Organ Procurement Organization/Histcompatibility Laboratory Statement of Reimbursable Costs, Manual Instructions (CMS-216-94)

CHAPTER 33

ORGAN PROCUREMENT ORGANIZATION

AND TISSUE TYPING LABORATORY

COST REPORT

FORM CMS-216-94

Section
General .................................................................................................................3300

Recommended Sequence for Completing OPO/LAB Cost Report......................3301

Rounding Standards for Fractional Computations ...............................................3301.1

Worksheet S - Organ Procurement Organization/

Histocompatibility Laboratory General Data and
Certification Statement .....................................................................................3302

Part I - General ...............................................................................................3302.1

Part II - Certification By Officer or Administrator of Facility.......................3302.2

Part III – Settlement Summary.......................................................................3302.3

Worksheet S-1 - Organ Procurement Organization/
Histocompatibility Laboratory Identification Data ...........................................3303

Part I - OPO Statistics (To be completed by OPOs only) ..............................3303.1

Part II - Lab Statistics (To be completed by Labs only).................................3303.2

Part III - Full Time Equivalent Employees (FTEs)........................................3303.3

Worksheet A - Reclassification and Adjustment of Trial
Balance of Expenses .........................................................................................3304

Worksheet A-1 - Administrative and General Expenses .....................................3305

Worksheet A-2 - Organ Acquisition Costs (OPOs only) .....................................3306

Worksheet A-3 - Tissue Typing Laboratory Costs ..............................................3307

Worksheet A-4 - Reclassifications.......................................................................3308

Worksheet A-5 - Adjustments to Expenses .........................................................3309

Worksheet A-6 - Capital Expenditures and Depreciation

Reconciliation ...................................................................................................3310

Worksheet B - Cost Allocation - General Service Costs and

Worksheet B-1 - Cost Allocation - Statistical

Basis..................................................................................................................3311

Worksheet C - Computation of Medicare Cost....................................................3312

Worksheet D - Calculation of Reimbursement Settlement..................................3313

Worksheet E - Balance Sheet...............................................................................3314

Worksheet E-1 - Statement of Operating Expenses and

Revenues ...........................................................................................................3315

Worksheet E-2 - Statement of Revenues and Expenses ......................................3316

Supplemental Worksheet A-5-1 - Statement of Costs of

Services from Related Organizations and Home Office Costs .........................3317

Kidney Placement Efforts - Documentation Requirements .................................3318

Exhibit 1 - Form CMS-216-94 Worksheets.........................................................3390

Electronic Reporting Specifications for Form CMS-216-94 ...............................3395

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GENERAL

All independent organ procurement organizations (OPOs) and independent histocompatibility
laboratories (Labs) must submit Form CMS-216-94 for cost reporting periods ending on or after
December 31, 1994. Effective for cost reporting periods ending on or after March 31, 2005, the
electronic cost report (ECR) file is considered the official means of cost report submission.
Form CMS-216-94 is used for the following cost reports:
o

Independent OPO,

o

Independent histocompatibility laboratory, and

o
Independent organizations which operate both an OPO and a Lab that have two CMS
certification numbers (CCNs) within the same administration.
Do not use the forms to calculate the amount of home office costs of a chain organization on the
OPO/Lab cost report. Chain organizations follow the procedure in CMS Pub. 15-2, Cost to Related
Organization chapter 10. These forms are not to be used by any hospital-based OPOs.
An OPO that only performs kidney procurement functions (and has no cost associated with other
organizations or other non-renal activities) can bypass the allocation Worksheets B and B-1. Flow
the cost directly from the trial balance of expenses (Worksheet A) to the total cost applicable to
kidney acquisition (Worksheet C).
An OPO that performs organ procurement for renal and non-renal organs must complete a separate
Worksheet A-2 for each type of organ. The OPO must go through cost finding to ensure that
overhead is allocated to all types of organ acquisition. Tissues, such as skin, cornea, bone, heart
valves, and pancreas islet absent adequate cost finding methodology need not go through cost
finding. Rather, income received is offset against cost associated with transplant coordinator costs
on Worksheet A.
A lab that only performs tissue typing tests (renal and non-renal) and has no cost associated with
organ procurement clinical laboratory tests, blood bank activities, other components requiring
overhead allocations, and other non- tissue typing tests, bypass the allocation Worksheets B and B-1.
Flow the cost directly from the trial balance of expenses (Worksheet A) to the total cost applicable
to tissue typing lab (Worksheet C). The Medicare kidney related cost of the lab services is
determined on Worksheet C. Few laboratories qualify to bypass Worksheets B and B-1 since clinical
laboratory tests are normally performed in the same organization.
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 0938-0102 (Expires 09/30/2020). The time required to
complete this information collection is estimated average 45 hours per response, including the time
to review instructions, search existing data 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: Centers for Medicare and
Medicaid Services, PRA Reports Clearance Officer, 7500 Security Boulevard, Mail Stop C4-26-05,
Baltimore, Md. 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.
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RECOMMENDED SEQUENCE FOR COMPLETING OPO/LAB COST REPORT
Worksheet

Page

Part I - General Statistics and Expense Reclassifications
and Adjustments (To Be Followed By All OPOs/Labs)
1

S, Part I
General

1

Complete Part I - General except for
certification statement.

2

S-1, Part I
OPO

2

OPOs complete Part I.

3

S-1, Part II
Labs

2

Labs complete Part II.

4

S-1, Part III
FTEs

2

All complete Part III.

5

A-1

4

Complete entire page.

6

A-2

5

OPOs complete entire page. (One form must be
completed for each type of organ acquisition.)

7

A-3

6

Labs complete entire page.

8

A

3

Complete columns 1 through 3, lines 1 through 26.

9

A-4

7

Complete, if applicable.

10

A

3

Complete columns 4 and 5, lines 1 through 26.

11

A-5

8

Complete entire page.

12

Supplemental A-5-1

7

If any costs on Worksheet A are with a related
organization, complete Part A. If the answer to Part A
is yes, complete both Parts B and C.

13

A

3

Complete columns 6 and 7, lines 1 through 26.

14

A-6

9

Complete entire page as applicable.

Part II - Cost Allocation (To Be Followed for OPOs/Labs That
Need to Allocate Overhead Costs When OPO is Not Totally
Kidney Related and Lab is Not Totally a Tissue Typing Lab)
NOTE: All OPOs that have acquired non-renal organs must complete Worksheets B and B-1.
1

B and B-1

10-11

Complete entire worksheet.

Part III - Computation of Medicare Cost - To Be Completed By
All OPOs and Tissue Typing Labs
1

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C

12

Complete entire worksheet.

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Worksheet

3302.1

Page

Part IV - Calculation of Reimbursement Settlement to OPOs/Labs
1

D

13

Complete entire worksheet and columns as
appropriate.

2

E

14

OPOs/Labs complete the worksheet.
Where multiple funds are maintained, combine
in the general fund.

3

E-1

15

Complete entire worksheet.

4

E-2

16

Complete entire worksheet.

5

S, Part II

1

Complete certification statement.

6

S, Part III

1

Complete settlement summary.

3301.1.

ROUNDING STANDARDS FOR FRACTIONAL COMPUTATIONS

Throughout the Medicare cost report, required computations result in the use of fractions. The
following rounding standards must be employed for such computation.
1.

Round to 2 decimal places
a. Percentages
b. Averages
c. Full time equivalent employees
d. Per diems, hourly rates

2.

Round to 4 decimal places
a. Sequestration (e.g., 2.092 percent is expressed as .0209)

3.

Round to 6 decimal places
a. Ratios (e.g., unit cost multipliers, cost/charge ratios)
b. Ratios (Medicare kidneys to total kidneys)

If a residual exists as a result of computing costs using a fraction, adjust the residual in the largest
amount resulting from the computation. For example, in cost finding, a unit cost multiplier is
applied to the statistics in determining costs. After rounding each computation, the sum of the
allocation may be more or less than the total cost being allocated. Adjust this residual to the largest
amount resulting from the allocation so that the sum of the allocated amounts equals the amount
being allocated.

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3302.

WORKSHEET
S
ORGAN
PROCUREMENT
ORGANIZATION/
HISTOCOMPATIBILITY LABORATORY GENERAL DATA AND CERTIFICATION
STATEMENT

3302.1

Part I - General.-­

Apply the following definitions:
Organ Procurement Organization.--An independent OPO is an organization which performs or
coordinates the procurement, preservation, and transport of organs and maintains a system for
locating prospective beneficiaries for available organs (see 42 CFR 486.302).
Laboratory or Histocompatibility Lab or Tissue Typing Lab.--An independent histocompatibility lab
is a laboratory meeting the provisions of 42 CFR 493.1278.
Line 1.--Enter the full name of the independent OPO or independent Lab in column 1. Enter the
OPO or Lab provider CCN in column 2. The provider CCN consists of two digits followed by either
a P or an HL, followed by two or more digits. (00-P-000 or 00-HL-00)
Line 1.01.--Enter the street address and P.O. Box (if applicable) of the OPO/Lab.
Line 1.02.--Enter the city, state and ZIP code of the OPO/Lab.
Line 2.--Enter the full name of the OPO based Lab and the provider number.
Line 2.01.--Enter the street address and P.O. Box (if applicable) of the OPO based Lab.
Line 2.02.--Enter the city, state and ZIP code of the OPO based Lab.
Line 3.--Enter the inclusive dates covered by this cost report. In accordance with 42 CFR 413.24(f),
each provider is required to submit periodic reports of operations which generally cover a
consecutive 12-month period of the provider’s operations. (See CMS Pub. 15-2, §102.1 through
§102.3 for situations where a short period cost report may be filed.)
Cost reports are due on or before the last day of the fifth month following the close of the period
covered by the cost report. A cost report from a provider which voluntarily or involuntarily ceases to
participate in the health insurance program or changes ownership is due no later than 5 months
following the effective date of the termination of the provider agreement or change of ownership.

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Line 4.-­
Column 1--Type of Control--Indicate the ownership or auspices under which the OPO/Lab
operates by entering the number below that corresponds to the type of control.
Proprietary
1=Individual
2=Corporation
3=Partnership
4=Other (Specify)

Voluntary Non-Profit
5=Church
6=Corporation
7=Foundation
8=Other (Specify)

Government

9=Federal

10=State

11=County

12=City

If item 4 or 8 is selected, “Other (Specify)” category, specify the type of control in column 2.
Column 3.--Type of Provider--Enter the number which corresponds to the type of provider as
defined above. Enter 1 for OPO and 2 for Lab.
Column 4.--Participation Date--Enter the date the OPO/Lab was certified for participation in the
Medicare program. All laboratories that were certified on October 1, 1978, have an effective
date of October 1, 1978, regardless of when the agreement was signed. If operations began after
October 1, 1978, enter the date found in the approval letter from the regional office of the
Department of Health and Human Services. Independent OPOs must have a certification date on
or after March 31, 1988.
Note: When an independent organization operates both an OPO and a Lab that have two CCN’s
within the same administration, enter the OPO information on line 4 and the Lab on subscripted
line 4.01.
3302.2 Part II - Certification By Officer or Administrator of Facility.--Prepare and sign the
certification after completion of the cost report.
3302.3

Part III - Settlement Summary.

Line 1.--Enter the balance due to or from the OPO/Lab. Transfer the settlement amounts from
Worksheet D, line 8 (organ acquisition from column 1 and tissue typing from column 2).

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3303.

WORKSHEET
S-1
ORGAN
PROCUREMENT
HISTOCOMPATIBILITY IDENTIFICATION DATA

3303.1

Part I - OPO Statistics (To be completed by OPOs only).-­

3303.1
ORGANIZATION/

Line 1.--Enter the total number of kidneys retrieved and/or processed administratively. This includes
all viable and nonviable kidneys retrieved locally as well as kidneys obtained from all other sources.
Line 2.--Enter the number of nonviable kidneys retrieved and/or processed administratively. This
includes kidneys that were not transplanted due to a defect and kidneys for which a recipient was not
located. Do not include kidneys that were sent to a foreign country for transplant on this line.
Include foreign kidneys on lines 1, 3, 4, and 6, as appropriate.
Note: Total kidneys included on line 1 and nonviable kidneys included on line 2 must include
kidneys that were determined to be unusable at the time of excision. For example, if
procurement is attempted and no kidneys are excised because they were determined to be
nonviable, two kidneys must be counted on both lines 1 and 2. However, kidneys that are
retrieved exclusively for research (known prior to retrieval) must be excluded from the count.
Line 3.--Enter the number of kidneys for which payment should have been received. It must equal
the amount entered on line 1 minus the amount entered on line 2 and correspond with the number of
kidneys transplanted and exported.
Line 4.--Enter the number of viable kidneys that were exported from your retrieval area. This
number includes viable kidneys sent to another independent or hospital-based OPO or to a foreign
country which received the kidney for potential transplant.
Line 5.--Enter the number of viable kidneys that were shared with a military hospital or VA hospital
in your retrieval area. Include this number in the total viable kidneys on line 3. A kidney sent to
another OPO, and subsequently sent to a VA or military hospital, is counted as a VA/military kidney
by the second OPO, not the originating OPO.
Note: OPOs that have an agreement with military and Veteran’s Affairs (VA) hospitals to
procure kidneys at no charge, but must give the military/VA institution the first opportunity to
use the kidneys, count these kidneys as sent to a military hospital or VA hospital on line 5.
These kidneys must also be shown as a local retrieval on lines 1, 2, and 3, as applicable, and
counted as sent to the military or VA hospital. In these cases, no revenue is shown. See CMS
Pub. 15-1, Chapter 27 Outpatient Maintenance Dialysis Services §2775.2 for an exception to
this instruction.

