the alpha characters A, B, C, D, E,
F, or G. [10/01/2014b]
1200S
Worksheet S-2, column 1, lines 4 through 11, must contain a “Y” or “N” response. If
column 1, line 4, is "Y", then column 2 must contain an “A”, “C”, or “R” response.
[10/01/2014b]
1000A
Worksheet A, columns 1 and 2, line 100, must be greater than zero. [10/01/2014b]
1050A
Moved to level 2 edit 2021A.
1120A
For reclassifications reported on Worksheet A-6, all increases (column 4 plus
column 4.01) must equal all decreases (column 7 plus column 7.01). [10/01/2014b]
1130A
For each line on Worksheet A-6, when an entry is present in column 4 or 4.01, there
must be an entry in columns 1 and 3, and if an entry is present in column 7 or 7.01,
there must be an entry in columns 1 and 6. All entries in column 1 must be upper case
alpha characters. [10/01/2014b]
1140A
A LOC worksheet indicator of 1, 2, 3, or 4, as applicable, must be present in column 8
of Worksheet A-6 when a Worksheet A line number 25 through 46 (or a subscript
thereof) is present in column 3 or 6. [10/01/2014b]
43-238
Rev. 2
07-15
FORM CMS-1984-14
4395 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 6 – EDITS
I. Level I Edits (Minimum File Requirements – Cont.)
1160A
Worksheet A-6, column 0, must have an explanation present on the first line for each
reclassification code. [10/01/2014b]
1180A
For Worksheet A-8 adjustments on lines 1, 2, and 6 through 9, if column 2 has an
amount, then columns 1 and 4 for that line must have entries, and if lines 11 through
49, column 2, have entries, then columns 0, 1, and 4, for that line must have entries.
[10/01/2014b]
1200A
Worksheet A-8, column 5, must have an entry of 1, 2, 3, or 4, as applicable, when a
Worksheet A line number 25 through 46 (or a subscript thereof) is present in column 4
and an amount is in column 2. [10/01/2014b]
1205A
Worksheet A-8-1, Part I, columns 1 and 3, must have an entry when there is an amount
in column 4 or 5 for each of lines 1 through 9. [10/01/2014b]
1230A
Worksheet A-8-1, Part I, column 7, must have an entry of 1, 2, 3 or 4, as applicable,
when a Worksheet A line number 25 through 46 (or a subscript thereof) is present in
column 1 and an amount is present in column 4 or 5. [10/01/2014b]
1000B
All Worksheet B-1 statistical amounts must be greater than zero, except for
reconciliation columns. [10/01/2014b]
1005B
Worksheet B, column 18, line 101, must be greater than zero. [10/01/2014b]
1010B
For each general service cost center with a net expense for cost allocation greater than
zero (Worksheet B, columns 1 through 17, line 101), the corresponding total cost
allocation statistics (Worksheet B-1, column 1, line 1; column 2, line 2, etc.) must also
be greater than zero. Exclude from this edit any column that uses accumulated cost as
its basis for allocation and any reconciliation column. [10/01/2014b]
1015B
For any column that uses accumulated cost as its basis of allocation (Worksheet B-1),
there may not exist on any statistical line amounts in both the reconciliation column and
the accumulated cost column, including the negative one, simultaneously.
[10/01/2014b]
Rev. 2
43-239
4395 (Cont.)
FORM CMS-1984-14
07-15
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 6 – EDITS
II.
Level II Edits (Potential Rejection Errors)
These conditions are usually, but not always, incorrect. These edit errors should be cleared when
possible through the cost report. When corrections on the cost report are not feasible, provide
additional information in schedules, notes, or any other manner as may be required by your
contractor. Failure to clear these errors in a timely fashion, as determined by your contractor,
may be grounds for withholding of payments.
Edit
Condition
2000
All type 3 records with numeric fields and a positive usage must have values equal to or
greater than zero (supporting documentation may be required for negative amounts).
[10/01/2014b]
2005
Only elements set forth in Table 3, with subscripts as appropriate, are required in the
file. [10/01/2014b]
2010
Removed and reserved.
2015
Standard cost center lines, descriptions, and codes cannot be changed. (See Table 5 for
standard descriptions and codes.) This edit applies to the standard line only and not
subscripts of that code. [10/01/2014b]
2020
All standard cost center codes must be entered on the designated standard cost center
line and subscripts thereof as indicated in Table 5. [10/01/2014b]
2035
Administrative and general standard cost center code 0400 may only appear on line 4,
and non-standard cost center codes 0450 through 0459 may only appear as subscripts
of line 4. Standard cost center code 0400 may not appear in addition to non-standard
cost center codes 0450 through 0459 (subscripts of line 4). [10/01/2014b]
2040
Removed and reserved.
43-240
Rev. 2
07-15
FORM CMS-1984-14
4395 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 6 – EDITS
II.
Level II Edits (Potential Rejection Errors – Cont.)
Edit
Condition
2015S
Removed and reserved.
2100S
Worksheet S-1, Part II, columns 1 through 4, lines 30 through 34, must be greater than
or equal to zero. [10/01/2014b]
2180S
Removed and reserved.
2200S
If Worksheet S-2, column 1, line 6 or line 7, is “Y”, then column 2 must contain a valid
date, respectively. [10/01/2014b]
2220S
Worksheet S-2, lines 12 through 14, all columns must be completed. [10/01/2014b]
2020A
If Worksheet A, line 70, column 7, is greater than zero, then Worksheet F-2, column 4,
line 10, must be greater than zero. [10/01/2014b]
2021A
There must be an entry on Worksheet A, column 7, lines 3, 4, 5, 13, 14, 28, 37, 38, and
41. [10/01/2014b]
2025A
Removed and reserved.
2030A
If Worksheet A-8, column 2, line 10, has an entry, then Worksheet A, column 3,
line 70, must be greater than zero. [10/01/2014b]
2000B
At least one cost center description (lines 1 through 3), at least one statistical basis label
(lines 4 and 5), and one statistical basis code for capital cost centers only (line 6) must
be present for each general service cost center with cost greater than zero
(Worksheet B-1, columns 1 through 17, line 101). Exclude any reconciliation columns
from this edit. [10/01/2014b]
Rev. 2
43-241
4395 (Cont.)
FORM CMS-1984-14
07-15
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14
TABLE 6 – EDITS
II.
Level II Edits (Potential Rejection Errors – Cont.)
Edit
Condition
2000F
Total assets on Worksheet F, line 32, must equal total liabilities and fund balances on
line 49. [10/01/2014b]
2010F
Net income or loss on Worksheet F-2, Part II, column 2, line 42, should not equal zero.
[10/01/2014b]
43-242
Rev. 2
| File Type | application/pdf |
| Author | CMS |
| File Modified | 2017-02-09 |
| File Created | 2015-08-04 |