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pdfChapter 45
COMMUNITY MENTAL HEALTH CENTER COST REPORT
FORM CMS-2088-17
Section
General........................................................................................................................ 4500
Rounding Standards for Fractional Computations .......................................................... 4500.1
Acronyms and Abbreviations........................................................................................ 4500.2
Recommended Sequence for Completing Form CMS-2088-17....................................... 4501
Worksheet S - Community Mental Health Center Provider Cost Report......................... 4502
Part I - Cost Report Status................................................................................. 4502.1
Part II - Certification by Chief Financial Officer or Administrator
of Provider ..................................................................................................... 4502.2
Part III - Settlement Summary........................................................................... 4502.3
Worksheet S-1 - Community Mental Health Center Identification Data......................... 4503
Part I - Identification Data ................................................................................ 4503.1
Part II - Statistical Data .................................................................................... 4503.2
Worksheet S-2 - Community Mental Health Center Reimbursement
Questionnaire ......................................................................................................... 4504
Worksheet A - Reclassification and Adjustment
of Trial Balance of Expenses. ................................................................................. 4505
Worksheet A-6 - Reclassifications. ............................................................................... 4506
Worksheet A-8 - Adjustments to Expenses. .................................................................. 4507
Worksheet A-8-1 - Statement of Costs of Services from Related
Organizations ......................................................................................................... 4508
Worksheet A-8-2 - Provider-Based Physicians Adjustments .......................................... 4509
Worksheet B - Cost Allocation - General Service Costs and Worksheet B-1 Cost Allocation - Statistical Basis. ........................................................................... 4510
Worksheet C - Apportionment of Patient Service Costs................................................. 4511
Worksheet D - Calculation of Reimbursement Settlement for Community
Mental Health Centers. ............................................................................................ 4512
Worksheet D-1 - Analysis of Payments to Community Mental Health Center for
Services Rendered to Program Beneficiaries. ............................................................. 4513
Financial Statements Worksheets ................................................................................. 4514
Worksheet F - Balance Sheet, ...................................................................................... 4514.1
Form CMS-2088-17 Worksheets.................................................................................. 4590
Electronic Reporting Specifications for Form CMS-2088-17.......................................... 4595
Rev. 2
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THIS PAGE IS RESERVED FOR FUTURE USE.
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Rev. 2
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4500.
FORM CMS-2088-17
4500
GENERAL
The Paperwork Reduction Act of 1995 establishes the requirement that the private sector be
informed why information is collected and how it will be used by the government. In accordance
with §§1815(a), 1866(e)(2), and 1861(v)(1)(A) of the Social Security Act (the Act), providers of
medical and other healthcare services as defined under §1861(ff), participating in the Medicare
program are required to submit annual information to achieve settlement of costs for health care
services rendered to Medicare beneficiaries. Community mental health centers (CMHCs)
providing partial hospitalization program (PHP) services must file cost reports in accordance with
42 CFR 413.24(f). The data submitted on the cost reports supports management of federal
programs. The information reported on Form CMS-2088-17, must conform to the requirements
and principles set forth in the Provider Reimbursement Manual, CMS Pub. 15-1, as well as those
set forth in the Medicare Benefit Policy Manual, CMS Pub. 100-02, chapter 6, §70.3.
Form CMS-2088-17 must be used by all freestanding CMHCs for cost reporting periods beginning
on or after October 1, 2017, and ending on or after September 30, 2018. CMHCs that file as part
of a hospital healthcare complex must use the Form CMS-2552. Cost reports are due on or before
the last day of the fifth month following the close of the period covered by the report. For cost
reports ending on a day other than the last day of the month, cost reports are due 150 days after
the last day of the cost reporting period, in accordance with 42 CFR 413.24(f)(2). The CMHC
cost report must be submitted to your Medicare administrative contractor (MAC) (hereafter
referred to as contractor) electronically in accordance with 42 CFR 413.24(f)(4).
The CMHC cost report provides for the determination of allowable costs which are reasonable and
necessary and the calculation of an overall cost-to-charge ratio (CCR). CMHCs are paid under the
outpatient prospective payment system (OPPS) for furnished Medicare PHP services. The OPPS
incorporates an outlier adjustment to ensure that outpatient services with variable and potentially
significant costs do not pose excessive financial risk to providers. For CMHCs, CMS determines
whether billed PHP services are eligible for outlier payment using the CMHCs CCR. The outlier
payment is a percentage of the difference between the cost estimate and the multiple threshold.
OPPS high cost outlier payments may be reconciled upon cost report settlement to account for
differences between the overall ancillary CCR used to pay the claim at its original submission by
the provider, and the CCR determined at final settlement of the cost reporting period during which
the service was furnished.
Rev. 2
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4500 (Cont.)
FORM CMS-2088-17
01-21
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 0938-0037 (Expires 05/31/2021). The time required to
complete this information collection is estimated average 90 hours per response, including the time
to review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have any comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to:
Centers for Medicare and Medicaid Services
PRA Reports Clearance Officer
7500 Security Boulevard
Mail Stop C4-26-05
Baltimore, Md. 21244-1850
Please do not send applications, claims, payments, medical records or any documents containing
sensitive information to the PRA Reports Clearance Office. Please note that any correspondence
not pertaining to the information collection burden approved under the associated OMB control
number listed on this form will not be reviewed, forwarded, or retained. If you have questions or
concerns regarding where to submit your documents, please contact 1-800-MEDICARE.
4500.1 Rounding Standards for Fractional Computations.--Throughout the Medicare cost
report, required computations result in the use of fractions. The following rounding standards
must be employed for such computations:
1.
Round to 2 decimal places
a. Percentages
b. Averages
c. Full time equivalent employees
d. Per diems, hourly rates
2.
Round to 6 decimal places
a. Ratios (e.g., unit cost multipliers, cost/charge ratios)
If a residual exists as a result of computing costs using a fraction, adjust the residual in the largest
amount resulting from the computation. For example, in cost finding, a unit cost multiplier is
applied to the statistics in determining costs. After rounding each computation, the sum of the
allocation may be more or less than the total cost being allocated. Adjust this residual to the largest
amount resulting from the allocation so that the sum of the allocated amounts equals the amount
being allocated.
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FORM CMS-2088-17
4500.2
4500.2 Acronyms and Abbreviations.--Throughout the Medicare cost report and instructions, a
number of acronyms and abbreviations are used. For your convenience, commonly used acronyms
and abbreviations are summarized below.
A&G
CAP REL
CCN
CFR
CMHC
CMS
COL
ECR
FR
FTE
HCRIS
HFS
HO/CO
MBI
OPPS
PHP
PPS
WKST
Rev. 2
-
Administrative and General
Capital-Related
CMS Certification Number
Code of Federal Regulations
Community Mental Health Center
Centers for Medicare & Medicaid Services
Column
Electronic Cost Report
Federal Register
Full Time Equivalent
Healthcare Cost Report Information System
Health Financial Systems
Home Office/Chain Organization
Medicare Beneficiary Identifier
Outpatient Prospective Payment System
Partial Hospitalization Program
Prospective Payment System
Worksheet
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4501
FORM CMS-2088-17
4501.
RECOMMENDED SEQUENCE FOR COMPLETING FORM CMS-2088-17
Step
Worksheet
Instructions
1
S
Read §§4502 through 4502.2. Complete Part I.
2
S-1
Read §4503.
Complete entire worksheet.
3
S-2
Read §4504.
Complete entire worksheet.
4
A
Read §4505.
Complete columns 1 through 3, all lines.
5
A-6
Read §4506.
Complete entire worksheet.
6
A
Read §4505.
Complete columns 4 and 5, all lines.
7
A-8
Read §4507.
Complete entire worksheet.
8
A-8-1
Read §4508.
Complete entire worksheet, if applicable.
9
A-8-2
Read §4509.
Complete entire worksheet, if applicable.