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Line 6.--Show the amount received for kidneys listed on line 5.
Line 7.--Enter Y or N in column 1, was payment received for kidneys furnished to foreign countries
and included on line 4? Enter the total number of kidneys furnished to foreign countries in column 2
and the amount of payment received in column 3. Provide a supplemental schedule identifying the
organ, the country it was shipped to, the date of shipment, the amount charged, and the amount of
payment received. A kidney sent to another OPO, and subsequently sent to a foreign country, is
counted as a foreign kidney of the second OPO, not the originating OPO.
Line 8.--For each organ identified enter in column 1, the total number of organs/tissues (not kidneys)
retrieved and/ or processed administratively. Enter in column 2, the number of organs/tissue that
were retrieved, but not used for transplant. Enter in column 3, the amount of payment received for
each type of organ. Include the amount received for transplanted organs and organs sent to research.
If no payment was received, enter zero.
3303.2

Part II - Lab Statistics (To be completed by Labs only).-­

Line 1.--Enter the total number of all tests performed. This includes clinical laboratory tests as well
as tissue typing tests.
Line 2.--Enter the total number of tests performed by the tissue typing lab. This includes all tests
whether or not they are related to kidney transplantation.
Line 3.--Enter the total number of kidney pre-transplantation tests included on line 2. These tests are
performed for potential kidney recipients, living related donors, living unrelated donors, and cadaver
kidneys.
Line 4.--List the tests performed specifically for kidney pre-transplant and the number of each type of
test. The total must equal line 3.
3303.3

Part III - Full Time Equivalent Employees (FTEs).-­

Lines 1 through 1.03.--Enter the number of FTEs by type of employee at the facility. Where the
number of "Other" employees exceeds 10 percent of the total or is greater than 10 percent, provide a
supplemental schedule detailing their duties. Enter in column 2, the corresponding FTEs for
Administrative employees listed in column 1, lines 1 through 1.03. These FTEs correspond with the
salaries shown on Worksheet A, lines 3 through 7, which includes Worksheet A-1. Enter in column
4, the corresponding FTEs for OPO employees listed in column 3, lines 1 through 1.03. These FTEs
correspond with the salaries shown on all Worksheet A-2s for all types of organ acquisitions. Enter
in column 6, the corresponding FTEs for Lab employees listed in column 5, lines 1 through 1.03.
These FTEs correspond with the salaries shown on Worksheet A-3. Prorate employees that perform
several different functions by type of function in the same manner as salaries are prorated on
Worksheets A-1, A-2, and A-3.
Line 2.--Enter the total number of FTEs at the facility. This number must equal the sum of all
categories appearing on lines 1 through 1.03.
NOTE: FTEs are computed on the basis of 2080 hours per year. Accordingly, divide total hours
worked per category by 2080 to obtain the equivalent number of FTEs.

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3304

WORKSHEET A - RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE
OF EXPENSES

This worksheet provides for recording the trial balance of expense accounts from the OPO/Labs
accounting records. It also provides for the necessary reclassifications and adjustments to certain
cost centers. The cost centers on this worksheet are listed in a manner which facilitates the transfer
of the various cost center data to the cost finding worksheets.
Not all of the cost centers listed may apply to all OPO/Labs.
A provider may elect to use different cost centers for allocation purposes in accordance with CMS
Pub. 15-1, §2313.
Standard (i.e., preprinted) CMS line numbers and cost center descriptions cannot be changed. If a
provider needs to use additional or different cost center descriptions, it may do so by adding
additional lines to the cost report. Added cost centers must be appropriately coded. Identify the
added line as a numeric subscript of the immediately preceding line. That is, if two lines are added
between lines 5 and 6, identify them as lines 5.01 and 5.02. If additional lines are added for general
services cost centers, corresponding columns must be added to Worksheets B and B-1 for cost
finding.
Cost center coding is a methodology for standardizing the meaning of cost center labels as used by
health care providers on the Medicare cost reports. Form CMS 216-94 provides for preprinted cost
center descriptions that may apply to OPO/Lab services on Worksheet A. In addition, a space is
provided for a cost center code. The preprinted cost center labels are automatically coded by CMSapproved cost reporting software. These cost center descriptions are hereafter referred to as the
standard cost centers. Additional cost center descriptions identified as “Other…” that have a general
meaning will hereafter be referred to as nonstandard labels. These nonstandard cost centers allow for
situations where no match in meaning to the standard cost centers can be found.
The use of this coding methodology allows providers to continue to use labels for cost centers that
have meaning within the individual facility. The four-digit cost center codes that are associated with
each cost center label in the electronic file provide standardized meaning for data analysis. The
preparer is required to compare any added or changed labels to the descriptions offered on the
standard or nonstandard cost center tables. A description of cost center coding and the cost center
codes are in Table 5 of the electronic reporting specifications.
Where the cost elements of a cost center are separately maintained on your books, a reconciliation of
the costs per the accounting books and records to those on this worksheet must be maintained and is
subject to review by the contractor.
Column Descriptions
Columns 1, 2, and 3.--List on the appropriate lines in columns 1, 2, and 3 the total expenses incurred
during the cost reporting period. The expenses must differentiate between salaries (column 1) and
other (column 2). Include all fringe benefits paid to employees in column 2. The sum of columns 1
and 2 must equal column 3. See CMS Pub. 15-1, §2144.1 for a definition of fringe benefits.
Column 1.--Include only those amounts for persons employed by the OPO/Lab. This includes all
persons reported on Federal Tax Form 941. Do not include any payments to individuals who are
self-employed. Show only salaried and hourly wage employees on which taxes are withheld and
paid.

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Column 2.--Include all other expenses not identified in column 1.
Column 3.--This amount represents the total expenses, the sum of columns 1 and 2 for each cost
center. Each cost center should agree with the working trial balance of expenses for that
classification. Prepare a supplemental workpaper which details the OPO/Lab expense accounts that
tie into the cost centers shown on Worksheet A. Line 26, column 3, must agree with total operating
expenses on the working trial balance.
Column 4.--Enter any reclassifications that are needed to affect proper cost allocation. Worksheet A­
4 is provided to detail any reclassifications affecting the expenses specified therein. This worksheet
(explained in §3308) must be completed to the extent that reclassifications are needed and
appropriate for the allocation of costs on Worksheet B. Show reductions in brackets. The net total
of entries in column 4 must equal zero on line 26.
Column 5.--For each cost center, enter the amount in column 3 plus or minus the amount in column
4 (increase or decrease).
Column 6.--Enter on the appropriate line in column 6 the amounts of any adjustments to expenses
indicated on Worksheet A-5 (explained in §3309). The total of Worksheet A, column 5, line 26,
must equal the amount on Worksheet A-5, column 2, line 17.
Column 7.--Add or subtract the amount in column 6 from the amount in column 5 and enter the
result in column 7.
Line Descriptions
Line 1.--This cost center includes amounts for depreciation and leases and rentals for the use of the
facility. It may also include taxes, interest and insurance on land and buildings. Do not include costs
for the repair and maintenance of the facility.
Line 2.--This cost center includes depreciation, leases, and rentals for the use of the equipment as
well as taxes, interest, and insurance on the equipment. Do not include costs for repair or
maintenance of the equipment.
Note: Other costs associated with taxes, interest, rentals, leases, and insurance not included in lines
1 or 2 above, are reported on Worksheet A-1 as A&G costs.
Line 3.--Enter in column 1, the salaries of employees working on employee benefits or personnel
matters, etc. Enter the costs of other employee benefits in column 2, e.g., hospitalization insurance
and pension plans.
Line 4.--Enter on this line for columns 1, 2, and 3 the total amount as shown on Worksheet A-1, line
20, columns 1, 2, and 3. Worksheet A-1 is explained in §3305.
Line 5.--Enter in column 1, the salaries of maintenance personnel, plant engineers, etc. Enter in
column 2, the costs for maintenance supplies, heat, light, power, and any other costs that relate to the
physical functioning of the OPO/Lab. Do not include costs incurred for capital repairs.
Line 6.--Enter in column 1, the total salaries of all personnel rendering janitorial and housekeeping
activities. Enter in column 2, the cost of supplies and contracted housekeeping services.

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Line 7.--Enter in column 1, the total salaries of employees working in central supply and enter in
column 2, the cost of medical supplies.
Line 8.--Enter general overhead costs that cannot be properly identified on one of the lines
mentioned above. Detail the cost of items included with supporting documentation. Report salary
amounts in column 1 and other costs in column 2.
Line 9.--This cost center includes all of the salaries and other direct costs (personal travel
allowances, bonus, etc.) of the procurement coordinators. Enter in column 1, the salaries and enter in
column 2, the other direct costs.
Line 10.--Enter all costs associated with the education of donor hospital personnel and physicians.
Include the expenses of meetings, seminars, slide shows, and presentations for the benefit of the
above mentioned individuals.
Line 11.--Enter the expenses of awareness programs designed to inform the general public of the
need for organs and organ transplant services.
Line 12.--Enter acquisition overhead costs that are applicable to the procurement of all type of
organs. Include a full description (e.g., technicians’ salaries) of the costs included on this line.
Line 13.--Enter in columns 1, 2, and 3 the total amount as shown on Worksheet A-2, columns 1, 2,
and 3, line 23. Worksheet A-2 is explained in §3306. Do not enter costs for the acquisition of nonrenal organs on this line. Accordingly, show costs for the acquisition of non-renal organs on lines 15
through 20.
Line 14.--Enter in columns 1, 2, and 3 the total amounts as shown on Worksheet A-3, columns 1, 2,
and 3, line 11. Worksheet A-3 is explained in §3307.
Lines 15 through 18.--Enter in columns 1, 2, and 3 the total amount shown on Worksheet A-2,
columns 1, 2, and 3, line 23 accordingly. A separate Worksheet A-2 is completed for each type of
renal and non-renal organ acquisition.
Line 19.--Enter other acquisitions not identified on lines 15 through 18. Subscript this line for each
additional non-renal organ as needed.
Line 20.--For cost reporting periods beginning on or after May 1, 2012, do not use this line. Use
subscripts of line 19.
Line 21.--Include the costs of non-reimbursable research. See CMS Pub. 15-1, Chapter 5 Research
Costs for a further explanation of research.
Line 22.--Enter costs which are totally directed to the operation of the blood bank. These are not
overhead costs which need to be allocated between the lab and the blood bank, but expenses that are
directly related only to the blood bank function.
Line 23.--Enter the direct costs of operating a non-tissue typing lab. Include salaries and other
expenses that are totally non-tissue typing. Tissue typing lab costs are shown on line 14.
Line 24.--Enter the direct costs associated with operating or furnishing services for maintenance
dialysis, peritoneal dialysis, training, self-dialysis, and home dialysis. These costs are totally related
to the furnishing of dialysis services and may not include any expenses that need to be allocated to a
reimbursable cost center.

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Line 25.--Use this line to record other non-reimbursable activities not shown on this worksheet.
Indicate the type of activity and if there is more than one activity, provide a separate schedule for
each.
Line 26.--Enter the total of line 1 through 25 for each of the columns 1 through 7. The amounts
shown in column 7 are transferred as follows:
1. If any of the costs shown on lines 1 through 12 need to be allocated to more than one of the
cost centers shown on lines 13 through 25, transfer the amounts in column 7 to the appropriate
columns on Worksheet B. It is necessary to transfer costs to Worksheet B in all cases where
expenses must be allocated between an OPO and a dialysis unit or kidney foundation or any other
activity other than kidney transplant services. It is also necessary to allocate expenses if the OPO
procures non-renal organs in addition to its renal organs. In the case of a laboratory, it is necessary to
transfer cost to Worksheet B when expenses must be allocated between the tissue typing laboratory
and clinical laboratory. It is also necessary to transfer lab costs to Worksheet B where overhead cost
must be allocated between the lab and the blood bank.
2. If the OPO’s sole function is to provide the organ procurement services listed in §3302.1,
item 1, and costs do not need to be allocated to a tissue typing lab, non-reimbursable cost center or
non-renal organs, then total costs as shown on line 26, column 7, can be transferred directly to
Worksheet C, column 1, line 4. If any cost needs to be allocated to another cost center, then the costs
in column 7 must be transferred to Worksheet B.
3. If the typing lab’s sole function is that of tissue typing and the lab does not provide
clinical lab services and must not allocate costs to research or blood bank or any non-reimbursable
cost center, then transfer the total cost as shown on column 7, line 26, to Worksheet C, column 2,
line 4. If any cost needs to be allocated to another cost center, then the cost in column 7 must be
transferred to Worksheet B.
3305.

WORKSHEET A-1 - ADMINISTRATIVE AND GENERAL EXPENSES

This worksheet provides for a detailed list of administrative and general (A&G) expenses.
Columns 1, 2, and 3.--The same explanation applies as shown in §3304 for columns 1 2, and 3 of
Worksheet A.
Line 1.--Enter the salaries and other costs of the medical director who has responsibility for the
operation of the entire Lab, OPO or blood bank. If the costs of the medical director are solely for the
tissue typing lab, do not report those cost on this line but report them on Worksheet A-3, line 1. If
the medical director performs actual testing (non-administrative functions), allocate his/her salary
between this line and the appropriate line on Worksheet A.
Line 2.--Enter the salaries and other costs of the administrator, executive director (not medical
director), officer, or individual who is responsible for the non-medical operation of the OPO/Lab. If
the medical director and administrator’s duties are performed by the same person, enter the salary
and other costs on line 1.

