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Skilled Nursing Facility and Skilled Nursing Facility Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, and 413.1
ICR 201806-0938-010 · OMB 0938-0463 · Object 84172501.
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| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
|---|---|
| File Title | Skilled Nursing Facility and Skilled Nursing Facility Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, and 413.1 |
| Author | CMS |
| Last Modified By | Calc |
| File Modified | 2018-06-29 |
| File Created | 2026-08-26 |
| Conversion State | complete |
Extracted Text
03-18
FORM CMS-2540-10
4190 (Cont.)
This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim
payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).
FORM APPROVED
OMB NO. 0938-0463
Expires: 6/30/2018
WORKSHEET S
PARTS I, II & III
SKILLED NURSING FACILITY AND SKILLED NURSING
FACILITY HEALTH CARE COMPLEX COST REPORT
CERTIFICATION AND SETTLEMENT SUMMARY
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
PART I - COST REPORT STATUS
Provider
1.
[ ]
Electronic filed cost report
Date:____________
Time:____________
use only
2.
[ ]
Manually submitted cost report
3.
[ ]
If this is an amended report enter the number of times the provider resubmitted this cost report.
3.01. [ ]
Medicare Utilization. Enter "F" for full or "L" for low.
Contractor
4.
[ ] Cost Report Status
5. Date Received _____________
use only:
[ 1 ] As Submitted:
6. Contractor No. _____________
[ 2 ] Settled without audit
7. [ ] First Cost Report for this Provider CCN
[ 3 ] Settled with audit
8. [ ] Last Cost Report for this Provider CCN
[ 4 ] Reopened
9. NPR Date: __________
[ 5 ] Amended
10. If line 4, column 1 is "4": Enter number of times reopened ______
11. Contractor Vendor Code ________
PART II - CERTIFICATION
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL, CIVIL, AND
ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED
THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE ILLEGAL, CRIMINAL, CIVIL, AND ADMINISTRATIVE ACTION, FINES
AND/OR IMPRISONMENT MAY RESULT.
CERTIFICATION BY CHIEF FINANCIAL OFFICER OR ADMINISTRATOR OF PROVIDERS)
I HEREBY CERTIFY that I have read the above certification statement and that I have examined the accompanying electronically filed or manually submitted cost report
and the Balance Sheet and Statement of Revenue and Expenses prepared by _________________________{Provider Name(s) and Provider CCN(s)} for the cost reporting
period beginning _______________ and ending _______________ and that to the best of my knowledge and belief, this report and statement are true, correct, complete and
prepared from the books and records of the provider in accordance with applicable instructions, except as noted. I further certify that I am familiar with the laws and regulations
regarding the provision of health care services, and that the services identified in this cost report were provided in compliance with such laws and regulations.
I have read and agree with the above certification statement. I certify that I intend my electronic signature on this certification statement to
be the legally binding equivalent of my original signature.
(Signed) ______________________________________________
Chief Financial Officer or Administrator of Provider(s)
______________________________________________
Title
______________________________________________
Date
PART III - SETTLEMENT SUMMARY
TITLE XVIII
TITLE V
1
A
2
1 SKILLED NURSING FACILITY
2 NURSING FACILITY
3 I C F / IID
4 SNF - BASED HHA
5 SNF - BASED RHC
6 SNF - BASED FQHC
7 SNF - BASED CMHC
100 TOTAL
The above amounts represent "due to" or "due from" the applicable Program for the element of the above complex indicated.
B
3
TITLE XIX
1
2
3
4
5
6
7
100
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 0938-0463. The time required to complete this information collection is estimated 202 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: CMS, 7500 Security Boulevard, Attn: PRA Report Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
***CMS Disclosure*** 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.
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4103)
Rev. 8
41-303
on collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions
any documents containing sensitive information to the PRA Reports Clearance Office. Please note that
4190 (Cont.)
FORM CMS-2540-10
SKILLED NURSING FACILITY AND SKILLED NURSING
FACILITY HEALTH CARE COMPLEX
IDENTIFICATION DATA
PROVIDER CCN:
Skilled Nursing Facility and Skilled Nursing Facility Complex Address:
1 Street:
2 City:
3 County:
P.O. Box:
State:
CBSA Code:
PERIOD :
FROM ______________
TO ________________
WORKSHEET S-2
PART I
ZIP Code
Urban / Rural:
SNF and SNF - Based Component Identification:
Component
0
4
5
6
7
8
9
10
11
12
13
14
15
SNF
Nursing Facility
I C F/IID
SNF-Based HHA
SNF-Based RHC
SNF-Based FQHC
SNF-Based CMHC
SNF-Based OLTC
SNF-Based HOSPICE
OTHER (specify)
Cost Reporting Period (mm/dd/yyyy)
Type of Control (see instructions)
Component Name
1
From:
Provider
CCN
2
To:
Type of Freestanding Skilled Nursing Facility
16 Is this a distinct part skilled nursing facility that meets the requirements set forth in 42 CFR section 483.5?
17 Is this a composite distinct part skilled nursing facility that meets the requirements set forth in 42 CFR section 483.5?
18 Are there any costs included in Worksheet A that resulted from transactions with related
organizations as defined in CMS Pub. 15-1, chapter 10? If yes, complete Worksheet A-8-1.
Miscellaneous Cost Reporting Information
19 Is this a low Medicare utilization cost report, enter "Y" for yes or "N" for no.
19.01 If the response to line 19 is "Y", does this cost report meet your contractor's criteria for filing a low utilization cost report? (Y/N)
Depreciation - Enter the amount of depreciation reported in this SNF for the method indicated on lines 20 - 22.
20 Straight Line
21 Declining Balance
22 Sum of the Year's Digits
23 Sum of line 20 through 22
24 If depreciation is funded, enter the balance as of the end of the period.
25 Were there any disposal of capital assets during the cost reporting period? (Y/N)
26 Was accelerated depreciation claimed on any assets in the current or any prior cost reporting period? (Y/N)
27 Did you cease to participate in the Medicare program at end of the period to which this cost report applies? (Y?N)
28 Was there a substantial decrease in health insurance proportion of allowable cost from prior cost reports? (Y/N)
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4104)
Y/N
Date
Certified
3
V
4
Payment System
(P, O or N)
XVIII
5
XIX
6
41-304
08-16
Rev. 8
4190 (Cont.)
FORM CMS-2540-10
SKILLED NURSING FACILITY AND SKILLED NURSING
FACILITY HEALTH CARE COMPLEX
IDENTIFICATION DATA
PROVIDER CCN:
PERIOD
FROM_____________
TO_____________
If this facility contains a public or non-public provider that qualifies for an exemption from the application of the lower of
costs or charges, enter "Y" for each component and type of service that qualifies for the exemption.
29 Skilled Nursing Facility
30 Nursing Facility
31 I C F/IID
32 SNF-Based HHA
33 SNF-Based RHC
34 SNF-Based FQHC
35 SNF-Based CMHC
36 SNF-Based OLTC
WORKSHEET S-2
PART I
Part
A
Part
B
Other
Y/N
37 Is the skilled nursing facility located in a state that certifies the provider as a SNF regardless of the level of care given for Titles V & XIX patients. (Y/N)
38 Are you legally required to carry malpractice insurance? (Y/N)
39 Is the malpractice a "claims-made" or "occurrence" policy? If the policy is "claims-made," enter 1. If the policy is "occurrence", enter 2.
Premiums
Paid Losses
41 List malpractice premiums and paid losses:
Y/N
42 Are malpractice premiums and paid losses reported in other than the Administrative and General cost center?
Enter Y or N. If "Y", check box, and submit supporting schedule listing cost centers and amounts.
43 Are there any home office costs as defined in CMS Pub. 15-1, chapter 10?
44 If line 43 = "Y", and there are costs for the home office, enter the applicable home office chain number in column 1.
If this facility is part of a chain organization, enter the name and address of the home office on the lines below.
45 Name:
46 Street:
P.O. Box:
47 City
State
ZIP Code
Contractor Name:
Contractor Number:
Self insurance
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4104)
Rev. 7
41-305
03-18
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
19.01
20
21
22
23
24
25
26
27
28
Rev. 8
4190 (Cont.)
29
30
31
32
33
34
35
36
37
38
39
41
42
43
44
45
46
47
41-305
4190 (Cont.)
FORM CMS-2540-10
SKILLED NURSING FACILITY AND SKILLED NURSING
FACILITY HEALTH CARE COMPLEX
REIMBURSEMENT QUESTIONNAIRE
PROVIDER CCN:
08-16
PERIOD :
FROM ______________
TO ________________
WORKSHEET S-2
PART II
General Instruction: For all column 1 responses, enter in column 1, "Y" for Yes or "N" for No
For all dates responses, use the format mm/dd/yyyy.
Completed by All Skilled Nursing Facilities
Y/N
1
Provider Organization and Operation
1 Has the provider changed ownership immediately prior to the beginning of the cost reporting period?
If column 1 is "Y", enter the date of the change in column 2. (see instructions)
Date
2
1
Y/N
1
Date
2
V/I
3
2 Has the provider terminated participation in the Medicare Program? If column 1 is "Y",
enter in column 2 the date of termination and in column 3, "V" for voluntary or "I" for involuntary.
3 Is the provider involved in business transactions, including management contracts, with individuals or
entities (e.g., chain home offices, drug or medical supply companies) that are related to the provider or
its officers, medical staff, management personnel, or members of the board of directors through
ownership, control, or family and other similar relationships? (see instructions)
2
3
Y/N
1
Financial Data and Reports
4 Column 1: Were the financial statements prepared by a Certified Public Accountant? (Y/N)
Column 2: If yes, enter "A" for Audited, "C" for Compiled, or "R" for Reviewed. Submit complete copy
or enter date available in column 3. (see instructions) If no, see instructions.
5 Are the cost report total expenses and total revenues different from those on the filed financial
statements? If column 1 is "Y", submit reconciliation.
Type
2
Date
3
4
5
Y/N
1
Approved Educational Activities
6 Column 1: Were costs claimed for nursing school? (Y/N)
Column 2: Is the provider the legal operator of the program? (Y/N)
7 Were costs claimed for allied health programs? (Y/N) (see instructions)
8 Were approvals and/or renewals obtained during the cost reporting period for nursing school and/or
allied health program? (Y/N) (see instructions)
Y/N
2
6
7
8
Y/N
1
Bad Debts
9 Is the provider seeking reimbursement for bad debts? (Y/N) (see instructions)
10 If line 9 is "Y", did the provider's bad debt collection policy change during this cost reporting period? If "Y", submit copy.
11 If line 9 is "Y", are patient deductibles and/or coinsurance waived? If "Y", see instructions.
9
10
11
Bed Complement
12 Have total beds available changed from prior cost reporting period? If "Y", see instructions.
PS&R Report Data
13 Was the cost report prepared using the PS&R only?
If either col. 1 or 3 is "Y", enter the paid-through date of the PS&R used
to prepare this cost report in cols. 2 and 4 . (see Instructions)
14 Was the cost report prepared using the PS&R for total and the provider's records
for allocation? If either col. 1 or 3 is "Y", enter the paid-through date of the PS&R
used to prepare this cost report in columns 2 and 4.
15 If line 13 or 14 is "Y", were adjustments made to PS&R data for additional claims that
have been billed but are not included on the PS&R used to file this cost report?
If "Y", see instructions.
16 If line 13 or 14 is "Y", were adjustments made to PS&R data for corrections of other
PS&R Report information? If yes, see instructions.
17 If line 13 or 14 is "Y", were adjustments made to PS&R data for Other?
Describe the other adjustments:________________________________
18 Was the cost report prepared only using the provider's records? If "Y", see instructions.
12
Y/N
Part A
1
Date
Part A
2
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4104.1)
Y/N
Part B
3
Date
Part B
4
13
14
15
16
17
18
41-306
Rev. 7
08-16
FORM CMS-2540-10
SKILLED NURSING FACILITY AND
SKILLED NURSING FACILITY HEALTH CARE COMPLEX
STATISTICAL DATA
Component
1
2
3
4
5
6
7
8
Bed
Days
Available
2
Title
V
3
Title
XVIII
4
Inpatient Days / Visits
Title
XIX
5
Other
6
Total
7
PERIOD :
FROM ______________
TO ________________
Title
V
8
Title
XVIII
9
Discharges
Title
XIX
10
WORKSHEET S-3
PART I
Other
11
Total
12
Skilled Nursing Facility
Nursing Facility
ICF / IID
Home Health Agency
Other Long Term Care
SNF-Based CMHC
Hospice
Total (sum of lines 1-7)
Component
1
2
3
4
5
6
Number
of
Beds
1
4190 (Cont.)
PROVIDER CCN:
1
2
3
4
5
6
7
8
Title
V
13
Average Length of Stay
Title
Title
XVIII
XIX
14
15
Total
16
Title
V
17
Skilled Nursing Facility
Nursing Facility
ICF / IID
Home Health Agency
Other Long Term Care
SNF-Based CMHC
Title
XVIII
18
Admissions
Title
XIX
19
Other
20
Total
21
Full Time
Equivalent
Employees
Nonpaid
on Payroll
Workers
22
23
1
2
3
4
5
6
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4105.1)
Rev. 7
41-307
4190 (Cont.)
SNF WAGE INDEX INFORMATION
FORM CMS-2540-10
PROVIDER CCN:
08-16
PERIOD :
FROM ______________
TO ________________
WORKSHEET S-3
PARTS II & III
PART II - DIRECT SALARIES
Amount
Reported
1
Reclass.
of Salaries
from Wkst.
A-6
2
Adjusted
Salaries
( col. 1 ±
col. 2 )
3
Paid Hours
Related
to Salary
in col. 3
4
Average
Hourly Wage
( col. 3 ÷
col. 4 )
5
SALARIES
1 Total salary (see instructions)
2 Physician salaries-Part A
3 Physician salaries-Part B
4 Home office personnel
5 Sum of lines 2 through 4
6 Revised wages (line 1 minus line 5)
7 Other Long Term Care
8 Home Health Agency
9 CMHC
10 Hospice
11 Other excluded areas
12 Subtotal excluded salary (sum of lines 7 through 11)
13 Total adjusted salaries (line 6 minus line 12)
OTHER WAGES AND RELATED COSTS
14 Contract Labor: Patient Related & Mgmt.
15 Contract Labor: Physician services-Part A
16 Home office salaries & wage related costs
WAGE RELATED COSTS
17 Wage related costs core (see Pt. IV)
18 Wage related costs other (see Pt. IV)
19 Wage related costs (excluded units)
20 Physicians Part A - WRC
21 Physicians Part B - WRC
22 Total adjusted wage related cost (see instructions)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
PART III - OVERHEAD COST - DIRECT SALARIES
Amount
Reported
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Reclass.
of Salaries
from
Wkst. A-6
2
Adjusted
Salaries
( col. 1 ±
col. 2 )
3
Paid Hours
Related
to Salary
in col. 3
4
Employee Benefits
Administrative & General
Plant Operation, Maintenance & Repairs
Laundry & Linen Service
Housekeeping
Dietary
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Nursing and Allied Health Ed. Act.
Other General Service (specify _______________)
Total (sum lines 1 through 13)
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4105.2 & 4105.3)
Average
Hourly Wage
( col. 3 ÷
col. 4 )
5
1
2
3
4
5
6
7
8
9
10
11
12
13
14
41-308
Rev. 7
08-16
FORM CMS-2540-10
SNF WAGE RELATED COSTS
PROVIDER CCN:
4190 (Cont.)
PERIOD :
FROM ______________
TO ________________
Part A - Core List
RETIREMENT COST
1 401k Employer Contributions
2 Tax Sheltered Annuity (TSA) Employer Contribution
3 Qualified and Non-Qualified Pension Plan Cost
4 Prior Year Pension Service Cost
PLAN ADMINISTRATIVE COSTS (Paid to External Organizations)
5 401K/TSA Plan Administration fees
6 Legal/Accounting/Management Fees-Pension Plan
7 Employee Managed Care Program Administration Fees
HEALTH AND INSURANCE COST
8 Health Insurance (Purchased or Self Funded)
9 Prescription Drug Plan
10 Dental, Hearing and Vision Plan
11 Life Insurance (If employee is owner or beneficiary)
12 Accidental Insurance (If employee is owner or beneficiary)
13 Disability Insurance (If employee is owner or beneficiary)
14 Long-Term Care Insurance (If employee is owner or beneficiary)
15 Workers' Compensation Insurance
16 Retirement Health Care Cost (Only current year, not the extraordinary
accrual required by FASB 106 Non cumulative portion)
TAXES
17 FICA - Employers Portion Only
18 Medicare Taxes - Employers Portion Only
19 Unemployment Insurance
20 State or Federal Unemployment Taxes
OTHER
21 Executive Deferred Compensation
22 Day Care Cost and Allowances
23 Tuition Reimbursement
24 Total Wage Related cost (sum of lines 1 -23)
Part B Other than Core Related Cost
25 Other Wage Related Costs (specify)_________________________________________
WORKSHEET S-3
PART IV
Amount
Reported
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Amount
Reported
25
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4105.4)
Rev. 7
41-309
4190 (Cont.)
SNF REPORTING OF DIRECT CARE
EXPENDITURES
OCCUPATIONAL CATEGORY
Direct Salaries
Nursing Occupations
1 Registered Nurses (RNs)
2 Licensed Practical Nurses (LPNs)
3 Certified Nursing Assistants/Nursing Assistants/Aides
4 Total Nursing (sum of lines 1 through 3)
5 Physical Therapists
6 Physical Therapy Assistants
7 Physical Therapy Aides
8 Occupational Therapists
9 Occupational Therapy Assistants
10 Occupational Therapy Aides
11 Speech Therapists
12 Respiratory Therapists
13 Other Medical Staff
Contract Labor
Nursing Occupations
14 Registered Nurses (RNs)
15 Licensed Practical Nurses (LPNs)
16 Certified Nursing Assistants/Nursing Assistants/Aides
17 Total Nursing (sum of lines 14 through 16)
18 Physical Therapists
19 Physical Therapy Assistants
20 Physical Therapy Aides
21 Occupational Therapists
22 Occupational Therapy Assistants
23 Occupational Therapy Aides
24 Speech Therapists
25 Respiratory Therapists
26 Other Medical Staff
FORM CMS-2540-10
PROVIDER CCN:
Amount
Reported
1
Fringe
Benefits
2
08-16
PERIOD :
FROM ______________
TO ________________
Adjusted
Paid Hours
Salaries
Related
( col. 1 +
to Salary
col. 2 )
in col. 3
3
4
WORKSHEET S-3
PART V
Average
Hourly Wage
( col. 3 ÷
col. 4 )
5
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4105.5)
41-309.1
Rev. 7
This page intentionally left blank.
4190 (Cont.)
SNF-BASED HOME HEALTH AGENCY
STATISTICAL DATA
FORM CMS-2540-10
PROVIDER CCN:
11-12
PERIOD :
FROM ______________
TO ________________
HHA CCN:
WORKSHEET S-4
HOME HEALTH AGENCY STATISTICAL DATA
1 County
DESCRIPTION
2 Home Health Aide Hours
3 Unduplicated Census Count (see instructions)
1
Title V
1
Title XVIII
2
Title XIX
3
Other
4
Total
5
2
3
Staff
1
HOME HEALTH AGENCY - NUMBER OF EMPLOYEES (FULL TIME EQUIVALENT)
4 Enter the number of hours in your normal work week
5 Administrator and Assistant Administrator(s)
6 Directors and Assistant Director(s)
7 Other Administrative Personnel
8 Direct Nursing Service
9 Nursing Supervisor
10 Physical Therapy Service
11 Physical Therapy Supervisor
12 Occupational Therapy Service
13 Occupational Therapy Supervisor
14 Speech Pathology Service
15 Speech Pathology Supervisor
16 Medical Social Service
17 Medical Social Service Supervisor
18 Home Health Aide
19 Home Health Aide Supervisor
20 Other (specify)
Contract
2
Total
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
HOME HEALTH AGENCY CBSA CODES
21 Enter in column 1 the number of CBSAs where you provided services during the cost reporting period.
22 List those CBSA code(s) in column 1 serviced during this cost reporting period (line 22 contains the first code).
PPS ACTIVITY DATA
23 Skilled Nursing Visits
24 Skilled Nursing Visit Charges
25 Physical Therapy Visits
26 Physical Therapy Visit Charges
27 Occupational Therapy Visits
28 Occupational Therapy Visit Charges
29 Speech Pathology Visits
30 Speech Pathology Visit Charges
31 Medical Social Service Visits
32 Medical Social Service Visit Charges
33 Home Health Aide Visits
34 Home Health Aide Visit Charges
35 Total Visits (sum of lines 23, 25, 27, 29, 31, and 33)
36 Other Charges
37 Total Charges (sum of lines 24, 26, 28, 30, 32, 34 and 36)
38 Total Number of Episodes (standard/non outlier)
39 Total Number of Outlier Episodes
40 Total Non-Routine Medical Supply Charges
Full Episodes
Without
With
Outliers
Outliers
1
2
21
22
LUPA
Episodes
3
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4106)
PEP only
Episodes
4
Total
( cols. 1
through 4 )
5
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41-310
Rev. 4
08-16
FORM CMS-2540-10
SNF-BASED RHC/FQHC STATISTICAL DATA
4190 (Cont.)
PROVIDER CCN:
RHC/FQHC CCN:
Check applicable box:
[
] RHC
[
PERIOD :
FROM ______________
TO ________________
WORKSHEET S-5
] FQHC
Clinic Address and Identification:
1 Street:
2 City:
3 Designation (for FQHC's only) - "U" for urban or "R" for rural
County:
Zip Code:
State:
Source of Federal funds:
4 Community Health Center (Section 330(d), PHS Act)
5 Migrant Health Center (Section 329(d), PHS Act)
6 Health Services for the Homeless (Section 340(d), PHS Act)
7 Appalachian Regional Commission
8 Look - Alikes
9 Other (specify)
1
2
3
Grant Award
Date
4
5
6
7
8
9
1
2
10 Does this facility operate as other than an RHC or FQHC? Enter "Y" for yes or "N" for no in column 1.
If yes, indicate the number of other operations in column 2.