10
A
Read §4505.
Complete columns 6 and 7, all lines.
11
B & B-1
Read §4510.
Complete entire worksheets.
12
C
Read §4511.
Complete entire worksheet.
13
D
Read §4512.
Complete lines 1 through 15.
14
D-1
Read §4513.
Complete entire worksheet.
15
D
Read §4512.
Complete lines 16 through 19.
16
S
Read §4502.3. Complete Part II and III.
17
F
Read §4514.1. Complete entire worksheet.
45-6
01-21
Rev. 2
01-21
4502.
FORM CMS-2088-17
4502.1
WORKSHEET S - COMMUNITY MENTAL HEALTH CENTER COST REPORT
4502.1 Part I - Cost Report Status.--This section is to be completed by the provider and
contractor as indicated on the worksheet.
Provider use only.--The provider completes lines 1 through 4.
Lines 1 and 2.--Indicate if this cost report is being prepared electronically or manually by checking
the appropriate box on line 1 or 2. Only providers submitting manually prepared cost reports, 1)
reporting low Medicare utilization in accordance with CMS Pub. 15-2, chapter 1, §110, or 2) after
demonstrating financial hardship in accordance with §133, may select line 2, manually prepared.
If this is an electronically prepared cost report, indicate the creation date and time in columns 2
and 3, respectively. The date and time are archived in the electronic cost report (ECR) as an
identifier for the file. This file is your original submission and must not be modified.
Line 3, column 1.--If this is an amended cost report, enter the number of times the cost report has
been amended.
Line 4, column 1.--Enter an “F” if this is full cost report, an “L” for a low Medicare utilizat ion
cost report or an “N” for no Medicare utilization. A provider that has not furnished any covered
services to Medicare beneficiaries during the entire cost report period may file a no Medicare
utilization cost report in accordance with CMS Pub. 15-2, chapter 1, §110(A). Providers must
obtain contractor approval prior to submitting a low Medicare utilization cost report. (See
CMS Pub. 15-2, chapter 1, §110(B).)
Contractor use only.--The contractor completes lines 5 through 12.
Line 5, column 1.--Enter the Healthcare Cost Report Information System (HCRIS) cost report
status code that corresponds to the status of the cost report: 1=as submitted; 2=settled without
audit; 3=settled with audit; 4=reopened; or 5=amended.
Line 6, column 2.--Enter the date (mm/dd/yyyy) an accepted cost report was received.
Line 7, column 2.--Enter the contractor number.
Lines 8 and 9, column 2.--If this is the very first cost report for this provider CMS certification
number (CCN), enter “Y” for yes on line 8. If this is the final (terminating) cost report for this
provider CCN, enter “Y” for yes on line 9. If the cost report is not a first or a final cost report for
this provider CCN, enter “N” for no on each respective line.
Line 10, column 3.--Enter the Notice of Program Reimbursement (NPR) date (mm/dd/yyyy). The
NPR date must be present if the cost report status code is 2, 3, or 4.
Line 11, column 3.--Enter the software vendor code of the cost report software used by the
contractor. Enter “3” for HFS CompuMax or “4” for HFS MCRIF32.
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Line 12, column 3.--If this is a reopened cost report (response to line 5 is “4”), enter the number
of times the cost report has been reopened. This field is only to be completed if the cost report
status code in line 5, is 4.
4502.2 Part II - Certification by a Chief Financial Officer or Administrator.--After the cost report
is completed, an administrator or the Chief Financial Officer completes this certification section
to comply with the regulations set forth in 42 CFR 413.24(f)(4)(iv)(A) and (B).
Line 1.--The signatory (administrator or Chief Financial Officer) must either:
• sign in column 1 as provided in 42 CFR 413.24(f)(4)(iv)(C)(1); and enter Y in column 2
to check the electronic signature checkbox to transmit the cost report electronically with
an electronic signature; or
• sign in column 1 as provided in 42 CFR 413.24(f)(4)(iv)(C)(1); and enter Y in column 2
to check the electronic signature checkbox to submit the cost report with an electronic
signature; or
• sign in column 1 as provided in 42 CFR 413.24(f)(4)(iv)(C)(2); and make no entry in
column 2 to submit the cost report with an original signature.
Lines 2, 3, and 4.--Enter the signatory name, the signatory title, and the date signed.
4502.3
Part III - Settlement Summary.
Line 1, column 1.--Enter the balance due to or from the CMHC. Transfer the settlement amount
from Worksheet D, line 19.
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01-21
4503.
FORM CMS-2088-17
4503.1
WORKSHEET S-1 - COST REPORT IDENTIFICATION DATA
4503.1 Part I - Identification Data.--The information required on this worksheet is needed to
properly identify the provider.
Line 1, columns 1 through 4.--Enter in the appropriate column the site name, provider CCN, core
based statistical area (CBSA) code (rural CBSA codes are assembled by placing the digits “999”
in front of the two digit state code, e.g., for the state of Maryland the rural CBSA code is 99921),
and certification date (mm/dd/yyyy).
Line 1, column 5.--Indicate the type of control under which the CMHC operates by entering a
number from the list below:
1
2
3
4
5
6
7
= Voluntary Nonprofit, Church
= Voluntary Nonprofit, Other
= Proprietary, Individual
= Proprietary, Corporation
= Proprietary, Partnership
= Proprietary, Other
= Governmental, Federal
8
9
10
11
12
13
= Governmental,
= Governmental,
= Governmental,
= Governmental,
= Governmental,
= Governmental,
City-County
County
State
Hospital District
City
Other
Line 2, columns 1 and 2.--Enter the street address and P.O. Box if applicable.
Line 3, columns 1 through 4.--Enter the city, state, ZIP code, and county for this CMHC.
Line 4.--Enter in column 1, the cost report beginning date and enter in column 2, the cost report
ending date.
Lines 5.--Indicate if this CMHC is part of a home office/chain organization (HO/CO) as defined
in CMS Pub. 15-1, chapter 21, §2150 that claimed HO/CO costs in a home office cost statement.
Enter “Y” for yes or “N” for no. If yes, complete lines 6 through 8. Otherwise, skip to line 9.
Lines 6 through 8.--If line 5 is yes, enter the name of the HO/CO, the street address, P.O. Box (if
applicable), the HO/CO CCN, city, state, and ZIP code.
Line 9.--Indicate if your CMHC is legally required to carry malpractice coverage. Enter “Y for
yes or “No” for no. Malpractice insurance premiums are money paid by the CMHC to a
commercial insurer to protect the CMHC against potential negligence claims made by their
patients/clients.
Line 10.--If line 9 is yes, indicate if your malpractice insurance is a claims-made or occurrence
policy. A claims-made insurance policy covers claims first made (reported or filed) during the
year the policy is in force for any incidents that occur that year or during any previous period
during which the insured was covered under a “claims-made” contract. The occurrence policy
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4503.2
FORM CMS-2088-17
01-21
covers an incident occurring while the policy is in force regardless of when the claim arising out
of that incident is filed. Enter 1, if the malpractice insurance is a claims-made policy. Enter 2, if
the malpractice insurance is an occurrence policy.
Line 11.--Enter in column 1, the total amounts of malpractice premiums. Enter in column 2 the
total amount of paid losses, and enter in column 3, the total amount of self-insurance premiums.
Malpractice insurance premiums are money paid by the provider to a commercial insurer to protect
the provider against potential negligence claims made by their patients/clients. Malpractice paid
losses is money paid by the healthcare provider to compensate a patient/client for professional
negligence. Malpractice self-insurance is money paid by the provider where the healthcare
provider acts as its own insurance company (either as a sole or part-owner) to financially protect
itself against professional negligence. Often providers will manage their own funds or purchase a
policy referred to as captive insurance, which provides insurance coverage they need but could not
obtain economically through the mainstream insurance market.
