Form CMS-2552-10 COST REPORT WORKSHEET

03-18

FORM CMS-2552-10

4090 (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).

HOSPITAL AND HOSPITAL HEALTH CARE
COMPLEX COST REPORT CERTIFICATION
AND SETTLEMENT SUMMARY

PROVIDER CCN:
______________

PERIOD
FROM __________
TO _____________

FORM APPROVED
OMB NO. 0938-0050
EXPIRES 05-31-2022
WORKSHEET S
PARTS I, II & III

PART I - COST REPORT STATUS
Provider use only 1. [ ] Electronically filed cost report
Date: __________
Time: __________
2. [ ] Manually submitted cost report
3. [ ] If this is an amended report enter the number of times the provider resubmitted this cost report
4. [ ] Medicare Utilization. Enter "F" for full or "L" for low.
Contractor 5. [ ] Cost Report Status
6. Date Received:_________
10. NPR Date:__________
use only
(1) As Submitted
7. Contractor No.:________
11. Contractor's Vendor Code: ___________
(2) Settled without audit
8. [ ] Initial Report for this Provider CCN
12. [ ] If line 5, column 1, is 4: Enter number of
(3) Settled with audit
9. [ ] Final Report for this Provider CCN
times reopened = 0-9.
(4) Reopened
(5) Amended
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 OR PROCURED 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 PROVIDER(S)
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
submitted cost report and the Balance Sheet and Statement of Revenue and Expenses prepared by _________________________{Provider Name(s) and Number(s)}for the
cost reporting period beginning ______________ and ending ______________ and 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 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 FinancialOfficer or Administrator of Provider(s)
______________________________________________
Title
______________________________________________
Date
PART III - SETTLEMENT SUMMARY
TITLE V
1

TITLE XVIII
PART A
2

PART B
3

HIT
4

TITLE XIX
5

1

HOSPITAL

1

2

SUBPROVIDER - IPF

2

3

SUBPROVIDER - IRF

3

4

SUBPROVIDER (OTHER)

4

5

SWING BED - SNF

5

6

SWING BED - NF

6

7

SNF

7

8

NF, ICF/IID

8

9

HOME HEALTH AGENCY

9

10

HOSPITAL-BASED - RHC

10

11

HOSPITAL-BASED - FQHC
OUTPATIENT REHABILITATION
PROVIDER (Specify)

11

12

200 TOTAL
The above amounts represent "due to" or "due from" the applicable program for the element of the above complex indicated.

12
200

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 0938-0050. The time required to complete this information collection is estimated to average 673 hours per response, including the time to review instructions, search existing resources,
gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Report Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send applications, claims, payments, medical records or any
documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated
OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact 1-800-MEDICARE.

FORM CMS-2552-10 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTIONS 4003.1-4003.3)

Rev. 14

40-503

4090 (Cont.)

FORM CMS-2552-10

03-18

HOSPITAL AND HOSPITAL HEALTH CARE
COMPLEX IDENTIFICATION DATA

PROVIDER CCN:
______________

Hospital and Hospital Health Care Complex Address:
1 Street:
2 City:
Hospital and Hospital-Based Component Identification:
Component
0
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

Hospital
Subprovider- IPF
Subprovider- IRF
Subprovider- (Other)
Swing Beds-SNF
Swing Beds-NF
Hospital-Based SNF
Hospital-Based NF
Hospital-Based OLTC
Hospital-Based HHA
Separately Certified ASC
Hospital-Based Hospice
Hospital-Based Health Clinic-RHC
Hospital-Based Health Clinic-FQHC
Hospital-Based (CMHC, CORF and OPT)
Renal Dialysis
Other
Cost Reporting Period (mm/dd/yyyy)
Type of control (see instructions)

P.O. Box:
State:
Component
Name
1

ZIP Code:
CCN
Number
2

CBSA
Number
3

1
2
Provider
Type
4

Date
Certified
5

V
6

Payment System (P, T, O, or N)
XVIII
7

XIX
8
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

From:______________ To: ______________

In-State
Medicaid
paid days
1

25

WORKSHEET S-2
PART I

County:

Inpatient PPS Information
22 Does this facility qualify and is it currently receiving payments for disproportionate share hospital adjustment, in accordance with 42 CFR 412.106? In column 1, enter "Y" for yes or "N" for no.
Is this facility subject to 42 CFR 412.106 (c )(2) (Pickle amendment hospital)? In column 2, enter "Y" for yes or "N" for no.
22.01 Did this hospital receive interim uncompensated care payments for this cost reporting period? Enter in column 1, "Y" for yes or "N" for no for the portion of the cost reporting period occurring prior to October 1.
Enter in column 2, "Y" for yes or "N" for no for the portion of the cost reporting period occurring on or after October 1. (see instructions)
22.02 Is this a newly merged hospital that requires final uncompensated care payments to be determined at cost report settlement? (see instructions) Enter in column 1, “Y” for yes or “N” for no,
for the portion of the cost reporting period prior to October 1. Enter in column 2, “Y” for yes or “N” for no, for the portion of the cost reporting period on or after October 1.
22.03 Did this hospital receive a geographic reclassification from urban to rural as a result of the OMB standards for delineating statistical areas adopted by CMS in FY2015? Enter in column 1, “Y” for yes or “N” for
no for the portion of the cost reporting period prior to October 1. Enter in column 2, "Y" for yes or "N" for no for the portion of the cost reporting period occurring on or after October 1. (see instructions)
Does this hospital contain at least 100 but not more than 499 beds (as counted in accordance with 42 CFR 412.105)? Enter in column 3, “Y” for yes or “N” for no.
23 Which method is used to determine Medicaid days on lines 24 and/or 25 below? In column 1, enter 1 if date of admission, 2 if census days, or 3 if date of discharge.
Is the method of identifying the days in this cost reporting period different from the method used in the prior cost reporting period? In column 2, enter "Y" for yes or "N" for no.

24

PERIOD
FROM __________
TO _____________

In-State
Medicaid eligible
unpaid days
2

Out-of State
Medicaid
paid days
3

1

2

3
22
22.01
22.02
22.03

23

Out-of State
Medicaid eligible
unpaid days
4

Medicaid
HMO
days
5

Other
Medicaid
days
6

If this provider is an IPPS hospital, enter the in-state Medicaid paid days in column 1, in-state Medicaid unpaid days in column 2, out-of-state
Medicaid paid days in column 3, out-of-state Medicaid eligible unpaid days in column 4, Medicaid HMO paid and eligible but unpaid days in
column 5, and other Medicaid days in column 6.
If this provider is an IRF, enter the in-state Medicaid paid days in column 1, in-state Medicaid eligible unpaid days in column 2, out-of-state
Medicaid paid days in column 3, out-of state Medicaid eligible unpaid days in column 4 Medicaid HMO paid and eligible but unpaid days in column 5.

24

25

1
26
27

Enter your standard geographic classification (not wage) status at the beginning of the cost reporting period. Enter "1" for urban or "2" for rural.
Enter your standard geographic classification (not wage) status at the end of the cost reporting period. Enter in column 1, "1" for urban or "2" for rural.

35
36

If applicable, enter the effective date of the geographic reclassification in column 2.
If this is a sole community hospital (SCH), enter the number of periods SCH status in effect in the cost reporting period.
Enter applicable beginning and ending dates of SCH status. Subscript line 36 for number of periods in excess of one and enter subsequent dates.

37 If this is a Medicare dependent hospital (MDH), enter the number of periods MDH status is in effect in the cost reporting period.
37.01 Is this hospital a former MDH that is eligible for the MDH transitional payment in accordance with the FY 2016 OPPS final rule? Enter "Y" for yes or "N" for no. (see instructions)
38  If line 37 is 1, enter the beginning and ending dates of MDH status.  If line 37 is greater than 1, subscript this line for the number of periods in excess of one and enter subsequent dates.
39 Does this facility qualify for the inpatient hospital payment adjustment for low volume hospitals in accordance with 42 CFR 412.101(b)(2)(i) or (ii)? Enter in column 1 “Y” for yes or “N” for no.
Does the facility meet the mileage requirements in accordance with 42 CFR 412.101(b)(2)(i) or (ii)?  Enter in column 2 "Y" for yes or "N" for no.  (see instructions)
40 Is this hospital subject to the HAC program reduction adjustment? Enter "Y" for yes or "N" for no in column 1, for discharges prior to October 1. Enter "Y" for yes or "N" for no in column 2,
for discharges on or after October 1. (see instructions)

2

3
26
27

Beginning:___________Ending: ______________

Beginning:___________Ending: ______________

35
36
37
37.01
38
39
40

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4004.1)

40-504

Rev. 14

03-18

FORM CMS-2552-10

4090 (Cont.)

HOSPITAL AND HOSPITAL HEALTH CARE
COMPLEX IDENTIFICATION DATA

PROVIDER CCN:
______________
V
1

Prospective Payment System (PPS)-Capital
45 Does this facility qualify and receive capital payment for disproportionate share in accordance with 42 CFR 412.320? (see instructions)
46 Is this facility eligible for additional payment exception for extraordinary circumstances pursuant to 42 CFR 412.348(f)? If yes, complete Wkst. L, Pt. III, and Wkst. L-1, Pt. I, through Pt. III.
47 Is this a new hospital under 42 CFR 412.300(b) PPS capital? Enter "Y for yes or "N" for no.
48 Is the facility electing full federal capital payment? Enter "Y" for yes or "N" for no.

1

61.20

Worksheet A
Line #
2

Pass-Through
Qualification
Criterion Code
3

Are you claiming nursing and allied health education (NAHE) costs for any programs that meet the criteria under 42 CFR 413.85? (see instructions)
If line 60 is yes, complete columns 2 and 3 for each program. (see instructions)

60
60.01

2

3

IME
4

Direct GME
5

Did your hospital receive FTE slots under ACA section 5503? Enter "Y" for yes or "N" for no in column 1. (see instructions)

61
IME
2

Direct GME
3

Enter the average number of unweighted primary care FTEs from the hospital's 3 most recent cost reports ending and submitted before March 23, 2010. (see instructions)
Enter the current year total unweighted primary care FTE count (excluding OB/GYN, general surgery FTEs, and primary care FTEs added under section 5503 of ACA). (see instructions)
Enter the base line FTE count for primary care and/or general surgery residents, which is used for determining compliance with the 75% test. (see instructions)
Enter the number of unweighted primary care/or surgery allopathic and/or osteopathic FTEs in the current cost reporting period. (see instructions)
Enter the difference between the baseline primary and/or general surgery FTEs and the current year's primary care and/or general surgery FTE counts (line 61.04 minus line 61.03). (see instructions)
Enter the amount of ACA §5503 award that is being used for cap relief and/or FTEs that are nonprimary care or general surgery. (see instructions)

61.01
61.02
61.03
61.04
61.05
61.06

Program Name
1
61.10

3

58
59

1
61.01
61.02
61.03
61.04
61.05
61.06

2

If line 56 is yes, did this facility elect cost reimbursement for physicians' services as defined in CMS Pub. 15-1, chapter 21, §2148? If yes, complete Wkst. D-5.
Are costs claimed on line 100 of Worksheet A? If yes, complete Wkst. D-2, Pt. I.

Y/N
1
61

XIX
3

56
57

NAHE
413.85
Y/N
1
60
60.01

WORKSHEET S-2
PART I (CONT.)

45
46
47
48

Teaching Hospitals
56 Is this a hospital involved in training residents in approved GME programs? Enter "Y" for yes or "N" for no.
57 If line 56 is yes, is this the first cost reporting period during which residents in approved GME programs trained at this facility? Enter "Y" for yes or "N" for no in column 1.
If column 1 is "Y", did residents start training in the first month of this cost reporting period? Enter "Y" for yes or "N" for no in column 2. If column 2 is "Y", complete Wkst. E-4.
If column 2 is "N", complete Wkst. D, Parts III & IV and D-2, Pt. II, if applicable.
58
59

PERIOD
FROM __________
TO _____________
XVIII
2

Program Code
2

Unweighted
IME
FTE Count
3

Unweighted
Direct GME
FTE Count
4

Of the FTEs in line 61.05, specify each new program specialty, if any, and the number of FTE residents for each new program. (see instructions)
Enter in column 1, the program name. Enter in column 2, the program code. Enter in column 3, the IME FTE unweighted count. Enter in column 4, the direct GME FTE unweighted count.
Of the FTEs in line 61.05, specify each expanded program specialty, if any, and the number of FTE residents for each expanded program. (see instructions)
Enter in column 1, the program name. Enter in column 2, the program code. Enter in column 3, the IME FTE unweighted count. Enter in column 4, the direct GME FTE unweighted count.

61.10
61.20

ACA Provisions Affecting the Health Resources and Services Administration (HRSA)
62 Enter the number of FTE residents that your hospital trained in this cost reporting period for which your hospital received HRSA PCRE funding. (see instructions)
62.01 Enter the number of FTE residents that rotated from a Teaching Health Center (THC) into your hospital during in this cost reporting period of HRSA THC program. (see instructions)
Teaching Hospitals that Claim Residents in Nonprovider Settings
63 Has your facility trained residents in nonprovider settings during this cost reporting period? Enter "Y" for yes or "N" for no. If yes, complete lines 64 through 67. (see instructions)

Section 5504 of the ACA Base Year FTE Residents in Nonprovider Settings--This base year is your cost reporting period that begins on or after July 1, 2009 and before June 30, 2010.
64 Enter in column 1, if line 63 is yes, or your facility trained residents in the base year period, the number of unweighted non-primary care resident FTEs attributable to rotations occurring in all non-provider settings.
Enter in column 2 the number of unweighted non-primary care resident FTEs that trained in your hospital.
Enter in column 3 the ratio of (column 1 divided by (column 1 + column 2)). (see instructions)

1
62
62.01
1

2

3

Unweighted
FTEs
Nonprovider Site
1

Unweighted
FTEs
in Hospital
2

Ratio
(col. 1 ÷
(col. 1 + col. 2))
3

63

64

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4004.1

Rev. 14

40-505

4090 (Cont.)

FORM CMS-2552-10

03-18

HOSPITAL AND HOSPITAL HEALTH CARE
COMPLEX IDENTIFICATION DATA

PROVIDER CCN:

Program Name
1
65

Program Code
2

WORKSHEET S-2
PART I (CONT.)
Ratio
(col. 3/
(col. 3 + col. 4))
5

Enter in column 1, if line 63 is yes, or your facility trained residents in the base year period, the program name associated with primary care FTEs for each primary
care FTEs for each primary care program in which you trained residents. Enter in column 2, the program code. Enter in column 3, the number of unweighted primary
care FTE residents attributable to rotations occurring in all non-provider settings. Enter in column 4, the number of unweighted primary care resident FTEs that
trained in your hospital. Enter in column 5, the ratio of (column 3 divided by (column 3 + column 4)). (see instructions)

65

Section 5504 of the ACA Current Year FTE Residents in Nonprovider Settings--Effective for cost reporting periods beginning on or after July 1, 2010
66 Enter in column 1, the number of unweighted non-primary care resident FTEs attributable to rotations occurring in all nonprovider settings. Enter in column 2, the number of unweighted non-primary care resident
FTEs that trained in your hospital. Enter in column 3, the ratio of (column 1 divided by (column 1 + column 2)). (see instructions)

Program Name
1
67

______________
Unweighted
FTEs
Nonprovider Site
3

PERIOD
FROM __________
TO _____________
Unweighted
FTEs
in Hospital
4

Program Code
2

Unweighted
FTEs
Nonprovider Site
1

Unweighted
FTEs
in Hospital
2

Ratio
(col. 1/
(col. 1 + col. 2))
3
66

Unweighted
FTEs
Nonprovider Site
3

Unweighted
FTEs
in Hospital
4

Ratio
(col. 3/
(col. 3 + col. 4))
5

Enter in column 1, the program name associated with each of your primary care programs in which you trained residents. Enter in column 2, the program code. Enter
column 3, the number of unweighted primary care FTE residents attributable to rotations occurring in all non-provider settings. Enter in column 4, the number of
unweighted primary care resident FTEs that trained in your hospital. Enter in column 5, the ratio of (column 3 divided by (column 3 + column 4)). (see instructions)

67

Inpatient Psychiatric Facility PPS
70 Is this facility an Inpatient Psychiatric Facility (IPF), or does it contain an IPF subprovider? Enter "Y" for yes or "N" for no.
71 If line 70 is yes:
Column 1: Did the facility have an approved GME teaching program in the most recent cost report filed on or before November 15, 2004? Enter "Y" for yes or "N" for no. (see 42 CFR 412.424(d)(1)(iii)(C))
Column 2: Did this facility train residents in a new teaching program in accordance with 42 CFR 412.424 (d)(1)(iii)(D)? Enter "Y" for yes or "N" for no.
Column 3: If column 2 is Y, indicate which program year began during this cost reporting period. (see instructions)

1

Inpatient Rehabilitation Facility PPS
75 Is this facility an Inpatient Rehabilitation Facility (IRF), or does it contain an IRF subprovider? Enter "Y" for yes or "N" for no.
76 If line 75 is yes:
Column 1: Did the facility have an approved GME teaching program in the most recent cost reporting period ending on or before November 15, 2004? Enter "Y" for yes or "N" for no.
Column 2: Did this facility train residents in a new teaching program in accordance with 42 CFR 412.424 (d)(1)(iii)(D)? Enter "Y" for yes or "N" for no.
Column 3: If column 2 is Y, indicate which program year began during this cost reporting period. (see instructions)

1

2

70
71

2

3
75
76

Long Term Care Hospital PPS
80 Is this a Long Term Care Hospital (LTCH)? Enter "Y" for yes or "N" for no.
81 Is this a LTCH co-located within another hospital for part or all of the cost reporting period? Enter “Y” for yes and “N” for no.

1

TEFRA Providers
85 Is this a new hospital under 42 CFR 413.40(f)(1)(i) TEFRA? Enter "Y" for yes or "N" for no.
86 Did this facility establish a new Other subprovider (excluded unit) under 42 CFR 413.40(f)(1)(ii)? Enter "Y" for yes or "N" for no.
87 Is this hospital an extended neoplastic disease care hospital classified under section 1886(d)(1)(B)(vi)? Enter "Y" for yes or "N" for no.

1

Title V and XIX Services
90 Does this facility have title V and/or XIX inpatient hospital services? Enter "Y" for yes or "N" for no in applicable column.
91 Is this hospital reimbursed for title V and/or XIX through the cost report either in full or in part? Enter "Y" for yes or "N" for no in the applicable column.
92 Are title XIX NF patients occupying title XVIII SNF beds (dual certification)? (see instructions) Enter "Y" for yes or "N" for no in the applicable column.
93 Does this facility operate an ICF/IID facility for purposes of title V and XIX? Enter "Y" for yes or "N" for no in the applicable column.
94 Does title V or title XIX reduce capital cost? Enter "Y" for yes or "N" for no in the applicable column.
95 If line 94 is "Y", enter the reduction percentage in the applicable column.
96 Does title V or title XIX reduce operating cost? Enter "Y" for yes or "N" for no in the applicable column.
97 If line 96 is "Y", enter the reduction percentage in the applicable column.
98 Does title V or XIX follow Medicare (title XVIII) for the interns and residents post stepdown adjustments on Wkst. B, Pt. I, col. 25? Enter "Y" for yes or "N" for no in column 1 for title V, and in column 2 for title XIX.
98.01 Does title V or XIX follow Medicare (title XVIII) for the reporting of charges on Wkst. C, Pt. I? Enter "Y" for yes or "N" for no in column 1 for title V, and in column 2 for title XIX.
98.02 Does title V or XIX follow Medicare (title XVIII) for the calculation of observation bed costs on Wkst. D-1, Pt. IV, line 89? Enter "Y" for yes or "N" for no in column 1 for title V, and in column 2 for title XIX.
98.03 Does title V or XIX follow Medicare (title XVIII) for a critical access hospital (CAH) reimbursed 101% of inpatient services cost? Enter "Y" for yes or "N" for no in column 1 for title V, and in column 2 for title XIX.
98.04 Does title V or XIX follow Medicare (title XVIII) for a CAH reimbursed 101% of outpatient services cost? Enter "Y" for yes or "N" for no in column 1 for title V, and in column 2 for title XIX.
98.05 Does title V or XIX follow Medicare (title XVIII) and add back the RCE disallowance on Wkst. C, Pt. I, col. 4? Enter "Y" for yes or "N" for no in column 1 for title V, and in column 2 for title XIX.
98.06 Does title V or XIX follow Medicare (title XVIII) when cost reimbursed for Wkst. D, Pts. I through IV? Enter "Y" for yes or "N" for no in column 1 for title V, and in column 2 for title XIX.

3

2
80
81
2
85
86
87

V
1

XIX
2
90
91
92
93
94
95
96
97
98
98.01
98.02
98.03
98.04
98.05
98.06

FORM CMS-2552-10 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4004.1)

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Rev. 14

11-17

4090 (Cont.)

FORM CMS-2552-10

HOSPITAL AND HOSPITAL HEALTH CARE
COMPLEX IDENTIFICATION DATA

PROVIDER CCN:
______________

PERIOD
FROM __________
TO _____________

Rural Providers
105 Does this hospital qualify as a CAH?
106 If this facility qualifies as a CAH, has it elected the all-inclusive method of payment for outpatient services? (see instructions)
107 If this facility qualifies as a CAH, is it eligible for cost reimbursement for I&R training programs? Enter "Y" for yes or "N" for no in column 1. (see instructions)
If yes, the GME elimination is not made on Wkst. B, Pt. I, col. 25, and the program is cost reimbursed. If yes, complete Wkst. D-2, Pt. II.
108 Is this a rural hospital qualifying for an exception to the CRNA fee schedule? See 42 CFR 412.113(c). Enter "Y" for yes or "N" for no.

WORKSHEET S-2
PART I (CONT.)

1
105
106
107
108
Physical
1

Occupational
2

109

If this hospital qualifies as a CAH or a cost provider, are therapy services provided by outside supplier? Enter "Y" for yes or "N" for no for each therapy.

110

Did this hospital participate in the Rural Community Hospital Demonstration project (§410A Demonstration) for the current cost reporting period? Enter "Y" for yes or "N" for no.
If yes, complete Worksheet E, Part A, lines 200 through 218, and Worksheet E-2, lines 200 through 215, as applicable.

111

If this facility qualifies as a CAH, did it participate in the Frontier Community Health Integration Project (FCHIP) demonstration for this cost reporting period? Enter "Y" for yes or "N" for no in column 1.
If the response to column 1 is Y, enter the integration prong of the FCHIP demo in which this CAH is participating in column 2. Enter all that apply: "A" for Ambulance services; "B" for additional beds; and/or "C" for tele-health services.

Speech
3

Respiratory
4
109
1
110

1

Miscellaneous Cost Reporting Information
115 Is this an all-inclusive rate provider? Enter "Y" for yes or "N" for no in column 1. If column 1 is yes, enter the method used (A, B, or E only) in column 2.
If column 2 is "E", enter in column 3 either "93" percent for short term hospital or "98" percent for long term care (includes psychiatric, rehabilitation and long term hospitals
providers) based on the definition in CMS Pub.15-1, chapter 22, §2208.1.

1

2
111

2

3
115

1
116
117
118

Is this facility classified as a referral center? Enter "Y" for yes or "N" for no.
Is this facility legally-required to carry malpractice insurance? Enter "Y" for yes or "N" for no.
Is the malpractice insurance a claims-made or occurrence policy? Enter 1 if the policy is claim- made. Enter 2 if the policy is occurrence.

116
117
118
Premiums
1

Paid losses
2

Self insurance
3

##### List amounts of malpractice premiums and paid losses:

118.01
1

2

##### Are malpractice premiums and paid losses reported in a cost center other than the Administrative and General? If yes, submit supporting schedule listing cost centers and amounts contained therein.
119 What is the liability limit for the malpractice insurance policy? Enter in column 1 the monetary limit per lawsuit. Enter in column 2 the monetary limit per policy year.
120 Is this a SCH or EACH that qualifies for the Outpatient Hold Harmless provision in ACA §3121 and applicable amendments? (see instructions) Enter in column 1, "Y" for yes or "N" for no. Is this a
rural hospital with <100 beds that qualifies for the Outpatient Hold Harmless provision in ACA §3121 and applicable amendments? (see instructions) Enter in column 2, "Y" for yes or "N" for no.
121 Did this facility incur and report costs for high cost implantable devices charged to patients? Enter "Y" for yes or "N" for no.
122 Does the cost report contain healthcare related taxes as defined in §1903(w)(3) of the Act? Enter "Y" for yes or "N" for no in column 1. If column 1 is "Y", enter in column 2 the Worksheet A line number where these taxes are included.
Transplant Center Information
125 Does this facility operate a transplant center? Enter "Y" for yes or "N" for no. If yes, enter certification date(s) (mm/dd/yyyy) below.
126 If this is a Medicare certified kidney transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.
127 If this is a Medicare certified heart transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.
128 If this is a Medicare certified liver transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.
129 If this is a Medicare certified lung transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.
130 If this is a Medicare certified pancreas transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.
131 If this is a Medicare certified intestinal transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.
132 If this is a Medicare certified islet transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.
133 If this is a Medicare certified other transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.
134 If this is an organ procurement organization (OPO), enter the OPO number in column 1 and termination date, if applicable, in column 2.

118.02
119
120
121
122
1

2
125
126
127
128
129
130
131
132
133
134

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4004.1)

Rev. 12

40-507

4090 (Cont.)

FORM CMS-2552-10

11-17

HOSPITAL AND HOSPITAL HEALTH CARE
COMPLEX IDENTIFICATION DATA

PROVIDER CCN:
______________

All Providers
140 Are there any related organization or home office costs as defined in CMS Pub. 15-1, chapter 10? Enter "Y" for yes or "N" for no in column 1.
If yes, and home office costs are claimed, enter in column 2 the home office chain number. (see instructions)

PERIOD
FROM __________
TO _____________
1

Contractor's Number: __________

1

146
147
148
149

2
140

If this facility is part of a chain organization, enter on lines 141 through 143 the name and address of the home office and enter the home office contractor name and contractor number.
141 Name:
Contractor's Name: ___________________
142 Street:
P. O. Box:
143 City:
State:
Zip Code:

144
145

WORKSHEET S-2
PART I (CONT.)

141
142
143
2

Are provider based physicians' costs included in Worksheet A?
If costs for renal services are claimed on Wkst. A, line 74, are the costs for inpatient services only? Enter "Y" for yes or "N" for no in column 1.
If column 1 is no, does the dialysis facility include Medicare utilization for this cost reporting period? Enter "Y" for yes or "N" for no in column 2.
Has the cost allocation methodology changed from the previously filed cost report? Enter "Y" for yes or "N" for no in column 1. (See CMS Pub. 15-2, chapter 40, §4020)
If yes, enter the approval date (mm/dd/yyyy) in column 2.
Was there a change in the statistical basis? Enter "Y" for yes or "N" for no.
Was there a change in the order of allocation? Enter "Y" for yes or "N" for no.
Was there a change to the simplified cost finding method? Enter "Y" for yes or "N" for no.

144
145
146
147
148
149
Title XVIII

Does this facility contain a provider that qualifies for an exemption from the application of the lower of costs or charges?
Enter "Y" for yes or "N" for no for each component for Part A and Part B. (see 42 CFR 413.13)
155 Hospital
156 Subprovider - IPF
157 Subprovider - IRF
158 Subprovider - Other
159 SNF
160 HHA
161 CMHC
Multicampus
165 Is this hospital part of a multicampus hospital that has one or more campuses in different CBSAs? Enter "Y" for yes or "N" for no.
166 If line 165 is yes, for each campus enter the name in column 0, county in column 1, state in column 2, ZIP in column 3, CBSA in column 4, FTE/Campus in column 5. (see instructions)
Name
County
0
1

Health Information Technology (HIT) incentive in the American Recovery and Reinvestment Act
167 Is this provider a meaningful user under §1886 (n)? Enter "Y" for yes or "N" for no.
168 If this provider is a CAH (line 105 is "Y") and is a meaningful user (line 167 is "Y"), enter the reasonable cost incurred for the HIT assets. (see instructions)
##### If this provider is a CAH and is not a meaningful user, does this provider qualify for a hardship exception under §413.70(a)(6)(ii)? Enter "Y" for yes or "N" for no. (see instructions)
169 If this provider is a meaningful user (line 167 is "Y") and is not a CAH (line 105 is "N"), enter the transition factor. (see instructions)
170 Enter in columns 1 and 2, the EHR beginning date and ending date for the reporting period, respectively (mm/dd/yyyy)
171 If line 167 is "Y", does this provider have any days for individuals enrolled in section 1876 Medicare cost plans reported on Wkst. S-3, Pt. I, line 2, col. 6? Enter “Y” for yes and “N” for no in column 1.
If column 1 is yes, enter the number of section 1876 Medicare days in column 2. (see instructions)

Part A
1

Part B
2

Title V
3

Title XIX
4
155
156
157
158
159
160
161

165
166
State
2

Zip Code
3

CBSA
4

1

FTE/Campus
5

2
167
168
168.01
169
170
171

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4004.1)

40-508

Rev. 12

09-15

4090 (Cont.)

FORM CMS-2552-10

HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX
REIMBURSEMENT QUESTIONNAIRE

PROVIDER CCN:
______________

PERIOD
FROM __________
TO _____________

WORKSHEET S-2
PART II

General Instruction: Enter Y for all YES responses. Enter N for all NO responses.
Enter all dates in the mm/dd/yyyy format.
COMPLETED BY ALL HOSPITALS

Y/N
1

Provider Organization and Operation
1 Has the provider changed ownership immediately prior to the beginning of the cost reporting period?
If yes, enter the date of the change in column 2. (see instructions)

1
Y/N
1

2
3

Date
2

Date
2

V/I
3

Has the provider terminated participation in the Medicare Program?
If yes, enter in column 2 the date of termination and in column 3, "V" for voluntary or "I" for involuntary.
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?
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 yes, submit reconciliation.

Type
2

Date
3
4

5

Y/N
1

Approved Educational Activities
6 Column 1: Are costs claimed for nursing school?
Column 2: If yes, is the provider is the legal operator of the program?
7 Are costs claimed for allied health programs? If yes, see instructions.
8 Were nursing school and/or allied health programs approved and/or renewed during the cost reporting period?
If yes, see instructions.
9 Are costs claimed for Interns and Residents in approved GME programs in the current cost report? If yes, see instructions.
10 Was an approved Intern and Resident GME program initiated or renewed in the current cost reporting period? If yes, see instructions.
11 Are GME costs directly assigned to cost centers other than I & R in an Approved Teaching Program on Worksheet A?
If yes, see instructions.

Y/N
2
6
7
8
9
10
11

Bad Debts
12 Is the provider seeking reimbursement for bad debts? If yes, see instructions.
13 If line 12 is yes, did the provider's bad debt collection policy change during this cost reporting period? If yes, submit copy.
14 If line 12 is yes, were patient deductibles and/or co-payments waived? If yes, see instructions.

Y/N
12
13
14

Bed Complement
15 Did total beds available change from the prior cost reporting period? If yes, see instructions.

15
Part A

PS&R Report Data
16 Was the cost report prepared using the PS&R Report only? If either column 1 or 3 is yes, enter the
paid-through date of the PS&R Report used in columns 2 and 4. (see instructions)
17 Was the cost report prepared using the PS&R Report for totals and the provider's records for allocation?

If either column 1 or 3 is yes, enter the paid-through date in columns 2 and 4. (see instructions)
18 If line 16 or 17 is yes, were adjustments made to PS&R Report data for additional claims that have been
billed but are not included on the PS&R Report used to file the cost report? If yes, see instructions.
19 If line 16 or 17 is yes, were adjustments made to PS&R Report data for corrections of other
PS&R Report information? If yes, see instructions.
20 If line 16 or 17 is yes, were adjustments made to PS&R Report data for Other?
Describe the other adjustments: _________________________________
21 Was the cost report prepared only using the provider's records? If yes, see instructions.

Y/N
1

Part B
Date
2

Y/N
3

Date
4
16
17

18
19
20
21

FORM CMS-2552-10 (09-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTIONS 4004.2)

Rev. 8

40-509

4090 (Cont.)

09-15

FORM CMS-2552-10

HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX
REIMBURSEMENT QUESTIONNAIRE

PROVIDER CCN:
______________

PERIOD
FROM __________
TO _____________

WORKSHEET S-2
Part II (CONT.)

General Instruction: Enter Y for all YES responses. Enter N for all NO responses.
Enter all dates in the mm/dd/yyyy format.
COMPLETED BY COST REIMBURSED AND TEFRA HOSPITALS ONLY (EXCEPT CHILDRENS HOSPITALS)

Capital Related Cost
22 Have assets been relifed for Medicare purposes? If yes, see instructions.
23 Have changes occurred in the Medicare depreciation expense due to appraisals made during the cost reporting period?
If yes, see instructions.
24 Were new leases and/or amendments to existing leases entered into during this cost reporting period? If yes, see instructions.
25 Have there been new capitalized leases entered into during the cost reporting period? If yes, see instructions.
26 Were assets subject to Sec.2314 of DEFRA acquired during the cost reporting period? If yes, see instructions.
27 Has the provider's capitalization policy changed during the cost reporting period? If yes, see instructions.

22
23
24
25
26
27

Interest Expense
28 Were new loans, mortgage agreements or letters of credit entered into during the cost reporting period? If yes, see instructions.
29 Did the provider have a funded depreciation account and/or bond funds (Debt Service Reserve Fund) treated as a funded depreciation
account? If yes, see instructions.
30 Has existing debt been replaced prior to its scheduled maturity with new debt? If yes, see instructions.
31 Has debt been recalled before scheduled maturity without issuance of new debt? If yes, see instructions.

28
29
30
31

Purchased Services
32 Have changes or new agreements occurred in patient care services furnished through contractual arrangements with suppliers of services?
If yes, see instructions.
33 If line 32 is yes, were the requirements of Sec. 2135.2 applied pertaining to competitive bidding?
If no, see instructions.

32
33

Provider-Based Physicians
34 Are services furnished at the provider facility under an arrangement with provider-based physicians? If "Y" see instructions.
35 If line 34 is yes, were there new agreements or amended existing agreements with the provider-based physicians during the cost
reporting period? If yes, see instructions.

34
35

Y/N
1

Home Office Costs
36 Are home office costs claimed on the cost report?
37 If line 36 is yes, has a home office cost statement been prepared by the home office? If yes, see instructions.
38 If line 36 is yes , was the fiscal year end of the home office different from that of the provider?
If yes, enter in column 2 the fiscal year end of the home office.
39 If line 36 is yes, did the provider render services to other chain components? If yes, see instructions.
40 If line 36 is yes, did the provider render services to the home office? If yes, see instructions.
Cost Report Preparer Contact Information
41 First name:
42 Employer:
43 Phone number:

Last name:

Date
2
36
37
38
39
40

Title:
E-mail Address:

41
42
43

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTIONS 4004.2)

40-510

Rev. 8

03-18

FORM CMS-2552-10

4090 (Cont.)

HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX
STATISTICAL DATA

PROVIDER CCN:

Inpatient Days / Outpatient Visits / Trips

Component
1

2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
24.10
25
26
27
28
29
30
31
32
32.01
33
33.01

Worksheet
A
Line
No.
1

No. of
Beds
2

Bed Days
Available
3

CAH
Hours
4

Title V
5

Hospital Adults & Peds. (columns 5, 6, 7, and 8, exclude Swing
Bed, Observation Bed and Hospice days) (see instructions for
col. 2 for the portion of LDP room available beds)
HMO and other (see instructions)
HMO IPF Subprovider
HMO IRF Subprovider
Hospital Adults & Peds. Swing Bed SNF
Hospital Adults & Peds. Swing Bed NF
Total Adults and Peds. (exclude
observation beds) (see instructions)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care
Nursery
Total (see instructions)
CAH visits
Subprovider - IPF
Subprovider - IRF
Subprovider - Other
Skilled Nursing Facility
Nursing Facility
Other Long Term Care
Home Health Agency
ASC (Distinct Part)
Hospice (Distinct Part)
Hospice (non-distinct part)
CMHC
RHC/FQHC (specify)
Total (sum of lines 14-26)
Observation Bed Days
Ambulance Trips
Employee discount days (see instructions)
Employee discount days -IRF
Labor & delivery (see instructions)
Total ancillary labor & delivery room
outpatient days (see instructions)
LTCH non-covered days
LTCH site neutral days and discharges

Title
XVIII
6

Title
XIX
7

Total
All
Patients
8

______________
Full Time Equivalents
Total
Interns &
Residents
9

Employees
On
Payroll
10

Nonpaid
Workers
11

PERIOD
WORKSHEET S-3
FROM __________
PART I
TO _____________
Discharges

Title V
12

Title
XVIII
13

Title
XIX
14

Total
All
Patients
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
24.10
25
26
27
28
29
30
31
32
32.01
33
33.01

FORM CMS-2552-10 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4005.1)

Rev. 14

40-511

4090 (Cont.)

03-18

FORM CMS-2552-10

HOSPITAL WAGE INDEX INFORMATION

PROVIDER CCN: PERIOD
WORKSHEET S-3
FROM ___________ PART II
______________ TO _____________

Part II - Wage Data
Wkst. A
Line
Number
1
1
2
3
4
4.01
5
6
7
7.01
8
9
10
11
12
13
14
14.01
14.02
15
16
17
18
19
20
21
22
22.01
23
24
25
25.50
25.51
25.52
25.53

Amount
Reported
2

Reclassification
of Salaries
(from
Wkst. A-6)
3

Adjusted
Salaries
(column 2 ±
column 3)
4

SALARIES
Total salaries (see instructions)
Non-physician anesthetist Part A
Non-physician anesthetist Part B
Physician-Part A - Administrative
Physician-Part A - Teaching
Physician and Non Physician-Part B
Non-physician-Part B for hospital-based RHC and FQHC services
Interns & residents (in an approved program)
Contracted interns & residents (in an approved program)
Home office and/or related organization personnel
SNF
Excluded area salaries (see instructions)
OTHER WAGES AND RELATED COSTS
Contract labor : Direct Patient Care
Contract labor: Top level management and other management and
administrative services
Contract labor: Physician-Part A - Administrative
Home office and/or related orgainzation salaries and wage-related costs
Home office salaries
Related organization salaries
Home office: Physician Part A - Administrative
Home office & Contract Physicians Part A - Teaching
WAGE-RELATED COSTS
Wage-related costs (core) (see instructions)
Wage-related costs (other) (see instructions)
Excluded areas
Non-physician anesthetist Part A
Non-physician anesthetist Part B
Physician Part A - Administrative
Physician Part A - Teaching
Physician Part B
Wage-related costs (RHC/FQHC)
Interns & residents (in an approved program)
Home office wage-related (core)
Related organization wage-related (core)
Home office: Physician Part A - Administrative - wage-related (core)
Home office & Contract Physicians Part A - Teaching - wage-related (core)

Paid Hours
Related
to Salaries
in column 4
5

Average
Hourly Wage
(column 4 ÷
column 5)
6
1
2
3
4
4.01
5
6
7
7.01
8
9
10
11
12
13
14
14.01
14.02
15
16
17
18
19
20
21
22
22.01
23
24
25
25.50
25.51
25.52
25.53

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4005.2 - 4005.3)

40-512

Rev. 14

11-16

4090 (Cont.)