10
Facility hours of operations (1)
Sunday
Type of Operation
0
from
1
Monday
to
2
from
3
to
4
Tuesday
from
to
5
6
Wednesday
from
to
7
8
Thursday
from
to
9
10
Friday
from
11
to
12
Saturday
from
to
13
14
11 Clinic
11
(1) Enter clinic/center hours of operation on line 11 and other type operations on subscripts of line 11 (both type and hours of operation).
List hours of operation based on a 24 hour clock. For example: 8:00am is 0800, 6:30pm is 1830, and midnight is 2400.
1
12 Have you received an approval for an exception to the productivity standard?
13 Is this a consolidated cost report in accordance with CMS Pub. 100-04, Chapter 9, §30.8? Enter "Y" for yes or "N" for no in column 1.
If yes, enter in column 2 the number of RHC/FQHC's included in this report. List the names of all RHC/FQHC's and numbers below.
14 RHC/FQHC Name:
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4107)
2
12
13
CCN Number:
14
Rev. 7
41-311
4190 (Cont.)
FORM CMS-2540-10
SNF-BASED COMMUNITY
MENTAL HEALTH CENTER AND OTHER OUTPATIENT
REHABILITATION FACILITIES STATISTICAL DATA
Check applicable box:
[ ] CMHC
[ ] CORF
PROVIDER CCN:
COMPONENT CCN:
[ ] OPT
08-16
PERIOD :
FROM ______________
TO ________________
[ ] OOT
[ ] OSP
Staff
1
Contract
2
WORKSHEET S-6
Enter the number of hours in your normal workweek ________
NUMBER OF EMPLOYEES (FULL TIME EQUIVALENT)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Administrator and Assistant Administrator(s)
Director(s) and Assistant Director(s)
Other Administrative Personnel
Direct Nursing Service
Nursing Supervisor
Physical Therapy Service
Physical Therapy Supervisor
Occupational Therapy Service
Occupational Therapy Supervisor
Speech Pathology Service
Speech Pathology Supervisor
Medical Social Service
Medical Social Service Supervisor
Respiratory Therapy Service
Respiratory Therapy Supervisor
Psychiatric/Psychological Service
Psychiatric/Psychological Service Supervisor
Other (specify)
Other (specify)
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4108)
Total
( col. 1 + col. 2 )
3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
41-312
Rev. 7
08-16
FORM CMS-2540-10
PROSPECTIVE PAYMENT FOR SNF
STATISTICAL DATA
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
GROUP
1
RUX
RUL
RVX
RVL
RHX
RHL
RMX
RML
RLX
RUC
RUB
RUA
RVC
RVB
RVA
RHC
RHB
RHA
RMC
RMB
RMA
RLB
RLA
ES3
ES2
ES1
HE2
HE1
HD2
HD1
HC2
HC1
HB2
HB1
LE2
LE1
LD2
LD1
LC2
LC1
LB2
LB1
CE2
CE1
CD2
CD1
CC2
CC1
CB2
CB1
PROVIDER CCN:
4190 (Cont.)
PERIOD :
FROM ______________
TO ________________
WORKSHEET S-7
Days
2
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4109)
Rev. 7
41-313
4190 (Cont.)
PROSPECTIVE PAYMENT FOR SNF
STATISTICAL DATA
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
99
100
FORM CMS-2540-10
PROVIDER CCN:
08-16
PERIOD:
FROM ________
TO ___________
GROUP
1
CA2
CA1
SE3
SE2
SE1
SSC
SSB
SSA
IB2
IB1
IA2
IA1
BB2
BB1
BA2
BA1
PE2
PE1
PD2
PD1
PC2
PC1
PB2
PB1
PA2
PA1
AAA
Total
A notice published in the "Federal Register" Vol. 68, No. 149 August 4, 2003 provided for an increase in the RUG payments beginning 10/01/2003.
Congress expected this increase to be used for direct patient care and related expenses. For lines 101 through 106: Enter in column 1
the amount of expense for each category. Enter in column 2 the percentage of total expenses for each category to total SNF revenue
from Worksheet G-2, Part I line 1 column3. Indicate in column 3 "Y" for yes or "N" for no if the spending reflects increases associated
with direct patient care and related expenses for each category. (If column 2 is zero, enter N/A in column 3) (see instructions)
Expenses
Percentage
1
2
101 Staffing
102 Recruitment
103 Retention of employees
104 Training
105 Other (Specify)
106 Total SNF revenue (Wkst. G-2, Pt. I, line 1, col. 3)
WORKSHEET S-7
Days
2
Y/N
3
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4109 - 4109.1)
41-314
Rev. 7
4190 (Cont.)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
41-313
08-16
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
99
100
101
102
103
104
105
106
Rev. 7
03-18
FORM CMS-2540-10
SNF-BASED HOSPICE IDENTIFICATION DATA
4190 (Cont.)
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
HOSPICE CCN:
WORKSHEET S - 8
PARTS I, II, III & IV
PART I - ENROLLMENT DAYS FOR COST REPORTING PERIODS BEGINNING BEFORE OCTOBER 1, 2015
Title XVIII
1
1
2
3
4
5
Title XIX
2
Title XVIII
Skilled Nursing
Facility
3
Unduplicated Days
Title XIX
Nursing
Facility
4
All
Other
5
Total
( sum of
col. 1, 2 & 5 )
6
Hospice Continuous Home Care
Hospice Routine Home Care
Hospice Inpatient Respite Care
Hospice General Inpatient Care
Total Hospice Days
1
2
3
4
5
PART II - CENSUS DATA FOR COST REPORTING PERIODSENDING BEGINNING BEFORE OCTOBER 1, 2015
Title XVIII
1
6
7
8
9
Title XIX
2
Title XVIII
Skilled
Nursing facility
3
Title XIX
Nursing
Facility
4
All
Other
5
Total
( sum of
col. 1, 2 & 5 )
6
Number of patients receiving hospice care
Total number of unduplicated Continuous Care hours billable to Medicare
Average length of stay (line 5 / line 6)
Unduplicated census count
6
7
8
9
PART III - ENROLLMENT DAYS BASED ON LEVEL OF CARE FOR COST REPORTING PERIODS BEGINNING ON OR AFTER OCTOBER 1, 2015
Unduplicated Days
Title XVIII
1
Title XIX
2
Other
3
Total
(sum of
cols. 1 through 3)
4
10 Hospice Continuous Home Care
11 Hospice Routine Home Care
12 Hospice Inpatient Respite Care
13 Hospice General Inpatient Care
14 Total Hospice Days
10
11
12
13
14
PART IV - CONTRACTED STATISTICAL DATA FOR COST REPORTING PERIODS BEGINNING ON OR AFTER OCTOBER 1, 2015
Total
Title XVIII
1
15 Hospice Inpatient Respite Care
16 Hospice General Inpatient Care
NOTE: Parts I and II, columns 1 and 2 also include the days reported in columns 3 and 4 .
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4110)
Title XIX
2
Other
3
(sum of
cols. 1 through 3)
4
15
16
Rev. 8
41-315
4190 (Cont.)
FORM CMS-2540-10
RECLASSIFICATION AND ADJUSTMENT
OF TRIAL BALANCE OF EXPENSES
Cost Center Description
A
B
C
GENERAL SERVICE COST CENTERS
1 0100 Capital-Related Costs - Buildings & Fixtures
2 0200 Capital-Related Costs - Movable Equipment
3 0300 Employee Benefits
4 0400 Administrative and General
5 0500 Plant Operation, Maintenance and Repairs
6 0600 Laundry and Linen Service
7 0700 Housekeeping
8 0800 Dietary
9 0900 Nursing Administration
10 1000 Central Services and Supply
11 1100 Pharmacy
12 1200 Medical Records and Library
13 1300 Social Service
14 1400 Nursing and Allied Health Education
15
Other General Service Cost
INPATIENT ROUTINE SERVICE COST CENTERS
30 3000 Skilled Nursing Facility
31 3100 Nursing Facility
32 3200 ICF/IID
33 3300 Other Long Term Care
ANCILLARY SERVICE COST CENTERS
40 4000 Radiology
41 4100 Laboratory
42 4200 Intravenous Therapy
43 4300 Oxygen (Inhalation) Therapy
44 4400 Physical Therapy
45 4500 Occupational Therapy
46 4600 Speech Pathology
47 4700 Electrocardiology
03-18
PROVIDER CCN:
SALARIES
1
OTHER
2
TOTAL
( col. 1 + col. 2 )
3
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4113)
RECLASSIFICATIONS
Increase/Decrease
( from Wkst. A-6 )
4
PERIOD:
FROM ______________
TO _________________
RECLASSIFIED
ADJUSTMENTS
TRIAL
TO EXPENSES
BALANCE
Increase/Decrease
( col. 3 +/- col. 4 )
( from Wkst. A-8 )
5
6
WORKSHEET A
NET EXPENSES
FOR COST
ALLOCATION
( col. 5 +/- col. 6 )
7
41-316
Rev. 8
09-11
FORM CMS-2540-10
RECLASSIFICATION AND ADJUSTMENT
OF TRIAL BALANCE OF EXPENSES
Cost Center Description
A
B
C
48 4800 Medical Supplies Charged to Patients
49 4900 Drugs Charged to Patients
50 5000 Dental Care - Title XIX only
51 5100 Support Surfaces
52
Other Ancillary Service Cost
OUTPATIENT SERVICE COST CENTERS
60 6000 Clinic
61 6100 Rural Health Clinic (RHC)
62 6200 FQHC
63
Other Outpatient Service Cost
OTHER REIMBURSABLE COST CENTERS
70 7000 Home Health Agency Cost
71 7100 Ambulance
72
Outpatient Rehabilitation (specify)
73 7300 CMHC
74
Other Reimbursable Cost
SPECIAL PURPOSE COST CENTERS
80 8000 Malpractice Premiums & Paid Losses
81 8100 Interest Expense
82 8200 Utilization Review
83 8300 Hospice
84
Other Special Purpose Cost
89
SUBTOTALS (sum of lines 1 through 84)
NON REIMBURSABLE COST CENTERS
90 9000 Gift, Flower, Coffee Shops and Canteen
91 9100 Barber and Beauty Shop
92 9200 Physicians' Private Offices
93 9300 Nonpaid Workers
94 9400 Patients' Laundry
95
Other Nonreimbursable Cost
100
TOTAL
4190 (Cont.)
PROVIDER CCN:
SALARIES
1
OTHER
2
TOTAL
( col. 1 + col. 2 )
3
RECLASSIFICATIONS
Increase/Decrease
( from Wkst. A-6 )
4
PERIOD :
FROM ______________
TO ________________
RECLASSIFIED
ADJUSTMENTS
TRIAL
TO EXPENSES
BALANCE
Increase /Decrease
( col. 3 +/- col. 4 )
( from Wkst. A-8 )
5
6
WORKSHEET A (Cont.)
NET EXPENSES
FOR COST
ALLOCATION
( col. 5 +/- col. 6 )
7
-0-0-0-
FORM CMS-2540-10 (09/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4113)
Rev. 2
41-317
03-18
A
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
30
31
32
33
40
41
42
43
44
45
46
47
Rev. 8
4190 (Cont.)
WORKSHEET A (Cont.)
48
49
50
51
52
60
61
62
63
70
71
72
73
74
80
81
82
83
84
89
90
91
92
93
94
95
100
41-317
4190 (Cont.)
FORM CMS-2540-10
09-11
RECLASSIFICATIONS
EXPLANATION OF RECLASSIFICATION(S)
PROVIDER CCN:
CODE
(1)
1
COST CENTER
2
INCREASE
LN NO.
3
SALARY
4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
100 TOTAL RECLASSIFICATIONS (Sum of columns 4 and 5 must equal
sum of columns 8 and 9 (2)
(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
(2) Transfer the amounts in columns 4, 5, 8 and 9 to Worksheet A, column 4, lines as appropriate.
FORM CMS-2540-10 (09/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4114)
NON SALARY
5
COST CENTER
6
PERIOD :
FROM ______________
TO ________________
DECREASE
LN NO.
7
SALARY
8
WORKSHEET A-6
NON SALARY
9
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
100
41-318
Rev. 2
05-11
FORM CMS-2540-10
ANALYSIS OF CHANGES IN
CAPITAL ASSET BALANCES
4190 (Cont.)
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
Acquisitions
Description
1
2
3
4
5
6
7
8
9
Beginning
Balances
1
Purchases
2
Donation
3
Total
4
Disposals
and
Retirements
5
Land
Land Improvements
Buildings and Fixtures
Building Improvements
Fixed Equipment
Movable Equipment
Subtotal (sum of lines 1-6)
Reconciling Items
Total (line 7 minus line 8)
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4115)
Ending
Balance
6
WORKSHEET A-7
Fully
Depreciated
Assets
7
1
2
3
4
5
6
7
8
9
Rev. 1
41-319
4190 (Cont.)
FORM CMS-2540-10
ADJUSTMENTS TO EXPENSES
1
2
3
4
5
6
7
Description (1)
0
Investment income on restricted funds
(Chapter 2)
Trade, quantity and time discounts
on purchases (Chapter 8)
Refunds and rebates of expenses
Chapter 8)
Rental of provider space by suppliers
Chapter 8)
Telephone services (pay stations
excluded) (Chapter 21)
Television and radio service
(Chapter 21)
Parking lot (Chapter 21)
PROVIDER CCN:
Basis
for
Adjustment (2)
1
8 Remuneration applicable to providerbased physician adjustment
9 Home office costs (Chapter 21)
10 Sale of scrap, waste, etc.
(Chapter23)
11 Nonallowable costs related to certain
Capital expenditures (Chapter 24)
12 Adjustment resulting from transactions
with related organizations (Chapter 10)
13 Laundry and Linen service
Amount
2
05-11
PERIOD :
WORKSHEET A-8
FROM ______________
TO ________________
Expense Classification on Wkst. A
to/from which the amount is to be adjusted
Cost Center
Line No.
3
4
Worksheet
A-8-2
Worksheet
A-8-1
14 Revenue - Employee meals
15 Cost of meals - Guests
16 Sale of medical supplies to other than patients
17 Sale of drugs to other than patients
18 Sale of medical records and abstracts
19 Vending machines
20 Income from imposition of interest,
finance or penalty charges (Chapter 21)
21 Interest expense on Medicare overpayments
and borrowings to repay Medicare overpayments
22 Utilization review--physicians'
compensation (Chapter 21)
23 Depreciation--buildings and fixtures
24 Depreciation--movable equipment
Utilization Review- SNF
82
Capital Related Cost- Building
1
Capital Related Cost-Movable
2
25 Other Adjustment
100 TOTAL (sum of lines 1 through 99)
(transfer to Wkst. A, col. 6, line 100)
(1) Description - all chapter references in this column pertain to CMS Pub. 15-1
(2) Basis for adjustment (see instructions)
A. Costs - if cost, including applicable overhead, can be determined
B. Amount Received - if cost cannot be determined
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4116)
41-320
Rev. 1
05-11
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
100
Rev. 1
08-16
FORM CMS-2540-10
STATEMENT OF COSTS OF SERVICES
FROM RELATED ORGANIZATIONS AND
HOME OFFICE COSTS
PROVIDER CCN:
4190 (Cont.)
PERIOD :
FROM ______________
TO ________________
PART I - COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED
ORGANIZATIONS OR CLAIMED HOME OFFICE COSTS
Amount
Amount
Allowable
Included in
Line No.
Cost Center
Expense Items
In Cost
Wkst. A., col. 5
1
2
3
4
5
1
2
3
4
5
6
7
8
9
10 TOTALS (sum of lines 1-9)
(Transfer column 6, line 10 to Wkst. A-8, col. 3, line 12)
WORKSHEET A-8-1
Adjustments
( col. 4 minus
col. 5 )
6
1
2
3
4
5
6
7
8
9
10
PART II - INTERRELATIONSHIP TO RELATED ORGANIZATION(S) AND / OR HOME OFFICE
The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires that you furnish
the information requested under Part II of this worksheet.
This information is used by the Centers for Medicare and Medicaid Services and its intermediaries/contractors in determining that the costs applicable to
services, facilities, and supplies furnished by organizations related to you by common ownership or control represent reasonable costs as determined under
section 1861 of the Social Security Act. If you do not provide all or any part of the requested information, the cost report is considered incomplete and not
acceptable for purposes of claiming reimbursement under title XVIII.
(1)
Symbol
1
Name
2
Percentage
of
Ownership
3
Name
4
Related Organization(s)
Percentage
of
Ownership
5
Type of
Business
6
1
2
3
4
5
6
7
8
9
10
(1) Use the followings symbols to indicate interrelationship to related organizations:
A. Individual has financial interest (stockholder, partner, etc.)
in both related organization and in provider.
B. Corporation, partnership or other organization has financial
interest in provider.
C. Provider has financial interest in corporation, partnership,
or other organization.
D. Director, officer, administrator or key person of provider or
organization.
1
2
3
4
5
6
7
8
9
10
E. Individual is director, officer, administrator or key person of provider
and related organization.
F. Director, officer, administrator or key person of related organization
or relative of such person has financial interest in provider.
G. Other (financial or non-financial) specify ______________________
_____________________________________________________
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4117)
Rev. 7
41-321
4190 (Cont.)
FORM CMS-2540-10
PROVIDER - BASED PHYSICIAN ADJUSTMENTS
Wkst. A
Line No.
1
1
2
3
4
5
6
7
8
9
10
11
100
Cost Center /
Physician
Identifier
2
Total
Remuneration
3
Professional
Component
4
Provider
Component
5
Cost Center /
Physician
Identifier
11
Cost of
Memberships
& Continuing
Education
12
Provider
Component
Share of
Col. 12
13
Physician
Cost of
Malpractice
Insurance
14
PERIOD :
FROM ______________
TO ________________
WORKSHEET A-8-2
RCE
Amount
6
Physician /
Provider
Component
Hours
7
Unadjusted
R C E Limit
8
5 Percent of
Unadjusted
R C E Limit
9
Provider
Component
Share of
Col. 14
15
Adjusted
R C E Limit
16
RCE
Disallowance
17
Adjustment
18
TOTAL
Wkst. A
Line No.
10
1
2
3
4
5
6
7
8
9
10
11
100
08-16
PROVIDER CCN:
TOTAL
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4118)
41-322
Rev. 7
08-16
WORKSHEET A-8-2
1
2
3
4
5
6
7
8
9
10
11
100
1
2
3
4
5
6
7
8
9
10
11
100
Rev. 7
03-18
FORM CMS-2540-10
COST ALLOCATION - GENERAL SERVICE COSTS
NET EXPENSES
FOR COST
ALLOCATION
( from Wkst. A, col. 7 )
Cost Center Description
GENERAL SERVICE COST CENTERS
1 Capital-Related Costs - Buildings & Fixtures
2 Capital-Related Costs - Movable Equipment
3 Employee Benefits
4 Administrative and General
5 Plant Operation, Maintenance and Repairs
6 Laundry and Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Central Services and Supply
11 Pharmacy
12 Medical Records and Library
13 Social Service
14 Nursing and Allied Health Education
15 Other General Service Cost
INPATIENT ROUTINE SERVICE COST CENTERS
30 Skilled Nursing Facility
31 Nursing Facility
32 ICF/IID
33 Other Long Term Care
ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost
4190 (Cont.)
PROVIDER CCN:
0
CAP. REL
BUILDINGS
& FIXTURES
1
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
PERIOD :
FROM ______________
TO ________________
CAP. REL
MOVABLE
EQUIPMENT
2
EMPLOYEE
BENEFITS
3
WORKSHEET B
PART I
SUBTOTAL
( sum of
cols. 0 - 3 )
3A
ADMINISTRATIVE
& GENERAL
4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
30
31
32
33
40
41
42
43
44
45
46
47
48
49
50
51
52
Rev. 8
4190 (Cont.)
41-323
FORM CMS-2540-10
COST ALLOCATION - GENERAL SERVICE COSTS
NET EXPENSES
FOR COST
ALLOCATION
( from Wkst. A, col. 7 )
Cost Center Description
OUTPATIENT SERVICE COST CENTERS
60 Clinic
61 Rural Health Clinic (RHC)
62 FQHC
63 Other Outpatient Service Cost
OTHER REIMBURSABLE COST CENTERS
70 Home Health Agency Cost
71 Ambulance
72 Outpatient Rehabilitation (specify)
73 CMHC
74 Other Reimbursable Cost
SPECIAL PURPOSE COST CENTERS
83 Hospice
84 Other Special Purpose Cost
89 Subtotals
NON REIMBURSABLE COST CENTERS
90 Gift, Flower, Coffee Shops and Canteen
91 Barber and Beauty Shop
92 Physicians' Private Offices
93 Nonpaid Workers
94 Patients' Laundry
95 Other Nonreimbursable Cost
98 Cross Foot Adjustments
99 Negative Cost Center
100 Total
03-18
PROVIDER CCN:
0
CAP. REL
BUILDINGS
& FIXTURES
1
PERIOD:
FROM ________________
TO ________________
CAP. REL
MOVABLE
EQUIPMENT
2
EMPLOYEE
BENEFITS
3
SUBTOTAL
( sum of
cols. 0 - 3 )
3A
WORKSHEET B
PART I
ADMINISTRATIVE
& GENERAL
4
60
61
62
63
70
71
72
73
74
83
84
89
90
91
92
93
94
95
98
99
100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
41-324
Rev. 8
03-18
FORM CMS-2540-10
COST ALLOCATION - GENERAL SERVICE COSTS
Cost Center Description
GENERAL SERVICE COST CENTERS
1 Capital-Related Costs - Buildings & Fixtures
2 Capital-Related Costs - Movable Equipment
3 Employee Benefits
4 Administrative and General
5 Plant Operation, Maintenance and Repairs
6 Laundry and Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Central Services and Supply
11 Pharmacy
12 Medical Records and Library
13 Social Service
14 Nursing and Allied Health Education
15 Other General Service Cost
INPATIENT ROUTINE SERVICE COST CENTERS
30 Skilled Nursing Facility
31 Nursing Facility
32 ICF/IID
33 Other Long Term Care
ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost
4190 (Cont.)
PROVIDER CCN:
PLANT OPER.
MAINTENANCE
& REPAIRS
5
LAUNDRY
& LINEN
SERVICE
6
HOUSE
KEEPING
7
PERIOD:
FROM ________________
TO ________________
DIETARY
8
NURSING
ADMINISTRATION
9
CENTRAL
SERVICES
& SUPPLY
10
WORKSHEET B
PART I
PHARMACY
11
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
30
31
32
33
40
41
42
43
44
45
46
47
48
49
50
51
52
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
Rev. 8
41-325
4190 (Cont.)