Line 12.--Indicate whether malpractice premiums paid, paid losses, or self-insurance are reported
in a cost center other than the A&G cost center. Enter “Y” for yes or “N” for no. If yes, submit
supporting schedule listing cost centers and amounts.
Line 13.--Did this facility participate in any payment demonstrations during this cost reporting
period? Enter “Y” for yes or “N” for no. If column 1 is yes, enter the type of demonstration in
column 2. If the CMHC participated in more than one demonstration, subscript this line for
column 2 accordingly.
Line 14.--Are there any related organization costs claimed as defined in CMS Pub. 15-1
chapter 10? Enter “Y” for yes or “N” for no. If yes, complete Worksheet A-8-1.
4503.2
Part II - Statistical Data.--This section collects unduplicated days data.
Columns 1 and 3.--Enter on the appropriate lines the number of Medicare visits in column 1 and
total visits in column 3, by type of service. If more than one treatment was furnished to a patient
in the same visit, record a separate visit for each different treatment rendered to the patient.
Column 2.--Enter on the appropriate lines the number of visits by type of service for all other
patients by subtracting Medicare visits reported in column 1 from total visits reported in column 3.
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FORM CMS-2088-17
4503.2 (Cont.)
Columns 4 and 6.--Enter on the appropriate lines the number of Medicare patient days in column 4
and total patient days in column 6, who received services during the cost reporting period,
regardless of the number of visits for each individual patient. For example, if a patient receives
multiple services on the same day, he or she is counted once for each service rendered in
accordance with billing guidelines.
Column 5.--Enter on the appropriate lines the number of patient days by type of service for all
other patients by subtracting Medicare patient days reported in column 4 from total patient days
reported in column 6.
Columns 7 through 10.--Enter on columns 7 through 10 the number of full-time equivalent
employees (FTE) for each cost center. The average number of FTEs for the period may be
determined either on a quarterly or semiannual basis. When quarterly data is used, add the total
number of hours worked by category for all employees using the first week of the first payroll
period for each quarter, and divide the sum by 160 (4 times 40). When semiannual data is used,
add the total number of hours worked by category for all employees using the first week of the
first payroll period for the first and seventh months of the cost reporting period. Divide this sum
by 80 (2 times 40).
Line 11.--Enter the sum of lines 1 through 10 for all columns as appropriate.
Line 12.--Enter in the appropriate column (columns 4 through 6) the unduplicated census count
for Medicare patient days and all other patient days provided by employees of the provider or
provided under contract during the reporting period. Count each patient day only once for each
day of care they received at this facility. The total unduplicated census count may not equal the
total patient days reported on line 11.
Rev. 2
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4504
4504.
FORM CMS-2088-17
01-21
WORKSHEET S-2 - COST REPORT REIMBURSEMENT QUESTIONNAIRE
The information required on this worksheet (formerly Form CMS-339) must be completed by all
CMHCs submitting cost reports to the contractor under title XVIII of the Act. Where the
instructions for this worksheet direct you to submit documentation/information, mail or otherwise
transmit to the contractor with submission of the ECR. The contractor has the right under
§§1815(a) and 1883(e) of the Act to request any missing documentation.
NOTE: The responses on all lines are “yes” or “no” unless otherwise indicated. When the
instructions require documentation, indicate on the documentation the Worksheet S-2 line number
that the documentation supports. Lines 1 through 14 must be completed.
Line Descriptions
Line 1.--Indicate whether the CMHC has changed ownership and this is the first cost report filed
under this new ownership? Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, enter
the date the change of ownership occurred in column 2. Also, submit the name and address of the
new owner and a copy of the sales agreement with the cost report.
Line 2.--Indicate whether the CMHC has terminated participation in the Medicare program. Enter
“Y” for yes or “N” for no in column 1. If column 1 is “Y”, enter the date of termination in
column 2, and “V” for voluntary or “I” for involuntary in column 3.
Line 3.--Indicate whether the CMHC is involved in business transactions, including management
contracts, with individuals or entities (e.g., HO/CO, drug or medical supply companies) that are
related to the CMHC or its officers, medical staff, management personnel, or members of the board
of directors through ownership, control, or family and other similar relationships. Enter Y” for
yes or “N” for no in column 1. If column 1 is “Y”, submit a list of the individuals, the organizations
involved, and a description of the transactions with the cost report.
NOTE: A related party transaction occurs when services, facilities, or supplies are furnished to
the provider by organizations related to the provider through common ownership or control. (See
CMS Pub. 15-1, chapter 10 and 42 CFR 413.17.)
Line 4.--Indicate whether the financial statements were prepared by a certified public accountant;
enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, enter “A” for audited, “C” for
compiled, or “R” for reviewed in column 2. Submit a complete copy of the financial statements
(i.e., the independent public accountant’s opinion, the statements themselves, and the footnotes)
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FORM CMS-2088-17
4504 (Cont.)
with the cost report. If the financial statements are not available for submission with the cost report
enter the date they will be available in column 3.
If you answer “N” in column 1, submit a copy of the financial statements you prepared, and written
statements of significant accounting policy and procedure changes affecting Medicare
reimbursement which occurred during the cost reporting period. You may submit the changed
accounting or administrative procedures manual in lieu of written statements.
Line 5.--Indicate whether the total expenses and total revenues reported on the cost report differ
from those on the financial statements. Enter “Y” for yes or “N” for no in column 1. If yes, submit
a schedule reconciling the financial statements with the cost report.
Line 6.--Indicate whether you are seeking reimbursement for bad debts resulting from Medicare
deductible and/or coinsurance amounts which are uncollectible from Medicare beneficiaries. (See
42 CFR 413.89(e) and CMS Pub. 15-1, chapter 3, §§306 through 324 for the criteria for an
allowable bad debt.) Enter “Y” for yes or “N” for no in column 1. If you answer “Y” in column 1,
submit a completed Exhibit 1, or internal schedules that at a minimum duplicate the documentation
requested on Exhibit 1, to support the bad debts claimed.
Exhibit 1 requires the following documentation:
Columns 1, 2, 3, 4 - Patient Names, Medicare Beneficiary Identifier (MBI) Number, and Dates of
Service (From - To).--The documentation required for these columns is derived from the
beneficiary’s bill. Furnish the patient’s name, MBI number, and dates of service that correlate to
the filed bad debt. (See CMS Pub. 15-1, chapter 3, §314 and 42 CFR 413.89.)
Columns 5 & 6 - Indigence/Medicaid Beneficiary.--If the patient included in column 1 has been
deemed indigent, place a check in column 5. If the patient in column 1 has a valid Medicaid
number, include this number in column 6. See the criteria in CMS Pub. 15-1, chapter 3, §§312
and 322 and 42 CFR 413.89 for guidance on the billing requirements for indigent and Medicaid
beneficiaries.
Columns 7 & 8 - Date First Bill Sent to Beneficiary & Date Collection Efforts Ceased.--This
information should be obtained from the provider’s files and should correlate with the beneficiary
name, MBI number, and dates of service shown in columns 1, 2, 3 and 4, of this exhibit. The date
in column 8 represents the date that the unpaid account is deemed worthless, whereby all collection
efforts, both internal and by an outside entity ceased,
Rev. 1
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4504 (Cont.)
FORM CMS-2088-17
05-18
and there is no likelihood of recovery of the unpaid account. (See CFR 413.89(e) and (f), and
CMS Pub. 15-1, chapter 3, §§308, 310, and 314.)
Column 9 - Medicare Remittance Advice Dates.--Enter in this column the remittance advice dates
that correlate with the beneficiary name, MBI number, and dates of service shown in columns 1,
2, 3, and 4, of this exhibit.
Columns 10 & 11 - Deductibles & Coinsurance.--Record in these columns the beneficiary’s unpaid
deductible and coinsurance amounts that relate to covered services.