FORM CMS-2552-10

HOSPITAL WAGE INDEX INFORMATION

PROVIDER CCN: PERIOD
WORKSHEET S-3
FROM __________ PART II & III
______________ TO _____________

Part II - Wage Data
Worksheet
A
Line
Number
1
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43

OVERHEAD COSTS - DIRECT SALARIES
Employee Benefits Department
Administrative & General
Administrative & General under contract (see instructions)
Maintenance & Repairs
Operation of Plant
Laundry & Linen Service
Housekeeping
Housekeeping under contract (see instructions)
Dietary
Dietary under contract (see instructions)
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service

Amount
Reported
2

Reclassification
of Salaries
(from
Worksheet A-6)
3

Adjusted
Salaries
(column 2 ±
column 3)
4

4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

Part III - Hospital Wage Index Summary
1 Net salaries (see instructions)
2 Excluded area salaries (see instructions)
3 Subtotal salaries (line 1 minus line 2)
4 Subtotal other wages and related costs (see instructions)
5 Subtotal wage-related costs (see instructions)
6 Total (sum of lines 3 through 5)
7 Total overhead cost (see instructions)

Paid Hours
Related
to Salaries
in column 4
5

Average
Hourly Wage
(column 4 ÷
column 5)
6
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43

1
2
3
4
5
6
7

FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4005.2 - 4005.3)

Rev. 10

40-513

4090 (Cont.)

11-16

FORM CMS-2552-10

HOSPITAL WAGE RELATED COSTS

PROVIDER CCN:
______________

PERIOD
FROM __________
TO _____________

WORKSHEET S-3
PART IV

Part IV - Wage Related Cost
Part A - Core List

Amount
Reported
RETIREMENT COST
1 401k Employer Contributions
2 Tax Sheltered Annuity (TSA) Employer Contribution
3 Nonqualified Defined Benefit Plan Cost (see instructions)
4 Qualified Defined Benefit Plan Cost (see instructions)
PLAN ADMINISTRATIVE COSTS (Paid to External Organization):
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)
8.01 Health Insurance (Self Funded without a Third Party Administrator)
8.02 Health Insurance (Self Funded with a Third Party Administrator)
8.03 Health Insurance (Purchased)
9 Prescription Drug Plan
10 Dental, Hearing and Vision Plan
11 Life Insurance (If employee is owner or beneficiary)
12 Accident 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 (Other Than Retirement Cost Reported on lines 1 through 4 above)(see instructions)
22 Day Care Cost and Allowances
23 Tuition Reimbursement
24 Total Wage Related cost (Sum of lines 1 through 23)

Part B - Other than Core Related Cost
25 Other Wage Related Costs (specify) _________________________________________

1
2
3
4
5
6
7
8
8.01
8.02
8.03
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

25

FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4005.4)

40-514

Rev. 10

10-12

4090 (Cont.)

FORM CMS-2552-10

HOSPITAL CONTRACT LABOR AND BENEFIT COST

PROVIDER CCN:
______________

PERIOD:
FROM __________
TO _____________

WORKSHEET S-3
PART V

Part V - Contract Labor and Benefit Cost
Hospital and Hospital-Based Component Identification:

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

Component
0
Total facility contract labor and benefit cost
Hospital
Subprovider- IPF
Subprovider- IRF
Subprovider- (Other)
Swing Beds-SNF
Swing Beds-NF
Hospital-Based SNF
Hospital-Based NF
Hospital-Based OLTC
Hospital-Based HHA
Separately Certified ASC
Hospital-Based Hospice
Hospital-Based Health Clinic RHC
Hospital-Based Health Clinic FQHC
Hospital-Based-CMHC
Renal Dialysis
Other

Contract
Labor
1

Benefit
Cost
2
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4005.5)

Rev. 3

40-515

4090 (Cont.)

10-12

FORM CMS-2552-10

HOSPITAL-BASED HOME HEALTH AGENCY
STATISTICAL DATA

PROVIDER CCN:
______________
HHA CCN:
______________

HOME HEALTH AGENCY STATISTICAL DATA

1
2

Description
Home Health Aide Hours
Unduplicated Census Count (see instructions)

PERIOD:
FROM __________
TO _____________

WORKSHEET S-4

County: __________________
Title V
1

Title XVIII
2

Title XIX
3

Other
4

Total
5
1
2

HOME HEALTH AGENCY - NUMBER OF EMPLOYEES
Number of Employees
(Full Time Equivalent)
Staff
Contract
Total
1
2
3

Enter the number of hours in
your normal work week _______
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

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
Home Health Aide
Home Health Aide Supervisor
Other (specify)

3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

19
20

HOME HEALTH AGENCY CBSA CODES
Enter the number of CBSAs where you provided services during the cost reporting period.
List those CBSA code(s) serviced during this cost reporting period (line 20 contains the first code).

19
20

PPS ACTIVITY
Full Episodes
Without
With
Outliers
Outliers
1
2
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38

Skilled Nursing Visits
Skilled Nursing Visit Charges
Physical Therapy Visits
Physical Therapy Visit Charges
Occupational Therapy Visits
Occupational Therapy Visit Charges
Speech Pathology Visits
Speech Pathology Visit Charges
Medical Social Service Visits
Medical Social Service Visit Charges
Home Health Aide Visits
Home Health Aide Visit Charges
Total visits (sum of lines 21, 23, 25, 27, 29, and 31)
Other Charges
Total Charges (sum of lines 22, 24, 26, 28, 30, 32, and 34)
Total Number of Episodes (standard/non-outlier)
Total Number of Outlier Episodes
Total Non-Routine Medical Supply Charges

LUPA
Episodes
3

PEP only
Episodes
4

Total
(columns 1
through 4)
5
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4006)

40-516

Rev. 3

11-16

4090 (Cont.)

FORM CMS-2552-10

HOSPITAL RENAL DIALYSIS DEPARTMENT
STATISTICAL DATA

PROVIDER CCN:
______________

PERIOD:
FROM ___________
TO ______________

WORKSHEET S-5

RENAL DIALYSIS STATISTICS
Outpatient

1

2

3
4
5
6
7
8
9
10

DESCRIPTION
Number of patients in
program at end of cost
reporting period
Number of times per
week patient receives
dialysis
Average patient dialysis
time including setup
CAPD exchanges per day
Number of days in year
dialysis furnished
Number of stations
Treatment capacity per
day per station
Utilization (see instructions)
Average times
dialyzers re-used
Percentage of patients
re-using dialyzers

Regular
1

High Flux
2

Training
Hemodialysis
3

CAPD
CCPD
4

Home
Hemodialysis
5

CAPD
CCPD
6
1

2

3
4
5
6
7
8
9
10

ESRD PPS
Is the dialysis facility approved as a low-volume facility for this cost reporting period?
Enter "Y" for yes or "N" for no. (see instructions)
10.02 Did your facility elect 100% PPS effective January 1, 2011? Enter "Y" for yes or "N" for no.
(See instructions for "new" providers.)
10.03 If you responded "N" to line 10.02, enter in column 1 the year of transition for periods prior to January 1 and
enter in column 2 the year of transition for periods after December 31. (see instructions)

1

2

10.01

10.01
10.02
10.03

TRANSPLANT INFORMATION
11 Number of patients on transplant list
12 Number of patients transplanted during the cost reporting period

11
12

EPOETIN
13 Net costs of Epoetin furnished to all maintenance dialysis patients by the provider
14 Epoetin amount from Worksheet A for home dialysis program
15 Number of EPO units furnished relating to the renal dialysis department
16 Number of EPO units furnished relating to the home dialysis department

13
14
15
16

ARANESP
17 Net costs of ARANESP furnished to all maintenance dialysis patients by the provider
18 ARANESP amount from Worksheet A for home dialysis program
19 Number of ARANESP units furnished relating to the renal dialysis department
20 Number of ARANESP units furnished relating to the home dialysis department

17
18
19
20

21

22

PHYSICIAN PAYMENT METHOD (Enter "X" for applicable method(s))
MCP_________
INITIAL METHOD__________

Erythropoiesis-Stimulating Agents (ESA) Statistics:
Enter in column 1 the ESA description.
Enter in column 2 the net costs of ESAs furnished
to all renal dialysis patients.
Enter in column 3 the net cost of ESAs furnished
to all home dialysis program patients.
Enter in column 4 the number of ESA units
furnished to patients in the renal dialysis
department.
Enter in column 5 the number of units furnished
to patients in the home dialysis program.
(see instructions)

ESA
Description
1

21
Net Cost of
ESAs for
Renal Patients
2

Net Cost of
ESAs for
Home Patients
3

LOW VOLUME
23 If line 10.01 is yes, enter in column 1 the CCN for each renal dialysis facility listed on Worksheet S-2, Part I, line 18, and
its subscripts. Enter in column 2, the total treatments for each CCN. (see instructions)

Number of ESA
Units - Renal
Dialysis Dept.
4

Number of ESA
Units - Home
Dialysis Dept.
5
22

CCN
1

Treatments
2
23

FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4007)

Rev. 10

40-517

4090 (Cont.)

11-16

FORM CMS-2552-10

HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND
OTHER OUTPATIENT REHABILITATION
PROVIDER STATISTICAL DATA

PROVIDER CCN:
_______________
COMPONENT CCN:
_______________

PERIOD:
FROM ___________
TO ______________

WORKSHEET S-6

COMMUNITY MENTAL HEALTH & OTHER OUTPATIENT REHABILITATION PROVIDER- NUMBER OF EMPLOYEES (FULL TIME EQUIVALENT)
Check
applicable
box:

[ ] CMHC
[ ] CORF
[ ] OPT

[ ] OOT
[ ] OSP

Enter the number of hours in your normal workweek ________

Staff
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

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)

Contract
2

Total
(column 1 + column 2)
3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4008)

40-518

Rev. 10

10-12

4090 (Cont.)

FORM CMS-2552-10

PROSPECTIVE PAYMENT FOR SNF
STATISTICAL DATA

PROVIDER CCN:
________________

PERIOD:
WORKSHEET S-7
FROM ____________
TO ______________
Y/N
1

1
2

Date
2

If this facility contains a hospital-based SNF, were all patients under managed care or was there no Medicare utilization?
Enter "Y" for yes and do not complete the rest of this worksheet.
Does this hospital have an agreement under either section 1883 or section 1913 for swing beds? Enter "Y" for yes or
"N" for no in column 1. If yes, enter the agreement date (mm/dd/yyyy) in column 2.

Group
1
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
51
52
53
54

SNF
Days
2

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
CA2
CA1

1
2

Swing Bed SNF
Days
3

TOTAL
(sum of col. 2 + 3)
4
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
51
52
53
54

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4009)

Rev. 3

40-519

4090 (Cont.)

10-12

FORM CMS-2552-10

PROSPECTIVE PAYMENT FOR SNF
STATISTICAL DATA

PROVIDER CCN:
________________

Group
1
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
199
200

SNF
Days
2

PERIOD:
WORKSHEET S-7
FROM ____________ (CONT.)
TO ______________
Swing Bed SNF
Days
3

TOTAL
(sum of col. 2 + 3)
4

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

55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
199
200

SNF SERVICES
CBSA at
Beginning of
Cost Reporting
Period
1
201

CBSA on/after
October 1 of the
Cost Reporting
Period (if applicable)
2

Enter in column 1 the SNF CBSA code, or 5 character non-CBSA code if a rural facility, in effect at the beginning of the
cost reporting period.
Enter in column 2 the code in effect on or after October 1 of the cost reporting period (if applicable).

201

A notice published in the Federal Register Volume 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 202 through 207: Enter in column 1 the amount of the 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 7, column 3. In column 3, enter "Y" or "N" for no if the spending reflects increases associated with direct patient care
and related expenses for each category. (see instructions)
Associated with
Direct Patient Care
Expenses
Percentage
and Related Expenses?
1
2
3
202 Staffing
203 Recruitment
204 Retention of employees
205 Training
206 Other (Specify)
207 Total SNF revenue (Worksheet G-2, Part I, line 7, column 3)

202
203
204
205
206
207

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4009)

40-520

Rev. 3

11-16

4090 (Cont.)

FORM CMS-2552-10

HOSPITAL-BASED RHC/FQHC STATISTICAL DATA

Check
applicable box:

PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
FROM ___________
TO __________

WORKSHEET S-8

[ ] Hospital-based RHC
[ ] Hospital-based FQHC

Clinic Address and Identification:
1 Street:
2 City:
State:
Zip Code:
3 HOSPITAL-BASED FQHCs ONLY: Designation - Enter "R" for rural or "U" for urban

1
2
3

County:

Source of Federal Funds:
Grant Award
1
4
5
6
7
8
9

Date
2

Community Health Center (Section 330(d), PHS Act)
Migrant Health Center (Section 329(d), PHS Act)
Health Services for the Homeless (Section 340(d), PHS Act)
Appalachian Regional Commission
Look-alikes
Other (specify)

4
5
6
7
8
9
1

2

10 Does this facility operate as other than a hospital-based 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 operations1
Type Operation
0

Sunday
from
to
1
2

Monday
from
to
3
4

Tuesday
from
to
5
6

Wednesday
from
to
7
8

Thursday
from
to
9
10

Friday
from
to
11
12

11

Clinic
Enter clinic 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.

12
13

Have you received an approval for an exception to the productivity standard?
Is this a consolidated cost report as defined in CMS Pub. 100-04, chapter 9, section 30.8? Enter "Y" for yes or "N" for no in column 1.
If yes, enter in column 2 the number of providers included in this report. List the names of all providers and numbers below.
RHC/FQHC name: _______________________________________________
CCN number: ________________

Saturday
from
to
13
14
11

1

14

Y/N
1
15

Have you provided all or substantially all GME cost? Enter "Y" for yes or "N" for no in column 1.
If yes, enter in columns 2, 3 and 4 the number of program visits performed by Intern & Residents for titles V,
XVIII, and XIX, as applicable. Enter in column 5 the number of total visits for this provider. (see instructions)

V
2

2
12
13
14

XVIII
3

XIX
4

Total
Visits
5
15

FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4010)

Rev. 10

40-521

4090 (Cont.)

FORM CMS-2552-10

HOSPITAL-BASED HOSPICE IDENTIFICATION DATA

11-16
PROVIDER CCN:
________________
HOSPICE CCN:
________________

PART I - ENROLLMENT DAYS FOR COST REPORTING PERIODS BEGINNING BEFORE OCTOBER 1, 2015
Unduplicated Days
Title XVIII
Title XIX
Skilled Nursing
Nursing
Title XVIII
Title XIX
Facility
Facility
1
2
3
4
1 Hospice Continuous Home Care
2 Hospice Routine Home Care
3 Hospice Inpatient Respite Care
4 Hospice General Inpatient Care
5 Total Hospice Days

PART II - CENSUS DATA FOR COST REPORTING PERIODS BEGINNING BEFORE OCTOBER 1, 2015
Title XVIII
Skilled Nursing
Title XVIII
Title XIX
Facility
1
2
3
6 Number of Patients Receiving
Hospice Care
7 Total Number of Unduplicated Continuous Care Hours Billable to Medicare
8 Average Length of Stay (line 5/line 6)
9 Unduplicated Census Count

Title XIX
Nursing
Facility
4

PERIOD:
FROM __________
TO __________

All
Other
5

WORKSHEET S-9
PARTS I THROUGH IV

Total
(sum of
cols. 1, 2 and 5)
6
1
2
3
4
5

All
Other
5

Total
(sum of
cols. 1, 2 and 5)
6
6
7
8
9

PART III - ENROLLMENT DAYS FOR COST REPORTING PERIODS BEGINNING ON OR AFTER OCTOBER 1, 2015
Unduplicated Days

Title XVIII
1
10
11
12
13
14

Title XIX
2

Other
3

Total
(sum of
cols. 1 through 3)
4

Hospice Continuous Home Care
Hospice Routine Home Care
Hospice Inpatient Respite Care
Hospice General Inpatient Care
Total Hospice Days

10
11
12
13
14

PART IV - CONTRACTED STATISTICAL DATA FOR COST REPORTING PERIODS BEGINNING ON OR AFTER OCTOBER 1, 2015

Title XVIII
1

Title XIX
2

15 Hospice Inpatient Respite Care
16 Hospice General Inpatient Care

Other
3

Total
(sum of
cols. 1 through 3)
4
15
16

NOTE: Parts I and II, columns 1 and 2 also include the days reported in columns 3 and 4 .

FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4011)

40-522

Rev. 10

03-18

4090 (Cont.)

FORM CMS-2552-10

HOSPITAL UNCOMPENSATED AND INDIGENT
CARE DATA

PROVIDER CCN:
________________

PERIOD:
FROM ___________
TO ______________

WORKSHEET S-10

Uncompensated and indigent care cost computation
1 Cost to charge ratio (Worksheet C, Part I, line 202, column 3, divided by line 202, column 8)

1

Medicaid (see instructions for each line)
2 Net revenue from Medicaid
3 Did you receive DSH or supplemental payments from Medicaid?
4 If line 3 is yes, does line 2 include all DSH and/or supplemental payments from Medicaid?
5 If line 4 is no, enter DSH and/or supplemental payments from Medicaid
6 Medicaid charges
7 Medicaid cost (line 1 times line 6)
8 Difference between net revenue and costs for Medicaid program (line 7 minus lines 2 and 5).
If line 7 is less than the sum of lines 2 and 5, then enter zero.

2
3
4
5
6
7
8

Children's Health Insurance Program (CHIP) (see instructions for each line)
9 Net revenue from stand-alone CHIP
10 Stand-alone CHIP charges
11 Stand-alone CHIP cost (line 1 times line 10)
12 Difference between net revenue and costs for stand-alone CHIP (line 11 minus line 9).
If line 11 is less than line 9, then enter zero.

9
10
11
12

Other state or local government indigent care program (see instructions for each line)
13 Net revenue from state or local indigent care program (not included on lines 2, 5, or 9)
14 Charges for patients covered under state or local indigent care program (not included in lines 6 or 10)
15 State or local indigent care program cost (line 1 times line 14)
16 Difference between net revenue and costs for state or local indigent care program (line 15 minus line 13)
If line 15 is less than line 13, then enter zero.

13
14
15
16

Grants, donations and total unreimbursed cost for Medicaid, CHIP and state/local indigent care programs (see instructions for each line)
17 Private grants, donations, or endowment income restricted to funding charity care
18 Government grants, appropriations or transfers for support of hospital operations
19 Total unreimbursed cost for Medicaid, CHIP, and state and local indigent care programs (sum of lines 8, 12, and 16)

17
18
19

Uncompensated Care (see instructions for each line)
Uninsured
patients
1

Insured
patients
2

Total
(col. 1 + col. 2)
3

20
21
22
23

Charity care charges and uninsured discounts for the entire facility (see instructions)
Cost of patients approved for charity care and uninsured discounts (see instructions)
Payments received from patients for amounts previously written off as charity care
Cost of charity care (line 21 minus line 22)

20
21
22
23

24

Does the amount on line 20, column 2, include charges for patient days beyond a length-of-stay limit imposed on patients covered
by Medicaid or other indigent care program?
If line 24 is yes, enter the charges for patient days beyond the indigent care program's length-of-stay limit (see instructions)
Total bad debt expense for the entire hospital complex (see instructions)
Medicare reimbursable bad debts for the entire hospital complex (see instructions)
Medicare allowable bad debts for the entire hospital complex (see instructions)
Non-Medicare bad debt expense (see instructions)
Cost of non-Medicare and non-reimbursable Medicare bad debt expense (see instructions)
Cost of uncompensated care (line 23 column 3 plus line 29)
Total unreimbursed and uncompensated care cost (line 19 plus line 30)

24

25
26
27
27.01
28
29
30
31

25
26
27
27.01
28
29
30
31

FORM CMS-2552-10 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4012)

Rev. 14

40-523

4090 (Cont.)

FORM CMS-2552-10

03-18

HOSPITAL-BASED FQHC IDENTIFICATION DATA

PROVIDER CCN:
______________
COMPONENT CCN:
______________

PERIOD:
FROM: ___________
TO: ___________

Date
Decertified
3

V/I
Decertification
4

WORKSHEET S-11
PART I

PART I - HOSPITAL-BASED FQHC IDENTIFICATION DATA

1
1 Site Name:
2 Street:
P.O. Box:
3 City:
State:
ZIP Code:
County:
4 Is this hospital-based FQHC part of an entity that owns, leases or controls multiple FQHCs? Enter "Y" for yes or "N" for no. If yes,
enter the entity's information below.
5 Name of Entity:
6 Street:
P.O. Box:
HRSA Award Number:
7 City:
State:
ZIP Code:

Type of control
(see instructions)
2

Date of
CHOW
5
1
2
3
4

Designation - Enter "R" for rural or "U" for urban:

Consolidated Cost Report
8 Is this hospital-based FQHC filing a consolidated cost report per CMS Pub. 100-04, chapter 9, §30.8? Enter "Y" for yes or "N" for no in column 1.
If column 1 is yes, complete columns 2 through 4, and line 9 beginning with line 9.01. If column 1 is no, leave line 9 blank. (see instructions)
1
9 List of Consolidated Providers:
9.01 Site Name:
Hospital-Based FQHC Operations
10 What type of organization is this hospital-based FQHC? If you operate as more than one sub-type of an organization, enter only the applicable alpha
characters in column 2. (see instructions)
11 Did this hospital-based FQHC receive a grant under §330 of the PHS Act during this cost reporting period? If this is a consolidated cost report, did the hospital-based FQHC reported
on line 1, column 1, receive a grant under §330 of the PHS Act during this cost reporting period? Enter "Y" for yes or "N" for no. (complete line 12)
12 If the response to line 11 is yes, indicate in column 1, the type of HRSA grant that was awarded (see instructions). Enter the date of the grant award in
column 2, and enter the grant award number in column 3. If you received more than one grant subscript this line accordingly.
Medical Malpractice
13 Did this hospital-based FQHC submit an initial deeming or annual redeeming application for medical malpractice coverage under the FTCA with HRSA? Enter "Y" for
yes or "N" for no in column 1. If column 1 is yes, enter the effective date of coverage in column 2.
Interns and Residents
14 Did this hospital-based FQHC receive a THC development grant authorized under Part C of Title VII of the PHS Act from HRSA? Enter "Y" for
yes or "N" for no in column 1. If yes, enter in column 2, the number of FTE residents that your hospital-based FQHC trained and received funding through your

5
6
7
1
Y/N

2
Date Requested

3
Date Approved

4
Number of FQHCs

CCN
2

CBSA
3

Date Requested
4

Date Approved
5

8

9
9.01
1

2

3
10
11
12

13

14

THC grant in this cost reporting period and in column 3, enter the total number of visits performed by residents funded by the THC grant in this cost reporting
period. (see instructions)

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4010.1)

40-523.1

Rev. 14

11-16

FORM CMS-2552-10

4090 (Cont.)

HOSPITAL-BASED FQHC IDENTIFICATION DATA

PROVIDER CCN:
______________
COMPONENT CCN:
______________
SUBCOMPONENT CCN:
______________

PERIOD:
FROM ___________
TO ___________

WORKSHEET S-11
PART II

PART II - HOSPITAL-BASED FQHC CONSOLIDATED COST REPORT PARTICIPANT IDENTIFICATION DATA
Date
Certified
2

1
1 Site Name:
2 Street:
3 City:

P.O. Box:
State:

ZIP Code:

County:

Type of control
(see instructions)
3

Date
Decertified
4

V/I
Decertification
5

Date of
CHOW
6
1
2
3

Designation - Enter "R" for rural or "U" for urban:

Hospital-Based FQHC Operations
4 What type of organization is this hospital-based FQHC? If you operate as more than one sub-type of an organization, enter only the applicable
alpha characters in column 2. (see instructions)
5 Did this hospital-based FQHC receive a grant under §330 of the PHS Act during this cost reporting period? Enter "Y" for yes or "N" for no. (complete line 6)
6 If the response to line 5 is yes, indicate in column 1, the type of HRSA grant that was awarded (see instructions). Enter the date of the grant award in
column 2 and enter the grant award number in column 3. If you received more than one grant subscript this line accordingly.
Medical Malpractice
7 Did this hospital-based FQHC submit an initial deeming or annual redeeming application for medical malpractice coverage under the FTCA with HRSA?
Enter "Y" for yes or "N" for no in column 1. If column 1 is yes, enter the effective date of coverage in column 2.
Interns and Residents
8 Did this hospital-based FQHC receive a THC development grant authorized under Part C of Title VII of the PHS Act from HRSA?
Enter "Y" for yes or "N" for no in column 1. If yes, enter in column 2 the number of FTE residents that your FQHC trained and received funding through
your THC grant in this cost reporting period and in column 3, enter the total number of visits performed by residents funded by the THC grant
in this cost reporting period. (see instructions)

1

2

3
4
5
6

7

8

FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4010.2)

Rev. 10

40-523.2

4090 (Cont.)

FORM CMS-2552-10

HOSPITAL-BASED FQHC IDENTIFICATION DATA

11-16
PROVIDER CCN:
___________
COMPONENT CCN:
______________

PERIOD:
FROM ___________
TO ___________

WORKSHEET S-11
PART III

PART III - HOSPITAL-BASED FQHC STATISTICAL DATA

COMPONENT
CCN
0
1
2
3
4

Title V
1

Title
XVIII
2

Title
XIX
3

Medical Visits
Total Medical Visits
Mental Health Visits
Total Mental Health Visits

Other
4

Total
All
Patients
5
1
2
3
4

FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4010.3)

40-523.3

Rev. 10

11-16

FORM CMS-2552-10

4090 (Cont.)

This page is reserved for future use.

FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4010.3)

Rev. 10

40-523.4

4090 (Cont.)

FORM CMS-2552-10

11-16

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES

COST CENTER DESCRIPTIONS
(omit cents)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

00100
00200
00300
00400
00500
00600
00700
00800
00900
01000
01100
01200
01300
01400
01500
01600
01700
01900
02000
02100
02200

03000
03100
03200
03300
03400
04000
04100
04300
04400
04500
04600

PROVIDER CCN:

SALARIES
1

OTHER
2

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Other Capital Related Costs
Employee Benefits Department
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Ed. Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care (specify)
Subprovider - IPF
Subprovider - IRF
Subprovider (specify)
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

TOTAL
(col. 1 + col. 2)
3

RECLASSIFICATIONS
4

________________
RECLASSIFIED
TRIAL BALANCE
(col. 3 ± col. 4)
5

PERIOD:
FROM ____________
TO _______________

ADJUSTMENTS
6

WORKSHEET A

NET EXPENSES
FOR ALLOCATION
(col. 5 ± col. 6)
7

-0-

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4013)

40-524

Rev. 10

11-17

FORM CMS-2552-10

4090 (Cont.)

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES

COST CENTER DESCRIPTIONS
(omit cents)

50
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
77

05000
05100
05200
05300
05400
05500
05600
05700
05800
05900
06000
06100
06200
06300
06400
06500
06600
06700
06800
06900
07000
07100
07200
07300
07400
07500

88
89
90
91
92
93
93.99

08800
08900
09000
09100
09200

07700

09399

PROVIDER CCN:

SALARIES
1

OTHER
2

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
Allogeneic Stem Cell Acquisition
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)
Partial Hospitalization Program

TOTAL
(col. 1 + col. 2)
3

RECLASSIFICATIONS
4

________________
RECLASSIFIED
TRIAL BALANCE
(col. 3 ± col. 4)
5

PERIOD:
FROM ____________
TO _______________

ADJUSTMENTS
6

WORKSHEET A

NET EXPENSES
FOR ALLOCATION
(col. 5 ± col. 6)
7
50
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
77
88
89
90
91
92
93
93.99

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4013)

Rev. 12

40-525

4090 (Cont.)

FORM CMS-2552-10

11-17

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES

COST CENTER DESCRIPTIONS
(omit cents)

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
113
114
115
116
117
118
190
191
192
193
194
200

09400
09500
09600
09700

10000
10100
10500
10600
10700
10800
10900
11000
11100
11300
11400
11500
11600

19000
19100
19200
19300

PROVIDER CCN:

SALARIES
1

OTHER
2

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Interest Expense
Utilization Review-SNF
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1 through 117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
TOTAL (sum of lines 118 through 199)

TOTAL
(col. 1 + col. 2)
3

RECLASSIFICATIONS
4

________________
RECLASSIFIED
TRIAL BALANCE
(col. 3 ± col. 4)
5

PERIOD:
FROM ____________
TO _______________

ADJUSTMENTS
6

WORKSHEET A

NET EXPENSES
FOR ALLOCATION
(col. 5 ± col. 6)
7
94
95
96
97
98
99
100
101

-0-0-

-0-

105
106
107
108
109
110
111
112
113
114
115
116
117
118
190
191
192
193
194
200

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4013)

40-526

Rev. 12

10-12

FORM CMS-2552-10

4090 (Cont.)

RECLASSIFICATIONS

PROVIDER CCN:
________________
INCREASES
EXPLANATION OF RECLASSIFICATION(S)

CODE
(1)
1

COST CENTER
2

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
500 Total reclassifications (sum of columns 4 and 5
must equal sum of columns 8 and 9)
(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
Transfer the amounts in columns 4, 5, 8, and 9 to Worksheet A, column 4, lines as appropriate.

LINE #
3

SALARY
4

OTHER
5

COST CENTER
6

PERIOD:
FROM ____________
TO _______________
DECREASES
LINE #
7

SALARY
8

WORKSHEET A-6

OTHER
9

Wkst.
A-7
Ref.
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
500

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4014)

Rev. 3

40-527

4090 (Cont.)

FORM CMS-2552-10

10-12

RECONCILIATION OF CAPITAL COSTS CENTERS

PROVIDER CCN:
________________

PERIOD:
WORKSHEET A-7,
FROM ____________ PARTS I, II & III
TO _______________

PART I - ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCES
Acquisitions
Description

Beginning
Balances
1

Purchases
2

Donation
3

Total
4

Disposals
and
Retirements
5

Ending
Balance
6

Fully
Depreciated
Assets
7

1 Land
2 Land Improvements
3 Buildings and Fixtures
4 Building Improvements
5 Fixed Equipment
6 Movable Equipment
7 HIT-designated Assets
8 Subtotal (sum of lines 1-7)
9 Reconciling Items
10 Total (line 7 minus line 9)
PART II - RECONCILIATION OF AMOUNTS FROM WORKSHEET A, COLUMN 2, LINES 1 AND 2

1
2
3
4
5
6
7
8
9
10
SUMMARY OF CAPITAL

Description
*

Depreciation
9

Lease
10

Interest
11

Insurance
(see instructions)
12

Taxes
(see instructions)
13

Other CapitalRelated Costs
(see instructions)
14

Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Total (sum of lines 1-2)
The amount in columns 9 through 14 must equal the amount on Worksheet A, column 2, lines 1 and 2. Enter in each column the appropriate amounts including any directly assigned cost that may have been included in Worksheet A,
column 2, lines 1 and 2.
* All lines numbers are to be consistent with Worksheet A line numbers for capital cost centers.
PART III - RECONCILIATION OF CAPITAL COSTS CENTERS
COMPUTATION OF RATIOS
ALLOCATION OF OTHER CAPITAL
Gross Assets
Capitalized
for Ratio
Ratio
Other CapitalDescription
Gross Assets
Leases
(col. 1 - col. 2)
(see instructions)
Insurance
Taxes
Related Costs
*
1
2
3
4
5
6
7
1 Capital Related Costs-Buildings and Fixtures
2 Capital Related Costs-Movable Equipment
3 Total (sum of lines 1-2)
1.000000

Total (1)
(sum of
cols. 9 through 14)
15

1
2
3
(1)

1
2
3

Total
(sum of
cols. 5 through 7)
8
1
2
3

SUMMARY OF CAPITAL

Description
*
1
2
3
(2)

Depreciation
9

Lease
10

Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Total (sum of lines 1-2)
The amounts on lines 1 and 2 must equal the corresponding amounts on Worksheet A, column 7, lines 1 and 2. Columns 9 through 14 should include related
Worksheet A-6 reclassifications, Worksheet A-8 adjustments, and Worksheet A-8-1 related organizations and home office costs. (See instructions.)

Interest
11

Insurance
(see instructions)
12

Taxes
(see instructions)
13

Other CapitalRelated Costs
(see instructions)
14

Total (2)
(sum of
cols. 9 through 14)
15
1
2
3

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4015)

40-528

Rev. 3

03-18

PROVIDER CCN:
____________

DESCRIPTION (1)
BASIS /
CODE (2)
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
28
29
30
30.99
31
32
33
50

4090 (Cont.)

FORM CMS-2552-10

ADJUSTMENTS TO EXPENSES

Investment income - buildings and fixtures (chapter 2)
Investment income - movable equipment (chapter 2)
Investment income - other (chapter 2)
Trade, quantity, and time discounts (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-based physician adjustment
Sale of scrap, waste, etc. (chapter 23)
Related organization transactions (chapter 10)
Laundry and linen service
Cafeteria-employees and guests
Rental of quarters to employee and others
Sale of medical and surgical
supplies to other than patients
Sale of drugs to other than patients
Sale of medical records and abstracts
Nursing and allied health education (tuition,
fees, books, etc.)
Vending machines
Income from imposition of interest,
finance or penalty charges (chapter 21)
Interest expense on Medicare overpayments and
borrowings to repay Medicare overpayments
Adjustment for respiratory therapy
costs in excess of limitation (chapter 14)
Adjustment for physical therapy costs
in excess of limitation (chapter 14)
Utilization review - physicians' compensation (chapter 21)
Depreciation - buildings and fixtures
Depreciation - movable equipment
Non-physician Anesthetist
Physicians' assistant
Adjustment for occupational therapy costs
in excess of limitation (chapter 14)
Hospice (non-distinct) (see instructions)
Adjustment for speech pathology costs
in excess of limitation (chapter 14)
CAH HIT adjustment for depreciation
(3)
Other adjustments (specify)
TOTAL (sum of lines 1 through 49)
(Transfer to Worksheet A, column 6, line 200)

AMOUNT
2

PERIOD:
FROM ____________
TO _______________

WORKSHEET A-8

EXPENSE CLASSIFICATION ON
WORKSHEET A TO/FROM WHICH
THE AMOUNT IS TO BE ADJUSTED
COST CENTER
LINE #
3
4
Buildings and Fixtures
1
Movable Equipment
2

Worksheet A-8-2
Worksheet A-8-1

Wkst.
A-7
Ref.
5
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

Worksheet A-8-3

Respiratory Therapy

65

Worksheet A-8-3

Physical Therapy
Utilization Review - SNF
Buildings and Fixtures
Movable Equipment
Nonphysician Anesthetist

66
114
1
2
19

Occupational Therapy
Adults and Pediatrics

67
30

Speech Pathology

68

24

Worksheet A-8-3

Worksheet A-8-3

25
26
27
28
29
30
30.99
31
32
33
50

(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
(3) Additional adjustments may be made on lines 33 through 49 and subscripts thereof.
Note: See instructions for column 5 referencing to Worksheet A-7.

FORM CMS-2552-10 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4016)

Rev. 14

40-529

4090 (Cont.)

FORM CMS-2552-10

STATEMENT OF COSTS OF SERVICES
FROM RELATED ORGANIZATIONS AND
HOME OFFICE COSTS

03-18

PROVIDER CCN:
________________

PERIOD:
FROM ____________
TO _______________

A. COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS
OR CLAIMED HOME OFFICE COSTS:
Amount
Amount of
included in
Allowable
Wkst. A
Cost Center
Expense Items
Cost
column 5
Line No.
2
3
4
5
1
1
2
3
4
5 TOTALS (sum of lines 1-4) Transfer column 6, line 5 to Worksheet A-8, column 2, line 12.

WORKSHEET A-8-1

Net
Adjustments
(col. 4 minus
col. 5) *
6

Wkst.
A-7
Ref.
7
1
2
3
4
5

* The amounts on lines 1 through 4 (and subscripts as appropriate) are transferred in detail to Worksheet A, column 6, lines as appropriate.
Positive amounts increase cost and negative amounts decrease cost. For related organization or home office cost which have not
been posted to Worksheet A, columns 1 and/or 2, the amount allowable should be indicated in column 4 of this part.

B. 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 B 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.

Symbol
(1)
1

Name
2

Percentage
of
Ownership
3

Name
4

Related Organization(s) and/or Home Office
Percentage
of
Ownership
5

6
7
8
9
10

Type of
Business
6
6
7
8
9
10

(1) Use the following 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 relative of such
person has financial interest in related organization.
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-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4017)

40-530

Rev. 14

10-12

FORM CMS-2552-10

4090 (Cont.)

PROVIDER-BASED PHYSICIANS ADJUSTMENTS

PROVIDER CCN:
________________

Wkst. A
Line #
1

Cost Center/
Physician
Identifier
2

Total
Remuneration
3

Professional
Component
4

Provider
Component
5

RCE
Amount
6

Physician/
Provider
Component Hours
7

PERIOD:
WORKSHEET A-8-2
FROM ____________
TO _______________

Unadjusted
RCE Limit
8

5 Percent of
Unadjusted
RCE Limit
9

1
2
3
4
5
6
7
8
9
10
11
200 TOTAL

Wkst. A
Line #
10

1
2
3
4
5
6
7
8
9
10
11
200

Cost Center/
Physician
Identifier
11

Cost of
Memberships
& Continuing
Education
12

Provider
Component
Share of
col. 12
13

1
2
3
4
5
6
7
8
9
10
11
200 TOTAL

Physician
Cost of
Malpractice
Insurance
14

Provider
Component
Share of
col. 14
15

Adjusted
RCE Limit
16

RCE
Disallowance
17

Adjustment
18
1
2
3
4
5
6
7
8
9
10
11
200

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4018)

Rev. 3

40-531

4090 (Cont.)