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FORM CMS -216-94

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Line 3.--Enter the total costs for home office or central administration that were allocated and
recorded on your books throughout the cost reporting period. Adjustments resulting from the Home
Office Cost Statement are made on supplemental Worksheet A-5-1.
Line 4.--Enter the data processing costs associated with the management and accounting functions.
Do not include the cost of registering potential recipients, maintaining and utilizing the services of
the United Network for Organ Sharing (UNOS) or a similar network, and time sharing expenses on
this line. Those costs are shown on Worksheet A-2, line 11.
Lines 5 through 8.--List the salaries and other costs related to these functions. Do not include capital
related leases and rent, they are reported or must be reclassified to Worksheet A, line 1.
Line 9.--Enter the expenses of attending meetings and seminars which are administrative in nature.
Do not enter professional education costs for nurses and physicians or public awareness costs.
Line 10.--Enter insurance expenses (e.g., liability, and malpractice). Capital related insurance
expenses (e.g., auto, building) must not be included on this line or if included must be reclassified to
Worksheet A, line 1 or 2.
Line 11.--Enter the costs of travel, registration, and other expenses relating to the professional
education of employees.
Line 12.--Enter the costs incurred for advertising and promotion of non-renal related activities, e.g.,
blood bank promotions and dialysis unit advertising.
Lines 13 through 19.--Costs included on these lines that pertain to capital costs must be reclassified
on Worksheet A.
Line 20.--Transfer the totals of columns 1, 2, and 3 to Worksheet A, columns 1, 2, and 3, line 4.
3306.

WORKSHEET A-2 - ORGAN ACQUISITION COSTS (OPOs only)

This worksheet provides for a detailed listing of organ acquisition costs. Complete Worksheet A-2
for each type of solid organ acquisition performed by the OPO by placing a checkmark in the
appropriate box on the top of this worksheet. This worksheet is only for solid organs and does not
apply to cornea and skin acquisitions.
Amounts Paid to Excision Hospitals.--A breakdown of hospital costs is necessary to properly report
organ acquisition costs for each type of organ procured. Obtain detailed bills from the donor
hospital. If the donor hospital does not sufficiently detail its bills, enter the identified costs on lines 1
through 8, and enter the balance on line 9. If the donor hospital excises and bills for more than renal
organs on a single bill, the bill must be split by each type of organ procured. If there are costs on the
bill that are exclusively identifiable to a specific organ, enter those costs directly on the appropriate
Worksheet A-2. The remaining organ acquisition costs that are not specifically identified are
allocated to renal and non-renal organs based on the number of organs retrieved. When both kidneys
are procured from a donor each kidney is counted as one (2 kidneys procured equals 2 organs
counted for allocation purposes except for pediatric kidneys procured “en bloc”). Pediatric kidneys
procured for transplantation “en bloc" are counted as one kidney for allocation purposes. If one
kidney is usable and one is not, they are still counted as two kidneys (one viable and one nonviable).
If prior to retrieval it is determined that the donor has only one potential kidney, count one kidney
for allocation purposes. Count heart/lung procurement as one organ.

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Lines 1 through 8.--These lines are self-explanatory and detail the costs billed by the donor hospitals.
Line 9. --Enter all other excision hospital costs. Identify the cost included on this line. If more than
one line is necessary, subscript accordingly.
Line 10--Enter the sum of lines 1 through 9.
Other Acquisition Costs
Line 11--Enter the cost of registering potential recipients, maintaining and utilizing the services of
the United Network for Organ Sharing (UNOS), or a similar network and time sharing expenses. Do
not enter computer costs associated with the management or accounting functions. Those costs are
entered on Worksheet A-1, line 4. If computer registry costs apply to more than one type of organ
and the costs cannot be separately identified, enter the costs on Worksheet A, line 12, and allocate to
all organs on Worksheet B.
Line 12.--Enter costs incurred for the evaluation of potential donors.
Line 13.--Self-explanatory.
Line 14.--Enter the costs associated with the perfusion lab, i.e., direct salaries and supplies. Enter
these costs regardless of whether the lab was a contracted or purchased service or an in-house
operation. When preservation applies to only one type of organ, enter the cost on line 14. However,
when preservation costs apply to several types of organs, it must be placed on Worksheet A-2, line
14, for the appropriate organ.
Lines 15 and 16.--Use these lines when services are purchased from an independent or hospital-based
lab. Costs of services purchased under agreement are reported on line 19 and must not be reported
on lines 15 and 16. Show the cost for services provided by an in-house lab under tissue typing costs
on Worksheet A-3.
Line 17.--Enter the total direct costs of importing organs from another OPO. Include any
transportation costs associated with the receipt of the organ.
Line 18.--Enter all costs associated with the transportation of organs retrieved locally and exported
outside of your retrieval area.
Line 19.--Enter costs of tissue typing purchased under agreement where the independent or hospitalbased lab bills you for the service. Exclude costs shown on lines 15 and 16. If the lab bills the
transplant hospital for the tests, do not complete this line.
Line 20--Enter all costs for anesthesiologist professional fees.
Line 21.--Enter all other acquisition costs that have not been provided for above. Identify the costs
included on this line. If more than one line is necessary, subscript accordingly.
Line 22.--Enter the sum of the amounts on lines 11 through 21.
Line 23.--Enter the sum of the amounts on lines 10 and 22. Transfer the total costs from columns 1
and 2, to Worksheet A, columns 1 and 2, lines 13 and 15 through 19 or 20, as appropriate.

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3307
3307.

FORM CMS-216-94

06-15

WORKSHEET A-3 - TISSUE TYPING LABORATORY COSTS

This worksheet provides for a detailed listing of tissue typing direct costs.
Line 1.--Enter the direct salary and other costs of the Medical Director of the tissue typing lab.
If the medical director’s salary and other benefits are totally attributable to the tissue typing lab, then
include the entire cost on Worksheet A-3, line 1.
If the Medical Director has management responsibility in addition to the tissue typing lab, then
include all of the cost on Worksheet A-1, line 1.
If the Medical Director has management responsibility for both the tissue typing lab and clinical lab,
then utilize a time study to calculate the cost applicable to each lab. If a time study is used, it must
detail the services performed for each lab and the actual time spent performing the services (see
CMS Pub. 15-1, chapter 23, Adequate Cost Data and Cost Finding §2313.2E). Retain the time study
for future reference. If a time study is not available, place the cost on Worksheet A, line 8, and
allocate on Worksheet B.
Line 2.--Enter the salaries and related cost of the technologist working in tissue typing only. If a
technologist works in both tissue typing and an area other than tissue typing, a time study can be
used to calculate the cost applicable to each cost center, or the cost can be placed on the “other
overhead” cost center on Worksheet A, line 8, and allocated on Worksheet B.
Line 3.--Enter the salaries and other costs associated with the ongoing development of reagents. This
includes local cell panel construction and maintenance, including freezing technique and local
reagent (antibody) characterization. Other expenses of this nature are also included on this line.
Line 4.--Enter maintenance cost of equipment used only for tissue typing procedures.
Lines 5 through 10.--Include any expenses which cannot properly be reported on lines 1 through 4.
If additional lines are needed subscript line 10.
Line 11.--Total tissue typing costs (sum of columns 1, 2, and 3, lines 1 through 10) are transferred to
Worksheet A, columns 1, 2, and 3, line 14. Include on this line direct expenses only attributable to
tissue typing and not related to the clinical lab or any other cost center on Worksheet A, lines 13 or
15 through 25.
3308.

WORKSHEET A-4 - RECLASSIFICATIONS

This worksheet provides for the reclassification of expenses needed to effectuate a proper allocation
of costs on Worksheet B.
The following are some examples of costs which must be reclassified on this worksheet.

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3309

1. Reclassify rental expense on a specific piece of movable equipment which was charged
directly to the appropriate cost center on this worksheet to the Capital Costs - Movable Equipment
cost center unless the OPO/Lab has identified and charged all depreciation and rental expense for all
movable equipment to the appropriate cost centers. The OPO or Lab may not direct cost individual
pieces of equipment, unless all equipment can be direct allocated.
2. The expenses related to medical directors in the A&G cost center and tissue typing
technologies in the tissue typing lab may be reclassified on this worksheet if a time study can support
the reclassification of costs between two different functions. Reclassification is also applicable to
the lab medical director (in the tissue typing cost center) if the director is responsible for more than
one type of lab.
3. Reclassify the costs of any other item which was posted to your accounting records, but is
more appropriately included in another cost center for cost finding. For example, a procurement
coordinator’s salary and other costs related to non- renal organs which were included in kidney
acquisition costs must be reclassified to the appropriate organ-type cost center(s).
4. Capital related costs of rental leases, taxes, insurance, and interest included in A&G must
be reclassified to the capital-related expense cost centers.
Columns 4 and 7.--Transfer the amounts shown in these columns to the appropriate lines of
Worksheet A, column 4.
3309.

WORKSHEET A-5 - ADJUSTMENTS TO EXPENSES

This worksheet provides for adjustments to the expenses listed on Worksheet A, column 5, and are
shown or summarized on Worksheet A, column 6. Make the required adjustments on the basis of
cost or amount received. Enter the amount received only if the costs (including direct cost and all
applicable overhead) cannot be determined. If the total direct and indirect cost can be determined,
enter the cost. If cost is used, retain the calculation of the cost for future reference. Once an
adjustment to an expense is made on the basis of cost, do not, in future periods, determine the
required adjustment on the basis of revenue. Indicate the basis for the adjustment by entering an “A”
for cost or a “B” for amount received. Line descriptions indicate the more common activities that
affect allowable cost or result in costs incurred for reasons other than organ transplantation and thus
require adjustments.
Types of adjustments entered on this worksheet include (1) adjustment to expenses to reflect actual
cost incurred, (2) adjustment that constitute a recovery of costs through sales, charges , or fees, (3)
adjustment to expenses in accordance with the Medicare principles of reimbursement, and
(4)adjustments for those items that are provided for separately in the cost apportionment process.
When an adjustment to an expense affects more than one cost center, record the adjustment to each
cost center on a separate line on Worksheet A-5.

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FORM CMS-216-94

06-15

Lines 1 and 2.--Do not consider discounts, allowances, refunds, and rebates a form of income. Use
them to reduce the specific costs to which they apply in the accounting period in which the purchase
occurs. (See CMS Pub. 15-1, chapter 8 Purchases Discounts and Allowances and Refunds.)
Line 3.--Enter the allowable home office costs which have been allocated to the OPO/Lab. The
home office cost report on which the allocation is made must be submitted to the contractor. (See
CMS Pub. 15-2, chapter 1, Depreciation §112.) For cost reporting periods beginning on or after
January 1, 2015, do not use this line. Home office costs must be reported on Supplemental
Worksheet A-5-1.
Line 4.--Obtain the amount to be entered on this line from Supplemental Worksheet A-5-1, Part B,
column 6, line 5. Worksheet A-5-1, represents the detail of various cost centers to be adjusted on
Worksheet A. (See CMS Pub. 15-1, chapter 10.)
Line 5.--Enter the total amount received from the procurement of any tissues such as corneas, bone,
heart valves, pancreas islet, and skin. Do not offset income for solid organ acquisitions, such as
livers, hearts, pancreas, and lungs, as they must go through cost finding on Worksheet B.
Line 6.--Remove the direct cost and applicable overhead of operating vending machines from
allowable cost. If cost cannot be calculated, then income received may be used.
Line 7.--Use income received from the rental or lease of equipment to reduce the cost of specific
equipment. When a building is owned or operated by the OPO/Lab and space is leased or rented, the
preferable treatment is to establish a non-reimbursable cost center on Worksheet A, line 25. Record
in this cost center the direct cost plus all applicable overhead of the rented or leased space. A
separate calculation of the cost of leased space may be acceptable and the cost offset on line 7 of
Worksheet A-5 when the amount of the adjustment is minor. Only in rare situations is the rental or
lease income used as the offset on this line. If space is leased or rented to an outside organization for
the provision of a service needed for kidney transplantation (such as a perfusion lab), then the
income received from the organization for rent must be offset on this line.
Line 8.--Enter the amount of proceeds from the sale of organs which were retrieved exclusively for
research (known prior to retrieval) and sold.
Line 9.--Enter the costs incurred for public relations not related to organ procurement. See CMS
Pub 15-1, §2136 for an explanation of this area.
Line 10.--Offset revenue received from fees charged to attendees for OPO/lab conducted seminars
and meetings against A&G. If a good faith effort is made to recover the costs in the form of fees,
CMS allows the costs not fully recovered.
Line 11.--The amount received from the sale of supplies to employees and others is a recovery of
cost and must be offset against the specific expenses.
Line 12.--Offset the amount received in investment income against interest expense. (See CMS Pub.
15-1, chapter 2, Interest Expense)

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3310

Lines 13 and 14.--If depreciation expense computed in accordance with Medicare principles of
reimbursement differs from the depreciation expenses shown on your books, enter the difference on
line 13 and/or 14. (See CMS Pub. 15-1, chapter 1 Depreciation.) Examples of possible situations
are:
1. When the OPO/Lab utilizes the double declining balance method of depreciation on assets
purchased after August 1, 1970, the expense claimed on Worksheet A must be adjusted to reflect the
straight line method;
2. When the replacement cost method of accounting for fixed assets and depreciation has
been used, it must be adjusted to straight line;
3. When the 20 percent bonus depreciation has been used for book purposes, it must be
adjusted to straight line; and
4. When 150 percent declining balance has been used without approval, an adjustment is
required.
When adjustments are required due to differences in useful lives or depreciation methods, maintain
the fixed asset and depreciation records to support the depreciation expense allowed by Medicare
principles of reimbursement.
Line 17.--The total amount shown in column 2 must agree with Worksheet A, column 6, line 26.
Post the amounts shown in column 2 to the appropriate line of Worksheet A, column 6.
3310.