Column 12 - Total Medicare Bad Debts.--Enter on each line of this column, the sum of the amounts
in columns 10 and 11. Calculate the total bad debts by summing up the amounts on all lines of
column 12. This “total” must agree with the bad debts claimed on the cost report. Attach
additional supporting schedules, if necessary, for bad debt recoveries.
Line 7.--If line 6 is yes, indicate whether your bad debt collection policy changed during the cost
reporting period. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a copy
of the policy with the cost report.
Line 8.--If line 6 is yes, indicate whether patient deductibles and/or coinsurance amounts were
waived. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, ensure that they are not
included on the bad debt listings (i.e., Exhibit 1 or your internal schedules) submitted with the cost
report.
Line 9.--Indicate whether the cost report was prepared using the PS&R report only. Enter “Y” for
yes or “N” for no in column 1. If column 1 is “Y” enter the paid through date of the PS&R in
column 2. Also, submit a crosswalk between revenue codes and charges found on the PS&R to
the cost center groupings on Worksheet C of the cost report. This crosswalk will reflect a cost
center to revenue code match only.
Line 10.--Indicate whether the cost report was prepared using the PS&R for totals and provider
records for allocation. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y” enter the
paid through date of the PS&R used to prepare this cost report in column 2. Also, submit a detailed
crosswalk between revenue codes and charges on the PS&R to the cost center groupings on
Worksheet C of the cost report. This crosswalk must show dollars by cost center and include
which revenue codes were allocated to each cost center. The total revenue on the cost report must
match the total charges on the PS&R (as appropriately adjusted for unpaid claims, etc.) to use this
method. Supporting work papers must accompany this crosswalk to provide sufficient
documentation as to the accuracy of the provider records. If the contractor does not find the
documentation sufficient, the PS&R will be used in its entirety.
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FORM CMS-2088-17
4504 (cont.)
Line 11.--If you entered “Y” on either line 9 or 10, indicate whether adjustments were made to the
PS&R data for additional claims that have been billed but not included on the PS&R used to file
this cost report. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, include a
schedule which supports any claims not included on the PS&R. This schedule should include
totals consistent with the breakdowns on the PS&R, and should reflect claims that are unprocessed
or unpaid as of the cut-off date of the PS&R used to file the cost report.
Line 12.--If you entered “Y” on either line 9 or 10, column 1, indicate whether adjustments were
made to the PS&R data for corrections of other PS&R information. Enter “Y” for yes or “N” for
no in column 1. If column 1 is “Y”, submit a detailed explanation and documentation which
provides an audit trail from the PS&R to the cost report.
Line 13.--If you entered “Y” on either line 9 or 10, column 1, indicate whether other adjustments
were made to the PS&R data. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”,
include a description of the other adjustments and documentation which provides an audit trail
from the PS&R to the cost report.
Line 14.--Indicate whether the cost report was prepared using CMHC records only. Enter “Y” for
yes or “N” for no in column 1. If column 1 is “Y”, submit detailed documentation of the system
used to support the data reported on the cost report. If detail documentation was previously
supplied, submit only necessary updated documentation with the cost report.
The minimum requirements are:
Rev. 1
•
Internal records supporting program utilization statistics, charges, prevailing rates
and payment information broken into each Medicare bill type in a manner
consistent with the PS&R report.
•
A reconciliation of remittance totals to the provider’s internal records.
•
The name of the system used and system maintainer (vendor or provider). If the
provider maintained the system, include date of last software update.
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FORM CMS-2088-17
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NOTE: Additional information may be supplied such as narrative documentation, internal flow charts,
or outside vendor informational material to further describe and validate the reliability of your system.
Line 15.--Enter the first name, last name and the title/position held by the cost report preparer in columns
1, 2, and 3, respectively.
Line 16.--Enter the employer/company name of the cost report preparer.
Line 17.--Enter the telephone number and email address of the cost report preparer in columns 1 and 2,
respectively.
45-16
Rev. 1
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FORM CMS-2088-17
4504 (Cont.)
EXHIBIT 1
LISTING OF MEDICARE BAD DEBTS AND APPROPRIATE SUPPORTING DATA
PROVIDER __________________
CCN __________________ ______
FYE _________________________
(1)
Patient
Name
(2)
MBI
No.
(3)
Dates of
Service
From
PREPARED BY _____________________
DATE PREPARED ____________________
(4)
Indigence/Medicaid
Beneficiary
(Check if applicable)
To
Yes
(5)
Date First Bill
Sent
to
Beneficiary
(6)
Date
Collection
Efforts
Ceased
(7)
Remittance
Advice
Dates
(8)
Deductible *
(9)
(10)
CoTotal Medicare
Insurance Bad Debts*
Medicaid
Number
*These amounts must not be claimed unless the CMHC bills for these services with the intention of payment.
See instructions for columns 4 - Indigence/Medicaid Beneficiary, for possible exception. These amounts must not be claimed if they
were included on a previous Medicare bad debt listing or cost report.
Rev. 1
45-17
4505
4505.
FORM CMS-2088-17
05-18
WORKSHEET A - RECLASSIFICATION AND ADJUSTMENT OF TRIAL
BALANCE OF EXPENSES
Worksheet A provides for recording the trial balance of expense accounts from the CMHC’s
accounting books and records. It also provides for reclassification and adjustments to certain
accounts. The cost centers on this worksheet are listed in a manner that facilitates the combination
of the various groups of cost centers for purposes of cost finding. Cost centers listed may not apply
to every provider using these forms. Complete only those lines that are applicable.
If the cost elements of a cost center are separately maintained on the accounting books, reconcile
the costs from the accounting books and records with those reported on this worksheet. The
reconciliation is subject to review by the contractor.
Standard (i.e., preprinted) CMS line numbers and cost center descriptions cannot be changed. If
additional or different cost center descriptions are needed, add (subscript) additional lines to the
cost report. Where an added cost center description bears a logical relationship to a standard line
description, the added label must be inserted immediately after the related standard line. The added
line is identified as a numeric subscript of the immediately preceding line. For example, if two
lines are added between lines 5 and 6, identify them as lines 5.01 and 5.02. If additional lines are
added for general service cost centers, add corresponding columns for cost finding.
Submit the working trial balance of the facility with the cost report. A working trial balance is a
listing of the balances of the accounts in the general ledger to which adjustments are appended in
supplementary columns and is used as a basic summary for financial statements.
Cost center coding is a methodology for standardizing the meaning of cost center labels as used
by health care providers on the Medicare cost report. Form CMS-2088-17 provides for preprinted
cost center descriptions on Worksheet A. In addition, a space is provided for a cost center code.
The preprinted cost center labels are automatically coded by CMS approved cost reporting
software. These cost center descriptions are hereafter referred to as the standard cost centers. The
CMS approved cost reporting software also accommodates cost centers that are frequently used
by health care providers but not included as standard cost centers, hereafter referred to as the
nonstandard cost centers.
This coding methodology allows providers to continue to use labels for cost centers that have
meaning within the individual institution. The four digit cost center codes that are associated with
each provider label in the ECR provide standardized meaning for data analysis. Providers are
required to compare any added or changed label to the descriptions offered on the standard and
nonstandard cost center tables. A description of cost center coding and the table of cost center
codes are in §4495, table 5.
45-18
Rev. 1
01-21
FORM CMS-2088-17
4505 (Cont.)
Column Descriptions
List on the appropriate lines in columns 1, 2, and 3, the total expenses incurred during the cost
reporting period. Any needed reclassifications and adjustments must be rendered in columns 4
and 6, as appropriate. Blank lines are provided for additional cost centers, as required.
Column 1.--Salaries are the gross salaries paid to employees before taxes and other items are
withheld. Salaries include deferred compensation, overtime, incentive pay, and bonuses. (See
CMS Pub. 15-1, chapter 21.) Enter salaries from the CMHC’s accounting books and records.
Column 2.--Enter all costs other than salaries and contracted purchased services from the CMHC’s
accounting books and records.