FORM CMS-2552-10

10-12

REASONABLE COST DETERMINATION FOR THERAPY SERVICES
FURNISHED BY OUTSIDE SUPPLIERS

PROVIDER CCN:
________________

Check applicable box:

[ ] Occupational

[ ] Physical

[ ] Respiratory

PERIOD:
WORKSHEET A-8-3,
FROM ____________ PARTS I & II
TO _______________

[ ] Speech Pathology

PART I - GENERAL INFORMATION
1 Total number of weeks worked (excluding aides) (see instructions)
2 Line 1 multiplied by 15 hours per week
3 Number of unduplicated days in which supervisor or therapist was on provider site (see instructions)
4 Number of unduplicated days in which therapy assistant was on provider site but neither supervisor nor therapist was on provider site (see instructions)
5 Number of unduplicated offsite visits - supervisors or therapists (see instructions)
6 Number of unduplicated offsite visits - therapy assistants (include only visits made by therapy assistant and on which
supervisor and/or therapist was not present during the visit(s)) (see instructions)
7 Standard travel expense rate
8 Optional travel expense rate per mile

1
2
3
4
5
6
7
8
Supervisors
1

Therapists
2

Assistants
3

9 Total hours worked
10 AHSEA (see instructions)
11 Standard travel allowance (columns 1 and 2, one-half of column 2,
line 10; column 3, one-half of column 3, line 10)
12 Number of travel hours (see instructions)
13 Number of miles driven (see instructions)
PART II - SALARY EQUIVALENCY COMPUTATION
14 Supervisors (column 1, line 9 times column 1, line 10)
15 Therapists (column 2, line 9 times column 2, line 10)
16 Assistants (column 3, line 9 times column 3, line10)
17 Subtotal allowance amount (sum of lines 14 and 15 for respiratory therapy or lines 14-16 for all others)
18 Aides (column 4, line 9 times column 4, line 10)
19 Trainees (column 5, line 9 times column 9, line 10)
20 Total allowance amount (sum of lines 17-19 for respiratory therapy or lines 17 and 18 for all others)
If the sum of columns 1 and 2 for respiratory therapy or columns 1 through 3 for physical therapy, speech pathology or occupational therapy, line 9, is greater than line 2, make no entries on lines 21 and 2, and enter on line 23
the amount from line 20. Otherwise complete lines 21 through 23.
21 Weighted average rate excluding aides and trainees (line 17 divided by sum of columns 1 and 2, line 9 for respiratory therapy or columns 1 through 3, line 9 for all others)
22 Weighted allowance excluding aides and trainees (line 2 times line 21)
23 Total salary equivalency (see instructions)

Aides
4

Trainees
5
9
10
11
12
13

14
15
16
17
18
19
20

21
22
23

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4019)

40-532

Rev. 3

03-16

FORM CMS-2552-10

REASONABLE COST DETERMINATION FOR THERAPY SERVICES
FURNISHED BY OUTSIDE SUPPLIERS

4090 (Cont.)
PROVIDER CCN:
________________

Check applicable box:

[ ] Occupational

[ ] Physical

[ ] Respiratory

PERIOD:
WORKSHEET A-8-3,
FROM ____________ PARTS III & IV
TO _______________

[ ] Speech Pathology

PART III - STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - PROVIDER SITE
Standard Travel Allowance
24 Therapists (line 3 times column 2, line 11)
25 Assistants (line 4 times column 3, line 11)
26 Subtotal (line 24 for respiratory therapy or sum of lines 24 and 25 for all others)
27 Standard travel expense (line 7 times line 3 for respiratory therapy or sum of lines 3 and 4 for all others)
28 Total standard travel allowance and standard travel expense at the provider site (sum of lines 26 and 27)

24
25
26
27
28

Optional Travel Allowance and Optional Travel Expense
29 Therapists (column 2, line 10 times the sum of columns 1 and 2, line 12 )
30 Assistants (column 3, line 10 times column 3, line 12)
31 Subtotal (line 29 for respiratory therapy or sum of lines 29 and 30 for all others)
32 Optional travel expense (line 8 times columns 1 and 2, line 13 for respiratory therapy or sum of columns 1-3, line 13 for all others)
33 Standard travel allowance and standard travel expense (line 28)
34 Optional travel allowance and standard travel expense (sum of lines 27 and 31)
35 Optional travel allowance and optional travel expense (sum of lines 31 and 32)

29
30
31
32
33
34
35

PART IV - STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - SERVICES OUTSIDE PROVIDER SITE
Standard Travel Expense
36 Therapists (line 5 times column 2, line 11)
37 Assistants (line 6 times column 3, line 11)
38 Subtotal (sum of lines 36 and 37)
39 Standard travel expense (line 7 times the sum of lines 5 and 6)

36
37
38
39

Optional Travel Allowance and Optional Travel Expense
40 Therapists (sum of columns 1 and 2, line 12.01 times column 2, line 10)
41 Assistants (column 3, line 12.01 times column 3, line 10)
42 Subtotal (sum of lines 40 and 41)
43 Optional travel expense (line 8 times the sum of columns 1-3, line 13.01)

40
41
42
43

Total Travel Allowance and Travel Expense - Offsite Services: Complete one of the following three lines 44, 45, or 46, as appropriate.
44 Standard travel allowance and standard travel expense (sum of lines 38 and 39) (see instructions)
45 Optional travel allowance and standard travel expense (sum of lines 39 and 42) (see instructions)
46 Optional travel allowance and optional travel expense (sum of lines 42 and 43) (see instructions)

44
45
46

FORM CMS-2552-10 (03-2016) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4019)

Rev. 9

40-533

4090 (Cont.)

FORM CMS-2552-10

03-16

REASONABLE COST DETERMINATION FOR THERAPY SERVICES
FURNISHED BY OUTSIDE SUPPLIERS

PROVIDER CCN:
________________

Check applicable box:

[ ] Occupational

[ ] Physical

[ ] Respiratory

PERIOD:
WORKSHEET A-8-3,
FROM ____________ PARTS V-VI
TO _______________

[ ] Speech Pathology

PART V - OVERTIME COMPUTATION
Therapists
1
47

Overtime hours worked during reporting period (if column 5, line 47, is zero or equal to or great than 2,080, do not complete
lines 48-55 and enter zero in each column of line 56)
48 Overtime rate (see instructions)
49 Total overtime (including base and overtime allowance) (multiply line 47 times line 48)
CALCULATION OF LIMIT
50 Percentage of overtime hours by category (divide the hours in each column on liine 47 by the total overtime worked in column 5, line 47.
51 Allocation of provider's standard work year for one full-time employee times the percentages on line 50) (see instructions)
DETERMINATION OF OVERTIME ALLOWANCE
52 Adjusted hourly salary equivalency amount (see instructions)
53 Overtime cost limitation (line 51 times line 52)
54 Maximum overtime cost (enter the lesser of line 49 or line 53)
55 Portion of overtime already included in hourly computation at the AHSEA (multiply
line 47 times line 52)
56 Overtime allowance (line 54 minus line 55 - if negative enter zero) ( Enter in column 5, the sum of columns 1, 3, and 4, for respiratory
therapy, and columns 1 through 3 for all others.)
PART VI - COMPUTATION OF THERAPY LIMITATION AND EXCESS COST ADJUSTMENT
57 Salary equivalency amount (from line 23)
58 Travel allowance and expense - provider site (from lines 33, 34, or 35))
59 Travel allowance and expense - Offsite services (from lines 44, 45, or 46)
60 Overtime allowance (from column 5, line 56)
61 Equipment cost (see instructions)
62 Supplies (see instructions)
63 Total allowance (sum of lines 57-62)
64 Total cost of outside supplier services (from provider records)
65 Excess over limitation (line 64 minus line 63; if negative, enter zero)

Assistants
2

Aides
3

Trainees
4

Total
5
47
48
49

50
51

52
53
54
55
56

57
58
59
60
61
62
63
64
65

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4019)

40-534

Rev. 9

11-17

FORM CMS-2552-10

4090 (Cont.)

COST ALLOCATION - GENERAL SERVICE COSTS

PROVIDER CCN:
________________

COST CENTER DESCRIPTIONS

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

NET EXPENSES
FOR COST
ALLOCATION
(from Wkst.
A col. 7)
0

PERIOD:
WORKSHEET B,
FROM ____________ PART I
TO _______________

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits Department
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Education Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider (specify)
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

EMPLOYEE
BENEFITS
DEPARTMENT
4

SUBTOTAL
(cols. 0-4)
4A

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE &
REPAIRS
6

OPERATION
OF PLANT
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

Rev. 12

40-535

4090 (Cont.)

FORM CMS-2552-10

11-17

COST ALLOCATION - GENERAL SERVICE COSTS

PROVIDER CCN:
________________

COST CENTER DESCRIPTIONS

50
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
77
88
89
90
91
92
93
93.99

NET EXPENSES
FOR COST
ALLOCATION
(from Wkst.
A col. 7)
0

PERIOD:
WORKSHEET B,
FROM ____________ PART I
TO _______________

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
Allogeneic Stem Cell Acquisition
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)
Partial Hospitalization Program

EMPLOYEE
BENEFITS
DEPARTMENT
4

SUBTOTAL
(cols. 0-4)
4A

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE &
REPAIRS
6

OPERATION
OF PLANT
7
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
82
73
74
75
76
77
88
89
90
91
92
93
93.99

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

40-536

Rev. 12

11-17

FORM CMS-2552-10

4090 (Cont.)

COST ALLOCATION - GENERAL SERVICE COSTS

PROVIDER CCN:
________________

COST CENTER DESCRIPTIONS

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202

NET EXPENSES
FOR COST
ALLOCATION
(from Wkst.
A col. 7)
0

PERIOD:
WORKSHEET B,
FROM ____________ PART I
TO _______________

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1 through 117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross Foot Adjustments
Negative Cost Centers
TOTAL (sum lines 118 through 201)

EMPLOYEE
BENEFITS
DEPARTMENT
4

SUBTOTAL
(cols. 0-4)
4A

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE &
REPAIRS
6

OPERATION
OF PLANT
7
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

Rev. 12

40-537

4090 (Cont.)

FORM CMS-2552-10

COST ALLOCATION - GENERAL SERVICE COSTS

11-17
PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

LAUNDRY
& LINEN
SERVICE
8

HOUSEKEEPING
9

DIETARY
10

CAFETERIA
11

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits Department
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Education Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider (specify)
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

MAINTENANCE OF
PERSONNEL
12

NURSING
ADMINISTRATION
13

CENTRAL
SERVICES &
SUPPLY
14

PHARMACY
15

WORKSHEET B,
PART I

MEDICAL
RECORDS &
LIBRARY
16

SOCIAL
SERVICE
17
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

40-538

Rev. 12

11-17

FORM CMS-2552-10

COST ALLOCATION - GENERAL SERVICE COSTS

4090 (Cont.)
PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

50
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
77
88
89
90
91
92
93
93.99

LAUNDRY
& LINEN
SERVICE
8

HOUSEKEEPING
9

DIETARY
10

CAFETERIA
11

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
Allogeneic Stem Cell Acquisition
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)
Partial Hospitalization Program

MAINTENANCE OF
PERSONNEL
12

NURSING
ADMINISTRATION
13

CENTRAL
SERVICES &
SUPPLY
14

PHARMACY
15

WORKSHEET B,
PART I

MEDICAL
RECORDS &
LIBRARY
16

SOCIAL
SERVICE
17
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
82
73
74
75
76
77
88
89
90
91
92
93
93.99

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

Rev. 12

40-539

4090 (Cont.)

FORM CMS-2552-10

COST ALLOCATION - GENERAL SERVICE COSTS

11-17
PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202

LAUNDRY
& LINEN
SERVICE
8

HOUSEKEEPING
9

DIETARY
10

CAFETERIA
11

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1 through 117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross Foot Adjustments
Negative Cost Centers
TOTAL (sum lines 118 through 201)

MAINTENANCE OF
PERSONNEL
12

NURSING
ADMINISTRATION
13

CENTRAL
SERVICES &
SUPPLY
14

PHARMACY
15

WORKSHEET B,
PART I

MEDICAL
RECORDS &
LIBRARY
16

SOCIAL
SERVICE
17
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

40-540

Rev. 12

11-17

FORM CMS-2552-10

COST ALLOCATION - GENERAL SERVICE COSTS

4090 (Cont.)
PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

OTHER
GENERAL
SERVICE
18

NONPHYSICIAN
ANESTHETISTS
19

NURSING
SCHOOL
20

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits Department
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Education Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider (specify)
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

INTERNS &
RESIDENTS
SALARY AND
FRINGES
21

INTERNS &
RESIDENTS
PROGRAM
COSTS
22

PARAMEDICAL
EDUCATION
(SPECIFY)
23

SUBTOTAL
24

INTERN &
RESIDENT
COST & POST
STEPDOWN
ADJUSTMENTS
25

WORKSHEET B,
PART I

TOTAL
26
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

Rev. 12

40-541

4090 (Cont.)

FORM CMS-2552-10

COST ALLOCATION - GENERAL SERVICE COSTS

11-17
PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

50
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
77
88
89
90
91
92
93
93.99

OTHER
GENERAL
SERVICE
18

NONPHYSICIAN
ANESTHETISTS
19

NURSING
SCHOOL
20

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
Allogeneic Stem Cell Acquisition
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)
Partial Hospitalization Program

INTERNS &
RESIDENTS
SALARY AND
FRINGES
21

INTERNS &
RESIDENTS
PROGRAM
COSTS
22

PARAMEDICAL
EDUCATION
(SPECIFY)
23

SUBTOTAL
24

INTERN &
RESIDENT
COST & POST
STEPDOWN
ADJUSTMENTS
25

WORKSHEET B,
PART I

TOTAL
26
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
82
73
74
75
76
77
88
89
90
91
92
93
93.99

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

40-542

Rev. 12

11-17

FORM CMS-2552-10

COST ALLOCATION - GENERAL SERVICE COSTS

4090 (Cont.)
PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202

OTHER
GENERAL
SERVICE
18

NONPHYSICIAN
ANESTHETISTS
19

NURSING
SCHOOL
20

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1 through 117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross Foot Adjustments
Negative Cost Centers
TOTAL (sum lines 118 through 201)

INTERNS &
RESIDENTS
SALARY AND
FRINGES
21

INTERNS &
RESIDENTS
PROGRAM
COSTS
22

PARAMEDICAL
EDUCATION
(SPECIFY)
23

SUBTOTAL
24

INTERN &
RESIDENT
COST & POST
STEPDOWN
ADJUSTMENTS
25

WORKSHEET B,
PART I

TOTAL
26
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

Rev. 12

40-543

4090 (Cont.)

FORM CMS-2552-10

11-17

ALLOCATION OF CAPITAL-RELATED COSTS

PROVIDER CCN:
________________

COST CENTER DESCRIPTIONS

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

DIRECTLY
ASSIGNED
NEW CAPITAL
RELATED
COSTS
0

PERIOD:
WORKSHEET B,
FROM ____________ PART II
TO _______________

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits Department
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Education Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider (specify)
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

SUBTOTAL
(sum of
(cols. 0-2)
2A

EMPLOYEE
BENEFITS
DEPARTMENT
4

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE &
REPAIRS
6

OPERATION
OF PLANT
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
30
31
32
33
34
36
40
41
42
43
44
45
46

FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)

40-544

Rev. 12

11-17

FORM CMS-2552-10

4090 (Cont.)

ALLOCATION OF CAPITAL-RELATED COSTS

PROVIDER CCN:
________________

COST CENTER DESCRIPTIONS

50
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
77
88
89
90
91
92
93
93.99

DIRECTLY
ASSIGNED
NEW CAPITAL
RELATED
COSTS
0

PERIOD:
WORKSHEET B,
FROM ____________ PART II
TO _______________

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
Allogeneic Stem Cell Acquisition
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)
Partial Hospitalization Program

SUBTOTAL
(sum of
(cols. 0-2)
2A

EMPLOYEE
BENEFITS
DEPARTMENT
4

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE &
REPAIRS
6

OPERATION
OF PLANT
7
50
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
77
88
89
90
91
92
93
93.99

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)

Rev. 12

40-545

4090 (Cont.)

FORM CMS-2552-10

11-17

ALLOCATION OF CAPITAL-RELATED COSTS

PROVIDER CCN:
________________

COST CENTER DESCRIPTIONS

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202

DIRECTLY
ASSIGNED
NEW CAPITAL
RELATED
COSTS
0

PERIOD:
WORKSHEET B,
FROM ____________ PART II
TO _______________

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1 through 117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross Foot Adjustments
Negative Cost Centers
TOTAL (sum lines 118 through 201)

SUBTOTAL
(sum of
(cols. 0-2)
2A

EMPLOYEE
BENEFITS
DEPARTMENT
4

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE &
REPAIRS
6

OPERATION
OF PLANT
7
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
113
117
118
190
191
192
193
194
200
201
202

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)

40-546

Rev. 12

11-17

FORM CMS-2552-10

ALLOCATION OF CAPITAL-RELATED COSTS

4090 (Cont.)
PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

LAUNDRY
& LINEN
SERVICE
8

HOUSEKEEPING
9

DIETARY
10

CAFETERIA
11

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits Department
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Education Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider (specify)
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

MAINTENANCE OF
PERSONNEL
12

NURSING
ADMINISTRATION
13

CENTRAL
SERVICES &
SUPPLY
14

PHARMACY
15

WORKSHEET B,
PART II

MEDICAL
RECORDS &
LIBRARY
16

SOCIAL
SERVICE
17
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
30
31
32
33
34
36
40
41
42
43
44
45
46

FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)

Rev. 12

40-547

4090 (Cont.)

FORM CMS-2552-10

ALLOCATION OF CAPITAL-RELATED COSTS

11-17
PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

50
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
77
88
89
90
91
92
93
93.99

LAUNDRY
& LINEN
SERVICE
8

HOUSEKEEPING
9

DIETARY
10

CAFETERIA
11

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
Allogeneic Stem Cell Acquisition
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)
Partial Hospitalization Program

MAINTENANCE OF
PERSONNEL
12

NURSING
ADMINISTRATION
13

CENTRAL
SERVICES &
SUPPLY
14

PHARMACY
15

WORKSHEET B,
PART II

MEDICAL
RECORDS &
LIBRARY
16

SOCIAL
SERVICE
17
50
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
77
88
89
90
91
92
93
93.99

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)

40-548

Rev. 12

11-17

FORM CMS-2552-10

ALLOCATION OF CAPITAL-RELATED COSTS

4090(Cont.)
PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202

LAUNDRY
& LINEN
SERVICE
8

HOUSEKEEPING
9

DIETARY
10

CAFETERIA
11

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1 through 117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross Foot Adjustments
Negative Cost Centers
TOTAL (sum lines 118 through 201)

MAINTENANCE OF
PERSONNEL
12

NURSING
ADMINISTRATION
13

CENTRAL
SERVICES &
SUPPLY
14

PHARMACY
15

WORKSHEET B,
PART II

MEDICAL
RECORDS &
LIBRARY
16

SOCIAL
SERVICE
17
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
113
117
118
190
191
192
193
194
200
201
202

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)

Rev. 12

40-549

4090 (Cont.)

FORM CMS-2552-10

ALLOCATION OF CAPITAL-RELATED COSTS

11-17
PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

OTHER
GENERAL
SERVICE
18

NONPHYSICIAN
ANESTHETISTS
19

NURSING
SCHOOL
20

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits Department
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Education Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider (specify)
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

INTERNS &
RESIDENTS
SALARY AND
FRINGES
21

INTERNS &
RESIDENTS
PROGRAM
COSTS
22

PARAMEDICAL
EDUCATION
(SPECIFY)
23

SUBTOTAL
24

INTERN &
RESIDENT
COST & POST
STEPDOWN
ADJUSTMENTS
25

WORKSHEET B,
PART II

TOTAL
26
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
30
31
32
33
34
36
40
41
42
43
44
45
46

FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)

40-550

Rev. 12

11-17

FORM CMS-2552-10

ALLOCATION OF CAPITAL-RELATED COSTS

4090 (Cont.)
PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

50
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
77
88
89
90
91
92
93
93.99

OTHER
GENERAL
SERVICE
18

NONPHYSICIAN
ANESTHETISTS
19

NURSING
SCHOOL
20

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
Allogeneic Stem Cell Acquisition
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)
Partial Hospitalization Program

INTERNS &
RESIDENTS
SALARY AND
FRINGES
21

INTERNS &
RESIDENTS
PROGRAM
COSTS
22

PARAMEDICAL
EDUCATION
(SPECIFY)
23

SUBTOTAL
24

INTERN &
RESIDENT
COST & POST
STEPDOWN
ADJUSTMENTS
25

WORKSHEET B,
PART II

TOTAL
26
50
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
77
88
89
90
91
92
93
93.99

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)

Rev. 12

40-551

4090 (Cont.)

FORM CMS-2552-10

ALLOCATION OF CAPITAL-RELATED COSTS

11-17
PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202

OTHER
GENERAL
SERVICE
18

NONPHYSICIAN
ANESTHETISTS
19

NURSING
SCHOOL
20

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1 through 117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross Foot Adjustments
Negative Cost Centers
TOTAL (sum lines 118 through 201)

INTERNS &
RESIDENTS
SALARY AND
FRINGES
21

INTERNS &
RESIDENTS
PROGRAM
COSTS
22

PARAMEDICAL
EDUCATION
(SPECIFY)
23

SUBTOTAL
24

INTERN &
RESIDENT
COST & POST
STEPDOWN
ADJUSTMENTS
25

WORKSHEET B,
PART II

TOTAL
26
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
113
117
118
190
191
192
193
194
200
201
202

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)

40-552

Rev. 12

11-17

FORM CMS-2552-10

4090 (Cont.)

COST ALLOCATION - STATISTICAL BASIS

COST CENTER DESCRIPTIONS

PROVIDER CCN:

CAPITAL RELATED COST
BLDGS. &
MOVABLE
FIXTURES
EQUIPMENT
(SQUARE
(DOLLAR
FEET)
VALUE)
1
2

GENERAL SERVICE COST CENTERS
1 Capital Related Costs-Buildings and Fixtures
2 Capital Related Costs-Movable Equipment
4 Employee Benefits Department
5 Administrative and General
6 Maintenance and Repairs
7 Operation of Plant
8 Laundry and Linen Service
9 Housekeeping
10 Dietary
11 Cafeteria
12 Maintenance of Personnel
13 Nursing Administration
14 Central Services and Supply
15 Pharmacy
16 Medical Records & Medical Records Library
17 Social Service
18 Other General Service (specify)
19 Nonphysician Anesthetists
20 Nursing School
21 Intern & Res. Service-Salary & Fringes (Approved)
22 Intern & Res. Other Program Costs (Approved)
23 Paramedical Education Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
30 Adults and Pediatrics (General Routine Care)
31 Intensive Care Unit
32 Coronary Care Unit
33 Burn Intensive Care Unit
34 Surgical Intensive Care Unit
35 Other Special Care Unit (specify)
40 Subprovider IPF
41 Subprovider IRF
42 Subprovider (specify)
43 Nursery
44 Skilled Nursing Facility
45 Nursing Facility
46 Other Long Term Care

EMPLOYEE
BENEFITS
DEPARTMENT
(GROSS
SALARIES)
4

RECONCILIATION
5A

________________
ADMINISTRATIVE &
GENERAL
(ACCUM.
COST)
5

PERIOD:
FROM ____________
TO _______________
MAINTENANCE &
REPAIRS
(SQUARE
FEET)
6

WORKSHEET B-1

OPERATION
OF PLANT
(SQUARE
FEET)
7
1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

Rev. 12

40-553

4090 (Cont.)

FORM CMS-2552-10

11-17

COST ALLOCATION - STATISTICAL BASIS

COST CENTER DESCRIPTIONS

50
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
77
88
89
90
91
92
93
93.99

PROVIDER CCN:

CAPITAL RELATED COST
BLDGS. &
MOVABLE
FIXTURES
EQUIPMENT
(SQUARE
(DOLLAR
FEET)
VALUE)
1
2

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
Allogeneic Stem Cell Acquisition
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)
Partial Hospitalization Program

EMPLOYEE
BENEFITS
DEPARTMENT
(GROSS
SALARIES)
4

RECONCILIATION
5A

________________
ADMINISTRATIVE &
GENERAL
(ACCUM.
COST)
5

PERIOD:
FROM ____________
TO _______________
MAINTENANCE &
REPAIRS
(SQUARE
FEET)
6

WORKSHEET B-1

OPERATION
OF PLANT
(SQUARE
FEET)
7
50
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
77
88
89
90
91
92
93
93.99

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

40-554

Rev. 12

03-18

FORM CMS-2552-10

4090 (Cont.)

COST ALLOCATION - STATISTICAL BASIS

COST CENTER DESCRIPTIONS

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202
203
204
205
206
207

PROVIDER CCN:

CAPITAL RELATED COST
BLDGS. &
MOVABLE
FIXTURES
EQUIPMENT
(SQUARE
(DOLLAR
FEET)
VALUE)
1
2

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1 through 117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross foot adjustments
Negative cost centers
Cost to be allocated (per Worksheet B, Part I)
Unit cost multiplier (Worksheet B, Part I)
Cost to be allocated (per Worksheet B, Part II)
Unit cost multiplier (Worksheet B, Part II)
NAHE adjustment amount to be allocated (per Wkst. B-2)
NAHE unit cost multiplier (Wkst. D, Parts III and IV)

EMPLOYEE
BENEFITS
DEPARTMENT
(GROSS
SALARIES)
4

RECONCILIATION
5A

________________
ADMINISTRATIVE &
GENERAL
(ACCUM.
COST)
5

PERIOD:
FROM ____________
TO _______________
MAINTENANCE &
REPAIRS
(SQUARE
FEET)
6

WORKSHEET B-1

OPERATION
OF PLANT
(SQUARE
FEET)
7
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202
203
204
205
206
207

FORM CMS-2552-10 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

Rev. 14

40-555

4090 (Cont.)

FORM CMS-2552-10

COST ALLOCATION - STATISTICAL BASIS

COST CENTER DESCRIPTIONS

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

03-18
PROVIDER CCN:

LAUNDRY
& LINEN
SERVICE
(POUNDS OF
LAUNDRY)
8

HOUSEKEEPING
(HOURS OF
SERVICE)
9

DIETARY
(MEALS
SERVED)
10

CAFETERIA
(MEALS
SERVED)
11

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits Department
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Education Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider (specify)
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

MAINTENANCE OF
PERSONNEL
(NUMBER
HOUSED)
12

________________
NURSING
ADMINISTRATION
(DIRECT
NURS. HRS)
13

PERIOD:
FROM ____________
TO _______________
CENTRAL
SERVICES &
SUPPLY
(COSTED
REQUIS.)
14

PHARMACY
(COSTED
REQUIS.)
15

WORKSHEET B-1

MEDICAL
RECORDS &
LIBRARY
(TIME
SPENT)
16

SOCIAL
SERVICE
(TIME
SPENT)
17
1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

40-556

Rev. 14

03-18

FORM CMS-2552-10

COST ALLOCATION - STATISTICAL BASIS

COST CENTER DESCRIPTIONS

50
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
77
88
89
90
91
92
93
93.99

4090 (Cont.)
PROVIDER CCN:

LAUNDRY
& LINEN
SERVICE
(POUNDS OF
LAUNDRY)
8

HOUSEKEEPING
(HOURS OF
SERVICE)
9

DIETARY
(MEALS
SERVED)
10

CAFETERIA
(MEALS
SERVED)
11

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
Allogeneic Stem Cell Acquisition
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)
Partial Hospitalization Program

MAINTENANCE OF
PERSONNEL
(NUMBER
HOUSED)
12

________________
NURSING
ADMINISTRATION
(DIRECT
NURS. HRS)
13

PERIOD:
FROM ____________
TO _______________
CENTRAL
SERVICES &
SUPPLY
(COSTED
REQUIS.)
14

PHARMACY
(COSTED
REQUIS.)
15

WORKSHEET B-1

MEDICAL
RECORDS &
LIBRARY
(TIME
SPENT)
16

SOCIAL
SERVICE
(TIME
SPENT)
17
50
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
77
88
89
90
91
92
93
93.99

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

Rev. 14

40-557

4090 (Cont.)

FORM CMS-2552-10

COST ALLOCATION - STATISTICAL BASIS

COST CENTER DESCRIPTIONS

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202
203
204
205
206
207

03-18
PROVIDER CCN:

LAUNDRY
& LINEN
SERVICE
(POUNDS OF
LAUNDRY)
8

HOUSEKEEPING
(HOURS OF
SERVICE)
9

DIETARY
(MEALS
SERVED)
10

CAFETERIA
(MEALS
SERVED)
11

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1 through 117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross foot adjustments
Negative cost centers
Cost to be allocated (per Worksheet B, Part I)
Unit cost multiplier (Worksheet B, Part I)
Cost to be allocated (per Worksheet B, Part II)
Unit cost multiplier (Worksheet B, Part II)
NAHE adjustment amount to be allocated (per Wkst. B-2)
NAHE unit cost multiplier (Wkst. D, Parts III and IV)

MAINTENANCE OF
PERSONNEL
(NUMBER
HOUSED)
12

________________
NURSING
ADMINISTRATION
(DIRECT
NURS. HRS)
13

PERIOD:
FROM ____________
TO _______________
CENTRAL
SERVICES &
SUPPLY
(COSTED
REQUIS.)
14

PHARMACY
(COSTED
REQUIS.)
15

WORKSHEET B-1

MEDICAL
RECORDS &
LIBRARY
(TIME
SPENT)
16

SOCIAL
SERVICE
(TIME
SPENT)
17
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202
203
204
205
206
207

FORM CMS-2552-10 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

40-558

Rev. 14

11-17

FORM CMS-2552-10

COST ALLOCATION - STATISTICAL BASIS

COST CENTER DESCRIPTIONS

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

4090 (Cont.)
PROVIDER CCN:

OTHER
GENERAL
SERVICE
(SPECIFY)
18

NONPHYSICIAN
ANESTHETISTS
(ASGND TIME)
19

NURSING
SCHOOL
(ASSIGNED
TIME)
20

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits Department
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Education Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider (specify)
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

________________
INTERNS & RESIDENTS
SALARY AND
PROGRAM
FRINGES
COSTS
(ASSIGNED
(ASSIGNED
TIME)
TIME)
21
22

PERIOD:
FROM ____________
TO _______________
PARAMEDICAL
EDUCATION
(ASSIGNED
TIME)
23

SUBTOTAL
24

WORKSHEET B-1

INTERN &
RESIDENT
COST & POST
STEPDOWN
ADJUSTMENTS
25

TOTAL
26
1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

Rev. 12

40-559

4090 (Cont.)

FORM CMS-2552-10

COST ALLOCATION - STATISTICAL BASIS

COST CENTER DESCRIPTIONS

50
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
77
88
89
90
91
92
93
93.99

11-17
PROVIDER CCN:

OTHER
GENERAL
SERVICE
(SPECIFY)
18

NONPHYSICIAN
ANESTHETISTS
(ASGND TIME)
19

NURSING
SCHOOL
(ASSIGNED
TIME)
20

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
Allogeneic Stem Cell Acquisition
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)
Partial Hospitalization Program

________________
INTERNS & RESIDENTS
SALARY AND
PROGRAM
FRINGES
COSTS
(ASSIGNED
(ASSIGNED
TIME)
TIME)
21
22

PERIOD:
FROM ____________
TO _______________
PARAMEDICAL
EDUCATION
(ASSIGNED
TIME)
23

SUBTOTAL
24

WORKSHEET B-1

INTERN &
RESIDENT
COST & POST
STEPDOWN
ADJUSTMENTS
25

TOTAL
26
50
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
77
88
89
90
91
92
93
93.99

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

40-560

Rev. 12

03-18

FORM CMS-2552-10

COST ALLOCATION - STATISTICAL BASIS

COST CENTER DESCRIPTIONS

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202
203
204
205
206
207

4090 (Cont.)
PROVIDER CCN:

OTHER
GENERAL
SERVICE
(SPECIFY)
18

NONPHYSICIAN
ANESTHETISTS
(ASGND TIME)
19

NURSING
SCHOOL
(ASSIGNED
TIME)
20

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1 through 117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross foot adjustments
Negative cost centers
Cost to be allocated (per Worksheet B, Part I)
Unit cost multiplier (Worksheet B, Part I)
Cost to be allocated (per Worksheet B, Part II)
Unit cost multiplier (Worksheet B, Part II)
NAHE adjustment amount to be allocated (per Wkst. B-2)
NAHE unit cost multiplier (Wkst. D, Parts III and IV)

________________
INTERNS & RESIDENTS
SALARY AND
PROGRAM
FRINGES
COSTS
(ASSIGNED
(ASSIGNED
TIME)
TIME)
21
22

PERIOD:
FROM ____________
TO _______________
PARAMEDICAL
EDUCATION
(ASSIGNED
TIME)
23

SUBTOTAL
24

WORKSHEET B-1

INTERN &
RESIDENT
COST & POST
STEPDOWN
ADJUSTMENTS
25

TOTAL
26
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202
203
204
205
206
207

FORM CMS-2552-10 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

Rev. 14

40-561

4090 (Cont.)

03-18

FORM CMS-2552-10

POST STEPDOWN ADJUSTMENTS

PROVIDER CCN:
________________
DESCRIPTION
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
28
29
30
31
32
33
34
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

Adjustment for EPO costs in Renal Dialysis cost center
Adjustment for EPO costs in Home Program Dialysis cost center
Adjustment for ARANESP costs in Renal Dialysis cost center
Adjustment for ARANESP costs in Home Program Dialysis cost center
Adjustment for ESA costs in Renal Dialysis cost center (see instructions)
Adjustment for ESA costs in Home Program Dialysis cost center (see instructions)

PERIOD:
WORKSHEET B-2
FROM ____________
TO _______________
WORKSHEET
CODE
LINE NO.
AMOUNT
2
3
4
1
74
1
94
1
74
1
94
1
74
1
94

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
51
52
53
54
55
56
57
58
59

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4022)

40-562

Rev. 14

11-17

FORM CMS-2552-10

4090 (Cont.)

COMPUTATION OF RATIO OF COSTS TO CHARGES

COST CENTER DESCRIPTIONS

30
31
32
33
34
35
40
41
42
43
44
45
46
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68

PROVIDER CCN:

Total Cost
(from Wkst.
B, Part I,
col. 26)
1

Therapy
Limit
Adj.
2

Total
Costs
3

Costs
RCE
Disallowance
4

INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care (specify)
Subprovider IPF
Subprovider IRF
Subprovider (Specify)
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care
ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Prgm. Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology

PERIOD:
FROM ____________
TO _______________

_______________
Charges
Total
Costs
5

Inpatient
6

Outpatient
7

Total
(column 6
+ column 7)
8

Cost or
Other Ratio
9

WORKSHEET C
PART I

TEFRA
Inpatient
Ratio
10

PPS
Inpatient
Ratio
11
30
31
32
33
34
35
40
41
42
43
44
45
46
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4023)

Rev. 12

40-563

4090 (Cont.)

FORM CMS-2552-10

11-17

COMPUTATION OF RATIO OF COSTS TO CHARGES

COST CENTER DESCRIPTIONS

69
70
71
72
73
74
75
76
77
88
89
90
91
92
93
93.99
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
200
201
202

PROVIDER CCN:

Total Cost
(from Wkst.
B, Part I,
col. 26)
1

Therapy
Limit
Adj.
2

Total
Costs
3

Costs
RCE
Disallowance
4

Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
Allogeneic Stem Cell Acquisition
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds (see instructions)
Other Outpatient Service (specify)
Partial Hospitalization Program
OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
Subtotal (see instructions)
Less Observation Beds
Total (see instructions)

PERIOD:
FROM ____________
TO _______________

_______________
Charges
Total
Costs
5

Inpatient
6

Outpatient
7

Total
(column 6
+ column 7)
8

Cost or
Other Ratio
9

WORKSHEET C
PART I

TEFRA
Inpatient
Ratio
10

PPS
Inpatient
Ratio
11
69
70
71
72
73
74
75
76
77
88
89
90
91
92
93
93.99
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
200
201
202

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4023)

40-564

Rev. 12

11-17

FORM CMS-2552-10

4090 (Cont.)

CALCULATION OF OUTPATIENT SERVICE COST TO
CHARGE RATIOS NET OF REDUCTIONS FOR MEDICAID ONLY

PROVIDER CCN:
________________

Check applicable box:

[ ] Title V

Cost Center Descriptions

50
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
77

PERIOD:
WORKSHEET C,
FROM ____________ PART II
TO _______________

[ ] Title XIX

Total Cost
(Wkst. B,
Part I, col. 26)
1

Capital Cost
(Wkst B,
Part II,
col. 26)
2

Operating Cost
Net of
Capital Cost
(col. 1 - col. 2)
3

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catherization
Laboratory
PBP Clinical Laboratory Services-Prgm. Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
Allogeneic Stem Cell Acquisition

Capital
Reduction
4

Operating Cost
Reduction
Amount
5

Cost Net of
Capital and
Operating Cost
Reduction
6

Total
Charges
(Worksheet C,
Part I, column 8)
7

Outpatient Cost
to Charge Ratio
(col. 6 ÷ col. 7)
8
50
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
77

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4023 & 4023.2)

Rev. 12

40-565

4090 (Cont.)

FORM CMS-2552-10

11-17

CALCULATION OF OUTPATIENT SERVICE COST TO
CHARGE RATIOS NET OF REDUCTIONS FOR MEDICAID ONLY

PROVIDER CCN:
________________

Check applicable box:

[ ] Title V

Cost Center Descriptions

88
89
90
91
92
93
93.99
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
200
201
202

PERIOD:
WORKSHEET C.
FROM ____________ PART II (CONT.)
TO _______________

[ ] Title XIX

Total Cost
(Wkst. B,
Part I, col. 26)
1

Capital Cost
(Wkst B,
Part II,
col. 26)
2

Operating Cost
Net of
Capital Cost
(col. 1 - col. 2)
3

OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds (see instructions)
Other Outpatient Service (specify)
Partial Hospitalization Program
OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
Subtotal (sum of lines 50 through 199)
Less Observation Beds
Total (line 200 minus line 201)

Capital
Reduction
4

Operating Cost
Reduction
Amount
5

Cost Net of
Capital and
Operating Cost
Reduction
6

Total
Charges
(Worksheet C,
Part I, column 8)
7

Outpatient Cost
to Charge Ratio
(col. 6 ÷ col. 7)
8
88
89
90
91
92
93
93.99
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
200
201
202

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4023 & 4023.2)

40-566

Rev. 12

11-17

FORM CMS-2552-10

APPORTIONMENT OF INPATIENT ROUTINE
SERVICE CAPITAL COSTS

4090 (Cont.)

PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

______________
Check
applicable
boxes:

[ ] Title V
[ ] Title XVIII, Part A
[ ] Title XIX

[ ] PPS
[ ] TEFRA

Cost Center Description
INPATIENT ROUTNE SERVICE COST CENTERS
Adults & Pediatrics
30 (General Routine Care)

(A)

31

WORKSHEET D,
PART I

Capital
Related Cost
(from Wkst.
B, Part II,
col. 26)
1

Swing
Bed
Adjustment
2

Reduced
Capital
Related
Cost
(col. 1 minus
col. 2)
3

Total
Patient
Days
4

Per
Diem
(col. 3 ÷
col. 4)
5

Inpatient
Program
Days
6

Inpatient
Program
Capital
Cost
(col. 5
x col. 6)
7

30

Intensive Care Unit

31

32 Coronary Care Unit

32

33

33

Burn Intensive Care Unit

34 Surgical Intensive Care Unit

34

35

35

Other Special Care Unit (specify)

40 Subprovider IPF

40

41 Subprovider IRF

41

42

42

Subprovider (Other)

43 Nursery

43

44

44

Skilled Nursing Facility

45 Nursing Facility
200

Total (lines 30 through 199)

45
200

(A) Worksheet A line numbers

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4024 - 4024.1)

Rev. 12

40-567

4090 (Cont.)

Check
applicable
boxes:

(A)
50
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
77
88
89
90
91
92
93
93.99
94
95
96
97
98
200

11-17

FORM CMS-2552-10

APPORTIONMENT OF INPATIENT ANCILLARY
SERVICE CAPITAL COSTS

[ ] Title V
[ ] Title XVIII, Part A
[ ] Title XIX

[ ] Hospital
[ ] IPF
[ ] IRF

Cost Center Description
ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Prgm. Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Transfusing
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
Allogeneic Stem Cell Acquisition
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)
Partial Hospitalization Program
OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Total (sum of lines 50 through 199)

PROVIDER CCN:
______________
COMPONENT CCN:
______________
[ ] Subprovider (Other)

Capital
Related Cost
(from Wkst.
B, Part II,
col. 26)
1

PERIOD:
WORKSHEET D
FROM ____________ PART II
TO _______________

[ ] PPS
[ ] TEFRA

Total Charges
(from Wkst. C,
Part I, col. 8)
2

Ratio of Cost
to Charges
(col .1 ÷
col. 2)
3

Inpatient
Program
Charges
4

Capital
Costs
(column 3 x
column 4)
5
50
51
52
53
54
55
56
57
58
60
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
88
89
90
91
92
93
93.99
94
95
96
97
98
200

(A) Worksheet A line numbers

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4024.2)

40-568

Rev. 12

03-18

FORM CMS-2552-10

4090 (Cont.)

APPORTIONMENT OF INPATIENT ROUTINE
SERVICE OTHER PASS-THROUGH COSTS

PROVIDER CCN:

PERIOD
FROM __________
TO _____________

______________
Check
applicable
boxes:

[ ] Title V
[ ] Title XVIII, Part A
[ ] Title XIX

(A)

WORKSHEET D,
PART III

[ ] PPS
[ ] TEFRA
[ ] Other

Cost Center Description
INPATIENT ROUTINE SERVICE COST CENTERS
Adults & Pediatrics
30 (General Routine Care)

Nursing
School
PostStepdown
Adjustments
1A

Nursing
School
1

Allied
Health
PostStepdown
Adjustments
2A

Allied Health
Cost
2

All
Other
Medical
Education
Cost
3

Swing-Bed
Adjustment
Amount
(see
instructions)
4

Total Costs
(sum of cols.
1, 2, and 3,
minus col. 4)
5

Total
Patient
Days
6

Per
Diem
(col. 5 ÷
col. 6)
7

Inpatient
Program
Days
8

Inpatient
Program
Pass-Through
Cost
(col. 7 x col. 8)
9

30

31

Intensive Care Unit

31

32

Coronary Care Unit

32

33

Burn Intensive Care Unit

33

34

Surgical Intensive Care Unit

34

35

Other Special Care Unit (specify)

35

40

Subprovider IPF

40

41

Subprovider IRF

41

42

Subprovider (Other)

42

43

Nursery

43

44

Skilled Nursing Facility

44

45

Nursing Facility

45

200

Total (sum of lines 30 through 199)

200

(A) Worksheet A line numbers

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4024.3)

Rev. 14

40-569

4090 (Cont.)