WORKSHEET A-6 - CAPITAL EXPENDITURES AND DEPRECIATION RECONCIL­
IATION

Part I – Analysis Of Changes In Capital Asset Balances During The Cost Reporting Period
Complete the analysis of changes in capital asset balances during the cost reporting period. Do not
reduce the amount by accumulated depreciation. The beginning balance refers to the amount as of
the first day of the cost reporting period.
Part II – Analysis Of Changes In Accumulated Depreciation
The analysis of changes in accumulated depreciation is completed in a similar manner to the asset
section in the first half of the form.
Part III – Depreciation Recorded in Cost Statement
Lines 1, 2, and 3.--Enter on the appropriate line the amount of depreciation used during the cost
reporting period. The amounts shown are after any adjustments made to recognize the Medicare
principles of reimbursement relating to depreciation. (See CMS Pub. 15-1, chapter 1.)
Line 4.--Enter the total of lines 1 through 3. This amount equals the amount of allowable
depreciation expense that is included on Worksheet A, column 7, lines 1 and 2. The sum of the
amounts on lines 1 and 2 of Worksheet A may be an amount greater than line 4 of Worksheet A-6.
This is due to column 7 of Worksheet A having reclassified costs included with depreciation, i.e.,
insurance and taxes.
Line 5.--Indicate whether a funded depreciation account was maintained during the period as defined
in CMS Pub. 15-1, chapter 2, §226. If a fund was maintained, list the ending balance of the fund.
Line 6.--Indicate whether there was a gain or loss on the sale of assets during the cost reporting
period. (See CMS Pub. 15-1, chapter 2, §132.) Do not complete for cost reporting periods ending
on or after December 1, 1997.
Rev. 6
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3311
3311.

FORM CMS-216-94

06-15

WORKSHEET B - COST ALLOCATION - GENERAL SERVICE COSTS AND
WORKSHEET B-1 COST ALLOCATION - STATISTICAL BASIS

Cost finding is the process of recasting the data derived from the accounts ordinarily kept by the
facility 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. The various cost finding
methods recognized are outlined in 42 CFR 413.24. Worksheets B and B-1 have been designed to
accommodate the step-down method of cost finding.
Worksheet B provides for cost finding using a methodology which combines similar types of costs
and apportions the costs to those cost centers which receive the services. The cost centers that are
serviced include all reimbursable and nonreimbursable cost centers within the facility. The total
direct expenses are obtained from Worksheet A, column 7. Schedule B-1 provides the statistics
necessary to allocate the cost to the revenue producing cost centers on Worksheet B. To facilitate the
allocation process, the general format of Worksheets B and B-1 are identical. The column and line
numbers for the general service cost centers are identical on the two worksheets.
The statistical allocation bases shown at the top of each column on Worksheet B-1 are the bases of
allocation of cost centers indicated. Certain centers are combined for cost allocation purposes.
OPOs and Labs must combine and allocate these costs as shown on the worksheet. Per CMS Pub.
15-1, chapter 23, §2313, a provider can change the order of allocation and/or allocation basis, as
appropriate, for the current cost reporting period if they submit a written request to their contractor,
90 days prior to the end of the reporting period and the contractor approves the request. The total
costs of each combined group of cost centers are allocated in one process to the revenue producing
and nonreimbursable cost centers.
On Worksheet B-1, enter on line 16 in each column the total statistical base over which the expenses
are allocated. For example in column 2, Cap-Bldg, OP Plant & Housekeeping, enter on line 16 the
total square feet of the facility. For all cost centers that column 2 costs should be allocated, enter that
portion of the total statistical base applicable to each. The sum of the statistical base applied to each
cost center receiving the services rendered must equal the total base entered on line 16. The statistics
shown on Worksheet B-1 are multiplied by the unit cost multiplier on line 18 of Worksheet B-1.
Place the result on the corresponding line and column of Worksheet B.
Column Descriptions
Column 1.--Enter the direct costs for allocation from Worksheet A, column 7. Column 1, line 1
must equal the sum of the amounts on Worksheet A, column 7, lines 1 through 8.
Column 2.--Enter on Worksheet B, all costs that are allocated on the statistical basis of square feet
(sum of Worksheet A, column 7, lines 1, 5 and 6). Enter on Worksheet B-1 using the statistical basis
square feet, the actual square footage contained in each department or cost center. Include in the
organ acquisition cost center the square footage for the area occupied by the coordinators, the direct
clerical staff, files, etc.
Column 3.--Enter on Worksheet B, the costs from Worksheet A, column 7, line 2. The
recommended statistical basis on Worksheet B-1 is the dollar value of capital related movable
equipment located in each department.
Column 4.--Enter on Worksheet B, the costs from Worksheet A, column 7, line 3 that are allocated
on the statistical basis of direct salaries. The direct salaries statistics on Worksheet B-1 generally
are from Worksheet A, column 1 for each department. However, the salaries may need to be
adjusted to reflect changes to salaries shown as reclassifications and adjustments in columns 5 and 7
of Worksheet A. When a large number of changes to salaries are necessary, attach a separate
schedule to show the accumulation and reclassification of salaries by cost center.
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Column 5.--Enter on Worksheet B, the costs from Worksheet A, column 7, line 7. The
recommended statistical basis on Worksheet B-1 is costed requisition. Enter on Worksheet B-1, the
costed requisition amount of medical supplies for each department.
Column 6.--Enter on Worksheet B, the costs of other overhead specified on Worksheet A, column 7,
line 8. Other overhead costs are allocated on Worksheet B-1, using an appropriate basis. If
Worksheet A, line 8 is subscripted, subscript column 6 accordingly.
Column 7.--Do not use for cost reporting periods beginning on or after May 1, 2012.
Column 8.--Enter on Worksheet B, the direct and indirect costs, sum of columns 1 through 7
associated with internal organ acquisitions. The total costs accumulated in column 8, line 2, are
allocated to the specific types of organ acquisition based on the number of organs procured. Utilize
the statistics (number of organs procured) on Worksheet B-1. The number of organs procured means
the total number of solid organs procured during the period including imported organs as well as
nonviable organs. For overhead allocation purposes, count a heart/lung acquisition as one organ.
Column 9.--Enter the sum of columns 1 through 8, for each cost center on Worksheet B. The sum
for each cost center is the accumulated cost statistic. Unless an adjustment is required, enter the sum
for each cost center on Worksheet B-1, column 10 as the statistic for allocating A&G costs.
Columns 10 and 10A.--Accumulated costs are used to allocate A&G costs on Worksheet B, column
10. Enter the accumulated costs from Worksheet B, column 9 to Worksheet B-1, column 10. If an
adjustment to the accumulated cost statistic on Worksheet B-1, column 10, is required to properly
allocate A&G costs, enter the adjustment amount on Worksheet B-1, column 10A for the applicable
cost center and adjust column 10 accordingly.
Note: In accordance with CMS Pub. 15-1 §2314, allocation of indirect costs to a cost center that
includes only the cost of the Medicare portion would result in excessive assignment of indirect costs
to the program. For example, when the transportation costs for non-renal organs and tissue typing
materials are billed directly to the receiving transplant center and renal organs transportation costs
remain at the OPO, the reconciliation column on Worksheet B-1, column 10A, should be used to
reduce transportation costs from the accumulated cost statistic.
Column 11.--Enter on Worksheet B, the sum of columns 9 and 10. Total expenses in column 11
represent the full cost (direct and indirect) used for settlement purposes. Transfer kidney acquisition
costs on line 3, to Worksheet C, Part I, line 4. Transfer the tissue typing lab costs on line 4, to
Worksheet C, Part II, line 4. The remaining lines 5 through 14 are considered non-reimbursable
costs.
Line Descriptions - (For lines 1 through 16, enter on Worksheet B, column 1)
Line 1.--Enter the general overhead costs from Worksheet A, column 7, sum of lines 1 through 8.
These costs are allocated in columns 2 through 7 and 10. The sum of columns 2 through 7 and 10,
line 1 must equal line 1, column 1. The costs in columns 2 through 7, line 1 are allocated to the cost
centers listed on lines 2 through 14 or 15.
Line 2.--Enter the costs from Worksheet A, column 7, lines 9 through 12. After all overhead has
been allocated, allocate organ acquisition costs to the various types of organ acquisition in column 8.
Line 3.--Enter the total cost from Worksheet A, column 7, line 13. After the completion of overhead
allocations, transfer the total costs in column 11 to Worksheet C, Part I, line 4.
Line 4.--Enter the total cost from Worksheet A, column 7, line 14. After the completion of overhead
allocations, transfer the total costs in column 11 to Worksheet C, Part II, line 4.
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Lines 5.--Enter the total cost from Worksheet A, column 7, line 15. This line captures the total costs
(direct and indirect) of this nonreimbursable cost center.
Lines 6.--Enter the total cost from Worksheet A, column 7, line 16. This line captures the total costs
(direct and indirect) of this nonreimbursable cost center.
Lines 7.--Enter the total cost from Worksheet A, column 7, line 17. This line captures the total costs
(direct and indirect) of this nonreimbursable cost center.
Lines 8.--Enter the total cost from Worksheet A, column 7, line 18. This line captures the total costs
(direct and indirect) of this nonreimbursable cost center.
Lines 9.--Enter the total cost from Worksheet A, column 7, line 19 or line 20. If Worksheet A, line
19 or 20 is subscripted, subscript line 9 accordingly. This line captures the total costs (direct and
indirect) of this nonreimbursable cost center. Effective for cost reporting period beginning on or
after May 1, 2012, Worksheet A, line 20 is not used.
Lines 10.--Enter the total cost from Worksheet A, column 7, line 21. This line captures the total
costs (direct and indirect) of this nonreimbursable cost center.
Lines 11.--Enter the total cost from Worksheet A, column 7, line 22. This line captures the total
costs (direct and indirect) of this nonreimbursable cost center.
Lines 12.--Enter the total cost from Worksheet A, column 7, line 23. This line captures the total
costs (direct and indirect) of this nonreimbursable cost center.
Lines 13.--Enter the total cost from Worksheet A, column 7, line 24. This line captures the total
costs (direct and indirect) of this nonreimbursable cost center.
Lines 14.--Enter the total cost from Worksheet A, column 7, line 25. If Worksheet A, line 25 is
subscripted, subscript line 14 accordingly. This line captures the total costs (direct and indirect) of
this nonreimbursable cost center.
Line 15.--Do not use for cost reporting periods beginning on or after May 1, 2012.
Line 16.--Enter in column 1, the sum of lines 1 through 14 or 15. This amount must agree with
Worksheet A, column 7, line 26. Columns 2 through 8 and 10 are zero since the costs on line 1 are
negative and are allocated to the cost centers in lines 2 through 14 or 15, as appropriate. Enter in
column 11, the sum of lines 1 through 14 or 15
Line 17.--Enter on Worksheet B-1 the costs to be allocated from Worksheet B. Transfer these costs
from the appropriate column of Worksheet B, line 1. Transfer organ acquisition costs in column 8
from Worksheet B, line 2, column 8.
Line 18.--Enter on Worksheet B-1 for each column, the result of dividing line 17 by line 16. This
unit cost multiplier rounded to six (6) decimal places. Multiply the unit cost multiplier by that
portion of the total statistics applicable to each cost center receiving the services rendered. Enter the
result of each computation on Worksheet B, in the corresponding column and line.

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3312.

FORM CMS-216-94

3312 (Cont.)