FORM CMS-2540-10
COST ALLOCATION - GENERAL SERVICE COSTS
Cost Center Description
OUTPATIENT SERVICE COST CENTERS
60 Clinic
61 Rural Health Clinic (RHC)
62 FQHC
63 Other Outpatient Service Cost
OTHER REIMBURSABLE COST CENTERS
70 Home Health Agency Cost
71 Ambulance
72 Outpatient Rehabilitation (specify)
73 CMHC
74 Other Reimbursable Cost
SPECIAL PURPOSE COST CENTERS
83 Hospice
84 Other Special Purpose Cost
89 Subtotals
NON REIMBURSABLE COST CENTERS
90 Gift, Flower, Coffee Shops and Canteen
91 Barber and Beauty Shop
92 Physicians' Private Offices
93 Nonpaid Workers
94 Patients' Laundry
95 Other Nonreimbursable Cost
98 Cross Foot Adjustments
99 Negative Cost Center
100 Total
03-18
PROVIDER CCN:
PLANT OPER.
MAINTENANCE
& REPAIRS
5
LAUNDRY
& LINEN
SERVICE
6
HOUSE
KEEPING
7
PERIOD:
FROM ________________
TO ________________
DIETARY
8
NURSING
ADMINISTRATION
9
CENTRAL
SERVICES
& SUPPLY
10
WORKSHEET B
PART I
PHARMACY
11
60
61
62
63
70
71
72
73
74
83
84
89
90
91
92
93
94
95
98
99
100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
41-326
Rev. 8
03-18
FORM CMS-2540-10
COST ALLOCATION - GENERAL SERVICE COSTS
Cost Center Description
GENERAL SERVICE COST CENTERS
1 Capital-Related Costs - Buildings & Fixtures
2 Capital-Related Costs - Movable Equipment
3 Employee Benefits
4 Administrative and General
5 Plant Operation, Maintenance and Repairs
6 Laundry and Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Central Services and Supply
11 Pharmacy
12 Medical Records and Library
13 Social Service
14 Nursing and Allied Health Education
15 Other General Service Cost
INPATIENT ROUTINE SERVICE COST CENTERS
30 Skilled Nursing Facility
31 Nursing Facility
32 ICF/IID
33 Other Long Term Care
ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost
4190 (Cont.)
PROVIDER CCN:
MEDICAL
RECORDS
& LIBRARY
12
SOCIAL
SERVICE
13
NURSING &
ALLIED
HEALTH
EDUCATION
14
PERIOD:
FROM ________________
TO ________________
OTHER
GENERAL
SERVICE
COST
15
SUBTOTAL
16
POST
STEP-DOWN
ADJUSTMENTS
17
WORKSHEET B
PART I
TOTAL
18
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
30
31
32
33
40
41
42
43
44
45
46
47
48
49
50
51
52
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
Rev. 8
41-327
4190 (Cont.)
FORM CMS-2540-10
COST ALLOCATION - GENERAL SERVICE COSTS
Cost Center Description
OUTPATIENT SERVICE COST CENTERS
60 Clinic
61 Rural Health Clinic (RHC)
62 FQHC
63 Other Outpatient Service Cost
OTHER REIMBURSABLE COST CENTERS
70 Home Health Agency Cost
71 Ambulance
72 Outpatient Rehabilitation (specify)
73 CMHC
74 Other Reimbursable Cost
SPECIAL PURPOSE COST CENTERS
83 Hospice
84 Other Special Purpose Cost
89 Subtotals
NON REIMBURSABLE COST CENTERS
90 Gift, Flower, Coffee Shops and Canteen
91 Barber and Beauty Shop
92 Physicians' Private Offices
93 Nonpaid Workers
94 Patients' Laundry
95 Other Nonreimbursable Cost
98 Cross Foot Adjustments
99 Negative Cost Center
100 Total
03-18
PROVIDER CCN:
MEDICAL
RECORDS
& LIBRARY
12
SOCIAL
SERVICE
13
NURSING &
ALLIED
HEALTH
EDUCATION
14
PERIOD:
FROM ________________
TO ________________
OTHER
GENERAL
SERVICE
COST
15
SUBTOTAL
16
POST
STEP-DOWN
ADJUSTMENTS
17
WORKSHEET B
PART I
TOTAL
18
60
61
62
63
70
71
72
73
74
83
84
89
90
91
92
93
94
95
98
99
100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
41-328
Rev. 8
03-18
FORM CMS-2540-10
COST ALLOCATION - STATISTICAL BASIS
4190 (Cont.)
PROVIDER CCN:
Cost Center Description
0
CAP. REL.
BUILDINGS
& FIXTURES
( Square
Feet )
1
GENERAL SERVICE COST CENTERS
1 Capital-Related Costs - Buildings & Fixtures
2 Capital-Related Costs - Movable Equipment
3 Employee Benefits
4 Administrative and General
5 Plant Operation, Maintenance and Repairs
6 Laundry and Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Central Services and Supply
11 Pharmacy
12 Medical Records and Library
13 Social Service
14 Nursing and Allied Health Education
15 Other General Service Cost
INPATIENT ROUTINE SERVICE COST CENTERS
30 Skilled Nursing Facility
31 Nursing Facility
32 ICF/IID
33 Other Long Term Care
ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
PERIOD :
FROM ______________
TO ________________
CAP. REL.
MOVABLE
EQUIPMENT
( Dollar Value or
Square Feet )
2
EMPLOYEE
BENEFITS
( Gross
Salaries )
3
WORKSHEET B - 1
RECONCILIATION
4A
ADMINISTRATIVE
& GENERAL
( Accumulated
Cost )
4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
30
31
32
33
40
41
42
43
44
45
46
47
48
49
50
51
52
Rev. 8
41-329
4190 (Cont.)
FORM CMS-2540-10
COST ALLOCATION - STATISTICAL BASIS
Cost Center Description
0
OUTPATIENT SERVICE COST CENTERS
60 Clinic
61 Rural Health Clinic (RHC)
62 FQHC
63 Other Outpatient Service Cost
OTHER REIMBURSABLE COST CENTERS
70 Home Health Agency Cost
71 Ambulance
72 Outpatient Rehabilitation (specify)
73 CMHC
74 Other Reimbursable Cost
SPECIAL PURPOSE COST CENTERS
83 Hospice
84 Other Special Purpose Cost
89 Subtotals
NON REIMBURSABLE COST CENTERS
90 Gift, Flower, Coffee Shops and Canteen
91 Barber and Beauty Shop
92 Physicians' Private Offices
93 Nonpaid Workers
94 Patients' Laundry
95 Other Nonreimbursable Cost
98 Cross Foot Adjustments
99 Negative Cost Center
102 Cost to be allocated (Per Wkst. B, Pt I.)
103 Unit Cost Multiplier (Wkst. B, Pt I.)
104 Cost to be allocated (Per Wkst. B, Pt. II)
105 Unit Cost Multiplier (Wkst B, Pt. II)
03-18
PROVIDER CCN:
CAP. REL.
BUILDINGS
& FIXTURES
( Square
Feet )
1
PERIOD:
FROM ________________
TO ________________
CAP. REL.
MOVABLE
EQUIPMENT
( Dollar Value or
Square Feet )
2
EMPLOYEE
BENEFITS
( Gross
Salaries )
3
RECONCILIATION
4A
WORKSHEET B - 1
ADMINISTRATIVE
& GENERAL
( Accumulated
Cost )
4
60
61
62
63
70
71
72
73
74
83
84
89
90
91
92
93
94
95
98
99
102
103
104
105
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
41-330
Rev. 8
03-18
FORM CMS-2540-10
COST ALLOCATION - STATISTICAL BASIS
Cost Center Description
4190 (Cont.)
PROVIDER CCN:
PLANT OPER.
MAINTENANCE
& REPAIRS
( Square
Feet )
5
LAUNDRY
& LINEN
SERVICE
( Pounds of
Laundry )
6
HOUSE
KEEPING
( Hours of
Service )
7
GENERAL SERVICE COST CENTERS
1 Capital-Related Costs - Buildings & Fixtures
2 Capital-Related Costs - Movable Equipment
3 Employee Benefits
4 Administrative and General
5 Plant Operation, Maintenance and Repairs
6 Laundry and Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Central Services and Supply
11 Pharmacy
12 Medical Records and Library
13 Social Service
14 Nursing and Allied Health Education
15 Other General Service Cost
INPATIENT ROUTINE SERVICE COST CENTERS
30 Skilled Nursing Facility
31 Nursing Facility
32 ICF/IID
33 Other Long Term Care
ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
DIETARY
( Meals
Served )
8
PERIOD:
FROM ________________
TO ________________
NURSING
CENTRAL
ADMINISSERVICES
TRATION
& SUPPLY
( Direct
( Costed
Nursing Hrs. )
Requisitions )
9
10
WORKSHEET B - 1
PHARMACY
( Costed
Requisitions )
11
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
30
31
32
33
40
41
42
43
44
45
46
47
48
49
50
51
52
Rev. 8
41-331
4190 (Cont.)
FORM CMS-2540-10
COST ALLOCATION - STATISTICAL BASIS
Cost Center Description
03-18
PROVIDER CCN:
PLANT OPER.
MAINTENANCE
& REPAIRS
( Square
Feet )
5
LAUNDRY
& LINEN
SERVICE
( Pounds of
Laundry )
6
HOUSE
KEEPING
( Hours of
Service )
7
OUTPATIENT SERVICE COST CENTERS
60 Clinic
61 Rural Health Clinic (RHC)
62 FQHC
63 Other Outpatient Service Cost
OTHER REIMBURSABLE COST CENTERS
70 Home Health Agency Cost
71 Ambulance
72 Outpatient Rehabilitation (specify)
73 CMHC
74 Other Reimbursable Cost
SPECIAL PURPOSE COST CENTERS
83 Hospice
84 Other Special Purpose Cost
89 Subtotals
NON REIMBURSABLE COST CENTERS
90 Gift, Flower, Coffee Shops and Canteen
91 Barber and Beauty Shop
92 Physicians' Private Offices
93 Nonpaid Workers
94 Patients' Laundry
95 Other Nonreimbursable Cost
98 Cross Foot Adjustments
99 Negative Cost Center
102 Cost to be allocated (Per Wkst. B, Pt I.)
103 Unit Cost Multiplier (Wkst. B, Pt I.)
104 Cost to be allocated (Per Wkst. B, Pt. II)
105 Unit Cost Multiplier (Wkst B, Pt. II)
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
DIETARY
( Meals
Served )
8
PERIOD:
FROM ________________
TO ________________
NURSING
CENTRAL
ADMINISSERVICES
TRATION
& SUPPLY
( Direct
( Costed
Nursing Hrs. )
Requisitions )
9
10
WORKSHEET B - 1
PHARMACY
( Costed
Requisitions )
11
60
61
62
63
70
71
72
73
74
83
84
89
90
91
92
93
94
95
98
99
102
103
104
105
41-332
Rev. 8
03-18
FORM CMS-2540-10
COST ALLOCATION - STATISTICAL BASIS
Cost Center Description
GENERAL SERVICE COST CENTERS
1 Capital-Related Costs - Buildings & Fixtures
2 Capital-Related Costs - Movable Equipment
3 Employee Benefits
4 Administrative and General
5 Plant Operation, Maintenance and Repairs
6 Laundry and Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Central Services and Supply
11 Pharmacy
12 Medical Records and Library
13 Social Service
14 Nursing and Allied Health Education
15 Other General Service Cost
INPATIENT ROUTINE SERVICE COST CENTERS
30 Skilled Nursing Facility
31 Nursing Facility
32 ICF/IID
33 Other Long Term Care
ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost
4190 (Cont.)
PROVIDER CCN:
MEDICAL
RECORDS
& LIBRARY
( Time
Spent )
12
SOCIAL
SERVICE
( Time
Spent )
13
NURSING &
ALLIED
HEALTH
EDUCATION
( Assigned Time )
14
PERIOD:
FROM ________________
TO ________________
OTHER
GENERAL
SERVICE
COST
15
SUBTOTAL
16
POST
STEP-DOWN
ADJUSTMENTS
17
WORKSHEET B - 1
TOTAL
18
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
30
31
32
33
40
41
42
43
44
45
46
47
48
49
50
51
52
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
Rev. 7
41-333
4190 (Cont.)
FORM CMS-2540-10
COST ALLOCATION - STATISTICAL BASIS
Cost Center Description
OUTPATIENT SERVICE COST CENTERS
60 Clinic
61 Rural Health Clinic (RHC)
62 FQHC
63 Other Outpatient Service Cost
OTHER REIMBURSABLE COST CENTERS
70 Home Health Agency Cost
71 Ambulance
72 Outpatient Rehabilitation (specify)
73 CMHC
74 Other Reimbursable Cost
SPECIAL PURPOSE COST CENTERS
83 Hospice
84 Other Special Purpose Cost
89 Subtotals
NON REIMBURSABLE COST CENTERS
90 Gift, Flower, Coffee Shops and Canteen
91 Barber and Beauty Shop
92 Physicians' Private Offices
93 Nonpaid Workers
94 Patients' Laundry
95 Other Nonreimbursable Cost
98 Cross Foot Adjustments
99 Negative Cost Center
102 Cost to be allocated (Per Wkst. B, Pt I.)
103 Unit Cost Multiplier (Wkst. B, Pt I.)
104 Cost to be allocated (Per Wkst. B, Pt. II)
105 Unit Cost Multiplier (Wkst B, Pt. II)
03-18
PROVIDER CCN:
MEDICAL
RECORDS
& LIBRARY
( Time
Spent )
12
SOCIAL
SERVICE
( Time
Spent )
13
NURSING &
ALLIED
HEALTH EDU
EDUCATION
( Assigned Time )
14
PERIOD:
FROM ________________
TO ________________
GENERAL
SERVICE
COST
COST
15
SUBTOTAL
16
POST
STEP-DOWN
ADJUSTMENTS
17
WORKSHEET B - 1
TOTAL
18
60
61
62
63
70
71
72
73
74
83
84
89
90
91
92
93
94
95
98
99
102
103
104
105
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
41-334
Rev. 8
03-18
FORM CMS-2540-10
ALLOCATION OF CAPITAL - RELATED COSTS
Cost Center Description
GENERAL SERVICE COST CENTERS
1 Capital-Related Costs - Buildings & Fixtures
2 Capital-Related Costs - Movable Equipment
3 Employee Benefits
4 Administrative and General
5 Plant Operation, Maintenance and Repairs
6 Laundry and Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Central Services and Supply
11 Pharmacy
12 Medical Records and Library
13 Social Service
14 Nursing and Allied Health Education
15 Other General Service Cost
INPATIENT ROUTINE SERVICE COST CENTERS
30 Skilled Nursing Facility
31 Nursing Facility
32 ICF/IID
33 Other Long Term Care
ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost
4190 (Cont.)
PROVIDER CCN:
DIRECTLY
ASSIGNED
CAPITAL
RELATED COSTS
0
CAP. REL
BUILDINGS
& FIXTURES
1
CAP. REL.
MOVABLE
EQUIPMENT
2
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4121)
PERIOD :
FROM ______________
TO ________________
SUBTOTAL
2A
EMPLOYEE
BENEFITS
3
WORKSHEET B
PART II
ADMINISTRATIVE
& GENERAL
4
PLANT OPER.
MAINTENANCE
& REPAIRS
5
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
30
31
32
33
40
41
42
43
44
45
46
47
48
49
50
51
52
Rev. 8
41-335
4190 (Cont.)
FORM CMS-2540-10
ALLOCATION OF CAPITAL - RELATED COSTS
Cost Center Description
OUTPATIENT SERVICE COST CENTERS
60 Clinic
61 Rural Health Clinic (RHC)
62 FQHC
63 Other Outpatient Service Cost
OTHER REIMBURSABLE COST CENTERS
70 Home Health Agency Cost
71 Ambulance
72 Outpatient Rehabilitation (specify)
73 CMHC
74 Other Reimbursable Cost
SPECIAL PURPOSE COST CENTERS
83 Hospice
84 Other Special Purpose Cost
89 Subtotals
NON REIMBURSABLE COST CENTERS
90 Gift, Flower, Coffee Shops and Canteen
91 Barber and Beauty Shop
92 Physicians' Private Offices
93 Nonpaid Workers
94 Patients' Laundry
95 Other Nonreimbursable Cost
98 Cross Foot Adjustments
99 Negative Cost Center
100 Total
03-18
PROVIDER CCN:
DIRECTLY
ASSIGNED
CAPITAL
RELATED COSTS
0
CAP. REL
BUILDINGS
& FIXTURES
1
CAP. REL.
MOVABLE
EQUIPMENT
2
PERIOD:
FROM ________________
TO ________________
SUBTOTAL
2A
EMPLOYEE
BENEFITS
3
ADMINISTRATIVE
& GENERAL
4
WORKSHEET B
PART II
PLANT OPER.
MAINTENANCE
& REPAIRS
5
60
61
62
63
70
71
72
73
74
83
84
89
90
91
92
93
94
95
98
99
100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4121)
41-336
03-18
Rev. 8
FORM CMS-2540-10
ALLOCATION OF CAPITAL - RELATED COSTS
Cost Center Description
GENERAL SERVICE COST CENTERS
1 Capital-Related Costs - Buildings & Fixtures
2 Capital-Related Costs - Movable Equipment
3 Employee Benefits
4 Administrative and General
5 Plant Operation, Maintenance and Repairs
6 Laundry and Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Central Services and Supply
11 Pharmacy
12 Medical Records and Library
13 Social Service
14 Nursing and Allied Health Education
15 Other General Service Cost
INPATIENT ROUTINE SERVICE COST CENTERS
30 Skilled Nursing Facility
31 Nursing Facility
32 ICF/IID
33 Other Long Term Care
ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost
4190 (Cont.)
PROVIDER CCN:
LAUNDRY
& LINEN
SERVICE
6
HOUSE
KEEPING
7
PERIOD:
FROM ________________
TO ________________
DIETARY
8
NURSING
ADMINISTRATION
9
CENTRAL
SERVICES
& SUPPLY
10
WORKSHEET B
PART II
PHARMACY
11
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
30
31
32
33
40
41
42
43
44
45
46
47
48
49
50
51
52
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4121)
Rev. 8
4190 (Cont.)
41-337
FORM CMS-2540-10
ALLOCATION OF CAPITAL - RELATED COSTS
Cost Center Description
OUTPATIENT SERVICE COST CENTERS
60 Clinic
61 Rural Health Clinic (RHC)
62 FQHC
63 Other Outpatient Service Cost
OTHER REIMBURSABLE COST CENTERS
70 Home Health Agency Cost
71 Ambulance
72 Outpatient Rehabilitation (specify)
73 CMHC
74 Other Reimbursable Cost
SPECIAL PURPOSE COST CENTERS
83 Hospice
84 Other Special Purpose Cost
89 Subtotals
NON REIMBURSABLE COST CENTERS
90 Gift, Flower, Coffee Shops and Canteen
91 Barber and Beauty Shop
92 Physicians' Private Offices
93 Nonpaid Workers
94 Patients' Laundry
95 Other Nonreimbursable Cost
98 Cross Foot Adjustments
99 Negative Cost Center
100 Total
03-18
PROVIDER CCN:
LAUNDRY
& LINEN
SERVICE
6
HOUSE
KEEPING
7
PERIOD:
FROM ________________
TO ________________
DIETARY
8
NURSING
ADMINISTRATION
9
CENTRAL
SERVICES
& SUPPLY
10
WORKSHEET B
PART II
PHARMACY
11
60
61
62
63
70
71
72
73
74
83
84
89
90
91
92
93
94
95
98
99
100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4121)
41-338
Rev. 8
03-18
FORM CMS-2540-10
ALLOCATION OF CAPITAL - RELATED COSTS
Cost Center Description
GENERAL SERVICE COST CENTERS
1 Capital-Related Costs - Buildings & Fixtures
2 Capital-Related Costs - Movable Equipment
3 Employee Benefits
4 Administrative and General
5 Plant Operation, Maintenance and Repairs
6 Laundry and Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Central Services and Supply
11 Pharmacy
12 Medical Records and Library
13 Social Service
14 Nursing and Allied Health Education
15 Other General Service Cost
INPATIENT ROUTINE SERVICE COST CENTERS
30 Skilled Nursing Facility
31 Nursing Facility
32 ICF/IID
33 Other Long Term Care
ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost
4190 (Cont.)
PROVIDER CCN:
MEDICAL
RECORDS
& LIBRARY
12
SOCIAL
SERVICE
13
NURSING &
ALLIED
HEALTH
EDUCATION
14
PERIOD:
FROM ________________
TO ________________
OTHER
GENERAL
SERVICE
COST
15
SUBTOTAL
16
POST
STEP-DOWN
ADJUSTMENTS
17
WORKSHEET B
PART II
TOTAL
18
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
30
31
32
33
40
41
42
43
44
45
46
47
48
49
50
51
52
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4121)
Rev. 8
41-339
4190 (Cont.)
FORM CMS-2540-10
ALLOCATION OF CAPITAL - RELATED COSTS
Cost Center Description
OUTPATIENT SERVICE COST CENTERS
60 Clinic
61 Rural Health Clinic (RHC)
62 FQHC
63 Other Outpatient Service Cost
OTHER REIMBURSABLE COST CENTERS
70 Home Health Agency Cost
71 Ambulance
72 Outpatient Rehabilitation (specify)
73 CMHC
74 Other Reimbursable Cost
SPECIAL PURPOSE COST CENTERS
83 Hospice
84 Other Special Purpose Cost
89 Subtotals
NON REIMBURSABLE COST CENTERS
90 Gift, Flower, Coffee Shops and Canteen
91 Barber and Beauty Shop
92 Physicians' Private Offices
93 Nonpaid Workers
94 Patients' Laundry
95 Other Nonreimbursable Cost
98 Cross Foot Adjustments
99 Negative Cost Center
100 Total
03-18
PROVIDER CCN:
MEDICAL
RECORDS
& LIBRARY
12
SOCIAL
SERVICE
13
NURSING &
ALLIED
HEALTH
EDUCATION
14
PERIOD:
FROM ________________
TO ________________
OTHER
GENERAL
SERVICE
COST
15
SUBTOTAL
16
POST
STEP-DOWN
ADJUSTMENTS
17
WORKSHEET B
PART II
TOTAL
18
60
61
62
63
70
71
72
73
74
83
84
89
90
91
92
93
94
95
98
99
100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4121)
41-340
Rev. 8
08-16
FORM CMS-2540-10
POST STEP DOWN ADJUSTMENTS
PROVIDER CCN:
Description
1
4190 (Cont.)