FORM CMS-2552-10

03-18

APPORTIONMENT OF INPATIENT/OUTPATIENT ANCILLARY
SERVICE OTHER PASS-THROUGH COSTS

Check
applicable
boxes:

(A)
50
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
77
88
89
90
91
92
93
93.99

[ ] Title V
[ ] Title XVIII, Part A
[ ] Title XIX

Cost Center Description
ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Serv.-Prgm. Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Transfusing
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged To Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
Allogeneic Stem Cell Acquisition
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)
Partial Hospitalization Program

[ ] Hospital
[ ] IPF
[ ] IRF

PROVIDER CCN:
______________
COMPONENT CCN:
______________
[ ] Subprovider (Other)
[ ] SNF
[ ] NF

Non
Physician
Anesthetist
Cost
1

[ ] ICF/IID

Nursing
School
PostStepdown
Adjustments
2A

Nursing
School
2

PERIOD:
WORKSHEET D,
FROM ____________ PART IV
TO _______________

[ ] PPS
[ ] TEFRA
[ ] Other

Allied
Health
PostStepdown
Adjustments
3A

Allied
Health
3

All
Other
Medical
Education
Cost
4

Total cost
(sum of cols. 1, 2
3, and 4)
5

Total
Outpatient
Cost
(sum of cols. 2,
3, and 4)
6
50
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
77
88
89
90
91
92
93
93.99

FORM CMS-2552-10 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4024.4)

40-570

Rev. 14

11-17

FORM CMS-2552-10

4090 (Cont.)

APPORTIONMENT OF INPATIENT/OUTPATIENT ANCILLARY
SERVICE OTHER PASS THROUGH COSTS

Check
applicable
boxes:

(A)
94
95
96
97
98
200

[ ] Title V
[ ] Title XVIII, Part A
[ ] Title XIX

Cost Center Description
OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Total (sum of lines 50 through 199)

[ ] Hospital
[ ] IPF
[ ] IRF

PROVIDER CCN:
______________
COMPONENT CCN:
______________
[ ] Subprovider (Other)
[ ] SNF
[ ] NF

Non
Physician
Anesthetist
Cost
1

Nursing
School
Post-Stepdown
Adjustments
2A

[ ] ICF/IID

Nursing
School
2

PERIOD:
WORKSHEET D,
FROM ____________ PART IV (Cont.)
TO _______________

[ ] PPS
[ ] TEFRA
[ ] Other

Allied
Health
Post-Stepdown
Adjustments
3A

Allied
Health
3

All
Other
Medical
Education
Cost
4

Total cost
(sum of cols. 1, 2
3, and 4)
5

Total
Outpatient
Cost
(sum of cols. 2,
3, and 4)
6
94
95
96
97
98
200

(A) Worksheet A line numbers

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4024.4)

Rev. 12

40-570.1

4090 (Cont.)

FORM CMS-2552-10

11-17

APPORTIONMENT OF INPATIENT/OUTPATIENT ANCILLARY
SERVICE OTHER PASS THROUGH COSTS

Check
applicable
boxes:

(A)
50
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
77
88
89
90
91
92
93
93.99

[ ] Title V
[ ] Title XVIII, Part A
[ ] Title XIX

Cost Center Description
ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Delivery Room and Labor Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Serv.-Prgm. Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Transfusing
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged To Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
Allogeneic Stem Cell Acquisition
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)
Partial Hospitalization Program

[ ] Hospital
[ ] IPF
[ ] IRF

PROVIDER CCN:
______________
COMPONENT CCN:
______________
[ ] Subprovider (Other)
[ ] SNF
[ ] NF

Total
Charges
(from Wkst. C,
Part I, col. 8)
7

[ ] ICF/IID

Ratio
of Cost
to Charges
(col. 5 ÷ col. 7)
8

PERIOD:
WORKSHEET D,
FROM ____________ PART IV (Cont.)
TO _______________

[ ] PPS
[ ] TEFRA
[ ] Other

Outpatient
Ratio
of Cost
to Charges
(col. 6 ÷ col. 7)
9

Inpatient
Program
Charges
10

Inpatient
Program
PassThrough
Costs
(col. 8 x col. 10)
11

Outpatient
Program
Charges
12

Outpatient
Program
PassThrough
Costs
(col. 9 x col. 12)
13
50
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
77
88
89
90
91
92
93
93.99

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4024.4)

40-570.2

Rev. 12

11-17

FORM CMS-2552-10

4090 (Cont.)

APPORTIONMENT OF INPATIENT/OUTPATIENT ANCILLARY
SERVICE OTHER PASS THROUGH COSTS

Check
applicable
boxes:

(A)
94
95
96
97
98
200

[ ] Title V
[ ] Title XVIII, Part A
[ ] Title XIX

Cost Center Description
OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Total (sum of lines 50 through 199)

[ ] Hospital
[ ] IPF
[ ] IRF

PROVIDER CCN:
______________
COMPONENT CCN:
______________
[ ] Subprovider (Other)
[ ] SNF
[ ] NF

Total
Charges
(from Wkst. C,
Part I, col. 8)
7

[ ] ICF/IID

Ratio
of Cost
to Charges
(col. 5 ÷ col. 7)
8

PERIOD:
WORKSHEET D,
FROM ____________ PART IV (Cont.)
TO _______________

[ ] PPS
[ ] TEFRA
[ ] Other

Outpatient
Ratio
of Cost
to Charges
(col. 6 ÷ col. 7)
9

Inpatient
Program
Charges
10

Inpatient
Program
PassThrough
Costs
(col. 8 x col. 10)
11

Outpatient
Program
Charges
12

Outpatient
Program
PassThrough
Costs
(col. 9 x col. 12)
13
94
95
96
97
98
200

(A) Worksheet A line numbers

FORM CMS-2552-10 (09-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4024.4)

Rev. 12

40-571

4090 (Cont.)

11-17

FORM CMS-2552-10

APPORTIONMENT OF MEDICAL AND OTHER
HEALTH SERVICES COSTS

PROVIDER CCN:
PERIOD:
______________
FROM ____________
COMPONENT CCN:
TO _______________
______________
Check
[ ] Title V - O/P
[ ] Hospital
[ ] Subprovider (Other)
[ ] Swing Bed SNF
applicable
[ ] Title XVIII, Part B
[ ] IPF
[ ] SNF
[ ] Swing Bed NF
boxes:
[ ] Title XIX - O/P
[ ] IRF
[ ] NF
[ ] ICF/IID
PART V - APPORTIONMENT OF MEDICAL AND OTHER HEALTH SERVICES COSTS
Program Charges
Program Cost
Cost
Cost
Cost
Cost
to
Reimbursed
Reimbursed
Reimbursed
Charge
PPS
Services
Services Not
PPS
Services
Ratio from
Reimbursed
Subject to
Subject to
Services
Subject to
Worksheet C,
Services
Ded. & Coins.
Ded. & Coins.
(see
Ded. & Coins.
Part I, col. 9
(see inst.)
(see inst.)
(see inst.)
(see inst.)
(see inst.)
Cost Center Description
(A)
1
2
3
4
5
6
ANCILLARY SERVICE COST CENTERS
50 Operating Room
51 Recovery Room
52 Labor & Delivery Room
53 Anesthesiology
54 Radiology-Diagnostic
55 Radiology-Therapeutic
56 Radioisotope
57 Computed Tomography (CT) Scan
58 Magnetic Resonance Imaging (MRI)
59 Cardiac Catheterization
60 Laboratory
61 PBP Clinical Laboratory Serv.-Prgm. Only
62 Whole Blood & Packed Red Blood Cells
63 Blood Storing, Processing, & Transfusing
64 Intravenous Therapy
65 Respiratory Therapy
66 Physical Therapy
67 Occupational Therapy
68 Speech Pathology
69 Electrocardiology
70 Electroencephalography
71 Medical Supplies Charged To Patients
72 Implantable Devices Charged to Patients
73 Drugs Charged to Patients
74 Renal Dialysis
75 ASC (Non-Distinct Part)
76 Other Ancillary (specify)
77 Allogeneic Stem Cell Acquisition
OUTPATIENT SERVICE COST CENTERS
88 Rural Health Clinic (RHC)
89 Federally Qualified Health Center (FQHC)
90 Clinic
91 Emergency
92 Observation Bed
93 Other Outpatient Service (specify)
93.99 Partial Hospitalization Program
OTHER REIMBURSABLE COST CENTERS
94 Home Program Dialysis
95 Ambulance
96 Durable Medical Equipment-Rented
97 Durable Medical Equipment-Sold
98 Other Reimbursable Cost Center
200 Subtotal (see instructions)
201 Less PBP Clinic Lab. Services-Program
Only Charges
202 Net Charges (line 200 - line 201 )

WORKSHEET D,
PART V

Cost
Reimbursed
Services Not
Subject to
Ded. & Coins.
(see inst.)
7
50
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
77
88
89
90
91
92
93
93.99
94
95
96
97
98
200
201
202

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4024.5)

40-572

Rev. 12

09-15
COMPUTATION OF INPATIENT
OPERATING COST

4090 (Cont.)

FORM CMS-2552-10
PROVIDER CCN:
______________
COMPONENT CCN:
______________
[ ] ICF/IID

Check
[ ] Title V - I/P
[ ] Hospital
[ ] Subprovider (other)
applicable
[ ] Title XVIII, Part A
[ ] IPF
[ ] SNF
boxes:
[ ] Title XIX - I/P
[ ] IRF
[ ] NF
PART I - ALL PROVIDER COMPONENTS
INPATIENT DAYS
1 Inpatient days (including private room days and swing-bed days, excluding newborn)
2 Inpatient days (including private room days, excluding swing-bed and newborn days)
3 Private room days (excluding swing-bed and observation bed days). If you have only private room days, do not complete this line.
4 Semi-private room days (excluding swing-bed and observation bed days)
5 Total swing-bed SNF type inpatient days (including private room days) through December 31 of the cost reporting period
6 Total swing-bed SNF type inpatient days (including private room days) after December 31 of the cost reporting period (if
calendar year, enter 0 on this line)
7 Total swing-bed NF type inpatient days (including private room days) through December 31 of the cost reporting period
8 Total swing-bed NF type inpatient days (including private room days) after December 31 of the cost reporting period (if
calendar year, enter 0 on this line)
9 Total inpatient days including private room days applicable to the Program (excluding swing-bed and newborn days)
10 Swing-bed SNF type inpatient days applicable to title XVIII only (including private room days) through December 31 of the
cost reporting period (see instructions).
11 Swing-bed SNF type inpatient days applicable to title XVIII only (including private room days) after December 31 of the
cost reporting period (if calendar year, enter 0 on this line)
12 Swing-bed NF type inpatient days applicable to titles V or XIX only (including private room days) through December 31 of
the cost reporting period.
13 Swing-bed NF type inpatient days applicable to titles V or XIX only (including private room days) after December 31 of the
cost reporting period (if calendar year, enter 0 on this line)
14 Medically necessary private room days applicable to the Program (excluding swing-bed days)
15 Total nursery days (title V or XIX only)
16 Nursery days (title V or XIX only)
SWING BED ADJUSTMENT
17 Medicare rate for swing-bed SNF services applicable to services through December 31 of the cost reporting period
18 Medicare rate for swing-bed SNF services applicable to services after December 31 of the cost reporting period
19 Medicaid rate for swing-bed NF services applicable to services through December 31 of the cost reporting period
20 Medicaid rate for swing-bed NF services applicable to services after December 31 of the cost reporting period
21 Total general inpatient routine service cost (see instructions)
22 Swing-bed cost applicable to SNF type services through December 31 of the cost reporting period (line 5 x line 17)
23 Swing-bed cost applicable to SNF type services after December 31 of the cost reporting period (line 6 x line 18)
24 Swing-bed cost applicable to NF type services through December 31 of the cost reporting period (line 7 x line 19)
25 Swing-bed cost applicable to NF type services after December 31 of the cost reporting period (line 8 x line 20)
26 Total swing-bed cost (see instructions)
27 General inpatient routine service cost net of swing-bed cost (line 21 minus line 26)
PRIVATE ROOM DIFFERENTIAL ADJUSTMENT
28 General inpatient routine service charges (excluding swing-bed and observation bed charges)
29 Private room charges (excluding swing-bed charges)
30 Semi-private room charges (excluding swing-bed charges)
31 General inpatient routine service cost/charge ratio (line 27 ÷ line 28)
32 Average private room per diem charge (line 29 ÷ line 3)
33 Average semi-private room per diem charge (line 30 ÷ line 4)
34 Average per diem private room charge differential (line 32 minus line 33) (see instructions)
35 Average per diem private room cost differential (line 34 x line 31)
36 Private room cost differential adjustment (line 3 x line 35)
37 General inpatient routine service cost net of swing-bed cost and private room cost differential (line 27 minus line 36)

PERIOD:
FROM ____________
TO _______________

WORKSHEET D-1,
PART I

[ ] PPS
[ ] TEFRA
[ ] Other

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

FORM CMS-2552-10 (09-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4025.1)

Rev. 8

40-573

4090 (Cont.)

09-15

FORM CMS-2552-10

COMPUTATION OF INPATIENT
OPERATING COST

PROVIDER CCN:
______________
COMPONENT CCN:
______________

Check
[ ] Title V - I/P
[ ] Hospital
[ ]Subprovider (other)
applicable
[ ] Title XVIII, Part A
[ ] IPF
boxes:
[ ] Title XIX - I/P
[ ] IRF
PART II - HOSPITAL AND SUBPROVIDERS ONLY
PROGRAM INPATIENT OPERATING COST BEFORE
PASS-THROUGH COST ADJUSTMENTS
38 Adjusted general inpatient routine service cost per diem (see instructions)
39 Program general inpatient routine service cost (line 9 x line 38)
40 Medically necessary private room cost applicable to the Program (line 14 x line 35)
41 Total Program general inpatient routine service cost (line 39 + line 40)
Total
Inpatient Cost
1
42

Total
Inpatient Days
2

PERIOD:
FROM ____________
TO _______________

WORKSHEET D-1,
PART II

[ ] PPS
[ ] TEFRA
[ ] Other

1
38
39
40
41
Average
Per Diem
(col. 1 ÷ col. 2)
3

Program
Days
4

Program Cost
(col. 3 x col. 4)
5

43
44
45
46
47

Nursery (title V & XIX only)
Intensive Care Type Inpatient
Hospital Units
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)

42

48
49

Program inpatient ancillary service cost (Worksheet D-3, column 3, line 200)
Total Program inpatient costs (sum of lines 41 through 48) (see instructions)

48
49

50
51
52
53

PASS-THROUGH COST ADJUSTMENTS
Pass through costs applicable to Program inpatient routine services (from Worksheet D, sum of Parts I and III)
Pass through costs applicable to Program inpatient ancillary services (from Worksheet D, sum of Parts II and IV)
Total Program excludable cost (sum of lines 50 and 51)
Total Program inpatient operating cost excluding capital related, nonphysician anesthetist, and medical education costs
(line 49 minus line 52)

50
51
52
53

43
44
45
46
47
1

TARGET AMOUNT AND LIMIT COMPUTATION
Program discharges
Target amount per discharge
Target amount (line 54 x line 55)
Difference between adjusted inpatient operating cost and target amount (line 56 minus line 53)
Bonus payment (see instructions)
Lesser of line 53 ÷ line 54 or line 55 from the cost reporting period ending 1996, updated and compounded by the market basket
Lesser of line 53 ÷ line 54 or line 55 from prior year cost report, updated by the market basket
If line 53 ÷ line 54 is less than the lower of lines 55, 59 or 60 enter the lesser of 50% of the amount by which operating costs
(line 53) are less than expected costs (lines 54 x 60), or 1 % of the target amount (line 56), otherwise enter zero.
(see instructions)
62 Relief payment (see instructions)
63 Allowable Inpatient cost plus incentive payment (see instructions)
54
55
56
57
58
59
60
61

64
65
66
67
68
69

PROGRAM INPATIENT ROUTINE SWING BED COST
Medicare swing-bed SNF inpatient routine costs through December 31 of the cost reporting period (see instructions)
(title XVIII only)
Medicare swing-bed SNF inpatient routine costs after December 31 of the cost reporting period (see instructions)
(title XVIII only)
Total Medicare swing-bed SNF inpatient routine costs (line 64 plus line 65) (Title XVIII only. For CAH, see instructions.)
Title V or XIX swing-bed NF inpatient routine costs through December 31 of the cost reporting period (line 12 x line 19)
Title V or XIX swing-bed NF inpatient routine costs after December 31 of the cost reporting period (line 13 x line 20)
Total title V or XIX swing-bed NF inpatient routine costs (line 67 + line 68)

54
55
56
57
58
59
60
61

62
63

64
65
66
67
68
69

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4025.2)

40-574

Rev. 8

03-16

4090 (Cont.)

FORM CMS-2552-10

COMPUTATION OF INPATIENT
OPERATING COST

Check
[ ] Title V - I/P
applicable
[ ] Title XVIII, Part A
boxes:
[ ] Title XIX - I/P
PART III - SNF, NF, AND ICF/IID ONLY

[ ] Hospital
[ ] IPF
[ ] IRF

[ ] Subprovider (other)
[ ] SNF
[ ] NF

PROVIDER CCN:
______________
COMPONENT CCN:
______________
[ ] ICF/IID

PERIOD:
FROM ____________
TO _______________

WORKSHEET D-1,
PARTS III & IV

[ ] PPS
[ ] TEFRA
[ ] Other

70

SNF / NF / ICF/IID routine service cost (line 37)

70

71

Adjusted general inpatient routine service cost per diem (line 70 ÷ line 2)

71

72

Program routine service cost (line 9 x line 71)

72

73

Medically necessary private room cost applicable to Program (line 14 x line 35)

73

74

Total Program general inpatient routine service costs (line 72 + line 73)

74

75

Capital-related cost allocated to inpatient routine service costs (from Worksheet B, Part II, column 26, line 45)

75

76

Per diem capital-related costs (line 75 ÷ line 2)

76

77

Program capital-related costs (line 9 x line 76)

77

78

Inpatient routine service cost (line 74 minus line 77)

78

79

Aggregate charges to beneficiaries for excess costs (from provider records)

79

80

Total Program routine service costs for comparison to the cost limitation (line 78 minus line 79)

80

81

Inpatient routine service cost per diem limitation

81

82

Inpatient routine service cost limitation (line 9 x line 81)

82

83

Reasonable inpatient routine service costs (see instructions)

83

84

Program inpatient ancillary services (see instructions)

84

85

Utilization review - physician compensation (see instructions)

85

86

Total Program inpatient operating costs (sum of lines 83 through 85)

86

PART IV - COMPUTATION OF OBSERVATION BED PASS-THROUGH COST
87

Total observation bed days (see instructions)

87

88

Adjusted general inpatient routine cost per diem (line 27 ÷ line 2)

88

89

Observation bed cost (line 87 x line 88) (see instructions)

89

COMPUTATION OF OBSERVATION BED PASS THROUGH COST

Cost
1

Routine
Cost
(from line 21)
2

column 1 ÷
column 2
3

Total
Observation
Bed Cost
(from line 89)
4

Observation Bed
Pass-Through Cost
(col. 3 x col. 4)
(see instructions)
5

90

Capital-related cost

90

91

Nursing School cost

91

92

Allied Health cost

92

93

All other Medical Education

93

FORM CMS-2552-10 (03-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4025.3 - 4025.4)

Rev. 9

40-575

4090 (Cont.)
APPORTIONMENT OF COST OF
SERVICES RENDERED BY
INTERNS AND RESIDENTS
PART I - NOT IN APPROVED TEACHING PROGRAM
Cost Centers
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Total cost of services rendered
Hospital Inpatient Routine Services:
Adults & pediatrics (general routine care)
Intensive care unit
Coronary care unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care (specify)
Nursery
Subtotal (sum of lines 2 through 8)
IPF - Inpatient routine service
IRF - Inpatient routine service
Subprovider (Other) - Inpatient routine service
Skilled Nursing Facility
Nursing Facility
Other Long Term Care
Home Health Agency
Outpatient Rehabilitation Providers
Ambulatory Surgical Center
Hospice
Subtotal (sum of lines 9 through 19)

PROVIDER CCN:
________________
Percent of
Assigned Time
1
100.00

Hospital Outpatient Services:
21
Rural Health Clinic (RHC)
22
Federally Qualified Health Center (FQHC)
23
Clinic
24
Emergency
25
Observation beds
26
Other Outpatient Service (specify)
27 Subtotal (sum of lines 21 through 26)
28 Total (sum of lines 20 and 27)
100.00
PART II - IN AN APPROVED TEACHING PROGRAM (TITLE XVIII, PART B INPATIENT ROUTINE COSTS ONLY)
Expenses Allocated
to cost centers
on Worksheet B, Part I
columns 21 and 22
Hospital Inpatient Routine Services:
1
29
Adults & Pediatrics (general routine care)
30
Swing Bed - SNF
31
Swing Bed - NF
32
Intensive care unit
33
Coronary care unit
34
Burn Intensive Care Unit
35
Surgical Intensive Care Unit
36
Other Special Care (specify)
37 Subtotal (sum of lines 29, and 32 through 36)
38 IPF - Inpatient routine service
39 IRF - Inpatient routine service
40 Subprovider (Other)- Inpatient routine service
41 Skilled Nursing Facility
42 Total (sum of lines 37 through 41)
PART III - SUMMARY FOR TITLE XVIII (TO BE COMPLETED ONLY IF BOTH PARTS I AND II ARE USED)

43
44
45
46
47
48
49

03-16

FORM CMS-2552-10

Hospital
Inpatient
Outpatient
Total Hospital (sum of lines 43 and 44)
IPF - Inpatient routine service
IRF - Inpatient routine service
Subprovider (Other)- Inpatient routine service
Skilled Nursing Facility

PERIOD:
FROM ____________
TO _______________
Expense
Allocation
2

WORKSHEET D-2,
PARTS I-III

Total Inpatient Days
All Patients
3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Total Charges
(from Worksheet C,
Part I, column 8,
lines 88 through 93)
21
22
23
24
25
26
27
28

Swing Bed
Amount
2

Net Cost
(column 1 plus
column 2)
3
29
30
31
32
33
34
35
36
37
38
39
40
41
42

Not In Approved Teaching Program
(from Part I)
Amount
1
2
column 9, line 9
column 9, line 27
column 9, line 10
column 9, line 11
column 9, line 12
column 9, line 13

43
44
45
46
47
48
49

FORM CMS-2552-10 (03-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4026)

40-576

Rev. 9

11-17

4090 (Cont.)

FORM CMS-2552-10

APPORTIONMENT OF COST OF
SERVICES RENDERED BY
INTERNS AND RESIDENTS
PART I - NOT IN APPROVED TEACHING PROGRAM
Average Cost
Health Care Program Inpatient Days
Per Day
Title V
Title XVIII, Part B
4
5
6
1

PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

Title XIX
7

Title V
(col. 4 x col. 5)
8

WORKSHEET D-2,
PARTS I-III (Cont.)

Title XVIII
(col. 4 x col. 6)
9

Title XIX
(col. 4 x col. 7)
10
1

2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Ratio of Cost
to Charges
(column 2 ÷
column 3)

Title
V

Titles V and XIX Outpatient and
Title XVIII Part B Charges
Title XVIII
Part B

Title
XIX

Title
V

Titles V and XIX Outpatient and
Title XVIII Part B Cost
Title XVIII
Part B

21
22
23
24
25
26
27
28
PART II - IN AN APPROVED TEACHING PROGRAM (TITLE XVIII, PART B INPATIENT ROUTINE COSTS ONLY)
Average Cost
Expenses
Total
Per Day
Title XVIII
Applicable
Inpatient Days (column 3 ÷
Part B
to Title XVIII
All Patients
column 4)
Inpatient Days
(col. 5 x col. 6)
4
5
6
7
29
30
31
32
33
34
35
36
37
38
39
40
41
42
PART III - SUMMARY FOR TITLE XVIII (TO BE COMPLETED ONLY IF BOTH PARTS I AND II ARE USED)
In Approved Teaching Program
Total Title XVIII Costs
(from Part II, col. 7)
Amount
(to Wkst. E, Part B)
(col. 2 + col. 4)
3
4
5
6
43
line 37
44
45
line 22
46
line 38
line 22
47
line 39
line 22
48
line 40
line 22
49
line 41
line 22

Title
XIX
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

FORM CMS-2552-10 (03-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4026)

Rev. 12

40-577

4090 (Cont.)

Check
applicable
boxes:

[ ] Title V
[ ] Title XVIII, Part A
[ ] Title XIX

PROVIDER CCN:
________________
COMPONENT CCN:
________________
[ ] Hospital
[ ] IPF
[ ] IRF

[ ] Subprovider (Other)
[ ] SNF
[ ] NF

COST CENTER DESCRIPTION
(A)
30
31
32
33
34
35
40
41
42
43
50
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
77
88
89
90
91
92
93
93.99
94
95
96
97
98
200
201
202

11-17

FORM CMS-2552-10

INPATIENT ANCILLARY SERVICE
COST APPORTIONMENT

[ ] Swing-Bed SNF
[ ] Swing-Bed NF
[ ] ICF/IID
Ratio of Cost
to Charges
1

INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care (specify)
Subprovider IPF
Subprovider IRF
Subprovider (Specify)
Nursery
ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Prgm. Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
Allogeneic Stem Cell Acquisition
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds (see instructions)
Other Outpatient Service (specify)
Partial Hospitalization Program
OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Total (sum of lines 50 through 94 and 96 through 98)
Less PBP Clinic Laboratory Services-Program only charges (line 61)
Net charges (line 200 minus line 201)

PERIOD:
FROM ____________
TO _______________
[ ] PPS
[ ] TEFRA
[ ] Other
Inpatient
Program Charges
2

WORKSHEET D-3

Inpatient Program Costs
(col. 1 x col. 2)
3
30
31
32
33
34
35
40
41
42
43
50
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
77
88
89
90
91
92
93
93.99
94
95
96
97
98
200
201
202

(A) Worksheet A line numbers

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4027)

40-578

Rev. 12

11-17

FORM CMS-2552-10

COMPUTATION OF ORGAN ACQUISITION COSTS AND CHARGES
FOR HOSPITALS WHICH ARE CERTIFIED TRANSPLANT CENTERS

Check
applicable box:

[ ] HEART
[ ] KIDNEY

[ ] LIVER
[ ] LUNG

[ ] PANCREAS
[ ] INTESTINE

4090 (Cont.)

PROVIDER CCN:
________________
OPO CCN:
________________

PERIOD:
FROM ____________
TO _______________

[ ] ISLET

PART I - COMPUTATION OF ORGAN ACQUISITION COSTS (INPATIENT ROUTINE AND ANCILLARY SERVICES)
Inpatient
Routine Organ
Computation of Inpatient
Per Diem Costs
Charges
Routine Service Costs
(from Wkst. D-1, Part II)
1
Applicable to Organ Acquisition
D
2
1 Adults and Pediatrics
38
2 Intensive Care
43
3 Coronary Care
44
4 Burn Intensive Care Unit
45
5 Surgical Intensive Care Unit
46
6 Other Special Care (specify)
47
7 TOTAL (sum of lines 1 through 6)

Computation of Ancillary
Service Costs Applicable
to Organ Acquisition
8 Operating Room
9 Recovery Room
10 Labor Room & Delivery Room
11 Anesthesiology
12 Radiology-Diagnostic
13 Radiology-Therapeutic
14 Radioisotope
15 Computed Tomography (CT) Scan
16 Magnetic Resonance Imaging (MRI)
17 Cardiac Catheterization
18 Laboratory
19 PBP Clinical Laboratory Services-Program Only
20 Whole Blood & Packed Red Blood Cells
21 Blood Storage, Processing, & Transfusing
22 IV Therapy
23 Respiratory Therapy
24 Physical Therapy
25 Occupational Therapy
26 Speech Pathology
27 Electrocardiology
28 Electroencephalography
29 Medical Supplies Charged to Patients
30 Implantable Devices Charged to Patients
31 Drugs Charged to Patients
32 Renal Dialysis
33 ASC (non-distinct part)
34 Other Ancillary (specify)
35 Rural Health Clinic (RHC)
36 Federally Qualified Health Center (FQHC)
37 Clinic
38 Emergency Room
39 Observation Beds
40 Other Outpatient Service (specify)
41 TOTAL (sum of lines 8 through 40)
C = Worksheet C line numbers

WORKSHEET D-4,
PART I

C
50
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
88
89
90
91
92
93

Ratio of Cost
to Charges
(from
Wkst. C)
1

Organ
Acquisition
Days
3

Cost
(col. 2 x col. 3)
4
1
2
3
4
5
6
7

Organ
Acquisition
Ancillary
Charges
2

Organ
Acquisition
Ancillary
Costs
3
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

D = Worksheet D-1 line numbers

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4028.1)

Rev. 12

40-579

4090 (Cont.)

Check
applicable box:

11-17

FORM CMS-2552-10

COMPUTATION OF ORGAN ACQUISITION COSTS AND CHARGES
FOR HOSPITALS WHICH ARE CERTIFIED TRANSPLANT CENTERS

[ ] HEART
[ ] KIDNEY

[ ] LIVER
[ ] LUNG

[ ] PANCREAS
[ ] INTESTINE

PROVIDER CCN:
________________
OPO CCN:
________________
[ ] ISLET

PERIOD:
FROM ____________
TO _______________

PART II - COMPUTATION OF ORGAN ACQUISITION COSTS (OTHER THAN INPATIENT ROUTINE AND
ANCILLARY SERVICE COSTS)
Average Cost
Computation of the Cost of Inpatient
Per Day
Services of Interns and Residents Not
(from Wkst. D-2,
In Approved Teaching Program
Part I, col. 4)
D
1
42 Adults & Pediatrics (General routine care)
2
43 Intensive Care Unit
3
44 Coronary Care Unit
4
45 Burn Intensive Care Unit
5
46 Surgical Intensive Care Unit
6
47 Other Special Care (specify)
7
48 TOTAL (sum of lines 42 through 47)

Computation of the Cost of Outpatient
Services of Interns and Residents Not
In Approved Teaching Program
49
50
51
52
53
54
55

Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)
TOTAL (sum of lines 49 through 54)

Organ
Charges
(see instructions)
1

Organ
Acquisition Days
2

WORKSHEET D-4,
PART II

Organ
Acquisition
Costs
(col. 1 x col. 2)
3
42
43
44
45
46
47
48

D
21
22
23
24
25
26

Ratio of Cost
to Charges
from Wkst. D-2,
Part I, col. 4)
2

Organ
Acquisition
Costs
(col. 1 x col. 2)
3
49
50
51
52
53
54
55

D = Worksheet D-2, Part I, line numbers

FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4028.2)

40-580

Rev. 12

09-14

FORM CMS-2552-10

COMPUTATION OF ORGAN ACQUISITION COSTS AND CHARGES
FOR HOSPITALS WHICH ARE CERTIFIED TRANSPLANT CENTERS

Check
applicable box:

[ ] HEART
[ ] KIDNEY

[ ] LIVER
[ ] LUNG

[ ] PANCREAS
[ ] INTESTINE

4090 (Cont.)
PROVIDER CCN:
________________
OPO CCN:
________________

PERIOD:
WORKSHEET D-4,
FROM ____________ PARTS III & IV
TO _______________

[ ] ISLET

PART III - SUMMARY OF COSTS AND CHARGES
Cost
Part A
1
56
57
58
59
60
61
62
63
64
65
66
67
68
69

Charges
Part B
2

Part A
3

Part B
4

Routine and Ancillary from Part I
Interns and Residents (inpatient)
Interns and Residents (outpatient)
Direct Organ Acquisition (see instructions)
Cost of physicians' services in a teaching
hospital (see instructions)
Total (sum of lines 56 through 60)
Total Usable Organs (see instructions)
Medicare Usable Organs (see instructions)
Ratio of Medicare Usable Organs to Total Usable
Organs (line 63 ÷ line 62)
Medicare Cost/Charges (see instructions)
Revenue for Organs Sold
Subtotal (line 65 minus line 66)
Organs Furnished Part B
Net Organ Acquisition Cost and Charges (see instructions)

56
57
58
59
60
61
62
63
64
65
66
67
68
69

PART IV - STATISTICS
Living Related
1
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84

Organs Excised in Provider (1)
Organs Purchased from Other Transplant Hospitals (2)
Organs Purchased from Non-Transplant Hospitals
Organs Purchased from OPOs
Total (sum of lines 70 through 73)
Organs Transplanted
Organs Sold to Other Hospitals
Organs Sold to OPOs
Organs Sold to Transplant Hospitals
Organs Sold to Military or VA Hospitals
Organs Sold Outside the U.S.
Organs Sent Outside the U.S. (no revenue received)
Organs Used for Research
Unusable/Discarded Organs
Total (sum of lines 75 through 83 should equal line 74)

Cadaveric
2

Revenue
3
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84

(1) Organs procured outside your center by a procurement team from your center are not included in the count.
(2) Organs procured outside your center by a procurement team from your center are included in the count.

FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4028.3)

Rev. 6

40-581

4090 (Cont.)

FORM CMS-2552-10

09-14

APPORTIONMENT OF COST FOR PHYSICIANS' SERVICES IN A TEACHING HOSPITAL

PROVIDER CCN:
________________

Check applicable box:

[ ] Hospital Staff

PERIOD:
FROM ____________
TO _______________

WORKSHEET D-5,
PART I

[ ] Medical Staff

PART I - REASONABLE COMPENSATION EQUIVALENT COMPUTATION FOR COST REPORTING PERIODS ENDING BEFORE JUNE 30, 2014
Line
No.
1
1
2
3
4
5
6
7
8
9
10
11

Line
No.
9
1
2
3
4
5
6
7
8
9
10
11

Specialty
Description/Physician Identifier
2
General Practitioner Family Practice
Internal Medicine
Surgery
Pediatrics
Obstetrics-Gynecology
Radiology
Psychiatry
Anesthesiology
Pathology
All Other
Total

Specialty
Description/Physician Identifier
10
General Practitioner Family Practice
Internal Medicine
Surgery
Pediatrics
Obstetrics-Gynecology
Radiology
Psychiatry
Anesthesiology
Pathology
All Other
Total (transfer the amount in column 16, line 11, to Part II, line 1, column 1 or 2, as appropriate)

Total
Remuneration
3

Professional
Component
4

RCE
Amount
5

Physician/
Professional
Component Hours
6

Unadjusted
RCE Limit
7

5 Percent
of Unadjusted
RCE Limit
8
1
2
3
4
5
6
7
8
9
10
11

Cost of
Membership
& Continuing
Education
11

Professional
Component
Share of col. 11
12

Cost of
Physician
Malpractice
Insurance
13

Professional
Component
Share of col. 13
14

Adjusted
RCE Limit
15

Adjust Cost
of Physician's
Direct Medical &
Surgical Services
16
1
2
3
4
5
6
7
8
9
10
11

FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4029.1)

40-582

Rev. 6

09-14

4090 (Cont.)

FORM CMS-2552-10

APPORTIONMENT OF COST FOR PHYSICIANS' SERVICES IN A TEACHING HOSPITAL

PROVIDER CCN:
________________

Check
applicable box:

[ ] Hospital
[ ] IRF

PERIOD:
FROM ____________
TO _______________

WORKSHEET D-5,
PART II

[ ] IPF

PART II - APPORTIONMENT OF COST FOR PHYSICIANS' SERVICES IN A TEACHING HOSPITAL FOR COST REPORTING PERIODS ENDING BEFORE JUNE 30, 2014
Medical School
Total
Hospital Staff
Faculty
(col 1 + col 2)
1
2
3
1 Adjusted Cost of Physician's Direct Medical and Surgical Services
2 Total Inpatient Days and Outpatient Visit Days
3 Average Per Diem (line 1 ÷ line 2)

1
2
3

4
5
6
7
8
9
10
11
12
13
14
15
16
17

HEALTH CARE PROGRAM REIMBURSABLE DAYS
Title V - Inpatient
Title V - Outpatient
Title XVIII - Part A
Title XVIII - Part B
Title XIX - Inpatient
Title XIX - Outpatient
Inpatient and Outpatient Kidney Acquisition
Inpatient and Outpatient Liver Acquisition
Inpatient and Outpatient Heart Acquisition
Inpatient and Outpatient Lung Acquisition
Inpatient and Outpatient Pancreas Acquisition
Inpatient and Outpatient Intestine Acquisition
Inpatient and Outpatient Islet Acquisition
Other Organ Acquisition

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

HEALTH CARE PROGRAM REIMBURSABLE COST
Title V - Inpatient (line 3 x line 4)
Title V - Outpatient (line 3 x line 5)
Title XVIII - Part A (line 3 x line 6)
Title XVIII - Part B (line 3 x line 7)
Title XIX - Inpatient (line 3 x line 8)
Title XIX - Outpatient (line 3 x line 9)
Inpatient and Outpatient Kidney Acquisition (line 3 x line 10)
Inpatient and Outpatient Liver Acquisition (line 3 x line 11)
Inpatient and Outpatient Heart Acquisition (line 3 x line 12)
Inpatient and Outpatient Lung Acquisition (line 3 x line 13)
Inpatient and Outpatient Pancreas Acquisition (line 3 x line 14)
Inpatient and Outpatient Intestine Acquisition (line 3 x line 15)
Inpatient and Outpatient Islet Acquisition (line 3 x line 16)
Inpatient and Outpatient Other Organ Acquisition (line 3 x line 17)

18
19
20
21
22
23
24
25
26
27
28
29
30
31

Transfer the amounts in column 3 as follows:
Add lines 18 and 19, and transfer to Worksheet E-3, Part VII
Line 20 to Worksheet E, Part A, or Worksheet E-3, Part I to IV as appropriate
Line 21 to Worksheet E, Part B
Add lines 22 and 23, and transfer to Worksheet E-3, Part VII, as appropriate
Sum of lines 24 through 30 to Worksheet D-4, Part III, line 60

FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4029.2)

Rev. 6

40-583

4090 (Cont.)

FORM CMS-2552-10

09-14

APPORTIONMENT OF COST FOR PHYSICIANS' SERVICES IN A TEACHING HOSPITAL

PROVIDER CCN:
________________

PERIOD:
FROM ____________
TO _______________

WORKSHEET D-5,
PART III

PART III - REASONABLE COMPENSATION EQUIVALENT COMPUTATION FOR COST REPORTING PERIODS ENDING ON OR AFTER JUNE 30, 2014
Wkst. A
Line #
1
1
2
3
4
5
6
7
8
9
10
200

Cost Center / Physician Identifier
2

Total
Remuneration
3

Professional
Component
4

RCE
Amount
5

Physician/
Professional
Component Hours
6

Unadjusted
RCE Limit
7

5 Percent
of Unadjusted
RCE Limit
8
1
2
3
4
5
6
7
8
9
10
200

Total

Wkst. A
Line #
9
1
2
3
4
5
6
7
8
9
10
200

Cost Center / Physician Identifier
10

Cost of
Membership
& Continuing
Education
11

Total (transfer the amount in column 16, line 200, to Part IV, line 1)

Professional
Component
Share of Column 11
12

Cost of
Physician
Malpractice
Insurance
13

Professional
Component
Share of Column 13
14

Adjusted
RCE Limit
15

Adjust Cost
of Physician's
Direct Medical &
Surgical Services
16
1
2
3
4
5
6
7
8
9
10
200

FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4029.3)

40-583.1

Rev. 6

11-17

4090 (Cont.)