WORKSHEET C - COMPUTATION OF MEDICARE COST

Part I - Kidney Acquisition
Line 1.--Enter the total number of viable kidneys procured from Worksheet S-1, Part I, line 3,
column 3.
Line 2.--These are kidneys sent to Medicare transplant centers or certified OPOs. It does not include
kidneys sent to foreign countries, VA hospitals, or military hospitals. Kidneys sent to a military
transplant center that has a reciprocal sharing agreement with the OPO may be included on this line.
However, this agreement must be approved by the contractor and have been in effect prior to
March 3, 1988. Kidneys reported on this line must also be included in total viable kidneys reported
on line 1.
Line 3.--Divide the amount on line 2 by the amount on line 1 and enter the result, rounded to 6
decimal places.
Line 4.--Enter the total cost of kidney acquisition from Worksheet B, column 11, line 3 or Worksheet
A, column 7, line 26, as appropriate. (See instructions in §3304 for Worksheet A, column 7, and
Worksheet A, line 26, item 2.)
Line 5.--Multiply the ratio on line 3 times the cost on line 4. Transfer the result to Worksheet D,
column 1, line 1.
Part II - Tissue Typing Laboratory
The gross ratio of Medicare charges to total charges applied to cost is the formula used to calculate
Medicare reimbursable cost for kidney transplant related tests. This formula requires that the amount
charged for each test be the same for all types of payers for similar services, e.g., Histocompatibility
Locus Antigen (HLA) typing is charged at the same rate for a kidney transplant patient, paternity,
and bone marrow. The amount recorded as the charge or revenue must be the gross charge prior to
any discounts or contractual allowances.
Line 1.--Enter the gross charges recorded for all tests (renal and non-renal) performed in the tissue
typing lab. The amount is prior to any discounts or contractual allowances. Base this amount on the
accrual basis of accounting.
Line 2.--Enter the gross charges recorded for pre-transplant kidney related tissue typing tests. This
amount is prior to discounts or contractual allowances and is on the accrual basis of accounting.
NOTE: If the cost report is a partial year under the program (e.g., expenses are from July 1 - June
30, but cost reimbursement is effective April 1 or three of the twelve months), show on
line 2 only the kidney related charges starting with the effective date of cost
reimbursement.
Line 3.--Divide the amount on line 2 by the amount on line 1 and enter the result, rounded to 6
decimal places.
Line 4.--Enter the total cost of the tissue typing lab from Worksheet B, column 11, line 4 or
Worksheet A, column 7, line 26, as appropriate. (See instructions in §3304 for Worksheet A,
column 7, and Worksheet A, line 26, item 3.)
Line 5.--Multiply the ratio on line 3 times the amount on line 4. Transfer the result to Worksheet D,
column 2, line 1.
Rev. 6

33-21

3313
3313.

FORM CMS-216-94

06-15

WORKSHEET D - CALCULATION OF REIMBURSEMENT SETTLEMENT

Line 1, Column 1.--Enter the amount from Worksheet C, Part I, line 5.
Line 1, Column 2.--Enter the amount from Worksheet C, Part II, line 5.
Lines 2 through 8, Columns 1 and 2.-­
Line 2.--Enter the amount received for lab services furnished to transplant centers in foreign
countries, military hospitals, and VA hospitals. Foreign transplant centers, military, and VA
hospitals are not in the Medicare program. Use the amounts received as a reduction of cost.
Line 3.--Enter the total reimbursable cost to OPO/Lab (the amount on line 1 minus the amount on
line 2).
Line 4.--Enter the amount of payments received or receivable from transplant hospitals or other
OPOs for furnishing organ procurement and tissue typing services for kidney transplant or tissue
typing laboratory services. It includes all payments received for furnishing kidneys to transplant
hospitals (non-military) and to other OPOs.
Line 5.--Enter the result of line 3 minus line 4.
Line 6.--For cost reports that overlap or begin on or after April 1, 2013, enter the sequestration
adjustment amount as (2 percent times (total days in the cost reporting period that occur during the
sequestration period beginning on or after April 1, 2013, divided by total days in the entire cost
reporting period, rounded to four decimal places)) times Medicare reimbursable costs, line 5. When
line 5 shows an amount due the program, make no adjustment on this line.
Line 7.--Enter all payments received from the contractor for furnishing organ procurement and tissue
typing services for kidney transplants (from contractor records).
Line 8.--Enter the net amount due to/from the OPO/Lab (line 5 minus the sum of lines 6 and 7).
3314.

WORKSHEET E - BALANCE SHEET

Complete the balance sheet in a manner consistent with the financial statements of the OPO/Lab. If
fund type accounting records are maintained, combine and place all funds in the general fund
columns. Certified accounting statements by an independent certified public accounting firm are
acceptable if the detail is equal to that of Worksheet E.
3315.

WORKSHEET E-1 - STATEMENT OF OPERATING EXPENSES AND REVENUES

This worksheet shows the revenues and expenses generated from the provision of services and does
not include other revenue or nonoperating revenue and expenses. This worksheet must be completed
by all OPOs/Labs.
3316.

WORKSHEET E-2 - STATEMENT OF REVENUES AND EXPENSES

This worksheet provides for the recording of other income and nonoperating revenues and expense
and all adjustments that are required to show the net income or loss for the period. The net income
or loss shown on line 29 must agree with the financial statements prepared under the accrual basis of
accounting.

33-22

Rev. 6

06-15
3317.

FORM CMS-216-94

3317

SUPPLEMENTAL WORKSHEET A-5-1 - 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 413.14(d)), costs applicable to
services, facilities, and supplies furnished to an OPO or lab by organizations related by common
ownership or control are includable in the allowable cost of the facility at the cost to the related
organization. This worksheet provides for the computation of any needed adjustments to costs
applicable to services, facilities, and supplies furnished to the facility by related organizations or
costs associated with the home office. (See CMS Pub. 15-1, chapter 10.)
Part A.--This worksheet must be completed by all facilities. If the answer to Part A is "Yes",
complete Parts B and C.
Part B.--Costs applicable to services, facilities, and supplies furnished to you by a home office or
other organizations related to you by common ownership or control, are includable in your allowable
cost at the cost to the related organization. However, such costs must not exceed the amount a
prudent and cost conscious buyer would pay for comparable services, facilities, and supplies that
could be purchased elsewhere.
Part C.--Use this part to show your interrelationship to organizations furnishing services, facilities,
and supplies to you. The requested data relative to all individuals, partnerships, corporations or other
organizations having either a related interest to you, a common ownership of the facility, or control
over you as defined in CMS Pub. 15-1, chapter 10, must be shown in columns 1 through 6 as
appropriate.
Complete only those columns which are pertinent to the type of relationship which exists.
Column 1.--Enter the appropriate symbol which describes your interrelationship to the related
organization.
Column 2.--If the symbol A, D, E, F, or G is entered in column 1, enter the name of the related
individual in column 2.
Column 3.--If the individual indicated in column 2 or the organization indicated in column 4 has a
financial interest in the facility, enter the percent of ownership/control in such organization.
Column 4.--Enter the name of the related corporation, partnership, or other organization.
Column 5.--If the individual indicated in column 2 or the facility has a financial interest in the related
organizations, enter the percent of ownership/control in such organization.
Column 6.--Enter the type of business in which the related organization engages (e.g., medical drugs
and/or supplies, laundry and linen service).

Rev. 6

33-23

3318

FORM CMS-216-94

3318.

06-15

KIDNEY PLACEMENT EFFORTS - DOCUMENTATION REQUIREMENTS

To ensure proper utilization and distribution of kidneys, OPOs and certified transplant centers
(CTCs) furnishing organ procurement services for kidney transplants under the Medicare program
must maintain adequate and verifiable records for each kidney retrieved and furnished to a Medicare
patient. Since it is not possible to determine at the time of retrieval whether an individual kidney
will be placed with a Medicare beneficiary, a placement effort record must be maintained for every
kidney.
A. For each kidney retrieved, independent and hospital-based OPOs and CTCs must maintain
a record (e.g., a log) showing the attempts to place the kidney with Medicare transplant patients and
the final disposition of the kidney. Include the following information:
o
Name of individual making calls;
o
Name of donor;
o
Time (date, hour, minute, e.g., 11/18/86, 9:45 p.m.) of retrieval;
o
Name of donor center;
o
Name and telephone number of each OPO/CTC contacted as a potential user, including the
name of the person talked to at the OPO/CTC and the time (date, hour, and minute) of contact;
o
Name of OPO or CTC that accepts the kidney and time and date sent;
o
Disposition of the kidney if not placed, i.e., non-viable; and
o
Age of kidney when shipped.
Attach to the log a copy of their computer printout on the kidney.
B. Independent and hospital-based OPOs and CTCs that are offered kidneys must maintain
records (e.g., a log) containing the following information:
o
Name and telephone number of OPO or CTC offering the kidney;
o
Name of donor;
o
Time (date, hour, and minute) of retrieval or age of the organ at time of offering;
o
If accepted, indicate time accepted, name of recipient, and social security number (or
health insurance number), or other identifying information; and
o
Reason kidney not accepted (if applicable).
C.

33-24

Furnish the information in subsections A and B to the contractor upon request.

Rev. 6

06-15

FORM CMS-216-94

3390

EXHIBIT 1

The following is a listing of the Form CMS –216-94 worksheets and the page number location.
Worksheets

Page(s)

Wkst. S.....................................................................................................33-303

Wkst. S-1 .................................................................................................33-304

Wkst. A ...................................................................................................33-305

Wkst. A-1.................................................................................................33-306

Wkst. A-2 ................................................................................................33-307

Wkst. A-3 ................................................................................................33-308

Wkst. A-4 ................................................................................................33-309

Wkst. A-5.................................................................................................33-310

Wkst. A-6.................................................................................................33-311

Wkst. B ...................................................................................................33-312

Wkst. B-1 .................................................................................................33-313

Wkst. C ...................................................................................................33-314

Wkst. D ...................................................................................................33-315

Wkst. E.....................................................................................................33-316

Wkst. E-1 .................................................................................................33-317

Wkst. E-2 .................................................................................................33-318

Supp. Wkst. A-5-1 ...................................................................................33-319

Rev. 6

33-301

3390 (Cont.)

FORM CMS-216-94

06-15

Intentionally left blank

33-302

Rev. 6

06-15

FORM CMS 216-94

3395

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94

TABLE OF CONTENTS
Topic

Page(s)

Table 1:

Record Specifications

33-503 - 33-508

Table 2:

Worksheet Indicators

33-509 - 33-511

Table 3:

List of Data Elements With Worksheet, Line, and Column
Designations

33-512 - 33-520

Table 3A:

Worksheets Requiring No Input

33-521

Table 3B:

Tables to Worksheet S-2

33-521

Table 3C:

Lines That Cannot Be Subscripted

Table 4:

Reserved for future use

Table 5:

Cost Center Coding

Table 6:

Edits:

Rev. 6

33-521 - 33-522
33-523 - 33-526

Level I Edits

33-527 - 33-529

Level II Edits

33-530 - 33-532

33-501

3395 (Cont.)

FORM CMS-216-94

06-15

This page intentionally left blank.

33-502

Rev. 6

06-15

FORM CMS-216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94

TABLE 1 - RECORD SPECIFICATIONS

Table 1 specifies the standard record format to be used for electronic cost reporting. Each electronic
cost report submission (file) has three types of records. The first group (type one records) contains
information for identifying, processing, and resolving problems. The text used throughout the cost
report for variable line labels (e.g., Worksheet A) and variable column headers (Worksheet B-1) is
included in the type two records. Refer to Table 5 for cost center coding. The data detailed in Table
3 are identified as type three records. The encryption coding at the end of the file, records 1, 1.01,
and 1.02, are type 4 records.
The medium for transferring cost reports submitted electronically to contractors is CD, flash drive, or
contractor-approved form such as electronic mail, or secured website. The character set must be
ASCII. You must seek approval from your contractor regarding alternate methods 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 01P002201427420152735A99P001201532020140274

1
4
14:30

Record #1:

Rev. 6

This is a cost report file submitted by CCN 01P002 for the period from October 1,
2014 (2014274) through September 30, 2015 (2015273). It is filed on the Form
CMS-216-94. 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 OPO on November 16, 2015
(2015320). The electronic cost report specifications, dated October 1, 2014
(2014274), are used to prepare this file.

33-503

3395 (Cont.)

FORM CMS-216-94

06-15

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:
OPNNPNNN.YYLC, where
1. OP (OPO and Histocompatibility Lab electronic cost report) is constant;
2. NNXXNN is the 6 digit CCN consisting of two digits and a P, followed by three digits for
an OPO or an OPO based Tissue Typing Lab, and two digits and an HL, followed by two
digits for a Histocompatibility Lab.
3. YY is the year in which the cost reporting period ends; and
4. L is a character variable (A-Z) to enable separate identification of files from OPO/HL 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. NNXXNN is the 6 digit CMS Certification Number;
3. YY is the year in which the provider's cost reporting period ends; and
4. L is a character variable (A -Z) to enable separate identification of files from OPOs 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
Size Usage
Loc.
Remarks
1. Record Type

1

X

1

Constant "1"

10

9

2-11

Numeric only

3. Spaces

1

X

12

4. Record Number

1

X

13

5. Spaces

3

X

14-16

6. OPO/LAB CCN

6

9

17-22

Field must have 6 alphanumeric
characters.

7. Fiscal Year
Beginning Date

7

9

23-29

YYYYDDD - Julian date; first day
covered by this cost report

8. Fiscal Year
Ending Date

7

9

30-36

YYYYDDD - Julian date; last day
covered by this cost report

9. MCR Version

1

9

37

Constant "7" (for FORM CMS-216-94)

10. Vendor Code

3

X

38-40

To be supplied upon approval. Refer to
page 32-503.

11.

1

X

41

2. NPI

33-504

Vendor Equipment

Constant "1"

P = PC; M = Main Frame

Rev. 6

06-15

FORM CMS 216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-14

TABLE 1 – RECORD SPECIFICATIONS

RECORD NAME: Type 1 Records - Record Number 1 (Cont.)

12. Version Number

3

X

42-44

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).

13. Creation Date

7

9

45-51

YYYYDDD – Julian date; date on
which the file was created (extracted
from the cost report)

14. ECR Spec. Date

7

9

52-58

YYYYDDD – Julian date; date of
electronic cost report specifications used
in producing each file. Valid for cost
reporting periods beginning on or after
2014121 (May 1, 2014).
Prior
approvals 2013091, 2004366.

RECORD NAME: Type 1 Records - Record Numbers 2 - 99
Size Usage
Loc.
Remarks
1.