PERIOD :
FROM ______________
TO ________________
Worksheet B
Part No.
Line No.
2
3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4122)
WORKSHEET B-2
Amount
4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
Rev. 7
41-341
4190 (Cont.)
FORM CMS-2540-10
RATIO OF COST TO CHARGES
FOR ANCILLARY AND OUTPATIENT
COST CENTERS
PROVIDER CCN:
Cost Center Description
ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost
OUTPATIENT SERVICE COST CENTERS
60 Clinic
61 Rural Health Clinic (RHC)
62 FQHC
63 Other Outpatient Service Cost
71 Ambulance
100 Total
08-16
PERIOD :
FROM ______________
TO ________________
Total
( from Wkst. B,
Pt. I, col. 18 )
1
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4123)
WORKSHEET C
Total
Charges
2
Ratio
( col. 1 divided
by col. 2 )
3
40
41
42
43
44
45
46
47
48
49
50
51
52
60
61
62
63
71
100
41-342
Rev. 7
03-18
FORM CMS-2540-10
APPORTIONMENT OF ANCILLARY AND
OUTPATIENT COST
Check applicable box:
Check applicable box:
4190 (Cont.)
PROVIDER CCN:
[ ] Title V (1)
[ ] SNF
[ ] Title XVIII
[ ] NF
[ ] Title XIX ( 1 )
[ ] ICF / IID
[
] Other
PERIOD :
FROM ______________
TO ________________
______________________
[
WORKSHEET D
PART I
] PPS - Must also complete Part II
PART I - CALCULATION OF ANCILLARY AND OUTPATIENT COST
Cost Center Description
Ratio of
Cost to
Charges
( from Wkst. C,
col. 3 )
1
ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost
OUTPATIENT COST CENTERS
60 Clinic
61 Rural Health Clinic (RHC)
62 FQHC
63 Other Outpatient Service Cost
71 Ambulance (2)
100 Total (sum of lines 40 - 71)
(1) For titles V and XIX use columns 1, 2 and 4 only.
(2) Line 71 columns 2 and 4 are for titles V and XIX. No amounts should be entered here for title XVIII.
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4124)
Health Care
Program Charges
Part A
2
Healthcare
Program Cost
Part B
3
Part A
( col. 1 x col. 2 )
4
Part B
( col. 1 x col. 3 )
5
Rev. 8
41-343
4190 (Cont.)
40
41
42
43
44
45
46
47
48
49
50
51
52
60
61
62
63
71
100
41-343
4190 (Cont.)
FORM CMS-2540-10
APPORTIONMENT OF ANCILLARY AND
OUTPATIENT COST
03-18
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
WORKSHEET D
PARTS II & III
TITLE XVIII ONLY
PART II - APPORTIONMENT OF VACCINE COST
1 Drugs charged to patients - ratio of cost to charges (from Wkst. C, col. 3, line 49)
2 Program vaccine charges ( From your records or the PS&R report)
3 Program costs (line 1 x line 2) (Title XVIII, PPS providers, transfer this amount to Wkst. E, Pt. I, line 18)
PART III - CALCULATION OF PASS THROUGH COSTS FOR NURSING & ALLIED HEALTH
Cost Center Description
Total Cost
( from Wkst. B,
Pt. I, col. 18 )
1
ANCILLARY SERVICE COST CENTERS
40 Radiology
41 Laboratory
42 Intravenous Therapy
43 Oxygen (Inhalation) Therapy
44 Physical Therapy
45 Occupational Therapy
46 Speech Pathology
47 Electrocardiology
48 Medical Supplies Charged to Patients
49 Drugs Charged to Patients
50 Dental Care - Title XIX only
51 Support Surfaces
52 Other Ancillary Service Cost
100 Total (sum of lines 40 - 52)
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4124.1)
Nursing &
Allied Health
( from Wkst. B,
Pt. I, col. 14 )
2
Ratio of Nursing
& Allied Health
Costs to Total
Costs - Part A
( col. 2 / col. 1 )
3
Program
Part A Cost
( from Wkst. D.,
Pt. I, col. 4 )
4
Part A
Nursing & Allied
Health Costs for
Pass Through
( col. 3 x col. 4 )
5
41-344
Rev. 8
03-18
1
2
3
40
41
42
43
44
45
46
47
48
49
50
51
52
100
Rev. 8
03-18
FORM CMS-2540-10
COMPUTATION OF INPATIENT
ROUTINE COSTS
Check applicable box:
Check applicable box:
[
[
] Title V
] SNF
PROVIDER CCN:
[
[
] Title XVIII
] NF
[
[
4190 (Cont.)
PERIOD :
FROM ______________
TO ________________
WORKSHEET D-1
PARTS I & II
] Title XIX
] ICF / IID
PART I - CALCULATION OF INPATIENT ROUTINE COSTS
INPATIENT DAYS
1 Inpatient days including private room days
2 Private room days
3 Inpatient days including private room days applicable to the Program
4 Medically necessary private room days applicable to the Program
5 Total general inpatient routine service cost
PRIVATE ROOM DIFFERENTIAL ADJUSTMENT
6 General inpatient routine service charges
7 General inpatient routine service cost/charge ratio (line 5 divided by line 6)
8 Enter private room charges from your records
9 Average private room per diem charge (private room charges on line 8 divided by private room days on line 2)
10 Enter semi-private room charges from your records
11 Average semi-private room per diem charge (semi-private room charges on line 10 divided by semi-private room days)
12 Average per diem private room charge differential (line 9 minus line 11)
13 Average per diem private room cost differential (line 7 times line 12 )
14 Private room cost differential adjustment (line 2 times line 13)
15 General inpatient routine service cost net of private room cost differential (line 5 minus line 14)
PROGRAM INPATIENT ROUTINE SERVICE COSTS
16 Adjusted general inpatient service cost per diem (line 15 divided by line 11)
17 Program routine service cost (line 3 times line 16)
18 Medically necessary private room cost applicable to program (line 4 times line 13)
19 Total program general inpatient routine service cost (line 17 plus line 18)
20 Capital related cost allocated to inpatient routine service costs (from Wkst. B, Pt. II, col. 18, line 30 for SNF; line 31 for NF; or
line 32 for ICF/IID)
21 Per diem capital related costs (line 20 divided by line 1)
22 Program capital related cost (line 3 times line 21)
23 Inpatient routine service cost (line 19 minus line 22)
24 Aggregate charges to beneficiaries for excess costs (from provider records)
25 Total program routine service costs for comparison to the cost limitation (line 23 minus line 24)
26 Enter the per diem limitation (1)
27 Inpatient routine service cost limitation (line 3 times the per diem limitation line 26) (1)
28 Reimbursable inpatient routine service costs (line 22 plus the lesser of line 25 or line 27)
(Transfer to Wkst. E, Pt. II, line 4) (see instructions)
PART II - CALCULATION OF INPATIENT NURSING & ALLIED HEALTH COSTS FOR PPS PASS-THROUGH
1 Total inpatient days
2 Program inpatient days (see instructions)
3 Total nursing & allied health costs (see instructions)
4 Nursing & allied health ratio (line 2 divided by line 1)
5 Program nursing & allied health costs for pass-through (line 3 times line 4)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
1
2
3
4
5
(1) Lines 26, 27 and 28 are not applicable for title XVIII, but may be used for title V and or title XIX
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4125)
Rev. 8
41-345
4190 (Cont.)
CALCULATION OF
REIMBURSEMENT SETTLEMENT
FOR TITLE XVIII
FORM CMS-2540-10
PROVIDER CCN:
03-18
PERIOD :
FROM ______________
TO ________________
WORKSHEET E
PART I
PART A - INPATIENT SERVICE PPS PROVIDER COMPUTATION OF REIMBURSEMENT
1 Inpatient PPS amount (see instructions)
2 Nursing and Allied Health Education Activities (pass through payments)
3 Subtotal (sum of lines 1 and 2)
4 Primary payer amounts
5 Coinsurance
6 Allowable bad debts (from your records)
7 Allowable Bad debts for dual eligible beneficiaries (see instructions)
8 Reimbursable bad debts (see instructions)
9 Recovery of bad debts - for statistical records only
10 Utilization review
11 Subtotal (see instructions)
12 Interim payments (see instructions)
13 Tentative adjustment
14 Other adjustment (see instructions)
14.50 Pioneer ACO demonstration payment adjustment (see instructions)
14.99 Sequestration amount (see instructions)
15 Balance due provider/program (see instructions)
(Indicate overpayment in parentheses)
16 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2
PART B - ANCILLARY SERVICE COMPUTATION OF REIMBURSEMENT LESSER OF COST OR CHARGES - TITLE XVIII ONLY
17 Ancillary services Part B
18 Vaccine cost (from Wkst. D, Pt. II, line 3)
19 Total reasonable costs (sum of lines 17 and 18)
20 Medicare Part B ancillary charges (see instructions)
21 Cost of covered services (lesser of line 19 or line 20)
22 Primary payer amounts
23 Coinsurance and deductibles
24 Allowable bad debts (from your records)
24.01 Allowable bad debts for dual eligible beneficiaries (see instructions)
24.02 Reimbursable bad debts (see instructions)
25 Subtotal (sum of lines 21 and 24.02, minus lines 22 and 23)
26 Interim payments (see instructions)
27 Tentative adjustment
28 Other Adjustments (Specify ______________) (see instructions)
28.50 Pioneer ACO demonstration payment adjustment (see instructions)
28.99 Sequestration amount (see instructions)
29 Balance due provider/program (see instructions)
(indicate overpayments in parentheses)
30 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2
1
2
3
4
5
6
7
8
9
10
11
12
13
14
14.50
14.99
15
16
17
18
19
20
21
22
23
24
24.01
24.02
25
26
27
28
28.50
28.99
29
30
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4130)
41-346
Rev. 8
03-18
FORM CMS-2540-10
CALCULATION OF
REIMBURSEMENT SETTLEMENT
FOR TITLE V and TITLE XIX ONLY
Check applicable box:
Check applicable box:
[ ] Title V
[ ] SNF
PROVIDER CCN:
[ ] Title XIX
[ ] NF
4190 (Cont.)
PERIOD :
FROM ______________
TO ________________
[ ] ICF / IID
COMPUTATION OF NET COST OF COVERED SERVICES
1 Inpatient ancillary services (see instructions)
2 Nursing & Allied Health Cost (from Wkst. D-1, Pt. II, line 5)
3 Outpatient services
4 Inpatient routine services (see instructions)
5 Utilization review - physicians' compensation (from provider records)
6 Cost of covered services (sum of lines 1 - 5)
7 Differential in charges between semiprivate accommodations and less
than semiprivate accommodations
8 Subtotal (line 6 minus line 7)
9 Primary payer amounts
10 Total reasonable cost (line 8 minus line 9)
REASONABLE CHARGES
11 Inpatient ancillary service charges
12 Outpatient service charges
13 Inpatient routine service charges
14 Differential in charges between semiprivate accommodations and less
than semiprivate accommodations
15 Total reasonable charges
CUSTOMARY CHARGES
16 Aggregate amount actually collected from patients liable for payment for
services on a charge basis
17 Amounts that would have been realized from patients liable for payment for services
on a charge basis had such payment been made in accordance with 42 CFR 413.13(e)
18 Ratio of line 16 to line 17 (not to exceed 1.000000)
19 Total customary charges (see instructions)
COMPUTATION OF REIMBURSEMENT SETTLEMENT
20 Cost of covered services (see instructions)
21 Deductibles
22 Subtotal (line 20 minus line 21)
23 Coinsurance
24 Subtotal (line 22 minus line 23)
25 Allowable bad debts (from your records)
26 Subtotal (sum of lines 24 and 25)
27 Unrefunded charges to beneficiaries for excess costs erroneously collected
based on correction of cost limit
28 Recovery of excess depreciation resulting from provider termination or a decrease
in program utilization
29 Other adjustments (Specify ______________) (see instructions)
30 Amounts applicable to prior cost reporting periods resulting from disposition of
depreciable assets (if minus, enter amount in parentheses)
31 Subtotal (line 26 plus or minus lines 29, and 30, minus lines 27 and 28)
32 Interim payments
33 Balance due provider/program (line 31 minus line 32)
(indicate overpayments in parentheses) (see instructions)
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4130.2)
WORKSHEET E
PART II
Rev. 8
41-347
4190 (Cont.)
PART II
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
41-347
4190 (Cont.)
FORM CMS-2540-10
ANALYSIS OF PAYMENTS TO PROVIDERS
FOR SERVICES RENDERED
03-18
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
Inpatient Part A
Description
1 Total interim payments paid to provider
2 Interim payments payable on individual bills, either submitted
or to be submitted to the intermediary/contractor for services
rendered in the cost reporting period. If none, enter zero.
2 List separately each retroactive lump sum
adjustment amount based on subsequent revision of
the interim rate for the cost reporting period
Also show date of each payment.
If none, write "NONE," or enter a zero. (1)
mm/dd/yyyy
1
Program
to
Provider
SUBTOTAL (sum of lines 3.01 - 3.49 minus sum of lines 3.50 - 3.98)
4 TOTAL INTERIM PAYMENTS (sum of lines 1, 2 & 3.99)
(Transfer to Wkst. E, Pt. I, line 12 for Part A, and line 26 for Part B.)
SUBTOTAL (sum of lines 5.01 - 5.49 minus sum of lines 5.50 - 5.98)
6 Determine net settlement amount (balance
due) based on the cost report (1)
7 TOTAL MEDICARE PROGRAM LIABILITY (see instructions)
8 Name of Contractor
Part B
Amount
2
mm/dd/yyyy
3
Amount
4
1
2
Provider
to
Program
TO BE COMPLETED BY CONTRACTOR
5 List separately each tentative settlement
payment after desk review. Also show
date of each payment.
If none, write "NONE," or enter a zero. (1)
WORKSHEET E-1
Program
to
Provider
Provider
to
Program
Program to Provider
Provider to Program
.02
.03
.04
.05
.50
.51
.52
.53
.54
.99
.01
.02
.03
.50
.51
.52
.99
.01
.02
Contractor Number
(1) On lines 3, 5, and 6, where an amount is due "Provider to Program," show the amount and date on which the provider agrees to the amount of repayment even though total repayment is not accomplished until a later date.
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4131)
3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54
3.99
4
5.01
5.02
5.03
5.50
5.51
5.52
5.99
6.01
6.02
7
8
41-348
Rev. 8
03-18
FORM CMS-2540-10
BALANCE SHEET
(If you are nonproprietary and do not maintain fund-type
accounting records, complete the "General Fund" column only.)
Assets
CURRENT ASSETS
1 Cash on hand and in banks
2 Temporary investments
3 Notes receivable
4 Accounts receivable
5 Other receivables
6 Less: allowances for uncollectible notes
and accounts receivable
7 Inventory
8 Prepaid expenses
9 Other current assets
10 Due from other funds
11 TOTAL CURRENT ASSETS
(sum of lines 1 - 10)
FIXED ASSETS
12 Land
13 Land improvements
14 Less: Accumulated depreciation
15 Buildings
16 Less Accumulated depreciation
17 Leasehold improvements
18 Less: Accumulated Amortization
19 Fixed equipment
20 Less: Accumulated depreciation
21 Automobiles and trucks
22 Less: Accumulated depreciation
23 Major movable equipment
24 Less: Accumulated depreciation
25 Minor equipment - Depreciable
26 Minor equipment nondepreciable
27 Other fixed assets
28 TOTAL FIXED ASSETS
(sum of lines 12 - 27)
OTHER ASSETS
29 Investments
30 Deposits on leases
31 Due from owners/officers
32 Other assets
33 TOTAL OTHER ASSETS
(sum of lines 29 - 32)
34 TOTAL ASSETS
(sum of lines 11, 28 and 33)
(
PROVIDER CCN:
Specific
Purpose
Fund
2
General
Fund
1
(
)
4190 (Cont.)
PERIOD :
FROM ______________
TO ________________
(
)
WORKSHEET G
Endowment
Fund
3
(
)
Plant
Fund
4
(
)
1
2
3
4
5
6
7
8
9
10
11
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
) = contra amount
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4140)
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
Rev. 8
41-349
4190 (Cont.)
FORM CMS-2540-10
BALANCE SHEET
(If you are nonproprietary and do not maintain fund-type
accounting records, complete the "General Fund" column only.)
Liabilities and Fund
Balances
CURRENT LIABILITIES
35 Accounts payable
36 Salaries, wages & fees payable
37 Payroll taxes payable
38 Notes & loans payable (short term)
39 Deferred income
40 Accelerated payments
41 Due to other funds
42 Other current liabilities
43 TOTAL CURRENT LIABILITIES
(sum of lines 35 - 42)
LONG TERM LIABILITIES
44 Mortgage payable
45 Notes payable
46 Unsecured loans
47 Loans from owners:
48 Other long term liabilities
49 Other (specify)
50 TOTAL LONG TERM LIABILITIES
(sum of lines 44 - 49)
51 TOTAL LIABILITIES
(sum of lines 43 and 50)
CAPITAL ACCOUNTS
52 General fund balance
53 Specific purpose fund
54 Donor created - endowment fund
balance - restricted
55 Donor created - endowment fund
balance - unrestricted
56 Governing body created - endowment
fund balance
57 Plant fund balance - invested in plant
58 Plant fund balance - reserve for
plant improvement, replacement and
expansion
59 TOTAL FUND BALANCES
(sum of lines 52 thru 58)
60 TOTAL LIABILITIES AND
FUND BALANCES
(sum of lines 51 and 59)
(
PROVIDER CCN:
General
Fund
1
Specific
Purpose
Fund
2
03-18
PERIOD :
FROM ______________
TO ________________
Endowment
Fund
3
) = contra amount
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4140)
WORKSHEET G
Plant
Fund
4
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
41-350
Rev. 8
08-16
FORM CMS-2540-10
STATEMENT OF CHANGES IN FUND BALANCES
General Fund
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
4190 (Cont.)
PROVIDER CCN:
2
Fund balances at beginning of period
Net income (loss) (from Wkst. G-3, line 31)
Total (sum of line 1 and line 2)
Additions (credit adjustments)
Total additions (sum of lines 5 - 9)
Subtotal (line 3 plus line 10)
Deductions (debit adjustments)
Total deductions (sum of lines 13 - 17)
Fund balance at end of period per balance sheet (line 11 - line 18)
FORM CMS-2540-10 (09/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4140)
Special Purpose Fund
3
4
PERIOD :
FROM ______________
TO ________________
Endowment Fund
5
6
WORKSHEET G - 1
Plant Fund
7
8
Rev. 7
41-351
4190 (Cont.)
WORKSHEET G - 1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
41-351
4190 (Cont.)
STATEMENT OF PATIENT REVENUES
AND OPERATING EXPENSES
FORM CMS-2540-10
PROVIDER CCN:
08-16
PERIOD :
FROM ______________
TO ________________
WORKSHEET G - 2
PARTS I & II
PART I - PATIENT REVENUES
Revenue Center
General Inpatient Routine Care Services
1 Skilled nursing facility
2 Nursing facility
3 ICF / IID
4 Other long term care
5 Total general inpatient care services
(sum of lines 1 - 4)
All Other Care Service
6 Ancillary services
7 Clinic
8 Home health agency
9 Ambulance
10 RHC/FQHC
11 CMHC
12 Hospice
13 Other (specify)
14 Total patient revenues (sum of lines 5 - 13)
(transfer to Wkst. G-3, col. 3, line 1 )
INPATIENT
1
OUTPATIENT
2
PART II - OPERATING EXPENSES
1 Operating Expenses (per Wkst. A, col. 3, line 100)
TOTAL
3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
1
2 Add ( Specify )
2
3
3
4
4
5
5
6
6
7
7
8 Total Additions (sum of lines 2 - 7)
8
9 Deduct (Specify)
9
10
10
11
11
12
12
13
13
14 Total Deductions (sum of lines 9 - 13)
14
15 Total Operating Expenses (sum of lines 1 and 8, minus line 14)
15
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4140)
41-352
Rev. 7
08-16
FORM CMS-2540-10
STATEMENT OF REVENUES
AND EXPENSES
1
2
3
4
5
PROVIDER CCN:
4190 (Cont.)
PERIOD :
FROM ______________
TO ________________
Total patient revenues (from Wkst. G-2, Pt. I, col. 3, line 14)
Less: contractual allowances and discounts on patients accounts
Net patient revenues (line 1 minus line 2)
Less: total operating expenses (form Wkst. G-2, Pt. II, line 15)
Net income from service to patients (line 3 minus 4)
Other income:
Contributions, donations, bequests, etc.
Income from investments
Revenues from communications (telephone and internet service)
Revenue from television and radio service
Purchase discounts
Rebates and refunds of expenses
Parking lot receipts
Revenue from laundry and linen service
Revenue from meals sold to employees and guests
Revenue from rental of living quarters
Revenue from sale of medical and surgical supplies to other than patients
Revenue from sale of drugs to other than patients
Revenue from sale of medical records and abstracts
Tuition (fees, sale of textbooks, uniforms, etc.)
Revenue from gifts, flower, coffee shops, canteen
Rental of vending machines
Rental of skilled nursing space
Governmental appropriations
Other miscellaneous revenue (specify ______________)
Total other income (sum of lines 6 - 24)
Total (line 5 plus line 25)
Other expenses (specify ________________)
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30 Total other expenses (sum of lines 27 - 29)
31 Net income (or loss) for the period (line 26 minus line 30)
FORM CMS-2540-10 (09/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4140)
WORKSHEET G-3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Rev. 7
41-353
4190 (Cont.)