FORM CMS-2552-10

APPORTIONMENT OF COST FOR PHYSICIANS' SERVICES IN A TEACHING HOSPITAL

PROVIDER CCN:
________________

Check applicable box:

[ ] Hospital

[ ] IPF

PERIOD:
FROM ____________
TO _______________

WORKSHEET D-5,
PART IV

[ ] IRF

PART IV - APPORTIONMENT OF COST FOR PHYSICIANS' SERVICES IN A TEACHING HOSPITAL FOR COST REPORTING PERIODS ENDING ON OR AFTER JUNE 30, 2014
1 Adjusted cost of physicians' direct medical and surgical services
2 Total inpatient days and outpatient visit days
3 Average per diem (line 1 ÷ line 2)

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

HEALTH CARE PROGRAM REIMBURSABLE DAYS
Title V - Inpatient
Title V - Outpatient
Title XVIII - Part A
Title XVIII - Part B
Title XIX - Inpatient
Title XIX - Outpatient
Inpatient and outpatient kidney acquisition
Inpatient and outpatient liver acquisition
Inpatient and outpatient heart acquisition
Inpatient and outpatient lung acquisition
Inpatient and outpatient pancreas acquisition
Inpatient and outpatient intestine acquisition
Inpatient and autpatient islet acquisition

HEALTH CARE PROGRAM REIMBURSABLE COST
Title V - Inpatient (line 3 x line 4)
Title V - Outpatient (line 3 x line 5)
Title XVIII - Part A (line 3 x line 6)
Title XVIII - Part B (line 3 x line 7)
Title XIX - Inpatient (line 3 x line 8)
Title XIX - Outpatient (line 3 x line 9)
Inpatient and outpatient kidney acquisition (line 3 x line 10)
Inpatient and outpatient liver acquisition (line 3 x line 11)
Inpatient and outpatient heart acquisition (line 3 x line 12)
Inpatient and outpatient lung acquisition (line 3 x line 13)
Inpatient and outpatient pancreas acquisition (line 3 x line 14)
Inpatient and outpatient intestine acquisition (line 3 x line 15)
Inpatient and outpatient islet acquisition (line 3 x line 16)

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

Transfer amounts as follows:
Add lines 18 and 19, and transfer to Worksheet E-3, Part VII, line 20 (title V hospital or component)
Line 20 to Worksheet E, Part A, line 56 (Medicare IPPS); Worksheet E-3, Part I, line 3 (TEFRA); Worksheet E-3, Part II, line 15 (IPF);
Worksheet E-3, Part III, line 16 (IRF); Worksheet E-3, Part IV, line 6 (LTCH); or, Worksheet E-3, Part V, line 17 (Cost reimbursement)
Line 21 to Worksheet E, Part B , line 23 (Medicare Part B Medical and Other Health Services)
Add lines 22 and 23, and transfer to Worksheet E-3, Part VII, line 20 (title XIX hospital or component)
Sum of lines 24 through 30 to Worksheet D-4, Part III, line 60

FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4029.4)

Rev. 12

40-583.2

4090 (Cont.)
CALCULATION OF REIMBURSEMENT
SETTLEMENT

11-17

FORM CMS-2552-10
PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
FROM ___________
TO ______________

PART A - INPATIENT HOSPITAL SERVICES UNDER IPPS
1 DRG amounts other than outlier payments
1.01 DRG amounts other than outlier payments for discharges occurring prior to October 1 (see instructions)
1.02 DRG amounts other than outlier payments for discharges occurring on or after October 1 (see instructions)
1.03 DRG for federal specific operating payment for Model 4 BPCI for discharges occurring prior to October 1 (see instructions)
1.04 DRG for federal specific operating payment for Model 4 BPCI for discharges occurring on or after October 1 (see instructions)
2 Outlier payments for discharges (see instructions)
2.01 Outlier reconciliation amount
2.02 Outlier payment for discharges for Model 4 BPCI (see instructions)
3 Managed care simulated payments
4 Bed days available divided by number of days in the cost reporting period (see instructions)
Indirect Medical Education Adjustment Calculation for Hospitals
5 FTE count for allopathic and osteopathic programs for the most recent cost reporting period ending on or before 12/31/1996 (see instructions)
6 FTE count for allopathic and osteopathic programs which meet the criteria for an add-on to the cap for new programs in accordance with 42 CFR 413.79(e)
7 MMA §422 reduction amount to the IME cap as specified under 42 CFR §412.105(f)(1)(iv)(B)(1)
7.01 ACA §5503 reduction amount to the IME cap as specified under 42 CFR §412.105(f)(1)(iv)(B)(2). If the cost report straddles July 1, 2011, see instructions.
8 Adjustment (increase or decrease) to the FTE count for allopathic and osteopathic programs for affiliated programs in accordance
with 42 CFR 413.75(b), 413.79(c)(2)(iv), 64 FR 26340 (May 12, 1998), and 67 FR 50069 (August 1, 2002).
8.01 The amount of increase if the hospital was awarded FTE cap slots under §5503 of the ACA. If the cost report straddles July 1, 2011, see instructions.
8.02 The amount of increase if the hospital was awarded FTE cap slots from a closed teaching hospital under §5506 of ACA. (see instructions)
9 Sum of lines 5 plus 6, minus lines 7 and 7.01, plus/minus line 8, plus lines 8.01 and 8.02 (see instructions)
10 FTE count for allopathic and osteopathic programs in the current year from your records
11 FTE count for residents in dental and podiatric programs
12 Current year allowable FTE (see instructions)
13 Total allowable FTE count for the prior year
14 Total allowable FTE count for the penultimate year if that year ended on or after September 30, 1997; otherwise enter zero.
15 Sum of lines 12 through 14 divided by 3
16 Adjustment for residents in initial years of the program
17 Adjustment for residents displaced by program or hospital closure
18 Adjusted rolling average FTE count
19 Current year resident to bed ratio (line 18 divided by line 4)
20 Prior year resident to bed ratio (see instructions)
21 Enter the lesser of lines 19 or 20 (see instructions)
22 IME payment adjustment (see instructions)
22.01 IME payment adjustment - Managed Care (see instructions)
Indirect Medical Education Adjustment for the Add-on for §422 of the MMA
23 Number of additional allopathic and osteopathic IME FTE resident cap slots under 42 CFR 412.105 (f)(1)(iv)(C ).
24 IME FTE resident count over cap (see instructions)
25 If the amount on line 24 is greater than -0-, then enter the lower of line 23 or line 24 (see instructions)
26 Resident to bed ratio (divide line 25 by line 4)
27 IME payments adjustment factor (see instructions)
28 IME add-on adjustment amount (see instructions)
28.01 IME add-on adjustment amount - Managed Care (see instructions)
29 Total IME payment (sum of lines 22 and 28)
29.01 Total IME payment - Managed Care (sum of lines 22.01 and 28.01)
Disproportionate Share Adjustment
30 Percentage of SSI recipient patient days to Medicare Part A patient days (see instructions)
31 Percentage of Medicaid patient days to total patient days (see instructions)
32 Sum of lines 30 and 31
33 Allowable disproportionate share percentage (see instructions)
34 Disproportionate share adjustment (see instructions)
Uncompensated Care Adjustment
Prior to October 1
35 Total uncompensated care amount (see instructions)
35.01 Factor 3 (see instructions)
35.02 Hospital uncompensated care payment (If line 34 is zero, enter zero on this line) (see instructions)
35.03 Pro rata share of the hospital uncompensated care payment amount (see instructions)
35.04 Pro rata share of the hospital uncompensated care payment amount (MDH) (see instructions)
35.05 Pro rata share of the hospital uncompensated care payment amount (SCH) (see instructions)
36 Total uncompensated care (sum of columns 1 and 2 on line 35.03)
Additional Payment for High Percentage of ESRD Beneficiary Discharges (lines 40 through 46)
40 Total Medicare discharges, excluding discharges for MS-DRGs 652, 682, 683, 684 and 685 (see instructions)
41 Total ESRD Medicare discharges excluding MS-DRGs 652, 682, 683, 684 an 685 (see instructions)
41.01 Total ESRD Medicare covered and paid discharges excluding MS-DRGs 652, 682, 683, 684, and 685 (see instructions)
42 Divide line 41 by line 40 (if less than 10%, you do not qualify for adjustment)
43 Total Medicare ESRD inpatient days excluding MS-DRGs 652, 682, 683, 684 and 685 (see instructions)
44 Ratio of average length of stay to one week (line 43 divided by line 41.01 divided by 7 days)
45 Average weekly cost for dialysis treatments (see instructions)
46 Total additional payment (line 45 times line 44 times line 41.01)
47 Subtotal (see instructions)
48 Hospital specific payments (to be completed by SCH and MDH, small rural hospitals only (see instructions)
49 Total payment for inpatient operating costs (see instructions)
50 Payment for inpatient program capital (from Wkst. L, Pt. I, or Pt. II, as applicable)
51 Exception payment for inpatient program capital (Wkst. L, Pt. III) (see instructions)
52 Direct graduate medical education payment (from Wkst. E-4, line 49) (see instructions).
53 Nursing and allied health managed care payment
54 Special add-on payments for new technologies
54.01 Islet isolation add-on payment
55 Net organ acquisition cost (Wkst. D-4 Pt. III, col. 1, line 69)

WORKSHEET E,
PART A

1
1.01
1.02
1.03
1.04
2
2.01
2.02
3
4
5
6
7
7.01
8
8.01
8.02
9
10
11
12
13
14
15
16
17
18
19
20
21
22
22.01
23
24
25
26
27
28
28.01
29
29.01
30
31
32
33
34
On or after October 1
35
35.01
35.02
35.03
35.04
35.05
36
40
41
41.01
42
43
44
45
46
47
48
49
50
51
52
53
54
54.01
55

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4030.1)

40-584

Rev. 12

03-18
CALCULATION OF REIMBURSEMENT
SETTLEMENT

4090 (Cont.)

FORM CMS-2552-10
PROVIDER CCN:
________________
COMPONENT CCN:
________________

PART A - INPATIENT HOSPITAL SERVICES UNDER IPPS
56 Cost of physicians' services in a teaching hospital (see instructions)
57 Routine service other pass through costs (from Wkst .D, Pt. III, col. 9, lines 30 through 35)
58 Ancillary service other pass through costs (from Wkst. D, Pt. IV, col. 11, line 200)
59 Total (sum of amounts on lines 49 through 58)
60 Primary payer payments
61 Total amount payable for program beneficiaries (line 59 minus line 60)
62 Deductibles billed to program beneficiaries
63 Coinsurance billed to program beneficiaries
64 Allowable bad debts (see instructions)
65 Adjusted reimbursable bad debts (see instructions)
66 Allowable bad debts for dual eligible beneficiaries (see instructions)
67 Subtotal (line 61 plus line 65 minus lines 62 and 63)
68 Credits received from manufacturers for replaced devices for applicable MS-DRGs (see instructions)
69 Outlier payments reconciliation (sum of lines 93, 95 and 96) (for SCH see instructions)
70 Other adjustments (specify) (see instructions)
70.50 Rural Community Hospital Demonstration Project (§410A Demonstration) adjustment (see instructions)
70.87 Demonstration payment adjustment amount before sequestration
70.88 SCH or MDH volume decrease adjustment (contractor use only)
70.89 Pioneer ACO demonstration payment adjustment amount (see instructions)
70.90 HSP bonus payment HVBP adjustment amount (see instructions)
70.91 HSP bonus payment HRR adjustment amount (see instructions)
70.92 Bundled Model 1 discount amount (see instructions)
70.93 HVBP payment adjustment amount (see instructions)
70.94 HRR adjustment amount (see instructions)
70.95 Recovery of accelerated depreciation
70.96 Low volume adjustment for federal fiscal year (yyyy)
70.97 Low volume adjustment for federal fiscal year (yyyy)
70.99 HAC adjustment amount (see instructions)
71 Amount due provider (see instructions)
71.01 Sequestration adjustment (see instructions)
71.02 Demonstration payment adjustment amount after sequestration
72 Interim payments
73 Tentative settlement (for contractor use only)
74 Balance due provider/program (line 71 minus lines 71.01, 71.02, 72, and 73)
75 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2
TO BE COMPLETED BY CONTRACTOR (lines 90 through 96)
90 Operating outlier amount from Wkst. E, Pt. A, line 2 (see instructions)
91 Capital outlier from Wkst. L, Pt. I, line 2
92 Operating outlier reconciliation adjustment amount (see instructions)
93 Capital outlier reconciliation adjustment amount (see instructions)
94 The rate used to calculate the time value of money (see instructions)
95 Time value of money for operating expenses (see instructions)
96 Time value of money for capital related expenses (see instructions)
HSP Bonus Payment Amount
100 HSP bonus amount (see instructions)
HVBP Adjustment for HSP Bonus Payment
101 HVBP adjustment factor (see instructions)
102 HVBP adjustment amount for HSP bonus payment (see instructions)
HRR Adjustment for HSP Bonus Payment
103 HRR adjustment factor (see instructions)
104 HRR adjustment amount for HSP bonus payment (see instructions)
Rural Community Hospital Demonstration Project (§410A Demonstration) Adjustment
200 Is this the first year of the current 5-year demonstration period under the 21st Century Cures Act? Enter "Y" for yes or "N" for no.
Cost Reimbursement
201 Medicare inpatient service costs (from Wkst. D-1, Pt. II, line 49)
202 Medicare discharges (see instructions)
203 Case-mix adjustment factor (see instructions)
Computation of Demonstration Target Amount Limitation (N/A in first year of the current 5-year demonstration period)
204 Medicare target amount
205 Case-mix adjusted target amount (line 203 times line 204)
206 Medicare inpatient routine cost cap (line 202 times line 205)
Adjustment to Medicare Part A Inpatient Reimbursement
207 Program reimbursement under the §410A Demonstration (see instructions)
208 Medicare Part A inpatient service costs (from Wkst. E, Pt. A, line 59)
209 Adjustment to Medicare IPPS payments (see instructions)
210 Reserved for future use
211 Total adjustment to Medicare IPPS payments (see instructions)
Comparison of PPS versus Cost Reimbursement
212 Total adjustment to Medicare Part A IPPS payments (from line 211)
213 Low-volume adjustment (see instructions)
218 Net Medicare Part A IPPS adjustment (difference between PPS and cost reimbursement) (line 212 minus line 213) (see instructions)

PERIOD:
FROM ___________
TO ______________

WORKSHEET E,
PART A (Cont.)

56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
70.50
70.87
70.88
70.89
70.90
70.91
70.92
70.93
70.94
70.95
70.96
70.97
70.99
71
71.01
71.02
72
73
74
75
90
91
92
93
94
95
96
Prior to 10/1

On or After 10/1

Prior to 10/1

On or After 10/1

100
101
102
Prior to 10/1

On or After 10/1
103
104
200
201
202
203
204
205
206
207
208
209
210
211
212
213
218

FORM CMS-2552-10 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4030.1)

Rev. 14

40-585

4090 (Cont.)
CALCULATION OF
REIMBURSEMENT SETTLEMENT

03-18

FORM CMS-2552-10
PROVIDER CCN:
________________
COMPONENT CCN:
________________
[ ] Subprovider (Other)
[ ] SNF

Check applicable box:
[ ] Hospital
[ ] IPF
[ ] IRF
PART B - MEDICAL AND OTHER HEALTH SERVICES
1 Medical and other services (see instructions)
2 Medical and other services reimbursed under OPPS (see instructions)
3 OPPS payments
4 Outlier payment (see instructions)
4.01 Outlier reconciliation amount (see instructions)
5 Enter the hospital specific payment to cost ratio (see instructions)
6 Line 2 times line 5
7 Sum of lines 3, 4, and 4.01, divided by line 6
8 Transitional corridor payment (see instructions)
9 Ancillary service other pass through costs from Wkst. D, Pt. IV, col. 13, line 200
10 Organ acquisition
11 Total cost (sum of lines 1 and 10) (see instructions)
COMPUTATION OF LESSER OF COST OR CHARGES
Reasonable charges
12 Ancillary service charges
13 Organ acquisition charges (from Wkst. D-4, Part III, col. 4, line 69)
14 Total reasonable charges (sum of lines 12 and 13)
Customary charges
15 Aggregate amount actually collected from patients liable for payment for services on a charge basis
16 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)
17 Ratio of line 15 to line 16 (not to exceed 1.000000)
18 Total customary charges (see instructions)
19 Excess of customary charges over reasonable cost (complete only if line 18 exceeds line 11) (see instructions)
20 Excess of reasonable cost over customary charges (complete only if line 11 exceeds line 18) (see instructions)
21 Lesser of cost or charges (see instructions)
22 Interns and residents (see instructions)
23 Cost of physicians' services in a teaching hospital (see instructions)
24 Total prospective payment (sum of lines 3, 4, 4.01, 8, and 9)
COMPUTATION OF REIMBURSEMENT SETTLEMENT
25 Deductibles and coinsurance (see instructions)
26 Deductibles and Coinsurance relating to amount on line 24 (see instructions)
27 Subtotal [(lines 21 and 24 minus the sum of lines 25 and 26) plus the sum of lines 22 and 23] (see instructions)
28 Direct graduate medical education payments (from Wkst. E-4, line 50)
29 ESRD direct medical education costs (from Wkst. E-4, line 36)
30 Subtotal (sum of lines 27 through 29)
31 Primary payer payments
32 Subtotal (line 30 minus line 31)
ALLOWABLE BAD DEBTS (EXCLUDE BAD DEBTS FOR PROFESSIONAL SERVICES)
33 Composite rate ESRD (from Wkst. I-5, line 11)
34 Allowable bad debts (see instructions)
35 Adjusted reimbursable bad debts (see instructions)
36 Allowable bad debts for dual eligible beneficiaries (see instructions)
37 Subtotal (see instructions)
38 MSP-LCC reconciliation amount from PS&R
39 Other adjustments (specify) (see instructions)
39.50 Pioneer ACO demonstration payment adjustment (see instructions)
39.97 Demonstration payment adjustment amount before sequestration
39.98 Partial or full credits received from manufacturers for replaced devices (see instructions)
39.99 Recovery of Accelerated depreciation
40 Subtotal (see instructions)
40.01 Sequestration adjustment (see instructions)
40.02 Demonstration payment adjustment amount after sequestration
41 Interim payments
42 Tentative settlement (for contractors use only)
43 Balance due provider/program (see instructions)
44 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2

PERIOD:
FROM ____________
TO _______________

WORKSHEET E,
PART B

1
2
3
4
4.01
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
39.50
39.97
39.98
39.99
40
40.01
40.02
41
42
43
44

FORM CMS-2552-10 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4030.2)

40-586

Rev. 14

03-15

Check applicable box:
[ ] Hospital
[ ] IPF
PART B - MEDICAL AND OTHER HEALTH SERVICES

4090 (Cont.)

FORM CMS-2552-10

CALCULATION OF
REIMBURSEMENT SETTLEMENT

[ ] IRF

PROVIDER CCN:
________________
COMPONENT CCN:
________________
[ ] Subprovider (Other)
[ ] SNF

TO BE COMPLETED BY CONTRACTOR
90 Original outlier amount (see instructions)
91 Outlier reconciliation adjustment amount (see instructions)
92 The rate used to calculate the Time Value of Money
93 Time Value of Money (see instructions)
94 Total (sum of lines 91 and 93)

PERIOD:
FROM ____________
TO _______________

WORKSHEET E,
PART B (Cont.)

90
91
92
93
94

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4030.2)

Rev. 7

40-587

4090 (Cont.)

FORM CMS-2552-10

03-15

ANALYSIS OF PAYMENTS TO PROVIDERS
FOR SERVICES RENDERED

Check
applicable
box:

[ ] Hospital
[ ] IPF
[ ] IRF

PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
FROM ____________
TO _______________

[ ] Subprovider (Other)
[ ] SNF
[ ] Swing-Bed SNF
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
for services rendered in the cost reporting period. If none, write "NONE" or enter a 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)

4

5

6
7
8

mm/dd/yyyy
1

Subtotal (sum of lines 5.01-5.49 minus sum of lines 5.50 -5.98)
Determined net settlement amount (balance
due) based on the cost report (1)
Total Medicare program liability (see instructions)
Name of Contractor

Part B
Amount
2

mm/dd/yyyy
3

Amount
4
1
2

Program to Provider

Provider to Program

Subtotal (sum of lines 3.01- 3.49 minus sum of lines 3.50-3.98)
Total interim payments (sum of lines 1, 2, and 3.99)
(transfer to Wkst. E or Wkst. E-3, line
and column as appropriate)
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,
PART I

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

NPR Date (Month/Day/Year)

(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-2552-10 (03-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4031.1)

40-588

Rev. 7

03-18

Check
applicable box:

4090 (Cont.)

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT
SETTLEMENT FOR HIT

[ ] Hospital

PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
WORKSHEET E-1,
FROM ____________ PART II
TO _______________

[ ] CAH

HEALTH INFORMATION TECHNOLOGY DATA COLLECTION AND CALCULATION
1 Total hospital discharges as defined in ARRA §4102 (Wkst. S-3, Pt. I, col. 15, line 14)
2 Medicare days (Wkst. S-3, Pt. I, col. 6, sum of lines 1 and 8 through 12)
3 Medicare HMO days (Wkst. S-3, Pt. I, col. 6, line 2)
4 Total inpatient days (Wkst. S-3, Pt. I, col. 8, sum of lines 1 and 8 through 12)
5 Total hospital charges (Wkst. C, Pt. I, col. 8, line 200)
6 Total hospital charity care charges (Wkst. S-10, col. 3, line 20)
7 CAH only - The reasonable cost incurred for the purchase of certified HIT technology (Wkst. S-2, Pt. I, line 168)
8 Calculation of the HIT incentive payment (see instructions)
9 Sequestration adjustment amount (see instructions)
10 Calculation of the HIT incentive payment after sequestration (see instructions)

1
2
3
4
5
6
7
8
9
10

INPATIENT HOSPITAL SERVICES UNDER THE IPPS & CAH
30 Initial/interim HIT payment(s).
31 Initial/interim HIT payment adjustments (see instructions)
32 Balance due provider (line 8 or line 10 minus line 30 and line 31) (see instructions)

30
31
32

* This worksheet is completed by the contractor for standard and non-standard cost reporting periods at cost report settlement. Providers may
may complete this worksheet for a standard cost reporting period.

FORM CMS-2552-10 (09-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4031.2)

Rev. 14

40-589

4090 (Cont.)

Check
applicable
boxes:

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
16.50
16.55
16.99
17
17.01
18
19
19.01
19.02
20
21
22
23

200
201
202
203
204
205
206
207
208
209
210
215

03-18

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT
SETTLEMENT - SWING BEDS

[ ] Title V
[ ] Title XVIII
[ ] Title XIX

PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
WORKSHEET E-2
FROM ____________
TO _______________

[ ] Swing Bed - SNF
[ ] Swing Bed - NF

COMPUTATION OF NET COST OF COVERED SERVICES
Inpatient routine services - swing bed-SNF (see instructions)
Inpatient routine services - swing bed-NF (see instructions)
Ancillary services (from Wkst. D-3, col. 3, line 200, for Part A; and sum of Wkst. D, Pt. V,
cols. 6 and 7, line 202, for Part B) (For CAH, see instructions)
Per diem cost for interns and residents not in approved teaching program (see instructions)
Program days
Interns and residents not in approved teaching program (see instructions)
Utilization review - physician compensation - SNF optional method only
Subtotal (sum of lines 1 through 3 plus lines 6 and 7)
Primary payer payments (see instructions)
Subtotal (line 8 minus line 9)
Deductibles billed to program patients (exclude amounts applicable to physician professional services)
Subtotal (line 10 minus line 11)
Coinsurance billed to program patients (from provider records) (exclude coinsurance for physician professional services)
80% of Part B costs (line 12 x 80%)
Subtotal (enter the lesser of line 12 minus line 13, or line 14)
Other adjustments (specify) (see instructions)
Pioneer ACO demonstration payment adjustment (see instructions)
Rural community hospital demonstration project (§410A Demonstration) payment adjustment (see instructions)
Demonstration payment adjustment amount before sequestration
Allowable bad debts (see instructions)
Adjusted reimbursable bad debts (see instructions)
Allowable bad debts for dual eligible beneficiaries (see instructions)
Total (see instructions)
Sequestration adjustment (see instructions)
Demonstration payment adjustment amount after sequestration
Interim payments
Tentative settlement (for contractor use only)
Balance due provider/program (line 19 minus lines 19.01, 19.02, 20, and 21)
Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2
Rural Community Hospital Demonstration Project (§410A Demonstration) Adjustment
Is this the first year of the current 5-year demonstration period under the 21st Century Cures Act? Enter "Y" for yes or "N" for no.
Cost Reimbursement
Medicare swing-bed SNF inpatient routine service costs (from Wkst. D-1, Pt. II, line 66 (title XVIII hospital))
Medicare swing-bed SNF inpatient ancillary service costs (from Wkst. D-3, col. 3, line 200 (title XVIII swing-bed SNF))
Total (sum of lines 201 and 202)
Medicare swing-bed SNF discharges (see instructions)
Computation of Demonstration Target Amount Limitation (N/A in first year of the current 5-year demonstration period)
Medicare swing-bed SNF target amount
Medicare swing-bed SNF inpatient routine cost cap (line 205 times line 204)
Adjustment to Medicare Part A Swing-Bed SNF Inpatient Reimbursement
Program reimbursement under the §410A Demonstration (see instructions)
Medicare swing-bed SNF inpatient service costs (from Wkst. E-2, col. 1, sum of lines 1 and 3)
Adjustment to Medicare swing-bed SNF PPS payments (see instructions)
Reserved for future use
Comparison of PPS versus Cost Reimbursement
Total adjustment to Medicare swing-bed SNF PPS payment (line 209 plus line 210) (see instructions)

PART A
1

PART B
2
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
16.50
16.55
16.99
17
17.01
18
19
19.01
19.02
20
21
22
23

200
201
202
203
204
205
206
207
208
209
210
215

FORM CMS-2552-10 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4032)

40-590

Rev. 14

11-17

4090 (Cont.)

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT SETTLEMENT

PROVIDER CCN:
________________

PERIOD:
WORKSHEET E-3,
FROM ____________ PART I
TO _______________

PART I - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER TEFRA
1
1.01
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
17.50
17.99
18
18.01
18.02
19
20
21
22

Inpatient hospital services (see instructions)
Nursing and allied health managed care payment (see instructions)
Organ acquisition
Cost of physicians' services in a teaching hospital (see instructions)
Subtotal (sum of lines 1 through 3)
Primary payer payments
Subtotal (line 4 less line 5).
Deductibles
Subtotal (line 6 minus line 7)
Coinsurance
Subtotal (line 8 minus line 9)
Allowable bad debts (exclude bad debts for professional services) (see instructions)
Adjusted reimbursable bad debts (see instructions)
Allowable bad debts for dual eligible beneficiaries (see instructions)
Subtotal (sum of lines 10 and 12)
Direct graduate medical education payments (from Wkst. E-4, line 49)
Other pass through costs (see instructions). DO NOT USE THIS LINE.
Other adjustments (specify) (see instructions)
Pioneer ACO demonstration payment adjustment (see instructions)
Demonstration payment adjustment amount before sequestration
Total amount payable to the provider (see instructions)
Sequestration adjustment (see instructions)
Demonstration payment adjustment amount after sequestration
Interim payments
Tentative settlement (for contractor use only)
Balance due provider/program (line 18 minus lines 18.01, 18.02,19, and 20)
Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2

1
1.01
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
17.50
17.99
18
18.01
18.02
19
20
21
22

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.1)

Rev. 12

40-591

4090 (Cont.)

Check
applicable
box:

11-17

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT SETTLEMENT

PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
FROM __________
TO _____________

WORKSHEET E-3,
PART II

[ ] Hospital
[ ] Subprovider IPF

PART II - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER IPF PPS
1 Net Federal IPF PPS payment (excluding outlier, ECT, and medical education payments)
2 Net IPF PPS Outlier payment
3 Net IPF PPS ECT payment
4 Unweighted intern and resident FTE count in the most recent cost report filed on or before November 15, 2004 (see instructions)
4.01 Cap increases for the unweighted intern and resident FTE count for residents that were displaced by program or hospital closure,
that would not be counted without a temporary cap adjustment under 42 CFR §412.424(d)(1)(iii)(F)(1) or (2) (see instructions)
5 New teaching program adjustment (see instructions)
6 Current year unweighted FTE count of I&R excluding FTEs in the new program growth period
of a "new teaching program" (see instructions)
7 Current year unweighted I&R FTE count for residents within the new program growth period
of a "new teaching program" (see instructions)
8 Intern and resident count for IPF PPS medical education adjustment (see instructions)
9 Average daily census (see instructions)
10 Teaching Adjustment Factor {((1 + (line 8/line 9)) raised to the power of .5150 -1}.
11 Teaching Adjustment (line 1 multiplied by line 10).
12 Adjusted Net IPF PPS Payments (sum of lines 1, 2, 3, and 11)
13 Nursing and allied health managed care payment (see instructions)
14 Organ acquisition DO NOT USE THIS LINE
15 Cost of physicians' services in a teaching hospital (see instructions)
16 Subtotal (see instructions)
17 Primary payer payments
18 Subtotal (line 16 less line 17).
19 Deductibles
20 Subtotal (line 18 minus line 19)
21 Coinsurance
22 Subtotal (line 20 minus line 21)
23 Allowable bad debts (exclude bad debts for professional services) (see instructions)
24 Adjusted reimbursable bad debts (see instructions)
25 Allowable bad debts for dual eligible beneficiaries (see instructions)
26 Subtotal (sum of lines 22 and 24)
27 Direct graduate medical education payments (from Wkst. E-4, line 49) (For freestanding IPF only)
28 Other pass through costs (see instructions)
29 Outlier payments reconciliation
30 Other adjustments (specify) (see instructions)
30.50 Pioneer ACO demonstration payment adjustment (see instructions)
30.99 Demonstration payment adjustment amount before sequestration
31 Total amount payable to the provider (see instructions)
31.01 Sequestration adjustment (see instructions)
31.02 Demonstration payment adjustment amount after sequestration
32 Interim payments
33 Tentative settlement (for contractor use only)
34 Balance due provider/program (line 31 minus lines 31.01, 31.02, 32, and 33)
35 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2

TO BE COMPLETED BY CONTRACTOR
50 Original outlier amount from Worksheet E-3, Part II, line 2 (see instructions)
51 Outlier reconciliation adjustment amount (see instructions)
52 The rate used to calculate the Time Value of Money (see instructions)
53 Time Value of Money (see instructions)

1
2
3
4
4.01
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
30.50
30.99
31
31.01
31.02
32
33
34
35

50
51
52
53

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.2)

40-592

Rev. 12

03-18

4090 (Cont.)

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT SETTLEMENT

Check
applicable
box:

PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
FROM _________
TO ____________

WORKSHEET E-3,
PART III

[ ] Hospital
[ ] Subprovider IRF

PART III - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER IRF PPS
1
2
3
4
5
5.01
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
31.50
31.99
32
32.01
32.02
33
34
35
36

Net Federal PPS payment (see instructions)
Medicare SSI ratio (IRF PPS only) (see instructions)
Inpatient Rehabilitation LIP payments (see instructions)
Outlier payments
Unweighted intern and resident FTE count in the most recent cost reporting period ending
on or prior to November 15, 2004 (see instructions)
Cap increases for the unweighted intern and resident FTE count for residents that were displaced by program or hospital
closure, that would not be counted without a temporary cap adjustment under 42 CFR §412.424(d)(1)(iii)(F)(1) or (2)
New teaching program adjustment (see instructions)
Current year unweighted FTE count of I&R excluding FTEs in the new program growth period
of a "new teaching program" (see isntructions)
Current year unweighted I&R FTE count for residents within the new program growth period
of a “new teaching program” (see isntructions)
Intern and resident count for IRF PPS medical education adjustment (see instructions)
Average daily census (see instructions)
Teaching Adjustment Factor (see instructions)
Teaching Adjustment (see instructions)
Total PPS Payment (see instructions)
Nursing and allied health managed care payments (see instructions)
Organ acquisition DO NOT USE THIS LINE
Cost of physicians' services in a teaching hospital (see instructions)
Subtotal (see instructions)
Primary payer payments
Subtotal (line 17 less line 18)
Deductibles
Subtotal (line 19 minus line 20)
Coinsurance
Subtotal (line 21 minus line 22)
Allowable bad debts (exclude bad debts for professional services) (see instructions)
Adjusted reimbursable bad debts (see instructions)
Allowable bad debts for dual eligible beneficiaries (see instructions)
Subtotal (sum of lines 23 and 25)
Direct graduate medical education payments (from Wkst. E-4, line 49) (For free standing IRF only)
Other pass through costs (see instructions)
Outlier payments reconciliation
Other adjustments (specify) (see instructions)
Pioneer ACO demonstration payment adjustment (see instructions)
Demonstration payment adjustment amount before sequestration
Total amount payable to the provider (see instructions)
Sequestration adjustment (see instructions)
Demonstration payment adjustment amount after sequestration
Interim payments
Tentative settlement (for contractor use only)
Balance due provider/program (line 32 minus lines 32.01, 32.02, 33, and 34)
Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2

TO BE COMPLETED BY CONTRACTOR
50 Original outlier amount from Wkst. E-3, Pt. III, line 4 (see instructions)
51 Outlier reconciliation adjustment amount (see instructions)
52 The rate used to calculate the Time Value of Money (see instructions)
53 Time Value of Money (see instructions)

1
2
3
4
5
5.01
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
31.50
31.99
32
32.01
32.02
33
34
35
36

50
51
52
53

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.3)

Rev. 14

40-593

4090 (Cont.)

03-18

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT SETTLEMENT

PROVIDER CCN:
________________

PERIOD:
WORKSHEET E-3,
FROM ____________ PART IV
TO _______________

PART IV - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER LTCH PPS
1
1.01
1.02
1.03
1.04
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
21.50
21.99
22
22.01
22.02
23
24
25
26

Net Federal PPS payment (see instructions)
Full standard payment amount
Short stay outlier standard payment amount
Site neutral payment amount - Cost
Site neutral payment amount - IPPS comparable
Outlier payments
Total PPS payments (sum of lines 1 and 2)
Nursing and allied health managed care payments (see instructions)
Organ acquisition DO NOT USE THIS LINE
Cost of physicians' services in a teaching hospital (see instructions)
Subtotal (see instructions)
Primary payer payments
Subtotal (line 7 less line 8)
Deductibles
Subtotal (line 9 minus line 10)
Coinsurance
Subtotal (line 11 minus line 12)
Allowable bad debts (exclude bad debts for professional services) (see instructions)
Adjusted reimbursable bad debts (see instructions)
Allowable bad debts for dual eligible beneficiaries (see instructions)
Subtotal (sum of lines 13 and 15)
Direct graduate medical education payments (from Wkst. E-4, line 49)
Other pass through costs (see instructions)
Outlier payments reconciliation
Other adjustments (specify) (see instructions)
Pioneer ACO demonstration payment adjustment (see instructions)
Demonstration payment adjustment amount before sequestration
Total amount payable to the provider (see instructions)
Sequestration adjustment (see instructions)
Demonstration payment adjustment amount after sequestration
Interim payments
Tentative settlement (for contractor use only)
Balance due provider/program (line 22 minus lines 22.01, 22.02, 23, and 24)
Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2

TO BE COMPLETED BY CONTRACTOR
50 Original outlier amount from Wkst. E-3, Pt. IV, line 2 (see instructions)
51 Outlier reconciliation adjustment amount (see instructions)
52 The rate used to calculate the Time Value of Money (see instructions)
53 Time Value of Money (see instructions)

1
1.01
1.02
1.03
1.04
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
21.50
21.99
22
22.01
22.02
23
24
25
26

50
51
52
53

FORM CMS-2552-10 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.4)

40-594

Rev. 14

11-17

4090 (Cont.)

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT SETTLEMENT

PROVIDER CCN:
________________

PERIOD:
WORKSHEET E-3,
FROM ____________ PART V
TO _______________

PART V - CALCULATION OF REIMBURSEMENT SETTLEMENT FOR MEDICARE PART A SERVICES - COST REIMBURSEMENT
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
29.50
29.99
30
30.01
30.02
31
32
33
34

Inpatient services
Nursing and allied health managed care payment (see instructions)
Organ acquisition
Subtotal (sum of lines 1 through 3)
Primary payer payments
Total cost (see instructions)
COMPUTATION OF LESSER OF COST OR CHARGES
Reasonable charges
Routine service charges
Ancillary service charges
Organ acquisition charges, net of revenue
Total reasonable charges
Customary charges
Aggregate amount actually collected from patients liable for payment for services on a charge basis
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)
Ratio of line 11 to line 12 (not to exceed 1.000000)
Total customary charges (see instructions)
Excess of customary charges over reasonable cost (complete only if line 14 exceeds line 6) (see instructions)
Excess of reasonable cost over customary charges (complete only if line 6 exceeds line 14) (see instructions)
Cost of physicians' services in a teaching hospital (see instructions)
COMPUTATION OF REIMBURSEMENT SETTLEMENT
Direct graduate medical education payments
Cost of covered services (sum of lines 6 and 17)
Deductibles (exclude professional component)
Excess reasonable cost (from line 16)
Subtotal (line 19 minus lines 20 and 21)
Coinsurance
Subtotal (line 22 minus line 23)
Allowable bad debts (exclude bad debts for professional services) (see instructions)
Adjusted reimbursable bad debts (see instructions)
Allowable bad debts for dual eligible beneficiaries (see instructions)
Subtotal (sum of lines 24 and 25 or 26)
Other adjustments (specify) (see instructions)
Pioneer ACO demonstration payment adjustment (see instructions)
Demonstration payment adjustment amount before sequestration
Subtotal (see instructions)
Sequestration adjustment (see instructions)
Demonstration payment adjustment amount after sequestration
Interim payments
Tentative settlement (for contractor use only)
Balance due provider/program (line 30 minus lines 30.01, 30.02, 31, and 32)
Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2

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
29.50
29.99
30
30.01
30.02
31
32
33
34

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.5)

Rev. 12

40-595

4090 (Cont.)

11-17

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT SETTLEMENT

PROVIDER CCN:
PERIOD:
WORKSHEET E-3,
________________
FROM ____________ PART VI
COMPONENT CCN.: TO _______________
________________

PART VI - CALCULATION OF REIMBURSEMENT SETTLEMEMENT - TITLE XVIII PART A PPS SNF SERVICES

PROSPECTIVE PAYMENT AMOUNT (SEE INSTRUCTIONS)
1 Resource Utilization Group (RUGS) payment
2 Routine service other pass through costs
3 Ancillary service other pass through costs
4 Subtotal (sum of lines 1 through 3)
COMPUTATION OF NET COST OF COVERED SERVICES
5 Medical and other services. Do not use this line. (see instructions)
6 Deductibles
7 Coinsurance
8 Allowable bad debts (see instructions)
9 Reimbursable bad debts for dual eligible beneficiaries (see instructions)
10 Adjusted reimbursable bad debts (see instructions)
11 Utilization review
12 Subtotal (sum of lines 4 and 5, minus lines 6 and 7, plus lines 10 and 11) (see instructions)
13 Inpatient primary payer payments
14 Other adjustments (specify) (see instructions)
14.50 Pioneer ACO demonstration payment adjustment (see instructions)
14.99 Demonstration payment adjustment amount before sequestration
15 Subtotal (see instructions)
15.01 Sequestration adjustment (see instructions)
15.02 Demonstration payment adjustment amount after sequestration
16 Interim payments
17 Tentative settlement (for contractor use only)
18 Balance due provider/program (line 15 minus lines 15.01, 15.02, 16, and 17)
19 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2

1
2
3
4
5
6
7
8
9
10
11
12
13
14
14.50
14.99
15
15.01
15.02
16
17
18
19

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.6)

40-596

Rev. 12

11-16

Check
applicable
boxes:

4090 (Cont.)