Record Type

1

9

1

2.

Spaces

3.

Constant "1"

10

X

2-11

Record Number

2

9

12-13 #2-99 - Reserved for future use.

4.

Spaces

7

X

14-20 Spaces (optional)

5.

ID Information

40

X

21-60 Left justified to position 21.

RECORD NAME: Type 2 Records for Labels
Size Usage Loc.
Remarks
1.

Record Type

1

9

1

2.

Wkst. Indicator

7

X

2-8

3.

Spaces

2

X

9-10

4.

Line Number

3

9

11-13 Numeric

5.

Subline Number

2

9

14-15 Numeric

6.

Column Number

3

X

16-18 Alphanumeric

7.

Subcolumn Number

2

9

19-20 Numeric

4

9

21-24

8. Cost Center Code

Rev. 6

Constant "2"
Alphanumeric. Refer to Table 2.

Numeric.
Refer to Table 5 for
appropriate cost center codes.

33-505

3395 (Cont.)

FORM CMS 216-94

06-15

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94

TABLE 1 - RECORD SPECIFICATIONS

RECORD NAME: Type 2 Records for Labels

9.

Labels/Headings
a. Line Labels

36

X

25-60

Alphanumeric, left justified

b. Column Headings
Statistical Basis
& Code

10

X

21-30

Alphanumeric, left justified

The type 2 records contain both the text that appears on the pre-printed cost report and any labels
added by the preparer. Of these, there are three groups: (1) Worksheet A cost center names (labels);
(2) column headings for stepdown entries; and (3) other text appearing in various places throughout
the cost report.
A Worksheet A cost center label must be furnished for every cost center with cost or charge data
anywhere in the cost report. The line and subline numbers for each label must be the same as the
line and subline numbers of the corresponding cost center on Worksheet A. The columns and
subcolumn numbers are always set to zero.

33-506

Rev. 6

06-15

FORM CMS 216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94

TABLE 1 - RECORD SPECIFICATIONS

Column headings for the General Service cost centers on Worksheets B and B-1 are supplied once.
They consist of one to three records. Each statistical basis shown on Worksheet B-1 is also to be
reported. The statistical basis consists of one or two records (lines 4-5). Statistical basis code is
supplied only to Worksheet B-1 columns and is recorded as line 6. The statistical code must agree
with the statistical bases 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.
The following type 2 cost center descriptions are to be used for all Worksheet A standard cost center
lines.
Line
1
2
3
4
5
6
7
9
10
11
13
14
15
16
17
18
21
22
23
24

Rev. 6

Description
CAPITAL COSTS-BLDG & FIXT
CAPITAL COSTS-MVBLE EQUIPMENT
EMPLOYEE BENEFITS
ADMINISTRATIVE & GENERAL
OPERATION AND MAINTENANCE OF PLANT
HOUSEKEEPING
MEDICAL SUPPLIES
PROCUREMENT COORDINATORS
PROFESSIONAL EDUCATION
PUBLIC EDUCATION
KIDNEY ACQUISITIONS
TISSUE TYPING LABORATORY
LIVER ACQUISITIONS
HEART ACQUISITIONS
PANCREAS ACQUISITIONS
LUNG ACQUISITIONS
RESEARCH
BLOOD BANK
LABORATORY-NON-TISSUE TYPING
DIALYSIS UNITS

33-506.1

3395 (Cont.)

FORM CMS 216-94

06-15

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94

TABLE 1 - RECORD SPECIFICATIONS

Type 2 records for Worksheet B-1, columns 1-8, and 10 for lines 1-6 are listed below. The numbers
running vertical to line 1 descriptions are the general service cost center line designations.

2
3
4
5
8
10

1

2

CAP BLDG
CAP COSTS
EMPLOYEE
MEDICAL
ORGAN
ADMIN &

OP PLANT &
MOVABLE
BENEFITS
SUPPLIES
ACQUISITN
GENERAL

LINE
3
HOUSEKEEP
EQUIPMENT
COSTS

4
SQUARE
DOLLAR
ADJUST
COSTED
NUMBER
ACCUM

5
FEET
VALUE
SALARIES
REQUISIT
ORGANS
COSTS

6
1
2
3
3
3
3

Examples of type 2 records are below. Either zeros or spaces may be used in the line, subline,
column, and subcolumn number fields (positions 11-20). However, spaces are preferred. Refer to
Table 5 and 6 for additional cost center code requirements.
Examples:
Worksheet A line labels with embedded cost center codes:
2A000000
2A000000
2A000000
2A000000
2A000000
2A000000

1
2
3
5
6
7

0100CAPITAL COSTS-BLDG & FIXT
0200CAPITAL COSTS-MVBLE EQUIP
0300EMPLOYEE BENEFITS
0500OPERATION & MAINT OF PLANT
0600HOUSEKEEPING
0700MEDICAL SUPPLIES

Examples of column headings for Worksheets B-1 and B; statistical bases used in cost allocation on
Worksheet B-1 ; and statistical codes used for Worksheet B-1 (line 6) are displayed below
2B10000*
2B10000*
2B10000*
2B10000*
2B10000*
2B10000*

33-506.2

1
2
3
4
5
6

3
3
3
3
3
3

CAP COSTS
MOVABLE
EQUIPMENT
DOLLAR
VALUE
2

Rev. 6

06-15

FORM CMS 216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94

TABLE 1 - RECORD SPECIFICATIONS

RECORD NAME: Type 3 Records for Nonlabel Data

Size

Usage

Loc.

Remarks

1.

Record Type

1

9

1

2.

Wkst. Indicator

7

X

2-8

3.

Spaces

2

X

9-10

4.

Line Number

3

9

11-13

Numeric

5.

Subline Number

2

9

14-15

Numeric

6.

Column Number

3

X

16-18

Alphanumeric

7.

Subcolumn Number

2

9

19-20

Numeric

8.

Field Data
36

X

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.

4

X

57-60

Spaces (optional).

16

9

21-36

Right justified. May contain embedded
decimal point. Leading zeros are
suppressed; trailing zeros to the right of
the decimal point are not. 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.

a. Alpha Data

b. Numeric Data

Constant "3"
Alphanumeric. Refer to Table 2.

A sample of type 3 records are below.
3A000000
3A000000
3A000000

Rev. 6

9
10
11

1

2

2

283833
50644
122693

33-507

3395 (Cont.)

FORM CMS 216-94

06-15

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94

TABLE 1 - RECORD SPECIFICATIONS

The line numbers are numeric. In several places throughout the cost report (see list below), the line
numbers themselves are data. The placement of the line and subline numbers as data must be
uniform.
Worksheet A-4, columns 3 and 6

Worksheet A-5, column 4

Supplemental Worksheet A-5-1, Part B, column 1

Examples of records (*) with a Worksheet A line number as data are below.

*
*

*
*

3A400010
3A400010
3A400010
3A400010
3A400010
3A400010

1
1
1
1
1
1

3A500010
3A500010
3A500010
3A500010

15
15
15
15

3A51000B
3A51000B
3A51000B
3A51000B

1
3
4
5

0
1
3
4
6
7

TO RECLASS TISSUE TYPING
A
13
345632
14
434711

0 RCH & ISLETS
1 A
2
-3900
4 9
1
1
1
1

7
MEDICAL SUPPLIES
5000
4000

RECORD NAME: Type 4 Records - File Encryption
This type 4 record consists of 3 records: 1, 1.01, and 1.02. These records are created at the point in
which the ECR file has been completed and saved to disk and insures the integrity of the file.

33-508

Rev. 6

06-15

FORM CMS-216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94

TABLE 2 - WORKSHEET INDICATORS

This table contains the worksheet indicators that are used for electronic cost reporting. A worksheet
indicator is provided for only those worksheets for which data are to be provided.
The worksheet indicator consists of seven digits in positions 2-8 of the record identifier. The first
two digits of the worksheet indicator (positions 2 and 3 of the record identifier) always show the
worksheet. The third digit of the worksheet indicator (position 4 of the record identifier) is used to
identify Supplemental Worksheet A-5-1. For Worksheets A-4 and A-5, if there is a need for extra
lines on multiple worksheets, the fifth and sixth digits of the worksheet indicator (positions 6 and 7
of the record identifier) identify the page number. The seventh digit of the worksheet indicator
(position 8 of the record identifier) represents the worksheet or worksheet part.
Worksheet

Rev. 6

Worksheet Indicator

S, Part I

S000001

S, Part III

S000003

S-1, Part I

S100001

S-1, Part II

S100002

S-1, Part III

S100003

A

A000000

A-1

A100000

A-2

A200000

A-3

A300000

A-4

A400010

A-5

A500010

A-6, Part A

A60000A

A-6, Part B

A60000B

A-6, Part C

A60000C

B-1 (For use in column
headings)

B10000*

B

B000000

B-1

B100000

(b)

(a)

33-509

3395 (Cont.)

FORM CMS-216-94

06-15

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94

TABLE 2 - WORKSHEET INDICATORS

Worksheet

33-510

Worksheet Indicator

C, Part I

C000001

C, Part II

C000002

D

D000000

E

E000000

E-1, Part I

E100001

E-1, Part II

E100002

E-2

E200000

Rev. 6

06-15

FORM CMS 216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94

TABLE 2 - WORKSHEET INDICATORS

FOOTNOTES:
(a) Multiple Worksheets for Reclassifications Before Stepdown
The fifth and sixth digits of the worksheet indicator (positions 6 and 7 of the record) are numeric
from 01-99 to accommodate reports with more lines on Worksheets A-4. For reports that do not
need additional worksheets, the default is 01. For reports that do need additional worksheets, the
first page is numbered 01. The number for each additional page of the worksheet is incremented
by 1.
(b) Multiple Worksheets A-2
This worksheet is used for kidney, liver, heart, pancreas, lung and other organ acquisition costs.
The fourth digit of the worksheet indicator (position 5 of the record) is an alpha character of K
for kidney, L for liver, H for heart, P for pancreas, U for lung and O for other. When more than
one “other organ” is identified the 7th digit of the worksheet indicator will be (1 to 9). The first
“other organ” indicator will always be zero. Two or more “other organ” indicators will be (1 to
9) (i.e. A20O000, A20O001).

Rev. 6

33-511

3395 (Cont.)

FORM CMS-216-94

06-15

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN

DESIGNATIONS

This table identifies those data elements necessary to calculate an OPO or Lab cost report. It also
identifies some figures from a completed cost report. These calculated fields (e.g., Worksheet B,
column 11) are needed to verify the mathematical accuracy of the raw data elements and to isolate
differences between the file submitted by the OPO or Lab complex and the report produced by the
fiscal intermediary. Where an adjustment is made, that record must be present in the electronic data
file. For explanations of the adjustments required, refer to the cost report instructions.
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 subline number
displayed as "01" or " 1" (with a space preceding the 1) in field locations 14-15. It is unacceptable to
format in a series of 10, 20, or skip subline numbers (i.e., 01, 03), except for skipping subline
numbers for prior year cost center(s) deleted in the current period or initially created cost center(s) no
longer in existence after cost finding. Exceptions are specified in this manual. For Other (specify)
lines, i.e., Worksheet settlement series, all subscripted lines should be in sequence and consecutively
numbered beginning with subscripted line number 01. Automated systems should reorder these
numbers where providers skip or delete a line 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 that are specified in Table 3 with a usage of "-9". Amounts that are within preprinted
parentheses on the worksheets, indicating the reduction of another number, are reported as positive
values.

33-512

Rev. 6

06-15

FORM CMS 216-94
3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN

DESIGNATIONS
DESCRIPTION
LINE(S) COLUMN(S) FIELD
USAGE
SIZE
WORKSHEET S
Part I

OPO or LAB Identification Data:

Name
Medicare Provider Number
Street
P.O. Box
City
State
Zip Code
PO based LAB Identification Data:
Name
Medicare Provider Number
Street
P.O. Box
City
State
Zip Code
Cost reporting period beginning
MM/DD/YYYY)
Cost reporting period ending
MM/DD/YYYY)
Type of control (See Table 3B.)
Type of Provider (See Table 3B.)
Participation Date (MM/DD/YYYY)
Part III

1
1
1.01
1.01
1.02
1.02
1.02

1
2
1
2
1
2
3

36
6
36
9
36
2
10

X
X
X
X
X
X
X

date

2
2
2.01
2.01
2.02
2.02
2.02
3

1
2
1
2
1
2
3
1

36
6
36
9
36
2
10
10

X
X
X
X
X
X
X
X

date

3

2

10

X

4
4
4

1
3
4

2
2
10

9
9
X

1

1-2

9

-9

Balances due provider or program:

WORKSHEET S-1
Part I
Total number of kidneys retrieved (viable and
nonviable)

1

1-3

9

9

Total number of kidneys included in line 1
that were non-viable

2

1-3

9

9

Total number of kidneys included in line 3,
column 3 that were exported out of local
retrieval area

4

1-3

9

9

Rev. 6

33-513

3395 (Cont.)

FORM CMS 216-94

06-15

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN

DESIGNATIONS
DESCRIPTION
LINE(S) COLUMN(S) FIELD
USAGE
SIZE
WORKSHEET S-1 (Continued)
Total number of kidneys sent to military or DVA
hospitals that were included in line 3, column 3

5

1-3

9

9

Amount received for kidneys listed in line 5

6

1-3

9

9

Was payment received for kidneys furnished to
foreign countries and included on line 4, column 2.
(Y/N)

7

1

1

X

If yes, total number of kidneys and amount
received.

