CMS-1728-19_Crosswalk

Form CMS-1728-19 HOME HEALTH AGENCY COST REPORT APPLICATION
FORMS AND INSTRUCTIONS
The Form CMS-1728-19, Home Health Agency (HHA) cost report replaces the HHA existing cost reporting Form CMS-1728-94. The new forms are
effective for cost reporting periods beginning on or after July 1, 2019 and ending on or after June 30, 2020.
Major changes in the cost report include:
1. Eliminated Worksheet A-1, A-2, and A-3. These worksheets are no longer applicable for cost reporting periods beginning on or after
October 1, 2000.
2. Eliminated Worksheets A-7; A-8-3; C, Part III; F-2; K; K-1; K-2; K-3; K-4; K-4, Parts I and II; K-5, Parts I, II, and III; K-6; CM-1,
Parts I, II, and III; CM-2, Parts I, II, and III; CM-3, Parts I and II; CM-4; RF-1; RF-2; RF-3; RF-4; and RF-5.
3. Added Worksheet S-3, Part V, which collects direct employee salaries and benefit costs, and contract labor salaries.
4. Added a cost center for Remote Patient Monitoring, Nursing Administration, and Medical Records.
The overall burden to HHAs is estimated at 195 hours compared to the existing burden associated with the CMS-1728-94 of 227 hours.
Issue
#

Instructions
Page #

Form
Page #

1. 47-3 - 47-6

Section

Old Package
Form
CMS-1728-94

4700 4703
4704 4704.3

Worksheet S,
Parts I and II

New Package
Form
CMS-1728-19

Reason for the Change/ Application of the instructions Burden
and accompanying worksheets
Effect
General Instructions

2. 47-7 - 47-8

47-503

3. 47-9 - 47-11

47-504

4705

Worksheet S-2

4. 47-12 - 47-16

47-505

4706

Worksheet S-2-1

5. 47-17 - 47-19

47-506

4707 4707.3

Worksheet S-3,
Parts I, II, and III

Worksheet S,
This worksheet provides the cost report status,
Parts I, II, and III certification statement, and settlement data for the HHA.
Settlement lines for the HHA-based CORF, CMHC, and
RHC/FQHC have been removed.
Worksheet S-2,
This worksheet incorporates only the required data
Part I
previously included on the Worksheet S-2. All lines
applicable to depreciation and non-public providers were
removed.
Worksheet S-2,
Existing worksheet incorporated into new cost report.
Part II
Worksheet S-3,
This worksheet collects statistical data, such as the
Parts I, II, and III number and types of visits by title, the number of visits
performed by discipline, patient census counts, FTEs,
and CBSA information.

N/A
Decrease

Decrease

N/A
N/A

6. 47-19 - 47-21

47-507

4707.4

7. 47-22

47-508

4707.5

8.

Worksheet S-3,
Part IV

Worksheet S-3,
Part IV
Worksheet S-3,
Part V

S-4

This worksheet collects visits and charges by episodes of
care payment category for each home health visit
discipline.
This worksheet collects contract labor and employee
benefit costs, the number of hours in a normal workweek
and the average hourly wage.
Previous worksheet was removed as FQHCs are now
required to file on Form CMS-224-14 and RHCs on
Form CMS-222-17.

9. 47-23 - 47-24

47-509

4708 4708.2

S-5, Part I, II, and S-4, Part I and II
III

10. 47-25 - 47-31

47-510

4709

Worksheet A

4710

Worksheet A-1,
A-2, and A-3
Worksheet A-4

Worksheet A-6

Existing worksheet incorporated into new cost report.

Worksheet A-7

Worksheet A-7

Remove obsolete worksheet.

11.
12. 47-32

47-511

13.

Worksheet A

This worksheet replaces the previous Worksheet S-5 and
eliminates data elements for cost reporting periods prior
to October 1, 2015. HHA-based hospices will complete
the new Worksheet S-4, Parts I and II .
This is an existing worksheet that was modified to
accommodate three new general service cost centers,
more HHA reimbursable service cost centers, and
remove HHA-based components now required to file
other CMS forms.
Removed obsolete worksheets.

N/A

Increase

Decrease

Decrease

Increase

Decrease
N/A
Decrease

14. 47-33 - 47-34

47-512

4711

Worksheet A-5

Worksheet A-8

Existing worksheet incorporated into new cost report.

N/A

15. 47-35 - 47-36

47-513

4712 –
4712.2

Worksheet A-6

Worksheet A-8-1 Existing worksheet incorporated into new cost report.

N/A

16.
17. 47-37 - 47-41

47-514
and
47-515

4713

Worksheet A-8-3,
Removed obsolete worksheet.
Parts I through V
Worksheets B
Worksheet B and Revised existing worksheet to add remote patient
and B-1
B-1
monitoring, skilled nursing care-licensed practical nurse,
physical therapy assistant, certified outpatient therapy
assistant, and disposable devices, telehealth, and to
remove HHA-based components now required to file
other CMS forms.

Decrease
Increase

18. 47-42 - 47-43

47-516

4714 –
4714.2

Worksheet C,
Part I through V

Worksheet C,
Part I and II

19. 47-44 - 47-47

47-517

4715 –
4715.2

Worksheet D

Worksheet D

20. 47-48 - 47-49

47-518

4716

Worksheet D-1

Worksheet D-1

21. 47-50 - 47-52

47-519

4717

Worksheet F

Worksheet F

22. 47-52 - 47-53

47-520

4718

Worksheet F-1

Worksheet F-1

23.
24.

27. 47-53 - 47-66

47-521
47-531

4719 4722

28. 47-66

47-532

4723

Worksheet F-2
Worksheets K;
K-1; K-2; K-3;
K-4; K-5; K-6
Worksheets CM1 and CM-2,
Parts I, II, and III;
CM-3, Parts I and
II; and CM-4
Worksheets RF-1
through RF-5
Worksheets O;
O-1; O-2; O-3;
O-4; O-5; O-6,
Parts I and II
Worksheet O-7

29. 47-67 - 47-68

47-533
47-534

4724

Worksheet O-8

25.

26.

Worksheet O;
O-1; O-2; O-3;
O-4; O-5; O-6,
Parts I and II
Worksheet O-7
Worksheet O-8

Revised existing worksheet to add skilled nursing carelicensed practical nurse, physical therapy assistant, and
certified outpatient therapy assistant cost and visits and
to aggregate HHA Medicare visit and cost data.
Removed Part III related to Outpatient Therapy Visits by
discipline.
Revised existing worksheet to remove RHC/FQHCs,
added various lines to accommodate new payment and
adjustment categories, and combined Part A and Part B
program payments and adjustments.
Removed Part A program payments and adjustments.

Decrease

Removed specific purpose, endowment, and plant fund
from the capital accounts section of the worksheet.
Includes a break-out of gross patient revenue by
program.
Removed obsolete worksheet.
Removed obsolete worksheets.

Decrease

Decrease

Decrease

Increase
Decrease
Decrease

Removed worksheets as community mental health
centers (CMHC) are now required to file Form
CMS-2088-17.

Decrease

Removed worksheets as FQHCs are now required to file
Form CMS-224-14 and RHCs file Form CMS-222-17.
No changes.

Decrease

Revised existing worksheet to add physical therapy
assistant and certified outpatient therapy assistant
No changes.

Increase

N/A

N/A