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT SETTLEMENT

[ ] Title V
[ ] Title XIX

[ ] Hospital
[ ] Subprovider
[ ] SNF

PROVIDER CCN:
________________
COMPONENT CCN:
________________
[ ] NF
[ ] ICF/IID

PERIOD:
WORKSHEET E-3,
FROM ____________ PART VII
TO _______________

[ ] PPS
[ ] TEFRA
[ ] Other

PART VII - CALCULATION OF REIMBURSEMENT - ALL OTHER HEALTH SERVICES FOR TITLES V OR XIX SERVICES

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

COMPUTATION OF NET COST OF COVERED SERVICES
Inpatient hospital/SNF/NF services
Medical and other services
Organ acquisition (certified transplant centers only)
Subtotal (sum of lines 1, 2 and 3)
Inpatient primary payer payments
Outpatient primary payer payments
Subtotal (line 4 less sum of lines 5 and 6)
COMPUTATION OF LESSER OF COST OR CHARGES
Reasonable Charges
Routine service charges
Ancillary service charges
Organ acquisition charges, net of revenue
Incentive from target amount computation
Total reasonable charges (sum of lines 8 through 11)
CUSTOMARY CHARGES
Amount actually collected from patients liable for payment for services on a charge basis
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)
Ratio of line 13 to line 14 (not to exceed 1.000000)
Total customary charges (see instructions)
Excess of customary charges over reasonable cost (complete only if line 16
exceeds line 4) (see instructions)
Excess of reasonable cost over customary charges (complete only if line 4 exceeds line 16) (see instructions)
Interns and residents (see instructions)
Cost of physicians' service in a teaching hospital (see instructions)
Cost of covered services (enter the lesser of line 4 or line 16)
PROSPECTIVE PAYMENT AMOUNT
Other than outlier payments
Outlier payments
Program capital payments
Capital exception payments (see instructions)
Routine and ancillary service other pass through costs
Subtotal (sum of lines 22 through 26)
Customary charges (title V or XIX PPS covered services only)
Titles V or XIX (sum of lines 21 and 27)
COMPUTATION OF REIMBURSEMENT SETTLEMENT
Excess of reasonable cost (from line 18)
Subtotal (sum of lines 19 and 20, plus 29 minus lines 5 and 6)
Deductibles
Coinsurance
Allowable bad debts (see instructions)
Utilization review
Subtotal (sum of lines 31, 34 and 35 minus the sum of lines 32 and 33)
Other adjustments (specify) (see instructions)
Subtotal (line 36 ± line 37)
Direct graduate medical education payments (from Wkst. E-4)
Total amount payable to the provider (sum of lines 38 and 39)
Interim payments
Balance due provider/program (line 40 minus line 41)
Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2

Inpatient
Title V or
Title XIX

Outpatient
Title V or
Title XIX
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

FORM CMS-2552-10 (09-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.7)

Rev. 10

40-597

4090 (Cont.)

11-16

FORM CMS-2552-10

DIRECT GRADUATE MEDICAL EDUCATION (GME)
PROVIDER CCN:
PERIOD:
WORKSHEET E-4
& ESRD OUTPATIENT DIRECT MEDICAL
________________
FROM ____________
EDUCATION COSTS
TO _______________
Check
[ ] Title V
applicable
[ ] Title XVIII
box:
[ ] Title XIX
COMPUTATION OF TOTAL DIRECT GME AMOUNT
1 Unweighted resident FTE count for allopathic and osteopathic programs for cost reporting periods ending on or before December 31, 1996
2 Unweighted FTE resident cap add-on for new programs per 42 CFR 413.79(e) (see instructions)
3 Amount of reduction to Direct GME cap under §422 of MMA
3.01 Direct GME cap reduction amount under ACA §5503 in accordance with 42 CFR §413.79 (m). (see instructions
for cost reporting periods straddling 7/1/2011)
4 Adjustment (plus or minus) to the FTE cap for allopathic and osteopathic programs due to a Medicare GME
4.01
4.02
5
6
7

8
9
10
10.01
11
12
13
14
15
15.01
16
16.01
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

32
33
34
35
36

affiliation agreement (42 CFR §413.75(b) and § 413.79 (f))
ACA §5503 increase to the direct GME FTE cap (see instructions for cost reporting periods straddling 7/1/2011)
ACA §5506 number of additional direct GME FTE cap slots (see instructions for cost reporting periods straddling 7/1/2011)
FTE adjusted cap (line 1 plus line 2 minus line 3 and 3.01 plus or minus line 4 plus lines 4.01 and 4.02 plus applicable subscripts
Unweighted resident FTE count for allopathic and osteopathic programs for the current year from your records (see instructions)
Enter the lesser of line 5 or line 6
Primary Care
1
Weighted FTE count for physicians in an allopathic and osteopathic program for
the current year
If line 6 is less than 5 enter the amount from line 8, otherwise multiply line 8 times
the result of line 5 divided by the amount on line 6
Weighted dental and podiatric resident FTE count for the current year
Unweighted dental and podiatric resident FTE count for the current year
Total weighted FTE count
Total weighted resident FTE count for the prior cost reporting year (see instructions)
Total weighted resident FTE count for the penultimate cost reporting year (see instr.)
Rolling average FTE count (sum of lines 11 through 13 divided by 3)
Adjustment for residents in initial years of new programs
Unweighted adjustment for residents in initial years of new programs
Adjustment for residents displaced by program or hospital closure
Unweighted adjustment for residents displaced by program or hospital closure
Adjusted rolling average FTE count
Per resident amount
Approved amount for resident costs
Additional unweighted allopathic and osteopathic direct GME FTE resident cap slots received under 42 §413.79(c )(4)
Direct GME FTE unweighted resident count over cap (see instructions)
Allowable additional direct GME FTE resident count (see instructions)
Enter the locality adjustment national average per resident amount (see instructions)
Multiply line 22 time line 23
Total direct GME amount (sum of lines 19 and 24)
COMPUTATION OF PROGRAM PATIENT LOAD
Inpatient Part A
Inpatient days (see instructions)
Total inpatient days (see instructions)
Ratio of inpatient days to total inpatient days
Program direct GME amount
Reduction for direct GME payments for Medicare Advantage
Net Program direct GME amount
DIRECT MEDICAL EDUCATION COSTS FOR ESRD COMPOSITE RATE - TITLE XVIII ONLY (NURSING SCHOOL AND
PARAMEDICAL EDUCATION COSTS)
Renal dialysis direct medical education costs (from Wkst. B, Pt. I, sum of col. 20 and 23, lines 74 and 94)
Renal dialysis and home dialysis total charges (Wkst. C, Pt. I, col. 8, sum of lines 74 and 94)
Ratio of direct medical education costs to total charges (line 32 ÷ line 33)
Medicare outpatient ESRD charges (see instructions)
Medicare outpatient ESRD direct medical education costs (line 34 x line 35)

1
2
3
3.01
4
4.01
4.02
5
6
7

Other
2

Total
3
8
9
10
10.01
11
12
13
14
15
15.01
16
16.01
17
18
19
20
21
22
23
24
25

Managed Care
26
27
28
29
30
31

32
33
34
35
36

FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4034)

40-598

Rev. 10

09-14

4090 (Cont.)

FORM CMS-2552-10

DIRECT GRADUATE MEDICAL EDUCATION (GME)
& ESRD OUTPATIENT DIRECT MEDICAL
EDUCATION COSTS
Check
[ ] Title V
applicable
[ ] Title XVIII
box:
[ ] Title XIX
APPORTIONMENT OF MEDICARE REASONABLE COST OF GME
Part A Reasonable Cost
37 Reasonable cost (see instructions)
38 Organ acquisition costs Wkst. D-4, Pt. III, col. 1, line 69)
39 Cost of physicians' services in a teaching hospital (see instructions)
40 Primary payer payments (see instructions)
41 Total Part A reasonable cost (sum of lines 37 through 39 minus line 40)
Part B Reasonable Cost
42 Reasonable cost (see instructions)
43 Primary payer payments (see instructions)
44 Total Part B reasonable cost (line 42 minus line 43)
45 Total reasonable cost (sum of lines 41 and 44)
46 Ratio of Part A reasonable cost to total reasonable cost (line 41 ÷ line 45)
47 Ratio of Part B reasonable cost to total reasonable cost (line 44 ÷ line 45)
ALLOCATION OF MEDICARE DIRECT GME COSTS BETWEEN PART A AND PART B
48 Total program GME payment (line 31)
49 Part A Medicare GME payment (line 46 x 48) (title XVIII only) (see instructions)
50 Part B Medicare GME payment (line 47 x 48) (title XVIII only) (see instructions)

PROVIDER CCN:
________________

PERIOD:
WORKSHEET E-4
FROM ____________
TO _______________

37
38
39
40
41
42
43
44
45
46
47
48
49
50

FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4034)

Rev. 6

40-599

4090 (Cont.)

FORM CMS-2552-10

BALANCE SHEET
(If you are nonproprietary and do not maintain fund-type
accounting records, complete the General Fund column only)

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

Assets
(Omit cents)
CURRENT ASSETS
Cash on hand and in banks
Temporary investments
Notes receivable
Accounts receivable
Other receivables
Allowances for uncollectible notes and
accounts receivable
Inventory
Prepaid expenses
Other current assets
Due from other funds
Total current assets (sum of lines 1-10)
FIXED ASSETS
Land
Land improvements
Accumulated depreciation
Buildings
Accumulated depreciation
Leasehold improvements
Accumulated depreciation
Fixed equipment
Accumulated depreciation
Automobiles and trucks
Accumulated depreciation
Major movable equipment
Accumulated depreciation
Minor equipment depreciable
Accumulated depreciation
HIT designated Assets
Accumulated depreciation
Minor equipment-nondepreciable
Total fixed assets (sum of lines 12-29)
OTHER ASSETS
Investments
Deposits on leases
Due from owners/officers
Other assets
Total other assets (sum of lines 31-34)
Total assets (sum of lines 11, 30, and 35)

PROVIDER CCN:

General
Fund
1

________________
Specific
Purpose
Fund
2

09-14
PERIOD:
WORKSHEET G
FROM ____________
TO _______________
Endowment
Fund
3

Plant
Fund
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

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4040)

40-600

Rev. 6

10-12

Liabilities and Fund
Balances
(Omit cents)
CURRENT LIABILITIES
37 Accounts payable
38 Salaries, wages, and fees payable
39 Payroll taxes payable
40 Notes and loans payable (short term)
41 Deferred income
42 Accelerated payments
43 Due to other funds
44 Other current liabilities
45 Total current liabilities (sum of
lines 37 thru 44)

4090 (Cont.)

FORM CMS-2552-10

BALANCE SHEET
(If you are nonproprietary and do not maintain fund-type
accounting records, complete the General Fund column only)

PROVIDER CCN:

General
Fund
1

________________
Specific
Purpose
Fund
2

PERIOD:
WORKSHEET G
FROM ____________ (CONT.)
TO _______________
Endowment
Fund
3

LONG TERM LIABILITIES
46 Mortgage payable
47 Notes payable
48 Unsecured loans
49 Other long term liabilities
50 Total long term liabilities (sum of
lines 46 thru 49)
51 Total liabilities (sum of lines 45 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)

Plant
Fund
4
37
38
39
40
41
42
43
44
45

46
47
48
49
50
51

52
53
54
55
56
57
58
59
60

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4040)

Rev. 3

40-601

4090 (Cont.)

FORM CMS-2552-10

10-12

STATEMENT OF CHANGES IN FUND BALANCES

PROVIDER CCN:

1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

GENERAL FUND
2

SPECIFIC PURPOSE FUND
3
4

Fund balances at beginning of period
Net income (loss) (from Worksheet G-3, line 29)
Total (sum of line 1 and line 2)
Additions (credit adjustments) (specify)

Total additions (sum of lines 4-9)
Subtotal (line 3 plus line 10)
Deductions (debit adjustments) (specify)

Total deductions (sum of lines 12-17)
Fund balance at end of period per balance
sheet (line 11 minus line 18)

5

________________
ENDOWMENT FUND
6

PERIOD:
WORKSHEET G-1
FROM ____________
TO _______________
PLANT FUND
7
8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4040)

40-602

Rev. 3

10-12

4090 (Cont.)

FORM CMS-2552-10

STATEMENT OF PATIENT REVENUES
AND OPERATING EXPENSES

PROVIDER CCN:
________________

PERIOD:
WORKSHEET G-2,
FROM ____________ PARTS I & II
TO _______________

PART I - PATIENT REVENUES

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

REVENUE CENTER
GENERAL INPATIENT ROUTINE CARE SERVICES
Hospital
Subprovider IPF
Subprovider IRF
Subprovider (Other)
Swing bed - SNF
Swing bed - NF
Skilled nursing facility
Nursing facility
Other long term care
Total general inpatient care services (sum of lines 1-9)
INTENSIVE CARE TYPE INPATIENT HOSPITAL SERVICES
Intensive care unit
Coronary care unit
Burn intensive care unit
Surgical intensive care unit
Other special care (specify)
Total intensive care type inpatient hospital services (sum of
of lines 11-15)
Total inpatient routine care services (sum of lines 10 and 16)
Ancillary services
Outpatient services
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Home health agency
Ambulance
Outpatient rehabilitation providers
ASC
Hospice
Other (specify)
Total patient revenues (sum of lines 17-27) (transfer column 3 to
Worksheet G-3, line 1)

INPATIENT
1

OUTPATIENT
2

TOTAL
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

PART II - OPERATING EXPENSES
1
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43

Operating expenses (per Wkst. A, column 3, line 200)
Add (specify)

Total additions (sum of lines 30-35)
Deduct (specify)

Total deductions (sum of lines 37-41)
Total operating expenses (sum of lines 29 and 36 minus line 42) (transfer to Worksheet G-3, line 4)

2
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4040)

Rev. 3

40-603

4090 (Cont.)
STATEMENT OF REVENUES
AND EXPENSES

10-12

FORM CMS-2552-10
PROVIDER CCN:
________________

1
2
3
4
5

Description
Total patient revenues (from Worksheet G-2, Part I, column 3, line 28)
Less contractual allowances and discounts on patients' accounts
Net patient revenues (line 1 minus line 2)
Less total operating expenses (from Worksheet G-2, Part II, line 43)
Net income from service to patients (line 3 minus line 4)

PERIOD:
WORKSHEET G-3
FROM ____________
TO _______________

1
2
3
4
5

OTHER INCOME
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29

Contributions, donations, bequests, etc
Income from investments
Revenues from telephone and other miscellaneous communication services
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, flowers, coffee shops, and canteen
Rental of vending machines
Rental of hospital space
Governmental appropriations
Other (specify)
Total other income (sum of lines 6-24)
Total (line 5 plus line 25)
Other expenses (specify)
Total other expenses (sum of line 27 and subscripts)
Net income (or loss) for the period (line 26 minus line 28)

6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4040)

40-604

Rev. 3

11-16

FORM CMS-2552-10

ANALYSIS OF HOSPITAL-BASED
HOME HEALTH AGENCY COSTS

SALARIES
COST CENTER DESCRIPTIONS
(omit cents)
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

4090 (Cont.)
PROVIDER CCN:
________________
HHA CCN:
________________

EMPLOYEE
BENEFITS
2

TRANSPORTATION
(see
instructions)
3

CONTRACTED/
PURCHASED
SERVICES
4

GENERAL SERVICE COST CENTERS
Capital Related-Bldgs. and Fixtures
Capital Related-Movable Equipment
Plant Operation & Maintenance
Transportation (see instructions)
Administrative and General
HHA REIMBURSABLE SERVICES
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies (see instructions)
Drugs
DME
HHA NONREIMBURSABLE SERVICES
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Total (sum of lines 1 through 23)

OTHER COSTS
5

TOTAL
(sum of cols.
1 thru 5)
6

PERIOD:
FROM ____________
TO _______________

RECLASSIFICATIONS
7

RECLASSIFIED
TRIAL
BALANCE
(col. 6 + col. 7)
8

WORKSHEET H

ADJUSTMENTS
9

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

Column, 6 line 24, should agree with the Worksheet A, column 3, line 101, or subscript as applicable.

FORM CMS 2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4041)

Rev. 10

40-605

4090 (Cont.)

FORM CMS-2552-10

11-16

COST ALLOCATION - HHA GENERAL SERVICE COST

PROVIDER CCN:
________________
HHA CCN:
________________
NET EXPENSES
FOR COST
ALLOCATION
(from Wkst.
H, col. 10)
0

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

PERIOD:
WORKSHEET H-1
FROM ____________ PART I
TO _______________

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

GENERAL SERVICE COST CENTERS
Capital Related-Bldgs. and Fixtures
Capital Related-Movable Equipment
Plant Operation & Maintenance
Transportation (see instructions)
Administrative and General
HHA REIMBURSABLE SERVICES
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies (see instructions)
Drugs
DME
HHA NONREIMBURSABLE SERVICES
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 through 23)

PLANT
OPERATION &
MAINTENANCE
3

TRANSPORTATION
4

SUBTOTAL
(cols. 0-4)
4a

ADMINISTRATIVE
& GENERAL
5

TOTAL
(cols. 4a + 5)
6
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4042)

40-606

Rev. 10

09-13

FORM CMS-2552-10

4090 (Cont.)

COST ALLOCATION - HHA STATISTICAL BASIS

PROVIDER CCN:
________________
HHA CCN:
________________
CAPITAL
RELATED COSTS
BLDGS. &
MOVABLE
FIXTURES
EQUIPMENT
(SQUARE
(DOLLAR
FEET)
VALUE)
1
2

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

GENERAL SERVICE COST CENTERS
Capital Related-Bldgs. and Fixtures
Capital Related-Movable Equipment
Plant Operation & Maintenance
Transportation (see instructions)
Administrative and General
HHA REIMBURSABLE SERVICES
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies (see instructions)
Drugs
DME
HHA NONREIMBURSABLE SERVICES
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Total (sum of lines 1-23)
Cost To Be Allocated (per Worksheet H-1, Part I)
Unit Cost Multiplier

PLANT
OPERATION &
MAINTENANCE
(SQUARE
FEET)
3

TRANSPORTATION
(MILEAGE)
4

PERIOD:
FROM ____________
TO _______________

RECONCILIATION
5a

WORKSHEET H-1,
PART II

ADMINISTRATIVE
& GENERAL
(ACCUM.
COST)
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-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4042)

Rev. 4

40-607

4090 (Cont.)

FORM CMS-2552-10

09-13

ALLOCATION OF GENERAL SERVICE
COSTS TO HHA COST CENTERS

HHA COST CENTER
(omit cents)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

PROVIDER CCN:
________________
HHA CCN:
________________
From
Wkst. H-1
Part I,
col. 6,
line
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

HHA
TRIAL
BALANCE
(1)
0

PERIOD:
WORKSHEET H-2,
FROM ____________ PART I
TO _______________

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

EMPLOYEE
BENEFITS
DEPARTMENT
4

Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
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 1-19) (2)
Unit Cost Multiplier: column 26, line 1 divided by the sum of column 26, line 20,
minus column 26, line 1, rounded to 6 decimal places.

SUBTOTAL
(cols. 0-4)
4A

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE &
REPAIRS
6

OPERATION
OF PLANT
7

LAUNDRY
& LINEN
SERVICE
8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

(1) Column 0, line 20 must agree with Wkst. A, column 7, line 101.
(2) Columns 0 through 26, line 20 must agree with the corresponding columns of Wkst. B, Part I, line 101.

FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4043.1)

40-608

Rev. 4

10-12

FORM CMS-2552-10

4090 (Cont.)

ALLOCATION OF GENERAL SERVICE
COSTS TO HHA COST CENTERS

HHA COST CENTER
(omit cents)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

PROVIDER CCN:
________________
HHA CCN:
________________

HOUSE
KEEPING
9

DIETARY
10

CAFETERIA
11

MAINTENANCE OF
PERSONNEL
12

Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
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 1-19) (2)
Unit Cost Multiplier: column 26, line 1 divided by the sum of column 26, line 20,
minus column 26, line 1, rounded to 6 decimal places.

NURSING
ADMINISTRATION
13

CENTRAL
SERVICES &
SUPPLY
14

PHARMACY
15

PERIOD:
FROM ____________
TO _______________

MEDICAL
RECORDS &
LIBRARY
16

SOCIAL
SERVICE
17

WORKSHEET H-2,
PART I (CONT.)

OTHER
GENERAL
SERVICE
18

NONPHYSICIAN
ANESTHETISTS
19
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

(2) Columns 0 through 26, line 20 must agree with the corresponding columns of Wkst. B, Part I, line 101.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4043.1)

Rev. 3

40-609

4090 (Cont.)

FORM CMS-2552-10

10-12

ALLOCATION OF GENERAL SERVICE
COSTS TO HHA COST CENTERS

HHA COST CENTER
(omit cents)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

PROVIDER CCN:
________________
HHA CCN:
________________

NURSING
SCHOOL
20

INTERNS & RESIDENTS
SALARY AND
PROGRAM
FRINGES
COSTS
21
22

PARAMEDICAL
EDUCATION
(SPECIFY)
23

Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
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 1-19) (2)
Unit Cost Multiplier: column 26, line 1 divided by the sum of column 26, line 20,
minus column 26, line 1, rounded to 6 decimal places.

SUBTOTAL
(sum of cols.
4a-23)
24

INTERN &
RESIDENT
COST & POST
STEPDOWN
ADJUSTMENTS
25

SUBTOTAL
(cols. 23 ± 24)
26

PERIOD:
WORKSHEET H-2,
FROM ____________ PART I
TO _______________

ALLOCATED
HHA
A&G (see
Part II)
27

TOTAL
HHA COSTS
28
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

(2) Columns 0 through 26, line 20 must agree with the corresponding columns of Wkst. B, Part I, line 101.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4043.1)

40-610

Rev. 3

09-13

FORM CMS-2552-10

4090 (Cont.)

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

PROVIDER CCN:
________________
HHA CCN:
________________
CAPITAL
RELATED COST
BLDGS. &
MOVABLE
FIXTURES
EQUIPMENT
(SQUARE
(DOLLAR
FEET)
VALUE)
1
2

EMPLOYEE
BENEFITS
DEPARTMENT
(GROSS
SALARIES)
4

Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
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 1-19)
Total cost to be allocated
Unit Cost Multiplier

RECONCILIATION
4A

ADMINISTRATIVE &
GENERAL
(ACCUM.
COST)
5

PERIOD:
FROM ____________
TO _______________

MAINTENANCE &
REPAIRS
(SQUARE
FEET)
6

WORKSHEET H-2,
PART II

OPERATION
OF PLANT
(SQUARE
FEET)
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4043.2)

Rev. 4

40-611

4090 (Cont.)

FORM CMS-2552-10

09-13

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

PROVIDER CCN:
________________
HHA CCN:
________________
LAUNDRY
& LINEN
SERVICE
(POUNDS OF
LAUNDRY)
8

HOUSEKEEPING
(HOURS OF
SERVICE)
9

DIETARY
(MEALS
SERVED)
10

CAFETERIA
(MEALS
SERVED)
11

Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
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 1-19)
Total cost to be allocated
Unit Cost Multiplier

MAINTENANCE OF
PERSONNEL
(NUMBER
HOUSED)
12

NURSING
ADMINISTRATION
(DIRECT
NURS. HRS)
13

CENTRAL
SERVICES &
SUPPLY
(COSTED
REQUIS.)
14

PERIOD:
WORKSHEET H-2,
FROM ____________ PART II (CONT.)
TO _______________

PHARMACY
(COSTED
REQUIS.)
15

MEDICAL
RECORDS &
LIBRARY
(TIME
SPENT)
16
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4043.2)

40-612

Rev. 4

03-15

FORM CMS-2552-10

4090 (Cont.)

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

PROVIDER CCN:
________________
HHA CCN:
________________

SOCIAL
SERVICE
(TIME
SPENT)
17

OTHER
GENERAL
SERVICE
(SPECIFY)
18

Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
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 1-19)
Total cost to be allocated
Unit Cost Multiplier

NONPHYSICIAN
ANESTHETISTS
(ASSIGNED
TIME)
19

NURSING
SCHOOL
(ASSIGNED
TIME)
20

PERIOD:
FROM ____________
TO _______________

INTERNS & RESIDENTS
SALARY &
PROGRAM
FRINGES
COSTS
(ASSIGNED
(ASSIGNED
TIME)
TIME)
21
22

WORKSHEET H-2,
PART II (CONT.)

PARAMEDICAL
EDUCATION
(SPECIFY)
(ASSIGNED
TIME)
23
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4043.2)

Rev. 7

40-613

4090 (Cont.)

Check applicable box:

03-15

FORM CMS-2552-10

APPORTIONMENT OF PATIENT SERVICE COSTS

[ ] Title V

PROVIDER CCN:
________________
HHA CCN:
________________
[ ] Title XVIII

PERIOD:
FROM ____________
TO _______________

WORKSHEET H-3,
Parts I & II

[ ] Title XIX

PART I - COMPUTATION OF THE AGGREGATE PROGRAM COST

Cost Per Visit Computation

1
2
3
4
5
6
7

From, Facility
Shared
Total
Wkst.
Costs
Ancillary HHA
H-2,
(from
Costs
Costs
Patient Services
Part I, Wkst. H-2, (from
(cols. 1
col. 28, Part I)
Part II)
+ 2)
line
1
2
3
Skilled Nursing Care
2
Physical Therapy
3
Occupational Therapy
4
Speech Pathology
5
Medical Social Service 6
Home Health Aide
7
Total (sum of lines 1-6)

Total
Visits
4

Program Visits
Average
Part B
Cost
Not
Per Visit
Subject to
Subject to
(col. 3
Deductibles
Deductibles
÷ col. 4) Part A & Coinsurance & Coinsurance
5
6
7
8

Part A
9

Cost of Services
Part B
Not
Total
Subject to
Subject to
Program Cost
Deductibles
Deductibles
(sum of
& Coinsurance & Coinsurance cols. 9-10)
10
11
12
1
2
3
4
5
6
7

Limitation Cost Computation

Patient Services

8
9
10
11
12
13
14

Part A
2

Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Total (sum of lines 8-13)

Supplies and Drugs Cost
Computations

Other Patient Services

15
16

CBSA
No. (1)
1

Program Visits
Part B
Not Subject to
Subject to
Deductibles
Deductibles
& Coinsurance & Coinsurance
3
4

Cost of Medical Supplies
Cost of Drugs

8
9
10
11
12
13
14

Facility Shared
Total
Total
From
Costs Ancillary HHA Charges
Wkst. H-2 (from
Costs
Costs
(from
Ratio
(col. 3
Part I, Wkst. H-2, (from (cols. 1 HHA
col. 28,
Part I)
Part II)
+ 2) Records) ÷ col. 4)
line
1
2
3
4
5
8
9

Program Covered Charges
Part B
Not
Subject to
Subject to
Deductibles Deductibles
Part A
& Coinsurance& Coinsurance
6
7
8

Part A
9

Cost of Services
Part B
Not
Subject to
Subject to
Deductibles
Deductibles
& Coinsurance & Coinsurance
10
11
15
16

PART II - APPORTIONMENT OF COST OF HHA SERVICES FURNISHED BY SHARED HOSPITAL DEPARTMENTS

1
2
3
4
5

Physical Therapy
Occupational Therapy
Speech Pathology
Cost of Medical Supplies
Cost of Drugs

From Wkst. C,
Part I, col. 9,
line
66
67
68
71
73

Cost
to Charge
Ratio
1

Total
HHA Charges HHA Shared
(from provider Ancillary Costs
records)
(col. 1 x col. 2)
2
3

Transfer to
Part I
as Indicated
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

FORM CMS-2552-10 (03-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4044)

40-614

Rev. 7

11-17

4090 (Cont.)

FORM CMS-2552-10

CALCULATION OF HHA REIMBURSEMENT
SETTLEMENT

Check applicable box:

[ ] Title V

PROVIDER CCN:
________________
HHA CCN:
________________
[ ] Title XVIII

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

1
2
3
4
5
6
7
8
9

Description
Reasonable Cost of Part A & Part B Services
Reasonable cost of services (see instructions)
Total charges
Customary Charges
Amount actually collected from patients liable for payment for services on a
charge basis (from your records)
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)
Ratio of line 3 to line 4 (not to exceed 1.000000)
Total customary charges (see instructions)
Excess of total customary charges over total reasonable cost (complete only if line 6 exceeds line 1)
Excess of reasonable cost over customary charges (complete only if line 1 exceeds line 6)
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 HHA REIMBURSEMENT SETTLEMENT

10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
30.50
30.99
31
31.01
31.02
32
33
34
35

Description
Total reasonable cost (see instructions)
Total PPS Reimbursement - Full Episodes without Outliers
Total PPS Reimbursement - Full Episodes with Outliers
Total PPS Reimbursement - LUPA Episodes
Total PPS Reimbursement - PEP Episodes
Total PPS Outlier Reimbursement - Full Episodes with Outliers
Total PPS Outlier Reimbursement - PEP Episodes
Total Other Payments
DME Payments
Oxygen Payments
Prosthetic and Orthotic Payments
Part B deductibles billed to Medicare patients (exclude coinsurance)
Subtotal (sum of lines 10 thru 20 minus line 21)
Excess reasonable cost (from line 8)
Subtotal (line 22 minus line 23)
Coinsurance billed to program patients (from your records)
Net cost (line 24 minus line 25)
Reimbursable bad debts (from your records)
Reimbursable bad debts for dual eligible (see instructions)
Total costs - current cost reporting period (line 26 plus line 27)
Other adjustments (see instructions) (specify)
Pioneer ACO demonstration payment adjustment (see instructions)
Demonstration payment adjustment amount before sequestration
Subtotal (see instructions)
Sequestration adjustment (see instructions)
Demonstration payment adjustment amount after sequestration
Interim payments (see instructions)
Tentative settlement (for contractor use only)
Balance due provider/program (line 31 minus lines 31.01, 31.02, 32, and 33)
Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §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
30.50
30.99
31
31.01
31.02
32
33
34
35

FORM CMS-2552-12 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4045.1 - 4045.2)

Rev. 12

40-615

4090 (Cont.)

11-17

FORM CMS-2552-10

ANALYSIS OF PAYMENTS TO HOSPITALBASED HHAs FOR SERVICES
RENDERED TO PROGRAM BENEFICIARIES

PROVIDER CCN:
________________
HHA CCN:
________________

PERIOD:
WORKSHEET H-5
FROM ____________
TO _______________

Part A
Description
1
2

3

mm/dd/yyyy
1

Total interim payments paid to provider
Interim payments payable on individual bills either submitted or
to be submitted to the intermediary for services rendered in the
cost reporting period. If none, write "NONE" or enter a zero.
List separately each retroactive lump sum
Program
adjustment amount based on subsequent revision
to
of the interim rate for the cost reporting period.
Provider
Also show date of each payment. If none, write
"NONE" or enter a zero.(1)
Provider
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. H-4, Part II, column as appropriate, line 32)

Part B
Amount
2

mm/dd/yyyy
3

Amount
4
1
2

.01
.02
.03
.04
.05
.50
.51
.52
.53
.54

3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54

.99

3.99
4

.01
.02
.03
.50
.51
.52

5.01
5.02
5.03
5.50
5.51
5.52

.99

5.99

TO BE COMPLETED BY INTERMEDIARY
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 (see instructions)

7 TOTAL MEDICARE PROGRAM LIABILITY
(see instructions)
8 Name of Contractor

Program
to
Provider
Provider
to
Program

Program
to
Provider
Provider
to
Program

Contractor Number

.01
6.01
.02
6.02
7
NPR Date: Month, Day, Year

8

(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-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4046)

40-616

Rev. 12

11-17

PROVIDER CCN:
________________

Check applicable box:

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

4090 (Cont.)

FORM CMS-2552-10

ANALYSIS OF RENAL DIALYSIS DEPARTMENT COSTS

[ ] Renal Dialysis Department

Registered Nurses
Licensed Practical Nurses
Nurses Aides
Technicians
Social Workers
Dieticians
Physicians
Non-patient Care Salary
Subtotal (sum of lines 1-8)
Employee Benefits
Capital Related Costs-Bldgs. & Fixtures
Capital Related Costs-Mov. Equip.
Machine Costs & Repairs
Supplies
Drugs
Other
Subtotal (sum of lines 9-16)*
Capital Related Costs-Bldgs. & Fixtures
Capital Related Costs-Mov. Equip.
Employee Benefits Department
Administrative and General
Maint./Repairs-Operation-Housekeeping
Medical Education Program Costs
Central Services & Supplies
Pharmacy
Other Allocated Costs
Subtotal (sum of lines 17-26)*
Laboratory (see instructions)
Respiratory Therapy (see instructions)
Other (see instructions)
Total costs (sum of lines 27-30)

[ ] Home Program Dialysis
TOTAL
COSTS
1

BASIS
2
Hours of Service
Hours of Service
Hours of Service
Hours of Service
Hours of Service
Hours of Service
Accumulated Cost
Accumulated Cost

PERIOD:
FROM ____________
TO _______________

STATISTICS
3

Salary
Square Feet
Percentage of Time
Percentage of Time
Requisitions
Requisitions
Accumulated Cost
Square Feet
Percentage of Time
Salary
Accumulated Cost
Square Feet
Requisitions
Requisitions
Accumulated Cost
Charges
Charges
Charges

WORKSHEET I-1

FTEs per
2080 Hours
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

* Line 17, column 1, should agree with Worksheet A, column 7 for line 74 or line 94, as appropriate,
and line 27, column 1, should agree with Worksheet B, Part I, column 24, less the sum of columns 21 and 22, for line 74 or line 94, as appropriate.

FORM CMS-2552-10 (03-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4048)

Rev. 12

40-617

4090 (Cont.)

FORM CMS-2552-10

11-17

ALLOCATION OF RENAL DEPARTMENT COSTS TO TREATMENT MODALITIES

PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________
Check applicable box:
OUTPATIENT SERVICES
COMPOSITE PAYMENT RATE

[ ] Renal Dialysis Department
CAPITAL AND
RELATED COSTS
BUILDING
EQUIPMENT
1
2

WORKSHEET I-2

[ ] Home Program Dialysis
DIRECT PATIENT
CARE SALARY
RNs
OTHER
3
4

EMPLOYEE
BENEFITS
DEPARTMENT
5

1

Total Renal Department Costs
MAINTENANCE
2 Hemodialysis
3 Intermittent Peritoneal
TRAINING
4 Hemodialysis
5 Intermittent Peritoneal
6 CAPD
7 CCPD
HOME
8 Hemodialysis
9 Intermittent Peritoneal
10 CAPD
11 CCPD
OTHER BILLABLE SERVICES
12 Inpatient Dialysis
13 Method II Home Patient
14 ESAs (included in Renal Department)
15 ARANESP (see instructions)
16 Other
17 Total (sum of lines 2 through 16)
18 Medical Educational Program Costs
19 Total Renal Costs (line 17 + line 18)

DRUGS
6

MEDICAL
SUPPLIES
7

ROUTINE
ANCILLARY
SERVICES
8

SUBTOTAL
(sum of
cols. 1-8)
9

OVERHEAD
10

TOTAL
(col. 9 +
col. 10)
11
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4049)

40-618

Rev. 12

11-17

FORM CMS-2552-10

DIRECT AND INDIRECT RENAL DIALYSIS COST ALLOCATION STATISTICAL BASIS

4090 (Cont.)
PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________
Check applicable box:

[ ] Renal Dialysis Department

COMPOSITE PAYMENT SERVICES

[ ] Home Program Dialysis
CAPITAL AND
RELATED COSTS
BUILDING
EQUIPMENT
(SQUARE
(% OF
FEET)
TIME)
1
2

DIRECT PATIENT
CARE SALARY
RNs
OTHERS
(HOURS)
(HOURS)
3
4

1

Total Renal Department Costs
MAINTENANCE
2 Hemodialysis
3 Intermittent Peritoneal
TRAINING
4 Hemodialysis
5 Intermittent Peritoneal
6 CAPD
7 CCDP
HOME
8 Hemodialysis
9 Intermittent Peritoneal
10 CAPD
11 CCDP
OTHER BILLABLE SERVICES
12 Inpatient Dialysis Treatments __________
13 Method II Home Patient
14 ESAs
15 ARANESP (see instructions)
16 Other
17 Total Statistical Basis
18 Unit Cost Multiplier (line 1 ÷ line 17)

EMPLOYEE
BENEFITS
DEPARTMENT
(SALARY)
5

DRUGS
(REQUIST.)
6

MEDICAL
SUPPLIES
(REQUIST.)
7

ROUTINE
ANCILLARY
SERVICES
(CHARGES)
8

WORKSHEET I-3

SUBTOTAL
9

OVERHEAD
(ACCUM.
COST)
10
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4050)

Rev. 12

40-619

4090 (Cont.)

FORM CMS-2552-10

11-17

COMPUTATION OF AVERAGE COST PER TREATMENT
FOR OUTPATIENT RENAL DIALYSIS

PROVIDER CCN:
________________

Check applicable box:

[ ] Renal Dialysis Department

12

Total Cost
(from Wkst.
I-2, col. 11)
2

Average Cost
of
Treatments
(col. 2 ÷ col. 1)
3

Number
of Program
Treatments
4

Number
of Program
Treatments
4.01

Number
of Program
Treatments
4.02

Maintenance - Hemodialysis
Maintenance - Peritoneal Dialysis
Training - Hemodialysis
Training - Peritoneal Dialysis
Training - CAPD
Training - CCPD
Home Program - Hemodialysis
Home Program - Peritoneal Dialysis

Total
Program
Expenses
(see instructions)
5

Total
Program
Payment
6

Total
Program
Payment
6.01

Total
Program
Payment
6.02

Average
Average
Average
Payment Rate Payment Rate
Payment Rate (col. 6.01 ÷
(col. 6.02 ÷
(col. 6 ÷ col. 4) col. 4.01)
col. 4.02)
7
7.01
7.02
1
2
3
4
5
6
7
8

Patient Weeks
9
10
11

WORKSHEET I-4

[ ] Home Program Dialysis

Number
of Total
Treatments
1
1
2
3
4
5
6
7
8

PERIOD:
FROM ____________
TO _______________

Patient Weeks Patient Weeks Patient Weeks

Home Program - CAPD
Home Program - CCPD
Totals (sum of lines 1 through 8, cols. 1 and 4)
(sum of lines 1 through 10, cols. 2, 5, and 6)
(see instructions)
Total treatments (sum of lines 1 through 8
plus (sum of lines 9 and 10 times 3))
(see instructions)

9
10
11

12

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4051)

40-620

Rev. 12

11-17

4090 (Cont.)