FORM CMS-2540-10
ANALYSIS OF SNF-BASED
HOME HEALTH AGENCY COSTS
08-16
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
HHA CCN:
COST CENTER DESCRIPTIONS
GENERAL SERVICE COST CENTERS
1 Capital Related - Bldgs. and Fixtures
2 Capital Related - Movable Equipment
3 Plant Operation & Maintenance
4 Transportation (see instructions)
5 Administrative and General
HHA REIMBURSABLE SERVICES
6 Skilled Nursing Care
7 Physical Therapy
8 Occupational Therapy
9 Speech Pathology
10 Medical Social Services
11 Home Health Aide
12 Supplies (see instructions)
13 Drugs
14 DME
15 Telemedicine
HHA NONREIMBURSABLE SERVICES
16 Home Dialysis Aide Services
17 Respiratory Therapy
18 Private Duty Nursing
19 Clinic
20 Health Promotion Activities
21 Day Care Program
22 Home Delivered Meals Program
23 Homemaker Service
24 All Others
25 Total (sum of lines 1-24)
SALARIES
1
EMPLOYEE
BENEFITS
2
TRANSPORTATION
( see
instructions )
3
CONTRACTED/
PURCHASED
SERVICES
4
OTHER
COSTS
5
Column, 6 line 25 should agree with the Worksheet A, column 3, line 70, or subscript as applicable.
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4141)
TOTAL
( sum of cols.
1 thru 5 )
6
RECLASSIFICATIONS
7
RECLASSIFIED
TRIAL BALANCE
( col. 6 + col. 7 )
8
ADJUSTMENTS
9
WORKSHEET H
NET
EXPENSES FOR
ALLOCATION
( col. 8 + col. 9 )
10
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
41-354
Rev. 7
11-12
FORM CMS-2540-10
COST ALLOCATION - HHA GENERAL SERVICE COST
4190 (Cont.)
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
HHA CCN:
NET EXPENSES
FOR COST
ALLOCATION
( from Wkst. H,
col. 10 )
0
WORKSHEET H-1
PART I
CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1
MOVABLE
EQUIPMENT
2
GENERAL SERVICE COST CENTERS
1 Capital Related - Bldgs. and Fixtures
2 Capital Related - Movable Equipment
3 Plant Operation & Maintenance
4 Transportation (see instructions)
5 Administrative and General
HHA REIMBURSABLE SERVICES
6 Skilled Nursing Care
7 Physical Therapy
8 Occupational Therapy
9 Speech Pathology
10 Medical Social Services
11 Home Health Aide
12 Supplies
13 Drugs
14 DME
15 Telemedicine
HHA NONREIMBURSABLE SERVICES
16 Home Dialysis Aide Services
17 Respiratory Therapy
18 Private Duty Nursing
19 Clinic
20 Health Promotion Activities
21 Day Care Program
22 Home Delivered Meals Program
23 Homemaker Service
24 All Others
25 Total (sum of lines 1-24)
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4142)
PLANT
OPERATION &
MAINTENANCE
3
TRANSPORTATION
4
SUBTOTAL
( cols. 0 through 4 )
4A
ADMINISTRATIVE
& GENERAL
5
TOTAL
( cols. 4A + 5 )
6
Rev. 4
41-355
4190 (Cont.)
WORKSHEET H-1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
41-355
4190 (Cont.)
FORM CMS-2540-10
COST ALLOCATION - HHA STATISTICAL BASIS
11-12
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
HHA CCN:
NET EXPENSES
FOR COST
ALLOCATION
0
CAPITAL
RELATED COSTS
BLDGS. &
MOVABLE
FIXTURES
EQUIPMENT
( Square
( Dollar Value
Feet )
or Square Feet )
1
2
GENERAL SERVICE COST CENTERS
1 Capital Related - Bldgs. and Fixtures
2 Capital Related - Movable Equipment
3 Plant Operation & Maintenance
4 Transportation (see instructions)
5 Administrative and General
HHA REIMBURSABLE SERVICES
6 Skilled Nursing Care
7 Physical Therapy
8 Occupational Therapy
9 Speech Pathology
10 Medical Social Services
11 Home Health Aide
12 Supplies
13 Drugs
14 DME
15 Telemedicine
HHA NONREIMBURSABLE SERVICES
16 Home Dialysis Aide Services
17 Respiratory Therapy
18 Private Duty Nursing
19 Clinic
20 Health Promotion Activities
21 Day Care Program
22 Home Delivered Meals Program
23 Homemaker Service
24 All Others
25 Total (sum of lines 1-24)
26 Cost to be allocated
27 Unit Cost Multiplier
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4142)
PLANT
OPERATION &
MAINTENANCE
( Square
Feet )
3
TRANSPORTATION
( Mileage )
4
RECONCILIATION
5A
ADMINISTRATIVE
& GENERAL
( Accumulated
Cost )
5
WORKSHEET H-1,
PART II
TOTAL
6
41-356
Rev. 4
11-12
WORKSHEET H-1,
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
Rev. 4
11-12
FORM CMS-2540-10
ALLOCATION OF GENERAL SERVICE
COSTS TO HHA COST CENTERS
4190 (Cont.)
PROVIDER CCN:
PERIOD:
FROM __________________
TO ________________
HHA CCN:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
HHA COST CENTER
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
Telemedicine
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Totals (sum of lines 1-20) (2)
Unit Cost Multiplier: column 18, line 1
divided by the sum of column 18,
line 21, minus column 18, line 1,
rounded to 6 decimal places.
From
Wkst.
H-1,
Pt. I,
col. 6,
line
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
HHA
TRIAL
BALANCE
(1)
0
WORKSHEET H-2,
PART I
CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1
MOVABLE
EQUIPMENT
2
(1) Column 0, line 21 must agree with Wkst. A, col. 7, line 70.
(2) Columns 0 through 18, line 21 must agree with the corresponding columns of Wkst. B, Pt. I, line 70.
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4143)
EMPLOYEE
BENEFITS
3
SUBTOTAL
( cols. 0
through 3 )
3A
ADMINISTRATIVE &
GENERAL
4
OPERATION
OF PLANT
5
LAUNDRY
& LINEN
SERVICE
6
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Rev. 4
41-357
4190 (Cont.)
FORM CMS-2540-10
ALLOCATION OF GENERAL SERVICE
COSTS TO HHA COST CENTERS
11-12
PROVIDER CCN:
PERIOD:
FROM __________________
TO ________________
HHA CCN:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
HHA COST CENTER
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
Telemedicine
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Totals (sum of lines 1-20) (2)
Unit Cost Multiplier: column 18, line 1
divided by the sum of column 18,
line 21, minus column 18, line 1,
rounded to 6 decimal places.
HOUSE
KEEPING
7
DIETARY
8
(2) Columns 0 through 18, line 21 must agree with the corresponding columns of Wkst. B, Pt. I, line 70.
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4143)
NURSING
ADMINISTRATION
9
CENTRAL
SERVICES &
SUPPLY
10
PHARMACY
11
MEDICAL
RECORDS &
LIBRARY
12
WORKSHEET H-2,
PART I
SOCIAL
SERVICE
13
41-358
Rev. 4
11-12 11-12
WORKSHEET H-2,
FORM CMS-2540-10
ALLOCATION OF GENERAL SERVICE
COSTS TO HHA COST CENTERS
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
HHA CCN:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
HHA COST CENTER
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
Telemedicine
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Totals (sum of lines 1-20) (2)
Unit Cost Multiplier: column 18, line 1
divided by the sum of column 18,
line 21, minus column 18, line 1,
rounded to 6 decimal places.
NURSING
AND ALLIED
HEALTH
EDUCATION
14
OTHER
GENERAL
SERVICE
15
(2) Columns 0 through 18, line 21 must agree with the corresponding columns of Wkst. B, Pt. I, line 70.
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4143)
SUBTOTAL
( sum of
cols. 3A
through 15 )
16
POST
STEPDOWN
ADJUSTMENTS
17
SUBTOTAL
( cols. 16 ± 17 )
18
ALLOCATED
HHA
A&G
( see Pt. II )
19
Rev. 4 Rev. 4
4190 (Cont.)
WORKSHEET H-2,
PART I
TOTAL
HHA COSTS
20
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
41-359
4190 (Cont.)
FORM CMS-2540-10
ALLOCATION OF GENERAL SERVICE
COSTS TO HHA COST CENTERS
STATISTICAL BASIS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
HHA COST CENTER
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
Telemedicine
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Totals (sum of lines 1-20)
Total cost to be allocated
Unit Cost Multiplier
11-12
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
HHA CCN:
CAPITAL
RELATED COSTS
BLDGS. &
MOVABLE
FIXTURES
EQUIPMENT
( Square
( Dollar Value
Feet )
or Square Feet )
1
2
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4143)
EMPLOYEE
BENEFITS
( Gross
Salaries )
3
RECONCILIATION
4A
ADMINISTRATIVE &
GENERAL
( Accumulated
Cost )
4
OPERATION
OF PLANT
( Square
Feet )
5
WORKSHEET H-2,
PART II
LAUNDRY
& LINEN
SERVICE
( Pounds of
Laundry )
6
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
41-360
Rev. 4
11-12
FORM CMS-2540-10
ALLOCATION OF GENERAL SERVICE
COSTS TO HHA COST CENTERS
STATISTICAL BASIS
HHA COST CENTER
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
4190 (Cont.)
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
HHA CCN:
HOUSEKEEPING
( Hours of
Service )
7
DIETARY
( Meals
Served )
8
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
Telemedicine
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Totals (sum of lines 1-20)
Total cost to be allocated
Unit Cost Multiplier
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4143)
NURSING
ADMINISTRATION
( Direct
Nursing Hrs. )
9
CENTRAL
SERVICES &
SUPPLY
( Costed
Requis. )
10
PHARMACY
( Costed
Requis. )
11
MEDICAL
RECORDS &
LIBRARY
( Time
Spent )
12
WORKSHEET H-2,
PART II
SOCIAL
SERVICE
( Time
Spent )
13
Rev. 4
41-361
4190 (Cont.) 4190 (Cont.)
FORM CMS-2540-10
ALLOCATION OF GENERAL SERVICE
COSTS TO HHA COST CENTERS
STATISTICAL BASIS
HHA COST CENTER
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
HHA CCN:
NURSING
AND ALLIED
HEALTH
EDUCATION
( Assigned
Time )
14
OTHER
GENERAL
SERVICE
( SPECIFY )
15
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
Telemedicine
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Totals (sum of lines 1-20)
Total cost to be allocated
Unit Cost Multiplier
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4143)
SUBTOTAL
( sum of
cols. 3A
through 15 )
16
POST
STEPDOWN
ADJUSTMENTS
17
SUBTOTAL
( cols. 16 ± 17 )
18
ALLOCATED
HHA A&G
( see Pt. II )
19
41-361 41-362
11-12
WORKSHEET H-2,
PART II
TOTAL
HHA COSTS
20
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Rev. 4
03-18
FORM CMS-2540-10
APPORTIONMENT OF PATIENT SERVICE COSTS
4190 (Cont.)
PROVIDER CCN:
HHA CCN:
Check applicable box:
[ ] Title V
[ ] Title XVIII
[ ] Title XIX
PART I - COMPUTATION OF THE AGGREGATE PROGRAM COST
Cost Per Visit Computation
From,
Facility
Shared
Total
Wkst.
Costs
Ancillary
HHA
H-2,
( from
Costs
Costs
Pt. I,
Wkst. H-2.
( from
( col. 1 +
Total
col. 20,
Pt. I )
Pt. II )
col 2 )
Visits
Patient Services
line 1
2
3
4
1 Skilled Nursing Care
2
2 Physical Therapy
3
3 Occupational Therapy
4
4 Speech Pathology
5
5 Medical Social Services
6
6 Home Health Aide
7
7 Total (sum of lines 1-6)
Average
Cost
Per Visit
( col. 3
÷ col. 4 )
5
Part A
6
Program Visits
Part B
Not Subject
Subject
to Deductibles
to Deductibles
& Coinsurance & Coinsurance
7
8
PERIOD :
FROM ______________
TO ________________
Part A
9
Cost of Services
Part B
Not Subject
Subject
to Deductibles
to Deductibles
& Coinsurance & Coinsurance
10
11
Total
Program Cost
( sum of
cols. 9-10 )
12
1
2
3
4
5
6
7
Patient Services by CBSA
Program Visits
CBSA
No. (1)
1
8
9
10
11
12
13
14
WORKSHEET H-3,
Parts I & II
Part A
2
Part B
Not Subject
Subject
to Deductibles
to Deductibles
& Coinsurance & Coinsurance
3
4
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Total (sum of lines 8-13)
8
9
10
11
12
13
14
Supplies and Drugs Cost
Computations
Other Patient Services
15 Cost of Medical Supplies
16 Cost of Drugs
From
Wkst. H-2,
Pt. I,
col. 20,
line 8
9
Facility
Costs
( from
Wkst.
H-2,
Pt. I )
1
Shared
Ancillary
Costs
( from
Pt. II )
2
Total
HHA
Cost
( cols. 1 + 2 )
3
Total
Charges
( from
HHA
records )
4
Ratio
( col. 3
÷ col. 4 )
5
Part A
6
Program Covered Charges
Part B
Not Subject
Subject
to
to
Deductibles & Deductibles &
Coinsurance
Coinsurance
7
8
PART II - APPORTIONMENT OF COST OF HHA SERVICES FURNISHED BY SHARED SKILLED NURSING FACILITY DEPARTMENTS
From
Cost to Charge
Total HHA Charges
Wkst. C,
Ratio
( from provider records )
col. 3, line 1
2
1 Physical Therapy
44
2 Occupational Therapy
45
3 Speech Pathology
46
4 Cost of Medical Supplies
48
5 Cost of Drugs
49
(1) The CBSA numbers flow from Wkst. S-4, line 22, and subscripts as indicated should be replicated on lines 8-13.
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4144)
Part A
9
Cost of Services
Part B
Not Subject
Subject
to
to
Deductibles &
Deductibles &
Coinsurance
Coinsurance
10
11
15
16
HHA Shared Ancillary Costs
( col. 1 x col. 2 )
3
Transfer to
Pt. 1 4
col. 2, line 2
col. 2, line 3
col. 2, line 4
col. 2, line 15
col. 2, line 16
1
2
3
4
5
Rev. 8
41-363
4190 (Cont.)
FORM CMS-2540-10
CALCULATION OF SNF-BASED HHA
REIMBURSEMENT SETTLEMENT
PROVIDER CCN:
HHA CCN:
Check applicable box:
[ ] Title V
[ ] Title XVIII
03-18
PERIOD :
WORKSHEET H-4,
FROM ______________ Parts I & II
TO ________________
[ ] Title XIX
PART I - COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES
Part B
Description
Reasonable Cost of Part A & Part B Services
1 Reasonable cost of services (see instructions)
2 Total charges
Customary Charges
3 Amount actually collected from patients liable for payment
for services on a charge basis (from your records)
4 Amount that would have been realized from patients liable
for payment for services on a charge basis had such
payment been made in accordance with 42 CFR 413.13(b)
5 Ratio of line 3 to line 4 (not to exceed 1.000000)
6 Total customary charges (see instructions)
7 Excess of total customary charges over total reasonable
cost (complete only if line 6 exceeds line 1)
8 Excess of reasonable cost over customary charges
(complete only if line 1 exceeds line 6)
9 Primary payer amounts
Part A
1
Not Subject to
Deductibles
& Coinsurance
2
Subject to
Deductibles
& Coinsurance
3
1
2
3
4
5
6
7
8
9
PART II - COMPUTATION OF SNF-BASED HHA REIMBURSEMENT SETTLEMENT
Description
10 Total reasonable cost (see instructions)
11 Total PPS Reimbursement - Full Episodes without Outliers
12 Total PPS Reimbursement - Full Episodes with Outliers
13 Total PPS Reimbursement - LUPA Episodes
14 Total PPS Reimbursement - PEP Episodes
15 Total PPS Outlier Reimbursement - Full Episodes with Outliers
16 Total PPS Outlier Reimbursement - PEP Episodes
17 Total Other Payments
18 DME Payments
19 Oxygen Payments
20 Prosthetic and Orthotic Payments
21 Part B deductibles billed to Medicare patients (exclude coinsurance)
22 Subtotal (sum of lines 10 through 20 minus line 21)
23 Excess reasonable cost (from line 8)
24 Subtotal (line 22 minus line 23)
25 Coinsurance billed to program patients (from your records)
26 Net cost (line 24 minus line 25)
27 Allowable bad debts (from your records)
28 Allowable bad debts for dual eligible beneficiaries (see instructions)
29 Total costs - current cost reporting period (line 26 plus line 27)
30 Other adjustments (see instructions) (specify)
30.99 Sequestration amount (see instructions)
31 Subtotal (see instructions)
32 Interim payments (see instructions)
33 Tentative settlement (for contractor use only)
34 Balance due provider/program (see instructions)
35 Protested amounts (nonallowable cost report items) in accordance with
CMS Pub. 15-2, section 115.2
Part A Services
1
Part B Services
2
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
30.99
31
32
33
34
35
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4145)
41-364
Rev. 8
08-16
FORM CMS-2540-10
ANALYSIS OF PAYMENTS TO SNF-BASED
HHA FOR SERVICES
RENDERED TO PROGRAM BENEFICIARIES
4190 (Cont.)
PROVIDER CCN:
HHA CCN:
PERIOD :
FROM ______________
TO ________________
Part A
Description
1 Total interim payments paid to provider
2 Interim payments payable on individual bills, either submitted
or to be submitted to the intermediary/contractor for services
rendered in the cost reporting period. If none, enter zero.
3 List separately each retroactive lump sum
adjustment amount based on subsequent revision of
the interim rate for the cost reporting period
Also show date of each payment.
If none, write "NONE," or enter a zero. (1)
mm/dd/yyyy
1
Program
to
Provider
SUBTOTAL (sum of lines 3.01 - 3.49 minus sum of lines 3.50 - 3.98)
4 TOTAL INTERIM PAYMENTS (sum of lines 1, 2, and 3.99)
(Transfer to Wkst. H-4, Part II, column as appropriate, line 32)
SUBTOTAL (sum of lines 5.01 - 5.49 minus sum of lines 5.50 - 5.98)
6 Determine net settlement amount (balance
due) based on the cost report (1)
7 TOTAL MEDICARE PROGRAM LIABILITY (see instructions)
8 Name of Contractor
Part B
Amount
2
mm/dd/yyyy
3
Amount
4
1
2
Provider
to
Program
TO BE COMPLETED BY CONTRACTOR
5 List separately each tentative settlement
payment after desk review. Also show
date of each payment.
If none, write "NONE," or enter a zero. (1)
WORKSHEET H-5
Program
to
Provider
Provider
to
Program
Program to Provider
Provider to Program
.02
.03
.04
.05
.50
.51
.52
.53
.54
.99
.01
.02
.03
.50
.51
.52
.99
.01
.02
Contractor Number
(1) On lines 3, 5, and 6, where an amount is due "Provider to Program," show the amount and date on which the provider agrees to the amount of repayment even though total repayment is not accomplished until a later date.
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4146)
3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54
3.99
4
5.01
5.02
5.03
5.50
5.51
5.52
5.99
6.01
6.02
7
8
Rev. 7
41-365
4190 (Cont.)
FORM CMS-2540-10
ANALYSIS OF SNF-BASED RHC/FQHC COSTS
08-16
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
RHC/FQHC CCN:
Check applicable box:
[
] RHC
[
WORKSHEET I-1
] FQHC
COMPENSATION
1
OTHER
COSTS
2
TOTAL
( col. 1 + col. 2 )
3
RECLASSIFICATIONS
4
HEALTH CARE STAFF COSTS
1 Physician
2 Physician Assistant
3 Nurse Practitioner
4 Visiting Nurse
5 Other Nurse
6 Clinical Psychologist
7 Clinical Social Worker
8 Laboratory Technician
9 Other health care staff costs
10 Subtotal (sum of lines 1 - 9)
COSTS UNDER AGREEMENT
11 Physician Services Under Agreement
12 Physician Supervision Under Agreement
13 Other costs under agreement
14 Subtotal (sum of lines 11 - 13)
OTHER HEALTH CARE COSTS
15 Medical Supplies
16 Transportation (Health Care Staff)
17 Depreciation - Medical Equipment
18 Professional Liability Insurance
19 Other health care costs
21 Subtotal (sum of lines 15 - 19)
22 Total cost of health care services
(sum of lines 10, 14, and 21)
COSTS OTHER THAN RHC / FQHC SERVICES
23 Pharmacy
24 Dental
25 Optometry
26 All other non reimbursable costs
28 Total nonreimbursable costs (sum of lines 23 - 26)
RHC/FQHC OVERHEAD
29 RHC/FQHC costs
30 Administrative costs
31 Total RHC/FQHC overhead (sum of lines 29-30)
32 Total RHC/FQHC costs (sum of lines 22, 28 and 31)
* The net expenses for cost allocation on Worksheet A for the RHC/FQHC cost center line must equal the total RHC/FQHC costs in column 7, line 32 of this worksheet.
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4148)
RECLASSIFIED
TRIAL
BALANCE
( col. 3 +/- col. 4 )
5
ADJUSTMENTS
6
NET EXPENSES
FOR
ALLOCATION
( col. 5 +/- col.6 )
7
41-366
Rev. 7
08-16
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
21
22
23
24
25
26
28
29
30
31
32
Rev. 7
03-18
FORM CMS-2540-10
ALLOCATION OF OVERHEAD
TO SNF-BASED RHC/FQHC SERVICES
PROVIDER CCN:
RHC/FQHC CCN:
Check applicable box:
[
] RHC
[
4190 (Cont. )
PERIOD :
FROM ______________
TO ________________
WORKSHEET I-2
] FQHC
PART I - VISITS AND PRODUCTIVITY
Number
of FTE
Personnel
1
1
2
3
4
5
6
7
8
9
10
11
Physicians
Physician Assistants
Nurse Practitioners
Subtotal (sum of lines 1 - 3)
Visiting Nurse
Clinical Psychologist
Clinical Social Worker
Medical Nutrition Therapist (FQHC only)
Diabetes Self Management Training (FQHC only)
Total FTEs and visits (sum of lines 4 - 9)
Physician Services Under Agreements
Total
Visits
2
Productivity
Standard
(1)
3
4200
2100
2100
Minimum
Visits
( col. 1 x col. 3 )
4
PART II - DETERMINATION OF TOTAL ALLOWABLE COST APPLICABLE TO SNF-BASED RHC / FQHC SERVICES
12 Total costs of health care services (from Wkst. I-1, col. 7, line 22)
13 Total nonreimbursable costs (from Wkst I-1, col 7, line 28)
14 Cost of all services - excluding overhead (sum of lines 12 and 13)
15 Ratio of RHC/FQHC services (line 12 divided by line 14)
16 Total RHC/FQHC overhead (from Wkst. I-1, col. 7, line 31)
17 Parent provider overhead allocated to RHC/FQHC (see instructions)
18 Total overhead (sum of lines 16 and 17)
19 Overhead applicable to RHC/FQHC services (lines 15 X line 18)
20 Total allowable cost of RHC/FQHC services (sum of lines 12 and 19)
(1) Productivity standards established by CMS are: 4200 visits for each physician, and 2100 visits for each nonphysician practitioner.