7

2-3

9

9

Total number of organs/tissue other than kidneys

retrieved and administratively processed.

8-8.19

1

9

9

Nonviable Organs

8-8.19

2

9

9

Enter the amount of payment received for each

type of organ.

8-8.19

3

9

9

Total number of tests performed- all laboratory.

1

1

9

9

Total number of tests performed-tissue typing

laboratory.

2

1

9

9

Total number of pre-transplant tests performed for

kidney transplantation that are included in line 2.

3

1

9

9

Test Name

4-4.19

1

36

X

Number

4-4.19

2

9

9

1.03-1.19

1,3,5

36

X

Total Full time equivalent employees

1-1.19

2,4,6

6

9(3).99

Total Full time equivalent employees

2

1

6

9(3).99

Part II

Tissue typing pre-transplant tests performed for

kidney transplant:

Part III
Text as needed for blank line

33-514

Rev. 6

06-15

FORM CMS-216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN

DESIGNATIONS

DESCRIPTION
LINE(S) COLUMN(S) FIELD
USAGE
SIZE
WORKSHEET A
2-3,5-8,9­
12,21-25
Total direct salaries
26
1-3,5-8,9­
Other direct costs by department
12,21-25
Total other direct costs
26
1-3,5-8,9­
Net expense for allocation
12,21-25
Total expenses for allocation
26
WORKSHEET A-1
Other administrative and general (specify)
17-19
Salaries and wages by position
1-2,4-5,8,
11-12,15,
17-19
All other administrative and general costs by
1-15,17-19
position.
Total salaries and administrative and general
20
costs.

Direct salaries by department

1

9

-9

1

9

9

2

9

-9

2

9

9

7

9

-9

7

9

9

0

36

X

1

9

-9

2

9

-9

1-2

9

9

WORKSHEET A-2
Other excision hospital costs (specify)
Other acquisition costs (specify)

9
21

0
0

36
36

X
X

11-21

1

9

-9

All other organ acquisition costs by position.

1-9,11-21

2

9

-9

Total salaries and other organ acquisition
costs

23

1-2

9

9

Salaries and wages by position.

WORKSHEET A-3
Other administrative and general (specify)

6-10

0

36

X

Salaries and wages by position

1-4,6-10

1

9

-9

All other tissue typing laboratory costs by
position.

1-4,6-10

2

9

-9

1-2

9

9

Total salaries and tissue typing costs.

Rev. 6

11

33-515

3395 (Cont.)

FORM CMS 216-94

06-15

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN

DESIGNATIONS

DESCRIPTION

LINE(S)

COLUMN(S)

FIELD
SIZE

USAGE

WORKSHEET A-4
For each expense reclassification:
Explanation

1-35

0

36

X

Reclassification identification code

1-35

1

2

X

Worksheet A line number

1-35

3

5

9(2).99

Reclassification amount

1-35

4

9

9

Worksheet A line number

1-35

6

5

9(2).99

Reclassification amount

1-35

7

9

9

15-16

0

36

X

Basis (A or B)

1-3,5-16

1

1

X

Amount

1-3,5-16

2

9

-9

Worksheet A line number

1-3,5-16

4

5

9(2).99

1

1

1

X

Worksheet A line number

1-4

1

5

9(2).99

Expense item(s)

1-4

3

36

X

Amount included in Worksheet A

1-4

4

9

-9

Amount allowable in cost

1-4

5

9

-9

Increases:

Decreases:

WORKSHEET A-5
Description of adjustment

SUPPLEMENTAL WORKSHEET A-5-1
Part A - Are there any related organization
costs included on Worksheet A? (Y/N)
Part B - For costs incurred and adjustments
required as a result of transactions with
related organization(s):

33-516

Rev. 6

06-15

FORM CMS-216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN

DESIGNATIONS

DESCRIPTION

LINE(S)

COLUMN(S)

FIELD
SIZE

USAGE

SUPPLEMENTAL WORKSHEET A-5-1 (Continued)
Part C - For each related organization:
Type of interrelationship (A
through G)

1-4

1

1

X

If type is G, specify description of
relationship

1-4

0

36

X

Name of related individual

1-4

2

36

X

Percent owned by provider

1-4

3

6

9(3).99

Name

1-4

4

36

X

Percent ownership of provider

1-4

5

6

9(3).99

Type of business

1-4

6

15

X

7

0

36

X

Beginning balances

1-7

1

9

9

Purchases

1-7

2

9

9

Donations

1-7

3

9

9

Disposals and retirements

1-7

5

9

9

of

related corporation,
partnership or other

WORKSHEET A-6
Part A
Other (specify)
Analysis of changes in capital assets balances
during cost reporting period for land, land
improvements, buildings and fixtures, fixed
auto, truck and van, and other movable
equipment, and in total:

Part B
Analysis of changes in Accumulated
depreciation for land, land improvements,
buildings
and
fixtures,
building
improvements, fixed and moveable
equipment, auto, truck, van, and other assets

Rev. 6

32-517

3395 (Cont.)

FORM CMS-216-94

06-15

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN

DESIGNATIONS

DESCRIPTION

LINE(S)

COLUMN(S)

FIELD
SIZE

USAGE

WORKSHEET A-6 (Continued)
Other (specify)

8

0

36

X

Beginning balances

1-8

1

9

9

Additions

1-8

2

9

9

Deletions

1-8

3

9

9

Straight Line

1

1

9

9

Declining Balance

2

1

9

9

Sum of Years Digits

3

1

9

9

Total Depreciation reported on
Worksheet A, column 7

4

1

9

9

Is depreciation funded (Y/N)

5

1

1

X

If yes, balance in fund at end of
period

5

2

9

9

Was there a gain or loss on sale of
assets during the cost reporting
period? (Y/N)

6

1

1

X

WORKSHEETS B and B-1
1-3 *

1-10

10

X

4, 5 *

1-10

10

X

Part C
Depreciation Reported

Column heading (cost center name)
Statistical basis
*

Refer to Table 1 for specifications and Table 2 for the worksheet identifier 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 that has less than five type 2 record entries, blank
records or the word blank is not required to maximize each column record count.

33-518

Rev. 6

06-15

FORM CMS-216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN

DESIGNATIONS

FIELD
DESCRIPTION
LINE(S) COLUMN(S)
USAGE
SIZE
WORKSHEET B
Costs after cost finding by department
Total costs after cost finding

All cost allocation statistics

3-15

11

9

-9

16

11

9

9

WORKSHEET B-1
2-14

2-8, 10

9

9

Reconciliation

2-14

10A

9

9

Costs to be allocated

2-14

2-8, 10

9

9

WORKSHEET C
Parts 1–Kidney Acquisition
Total number of viable kidneys procured

1

1

11

9

Total number of kidneys

2

1

11

9

Gross revenues-tissue typing laboratory-all
tests

1

1

11

9

Gross revenues-tissue typing laboratory-kidney
transplant related tests only

2

1

11

9

2

11

9

Parts 2-Tissue Typing Laboratory

WORKSHEET D
Total revenues received for laboratory services
2
furnished to foreign countries, military and
DVA hospitals.
Total payments received and receivable from
OPOs and transplant hospitals for kidneys
furnished or laboratory services provided for
kidney transplantation

4

1-2

11

9

Sequestration adjustment

6

1-2

11

9

Interim payments

7

1-2

11

-9

Balance due provider or Medicare

8

1-2

11

-9

Rev. 6

33-519

3395 (Cont.)

FORM CMS-216-94

06-15

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN

DESIGNATIONS

DESCRIPTION
LINE(S) COLUMN(S) FIELD
USAGE
SIZE

Balance sheet account balances

WORKSHEET E
1-10, 12-26,
28-31, 33­
41, 43-48,
51- 57, 59
9, 26, 31, 39,
41, 46-48

Text as needed for blank lines

1

9

-9

0

36

X

WORKSHEET E-1
Part I
Total revenues by department

1-11

1-2

9

9

Text as needed for blank lines

6-9

0

36

X

Increases to operating expenses reported on
Worksheet A

2-5

1

9

9

Decreases to operating expenses reported on
Worksheet A

7-10

1

9

9

2-5, 7-10

0

36

X

WORKSHEET E-2
Contract allowance and discount on services
2

2

9

-9

Other income

7-23

1

9

9

Other expenses

26-27

1

9

9

29

2

9

-9

15-23,
26-27

0

36

X

Part II

Text as needed for blank lines

Net income
Text as needed for blank lines

33-520

Rev. 6

11-05

FORM CMS-216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94
TABLE 3A - WORKSHEETS REQUIRING NO INPUT
Worksheet B
TABLE 3B - TABLES TO WORKSHEET S, Part I
Type of Control
1
2
3
4
5
6
7
8
9
10
11
12

=
=
=
=
=
=
=
=
=
=
=
=

Type of Provider

Proprietary, Individual
Proprietary, Corporation
Proprietary, Partnership
Proprietary, Other
Voluntary Non-Profit, Church
Voluntary Non-Profit, Corporation
Voluntary Non-Profit, Foundation
Voluntary Non-Profit, Other
Governmental, Federal
Governmental, State
Governmental, County
Governmental, Other

1
2

=
=

OPO
LAB

TABLE 3C - LINES THAT CANNOT BE SUBSCRIPTED
(BEYOND THOSE PREPRINTED)
Worksheet

Lines

S

1-3,5

S-1, Part I

1-7

S-1, Part II

1-3

S-1, Part III

2

A
A-1

1-18,20

A-2

1-8,10-20,22,23

A-3

1-5,11

A-4

1-34,36

A-5

1-14,17

A-6, Part A

1-6, 8

A-6, Part B

1-7, 9

A-6, Part C

All

B
B-1

Rev. 4

1-7,9-11,13-24,26

1-8, 10-13
1-8,10-13,16-18

C, Part I

All

C, Part II

All

33-521

3395 (Cont.)

FORM CMS-216-94

11-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94

TABLE 3C - LINES THAT CANNOT BE SUBSCRIPTED (BEYOND THOSE PREPRINTED)

(CONTINUED)
Worksheet

33-522

Lines

D

All

E

All

E-1, Part I

All (except line 9)

E-1, Part II

All (except lines 5 and 10)

E-2

All (except line 23 and 27)

A-5-1, Part A

All

A-5-1, Part B

1-3,5

A-5-1, Part C

1-3

Rev. 4

11-05

FORM CMS 216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94

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 peculiar to the reporting provider and give no hint as to the
actual function being reported. Using codes to standardize meanings makes practical data analysis
possible. The method to accomplish this must be rigidly controlled to assure accuracy.
For any added cost center names (the preprinted cost center labels must be precoded), preparers must
be presented with the allowable choices for that line or range of lines from the lists of standard and
nonstandard descriptions. They 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:
• Do not allow any pre-existing codes for the line to be carried over.
• Do not precode all Other lines.
• For cost centers, the order of choice must be standard first, then specific nonstandard, and finally
the nonstandard AOther . . ."
• For the nonstandard "Other . . .", prompt the preparers with, “Is this the most appropriate
choice?," and then offer the chance to answer yes or to select another description.
• Allow the preparers to invoke the cost center coding process again to make corrections.
• For the preparers’ review, provide a separate printed list showing their added cost center names
on the left with the chosen standard or nonstandard descriptions and codes on the right.
• On the screen next to the description, display the number of times the description can be selected
on a given report, decreasing this number with each usage to show how many remain. The
numbers are shown on the cost center tables.
• Do not change standard cost center lines, descriptions and codes. The acceptable formats for
these items are listed on page 33-525 & 33-526 of the Standard Cost Center Descriptions and
Codes. The proper line number is the first two digits of the cost center code.
INSTRUCTIONS FOR PREPARERS
Coding of Cost Center Labels
Cost center coding standardized the meaning of cost center labels used by health care providers on
the Medicare cost reporting forms. The use of this coding methodology allows providers to continue
to use their labels for cost centers that have meaning within the individual institution.
The four digit codes that are required to be associated with each label provide standardized meaning
for data analysis. Normally, it is necessary to code only added labels because the preprinted
standard labels are automatically coded by CMS approved cost report software.
When additional cost center descriptions have been identified, these additional descriptions are
hereafter referred to as the nonstandard labels. Included with the nonstandard descriptions is an
"Other . . ." designation to provide for situations where no match in meaning can be found.

Rev. 4

33-523

3395 (Cont.)

FORM CMS 216-94

11-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94

TABLE 5 - COST CENTER CODING

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. You are required to compare your added label to the descriptions
shown on the standard and nonstandard tables for purposes of selecting a code. Most CMS-approved
software provides an automated process to present you with the allowable choices for the
line/column being coded, and automatically associates the code for the selected matching description
with your label.
Additional Guidelines
Categories
Make a selection from the proper category such as general service description for general service
lines, organ acquisition overhead cost center descriptions for organ acquisition overhead cost center
lines, etc.
Use of a Cost Center Coding Description More Than Once
Often a description from the "standard" or "nonstandard" tables applies to more than one of the
labels being added or changed by the preparer. In the past, it was necessary to determine which code
was to be used and then increment the code number upwards by one for each subsequent use. This
was done to provide a unique code for each cost center label. Most approved software systems
associate the proper code, including increments as required, once a matching description is selected.
Remember to use your label. You are matching to CMS’s description only for coding purposes.
Cost Center Coding and Line Restrictions
Use cost center codes only in designated lines in accordance with the classification of cost center(s),
e.g., cost center codes within the nonreimbursable services cost center category of both standard and
nonstandard coding.