FORM CMS-2552-10

CALCULATION OF REIMBURSABLE
BAD DEBTS - TITLE XVIII - PART B

PROVIDER CCN:
________________

PERIOD:
FROM ____________
TO _______________

WORKSHEET I-5

Description
1

Total expenses related to care of program beneficiaries (see instructions)

1

2
2.01
2.02
2.03
2.04

Total payment due (from Wkst. I-4, col. 6, line 11) (see instructions)
Total payment due (from Wkst. I-4, col. 6.01, line 11) (see instructions)
Total payment due(from Wkst. I-4, col. 6.02, line 11) (see instructions)
Total payment due (see instructions)
Outlier payments

2
2.01
2.02
2.03
2.04

3
3.01
3.02
3.03
4
4.01
4.02
4.03
5
5.01

Deductibles billed to Medicare (Part B) patients (see instructions)
Deductibles billed to Medicare (Part B) patients (see instructions)
Deductibles billed to Medicare (Part B) patients (see instructions)
Total deductibles billed to Medicare (Part B) patients (see instructions)
Coinsurance billed to Medicare (Part B) patients (see instructions)
Coinsurance billed to Medicare (Part B) patients (see instructions)
Coinsurance billed to Medicare (Part B) patients (see instructions)
Total coinsurance billed to Medicare (Part B) patients (see instructions)
Bad debts for deductibles and coinsurance, net of bad debt recoveries
Transition period 1 (75-25%) bad debts for deductibles and coinsurance net of bad debt recoveries for
services rendered on or after 1/1/2011 but before 1/1/2012
Transition period 2 (50-50%) bad debts for deductibles and coinsurance net of bad debt recoveries for
services rendered on or after 1/1/2012 but before 1/1/2013
Transition period 3 (25-75%) bad debts for deductibles and coinsurance net of bad debt recoveries for
services rendered on or after 1/1/2013 but before 1/1/2014
100% PPS bad debts for deductibles and coinsurance net of bad debt recoveries for
services rendered on or after 1/1/2014
Allowable bad debts (sum of lines 5 through line 5.04)
Adjusted reimbursable bad debts (see instructions)
Allowable bad debts for dual eligible beneficiaries (see instructions)
Net deductibles and coinsurance billed to Medicare (Part B) patients (see instructions)
Program payment (see instructions)
Unrecovered from Medicare (Part B) patients (see instructions)
Reimbursable bad debts (see instructions) (transfer to Worksheet E, Part B, line 33)

3
3.01
3.02
3.03
4
4.01
4.02
4.03
5
5.01

1

5.02
5.03
5.04
5.05
6
7
8
9
10
11

PART
12
13
14

II - CALCULATION OF FACILITY SPECIFIC COMPOSITE COST PERCENTAGE
Total allowable expenses (see instructions)
Total composite costs (from Wkst. I-4, col. 2, line 11)
Facility specific composite cost percentage (line 13 divided by line 12)

2

5.02
5.03
5.04
5.05
6
7
8
9
10
11

12
13
14

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4052)

Rev. 12

40-621

4090 (Cont.)

FORM CMS-2552-10

11-17

ALLOCATION OF GENERAL SERVICE COSTS TO
COMMUNITY MENTAL HEALTH CENTERS

PART I - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS
NET
EXPENSES
CAPITAL
COMPONENT COST CENTER
FOR COST
RELATED COSTS
EMPLOYEE
(omit cents)
ALLOCATION
BLDGS. &
MOVABLE
BENEFITS
(see instru.)
FIXTURES
EQUIPMENT
DEPARTMENT
0
1
2
4
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 Therapies
12 Family Counseling
13 Diagnostic Services
14 Approved 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 Others
22 Totals (sum of lines 1-21)(1)
23 Unit Cost Multiplier (see instructions)

PROVIDER CCN:
________________
COMPONENT CCN:
________________

SUBTOTAL
(cols. 0-4)
4A

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE
& REPAIRS
6

PERIOD:
WORKSHEET J-1,
FROM ____________ PART I
TO _______________

OPERATION
OF PLANT
7

LAUNDRY
& LINEN
SERVICE
8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

(1) Columns 0 through 26, line 22 must agree with the corresponding columns of Wkst. B, Part I, lines as appropriate. See instructions.

FORM CMS-2552-10 (10-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.1)

40-622

Rev. 12

10-12

FORM CMS-2552-10

ALLOCATION OF GENERAL SERVICE COSTS TO
COMMUNITY MENTAL HEALTH CENTERS

4090 (Cont.)
PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
FROM ____________
TO _______________

WORKSHEET J-1,
PART I (CONT.)

PART I - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS

COMPONENT COST CENTER
(omit cents)

HOUSEKEEPING
9

DIETARY
10

CAFETERIA
11

MAINTENANCE
OF
PERSONNEL
12

NURSING
ADMINISTRATION
13

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 Therapies
12 Family Counseling
13 Diagnostic Services
14 Approved 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 Others
22 Totals (sum of lines 1-21)(1)
23 Unit Cost Multiplier (see instructions)

CENTRAL
SERVICES
&
SUPPLY
14

PHARMACY
15

MEDICAL
RECORDS
&
LIBRARY
16

SOCIAL
SERVICE
17

OTHER
GENERAL
SERVICE
18

NONPHYSICIAN
ANESTHETISTS
19
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

(1) Columns 0 through 26, line 22 must agree with the corresponding columns of Wkst. B, Part I, lines as appropriate. See instructions.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.1)

Rev. 3

40-623

4090 (Cont.)

FORM CMS-2552-10

10-12

ALLOCATION OF GENERAL SERVICE COSTS TO
COMMUNITY MENTAL HEALTH CENTERS

PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
WORKSHEET J-1,
FROM ____________ PART I
TO _______________

PART I - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS

COMPONENT COST CENTER
(omit cents)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

NURSING
SCHOOL
20

INTERNS & RESIDENTS
SALARY &
PROGRAM
FRINGES
COSTS
21
22

PARAMEDICAL
EDUCATION
(SPECIFY)
23

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 Therapies
Family Counseling
Diagnostic Services
Approved Patient Training & Education
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies
Medical Appliances
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
All Others
Totals (sum of lines 1-21)(1)
Unit Cost Multiplier (see instructions)

SUBTOTAL
(sum of
cols. 4A-23)
24

INTERN &
RESIDENT
COST & POST
STEPDOWN
ADJ.
25

SUBTOTAL
(sum of cols.
24 ± 25)
26

ALLOCATED
COMPONENT
A&G (see
Part II) (2)
27

TOTAL
(sum of cols.
26 ± 27)
28
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

(1) Columns 0 through 26, line 22 must agree with the corresponding columns of Wkst. B, Part I, lines as appropriate. See instructions.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.1)

40-624

Rev. 3

09-13

FORM CMS-2552-10

4090 (Cont.)

ALLOCATION OF GENERAL SERVICE COSTS TO
COMMUNITY MENTAL HEALTH CENTERS

PART II - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS - STATISTICAL BASIS
CAPITAL
RELATED COST
EMPLOYEE
BLDGS &
MOVABLE
BENEFITS
CMHC COST CENTER
FIXTURES
EQUIPMENT
DEPARTMENT
(omit cents)
(SQUARE
(SQUARE
(GROSS
RECONCILFEET)
FEET)
SALARIES)
IATION
0
1
2
4
4A
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 Therapies
12 Family Counseling
13 Diagnostic Services
14 Approved 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 Others
22 Totals (sum of lines 1-21)
23 Total Cost to be Allocated
24 Unit Cost Multiplier (see instructions)

PROVIDER CCN:
________________
COMPONENT CCN:
________________

ADMINISTRATIVE &
GENERAL
(ACCUM.
COST)
5

MAINTENANCE &
REPAIRS
(SQUARE
FEET)
6

PERIOD:
WORKSHEET J-1,
FROM ____________ PART II
TO _______________

OPERATION
OF PLANT
(SQUARE
FEET)
7

LAUNDRY
& LINEN
SERVICE
(POUNDS OF
LAUNDRY)
8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.2)

Rev. 4

40-625

4090 (Cont.)

FORM CMS-2552-10

09-13

ALLOCATION OF GENERAL SERVICE COSTS TO
COMMUNITY MENTAL HEALTH CENTERS

PART II - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS - STATISTICAL BASIS
MAINTENANCE
NURSING
CENTRAL
HOUSEOF
ADMINISSERVICES &
CORF COST CENTER
KEEPING
DIETARY
CAFETERIA PERSONNEL
TRATION
SUPPLY
(omit cents)
(HOURS OF
(MEALS
(MEALS
(NUMBER
(DIRECT
(COSTED
SERVICE)
SERVED)
SERVED)
HOUSED)
NURS. HRS)*
REQUIS.)
9
10
11
12
13
14
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 Therapies
12 Family Counseling
13 Diagnostic Services
14 Approved 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 Others
22 Totals (sum of lines 1-21)
23 Total Cost to be Allocated
24 Unit Cost Multiplier (see instructions)

PROVIDER CCN:
________________
COMPONENT CCN:
________________

PHARMACY
(COSTED
REQUIS.)
15

MEDICAL
RECORDS &
LIBRARY
(TIME
SPENT)
16

SOCIAL
SERVICE
(TIME
SPENT)
17

PERIOD:
WORKSHEET J-1,
FROM ____________ PART II (CONT.)
TO _______________

OTHER
GENERAL
SERVICE
(SPECIFY)
18

NONPHYSICIAN
ANESTHETISTS
(ASSIGNED
TIME)
19
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.2)

40-626

Rev. 4

10-12

FORM CMS-2552-10

4090 (Cont.)

ALLOCATION OF GENERAL SERVICE COSTS TO
COMMUNITY MENTAL HEALTH CENTERS

PART II - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS - STATISTICAL BASIS
PARAINTERNS & RESIDENTS
MEDICAL
NURSING
SALARY &
PROGRAM
EDUCATION
CORF COST CENTER
SCHOOL
FRINGES
COSTS
(SPECIFY)
(omit cents)
(ASSIGNED
(ASSIGNED
(ASSIGNED
(ASSIGNED
TIME)
TIME)
TIME)
TIME)
20
21
22
23
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 Therapies
12 Family Counseling
13 Diagnostic Services
14 Approved 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 Others
22 Totals (sum of lines 1-21)
23 Total Cost to be Allocated
24 Unit Cost Multiplier (see instructions)

PROVIDER CCN:
________________
COMPONENT CCN:
________________

24

25

26

PERIOD:
WORKSHEET J-1,
FROM ____________ PART II (CONT.)
TO _______________

27

28
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.2)

Rev. 3

40-627

4090 (Cont.)

FORM CMS-2552-10

10-12

COMPUTATION OF COMMUNITY MENTAL HEALTH CENTER PROVIDER COSTS

PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
WORKSHEET J-2,
FROM ____________ PART I
TO _______________

PART I - APPORTIONMENT OF CMHC COST CENTERS
(From
Wkst. J-1,
Pt. I,
col. 28)
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
(1)

Total
Component
Charges
2

Ratio of
Costs to
Charges
(col. 1 ÷ col. 2)
3

Title V
Component
Charges
4

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
Approved Patient Training & Education
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies
Medical Appliances
All Others (1)
Totals (sum of lines 1 through19)

Title V
Component
Costs (col. 3
x col. 4)
5

Title XVIII
Component
Charges
6

Title XVIII
Component
Costs (col. 3
x col. 6)
7

Title XIX
Component
Charges
8

Title XIX
Component
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

Enter amount in column 1 from Worksheet J-1, Part I, column 28, line 21.

FORM CMS-2552-10(10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4054.1)

40-628

Rev. 3

11-17

FORM CMS-2552-10

4090 (Cont.)

COMPUTATION OF COMMUNITY MENTAL HEALTH CENTER PROVIDER COSTS

PART II - APPORTIONMENT OF COST OF CMHC PROVIDER SERVICES FURNISHED BY SHARED HOSPITAL DEPARTMENTS
(From
Wkst. J-1,
Total
Ratio of
Pt. I,
Component
Costs to
col. 29)
Charges
Charges (1)
1
2
3
21 Respiratory Therapy
22 Physical Therapy
23 Occupational Therapy
24 Speech Pathology
25 Medical Supplies Charged to Patients
26 Implantable Devices Charged to Patients
27 Drugs Charged to Patients
28 Total (sum of lines 21-28)
29 Total component costs. Add the amount from Pt. I, line 20,
and the amounts from line 28, columns 5, 7, and 9. (3)

PROVIDER CCN:
________________
COMPONENT CCN:
________________

Title V
Component
Charges (2)
4

Title V
Component
costs (col. 3
x col. 4)
5

Title XVIII
Component
Charges (2)
6

Title XVIII
Component
costs (col. 3
x col. 6)
7

PERIOD:
WORKSHEET J-2,
FROM ____________ PART II
TO _______________

Title XIX
Component
Charges (2)
8

Title XIX
Component
costs (col. 3
x col. 8)
9
21
22
23
24
25
26
27
28
29

(1) From Worksheet C, Part I, column 9, lines as appropriate
(2) Charges for columns 4 and 8 are obtained from your records.
(3) Transfer the amounts on line 28, columns 5, 7, and 9, as appropriate, to Worksheet J-3, line 1.

FORM CMS-2552-10 (03-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4054.2)

Rev. 12

40-629

4090 (Cont.)

Check
applicable
box:

11-17

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT SETTLEMENT COMMUNITY
MENTAL HEALTH CENTER PROVIDER SERVICES

[ ] Title V

[ ] Title XVIII

PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
WORKSHEET J-3
FROM ____________
TO _______________

[ ] Title XIX
PROGRAM
COST

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
25.50
25.99
26
26.01
26.02
27
28
29
30

Cost of component services (from Wkst. J-2, Pt. II, line 29)
PPS payments received excluding outliers
Outlier payments
Primary payer payments
Total reasonable cost (see instructions)
Total charges for program services
CUSTOMARY CHARGES
Aggregate amount actually collected from patients liable for services on a charge basis
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(e)
Ratio of line 7 to line 8 (not to exceed 1.000000) (see instructions)
Total customary charges (see instructions)
Excess of customary charges over reasonable cost (see instructions)
Excess of reasonable cost over customary charges (see instructions)
COMPUTATION OF REIMBURSEMENT SETTLEMENT
Total reasonable cost (from line 5)
Part B deductible billed to program patients
Net cost (line 13 minus line 14)
Excess of reasonable cost over customary charges (from line 12)
Subtotal (line 15 minus line 16)
80 percent of costs (80% of line 17) (see instructions)
Actual coinsurance billed to program patients (from provider records)
Net cost less actual billed coinsurance (line 17 minus line 19)
Allowable bad debts (from provider records) (see instructions)
Adjusted reimbursable bad debts (see instructions)
Allowable bad debts for dual eligible beneficiaries (see instructions)
Net reimbursable amount (see instructions)
Other adjustments (see instructions) (specify)
Pioneer ACO demonstration payment adjustment (see instructions)
Demonstration payment adjustment amount before sequestration
Total cost (see instructions)
Sequestration adjustment (see instructions)
Demonstration payment adjustment amount after sequestration
Interim payments (see instructions)
Tentative settlement (for contractor use only)
Balance due component/program (line 26 minus lines 26.01, 26.02, 27, and 28)
Protested amounts (nonallowable cost report items in accordance with CMS Pub. 15-2, chapter 1, §115.2)

1
2
3
4
5
6
7
8
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
25.50
25.99
26
26.01
26.02
27
28
29
30

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4055)

40-630

Rev. 12

11-16

4090 (Cont.)

FORM CMS-2552-10

ANALYSIS OF PAYMENTS TO HOSPITAL-BASED COMMUNITY MENTAL HEALTH
CENTER FOR SERVICES RENDERED TO PROGRAM BENEFICIARIES

Check
applicable
boxes:

PROVIDER CCN:
______________
COMPONENT CCN:
______________

PERIOD:
WORKSHEET J-4
FROM ____________
TO _______________

[ ] Title XVIII
Part B
DESCRIPTION

1
mm/dd/yyyy

1 Total interim payments paid to providers
2 Interim payments payable on individual bills, either
submitted or to be submitted to the intermediary, for
services rendered in the cost reporting periods. If
none, write "NONE", or 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 zero (1).

4

1
2

Program
to
Provider

Provider
to
Program

Subtotal (sum of lines 3.01-3.49
minus sum of lines 3.50-3.98)
Total interim payments (sum of lines 1, 2, and 3.99)
(transfer to Worksheet J-3, line 27)

O BE COMPLETED BY INTERMEDIARY
5 List separately each tentative
settlement payment after desk review.
Also show date of each payment.
If none, write "NONE,"
or enter zero (1).

6

7
8

Program
to
Provider
Provider
to
Program

Subtotal (sum of lines 5.01-5.49 minus
sum of lines 5.50-5.98)
Determine net settlement amount
(balance due) based on the cost
report (see instructions). (1)

Total Medicare liability
(see instructions)
Name of Contractor

2
Amount

Program
to
Provider
to
Program

Contractor Number

.01
.02
.03
.04
.05
.50
.51
.52
.53
.54

3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54

.99

3.99
4

.01
.02
.03
.50
.51
.52

5.01
5.02
5.03
5.50
5.51
5.52

.99

5.99

.01

6.01

.02

6.02
7

NPR Date (Month, Day, Year)

8

(1) On lines 3, 5, and 6, where an amount is due provider to program, show the amount and date on which you agree to the amount of
repayment, even though the total repayment is not accomplished until a later date.

FORM CMS-2552-10 (03-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4056)

Rev. 10

40-631

4090 (Cont.)

FORM CMS-2552-10

11-16

ANALYSIS OF HOSPITAL-BASED
HOSPICE COSTS

COST CENTER DESCRIPTIONS

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

PROVIDER CCN:
________________
COMPONENT CCN:
________________
SALARIES
(from
Wkst. K-1)
1

EMPLOYEE
BENEFITS
(from
Wkst. K-2)
2

TRANSPORTATION
(see inst.)
3

CONTRACTED
SERVICES
(from
Wkst. K-3)
4

GENERAL SERVICE COST CENTERS
Capital Related Costs-Bldg and Fixt.
Capital Related Costs-Movable Equip.
Plant Operation and Maintenance
Transportation - Staff
Volunteer Service Coordination
Administrative and General
INPATIENT CARE SERVICE
Inpatient - General Care
Inpatient - Respite Care
VISITING SERVICES
Physician Services
Nursing Care
Nursing Care-Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemaker
HH Aide & Homemaker - Cont. Home Care
Other
OTHER HOSPICE SERVICE COSTS
Drugs, Biological and Infusion Therapy
Analgesics
Sedatives / Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (including E/R Dept.)
Radiation Therapy
Chemotherapy
Other
HOSPICE NONREIMBURSABLE SERVICE
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Total (sum of lines 1 thru 38)

OTHER
5

TOTAL
(cols. 1-5)
6

RECLASSIFICATION
7

SUBTOTAL
(col. 6
± col. 7)
8

PERIOD:
WORKSHEET K
FROM ____________
TO _______________

ADJUSTMENTS
9

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
25
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39

FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4057)

40-632

Rev. 10

11-16

FORM CMS-2552-10

4090 (Cont.)

HOSPICE COMPENSATION ANALYSIS
SALARIES AND WAGES

COST CENTER DESCRIPTIONS
(omit cents)

PROVIDER CCN:
________________
COMPONENT CCN:
________________
ADMINISTRATOR
1

DIRECTOR
2

MEDICAL
SOCIAL
WORKERS
3

SUPERVISORS
4

GENERAL SERVICE COST CENTERS
Capital Related Costs-Bldg and Fixt.
Capital Related Costs-Movable Equip.
Plant Operation and Maintenance
Transportation - Staff
Volunteer Service Coordination
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 thru 38)
(1) Transfer the amount in column 9 to Wkst. K, column 1
1
2
3
4
5
6

NURSES
5

TOTAL
THERAPISTS
6

AIDES
7

PERIOD:
WORKSHEET K-1
FROM ____________
TO _______________

ALL OTHER
8

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

FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4058)

Rev. 10

40-633

4090 (Cont.)

FORM CMS-2552-10

11-16

HOSPICE COMPENSATION ANALYSIS EMPLOYEE
BENEFITS (PAYROLL RELATED)

COST CENTER DESCRIPTIONS
(omit cents)

PROVIDER CCN:
________________
COMPONENT CCN:
________________
ADMINISTRATOR
1

DIRECTOR
2

MEDICAL
SOCIAL
WORKERS
3

GENERAL SERVICE COST CENTERS
Capital Related Costs-Bldg and Fixt.
Capital Related Costs-Movable Equip.
Plant Operation and Maintenance
Transportation - Staff
Volunteer Service Coordination
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 thru 38)
(1) Transfer the amount in column 9 to Wkst. K, column 2
1
2
3
4
5
6

SUPERVISORS
4

NURSES
5

TOTAL
THERAPISTS
6

AIDES
7

PERIOD:
WORKSHEET K-2
FROM ____________
TO _______________

ALL OTHER
8

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

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4059)

40-634

Rev. 10

09-13

FORM CMS-2552-10

4090 (Cont.)

HOSPICE COMPENSATION ANALYSIS
CONTRACTED SERVICES/PURCHASED SERVICES

COST CENTER DESCRIPTIONS
(omit cents)

PROVIDER CCN:
________________
HOSPICE CCN:
________________
ADMINISTRATOR
1

DIRECTOR
2

MEDICAL
SOCIAL
WORKERS
3

GENERAL SERVICE COST CENTERS
Capital Related Costs-Bldg and Fixt.
Capital Related Costs-Movable Equip.
Plant Operation and Maintenance
Transportation - Staff
Volunteer Service Coordination
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 thru 38)
(1) Transfer the amount in column 9 to Wkst. K, column 4
1
2
3
4
5
6

SUPERVISORS
4

NURSES
5

TOTAL
THERAPISTS
6

AIDES
7

PERIOD:
WORKSHEET K-3
FROM ____________
TO _______________

ALL OTHER
8

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

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4060)

Rev. 4

40-635

4090 (Cont.)

FORM CMS-2552-10

09-13

COST ALLOCATION - HOSPICE GENERAL SERVICE COST

COST CENTER DESCRIPTIONS

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

NET
EXPENSES
FOR COST
ALLOCATION
0

PROVIDER CCN:
________________
HOSPICE CCN:
________________
CAPITAL RELATED COST
BUILDINGS
MOVABLE
& FIXTURES
EQUIPMENT
1
2

PLANT
OPERATION
& MAINT.
3

GENERAL SERVICE COST CENTERS
Capital Related Costs-Bldg and Fixt.
Capital Related Costs-Movable Equip.
Plant Operation and Maintenance
Transportation - Staff
Volunteer Service Coordination
Administrative and General
INPATIENT CARE SERVICE
Inpatient - General Care
Inpatient - Respite Care
VISITING SERVICES
Physician Services
Nursing Care
Nursing Care-Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemaker
HH Aide & Homemaker - Cont. Home Care
Other
OTHER HOSPICE SERVICE COSTS
Drugs, Biological and Infusion Therapy
Analgesics
Sedatives / Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (including E/R Dept.)
Radiation Therapy
Chemotherapy
Other
HOSPICE NONREIMBURSABLE SERVICE
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Total (sum of lines 1 thru 38)

TRANSPORTATION
4

VOLUNTEER
SERVICES
COORDINATOR
5

SUBTOTAL
(cols. 0 - 5)
5A

PERIOD:
WORKSHEET K-4,
FROM ____________ PART I
TO _______________

ADMINISTRATIVE &
GENERAL
6

TOTAL
(col. 5
± col. 6)
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

FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4061)

40-636

Rev. 4

09-13

FORM CMS-2552-10

4090 (Cont.)

COST ALLOCATION - HOSPICE STATISTICAL BASIS

COST CENTER DESCRIPTIONS

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

CAPITAL RELATED COST
BUILDINGS
MOVABLE
& FIXTURES
EQUIPMENT
(SQ. FT.)
($ VALUE)
1
2

GENERAL SERVICE COST CENTERS
Capital Related Costs-Bldg and Fixt.
Capital Related Costs-Movable Equip.
Plant Operation and Maintenance
Transportation - Staff
Volunteer Service Coordination
Administrative and General
INPATIENT CARE SERVICE
Inpatient - General Care
Inpatient - Respite Care
VISITING SERVICES
Physician Services
Nursing Care
Nursing Care-Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemaker
HH Aide & Homemaker - Cont. Home Care
Other
OTHER HOSPICE SERVICE COSTS
Drugs, Biological and Infusion Therapy
Analgesics
Sedatives / Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (including E/R Dept.)
Radiation Therapy
Chemotherapy
Other
HOSPICE NONREIMBURSABLE SERVICE
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Cost To be Allocated (per Wkst. K-4, Part I)
Unit Cost Multiplier

PLANT
OPERATION
& MAINT.
(SQ. FT.)
3

TRANSPORTATION
(MILEAGE)
4

PROVIDER CCN:
________________
HOSPICE CCN:
________________
VOLUNTEER
SERVICES
COORDINATOR
(HOURS)
5

PERIOD:
FROM ____________
TO _______________

RECONCILIATION
6A

WORKSHEET K-4,
PART II

ADMINISTRATIVE &
GENERAL
(ACC. COST)
6
1
2
3
5
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

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4061)

Rev. 4

40-637

4090 (Cont.)

FORM CMS-2552-10

09-13

ALLOCATION OF GENERAL SERVICE
COSTS TO HOSPICE COST CENTERS

PROVIDER CCN:
________________
HOSPICE CCN:
________________

PERIOD:
WORKSHEET K-5,
FROM ____________ PART I
TO _______________

PART I - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS

HOSPICE COST CENTER
(omit cents)

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

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
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemaker
HH Aide & Homemaker - Cont. Home Care
Other
Drugs, Biological and Infusion Therapy
Analgesics
Sedatives / Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (including E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1-33) (2)
Unit Cost Multiplier (see instructions)

From
Wkst. K-4
Part 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
(1)
0

CAPITAL
RELATED COSTS
BLDGS. &
MOVABLE
FIXTURES
EQUIPMENT
1
2

EMPLOYEE
BENEFITS
DEPARTMENT
4

SUBTOTAL
(cols. 0-4)
4A

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE &
REPAIRS
6

OPERATION
OF PLANT
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

(1) Column 0, line 34 must agree with Wkst. A, column 7, line 116.
(2) Columns 0 through 25, line 34 must agree with the corresponding columns of Wkst. B, Part I, line 116.

FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.1)

40-638

Rev. 4

10-12

FORM CMS-2552-10

ALLOCATION OF GENERAL SERVICE
COSTS TO HOSPICE COST CENTERS

4090 (Cont.)
PROVIDER CCN:
________________
HOSPICE CCN:
________________

PERIOD:
FROM ____________
TO _______________

WORKSHEET K-5,
PART I (Cont.)

PART I - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS

HOSPICE COST CENTER
(omit cents)

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

LAUNDRY
& LINEN
SERVICE
8

HOUSEKEEPING
9

DIETARY
10

CAFETERIA
11

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
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemaker
HH Aide & Homemaker - Cont. Home Care
Other
Drugs, Biological and Infusion Therapy
Analgesics
Sedatives / Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (including E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1-33) (2)
Unit Cost Multiplier (see instructions)

MAINTENANCE OF
PERSONNEL
12

NURSING
ADMINISTRATION
13

CENTRAL
SERVICES &
SUPPLY
14

PHARMACY
15

MEDICAL
RECORDS &
LIBRARY
16

SOCIAL
SERVICE
17
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) Column 0, line 34 must agree with Wkst. A, column 7, line 116.
(2) Columns 0 through 25, line 34 must agree with the corresponding columns of Wkst. B, Part I, line 116.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.1)

Rev. 3

40-639

4090 (Cont.)

FORM CMS-2552-10

10-12

ALLOCATION OF GENERAL SERVICE
COSTS TO HOSPICE COST CENTERS

PROVIDER CCN:
_______________
HOSPICE CCN:
_______________

PERIOD:
FROM ____________
TO _______________

WORKSHEET K-5,
PART I (Cont.)

PART I - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS

HOSPICE COST CENTER
(omit cents)

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

OTHER
GENERAL
SERVICE
`8

NONPHYSICIAN
ANESTHETISTS
19

NURSING
SCHOOL
20

INTERNS & RESIDENTS
SALARY &
PROGRAM
FRINGES
COSTS
21
22

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
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemaker
HH Aide & Homemaker - Cont. Home Care
Other
Drugs, Biological and Infusion Therapy
Analgesics
Sedatives / Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (including E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1-33) (2)
Unit Cost Multiplier (see instructions)

PARAMEDICAL
EDUCATION
(SPECIFY)
23

SUBTOTAL
(cols. 4a-23)
24

INTERN &
RESIDENT
COST & POST
STEPDOWN
ADJUST.
25

SUBTOTAL
(cols. 24 ± 25)
26

ALLOCATED
HOSPICE
A&G (see
Part II)
27

TOTAL
HOSPICE
COSTS
(cols. 26 ± 27)
28
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) Column 0, line 34 must agree with Wkst. A, column 7, line 116.
(2) Columns 0 through 25, line 34 must agree with the corresponding columns of Wkst. B, Part I, line 116.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.1)

40-640

Rev. 3

09-13

FORM CMS-2552-10

4090 (Cont.)

ALLOCATION OF GENERAL SERVICE COSTS TO
HOSPICE COST CENTERS STATISTICAL BASIS

PART II - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS - STATISTICAL BASIS
CAPITAL
RELATED COST
BLDGS. &
MOVABLE
HOSPICE COST CENTER
FIXTURES
EQUIPMENT
(SQUARE
(DOLLAR
FEET)
VALUE)
1
2
1 Administrative and General
2 Inpatient - General Care
3 Inpatient - Respite Care
4 Physician Services
5 Nursing Care
6 Nursing Care-Continuous Home Care
7 Physical Therapy
8 Occupational Therapy
9 Speech/ Language Pathology
10 Medical Social Services
11 Spiritual Counseling
12 Dietary Counseling
13 Counseling - Other
14 Home Health Aide and Homemaker
15 HH Aide & Homemaker - Cont. Home Care
16 Other
17 Drugs, Biological and Infusion Therapy
18 Analgesics
19 Sedatives / Hypnotics
20 Other - Specify
21 Durable Medical Equipment/Oxygen
22 Patient Transportation
23 Imaging Services
24 Labs and Diagnostics
25 Medical Supplies
26 Outpatient Services (including E/R Dept.)
27 Radiation Therapy
28 Chemotherapy
29 Other
30 Bereavement Program Costs
31 Volunteer Program Costs
32 Fundraising
33 Other Program Costs
34 Totals (sum of lines 1-33) (2)
35 Total cost to be allocated
36 Unit Cost Multiplier (see instructions)

PROVIDER CCN:
________________
HOSPICE CCN:
________________

EMPLOYEE
BENEFITS
DEPARTMENT
(GROSS
SALARIES)
4

RECONCILIATION
5A

ADMINISTRATIVE &
GENERAL
(ACCUM.
COST)
5

PERIOD:
FROM ____________
TO _______________

MAINTENANCE &
REPAIRS
(SQUARE
FEET)
6

WORKSHEET K-5,
PART II

OPERATION
OF PLANT
(SQUARE
FEET)
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

FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.2)

Rev. 4

40-641

4090 (Cont.)

FORM CMS-2552-10

09-13

ALLOCATION OF GENERAL SERVICE COSTS TO
HOSPICE COST CENTERS STATISTICAL BASIS

PROVIDER CCN:
________________
HOSPICE CCN:
________________

PERIOD:
WORKSHEET K-5,
FROM ____________ PART II
TO _______________

PART II - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS - STATISTICAL BASIS

HOSPICE 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
24
25
26
27
28
29
30
31
32
33
34
35
36

LAUNDRY
& LINEN
SERVICE
(POUNDS OF
LAUNDRY)
8

HOUSEKEEPING
(HOURS OF
SERVICE)
9

DIETARY
(MEALS
SERVED)
10

CAFETERIA
(MEALS
SERVED)
11

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
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemaker
HH Aide & Homemaker - Cont. Home Care
Other
Drugs, Biological and Infusion Therapy
Analgesics
Sedatives / Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (including E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1-33) (2)
Total cost to be allocated
Unit Cost Multiplier (see instructions)

MAINTENANCE OF
PERSONNEL
(NUMBER
HOUSED)
12

NURSING
ADMINISTRATION
(DIRECT
NURS. HRS)
13

CENTRAL
SERVICES &
SUPPLY
(COSTED
REQUIS.)
14

PHARMACY
(COSTED
REQUIS.)
15

MEDICAL
RECORDS &
LIBRARY
(TIME
SPENT)
16
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

FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.2)

40-642

Rev. 4

10-12

FORM CMS-2552-10

4090 (Cont.)

ALLOCATION OF GENERAL SERVICE COSTS TO
HOSPICE COST CENTERS STATISTICAL BASIS

PROVIDER CCN:
________________
HOSPICE CCN:
________________

PERIOD:
FROM ____________
TO _______________

WORKSHEET K-5,
PART II

PART II - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS - STATISTICAL BASIS

HOSPICE 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
24
25
26
27
28
29
30
31
32
33
34
35
36

SOCIAL
SERVICE
(TIME
SPENT)
17

OTHER
GENERAL
SERVICE
(SPECIFY)
18

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
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemaker
HH Aide & Homemaker - Cont. Home Care
Other
Drugs, Biological and Infusion Therapy
Analgesics
Sedatives / Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (including E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1-33) (2)
Total cost to be allocated
Unit Cost Multiplier (see instructions)

NONPHYSICIAN
ANESTHETISTS
(ASSIGNED
TIME)
19

NURSING
SCHOOL
(ASSIGNED
TIME)
20

INTERNS & RESIDENTS
SALARY &
PROGRAM
FRINGES
COSTS
(ASSIGNED
(ASSIGNED
TIME)
TIME)
21
22

PARAMEDICAL
EDUCATION
(SPECIFY)
(ASSIGNED
TIME)
23
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

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.2)

Rev. 3

40-643

4090 (Cont.)

10-12

FORM CMS-2552-10

APPORTIONMENT OF HOSPICE SHARED SERVICES

PROVIDER CCN:
________________

PERIOD:
FROM ____________

HOSPICE CCN:
________________

TO _______________

WORKSHEET K-5,
PART III

PART III - COMPUTATION OF TOTAL HOSPICE SHARED COSTS

COST CENTER

1
2
3
4
5
6
7
8
9
10
11

ANCILLARY SERVICE COST CENTERS
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Drugs, Biological and Infusion Therapy
Durable Medical Equipment/Oxygen
Labs and Diagnostics
Medical Supplies
Outpatient Services (including E/R Dept.)
Radiation Therapy
Other
Totals (sum of lines 1-10)

Wkst. C,
Part I,
col. 9,
line
0

Cost to
Charge
Ratio
1

Total
Hospice
Charges
(Provider
Records)
2

66
67
68
73
96
60
71
93
55
76

Hospice
Shared
Ancillary
Costs
(cols. 1 x 2)
3
1
2
3
4
5
6
7
8
9
10
11

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4062.3)

40-644

Rev. 3

09-15

COMPUTATION OF PER DIEM COST
1
2
3
4
5
6
7
8
9
10
11
12
13

4090 (Cont.)

FORM CMS-2552-10

CALCULATION OF HOSPICE PER DIEM COST

PROVIDER CCN:
________________
HOSPICE CCN:
________________

TITLE XVIII
1

PERIOD:
FROM ____________
TO _______________

TITLE XIX
2

Total cost (see instructions)
Total unduplicated days (Worksheet S-9, column 6, line 5)
Average cost per diem (line 1 divided by line 2)
Unduplicated Medicare days (Worksheet S-9, column 1, line 5)
Aggregate Medicare cost (line 3 times line 4)
Unduplicated Medicaid days (Worksheet S-9, column 2, line 5)
Aggregate Medicaid cost (line 3 times line 6)
Unduplicated SNF days (Worksheet S-9, column 3, line 5)
Aggregate SNF cost (line 3 times line 8)
Unduplicated NF days (Worksheet S-9, column 4, line 5)
Aggregate NF cost (line 3 times line 10)
Other Unduplicated days (Worksheet S-9, column 5, line 5)
Aggregate cost for other days (line 3 times line 12)

OTHER
3

WORKSHEET K-6

TOTAL
4
1
2
3
4
5
6
7
8
9
10
11
12
13

Note: The data for the SNF and NF on lines 8 through 11 are included in the Medicare and Medicaid lines 4 through 7.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4063)

Rev. 8

40-645

4090 (Cont.)
CALCULATION OF CAPITAL PAYMENT

09-15

FORM CMS-2552-10
PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
WORKSHEET L
FROM ____________
TO _______________

[ ] Title V
[ ] Hospital
[ ] PPS
[ ] Title XVIII, Part A
[ ] Subprovider (other)
[ ] Cost Method
boxes:
[ ] Title XIX
PART I - FULLY PROSPECTIVE METHOD
CAPITAL FEDERAL AMOUNT
1 Capital DRG other than outlier
1.01 Model 4 BPCI Capital DRG other than outlier
2 Capital DRG outlier payments
2.01 Model 4 BPCI Capital DRG outlier payments
3 Total inpatient days divided by number of days in the cost reporting period (see instructions)
4 Number of interns & residents (see instructions)
5 Indirect medical education percentage (see instructions)
6 Indirect medical education adjustment (see instructions)
7 Percentage of SSI recipient patient days to Medicare Part A patient days (Worksheet E, Part A line 30) (see instructions)
8 Percentage of Medicaid patient days to total days (see instructions)
9 Sum of lines 7 and 8
10 Allowable disproportionate share percentage (see instructions)
11 Disproportionate share adjustment (see instructions)
12 Total prospective capital payments (see instructions)
PART II - PAYMENT UNDER REASONABLE COST
1 Program inpatient routine capital cost (see instructions)
2 Program inpatient ancillary capital cost (see instructions)
3 Total inpatient program capital cost (line 1 plus line 2)
4 Capital cost payment factor (see instructions)
5 Total inpatient program capital cost (line 3 x line 4)
PART III - COMPUTATION OF EXCEPTION PAYMENTS
1 Program inpatient capital costs (see instructions)
2 Program inpatient capital costs for extraordinary circumstances (see instructions)
3 Net program inpatient capital costs (line 1 minus line 2)
4 Applicable exception percentage (see instructions)
5 Capital cost for comparison to payments (line 3 x line 4)
6 Percentage adjustment for extraordinary circumstances (see instructions)
7 Adjustment to capital minimum payment level for extraordinary circumstances (line 2 x line 6)
8 Capital minimum payment level (line 5 plus line 7)
9 Current year capital payments (from Part I, line 12 as applicable)
10 Current year comparison of capital minimum payment level to capital payments (line 8 less line 9)
11 Carryover of accumulated capital minimum payment level over capital payment
(from prior year Worksheet L, Part III, line 14)
12 Net comparison of capital minimum payment level to capital payments (line 10 plus line 11)
13 Current year exception payment (if line 12 is positive, enter the amount on this line)
14 Carryover of accumulated capital minimum payment level over capital payment
for the following period (if line 12 is negative, enter the amount on this line)
15 Current year allowable operating and capital payment (see instructions)
16 Current year operating and capital costs (see instructions)
17 Current year exception offset amount (see instructions)
Check

applicable

1
1.01
2
2.01
3
4
5
6
7
8
9
10
11
12
1
2
3
4
5
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

FORM CMS-2552-10 (09-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4064.1 - 4064.3)

40-646

Rev. 8

11-17

FORM CMS-2552-10

4090 (Cont.)

ALLOCATION OF ALLOWABLE COSTS FOR
EXTRAORDINARY CIRCUMSTANCES

PROVIDER CCN:
________________

Cost Center Descriptions

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

EXTRAORDINARY
CAPITAL
RELATED
COSTS
0

PERIOD:
WORKSHEET L-1,
FROM ____________ PART I
TO _______________

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits Department
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Ed. Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

SUBTOTAL
(sum of
cols. 0-2)
2A

EMPLOYEE
BENEFITS
DEPARTMENT
4

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE &
REPAIRS
6

OPERATION
OF PLANT
7
1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)

Rev. 12

40-647

4690 (Cont.)

FORM CMS-2552-10

11-17

ALLOCATION OF ALLOWABLE COSTS FOR
EXTRAORDINARY CIRCUMSTANCES

PROVIDER CCN:
________________

Cost Center Descriptions

50
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
77
88
89
90
91
92
93
93.99

EXTRAORDINARY
CAPITAL
RELATED
COSTS
0

PERIOD:
WORKSHEET L-1,
FROM ____________ PART I
TO _______________

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catherization
Laboratory
PBP Clinical Laboratory Service-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
Allogeneic Stem Cell Acquisition
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient (specify)
Partial Hospitalization Program

SUBTOTAL
(sum of
cols. 0-2)
2A

EMPLOYEE
BENEFITS
DEPARTMENT
4

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE &
REPAIRS
6

OPERATION
OF PLANT
7
50
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
77
88
89
90
91
92
93
93.99

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)

40-648

Rev. 12

11-17

FORM CMS-2552-10

4090 (Cont.)