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4149)
Greater of
Column 2 or
Column 4
5
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Rev. 8
41-367
4190 (Cont.)
FORM CMS-2540-10
CALCULATION OF REIMBURSEMENT
SETTLEMENT FOR SNF-BASED RHC/FQHC SERVICES
PROVIDER CCN:
RHC/FQHC CCN:
Check applicable box:
Check applicable box:
[
[
] Title V
] RHC
[
] Title XVIII
[
03-18
PERIOD :
FROM ____________
TO ______________
WORKSHEET I-3
[ ] Title XIX
] FQHC
PART I - DETERMINATION OF RATE FOR SNF-BASED RHC/FQHC SERVICES
1 Total allowable cost of RHC/FQHC services (from Wkst. I-2, Pt. II, line 20)
2 Cost of vaccines and their administration (from Wkst. I-4, line 15)
3 Total allowable cost excluding vaccine (line 1 minus line 2)
4 Total FTEs and visits (from Wkkst. I-2, col. 5, line 10)
5 Physicians' visits under agreement (from Wkst. I-2, col. 5, line 11)
6 Total adjusted visits (line 4 plus line 5)
7 Adjusted cost per visit (line 3 divided by line 6)
CALCULATION OF LIMIT
Lines 8 through 14: Fiscal year RHC/FQHC use columns 1 and 2.
Lines 8 through 14: Calendar year RHC/FQHC use column 2 only.
8 Rate per visit limit (from your contractor)
9 Rate for Program covered visits (see instructions)
PART II - CALCULATION OF SETTLEMENT FOR SNF-BASED RHC/FQHC SERVICES
10 Program covered visits excluding mental health services (from contractor records)
11 Program cost excluding costs for mental health services (line 9 x line 10)
12 Program covered visits for mental health services (from contractor records)
13 Program covered cost for mental health services (line 9 x line 12)
14 Limit adjustment for mental health services (see instructions)
15 Total Program cost (sum of line 11 cols. 1 and 2, plus line 14 cols. 1 and 2)
15.01 Total Program charges (see instructions) (from contractor records)
15.02 Total Program preventive charges (see instructions) (from provider records)
15.03 Total Program preventive costs ((line 15.02/line 15.01) times line 15)
15.04 Total Program non-preventive costs ((line 15 minus lines 15.03 and 17) times .80)
15.05 Total Program cost (see instructions)
16 Primary payer amounts
17 Less: Beneficiary deductible for RHC only (see instructions) (from contractor records)
18 Less: Beneficiary coinsurance for RHC/FQHC services (see instructions) (from contractor records)
19 Net Program cost excluding vaccines (see instructions)
20 Program cost of vaccines and their administration (from Wkst. I -4, line 16)
21 Total reimbursable Program cost (line 19 plus 20)
22 Allowable bad debts
22.01 Reimbursable bad debts (see instructions)
23 Allowable bad debts for dual eligible beneficiaries (see instructions)
24 Other adjustments
25 Net reimbursable amount (see instructions)
25.01 Sequestration amount (see instructions)
26 Interim payments (from Wkst. I-5, line 4)
27 Tentative settlement (for contractor use only)
28 Balance due RHC/FQHC/Program (see instructions)
29 Protested amounts (nonallowable cost report items) in accordance with CMS Publ. 15-2, § 115.2
1
2
3
4
5
6
7
Prior to
January 1
1
On or after
January 1
2
8
9
10
11
12
13
14
15
15.01
15.02
15.03
15.04
15.05
16
17
18
19
20
21
22
22.01
23
24
25
25.01
26
27
28
29
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4150)
41-368
Rev. 8
08-16
FORM CMS-2540-10
COMPUTATION OF SNF-BASED RHC/FQHC PNEUMOCOCCAL
AND INFLUENZA VACCINE COST
PROVIDER CCN:
RHC/FQHC CCN:
Check applicable box:
Check applicable box:
[
[
] Title V
] RHC
[
] Title XVIII
[
4190 (Cont.)
PERIOD :
FROM ______________
TO ________________
WORKSHEET I-4
[ ] Title XIX
] FQHC
CALCULATION OF COST
PNEUMOCOCCAL
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Health care staff cost (from Wkst. I-1, col. 7, line 10)
Ratio of pneumococcal and influenza vaccine staff time to total health care staff time
Pneumococcal and influenza vaccine health care staff cost (line 1 x line 2)
Medical supplies cost - pneumococcal and influenza vaccine (from your records)
Direct cost of pneumococcal and influenza vaccine (sum of lines 3 and 4)
Total direct cost of the RHC/FQHC (from Wkst. I-1, col. 7, line 22)
Total overhead (from Wkst. I-2, line 19)
Ratio of pneumococcal and influenza vaccine direct cost to total direct cost (line 5 divided by line 6)
Overhead cost - pneumococcal and influenza vaccine (line 7 x line 8)
Total pneumococcal and influenza vaccine cost and its (their) administration (sum of lines 5 and 9)
Total number of pneumococcal and influenza vaccine injections (from your records)
Cost per pneumococcal and influenza vaccine injection (line 10 divided by line 11)
Number of pneumococcal and influenza vaccine injections administered to Medicare beneficiaries
Medicare cost of pneumococcal and influenza vaccine and their administration (line 12 x line 13)
Total cost of pneumococcal and influenza vaccine and its (their) administration (sum of
cols. 1 and 2, line 10) (transfer to Wkst. I-3, line 2)
16 Total Medicare cost of pneumococcal and influenza vaccine and its (their) administration (sum of
cols. 1 and 2, line 14) (transfer to Wkst. I-3, line 20)
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4151)
INFLUENZA
2
Rev. 7
41-369
4190 (Cont.)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
41-369
4190 (Cont. )
FORM CMS-2540-10
ANALYSIS OF PAYMENTS TO
SNF-BASED RHC/FQHC FOR SERVICES RENDERED
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
RHC/FQHC CCN:
Check applicable box:
[
] RHC
Description
1 Total interim payments paid to RHC/FQHC
2 Interim payments payable on individual bills, either submitted
or to be submitted to the intermediary/contractor for services
rendered in the cost reporting period. If none, enter zero.
3 List separately each retroactive lump sum
adjustment amount based on subsequent revision of
the interim rate for the cost reporting period
Also show date of each payment.
If none, write "NONE," or enter a zero. (1)
[
] FQHC
mm/dd/yyyy
1
Program
to
RHC/FQHC
RHC/FQHC
to
Program
SUBTOTAL (sum of lines 3.01 - 3.49 minus sum of lines 3.50 - 3.98)
4 TOTAL INTERIM PAYMENTS (sum of lines 1, 2, and 3.99)
(Transfer to Wkst. I-3, line 26)
TO BE COMPLETED BY CONTRACTOR
5 List separately each tentative settlement
payment after desk review. Also show
date of each payment.
If none, write "NONE," or enter a zero. (1)
SUBTOTAL (sum of lines 5.01 - 5.49 minus sum of lines 5.50 - 5.98)
6 Determine net settlement amount (balance
due) based on the cost report (1)
7 TOTAL MEDICARE PROGRAM LIABILITY (see instructions)
8 Name of Contractor
WORKSHEET I - 5
Program
to
RHC/FQHC
RHC/FQHC
to
Program
Program to RHC/FQHC
RHC/FQHC to Program
Amount
2
.01
.02
.03
.04
.05
.50
.51
.52
.53
.54
.99
.01
.02
.03
.50
.51
.52
.99
.01
.02
Contractor Number
(1) On lines 3, 5, and 6, where an amount is due "RHC/FQHC to Program," show the amount and date on which the
RHC/FQHC agrees to the amount of repayment, even though total repayment is not accomplished until a later date.
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4152)
41-370
Rev. 7
08-16
1
2
3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54
3.99
4
5.01
5.02
5.03
5.50
5.51
5.52
5.99
6.01
6.02
7
8
Rev. 7
11-12
FORM CMS-2540-10
ALLOCATION OF GENERAL SERVICE COSTS
TO COST CENTERS FOR CMHC
PROVIDER CCN:
COMPONENT CCN:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
COMPONENT COST CENTER
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Respiratory Therapy
Psychiatric/Psychological Services
Individual Therapy
Group Therapy
Individualized Activity Therapy
Family Counseling
Diagnostic Services
Appr. Patient Training & Education
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies
Medical Appliances
Durable Medical Equipment - Rented
Durable Medical Equipment - Sold
All Other
Totals (sum of lines 1-21) (1)
Unit Cost Multiplier (see instructions)
NET
EXPENSES
FOR COST
ALLOCATION
0
CAPITAL RELATED COST
BUILDS. &
MOVABLE
FIXTURES
EQUIPMENT
1
2
(1) Columns 0 through 18, line 22 must agree with the corresponding columns of Worksheet B, Part I, line 73, (subscripted line).
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4153)
4190 (Cont.)
PERIOD :
FROM ______________
TO ________________
EMPLOYEE
BENEFITS
3
WORKSHEET J-1
PART I
SUBTOTAL
( cols. 0
through 3 )
3A
ADMINISTRATIVE
&
GENERAL
4
Rev. 4
41-371
4190 (Cont.) 4190 (Cont.)
ALLOCATION OF GENERAL SERVICE COSTS
TO COST CENTERS FOR CMHC
FORM CMS-2540-10
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
COMPONENT CCN:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
COMPONENT COST CENTER
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Respiratory Therapy
Psychiatric/Psychological Services
Individual Therapy
Group Therapy
Individualized Activity Therapy
Family Counseling
Diagnostic Services
Appr. Patient Training & Education
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies
Medical Appliances
Durable Medical Equipment - Rented
Durable Medical Equipment - Sold
All Other
Totals (sum of lines 1-21) (1)
Unit Cost Multiplier (see instructions)
PLANT
OPERATION
MAINTENANCE
& REPAIRS
5
(1) Columns 0 through 18, line 22 must agree with the corresponding columns of Worksheet B, Part I, line 73, (subscripted line).
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4153)
LAUNDRY
& LINEN
SERVICE
6
HOUSE KEEPING
7
DIETARY
8
41-371 41-372
11-12 11-12
WORKSHEET J-1
PART I
FORM CMS-2540-10
ALLOCATION OF GENERAL SERVICE COSTS
TO COST CENTERS FOR CMHC
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
COMPONENT CCN:
NURSING
ADMINISTRATION
9
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
COMPONENT COST CENTER
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Respiratory Therapy
Psychiatric/Psychological Services
Individual Therapy
Group Therapy
Individualized Activity Therapy
Family Counseling
Diagnostic Services
Appr. Patient Training & Education
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies
Medical Appliances
Durable Medical Equipment - Rented
Durable Medical Equipment - Sold
All Other
Totals (sum of lines 1-21) (1)
Unit Cost Multiplier (see instructions)
CENTRAL
SERVICES
& SUPPLY
10
PHARMACY
11
(1) Columns 0 through 18, line 22 must agree with the corresponding columns of Worksheet B, Part I, line 73, (subscripted line).
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4153)
MEDICAL
RECORDS
& LIBRARY
12
SOCIAL
SERVICES
13
Rev. 4 Rev. 4
4190 (Cont.) 4190 (Cont. )
WORKSHEET J-1
PART I
FROM ______________
TO ________________
ALLOCATION OF GENERAL SERVICE COSTS
TO COST CENTERS FOR CMHC
FORM CMS-2540-10
PROVIDER CCN:
COMPONENT CCN:
NURSING &
ALLIED
HEALTH
EDUCATION
14
OTHER
GENERAL
SERVICE
15
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
COMPONENT COST CENTER
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Respiratory Therapy
Psychiatric/Psychological Services
Individual Therapy
Group Therapy
Individualized Activity Therapy
Family Counseling
Diagnostic Services
Appr. Patient Training & Education
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies
Medical Appliances
Durable Medical Equipment - Rented
Durable Medical Equipment - Sold
All Other
Totals (Sum of lines 1-21) (1)
Unit Cost Multiplier (see instructions)
SUBTOTAL
16
(1) Columns 0 through 18, line 22 must agree with the corresponding columns of Worksheet B, Part I, line 73, (subscripted line).
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4153)
POST
STEP-DOWN
ADJUSTMENTS
17
41-373 41-374
11-12
PERIOD :
FROM ______________
TO ________________
SUBTOTAL
18
WORKSHEET J-1
PART I
ALLOCATED
A&G
( see Pt. II )
19
TOTAL
( sum of cols.
18 and 19 ()
20
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Rev. 4
11-12
ALLOCATION OF GENERAL SERVICE COSTS
TO COST CENTERS FOR CMHC
FORM CMS-2540-10
PROVIDER CCN:
COMPONENT CCN:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
COMPONENT COST CENTER
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Respiratory Therapy
Psychiatric/Psychological Services
Individual Therapy
Group Therapy
Individualized Activity Therapy
Family Counseling
Diagnostic Services
App. Patient Training & Education
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies
Medical Appliances
Durable Medical Equipment - Rented
Durable Medical Equipment - Sold
All Other
Totals (sum of lines 1-21)
Total cost to be allocated
Unit Cost Multiplier
CAPITAL RELATED
MOVABLE
BUILDS.
EQUIPMENT
& FIXTURES
( Dollar Value or
( Square Feet )
Square Feet )
1
2
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4153)
4190 (Cont.)
PERIOD :
FROM ______________
TO ________________
EMPLOYEE
BENEFITS
( Gross Salaries )
3
WORKSHEET J-1
PART II
RECONCILIATION
4A
ADMINISTRATIVE
& GENERAL
( Accumulated
Cost )
4
Rev. 4
41-375
4190 (Cont.) 4190 (Cont.)
ALLOCATION OF GENERAL SERVICE COSTS
TO COST CENTERS FOR CMHC
FORM CMS-2540-10
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
COMPONENT CCN:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
COMPONENT COST CENTER
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Respiratory Therapy
Psychiatric/Psychological Services
Individual Therapy
Group Therapy
Individualized Activity Therapy
Family Counseling
Diagnostic Services
App. Patient Training & Education
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies
Medical Appliances
Durable Medical Equipment - Rented
Durable Medical Equipment - Sold
All Other
Totals (sum of lines 1-21)
Total cost to be allocated
Unit Cost Multiplier
PLANT
OPERATION
MAINTENANCE
& REPAIRS
( Square Feet )
5
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4153)
LAUNDRY
& LINEN
SERVICE
( Pounds of
Laundry )
6
HOUSE KEEPING
( Hours of
Service )
7
DIETARY
( Meals
Served )
8
41-375 41-376
11-12 11-12
WORKSHEET J-1
PART II
FORM CMS-2540-10
ALLOCATION OF GENERAL SERVICE COSTS
TO COST CENTERS FOR CMHC
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
COMPONENT CCN:
NURSING
ADMINISTRATION
( Direct Nursing
Hours of Service )
9
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
COMPONENT COST CENTER
Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Respiratory Therapy
Psychiatric/Psychological Services
Individual Therapy
Group Therapy
Individualized Activity Therapy
Family Counseling
Diagnostic Services
App. Patient Training & Education
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies
Medical Appliances
Durable Medical Equipment - Rented
Durable Medical Equipment - Sold
All Other
Totals (sum of lines 1-21)
Total cost to be allocated
Unit Cost Multiplier
CENTRAL
SERVICES
& SUPPLY
( Costed
Requisitions )
10
PHARMACY
( Costed
Requisitions )
11
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4153)
MEDICAL
RECORDS &
LIBRARY
( Time Spent )
12
SOCIAL
SERVICES
( Time Spent )
13
Rev. 4 Rev. 4
4190 (Cont.)
WORKSHEET J-1
PART II
FROM ______________
TO ________________
NURSING &
ALLIED
HEALTH
EDUCATION
( Assigned Time )
14
OTHER
GENERAL
SERVICE
(
)
15
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
41-377
4190 (Cont.)
FORM CMS-2540-10
COMPUTATION OF CMHC
REHABILITATION COSTS
11-12
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
COMPONENT CCN:
PART I - APPORTIONMENT OF CMHC COST CENTERS
Total Costs
( from Wkst. J-1,
Pt. I, col. 20 )
1
1 Administrative and General
2 Skilled Nursing Care
3 Physical Therapy
4 Occupational Therapy
5 Speech Pathology
6 Medical Social Services
7 Respiratory Therapy
8 Psychiatric/Psychological Services
9 Individual Therapy
10 Group Therapy
11 Individualized Activity Therapy
12 Family Counseling
13 Diagnostic Services
14 App. Patient Training & Education
15 Prosthetic and Orthotic Devices
16 Drugs and Biologicals
17 Medical Supplies
18 Medical Appliances
19 Durable Medical Equipment - Rented
20 Durable Medical Equipment - Sold
21 All Other
22 Totals (sum of lines 2-21)
Total
Charges
2
Ratio of
Costs to
Charges
3
Title V
Charges
4
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4154)
Costs
( col. 3 x col. 4 )
5
WORKSHEET J - 2
PART I
Title XVIII
Charges
6
Costs
( col. 3 x col. 6 )
7
Title XIX
Charges
8
Costs
( col. 3 x col. 8 )
9
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
41-378
Rev. 4
03-18
FORM CMS-2540-10
COMPUTATION OF CMHC
REHABILITATION COSTS
4190 (Cont.)
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
COMPONENT CCN:
PART II - APPORTIONMENT OF COST OF CMHC SERVICES FURNISHED BY SHARED DEPARTMENTS
Ratio of
Costs to
Charges
3
23 Oxygen (Inhalation) Therapy
24 Physical Therapy
25 Occupational Therapy
26 Speech Pathology
27 Medical Supplies Charged to Patients
28 Drugs Charged to Patients
29 Other Costs Furnished by shared Departments
30 Total (sum of lines 23 through 29)
31 Total component cost (sum of Pt. I, line 22 and Pt. II, line 30)
(Transfer to Wkst. J-3)
Title V
Charges
4
(1) Part II - From Wkst. C, col. 3, lines as applicable
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4154)
Costs
( col. 3 x col. 4 )
5
WORKSHEET J - 2
PART II
Title XVIII
Charges
6
Costs
( col. 3 x col. 6 )
7
Title XIX
Charges
8
Costs
( col. 3 x col. 8 )
9
23
24
25
26
27
28
29
30
31
Rev. 8
41-379
4190 (Cont.)
FORM CMS-2540-10
CALCULATION OF REIMBURSEMENT SETTLEMENT
FOR SNF-BASED COMMUNITY MENTAL HEALTH CENTER
SERVICES
Check applicable box:
[ ] Title V
[ ] Title XVIII
PROVIDER CCN:
COMPONENT CCN:
03-18
PERIOD :
FROM ______________
TO ________________
WORKSHEET J-3
[ ] Title XIX
PROGRAM
COST
1 Cost of component services (from Wkst. J-2, Pt. II, line 31)
2 PPS payments received excluding outliers
3 Outlier payments
4 Primary payer payments
5 Total reasonable cost (see instructions)
CUSTOMARY CHARGES
6 Total charges for program services
7 Excess of customary charges over reasonable cost (see instructions)
8 Excess of reasonable cost over customary charges (see instructions)
COMPUTATION OF REIMBURSEMENT SETTLEMENT
9 Total reasonable cost (see instructions)
10 Part B deductible billed to program patients
11 Part B coinsurance billed to program patients (from provider records)
12 Net cost (line 9 minus lines 10 and 11)
13 Allowable bad debts (from provider records) (see instructions)
13.01 Reimbursable bad debts (see instructions)
14 Allowable bad debts for dual eligible beneficiaries (see instructions)
15 Net reimbursable amount (see instructions)
16 Other adjustments (see instructions) (specify)
17 Total cost (line 15 plus or minus line 16)
17.01 Sequestration amount (see instructions)
18 Interim payments (see instructions)
19 Tentative settlement (for contractor use only)
20 Balance due component/program (see instructions)
21 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2
1
2
3
4
5
6
7
8
9
10
11
12
13
13.01
14
15
16
17
17.01
18
19
20
21
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4155)
41-380
Rev. 8
08-16
ANALYSIS OF PAYMENTS TO
SNF-BASED CMHC
FOR SERVICES RENDERED
TO PROGRAM BENEFICIARIES
Description
1 Total interim payments paid to CMHC
2 Interim payments payable on individual bills, either submitted
or to be submitted to the intermediary/contractor for services
rendered in the cost reporting period. If none, enter zero.
3 List separately each retroactive lump sum
adjustment amount based on subsequent revision of
the interim rate for the cost reporting period
Also show date of each payment.
If none, write "NONE," or enter a zero. (1)
FORM CMS-2540-10
mm/dd/yyyy
1
SUBTOTAL (sum of lines 5.01 - 5.49 minus sum of lines 5.50 - 5.98)
6 Determine net settlement amount (balance
due) based on the cost report (1)
7 TOTAL MEDICARE PROGRAM LIABILITY (see instructions)
8 Name of Contractor
WORKSHEET J - 4
Amount
2
1
2
Program
to
Provider
SUBTOTAL (sum of lines 3.01 - 3.49 minus sum of lines 3.50 - 3.98)
4 TOTAL INTERIM PAYMENTS (sum of lines 1, 2, and 3.99)
(Transfer to Wkst. J-3: Pt. I, line 18)
Also show date of each payment.
If none, write "NONE," or enter a zero. (1)
PERIOD :
FROM ______________
TO ________________
COMPONENT CCN:
Provider
to
Program
TO BE COMPLETED BY CONTRACTOR
5 List separately each tentative
settlement payment after desk review.
4190 (Cont.)
PROVIDER CCN:
Program
to
Provider
Provider
to
Program
Program to Provider
Provider to Program
.01
.02
.03
.04
.05
.50
.51
.52
.53
.54
.99
3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54
3.99
4
.01
.02
.03
.50
.51
.52
.99
.01
.02
5.01
5.02
5.03
5.50
5.51
5.52
5.99
6.01
6.02
7
8
Contractor Number
(1) On lines 3, 5, and 6, where an amount is due "Provider to Program," show the amount and date on which the
provider agrees to the amount of repayment, even though total repayment is not accomplished until a later date.