Column 3.--Enter all the costs of contracted purchased services from the CMHC’s accounting
books and records.
Column 4.--For each cost center, add the amounts in columns 1 through 3 and enter the total in
column 4.
Column 5.--For each cost center, enter the net amount of reclassifications from Worksheet A-6.
The net total of the entries in column 5 must equal zero on line 100. Show reductions to expenses
as negative numbers.
Column 6.--For each cost center, enter the total of the amount in column 4 plus or minus the
amount in column 5. The total on column 6, line 100, must equal the total on column 4, line 100.
Column 7.--For each cost center, enter the net of any increase and decrease amounts from
Worksheet A-8, column 2. The total on Worksheet A, column 7, line 100, must equal
Worksheet A-8, column 2, line 50.
Column 8.--For each cost center, enter the total of the amount in column 6 plus or minus the
amount in column 7.
Transfer the amounts in column 8, lines 2 through 100, to the corresponding line on Worksheet B,
column 0.
Line Descriptions
The Worksheet A segregates the trial balance of expenses into general service cost centers,
reimbursable cost centers, and nonreimbursable cost centers to facilitate the transfer of costs to the
various worksheets.
Rev. 2
45-19
4505 (Cont.)
FORM CMS-2088-17
01-21
GENERAL SERVICE COST CENTERS
General service cost centers include expenses incurred in operating the CMHC as a whole that are
not directly associated with furnishing patient care such as, but not limited to mortgage, rent, plant
operations, administrative salaries, utilities, telephone, and computer hardware and software costs.
General service cost centers furnish services to other general service cost centers and to
reimbursable and nonreimbursable cost centers.
Lines 1 and 2 - Capital Related Costs-Buildings & Fixtures and Capital Related Costs-Moveable
Equipment.--These cost centers include the capital-related costs for buildings and fixtures and the
capital-related costs for movable equipment including depreciation, leases and rentals for the use
of the facilities and/or equipment, interest incurred in acquiring land and depreciable assets used
for patient care, insurance on depreciable assets used for patient care and taxes on land or
depreciable assets used for patient care. Do not include in these cost centers the following costs:
costs incurred for the repair or maintenance of equipment or facilities; amounts included in the
rentals lease payments for repairs and/or maintenance; interest expense incurred to borrow
working capital or for any purpose other than the acquisition of land or depreciable assets used for
patient care; general liability of depreciable assets; or taxes other than those assessed on the basis
of some valuation of land or depreciable assets used for patient care.
Line 3 - Employee Benefits.--This cost center includes the costs of the employee benefits
department. In addition, this cost center includes the fringe benefits paid to, or on behalf of, an
employee when a provider’s accounting system is not designed to accumulate the benefits on a
departmentalized or cost center basis. (See CMS Pub. 15-1, chapter 21, §2144).
Line 4 - Administrative & General.--The administrative and general (A&G) cost center includes a
wide variety of provider administrative costs that benefit the entire facility. Examples include
fiscal services, legal services, accounting, data processing, taxes, and malpractice costs. Marketing
and advertising costs that are not related to patient care, fundraising costs, and other
nonreimbursable costs are not included here, but are reported in the appropriate nonreimbursable
cost center.
If the physician is paid a salary that compensates him or her for both provider services and
professional services, then include the salary in this cost center. The cost attributable to the
professional services is subsequently removed by an adjustment computed using
Worksheet A-8-2. See Worksheet A-8-2 for the instructions on that adjustment.
The professional services of physicians, physician’s assistants (PA) and clinical psychologists
(CP) are not considered as provider services and are not includable as an element of cost in the
provider’s cost report. These services are billed directly to a carrier for payment. A provider must
distinguish between professional services and provider services of the physicians, PA, and CP.
45-20
Rev. 2
01-21
FORM CMS-2088-17
4505 (Cont.)
The provider services are includable on the cost report. The payment for services of a physician
to providers is discussed in CMS Pub. 15-1, chapter 21, §2108. Not all provider services of
physicians are entered as an administrative and general cost, i.e., if a physician supervises a
revenue cost center such as physical therapy, then the physician’s salary or part of it is a cost of
the physical therapy cost center.
Line 5 - Maintenance & Repairs.--This cost center includes the maintenance of the facility grounds
such as landscaped and paved areas, streets on the property, sidewalks, fenced areas, fencing,
external recreation areas, and parking facilities. In addition it may include routine painting,
plumbing, and electrical repairs, mowing and snow removal. The costs of maintaining the safety
and well-being of personnel, visitors, and the provider’s facilities are also included in this cost
center.
Line 6 - Operation of Plant.--Plant operation costs include utility systems such as heat, light, water,
air conditioning and air treatment.
Line 7 - Laundry & Linen Service.--This cost center includes the cost of routine laundry and linen
services whether performed in-house or by outside contractors.
Line 8 - Housekeeping.--This cost center includes the cost of routine housekeeping activities such
as mopping, vacuuming, cleaning restrooms, lobbies, waiting areas, and otherwise maintaining
patient and non-patient care areas.
Line 9 - Cafeteria.--This cost center includes the cost of preparing food for provider personnel,
physicians working at the provider, visitors to the provider.
Line 10 - Central Services & Supplies.--This cost center includes the costs for minor medical or
surgical supplies. These are supplies for which patients are not separately charged, and for which
the recording of use by each individual patient is extremely time consuming and costly for
providers. Examples include cotton balls and alcohol prep.
Line 11 - Medical Records & Library.--This cost center includes the direct costs of the medical
records cost center including the medical records library.
Line 12 - Professional Education & Training (Approved).--This cost center includes training and
educational services related to the care and treatment of a patient’s disabling mental health
problems.
Line 13 - Other (Specify).--Use this line to report the costs of other general service costs not
previously identified on lines 1 through 11. If more than one other general service is offered,
subscript this line and provide an appropriate description and cost center code.
Rev. 2
45-21
4505 (Cont.)
FORM CMS-2088-17
01-21
Lines 14 through 22.--Reserved for future use.
Line 23 - Drug & Biologicals.--This cost center includes drugs and biologicals that are
(1) prescribed by a physician and administered by or under the supervision of a physician or a
registered professional nurse; and (2) not excluded from Medicare Part B payment for reasons
specified in 42 CFR §410.29.
Line 24 - Occupational Therapy.--This cost center includes the costs of purposeful goal-oriented
activities in the evaluation, diagnosis, and/or treatment of persons whose function is impaired by
physical illness or injury, emotional disorder, congenital or developmental disability, or the aging
process, in order to achieve optimum functioning, to prevent disability, and to maintain health.
Occupational therapy services may be provided for purposes of symptom control or to enable the
individual to maintain activities of daily living and basic functional skills.
Line 25 - Behavioral Health Treatment Services.--This cost center includes the costs for staff for
providing care and services to psychiatric patients. Administrative services, such as supervisory
duties, rendered by these individuals are includable in the administrative and general cost center.
Any services by these individuals which are nonreimbursable activities, such as diversionary
activities, social, or recreational therapies, custodial or respite care, vocational training, etc., shall
be entered in the appropriate nonreimbursable cost center.
Line 26 - Individual Therapy.--This cost center includes the costs for individual therapy with
physicians, psychologists, or other mental health professionals to the extent authorized under State
law. Do not include professional services of physicians, PAs, or CPs if billable to a Medicare
carrier.
Line 27 - Group Therapy.--This cost center includes the costs for group therapy with physicians,
psychologists, or other mental health professionals to the extent authorized under State law. Do
not include the expenses of professional services of physicians, PAs, or CPs if billable to a
Medicare carrier.
Line 28 - Activity Therapy.--This cost center includes the costs for individualized activity
therapies that are not primarily recreational or diversionary.
Line 29 - Family Therapy.--This cost center includes the costs for family counseling services, the
primary purpose of which is treatment of the beneficiary’s condition.