ALLOCATION OF ALLOWABLE COSTS FOR
EXTRAORDINARY CIRCUMSTANCES

PROVIDER CCN:
________________

Cost Center Descriptions

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202
203
204

EXTRAORDINARY
CAPITAL
RELATED
COSTS
0

PERIOD:
WORKSHEET L-1,
FROM ____________ PART I
TO _______________

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1 through 117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross Foot Adjustments
Negative Cost Centers
Total (sum of line 118 and lines 190 through 201)
Total Statistical Basis
Unit Cost Multiplier

SUBTOTAL
(sum of
cols. 0-4)
2A

EMPLOYEE
BENEFITS
DEPARTMENT
4

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE &
REPAIRS
6

OPERATION
OF PLANT
7
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202
203
204

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)

Rev. 12

40-649

4090 (Cont.)

FORM CMS-2552-10

11-17

ALLOCATION OF ALLOWABLE COSTS FOR
EXTRAORDINARY CIRCUMSTANCES

PROVIDER CCN:
________________

Cost Center Descriptions

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

LAUNDRY
& LINEN
SERVICE
8

HOUSEKEEPING
9

DIETARY
10

CAFETERIA
11

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits Department
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Ed. Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

MAINTENANCE OF
PERSONNEL
12

NURSING
ADMINISTRATION
13

CENTRAL
SERVICES &
SUPPLY
14

PHARMACY
15

PERIOD:
WORKSHEET L-1,
FROM ____________ PART I (Cont.)
TO _______________

MEDICAL
RECORDS &
LIBRARY
16

SOCIAL
SERVICE
17
1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)

40-650

Rev. 12

11-17

FORM CMS-2552-10

4090 (Cont.)

ALLOCATION OF ALLOWABLE COSTS FOR
EXTRAORDINARY CIRCUMSTANCES

PROVIDER CCN:
________________

Cost Center Descriptions

50
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
77
88
89
90
91
92
93
93.99

LAUNDRY
& LINEN
SERVICE
8

HOUSEKEEPING
9

DIETARY
10

CAFETERIA
11

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catherization
Laboratory
PBP Clinical Laboratory Service-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
Allogeneic Stem Cell Acquisition
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient (specify)
Partial Hospitalization Program

MAINTENANCE OF
PERSONNEL
12

NURSING
ADMINISTRATION
13

CENTRAL
SERVICES &
SUPPLY
14

PHARMACY
15

PERIOD:
WORKSHEET L-1,
FROM ____________ PART I (Cont.)
TO _______________

MEDICAL
RECORDS &
LIBRARY
16

SOCIAL
SERVICE
17
50
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
77
88
89
90
91
92
93
93.99

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)

Rev. 12

40-651

4090 (Cont.)

FORM CMS-2552-10

11-17

ALLOCATION OF ALLOWABLE COSTS FOR
EXTRAORDINARY CIRCUMSTANCES

PROVIDER CCN:
________________

Cost Center Descriptions

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202
203
204

LAUNDRY
& LINEN
SERVICE
8

HOUSEKEEPING
9

DIETARY
10

CAFETERIA
11

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1 through 117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross Foot Adjustments
Negative Cost Centers
Total (sum of line 118 and lines 190 through 201)
Total Statistical Basis
Unit Cost Multiplier

MAINTENANCE OF
PERSONNEL
12

NURSING
ADMINISTRATION
13

CENTRAL
SERVICES &
SUPPLY
14

PHARMACY
15

PERIOD:
WORKSHEET L-1,
FROM ____________ PART I (Cont.)
TO _______________

MEDICAL
RECORDS &
LIBRARY
16

SOCIAL
SERVICE
17
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202
203
204

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)

40-652

Rev. 12

4090 (Cont.)

FORM CMS-2552-10

11-17

ALLOCATION OF ALLOWABLE COSTS FOR
EXTRAORDINARY CIRCUMSTANCES

PROVIDER CCN:
________________

Cost Center Descriptions

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

OTHER
GENERAL
SERVICE
18

NONPHYSICIAN
ANESTHETISTS
19

NURSING
SCHOOL
20

INTERNS &
RESIDENTS
SALARY &
FRINGES
21

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits Department
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Ed. Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

INTERNS &
RESIDENTS
PROGRAM
COSTS
22

PARAMEDICAL
EDUCATION
(SPECIFY)
23

SUBTOTAL
24

PERIOD:
WORKSHEET L-1,
FROM ____________ PART I (Cont.)
TO _______________
INTERN &
RESIDENT
COST & POST
STEPDOWN
ADJUSTMENTS
TOTAL
25
26
1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)

Rev. 12

40-653

4690 (Cont.)

FORM CMS-2552-10

11-17

ALLOCATION OF ALLOWABLE COSTS FOR
EXTRAORDINARY CIRCUMSTANCES

PROVIDER CCN:
________________

Cost Center Descriptions

50
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
77
88
89
90
91
92
93
93.99

OTHER
GENERAL
SERVICE
18

NONPHYSICIAN
ANESTHETISTS
19

NURSING
SCHOOL
20

INTERNS &
RESIDENTS
SALARY AND
FRINGES
21

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catherization
Laboratory
PBP Clinical Laboratory Service-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
Allogeneic Stem Cell Acquisition
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient (specify)
Partial Hospitalization Program

INTERNS &
RESIDENTS
PROGRAM
COSTS
22

PARAMEDICAL
EDUCATION
(SPECIFY)
23

SUBTOTAL
24

PERIOD:
WORKSHEET L-1,
FROM ____________ PART I (Cont.)
TO _______________
INTERN &
RESIDENT
COST & POST
STEPDOWN
ADJUSTMENTS
TOTAL
25
26
50
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
77
88
89
90
91
92
93
93.99

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)

40-654

Rev. 12

10-12

FORM CMS-2552-10

4090 (Cont.)

ALLOCATION OF ALLOWABLE COSTS FOR
EXTRAORDINARY CIRCUMSTANCES

PROVIDER CCN:
________________

Cost Center Descriptions

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202
203
204

OTHER
GENERAL
SERVICE
18

NONPHYSICIAN
ANESTHETISTS
19

NURSING
SCHOOL
20

INTERNS &
RESIDENTS
SALARY AND
FRINGES
21

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1 through 117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross Foot Adjustments
Negative Cost Centers
Total (sum of line 118 and lines 190 through 201)
Total Statistical Basis
Unit Cost Multiplier

INTERNS &
RESIDENTS
PROGRAM
COSTS
22

PARAMEDICAL
EDUCATION
(SPECIFY)
23

SUBTOTAL
24

PERIOD:
WORKSHEET L-1,
FROM ____________ PART I (Cont.)
TO _______________
INTERN &
RESIDENT
COST & POST
STEPDOWN
ADJUSTMENTS
TOTAL
25
26
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202
203
204

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)

Rev. 3

40-655

4090 (Cont.)

FORM CMS-2552-10

10-12

COMPUTATION OF PROGRAM INPATIENT ROUTINE SERVICE
CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES

PROVIDER CCN:
________________

Check
applicable
box:

PERIOD:
FROM ____________
TO _______________

WORKSHEET L-1,
PART II

[ ] Title V
[ ] Title XVIII, Part A
[ ] Title XIX

Cost Center Description
(A)

Capital Cost
for Extraordinary
Circumstances
(from Wkst. L-1,
Part I, col. 26)
1

Swing Bed
Adjustment
2

Reduced
Capital Cost
for Extraordinary
Circumstances
(col. 1 - col. 2)
3

Total
Patient Days
4

Per Diem
(col. 3 ÷ col. 4)
5

Inpatient
Program Days
6

Inpatient Program
Capital Cost
(col. 5 x col. 6)
7

INPATIENT ROUTINE SERVICE
COST CENTERS
30

Adults & Pediatrics (General Routine Care)

30

31

Intensive Care Unit

31

32

Coronary Care Unit

32

33

Burn Intensive Care Unit

33

34

Surgical Intensive Care Unit

34

35

Other Special Care Unit (specify)

35

40

Subprovider IPF

40

41 Subprovider IRF

41

42 Subprovider (Other)

42

43

43

200

Nursery
Total (sum of lines 30-199)

200

(A) Worksheet A line numbers

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.2)

40-656

Rev. 3

11-17

FORM CMS-2552-10

4090 (Cont.)

COMPUTATION OF PROGRAM INPATIENT ANCILLARY SERVICE
CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES

Check
applicable

[ ] Hospital
[ ] Subprovider

boxes:

PERIOD:
FROM ____________
TO _______________

WORKSHEET L-1,
PART III

[ ] Title V
[ ] Title XVIII, Part A
[ ] Title XIX

Cost Center Description
(A)
50
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
77

PROVIDER CCN:
________________
COMPONENT CCN:
________________

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catherization
Laboratory
PBP Clinical Laboratory Service-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
Allogeneic Stem Cell Acquisition

Capital Cost for
Extraordinary
Circumstances
(from Wkst. L-1,
Part I, col. 26)
1

Total Charges
(from Wkst. C,
Part I, col. 6)
2

Ratio of Cost
to Charges
(col. 1 ÷ col. 2)
3

Inpatient
Program Charges
4

Program
Extraordinary
Capital Cost
(col. 3 x col. 4)
5
50
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
77

(A) Worksheet A line numbers

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4065.3)

Rev. 12

40-657

4090 (Cont.)

FORM CMS-2552-10

11-17

COMPUTATION OF PROGRAM INPATIENT ANCILLARY SERVICE
CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES

Check
applicable

[ ] Hospital
[ ] Subprovider

boxes:

PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
FROM ____________
TO _______________

WORKSHEET L-1,
PART III (CONT.)

[ ] Title V
[ ] Title XVIII, Part A
[ ] Title XIX

Cost Center Description
(A)
OUTPATIENT SERVICE COST CENTERS
88 Rural Health Clinic (RHC)
89 Federally Qualified Health Center (FQHC)
90 Clinic
91 Emergency
92 Observation Beds
93 Other Outpatient (specify)
93.99 Partial Hospitalization Program
OTHER REIMBURSABLE COST CENTERS
94 Home Program Dialysis
95 Ambulance Services
96 Durable Medical Equipment-Rented
97 Durable Medical Equipment-Sold
98 Other Reimbursable (specify)
200 Total (sum of lines 50 through 199)

Capital Cost for
Extraordinary
Circumstances
(from Wkst. L-1,
Part I, col. 26)
1

Total Charges
(from Wkst. C,
Part I, col. 6)
2

Ratio of Cost
to Charges
(col. 1 ÷ col. 2)
3

Inpatient
Program Charges
4

Program
Extraordinary
Capital Cost
(col. 3 x col. 4)
5
88
89
90
91
92
93
93.99
94
95
96
97
98
200

(A) Worksheet A line numbers

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4065.3)

40-658

Rev. 12

11-16

FORM CMS-2552-10

4090 (Cont.)

ANALYSIS OF HOSPITAL-BASED RHC/FQHC COSTS

Check applicable box:

[ ] Hospital-based RHC

PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
WORKSHEET M-1
FROM ____________
TO _______________

[ ] Hospital-based FQHC

COMPENSATION
1

OTHER COSTS
2

TOTAL
(col. 1 + col. 2)
3

FACILITY HEALTH CARE STAFF COSTS
Physician
Physician Assistant
Nurse Practitioner
Visiting Nurse
Other Nurse
Clinical Psychologist
Clinical Social Worker
Laboratory Technician
Other Facility Health Care Staff Costs
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
20 Allowable GME Costs
21 Subtotal (sum of lines 15-20)
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
25.01 Telehealth
25.02 Chronic Care Management
26 All other nonreimbursable costs
27 Nonallowable GME costs
28 Total Nonreimbursable Costs (sum of lines 23-27)
FACILITY OVERHEAD
29 Facility Costs
30 Administrative Costs
31 Total Facility Overhead (sum of lines 29 and 30)
32 Total facility costs (sum of lines 22, 28 and 31)
The net expenses for cost allocation on Worksheet A for the hospital-based RHC/FQHC cost center line must equal the total facility costs in column 7, line 32, of this worksheet.
1
2
3
4
5
6
7
8
9
10

RECLASSIFICATIONS
4

RECLASSIFIED
TRIAL
BALANCE
(col. 3 + col. 4)
5

ADJUSTMENTS
6

NET EXPENSES
FOR
ALLOCATION
(col. 5 + col. 6)
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
25.01
25.02
26
27
28
29
30
31
32

FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4066)

Rev. 10

40-659

4090 (Cont.)

Check applicable box:
VISITS AND PRODUCTIVITY

[ ] Hospital-based RHC

PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
FROM ____________
TO _______________

WORKSHEET M-2

[ ] Hospital-based FQHC
Number
of FTE
Personnel
1

Total
Visits
2

Positions
1 Physicians
2 Physician Assistants
3 Nurse Practitioners
4 Subtotal (sum of lines 1-3)
5 Visiting Nurse
6 Clinical Psychologist
7 Clinical Social Worker
7.01 Medical Nutrition Therapist (FQHC only)
7.02 Diabetes Self Management Training (FQHC only)
8 Total FTEs and Visits (sum of lines 4-7)
9 Physician Services Under Agreements
DETERMINATION OF ALLOWABLE COST APPLICABLE TO HOSPITAL-BASED RHC/FQHC SERVICES
10 Total costs of health care services (from Worksheet M-1, column 7, line 22)
11 Total nonreimbursable costs (from Worksheet M-1, column 7, line 28)
12 Cost of all services (excluding overhead) (sum of lines 10 and 11)
13 Ratio of hospital-based RHC/FQHC services (line 10 divided by line 12)
14 Total hospital-based RHC/FQHC overhead (from Worksheet M-1, column 7, line 31)
15 Parent provider overhead allocated to facility (see instructions)
16 Total overhead (sum of lines 14 and 15)
17 Allowable Direct GME overhead (see instructions)
18 Enter the amount from line 16
19 Overhead applicable to hospital-based RHC/FQHC services (line 13 x line 18)
20 Total allowable cost of hospital-based RHC/FQHC services (sum of lines 10 and 19)
(1)

11-16

FORM CMS-2552-10

ALLOCATION OF OVERHEAD
TO HOSPTIAL-BASED RHC/FQHC SERVICES

Productivity
Standard (1)
3

Minimum
Visits (col. 1
x col. 3)
4

Greater of
col. 2 or
col. 4
5
1
2
3
4
5
6
7
7.01
7.02
8
9
10
11
12
13
14
15
16
17
18
19
20

The productivity standard for physicians is 4,200 and 2,100 for physician assistants and nurse practitioners. If an exception
to the standard has been granted (Worksheet S-8, line 12 equals "Y"), column 3, lines 1thru 3 of this worksheet should contain,
at a minimum, one element that is different than the standard.

FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4067)

40-660

Rev. 10

11-17

Check
applicable boxes:

4090(Cont.)

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT
SETTLEMENT FOR HOSPITAL-BASED RHC/FQHC SERVICES

[ ] Hospital-based RHC
[ ] Hospital-based FQHC

[ ] Title V
[ ] Title XVIII

PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
FROM ___________
TO ___________

WORKSHEET M-3

[ ] Title XIX

DETERMINATION OF RATE FOR HOSPITAL-BASED RHC/FQHC SERVICES
1 Total allowable cost of hospital-based RHC/FQHC services (from Worksheet M-2, line 20)
2 Cost of vaccines and their administration (from Worksheet M-4, line 15)
3 Total allowable cost excluding vaccine (line 1 minus line 2)
4 Total visits (from Worksheet M-2, column 5, line 8)
5 Physicians visits under agreement (from Worksheet M-2, column 5, line 9)
6 Total adjusted visits (line 4 plus line 5)
7 Adjusted cost per visit (line 3 divided by line 6)

1
2
3
4
5
6
7
Calculation of Limit (1)
Payment Limit
Payment Limit
Period 1
Period 2
1
2

8 Per visit payment limit (from CMS Pub. 100-04, chapter 9, §20.6, or your contractor)
9 Rate for Program covered visits (see instructions)
CALCULATION OF SETTLEMENT
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 from mental health services (line 9 x line 12)
14 Limit adjustment for mental health services (see instructions)
15 Graduate Medical Education pass-through cost (see instructions)
16 Total Program cost (sum of lines 11, 14, and 15, columns 1, 2 and 3)
16.01 Total program charges (see instructions)(from contractor's records)
16.02 Total program preventive charges (see instructions)(from provider's records)
16.03 Total program preventive costs (see instructions)
16.04 Total program non-preventive costs (see instructions)
16.05 Total program cost (see instructions)
17 Primary payer amounts
18 Less: Beneficiary deductible for RHC only (see instructions) (from contractor records)
19 Less: Beneficiary coinsurance for RHC/FQHC services (see instructions) (from contractor records)
20 Net Medicare cost excluding vaccines (see instructions)
21 Program cost of vaccines and their administration (from Worksheet M-4, line 16)
22 Total reimbursable Program cost (line 20 plus line 21)
23 Allowable bad debts (see instructions)
23.01 Adjusted reimbursable bad debts (see instructions)
24 Allowable bad debts for dual eligible beneficiaries (see instructions)
25 Other adjustments (specify) (see instructions)
25.50 Pioneer ACO demonstration payment adjustment (see instructions)
25.99 Demonstration payment adjustment amount before sequestration
26 Net reimbursable amount (see instructions)
26.01 Sequestration adjustment (see instructions)
26.02 Demonstration payment adjustment amount after sequestration
27 Interim payments
28 Tentative settlement (for contractor use only)
29 Balance due component/program line 26 minus lines 26.01, 26.02, 27, and 28
30 Protested amounts (nonallowable cost report items) in accordance with CMS
Pub. 15-2, chapter 1, section 115.2
(1)

8
9
10
11
12
13
14
15
16
16.01
16.02
16.03
16.04
16.05
17
18
19
20
21
22
23
23.01
24
25
25.50
25.99
26
26.01
26.02
27
28
29
30

Lines 8 through 14: Fiscal year providers use columns 1 and 2 (and column 3, if applicable). Calendar year providers with one rate in effect for the entire cost reporting period use column 2 only.

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4068)

Rev. 12

40-661

4090(Cont.)

Check
applicable boxes:

11-17

FORM CMS-2552-10

COMPUTATION OFHOSPITAL-BASED RHC/FQHC PNEUMOCOCCAL AND INFLUENZA
VACCINE COST

[ ] Hospital-based RHC
[ ] Hospital-based FQHC

[ ] Title V
[ ] Title XVIII

PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
WORKSHEET M-4
FROM ____________
TO ____________

[ ] Title XIX
PNEUMOCOCCAL
1

1 Health care staff cost (from Worksheet M-1, column 7, line 10)
2 Ratio of pneumococcal and influenza vaccine staff time to total
health care staff time
3 Pneumococcal and influenza vaccine health care staff cost (line 1 x line 2)
4 Medical supplies cost - pneumococcal and influenza vaccine
(from your records)
5 Direct cost of pneumococcal and influenza vaccine (line 3 plus line 4)
6 Total direct cost of the hospital-based RHC/FQHC (from Worksheet M-1, column 7, line 22)
7 Total overhead (from Worksheet M-2, line 19)
8 Ratio of pneumococcal and influenza vaccine direct cost to total direct
cost (line 5 divided by line 6)
9 Overhead cost - pneumococcal and influenza vaccine (line 7 x line 8)
10 Total pneumococcal and influenza vaccine costs and their
administration costs (sum of lines 5 and 9)
11 Total number of pneumococcal and influenza vaccine injections
(from your records)
12 Cost per pneumococcal and influenza vaccine injection (line 10/line 11)
13 Number of pneumococcal and influenza vaccine injections administered
to Program beneficiaries
14 Program cost of pneumococcal and influenza vaccines and their
administration costs (line 12 x line 13)
15 Total cost of pneumococcal and influenza vaccines and their administration costs (sum of columns
1 and 2, line 10) (transfer this amount to Worksheet M-3, line 2)
16 Total Program cost of pneumococcal and influenza vaccines and their administration costs (sum
of columns 1 and 2, line 14) (transfer this amount to Worksheet M-3, line 21)

INFLUENZA
2
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

FORM CMS 2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4069)

40-662

Rev. 12

11-16

4090 (Cont.)

FORM CMS-2552-10

ANALYSIS OF PAYMENTS TO HOSPITAL-BASED
RHC/FQHC FOR SERVICES RENDERED
TO PROGRAM BENEFICIARIES
Check applicable box:

[ ] Hospital-based RHC

PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
FROM ___________
TO ___________

WORKSHEET M-5

[ ] Hospital-based FQHC
Part B

DESCRIPTION
Total interim payments paid to hospital-based RHC/FQHC
Interim payments payable on individual bills, either
submitted or to be submitted to the intermediary, for
services rendered in the cost reporting periods. If
none, write "NONE", or 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 zero (1).

1
mm/did/ivy

2
Amount

1
2

4

5

6

7
8

(1)

1
2

Program
to
Provider

Provider
to
Program

Subtotal (sum of lines 3.01-3.49 minus sum of lines 3.50-3.98)
Total interim payments (sum of lines 1, 2, and 3.99)
(transfer to Worksheet M-3, line 27)
TO BE COMPLETED BY CONTRACTOR
List separately each tentative
settlement payment after desk review.
Also show date of each payment.
If none, write "NONE,"
or enter zero (1).
Subtotal (sum of lines 5.01-5.49 minus sum of lines 5.50-5.98)
Determine net settlement amount
(balance due) based on the cost
report (see instructions). (1)

Total Medicare liability (see instructions)
Name of Contractor

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

5.01
5.02
5.03
5.50
5.51
5.52
5.99

.01

6.01

.02

6.02
7
8

Contractor Number

NPR Date
(Month/Day/Year)

On lines 3, 5, and 6, where an amount is due component to program,
show the amount and date on which you agree to the amount of repayment,
even though the total repayment is not accomplished until a later date.

FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4070)

Rev. 10

40-663

4090 (Cont.)

FORM CMS-2552-10

11-16

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES
FOR HOSPITAL-BASED FQHC

COST CENTER DESCRIPTIONS
(omit cents)

PROVIDER CCN:
_________________
COMPONENT CCN:
_________________

SALARIES
1

OTHER
2

GENERAL SERVICE COST CENTERS
1 Cap Rel Costs-Bldg and Fix
2 Cap Rel Costs-Mvble Equip
3 Employee Benefits
4 Administrative and General
5 Plant Operation and Maintenance
6 Janitorial
7 Medical Records
8 Subtotal - Administrative Overhead
9 Pharmacy
10 Medical Supplies
11 Transportation
12 Other General Service
13 Subtotal - Total Overhead
DIRECT CARE COST CENTERS
23 Physician
24 Physician Services Under Agreement
25 Physician Assistant
26 Nurse Practitioner
27 Visiting Registered Nurse
28 Visiting Licensed Practical Nurse
29 Certified Nurse Midwife
30 Clinical Psychologist
31 Clinical Social Worker
32 Laboratory Technician
33 Reg Dietician/Cert DSMT/MNT Educator
34 Physical Therapist
35 Occupational Therapist
36 Other Allied Health Personnel
37 Subtotal - Direct Patient Care Services

TOTAL
(col. 1 + col. 2)
3

RECLASSIFICATIONS
4

RECLASSIFIED
TRIAL BALANCE
(col. 3 ± col. 4)
5

PERIOD:
FROM: ___________
TO: ___________

ADJUSTMENTS
6

WORKSHEET N-1

NET
EXPENSES FOR
ALLOCATION
(col. 5 ± col. 6)
7
1
2
3
4
5
6
7
8
9
10
11
12
13
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37

FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4071)

40-664

Rev. 10

11-16

FORM CMS-2552-10

4090 (Cont.)

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES
FOR HOSPITAL-BASED FQHC

COST CENTER DESCRIPTIONS
(omit cents)

PROVIDER CCN:
_________________
COMPONENT CCN:
_________________

SALARIES
1

OTHER
2

REIMBURSABLE PASS THRO
47 Pneumococcal Vaccines & Med Supplies
48 Influenza Vaccines & Med Supplies
49 Subtotal - Reimbursable Pass through Costs
OTHER FQHC SERVICES
60 Medicare Excluded Services
61 Diagnostic & Screening Lab Tests
62 Radiology - Diagnostic
63 Prosthetic Devices
64 Durable Medical Equipment
65 Ambulance Services
66 Telehealth
67 Drugs Charged to Patients
68 Chronic Care Management
69 Other
70 Subtotal - Other FQHC Services
NONREIMBURSABLE COST CENTERS
77 Retail Pharmacy
78 Other Nonreimbursable
79 Subtotal - Non-Reimbursable Costs
100 TOTAL (sum of lines 13, 37, 49, 70, and 79)

TOTAL
(col. 1 + col. 2)
3

RECLASSIFICATIONS
4

RECLASSIFIED
TRIAL BALANCE
(col. 3 ± col. 4)
5

PERIOD:

WORKSHEET N-1

FROM ____________
TO ____________

ADJUSTMENTS
6

NET
EXPENSES FOR
ALLOCATION
(col. 5 ± col. 6)
7
47
48
49
60
61
62
63
64
65
66
67
68
69
70
77
78
79
100

FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4071)

Rev. 10

40-665

4090 (Cont.)

FORM CMS-2552-10

11-16

CALCULATION OF HOSPITAL-BASED FQHC COST PER VISIT

PROVIDER CCN:
__________________
COMPONENT CCN:
_____________
Total Visits

1
2
3
4
5
6
7
8
9
10
11
12
13

Positions
Physician
Physician Services Under Agreement
Physician Assistant
Nurse Practitioner
Visiting Registered Nurse
Visiting Licensed Practical Nurse
Certified Nurse Midwife
Clinical Psychologist
Clinical Social Worker
Reg Dietician/Cert DSMT/MNT Educator
Totals
Unit Cost Multiplier
Total Cost Per Visit

Other Direct
Total Medical Care Costs &
Direct Cost
& Mental Health Pharmacy Costs
by
From
Visits
Wkst. N-1, Practitioner
(see
instructions)
col. 7,
from Wkst. N-1 by Practitioner
line:
1
2
3
23
24
25
26
27
28
29
30
31
33

General
Service Cost
(see
instructions)
4

Total Costs
by
Practitioner
5

Average
Cost Per Visit
by Practitioner
6

Medical Visits
by Practitioner
7

Mental
Health Visits
by Practitioner
8

PERIOD:
FROM: ___________
TO: ___________

Title XVIII Visits

Medical Visits
by Practitioner
9

Mental
Health Visits
by Practitioner
10

WORKSHEET N-2

Title XVIII Costs

Medical Cost
by Practitioner
11

Mental
Health Cost
by Practitioner
12
1
2
3
4
5
6
7
8
9
10
11
12
13

FORM CMS-2552-10 (11-2016) INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4071.1)

40-666

Rev. 10

11-17

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

4090 (Cont.)

FORM CMS-2552-10

COMPUTATION OF HOSPITAL-BASED FQHC PNEUMOCOCCAL
AND INFLUENZA VACCINE COST

PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
FROM: ____________
TO: ____________

WORKSHEET N-3

PNEUMOCOCCAL
1

INFLUENZA
2

Health care staff cost (from Worksheet N-1, column 7, sum of lines 23, and 25 through 36)
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)
Vaccines and related medical supplies cost (from Worksheet N-1, column 7, lines 47 and 48, respectively)
Direct cost of pneumococcal and influenza vaccine (line 3 + line 4)
Total direct cost of the hospital-based FQHC (from Worksheet N-1, column 7, line 100, minus
Worksheet N-1, column 7, line 8)
Total administrative overhead (from Worksheet N-1, column 7, line 8)
Ratio of pneumococcal and influenza vaccine direct cost to total direct
cost (line 5 / line 6)
Overhead cost - pneumococcal and influenza vaccine (line 7 x line 8)
Total cost of pneumococcal and influenza vaccine and 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 / line 11)
Number of pneumococcal and influenza vaccine injections administered
to Medicare beneficiaries
Cost of pneumococcal and influenza vaccines and their
administration costs furnished to Medicare beneficiaries (line 12 x line 13)
Total cost of pneumococcal and influenza vaccines and their administration costs.
(sum of columns 1 and 2, line 10)
Total Medicare cost of pneumococcal and influenza vaccines and their administration costs (sum
of columns 1 and 2, line 14) (transfer this amount to Worksheet N-4, line 2)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4071.2)

Rev. 12

40-667

4090 (Cont.)

1
2
3
4
5
6
7
8
9
10
11
12
13
13.99
14
15
16
16.01
17
18
19
20

11-17

FORM CMS-2552-10

CALCULATION OF HOSPITAL-BASED FQHC REIMBURSEMENT SETTLEMENT

PROVIDER CCN:
________________
COMPONENT CCN:
________________

FQHC PPS Amount (see instructions)
Medicare cost of pneumococcal and influenza vaccine and administration (From Worksheet N-3, line 16)
Medicare advantage supplemental payments (for information only)
Total (sum of lines 1 through 2)
Primary payer payments
Total amount payable for program beneficiaries (line 4 minus line 5)
Coinsurance billed to program beneficiaries
Net Medicare reimbursement excluding bad debts (line 6 minus line 7)
Allowable bad debts (see instructions)
Adjusted reimbursable bad debts (see instructions)
Allowable bad debts for dual eligible beneficiaries (see instructions)
Subtotal (line 8 plus line 10)
Other adjustments (specify) (see instructions)
Demonstration payment adjustment amount before sequestration
Amount due hospital-based FQHC prior to the sequestration adjustment (see instructions)
Sequestration adjustment (see instructions)
Amount due hospital-based FQHC after sequestration adjustment (see instructions)
Demonstration payment adjustment amount after sequestration
Interim payments (from Worksheet N-5, col. 2, line 4)
Tentative settlement (for contractor use only)
Balance due hospital-based FQHC/program (line 16 minus lines 16.01, 17 and 18)
Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2

PERIOD:
FROM: ___________
TO: ___________

WORKSHEET N-4

1
2
3
4
5
6
7
8
9
10
11
12
13
13.99
14
15
16
16.01
17
18
19
20

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4071.3)

40-668

Rev. 12

11-16

4090 (Cont.)

FORM CMS-2552-10

ANALYSIS OF PAYMENTS TO HOSPITAL-BASED FQHC FOR SERVICES RENDERED

PROVIDER CCN:
_______________
COMPONENT CCN:
_______________

PERIOD:
WORKSHEET N-5
FROM: ____________
TO: ___________

Part B
Description
1 Total interim payments paid to hospital-based FQHC
2 Interim payments payable on individual bills, either submitted or to be submitted to the contractor
for services rendered in the cost reporting period. If none, write "NONE" or enter a 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.
(1)
If none, write "NONE" or enter a zero.

mm/dd/yyyy
1

1
2

Program to
Provider

Provider to
Program
Subtotal (sum of lines 3.01 through 3.49 minus sum of lines 3.50 through 3.98)
Total interim payments (sum of lines 1, 2, and 3.99)
(transfer to Wkst. N-4, line 17)
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)

Amount
2

.01
.02
.03
.04
.05
.50
.51
.52
.53
.54
.99

3.01
3.02
3.03
3.04
3.05
3.5
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
5.5
5.51
5.52
5.99
6.01
6.02
7

4

Program to
Provider

Provider to
Program
Subtotal (sum of lines 5.01 through 5.49 minus sum of lines 5.50 through 5.98)
6 Determine net settlement amount (balance
due) based on the cost report (1)
7 Total Medicare program liability (see instructions)

Program to provider
Provider to program

(1)

On lines 3, 5, and 6, where an amount is due hospital-based FQHC to program, show the amount and date on which the hospital-based FQHC agrees to the amount of repayment
even though total repayment is not accomplished until a later date.

FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4071.4)

Rev. 10

40-669

4090 (Cont.)

FORM CMS-2552-10

11-16

ANALYSIS OF HOSPITAL-BASED HOSPICE COSTS

PROVIDER CCN:
________________
HOSPICE CCN:
________________

SALARIES
1

OTHER
2

GENERAL SERVICE COST CENTERS
1 Cap Rel Costs-Bldg & Fixt*
2 Cap Rel Costs-Mvble Equip*
3 Employee Benefits Department*
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
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**

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-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072)

40-670

Rev. 10

03-18

FORM CMS-2552-10

4090 (Cont.)

ANALYSIS OF HOSPITAL-BASED HOSPICE COSTS

PROVIDER CCN:
________________
HOSPICE CCN:
________________

SALARIES
1

OTHER
2

DIRECT PATIENT CARE SERVICE COST CENTERS (Cont.)
40 Imaging Services**
41 Labs and Diagnostics**
42 Medical Supplies-Non-routine**
42.50 Drugs Charged to Patients**
43 Outpatient Services**
44 Palliative Radiation Therapy**
45 Palliative Chemotherapy**
46 Other Patient Care Services**
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*
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
42.50
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-2552-10 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072)

Rev. 14

40-671

4090 (Cont.)

FORM CMS-2552-10

03-18

ANALYSIS OF HOSPITAL-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
42.50 Drugs Charged to Patients
43 Outpatient Services
44 Palliative Radiation Therapy
45 Palliative Chemotherapy
46 Other Patient Care Svc
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
42.50
43
44
45
46
100

* Transfer the amount in column 7 to Wkst. O-5, column 1, line 50

FORM CMS-2552-10 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.1)

40-672

Rev. 14

03-18

FORM CMS-2552-10

4090 (Cont.)

ANALYSIS OF HOSPITAL-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
42.50 Drugs Charged to Patients
43 Outpatient Services
44 Palliative Radiation Therapy
45 Palliative Chemotherapy
46 Other Patient Care Svc
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
42.50
43
44
45
46
100

* Transfer the amount in column 7 to Wkst. O-5, column 1, line 51

FORM CMS-2552-10 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.1)

Rev. 14

40-673

4090 (Cont.)

FORM CMS-2552-10

03-18

ANALYSIS OF HOSPITAL-BASED HOSPICE COSTS
HOSPICE INPATIENT RESPITE 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
42.50 Drugs Charged to Patients
43 Outpatient Services
44 Palliative Radiation Therapy
45 Palliative Chemotherapy
46 Other Patient Care Svc
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
42.50
43
44
45
46
100

* Transfer the amount in column 7 to Wkst. O-5, column 1, line 52

FORM CMS-2552-10 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.1)

40-674

Rev. 14

03-18

FORM CMS-2552-10

4090 (Cont.)

ANALYSIS OF HOSPITAL-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
42.50 Drugs Charged to Patients
43 Outpatient Services
44 Palliative Radiation Therapy
45 Palliative Chemotherapy
46 Other Patient Care Svc
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
42.50
43
44
45
46
100

* Transfer the amount in column 7 to Wkst. O-5, column 1, line 53

FORM CMS-2552-10 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.1)

Rev. 14

40-675

4090 (Cont.)

FORM CMS-2552-10

COST ALLOCATION - DETERMINATION OF HOSPITAL-BASED HOSPICE
NET EXPENSES FOR ALLOCATION

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

PROVIDER CCN:
________________
HOSPICE CCN:
________________
HOSPICE
DIRECT
EXPENSES
( see instructions )
1

03-18
PERIOD:
FROM ___________
TO ____________
GENERAL
SERVICE
EXPENSES
FROM WKST B PART I
( 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-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4072.2)

40-676

Rev. 14

11-17

FORM CMS-2552-10

COST ALLOCATION - HOSPITAL-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

CAP REL
MVBLE
EQUIP
2

EMPLOYEE
BENEFITS
DEPARTMENT
3

SUBTOTAL
3A

4090 (Cont.)
PROVIDER CCN:
________________
HOSPICE CCN:
________________
ADMINISTRATIVE &
GENERAL
4

PERIOD:
FROM ___________
TO ____________
PLANT
OP &
MAINT
5

WORKSHEET O-6
PART I

LAUNDRY
& LINEN

HOUSEKEEPING

DIETARY

6

7

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-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.3)

Rev. 12

40-677

4090 (Cont.)

FORM CMS-2552-10

COST ALLOCATION - HOSPITAL-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 (specify)
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 (specify)
99 Negative Cost Center
100 Total

NURSING
ADMINISTRATION
9

ROUTINE
MEDICAL
SUPPLIES
10

MEDICAL
RECORDS
11

STAFF
TRANSPORTATION
12

VOLUNTEER
SVC COORDINATION
13

11-17
PROVIDER CCN:
________________
HOSPICE CCN:
________________
PHARMACY

14

PERIOD:
FROM ___________
TO ____________
PHYSICIAN
ADMIN
SERVICES
15

OTHER
GENERAL
SERVICE
16

WORKSHEET O-6
PART I

PATIENT /
RESIDENT
CARE SVCS
17

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-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.3)

40-678

Rev. 12

11-17

FORM CMS-2552-10

COST ALLOCATION - HOSPITAL-BASED HOSPICE GENERAL SERVICE COSTS 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
100 Cost to be allocated (per Wkst. O-6, Part I)
101 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

4090 (Cont.)
PROVIDER CCN:
________________
HOSPICE CCN:
________________
ADMINISTRATIVE &
GENERAL
( Accum.
Cost )
4

PERIOD:
FROM ___________
TO ____________
PLANT
OP &
MAINT
( Square
Feet )
5

WORKSHEET O-6
PART II

LAUNDRY
& LINEN

HOUSEKEEPING

DIETARY

( In-Facility Days )
6

( Square
Feet )
7

( In-Facility Days )
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
101

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.3)

Rev. 12

40-679

4090 (Cont.)

FORM CMS-2552-10

COST ALLOCATION - HOSPITAL-BASED HOSPICE GENERAL SERVICE COSTS 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
100 Cost to be allocated (per Wkst. O-6, Part I)
101 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

11-17
PROVIDER CCN:
________________
HOSPICE CCN:
________________
PHARMACY

( Charges )
14

PERIOD:
FROM ___________
TO ____________
PHYSICIAN
ADMIN
SERVICES
( Patient
Days )
15

OTHER
GENERAL
SERVICE
( Specify
Basis )
16

WORKSHEET O-6
PART II

PATIENT /
RESIDENT
CARE SVCS
( In-Facility Days )
17

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
101

FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.3)

40-680

Rev. 12

11-16

FORM CMS-2552-1

4090 (Cont.)

APPORTIONMENT OF HOSPITAL-BASED HOSPICE SHARED SERVICE COSTS BY LEVEL OF CARE

PROVIDER CCN:
________________
HOSPICE CCN:

PERIOD:
FROM ___________
TO ____________

WORKSHEET O-7

________________

1
2
3
4
5
6
7
8
9
10
11

Cost Center Descriptions
ANCILLARY SERVICE COST CENTERS
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Drugs, Biological and Infusion Therapy
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,
Pt. I, col. 9,
line
0

Cost to
Charge
Ratio
1

Charges by LOC (from Provider Records)
HCHC
2

HRHC
3

66
67
68
73
96
60
71
93
55
76

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

HGIP
( col. 1 x col. 5 )
9
1
2
3
4
5
6
7
8
9
10
11

FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4072.4)

Rev. 10

40-681

4090 (Cont.)

11-16

FORM CMS-2552-10

CALCULATION OF HOSPITAL-BASED HOSPICE PER DIEM COST

PROVIDER CCN:
________________
HOSPICE CCN:
________________
TITLE XVIII
MEDICARE
1

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-9, col. 4, line 10)
3 Total average cost per diem (line 1 divided by line 2)
4 Unduplicated program days (Wkst. S-9, 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-9, col. 4, line 11)
8 Total average cost per diem (line 6 divided by line 7)
9 Unduplicated program days (Wkst. S-9, 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-9, col. 4, line 12)
13 Total average cost per diem (line 11 divided by line 12)
14 Unduplicated program days (Wkst. S-9, 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-9, col. 4, line 13)
18 Total average cost per diem (line 16 divided by line 17)
19 Unduplicated program days (Wkst. S-9, 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-9, col. 4, line 14)
23 Average cost per diem (line 21 divided by line 22)

PERIOD:
FROM ___________
TO ___________
TITLE XIX
MEDICAID
2

WORKSHEET O-8

TOTAL
3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4072.5)

40-682

Rev. 10