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4156)
Rev. 7
41-381
4190 (Cont.)
FORM CMS-2540-10
ANALYSIS OF HOSPICE COSTS
08-16
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
HOSPICE CCN:
COST CENTER DESCRIPTIONS
GENERAL SERVICE COST CENTERS
1 Capital Related Costs-Bldg. and Fixt.
2 Capital Related Costs-Movable Equip.
3 Plant Operation and Maintenance
4 Transportation - Staff
5 Volunteer Service Coordination
6 Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
11 Nursing Care-Continuous Home Care
12 Physical Therapy
13 Occupational Therapy
14 Speech/ Language Pathology
15 Medical Social Services
16 Spiritual Counseling
17 Dietary Counseling
18 Counseling - Other
19 Home Health Aide and Homemaker
20 HH Aide & Homemaker-Cont. Home Care
21 Other
OTHER HOSPICE SERVICE COSTS
22 Drugs, Biological and Infusion Therapy
23 Analgesics
24 Sedatives / Hypnotics
25 Other - Specify
26 Durable Medical Equipment/Oxygen
27 Patient Transportation
28 Imaging Services
29 Labs and Diagnostics
30 Medical Supplies
31 Outpatient Services (including E/R Dept.)
32 Radiation Therapy
33 Chemotherapy
34 Other
HOSPICE NONREIMBURSABLE SERVICE
35 Bereavement Program Costs
36 Volunteer Program Costs
37 Fundraising
38 Other Program Costs
39 Total (sum of lines 1 through 38)
SALARIES
( from
Wkst. K-1 )
1
EMPLOYEE
BENEFITS
( from
Wkst. K-2 )
2
TRANSPORTATION
( see instruct. )
3
CONTRACTED
SERVICES
( from
Wkst. K-3 )
4
OTHER
5
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4157)
TOTAL
( cols. 1
through 5 )
6
RECLASSIFICATION
7
SUBTOTAL
( col. 6
± col. 7 )
8
ADJUSTMENTS
9
WORKSHEET K
TOTAL
( col. 8
± col. 9 )
10
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
41-382
Rev. 7
11-12
FORM CMS-2540-10
HOSPICE COMPENSATION ANALYSIS
SALARIES AND WAGES
4190 (Cont.)
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
HOSPICE CCN:
COST CENTER DESCRIPTIONS
GENERAL SERVICE COST CENTERS
1 Capital Related Costs-Bldg. and Fixt.
2 Capital Related Costs-Movable Equip.
3 Plant Operation and Maintenance
4 Transportation - Staff
5 Volunteer Service Coordination
6 Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
11 Nursing Care-Continuous Home Care
12 Physical Therapy
13 Occupational Therapy
14 Speech/ Language Pathology
15 Medical Social Services
16 Spiritual Counseling
17 Dietary Counseling
18 Counseling - Other
19 Home Health Aide and Homemaker
20 HH Aide & Homemaker-Cont. Home Care
21 Other
OTHER HOSPICE SERVICE COSTS
22 Drugs, Biological and Infusion Therapy
23 Analgesics
24 Sedatives / Hypnotics
25 Other - Specify
26 Durable Medical Equipment/Oxygen
27 Patient Transportation
28 Imaging Services
29 Labs and Diagnostics
30 Medical Supplies
31 Outpatient Services (including E/R Dept.)
32 Radiation Therapy
33 Chemotherapy
34 Other
HOSPICE NONREIMBURSABLE SERVICE
35 Bereavement Program Costs
36 Volunteer Program Costs
37 Fundraising
38 Other Program Costs
39 Total (sum of lines 1 through 38)
ADMINISTRATOR
1
DIRECTOR
2
SOCIAL
SERVICES
3
SUPERVISORS
4
(1) Transfer the amount in column 9 to Wkst. K, col. 1
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4158)
NURSES
5
TOTAL
THERAPISTS
6
AIDES
7
ALL OTHER
8
WORKSHEET K-1
TOTAL (1)
9
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
Rev. 4
41-383
4190 (Cont.)
FORM CMS-2540-10
HOSPICE COMPENSATION ANALYSIS
EMPLOYEE BENEFITS (PAYROLL RELATED)
11-12
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
HOSPICE CCN:
COST CENTER DESCRIPTIONS
GENERAL SERVICE COST CENTERS
1 Capital Related Costs-Bldg. and Fixt.
2 Capital Related Costs-Movable Equip.
3 Plant Operation and Maintenance
4 Transportation - Staff
5 Volunteer Service Coordination
6 Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
11 Nursing Care-Continuous Home Care
12 Physical Therapy
13 Occupational Therapy
14 Speech/ Language Pathology
15 Medical Social Services
16 Spiritual Counseling
17 Dietary Counseling
18 Counseling - Other
19 Home Health Aide and Homemaker
20 HH Aide & Homemaker-Cont. Home Care
21 Other
OTHER HOSPICE SERVICE COSTS
22 Drugs, Biological and Infusion Therapy
23 Analgesics
24 Sedatives / Hypnotics
25 Other - Specify
26 Durable Medical Equipment/Oxygen
27 Patient Transportation
28 Imaging Services
29 Labs and Diagnostics
30 Medical Supplies
31 Outpatient Services (including E/R Dept.)
32 Radiation Therapy
33 Chemotherapy
34 Other
HOSPICE NONREIMBURSABLE SERVICE
35 Bereavement Program Costs
36 Volunteer Program Costs
37 Fundraising
38 Other Program Costs
39 Total (sum of lines 1 through 38)
ADMINISTRATOR
1
DIRECTOR
2
SOCIAL
SERVICES
3
SUPERVISORS
4
(1) Transfer the amounts in column 9 to Wkst. K, col. 2
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4159)
NURSES
5
TOTAL
THERAPISTS
6
AIDES
7
ALL OTHER
8
WORKSHEET K-2
TOTAL (1)
9
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
41-384
Rev. 4
11-12
FORM CMS-2540-10
HOSPICE COMPENSATION ANALYSIS
CONTRATED SERVICES / PURCHASED SERVICES
4190 (Cont.)
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
HOSPICE CCN:
COST CENTER DESCRIPTIONS
GENERAL SERVICE COST CENTERS
1 Capital Related Costs-Bldg. and Fixt.
2 Capital Related Costs-Movable Equip.
3 Plant Operation and Maintenance
4 Transportation - Staff
5 Volunteer Service Coordination
6 Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
11 Nursing Care-Continuous Home Care
12 Physical Therapy
13 Occupational Therapy
14 Speech/ Language Pathology
15 Medical Social Services
16 Spiritual Counseling
17 Dietary Counseling
18 Counseling - Other
19 Home Health Aide and Homemaker
20 HH Aide & Homemaker-Cont. Home Care
21 Other
OTHER HOSPICE SERVICE COSTS
22 Drugs, Biological and Infusion Therapy
23 Analgesics
24 Sedatives / Hypnotics
25 Other - Specify
26 Durable Medical Equipment/Oxygen
27 Patient Transportation
28 Imaging Services
29 Labs and Diagnostics
30 Medical Supplies
31 Outpatient Services (including E/R Dept.)
32 Radiation Therapy
33 Chemotherapy
34 Other
HOSPICE NONREIMBURSABLE SERVICE
35 Bereavement Program Costs
36 Volunteer Program Costs
37 Fundraising
38 Other Program Costs
39 Total (sum of lines 1 through 38)
ADMINIS
TRATOR
1
DIRECTOR
2
SOCIAL
SERVICES
3
SUPERVISORS
4
(1) Transfer the amounts in column 9 to Wkst. K, col. 4
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4160)
NURSES
5
TOTAL
THERAPISTS
6
AIDES
7
ALL OTHER
8
WORKSHEET K-3
TOTAL (1)
9
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
Rev. 4
41-385
4190 (Cont.)
FORM CMS-2540-10
COST ALLOCATION - HOSPICE
GENERAL SERVICE COST
11-12
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
HOSPICE CCN:
COST CENTER DESCRIPTIONS
GENERAL SERVICE COST CENTERS
1 Capital Related Costs-Bldg. and Fixt.
2 Capital Related Costs-Movable Equip.
3 Plant Operation and Maintenance
4 Transportation - Staff
5 Volunteer Service Coordination
6 Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
11 Nursing Care-Continuous Home Care
12 Physical Therapy
13 Occupational Therapy
14 Speech/ Language Pathology
15 Medical Social Services
16 Spiritual Counseling
17 Dietary Counseling
18 Counseling - Other
19 Home Health Aide and Homemaker
20 HH Aide & Homemaker-Cont. Home Care
21 Other
OTHER HOSPICE SERVICE COSTS
22 Drugs, Biological and Infusion Therapy
23 Analgesics
24 Sedatives / Hypnotics
25 Other - Specify
26 Durable Medical Equipment/Oxygen
27 Patient Transportation
28 Imaging Services
29 Labs and Diagnostics
30 Medical Supplies
31 Outpatient Services (including E/R Dept.)
32 Radiation Therapy
33 Chemotherapy
34 Other
HOSPICE NONREIMBURSABLE SERVICE
35 Bereavement Program Costs
36 Volunteer Program Costs
37 Fundraising
38 Other Program Costs
39 Total (sum of lines 1 through 38)
NET EXPENSES
FOR COST
ALLOC. (1)
( from
Wkst. K, col. 10 )
0
CAPITAL RELATED COST
BUILDS. &
MOVABLE
FIXTURES
EQUIPMENT
1
2
PLANT
OPERATION
& MAINT.
3
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4161)
TRANSPORTATION
4
VOLUNTEER
SERVICE
COORDINATOR
5
SUBTOTAL
( cols. 0
through 5 )
5A
ADMINISTRATIVE &
GENERAL
6
WORKSHEET K-4
PART I
TOTAL
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
41-386
Rev. 4
11-12
FORM CMS-2540-10
COST ALLOCATION - HOSPICE
STATISTICAL BASIS
4190 (Cont.)
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
HOSPICE CCN:
COST CENTER DESCRIPTIONS
GENERAL SERVICE COST CENTERS
1 Capital Related Costs-Bldg. and Fixt.
2 Capital Related Costs-Movable Equip.
3 Plant Operation and Maintenance
4 Transportation - Staff
5 Volunteer Service Coordination
6 Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
11 Nursing Care-Continuous Home Care
12 Physical Therapy
13 Occupational Therapy
14 Speech/ Language Pathology
15 Medical Social Services
16 Spiritual Counseling
17 Dietary Counseling
18 Counseling - Other
19 Home Health Aide and Homemaker
20 HH Aide & Homemaker-Cont. Home Care
21 Other
OTHER HOSPICE SERVICE COSTS
22 Drugs, Biological and Infusion Therapy
23 Analgesics
24 Sedatives / Hypnotics
25 Other - Specify
26 Durable Medical Equipment/Oxygen
27 Patient Transportation
28 Imaging Services
29 Labs and Diagnostics
30 Medical Supplies
31 Outpatient Services (including E/R Dept.)
32 Radiation Therapy
33 Chemotherapy
34 Other
HOSPICE NONREIMBURSABLE SERVICE
35 Bereavement Program Costs
36 Volunteer Program Costs
37 Fundraising
38 Other Program Costs
39 Cost to be allocated (per Wkst. K-4, Pt. I)
40 Unit Cost Multiplier
CAPITAL RELATED COST
MOVABLE
BUILDS.
EQUIPMENT
& FIXTURES
( Dollar Value or
( Square Feet )
Square Feet )
1
2
PLANT
OPERATION
& MAINT.
( Square Feet )
3
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4161)
TRANSPORTATION
( Mileage )
4
VOLUNTEER
SERVICE
COORDINATOR
( Hours )
5
RECONCILIATION
6A
ADMINISTRATIVE &
GENERAL
( Accumulated
Cost )
6
WORKSHEET K-4
PART II
TOTAL
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
Rev. 4
41-387
4190 (Cont.)
FORM CMS-2540-10
ALLOCATION OF GENERAL SERVICE
COSTS TO HOSPICE COST CENTERS
PROVIDER CCN:
HOSPICE CCN:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
HOSPICE COST CENTER (1)
Administrative and General
Inpatient - General Care
Inpatient - Respite Care
Physician Services
Nursing Care
Nursing Care- Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services - Direct
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemakers
HH Aide & Homemaker - Cont. Home Care
Other
Drugs, Biologicals and Infusion
Analgesics
Sedative/Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (incl. E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1 through 33)
Unit Cost Multiplier
From
Wkst. K-4,
Pt. I,
col. 7,
line 6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
HOSPICE
TRIAL
BALANCE
0
CAPITAL RELATED
BLDGS. &
MOVABLE
FIXTURES
EQUIPMENT
1
2
(1) Columns 0 through 16, line 34 must agree with the corresponding columns of Wkst. B, Part I, line 83.
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4162)
11-12
PERIOD :
FROM ______________
TO ________________
EMPLOYEE
BENEFITS
3
WORKSHEET K-5,
PART I
SUBTOTAL
( cols. 0
through 3 )
3A
ADMINISTRATIVE &
GENERAL
4
41-388
Rev. 4
11-12 11-12
FORM CMS-2540-10
ALLOCATION OF GENERAL SERVICE
COSTS TO HOSPICE COST CENTERS
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
HOSPICE CCN:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
HOSPICE COST CENTER (1)
Administrative and General
Inpatient - General Care
Inpatient - Respite Care
Physician Services
Nursing Care
Nursing Care- Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services - Direct
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemakers
HH Aide & Homemaker - Cont. Home Care
Other
Drugs, Biologicals and Infusion
Analgesics
Sedative/Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (incl. E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1 through 33)
Unit Cost Multiplier
PLANT
OPERATION
MAINTENANCE
& REPAIRS
5
LAUNDRY
& LINEN
SERVICE
6
HOUSEKEEPING
7
(1) Columns 0 through 16, line 34 must agree with the corresponding columns of Wkst. B, Part I, line 83.
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4162)
DIETARY
8
NURSING
ADMINISTRATION
9
CENTRAL
SERVICES &
SUPPLY
10
Rev. 4 Rev. 4
4190 (Cont.) 4190 (Cont.)
WORKSHEET K-5
Part I
FORM CMS-2540-10
ALLOCATION OF GENERAL SERVICE
COSTS TO HOSPICE COST CENTERS
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
HOSPICE CCN:
PHARMACY
11
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
HOSPICE COST CENTER (1)
Administrative and General
Inpatient - General Care
Inpatient - Respite Care
Physician Services
Nursing Care
Nursing Care- Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services - Direct
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemakers
HH Aide & Homemaker - Cont. Home Care
Other
Drugs, Biologicals and Infusion
Analgesics
Sedative/Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (incl. E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1 through 33)
Unit Cost Multiplier
MEDICAL
RECORDS &
LIBRARY
12
SOCIAL
SERVICE
13
NURSING &
ALLIED
HEALTH
EDUCATION
14
(1) Columns 0 through 16, line 34 must agree with the corresponding columns of Wkst. B, Part I, line 83.
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4162)
OTHER
GENERAL
SERVICE
15
SUBTOTAL
( sum of cols.
3A through 15 )
16
41-389 41-390
11-12
WORKSHEET K-5
Part I
FROM ______________
TO ________________
ALLOCATED
HOSPICE A & G
( see Pt. II )
17
TOTAL
HOSPICE
COSTS
18
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
Rev. 4
11-12
ALLOCATION OF GENERAL SERVICE COSTS
TO HOSPICE COST CENTERS - STATISTICAL BASIS
FORM CMS-2540-10
4190 (Cont.)
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
HOSPICE CCN:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
HOSPICE COST CENTER (1)
Administrative and General
Inpatient - General Care
Inpatient - Respite Care
Physician Services
Nursing Care
Nursing Care- Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services - Direct
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemakers
HH Aide & Homemaker - Cont. Home Care
Other
Drugs, Biologicals and Infusion
Analgesics
Sedative/Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (incl. E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1 through 33)
Total cost to be allocated
Unit Cost Multiplier
CAPITAL
RELATED
BLDGS. &
FIXTURES
( Square Feet )
1
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4162)
CAPITAL
RELATED
MOVABLE
EQUIPMENT
( Dollar Value )
2
EMPLOYEE
BENEFITS
( Gross Salaries )
3
WORKSHEET K-5,
PART II
RECONCILIATION
4a
ADMINISTRATIVE &
GENERAL
( Accumulated
Cost )
4
Rev. 4
41-391
4190 (Cont.) 4190 (Cont.)
FORM CMS-2540-10
ALLOCATION OF GENERAL SERVICE COSTS
TO HOSPICE COST CENTERS - STATISTICAL BASIS
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
HOSPICE CCN:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
HOSPICE COST CENTER (1)
Administrative and General
Inpatient - General Care
Inpatient - Respite Care
Physician Services
Nursing Care
Nursing Care- Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services - Direct
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemakers
HH Aide & Homemaker - Cont. Home Care
Other
Drugs, Biologicals and Infusion
Analgesics
Sedative/Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (incl. E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1 through 33)
Total cost to be allocated
Unit Cost Multiplier
PLANT
OPERATION
MAINTENANCE
& REPAIRS
( Square Feet )
5
LAUNDRY
& LINEN
SERVICE
( Pounds of
Laundry )
6
HOUSE
KEEPING
( Hours of
Service )
7
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4162)
DIETARY
( Meals Served )
8
WORKSHEET K-5
PART II
NURSING
ADMINISTRATION
( Direct Nursing
Hours )
9
CENTRAL
SERVICES &
SUPPLY
( Costed
Requisitions )
10
41-391 41-392
11-12 11-12
FORM CMS-2540-10
ALLOCATION OF GENERAL SERVICE COSTS
TO HOSPICE COST CENTERS - STATISTICAL BASIS
PROVIDER CCN:
PERIOD :
FROM ______________
TO ________________
HOSPICE CCN:
PHARMACY
( Costed
Requisitions )
11
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
HOSPICE COST CENTER (1)
Administrative and General
Inpatient - General Care
Inpatient - Respite Care
Physician Services
Nursing Care
Nursing Care- Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services - Direct
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemakers
HH Aide & Homemaker - Cont. Home Care
Other
Drugs, Biologicals and Infusion
Analgesics
Sedative/Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (incl. E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1 through 33)
Total cost to be allocated
Unit Cost Multiplier
MEDICAL
RECORDS &
LIBRARY
( Time Spent )
12
SOCIAL
SERVICE
( Time Spent )
13
NURSING &
ALLIED
HEALTH
EDUCATION
( Assigned Time )
14
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4162)
OTHER
GENERAL
SERVICE
( Specify )
15
SUBTOTAL
16
Rev. 4 Rev. 4
4190 (Cont.)
WORKSHEET K-5
PART II
FROM ______________
TO ________________
ALLOCATED
HOSPICE A&G
17
TOTAL
HOSPICE
COSTS
18
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
41-393
4190 (Cont.)
FORM CMS-2540-10
APPORTIONMENT OF HOSPICE SHARED SERVICES
PROVIDER CCN:
11-12
HOSPICE CCN:
PERIOD :
FROM ______________
TO ________________
Cost to
Charge
Ratio
1
Total Hospice
Charges
( from provider records )
2
WORKSHEET K-5
Part III
PART III - COMPUTATION OF TOTAL HOSPICE SHARED COSTS
COST CENTER
ANCILLARY SERVICE COST CENTERS
1 Physical Therapy
2 Occupational Therapy
3 Speech/ Language Pathology
4 Drugs, Biologicals and Infusion
5 Labs and Diagnostics
6 Medical Supplies
7 Radiation Therapy
8 Other
9 Total (sum of lines 1-8)
Wkst. C,
col. 3,
line:
0
44
45
46
49
41
48
40
52
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4162)
Hospice Shared
Ancillary Costs
( col. 1 x col. 2 )
3
1
2
3
4
5
6
7
8
9
41-394
Rev. 4
02-18
FORM CMS-2540-10
CALCULATION OF HOSPICE PER DIEM COST
PROVIDER CCN:
HOSPICE CCN:
Tittle XVIII
1
Title XIX
2
4190 (Cont.)
PERIOD :
FROM ______________
TO ________________
Other
3
1 Total cost
(see instructions)
2 Total unduplicated days
(Wkst. S-8, line 5, col. 6)
3 Average cost per diem
(line 1 divided by line 2)
4 Unduplicated Medicare days
(Wkst. S-8, line 5, col. 1)
5 Average Medicare cost
(line 3 times line 4)
6 Unduplicated Medicaid days
(Wkst. S-8, line 5, col. 2)
7 Average Medicaid cost
(line 3 times line 6)
8 Unduplicated SNF days
(Wkst. S-8, line 5, col. 3)
9 Average SNF cost
(line 3 times line 8)
10 Unduplicated NF days
(Wkst. S-8, line 5, col. 4)
11 Average NF cost
(line 3 times line 10)
12 Other unduplicated days
(Wkst. S-8, line 5, col. 5)
13 Average cost for other days
(line 3 times line 12)
FORM CMS 2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4163)
WORKSHEET K-6
Total
4
1
2
3
4
5
6
7
8
9
10
11
12
13
Rev. 8
41-395
4190 (Cont.)
FORM CMS-2540-10
03-18
ANALYSIS OF SNF-BASED HOSPICE COSTS
PROVIDER CCN:
________________
HOSPICE CCN:
________________
SALARIES
1
OTHER
2
GENERAL SERVICE COST CENTERS
1
0100 Cap Rel Costs-Bldg & Fixt*
2
0200 Cap Rel Costs-Mvble Equip*
3
0300 Employee Benefits Department*
4
0400 Administrative & General *
5
0500 Plant Operation & Maintenance*
6
0600 Laundry & Linen Service*
7
0700 Housekeeping*
8
0800 Dietary*
9
0900 Nursing Administration*
10
1000 Routine Medical Supplies*
11
1100 Medical Records*
12
1200 Staff Transportation*
13
1300 Volunteer Service Coordination*
14
1400 Pharmacy*
15
1500 Physician Administrative Services*
16
1600 Other General Service*
17
1700 Patient/Residential Care Services
DIRECT PATIENT CARE SERVICE COST CENTERS
25
2500 Inpatient Care-Contracted**
26
2600 Physician Services**
27
2700 Nurse Practitioner**
28
2800 Registered Nurse**
29
2900 LPN/LVN**
30
3000 Physical Therapy**
31
3100 Occupational Therapy**
32
3200 Speech/ Language Pathology**
33
3300 Medical Social Services**
34
3400 Spiritual Counseling**
35
3500 Dietary Counseling**
36
3600 Counseling - Other**
37
3700 Hospice Aide and Homemaker Services**
38
3800 Durable Medical Equipment/Oxygen**
39
3900 Patient Transportation**
SUBTOTAL
( col. 1 plus
col. 2 )
3
RECLASSIFICATIONS
4
SUBTOTAL
5
PERIOD:
FROM ___________
TO ______________
ADJUSTMENTS
6
WORKSHEET O
TOTAL
( col. 5 ± col. 6 )
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
* Transfer the amounts in column 7 to Wkst. O-5, col. 1, line as appropriate.