Line 30 - Psychiatric Testing.--This cost center includes costs for psychological and
neuropsychological tests which includes tests performed by technicians and computers in addition
to those performed by physicians, clinical psychologists, independently practicing psychologists,
and other qualified non-physician practitioners.
45-22
Rev. 2
01-21
FORM CMS-2088-17
4505 (Cont.)
Line 31 - Education Training.--This cost center includes the costs for patient training and education
to the extent the training and educational activities are closely and clearly related to the
beneficiary’s care and treatment.
Lines 33 through 41.--Reserved for future use.
NONREIMBURSABLE COST CENTERS
Nonreimbursable cost centers include costs of nonreimbursable services and programs. Report the
costs applicable to nonreimbursable cost centers to which general service costs apply. If additional
lines are needed for nonreimbursable cost centers other than those shown, subscript one or more
of these lines with a numeric code. The subscripted lines must be appropriately labeled to indicate
the purpose for which they are being used. However, when the expense (direct and all applicable
overhead) attributable to any non-allowable cost area is so insignificant as to not warrant
establishment of a nonreimbursable cost center, remove the expense on Worksheet A-8. (See
CMS Pub. 15-1, chapter 23, §2328.)
Line 42 - Sheltered Workshops.--This cost center consists of programs to provide remunerative
employment or other occupational activities of an educational, therapeutic nature for individua ls
whose earning capacity is impaired by physical, mental, and/or social handicaps. Workshops may
provide job training, vocational evaluation, sheltered employment, and/or work adjustment
services.
Line 43 - Recreational Programs.--This cost center includes the costs for programs which are
primarily recreational.
Line 44 - Resident Day Camps.--This cost center includes the costs incurred by residential day
camps.
Line 45 - Diagnostic Clinics.--This cost center includes the costs incurred by the operation of
diagnostic clinics.
Line 46 - Physicians’ Private Offices.--A nonreimbursable cost center must be established to
accumulate the cost incurred by you for services related to the physicians’ private practice.
Examples of such costs are depreciation costs for the space occupied, movable equipment used by
the physicians’ offices, administrative services, medical records, housekeeping, maintenance and
repairs, operation of plant, drugs, medical supplies, and nursing services.
Line 47 - Fund Raising.--This cost center includes the costs of services related to fund raising (see
CMS Pub. 15-1, chapter 21, §2136).
Line 48 - Coffee Shops & Canteen.--This cost center includes the costs incurred for the operation
of a coffee shops and/or canteen.
Rev. 2
45-23
4506
FORM CMS-2088-17
01-21
Line 49 - Research.--This cost center includes the costs incurred by research.
Line 50 - Investment Property.--This cost center includes the costs incurred by owning investment
properties.
Line 51 - Advertising.--This cost center includes the costs incurred by advertising.
Line 52 - Franchise Fees & Other Assessments.--This cost center includes the costs incurred by
franchise fees and other assessments.
Line 53 - Pro Ed & Training (Not Approved).--This cost center includes the costs incurred by
professional education and training (Not Approved).
Line 54 - Meals & Transportation.--This cost center includes the costs incurred by providing meals
and transportation.
Line 55 - Activity Therapies.--This cost center includes programs which are primarily recreational
or diversional.
Line 56 - Psychosocial Programs.--This cost center includes community support groups for
chronically mentally ill persons for the purpose of social interaction. Partial hospitalizat ion
programs may include some psychosocial components, and to the extent these components are not
primarily for social purposes, they are covered.
Line 57 - Vocational Training.--This cost center includes the costs of services related solely to
specific employment opportunities, work skills, or work settings.
4506.
WORKSHEET A-6 - RECLASSIFICATIONS
Worksheet A-6 provides for the reclassification by cost centers of certain amounts necessary for
proper cost allocation.
Some providers may charge some of these amounts to the proper cost centers before the end of the
accounting period. Therefore, use Worksheet A-6 only to the extent that expenses have been
included in cost centers that effect improper cost allocation.
Any expenses that are includable in the administrative and general or capital related cost centers,
e.g., insurance or lease expense, but which were recorded in other cost centers on Worksheet A,
must be reclassified on Worksheet A-6.
45-24
Rev. 2
05-18
FORM CMS-2088-17
4507
It may be necessary to reclassify certain expenses pertaining to buildings, fixtures, and movable
equipment. These expenses must be directly assigned or allocated on the same basis as the
depreciation expense for the respective buildings, fixtures or movable equipment. Examples of
these expenses include insurance, rent on buildings, fixtures, or movable equipment, real estate
taxes, and personal property taxes. Interest on funds borrowed to purchase buildings, fixtures, or
movable equipment are included in these expenses. Interest borrowed for operating funds is not
included. Interest on funds borrowed for operating funds must be allocated with administration
and general expenses.
Employee health and welfare costs must be considered as part of each employee’s compensation
and charged to the various cost centers in the same proportion that the salary is charged.
Column 1.--Identify each reclassification adjustment by assigning an alpha character (e.g., A, B,
C) in column 1. Do not use numeric designations.
Columns 2, 3, 4 and 5.--For each increase reclassification, enter the corresponding cost center
description in column 2, the Worksheet A cost center line number reference in column 3, and
reclassification amount in columns 4 and 5.
Columns 6, 7, 8 and 9.--For each decrease reclassification, enter the corresponding cost center
description in column 6, the Worksheet A cost center line number reference in column 7, and
reclassification amount in columns 8 and 9.
For line 100, the sum of all increases in columns 4 and 5 must equal the sum of all decreases in
columns 8 and 9. Submit (with the cost report) copies of work papers used to compute the
reclassifications.
Transfer the amounts on Worksheet A-6, to Worksheet A, column 5, line as appropriate.
4507.
WORKSHEET A-8 - ADJUSTMENTS TO EXPENSES
In accordance with 42 CFR 413.9(c)(3), where operating costs include amounts not related to
patient care, specifically not reimbursable under the program, or flowing from the provision of
luxury items or services (i.e., those items or services substantially in excess of or more expensive
than those generally considered necessary for the provision of needed health services), such
amounts are not allowable. This worksheet provides for the adjustments in support of those listed
on Worksheet A, column 7. These adjustments, required under Medicare principles of
reimbursement, are made on the basis of cost or, only if the cost (including direct cost and all
applicable overhead) cannot be determined, amount received (revenue). If the total direct and
indirect cost can be determined, enter the cost. Adjustments to expenses based on cost cannot be
based on revenue in subsequent cost reporting periods. Indicate the basis used in column 1. There
Rev. 1
45-25
4507 (Cont.)
FORM CMS-2088-17
05-18
are, however, items on the worksheet which are adjusted on one basis only. For these items, the
basis for adjustment is printed in column 1. Line descriptions indicate the more common activities
which affect allowable cost or result in costs incurred for reasons other than patient care and thus
require adjustments.
If any of the adjustments you make on Worksheet A-8 flow from Worksheets A-8-1, complete that
worksheet before completing Worksheet A-8.
Line Descriptions
Lines 1 and 2.--If depreciation expense computed in accordance with the Medicare principles of
reimbursement differs from depreciation expense per your books enter the difference on lines 1
and/or 2. (See CMS Pub. 15-1, §100ff.)
Line 3.--Enter the amounts received for rendering administrative services to others, including
physicians and therapists. For example, you may arrange to process billings and collect the
proceeds on behalf of such specialists and charge a fee for these services. Reduce allowable costs
by the amount of such fees.
Line 4.--Reduce interest expense by investment income, except investment income earned by:
• Grants, gifts and endowments, (whether restricted or unrestricted),
• Funded depreciation,
• Pension funds, and
• Deferred compensation funds.
The offset of investment income against interest expense cannot exceed the total interest expense
included in allowable cost.
Lines 5 and 6.--Enter these discounts, rebates, and refunds on these lines only when such receipts
have not already been netted against the appropriate expense in the accounting records.