33-524

Rev. 4

11-05

FORM CMS 216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94

TABLE 5 - COST CENTER CODING

STANDARD COST CENTER DESCRIPTIONS AND CODES

CODE

USE

Capital Costs - Buildings and Fixtures

0100

(01)

Capital Costs - Movable Equipment

0200

(01)

Employee Benefits

0300

(01)

Administration and General

0400

(01)

Operation and Maintenance of Plant

0500

(01)

Housekeeping

0600

(01)

Medical Supplies

0700

(01)

Other Overhead

0800

(20)

Procurement Coordinators

0900

(01)

Professional Education

1000

(01)

Public Education

1100

(01)

Other Acquisition

1200

(20)

Kidney Acquisition

1300

(01)

Tissue Typing Laboratory

1400

(01)

Liver Acquisitions

1500

(01)

Heart Acquisitions

1600

(01)

Pancreas Acquisitions

1700

(01)

Lung Acquisitions

1800

(01)

Other Acquisitions

1900

(10)

Other Acquisitions

2000

(10)

Research

2100

(01)

Blood Bank

2200

(01)

GENERAL SERVICE COST CENTERS

ORGAN ACQUISITION OVERHEAD

REIMBURSABLE COST CENTERS

NON REIMBURSABLE COST CENTERS

Rev. 4

33-525

3395 (Cont.)

FORM CMS 216-94

11-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94
TABLE 5 - COST CENTER CODING
STANDARD COST CENTER DESCRIPTIONS AND CODES (CONTINUED)
CODE

USE

Laboratory-Non-Tissue Typing

2300

(01)

Dialysis Units

2400

(01)

Other Non-Reimbursable

2500

(10)

NON-REIMBURSABLE COST CENTERS (Continued)

NONSTANDARD COST CENTER DESCRIPTIONS AND CODES
GENERAL SERVICE COST CENTERS
Other Overhead

0800

(10)

1200

(10)

2500

(10)

ORGAN ACQUISITION OVERHEAD
Other Acquisition
NONREIMBURSABLE COST CENTERS
Other Nonreimbursable

33-526

Rev. 4

11-05

FORM CMS-216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94

TABLE 6 - EDITS

Medicare cost reports submitted electronically must be subjected to various edits, which are divided
into two categories: Level I and level II edits. These include mathematical accuracy edits, certain
minimum file requirements, and other data edits. Any vendor software that produces an electronic
cost report file for Medicare OPOs and/or HLs 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 OPO
or HL of the cause of every exception. The edit message generated by the vendor systems must
contain the related 4 digit and 1 alpha character, and where indicated, the reject/edit code specified
below. Any file containing a level I edit will be rejected by your fiscal intermediary without
exception.
Level I edits (1000 series reject codes) test that the file conforms to processing specifications,
identifying error conditions that would result in a cost report rejection. These edits also test for the
presence of some critical data elements specified in Table 3. Level II edits (2000 series edit codes)
identify potential inconsistencies and/or missing data items that may have exceptions and should not
automatically cause a cost report rejection. Resolve these items and submit appropriate worksheets
and/or data supporting the exceptions with the cost report. Failure to submit the appropriate data
with your cost report may result in payments being withheld pending resolution of the issue(s).
The vendor requirements (above) and the edits (below) reduce both intermediary processing time and
unnecessary rejections. Vendors should develop their programs to prevent their client OPOs and/or
HLs from generating either a hard copy substitute cost report or electronic cost report file where level
I edits exist. Ample warnings should be given to the provider where level II edit conditions are
violated.
NOTE: Dates in brackets [ ] at the end of an edit indicate the effective date of that edit for cost
reporting periods ending on or after that date. Dates followed by a “b” are for cost
reporting periods beginning on or after the specified date. Dates followed by an “s” are for
services rendered on or after the specified date unless otherwise noted. [10/31/2000]
I. Level I Edits (Minimum File Requirements)
Reject Code

Condition

1000

The first digit of every record must be either 1, 2, 3, or 4 (encryption code only).
[3/31/2005]

1005

No record may exceed 60 characters. [3/31/2005]

1010

All alpha characters must be in upper case. This is exclusive of the encryption code, type 4
record, record numbers 1, 1.01, and 1.02. [3/31/2005]

1015

For micro systems, the end of record indicator must be a carriage return and line feed, in
that sequence. [3/31/2005]

1020

The organ procurement organization provider number (record #1, positions 17-22) must be
valid and may be alphanumeric. [3/31/2005]

1025

All dates (record #1, positions 23-29, 30-36, 45-51, and 52-58) must be in Julian format
and legitimate. [3/31/2005]

1030

The fiscal year beginning date (record #1, positions 23-29) must be less than or equal to the
fiscal year ending date (record #1, positions 30-36). [3/31/2005]

Rev. 4

33-527

3395 (Cont.)

FORM CMS-216-94

11-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94

TABLE 6 - EDITS
Reject Code Condition
1035

The vendor code (record #1, positions 38-40) must be a valid code. [3/31/2005]

1055

All record identifiers (positions 1-20) must be unique. [3/31/2005]

1060

Only a Y or N is valid for fields which require a Yes/No response. [3/31/2005]

1065

Variable column (Worksheet B and Worksheet B-1) must have a corresponding type 2
record (Worksheet A label) with a matching line number. [3/31/2005]

1075

Cost center integrity must be maintained throughout the cost report. For subscripted lines,
the relative position must be consistent throughout the cost report. [3/31/2005]

1080

For every line used on Worksheets A and B there must be a corresponding type 2 record.
[3/31/2005]

1090

Fields requiring numeric data (numbers, tests, costs, FTEs, etc.) may not contain any alpha
character. [3/31/2005]

1100

In all cases where the file includes both a total and the parts that comprise that total, each
total must equal the sum of its parts. [3/31/2005]

1005S

The cost report ending date (Worksheet S, Part I, column 2, line 3) must be on or after
December 31, 2004. [3/31/2005]

1015S

The cost report period beginning date (Worksheet S, Part I, column 1, line 3) must precede
the cost report ending date (Worksheet S, Part I, column 2, line 3). [3/31/2005]

1020S

The organ procurement organization or histocompatibility lab name, provider number, and
participation date (Worksheet S, Part I, lines 1, 2, 4 columns 1, 2, and 4, respectively) must
be present and valid (the appropriate provider number range). [3/31/2005]

1000A

All amounts reported on Worksheet A, columns 1-2, line 26, must be greater than or equal
to zero. [3/31/2005]

1020A

For reclassifications reported on Worksheet A-4, the sum of all increases (column 4) must
equal the sum of all decreases (column 7). [3/31/2005]

1025A

For each line on Worksheet A-4, if there is an entry in columns 3, 4, 6, or 7, there must be
an entry in column 1. There must be an entry on each line of column 4 for each entry in
column 3 (and vice versa), and there must be an entry on each line of column 7 for each
entry in column 6 (and vice versa). [3/31/2005]

1040A

For Worksheet A-5 adjustments on lines 1-3, and 5-14, if either column 2 or 4 has an entry,
then both columns 2 and 4 must have entries, and if any one of columns 0, 1, 2, or 4 for
lines 15-16 and subscripts thereof has an entry, then all columns 0, 1, 2, and 4 must have
entries. Only valid line numbers may be used in column 4. [3/31/2005]

1045A

If there are any transactions with related organizations or home offices as defined in CMS
Pub. 15-I, chapter 10 ( Supplemental Worksheet A-5-1, Part A, column 1, line 1 is "Y"),
Supplemental Worksheet A-5-1, Part B, columns 4 or 5, sum of lines 1-4 must be greater
than zero; and Part C, column 1, any one of lines 1-4 must contain any one of alpha
characters A through G. Conversely, if Supplemental Worksheet A-5-1, Part A, column 1,
line 1 is "N", Supplemental Worksheet A-5-1, Parts B and C must not be completed.
[3/31/2005]

33-528

Rev. 4

11-05

FORM CMS-216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94

TABLE 6 - EDITS
Reject Code
Condition
1000B

On Worksheet B-1, all statistical amounts must be greater than or equal to zero.
[3/31/2005]

1005B

Worksheet B, column 11, line 16 must be greater than zero. [3/31/2005]

1000C

Worksheet C, line 2 must be greater than or equal to Worksheet C, line 1. [3/31/2005]

Rev. 4

33-529

3395 (Cont.)

FORM CMS-216-94

11-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94
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, note form, or any other manner as may be required by your
fiscal intermediary (FI). Failure to clear these errors in a timely fashion, as determined by your FI,
may be grounds for withholding 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). [3/31/2005]

2005

Only elements set forth in Table 3, with subscripts as appropriate, are required in the ECR file.
[3/31/2005]

2010

The cost center codes (positions 21-24) (type 2 records) must be a code from Table 5, and each
cost center code must be unique. [3/31/2005]

2015

Standard cost center lines, descriptions, and codes should not be changed. (See Table 5.) This edit
applies to the standard line only and not subscripts of that code. [3/31/2005]

2020

All standard cost center codes must be entered on the designated standard cost center line and
subscripts thereof as indicated in Table 5. [3/31/2005]

2025

Only nonstandard cost center codes within a cost center category may be placed on standard cost
center lines of that cost center category. [3/31/2005]

2030

The 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, unless indicated herein. [3/31/2005]
Cost Center

33-530

Line

Code

Cap Costs-Bldg & Fixt

1

0100

Cap Costs-Mvble Equip

2

0200

Employee Benefits

3

0300

Administrative and General

4

0400

Operation and Maintenance of Plant

5

0500

Housekeeping

6

0600

Medical Supplies

7

0700

Other Overhead

8

0800-0819

Procurement Coordinators

9

0900

Professional Education

10

1000

Public Education

11

1100

Other Acquisitions

12

1200-1219

Kidney Acquisition

13

1300

Rev. 4

11-05

Edit

FORM CMS-216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94

TABLE 6 - EDITS

Condition

Cost Center

Line

Code

Tissue Typing Laboratory

14

1400

Liver Acquisition

15

1500

Heart Acquisition

16

1600

Pancreas Acquisition

17

1700

Lung Acquisition

18

1800

Other Acquisition

19

1900-1909

Other Acquisition

20

2000-2009

Research

21

2100

Blood Bank

22

2200

Laboratory

23

2300

Dialysis Unit

24

2400

Other Non-Reimbursable

25

2500-2509

2035

The administrative and general standard cost center code (0400) may appear only on line 4.
[3/31/2005]

2040

All calendar format dates must be edited for 10 character format, e.g., 01/01/1996
(MM/DD/YYYY). [3/31/2005]

2045

All dates must be possible, e.g., no "00", no "30", or "31" of February. [3/31/97]

2005S

The combined amount due the provider or program (Worksheet D, line 8, columns 1 and 2) should
not equal zero. [3/31/2005]

2015S

The organ procurement organization participation date and the histocompatibility laboratory
participation date (see cost report instructions) (Worksheet S, column 4, line 4) should be on or
before the cost report beginning date (Worksheet S, column 1, line 3). [3/31/2005]

2020S

The length of the cost reporting period should be greater than 27 days and less than 459 days.
[3/31/2005]

2045S

Worksheet S, line 4, column 1 (type of control) must have a value of 1 through 12. (See Table 3B.)
[3/31/2005]

2100S

The following statistics from Worksheet S-1, Part I should be greater than zero:
a. Total number of kidneys retrieved for organ procurement organization (column 3, line 1)
[3/31/2005]

2110S

The following statistics from Worksheet S-1, Part II should be greater than zero:
a. Total number of tests performed by histocompatibility laboratory (column 1, line 1) [3/31/2005]

Rev. 4

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3395 (Cont.)

Edit
2120S

FORM CMS-216-94

11-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94

TABLE 6 - EDITS

Condition
The following statistics from Worksheet S-1, Part III should be greater than zero:
a. Total number of full time equivalents (column 1, line 2) [3/31/2005]

2000A

Worksheet A-4, column 1 (reclassification code) must be alpha characters. [3/31/2005]

2005A

If worksheet A-2 (when completed for kidneys), line 18, sum of columns 1 and 2 is greater than
zero, then each worksheet A-2 (when completed for liver, heart, pancreas, lung, & other organs,
respectively), line 18, sum of columns 1 and 2 must also be greater than zero. [3/31/2005]

2020A

Supplemental Worksheet A-5-1, Part A, must contain a "Y" or "N" response. [3/31/2005]

2000B

At least one cost center description (lines 1-3), at least one statistical basis label (lines 4-5), and
one statistical basis code (line 6) must be present for each general service cost center. This
edit applies to all general service cost centers required and/or listed. [3/31/2005]

2005B

b. The column numbering among these worksheets must be consistent. For example, data in
capital related costs - buildings and fixtures is identified as coming from column 1 on all
applicable worksheets. [3/31/2005]

2000F

Total assets on Worksheet E (line 33, sum of column 1) must equal total liabilities and fund
balances (line 59, sum of columns 1). [3/31/2005]

2005F

Net income or loss (Worksheet E-2, column 2, line 29) should not equal zero. [3/31/2005]

NOTE: CMS reserves the right to require additional edits to correct deficiencies that become
evident after processing the data commences and, as needed, to meet user requirements.

33-532

Rev. 4