** See instructions. Do not transfer the amounts in col. 7 to Wkst. O-5.
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164)
41-396
Rev. 8
03-18
FORM CMS-2540-10
4190 (Cont.)
ANALYSIS OF SNF-BASED HOSPICE COSTS
PROVIDER CCN:
________________
HOSPICE CCN:
________________
SALARIES
1
OTHER
2
DIRECT PATIENT CARE SERVICE COST CENTERS (Cont.)
40
4000 Imaging Services**
41
4100 Labs and Diagnostics**
42
4200 Medical Supplies-Non-routine**
43
4300 Outpatient Services**
44
4400 Palliative Radiation Therapy**
45
4500 Palliative Chemotherapy**
46
Other Patient Care Services **
NONREIMBURSABLE COST CENTERS
60
6000 Bereavement Program *
61
6100 Volunteer Program *
62
6200 Fundraising*
63
6300 Hospice/Palliative Medicine Fellows*
64
6400 Palliative Care Program*
65
6500 Other Physician Services*
66
6600 Residential Care *
67
6700 Advertising*
68
6800 Telehealth/Telemonitoring*
69
6900 Thrift Store*
70
7000 Nursing Facility Room & Board*
71
7100 Other Nonreimbursable*
100
Total
SUBTOTAL
( col. 1 plus
col. 2 )
3
RECLASSIFICATIONS
4
SUBTOTAL
5
PERIOD:
FROM ___________
TO ______________
ADJUSTMENTS
6
WORKSHEET O
TOTAL
( col. 5 ± col. 6 )
7
40
41
42
43
44
45
46
60
61
62
63
64
65
66
67
68
69
70
71
100
* Transfer the amounts in column 7 to Wkst. O-5, col. 1, line as appropriate.
** See instructions. Do not transfer the amounts in col. 7 to Wkst. O-5.
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164)
Rev. 8
41-397
4190 (Cont.)
FORM CMS-2540-10
03-18
ANALYSIS OF SNF-BASED HOSPICE COSTS
HOSPICE CONTINUOUS HOME CARE
PROVIDER CCN:
________________
HOSPICE CCN:
________________
SALARIES
1
OTHER
2
DIRECT PATIENT CARE SERVICE COST CENTERS
25 Inpatient Care - Contracted
26 Physician Services
27 Nurse Practitioner
28 Registered Nurse
29 LPN/LVN
30 Physical Therapy
31 Occupational Therapy
32 Speech/ Language Pathology
33 Medical Social Services
34 Spiritual Counseling
35 Dietary Counseling
36 Counseling - Other
37 Hospice Aide and Homemaker Services
38 Durable Medical Equipment/Oxygen
39 Patient Transportation
40 Imaging Services
41 Labs and Diagnostics
42 Medical Supplies-Non-routine
43 Outpatient Services
44 Palliative Radiation Therapy
45 Palliative Chemotherapy
46 Other Patient Care Services
100 Total *
SUBTOTAL
( col. 1 plus
col. 2 )
3
RECLASSIFICATIONS
4
SUBTOTAL
5
PERIOD:
FROM ___________
TO ______________
ADJUSTMENTS
6
WORKSHEET O-1
TOTAL
( col. 5 ± col. 6 )
7
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
100
* Transfer the amount in column 7 to Wkst. O-5, column 1, line 50
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164.1)
41-398
Rev. 8
03-18
FORM CMS-2540-10
4190 (Cont.)
ANALYSIS OF SNF-BASED HOSPICE COSTS
HOSPICE ROUTINE HOME CARE
PROVIDER CCN:
________________
HOSPICE CCN:
________________
SALARIES
1
OTHER
2
DIRECT PATIENT CARE SERVICE COST CENTERS
25 Inpatient Care - Contracted
26 Physician Services
27 Nurse Practitioner
28 Registered Nurse
29 LPN/LVN
30 Physical Therapy
31 Occupational Therapy
32 Speech/ Language Pathology
33 Medical Social Services
34 Spiritual Counseling
35 Dietary Counseling
36 Counseling - Other
37 Hospice Aide and Homemaker Services
38 Durable Medical Equipment/Oxygen
39 Patient Transportation
40 Imaging Services
41 Labs and Diagnostics
42 Medical Supplies-Non-routine
43 Outpatient Services
44 Palliative Radiation Therapy
45 Palliative Chemotherapy
46 Other Patient Care Services
100 Total *
SUBTOTAL
( col. 1 plus
col. 2 )
3
RECLASSIFICATIONS
4
SUBTOTAL
5
PERIOD:
FROM ___________
TO ______________
ADJUSTMENTS
6
WORKSHEET O-2
TOTAL
( col. 5 ± col. 6 )
7
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
100
* Transfer the amount in column 7 to Wkst. O-5, column 1, line 51
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164.1)
Rev. 8
41-399
4190 (Cont.)
FORM CMS-2540-1FORM CMS-2540-10
ANALYSIS OF SNF-BASED HOSPICE COSTS
HOSPICE INPATIENT RESPITE CARE
03-18
PROVIDER CCN:
________________
HOSPICE CCN:
________________
SALARIES
1
OTHER
2
DIRECT PATIENT CARE SERVICE COST CENTERS
25 Inpatient Care - Contracted
26 Physician Services
27 Nurse Practitioner
28 Registered Nurse
29 LPN/LVN
30 Physical Therapy
31 Occupational Therapy
32 Speech/ Language Pathology
33 Medical Social Services
34 Spiritual Counseling
35 Dietary Counseling
36 Counseling - Other
37 Hospice Aide and Homemaker Services
38 Durable Medical Equipment/Oxygen
39 Patient Transportation
40 Imaging Services
41 Labs and Diagnostics
42 Medical Supplies-Non-routine
43 Outpatient Services
44 Palliative Radiation Therapy
45 Palliative Chemotherapy
46 Other Patient Care Services
100 Total *
SUBTOTAL
( col. 1 plus
col. 2 )
3
RECLASSIFICATIONS
4
SUBTOTAL
5
PERIOD:
FROM ___________
TO ______________
ADJUSTMENTS
6
WORKSHEET O-3
TOTAL
( col. 5 ± col. 6 )
7
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
100
* Transfer the amount in column 7 to Wkst. O-5, column 1, line 52
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164.1)
41-400
Rev. 8
03-18
FORM CMS-2540-10
4190 (Cont.)
ANALYSIS OF SNF-BASED HOSPICE COSTS
HOSPICE GENERAL INPATIENT CARE
PROVIDER CCN:
________________
HOSPICE CCN:
________________
SALARIES
1
OTHER
2
DIRECT PATIENT CARE SERVICE COST CENTERS
25 Inpatient Care - Contracted
26 Physician Services
27 Nurse Practitioner
28 Registered Nurse
29 LPN/LVN
30 Physical Therapy
31 Occupational Therapy
32 Speech/ Language Pathology
33 Medical Social Services
34 Spiritual Counseling
35 Dietary Counseling
36 Counseling - Other
37 Hospice Aide and Homemaker Services
38 Durable Medical Equipment/Oxygen
39 Patient Transportation
40 Imaging Services
41 Labs and Diagnostics
42 Medical Supplies-Non-routine
43 Outpatient Services
44 Palliative Radiation Therapy
45 Palliative Chemotherapy
46 Other Patient Care Services
100 Total *
SUBTOTAL
( col. 1 plus
col. 2 )
3
RECLASSIFICATIONS
4
SUBTOTAL
5
PERIOD:
FROM ___________
TO ______________
ADJUSTMENTS
6
WORKSHEET O-4
TOTAL
( col. 5 ± col. 6 )
7
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
100
* Transfer the amount in column 7 to Wkst. O-5, column 1, line 53
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164.1)
Rev. 8
41-401
4190 (Cont.)
FORM CMS-2540-10
COST ALLOCATION - DETERMINATION OF SNF-BASED HOSPICE
NET EXPENSES FOR ALLOCATION
PROVIDER CCN:
________________
HOSPICE CCN:
________________
Descriptions
03-18
PERIOD:
FROM ___________
TO ______________
HOSPICE
DIRECT
EXPENSES
( see instructions )
1
GENERAL SERVICE COST CENTERS
1 Cap Rel Costs-Bldg & Fixt
2 Cap Rel Costs-Mvble Equip
3 Employee Benefits
4 Administrative & General
5 Plant Operation and Maintenance
6 Laundry & Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Routine Medical Supplies
11 Medical Records
12 Staff Transportation
13 Volunteer Service Coordination
14 Pharmacy
15 Physician Administrative Services
16 Other General Service
17 Patient/Residential Care Services
LEVEL OF CARE
50 Hospice Continuous Home Care
51 Hospice Routine Home Care
52 Hospice Inpatient Respite Care
53 Hospice General Inpatient Care
NONREIMBURSABLE COST CENTERS
60 Bereavement Program
61 Volunteer Program
62 Fundraising
63 Hospice/Palliative Medicine Fellows
64 Palliative Care Program
65 Other Physician Services
66 Residential Care
67 Advertising
68 Telehealth/Telemonitoring
69 Thrift Store
70 Nursing Facility Room & Board
71 Other Nonreimbursable
99 Negative Cost Center
100 Total
GENERAL
SERVICE
EXPENSES
FROM WKST B
( see instructions )
2
WORKSHEET O-5
TOTAL
EXPENSES
( sum of cols. 1 + 2 )
3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
50
51
52
53
60
61
62
63
64
65
66
67
68
69
70
71
99
100
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164.2)
41-402
Rev. 8
03-18
FORM CMS-2540-10
COST ALLOCATION - SNF-BASED HOSPICE GENERAL SERVICE COSTS
Descriptions
GENERAL SERVICE COST CENTERS
1 Cap Rel Costs-Bldg & Fixt
2 Cap Rel Costs-Mvble Equip
3 Employee Benefits
4 Administrative & General
5 Plant Operation and Maintenance
6 Laundry & Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Routine Medical Supplies
11 Medical Records
12 Staff Transportation
13 Volunteer Service Coordination
14 Pharmacy
15 Physician Administrative Services
16 Other General Service
17 Patient/Residential Care Services
LEVEL OF CARE
50 Hospice Continuous Home Care
51 Hospice Routine Home Care
52 Hospice Inpatient Respite Care
53 Hospice General Inpatient Care
NONREIMBURSABLE COST CENTERS
60 Bereavement Program
61 Volunteer Program
62 Fundraising
63 Hospice/Palliative Medicine Fellows
64 Palliative Care Program
65 Other Physician Services
66 Residential Care
67 Advertising
68 Telehealth/Telemonitoring
69 Thrift Store
70 Nursing Facility Room & Board
71 Other Nonreimbursable
99 Negative Cost Center
100 Total
TOTAL
EXPENSES
0
CAP REL
BLDG
& FIX
1
4190 (Cont.)
PROVIDER CCN: ______________
HOSPICE CCN: ________________
CAP REL
MVBLE
EQUIP
2
EMPLOYEE
BENEFITS
DEPARTMENT
3
SUBTOTAL
3A
ADMINISTRATIVE &
GENERAL
4
PLANT
OP &
MAINT
5
PERIOD:
FROM _____________________
TO _________________________
LAUNDRY
HOUSE& LINEN
KEEPING
6
7
WORKSHEET O-6
PART I
DIETARY
8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
50
51
52
53
60
61
62
63
64
65
66
67
68
69
70
71
99
100
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164.3)
Rev. 8
41-403
4190 (Cont.)
FORM CMS-2540-10
COST ALLOCATION - SNF-BASED HOSPICE GENERAL SERVICE COSTS
Descriptions
GENERAL SERVICE COST CENTERS
1 Cap Rel Costs-Bldg & Fixt
2 Cap Rel Costs-Mvble Equip
3 Employee Benefits
4 Administrative & General
5 Plant Operation and Maintenance
6 Laundry & Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Routine Medical Supplies
11 Medical Records
12 Staff Transportation
13 Volunteer Service Coordination
14 Pharmacy
15 Physician Administrative Services
16 Other General Service
17 Patient/Residential Care Services
LEVEL OF CARE
50 Continuous Home Care
51 Routine Home Care
52 Inpatient Respite Care
53 General Inpatient Care
NONREIMBURSABLE COST CENTERS
60 Bereavement Program
61 Volunteer Program
62 Fundraising
63 Hospice/Palliative Medicine Fellows
64 Palliative Care Program
65 Other Physician Services
66 Residential Care
67 Advertising
68 Telehealth/Telemonitoring
69 Thrift Store
70 Nursing Facility Room & Board
71 Other Nonreimbursable
99 Negative Cost Center
100 Total
NURSING
ADMINISTRATION
9
ROUTINE
MEDICAL
SUPPLIES
10
03-18
PROVIDER CCN: ______________
HOSPICE CCN: ________________
MEDICAL
RECORDS
11
STAFF
TRANSPORTATION
12
VOLUNTEER
SVC COORDINATION
13
PHARMACY
14
PHYSICIAN
ADMINISTRATIVE SVCS
15
PERIOD:
FROM _____________________
TO _________________________
OTHER
PATIENT /
GENERAL
RESIDENTIAL
SERVICE
CARE SVCS
16
17
WORKSHEET O-6
Part I
TOTAL
18
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
50
51
52
53
60
61
62
63
64
65
66
67
68
69
70
71
99
100
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164.3)
41-404
Rev. 8
03-18
FORM CMS-2540-10
COST ALLOCATION - SNF-BASED HOSPICE GENERAL SERVICE COST STATISTICAL BASIS
Cost Center Descriptions
GENERAL SERVICE COST CENTERS
1 Cap Rel Costs-Bldg & Fixt
2 Cap Rel Costs-Mvble Equip
3 Employee Benefits
4 Administrative & General
5 Plant Operation and Maintenance
6 Laundry & Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Routine Medical Supplies
11 Medical Records
12 Staff Transportation
13 Volunteer Service Coordination
14 Pharmacy
15 Physician Administrative Services
16 Other General Service
17 Patient/Residential Care Services
LEVEL OF CARE
50 Hospice Continuous Home Care
51 Hospice Routine Home Care
52 Hospice Inpatient Respite Care
53 Hospice General Inpatient Care
NONREIMBURSABLE COST CENTERS
60 Bereavement Program
61 Volunteer Program
62 Fundraising
63 Hospice/Palliative Medicine Fellows
64 Palliative Care Program
65 Other Physician Services
66 Residential Care
67 Advertising
68 Telehealth/Telemonitoring
69 Thrift Store
70 Nursing Facility Room & Board
71 Other Nonreimbursable
99 Negative Cost Center
101 Cost to be allocated (per Wkst. O-6, Part I)
102 Unit cost multiplier
CAP REL
BLDG
& FIX
( Square
Feet )
1
CAP REL
MVBLE
EQUIP
( Dollar
Value )
2
EMPLOYEE
BENEFITS
DEPARTMENT
( Gross
Salaries )
3
RECONCILIATION
4A
4190 (Cont.)
PROVIDER CCN: ______________ PERIOD:
HOSPICE CCN: ________________ FROM _____________________
TO _________________________
ADMINISPLANT
LAUNDRY
HOUSETRATIVE &
OP &
& LINEN
KEEPING
GENERAL
MAINT
( Accum.
( Square
( In-Facility
( Square
Cost )
Feet )
Days )
Feet )
4
5
6
7
WORKSHEET O-6
PART II
DIETARY
( In-Facility
Days )
8
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164.3)
Rev. 8
41-405
4190 (Cont.)
FORM CMS-2540-10
COST ALLOCATION - SNF-BASED HOSPICE GENERAL SERVICE COST STATISTICAL BASIS
Cost Center Descriptions
GENERAL SERVICE COST CENTERS
1 Cap Rel Costs-Bldg & Fixt
2 Cap Rel Costs-Mvble Equip
3 Employee Benefits
4 Administrative & General
5 Plant Operation and Maintenance
6 Laundry & Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Routine Medical Supplies
11 Medical Records
12 Staff Transportation
13 Volunteer Service Coordination
14 Pharmacy
15 Physician Administrative Services
16 Other General Service
17 Patient/Residential Care Services
LEVEL OF CARE
50 Continuous Home Care
51 Routine Home Care
52 Inpatient Respite Care
53 General Inpatient Care
NONREIMBURSABLE COST CENTERS
60 Bereavement Program
61 Volunteer Program
62 Fundraising
63 Hospice/Palliative Medicine Fellows
64 Palliative Care Program
65 Other Physician Services
66 Residential Care
67 Advertising
68 Telehealth/Telemonitoring
69 Thrift Store
70 Nursing Facility Room & Board
71 Other Nonreimbursable
99 Negative Cost Center
101 Cost to be allocated (per Wkst. O-6, Part I)
102 Unit cost multiplier
NURSING
ADMINISTRATION
( Direct
Nurs. Hrs. )
9
ROUTINE
MEDICAL
SUPPLIES
( Patient
Days )
10
MEDICAL
RECORDS
( Patient
Days )
11
STAFF
TRANSPORTATION
( Mileage )
12
VOLUNTEER
SVC COORDINATION
( Hours of
Service )
13
03-18
PROVIDER CCN: ______________ PERIOD:
HOSPICE CCN: ________________ FROM _____________________
TO _________________________
PHARMACY
PHYSICIAN
OTHER
PATIENT /
ADMINISTRAGENERAL
RESIDENTIAL
TIVE SVCS
SERVICE
CARE SVCS
( Patient
( Specify
( In-Facility
( Charges )
Days )
Basis )
Days )
14
15
16
17
WORKSHEET O-6
Part II
TOTAL
18
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164.3)
41-406
Rev. 8
4190 (Cont.)
WORKSHEET O-6
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
50
51
52
53
60
61
62
63
64
65
66
67
68
69
70
71
99
101
102
41-405
03-18
WORKSHEET O-6
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
50
51
52
53
60
61
62
63
64
65
66
67
68
69
70
71
99
101
102
Rev. 8
08-16
FORM CMS-2540-10
APPORTIONMENT OF SNF-BASED HOSPICE SHARED SERVICE COSTS BY LEVEL OF CARE
Cost Center Descriptions
ANCILLARY SERVICE COST CENTERS
1 Physical Therapy
2 Occupational Therapy
3 Speech/ Language Pathology
4 Drugs, Biological and Infusion Therapy
5
6
7
8
9
10
11
Durable Medical Equipment/Oxygen
Labs and Diagnostics
Medical Supplies
Outpatient Services (including E/R Dept.)
Radiation Therapy
Other
Totals (sum of lines 1 through 10)
Wkst. C,
col. 3,
line
0
Cost to
Charge
Ratio
1
4190 (Cont.)
PROVIDER CCN: _____________ PERIOD:
HOSPICE CCN: ________________ FROM _____________________
TO _________________________
Charges by LOC (from Provider Records)
HCHC
2
HRHC
3
HIRC
4
HGIP
5
HCHC
( col. 1 x col. 2 )
6
Shared Service Costs by LOC
HRHC
HIRC
( col. 1 x col. 3 )
( col. 1 x col. 4 )
7
8
WORKSHEET O-7
HGIP
( col. 1 x col. 5 )
9
44
45
46
49
1
2
3
4
51
41
48
63
40
52
5
6
7
8
9
10
11
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164.4)
Rev. 7
41-407
4190 (Cont.)
CALCULATION OF SNF-BASED HOSPICE PER DIEM COST
FORM CMS-2540-10
PROVIDER CCN:
________________
HOSPICE CCN:
________________
TITLE XVIII
MEDICARE
1
08-16
PERIOD:
FROM ___________
TO ______________
TITLE XIX
MEDICAID
2
WORKSHEET O-8
TOTAL
3
HOSPICE CONTINUOUS HOME CARE
1 Total cost (Wkst. O-6, Part I, col 18, line 50 plus Wkst. O-7, col. 6, line 11)
2 Total unduplicated days (Wkst. S-8, col. 4, line 10)
3 Total average cost per diem (line 1 divided by line 2)
4 Unduplicated program days (Wkst. S-8, col. as appropriate, line 10)
5 Program cost (line 3 times line 4)
HOSPICE ROUTINE HOME CARE
6 Total cost (Wkst. O-6, Part I, col. 18, line 51 plus Wkst. O-7, col. 7, line 11)
7 Total unduplicated days (Wkst. S-8, col. 4, line 11)
8 Total average cost per diem (line 6 divided by line 7)
9 Unduplicated program days (Wkst. S-8, col. as appropriate, line 11)
10 Program cost (line 8 times line 9)
HOSPICE INPATIENT RESPITE CARE
11 Total cost (Wkst. O-6, Part I, col. 18, line 52 plus Wkst. O-7, col. 8, line 11)
12 Total unduplicated days (Wkst. S-8, col. 4, line 12)
13 Total average cost per diem (line 11 divided by line 12)
14 Unduplicated program days (Wkst. S-8, col. as appropriate, line 12)
15 Program cost (line 13 times line 14)
HOSPICE GENERAL INPATIENT CARE
16 Total cost (Wkst. O-6, Part I, col. 18, line 53 plus Wkst. O-7, col. 9, line 11)
17 Total unduplicated days (Wkst. S-8, col. 4, line 13)
18 Total average cost per diem (line 16 divided by line 17)
19 Unduplicated program days (Wkst. S-8, col. as appropriate, line 13)
20 Program cost (line 18 times line 19)
TOTAL HOSPICE CARE
21 Total cost (sum of line 1 + line 6 + line 11 + line 16)
22 Total unduplicated days (Wkst. S-8, col. 4, line 14)
23 Average cost per diem (line 21 divided by line 22)
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4164.5)
41-408
Rev. 7
08-16
WORKSHEET O-8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Rev. 7