The recommended offset of these amounts against the administrative and general cost center is
appropriate only if the related expense cannot be identified. (See CMS Pub. 15-1, §804.)
Line 11.--If the expense applicable to these activities is insignificant, make the adjustment on this
line. However, these and similar activities are normally set up as nonreimbursable cost centers on
Worksheet B since the amounts involved are usually significant.
Line 15.--Obtain any amount entered on this line from Worksheet A-8-1.
Line 16.--Enter the amount obtained from Worksheet A-8-2, column 18, the total line.
45-26
Rev. 1
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FORM CMS-2088-17
4508
NOTE: Make the adjustments on Worksheet A, column 7, for the various cost centers affected
by provider-based physicians by referring to the adjustments for the corresponding cost centers on
Worksheet A-8-2, column 18. Reasonable compensation equivalent limits do not apply to a
medical director, a chief of medical staff, or to the compensation of any physician employed in a
capacity not requiring the services of a physician, such as a controller.
Lines 17 through 49.--Enter any additional adjustments which are required under the Medicare
principles of reimbursement. Appropriately label the lines to indicate the nature of the required
adjustments.
Line 50.--Enter the total of lines 1 through 49. Transfer all the amounts on lines 1 through 49,
column 2, to the appropriate lines on Worksheet A, column 7.
4508.
WORKSHEET A-8-1 - STATEMENT OF COSTS OF SERVICES FROM RELATED
ORGANIZATIONS
Worksheet A-8-1 provides for the computation of any needed adjustments to costs applicable to
services, facilities, and supplies furnished to the provider by organizations related to the provider
by common ownership or control. In addition, certain information concerning the related
organizations with which the provider has transacted business must be shown. (See
CMS Pub. 15-1, chapter 10, §1004.)
Part I.--Cost applicable to services, facilities, and supplies furnished to you by organizations
related to you by common ownership or control are includable in your allowable cost at the cost
to the related organizations. However, such cost must not exceed the amount a prudent and cost
conscious buyer pays for comparable services, facilities, or supplies that are purchased elsewhere.
Part II.--Use this part to show your relationship to HO/CO for which transactions were identified
in Part I. Show the requested data relative to all individuals, partnerships, corporations, or other
organizations having either a related interest to you, a common ownership with you, or control
over you as defined in CMS Pub. 15-1, chapter 10, §1004, in columns 1 through 6, as appropriate.
Complete only those columns which are pertinent to the type of relationship which exists.
Column 1.--Enter the appropriate symbol which describes relationship of the provider to the
related organization.
Column 2.--If the symbol A, D, E, F, or G, is entered in column 1, enter the name of the related
individual in column 2.
Rev. 2
45-27
4509
FORM CMS-2088-17
01-21
Column 3.--If the individual indicated in column 2 or the organization in column indicated in
column 4 has a financial interest in the provider, enter the percent of ownership as a ratio.
Column 4.--Enter the name of the related corporation, partnership or other organization.
Column 5.--If the individual in column 2 or the provider has a financial interest in the related
organization, enter the percent of ownership in such organization as a ratio.
Column 6.--Enter the type of business in which the related organization engages (e.g., medical
drugs and/or supplies, laundry and linen service).
4509.
WORKSHEET A-8-2 - PROVIDER-BASED PHYSICIAN ADJUSTMENTS
In accordance with 42 CFR 413.9, 42 CFR 415.55, 42 CFR 415.60, 42 CFR 415.70, and
42 CFR 415.102(d), you may claim as allowable cost only those costs which you incur for
physician services that benefit the general patient population of the provider. 42 CFR 415.70
imposes limits on the amount of physician compensation which may be recognized as a reasonable
provider cost.
Worksheet A-8-2 provides for the computation of the allowable provider-based physician cost you
incur. 42 CFR 415.60 provides that the physician compensation paid by you must be allocated
between services to individual patients (professional services), services that benefit your patients
generally (provider services), and nonreimbursable services such as research. Only provider
services are reimbursable to you through the cost report. This worksheet also provides for the
computation of the reasonable compensation equivalent (RCE) limits required by 42 CFR 415.70.
The methodology used in this worksheet applies the RCE limit to the total physician compensation
attributable to provider services reimbursable on a reasonable cost basis.
NOTE: Where several physicians work in the same department, see CMS Pub. 15-1, chapter 21,
§2182.6C, for a discussion of applying the RCE limit in the aggregate for the department
versus on an individual basis to each of the physicians in the department.
Column Descriptions
Columns 1 and 10.--Enter the line numbers from Worksheet A for each cost center that contained
compensation for physicians subject to RCE limits. Enter the line numbers in the same order as
displayed on Worksheet A.
Columns 2 and 11.--Enter the description of the cost center used on Worksheet A. When RCE
limits are applied on an individual basis to each physician in a department, list each physician on
successive lines directly under the cost center description line, or list the first physician on the
same line as the cost center description line and then eachsuccessive line below for eachadditional
physician in that cost center.
45-28
Rev. 2
05-18
FORM CMS-2088-17
4509 (Cont.)
List each physician using an individual identifier (not the physician’s name, NPI, UPIN or social
security number of the individual), but rather, Dr. A, Dr. B…, Dr. AA, Dr. BB, etcetera. However,
the identity of the physician must be made available to your contractor upon audit. When RCE
limits are applied on a departmental basis, insert the word "aggregate" (instead of the physician
identifiers) on the line below the cost center description.
Columns 3 through 9 and 12 through 18.--When the aggregate method is used, enter the data for
each of these columns on the aggregate line for each cost center. When the individual method is
used, enter the data for each column on the individual physician identifier lines for each cost center.
Column 3.--Enter the total physician compensation paid by the provider for each cost center.
Physician compensation is monetary payments, fringe benefits, deferred compensation, costs of
physician membership in professional societies, continuing education, malpractice, and any other
items of value (excluding office space or billing and collection services) that a provider or other
organization furnishes a physician in return for the physician’s services. (See 42 CFR 415.60(a).)
Include the compensation in column 4 of Worksheet A or, if necessary, through appropriate
reclassifications or as a cost paid by a related organization through Worksheet A-8-1.
Column 4.--Enter the amount of total remuneration included in column 3 which is applicable to
the physician’s services to individual patients (professional component). These services are
reimbursed on a reasonable charge basis by the Part B carrier in accordance with
42 CFR 415.102(a). The written allocation agreement between you and the physician specifying
how the physician spends his or her time is the basis for this computation. (See 42 CFR 415.60(f).)
Column 5.--Enter the amount of the total remuneration included in column 3, for each cost center,
applicable to general services to you (provider component). The written allocation agreement is
the basis for this computation. (See 42 CFR 415.60(f).)
NOTE: 42 CFR 415.60(b) requires that physician compensation be allocated between physician
services to patients, the provider, and nonallowable services such as research. Physicians'
nonallowable services must not be included in columns 4 or 5. The instructions for column 18
ensure that the compensation for nonallowable services included in column 3 is correctly
eliminated on Worksheet A-8.
Column 6.--Enter for each line of data, as applicable, the reasonable compensation equivalent
(RCE) limit applicable to the physician’s compensation included in that cost center. The amount
entered is the limit applicable to the physician specialty as published in the Federal Register before
any allowable adjustments.
The RCE limits are updated annually on the basis of updated economic index data. A notice is
published in the Federal Register, which sets forth the new limits. The RCE applicable to the
Rev. 1
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05-18
various specialties is obtained from that notice. If the physician specialty is not identified in the
table, use the RCE for the total category in the table. The beginning date of the cost reporting
period determines which calendar year (CY) RCE is used. Your location governs which of the
three geographical categories are applicable: non-metropolitan areas, metropolitan areas less than
one million, or metropolitan areas greater than one million.
Column 7.--For each line of data enter the physician’s hours allocated to provider services. For
example, if a physician works 2080 hours per year and 50 percent of his/her time is spent on
provider services, then enter 1040. The hours entered are the actual hours for which the physician
is compensated by the provider for furnishing services of a general benefit to its patients. If the
physician is paid for unused vacation, unused sick leave, etc., exclude the hours paid from the
hours entered in this column. Time records, or other documentation that supports this allocation,
must be available for verification by the contractor upon request. (See CMS Pub. 15-1, chapter 21,
§2182.3E.)
Column 8.--Enter the unadjusted RCE limit for each line of data. This amount is the product of
the RCE amount entered in column 6 and the ratio of the physician’s provider component hours
entered in column 7 to 2080 hours.
Column 9.--For each line of data enter five percent of the amounts entered in column 8.
Column 12.--The computed RCE limit in column 8 may be adjusted upward, up to five percent of
the computed limit (column 9), to take into consideration the actual costs of membership for
physicians in professional societies and continuing education paid by the provider.
Enter, for each line of data, the actual amounts of these expenses paid by you.
Column 13.--For each line of data enter the result of multiplying the amount in column 5 by the
amount in column 12, and divide the result by the amount in column 3.
Column 14.--The computed RCE limit in column 8 may also be adjusted upward to reflect the
actual malpractice expense incurred by you for the services of a physician or group of physicians
to your patients.
Enter for each line of data the actual amounts of these malpractice expenses paid by you.
Column 15.--For each line of data enter the result of multiplying the amount in column 5 by the
amount in column 14, and divide the result by the amount in column 3.
Column 16.--For each line of data enter the sum of the amounts in columns 8 and 15 plus the lesser
of the amounts in columns 9 or 13.
45-30
Rev. 1
01-21
FORM CMS-2088-17
4510
Column 17.--Compute the RCE disallowance for each cost center by subtracting the RCE limit in
column 16 from your component remuneration in column 5. If the result is a negative amount,
enter zero in this column.
Column 18.--The adjustment for each cost center to be entered represents the provider-based
physician (PBP) elimination from costs entered on Worksheet A-8, column 2, line 16. Compute
the amount by deducting, for each cost center, the lesser of the amounts recorded in column 5
(provider component remuneration) or column 16 (adjusted RCE limit) from the total
remuneration recorded in column 3.
Line 100 - Total Line.--Total the amounts in columns 3 through 5, 7 through 9, and 12 through 18.
4510.
WORKSHEET B - COST ALLOCATION - GENERAL SERVICE COSTS AND
WORKSHEET B-1 - COST ALLOCATION - STATISTICAL BASIS
In accordance with 42 CFR 413.24, cost data must be based on an approved method of cost finding
and on the accrual basis of accounting except where governmental institutions operate on a cash
basis of accounting. Cost finding is the process of recasting the data derived from the accounts
ordinarily kept by a provider to ascertain costs of the various types of services rendered. It is the
determination of these costs by the allocation of direct costs and proration of indirect costs. Obtain
the total direct expenses from Worksheet A, column 8.
Worksheets B and B-1 facilitate the step-down method of cost finding. This method recognizes
that general services of the CMHC are utilized by other general service, direct patient care service,
and nonreimbursable cost centers. Worksheet B provides for the equitable allocation of general
service costs based on statistical data reported on Worksheet B-1. To facilitate the allocation
process, the general format of Worksheets B and B-1 is identical. The column and line numbers
for each general service cost center are identical on the two worksheets. Prepare these worksheets
in conjunction with each other.
The statistical basis shown at the top of each column on Worksheet B-1 is the recommended basis
of allocation. The total statistic for cost centers using the same basis (e.g., square feet) may differ
with the closing of preceding cost centers.
Close the general service cost centers in accordance with 42 CFR 413.24(d)(1) so that the cost
centers rendering the most services to and receiving the least services from other cost centers are
closed first (see CMS Pub. 15-1, chapter 23, §2306.1). If a more accurate result is obtained by
allocating costs in a sequence that differs from the recommended sequence, the CMHC must
request approval in accordance with CMS Pub. 15-1, chapter 23, §2313.
If the amount of any cost center on Worksheet A, column 8, has a negative balance, show this
amount as a negative balance on Worksheet B, column 0. Allocate the costs from the overhead
Rev. 2
45-31
4510 (Cont.)
FORM CMS-2088-17
01-21
cost centers to applicable cost centers, including those with a negative balance. If after receiving
costs from the applicable overhead cost centers, a general service cost center has a credit balance
at the point it is to be allocated, do not allocate such general service cost center. Rather, enter the
credit balance in parenthesis on line 99 of the appropriate column, as well as the first line of the
column.
This enables you to cross foot column 14, line 99, to column 0, line 99. After receiving costs from
the applicable overhead cost centers, if a revenue producing cost center has a credit balance on
Worksheet B, column 14, do not carry such credit balance forward to Worksheet C.
On Worksheet B-1, enter on the first line of each column the total statistics applicable to the cost
center being allocated (e.g., in column 1, Capital-Related Costs - Buildings and Fixtures, enter on
line 1 the total square feet of buildings on which depreciation was taken). Use accumulated cost
for allocating A&G expenses.
For each cost center being allocated, enter that portion of the total statistical base applicable to
each cost center receiving services. For each column, the sum of the statistics entered for cost
centers receiving services must equal the total statistical base entered on the first line. Such
statistical base, including accumulated cost for allocating A&G expenses, does not include any
statistics related to services furnished under arrangements except where:
•
Both Medicare and non-Medicare costs of arranged for services are recorded in the
CMHC’s books/records; or
•
The contractor determines that the CMHC is able to and does gross up the costs and
charges for services to non-Medicare patients so that both cost and charges are recorded
as if the CMHC had furnished such services directly to all patients. (See
CMS Pub. 15-1, chapter 23, §2314.)
Enter on line 101 the total expenses of the cost center being allocated. Obtain this amount from
the same column and line number on Worksheet B used to enter the total statistical base on
Worksheet B-1. (In the case of buildings and fixtures, this amount is on Worksheet B, column 1,
line 1.)
Divide the amount entered on line 101 by the total statistical base entered in the same column on
the first line. Enter the resulting unit cost multiplier on line 102. Enter the resulting unit cost
multiplier (rounded to six decimal places) on line 102.
Multiply the unit cost multiplier by that portion of the total statistical base applicable to each cost
center receiving the services rendered. Enter the result of each computation on Worksheet B in
the corresponding column and line.
45-32
Rev. 2
05-18
FORM CMS-2088-17
4510 (Cont.)
After the unit cost multiplier has been applied to all the cost centers receiving the services rendered,
the total cost (line 101) of all of the cost centers receiving the allocation on Worksheet B must
equal the amount entered on the first line. Perform the preceding procedures for each general
service cost center. Complete the column for each cost center on both Worksheets B and B-1
before proceeding to the next column for the cost center.
After all the costs of the general service cost centers have been allocated on Worksheet B, enter in
column 14, the sum of expenses on lines 23 through 100, columns l through 13. The total expenses
entered in column 14, line 101, must equal the total expenses entered in column 0, line 101.
Transfer the totals in column 14, lines 23 through 32 of Worksheet B to Worksheet C, column l.
Do not transfer the nonreimbursable cost centers, lines 42 through 100.
NOTE: Whenever an adjustment is required to expenses after cost allocation, submit a supporting
worksheet showing the computation of the adjustment, the amount applicable to each cost center,
and the cost center balances which are to be carried forward from Worksheet B for cost
apportionment to the health care programs.
Column Descriptions
Column 1.--Depreciation on buildings and fixtures and expenses pertaining to buildings and
fixtures e.g., insurance, interest, rent, and real estate taxes are combined in this cost center to
facilitate cost allocation. Allocate all expenses to the cost centers on the basis of square feet of
area occupied.
If a CMHC occupies more than one building, it may allocate the depreciation and related expenses
by building, using a supportive worksheet showing the detail allocation and transferring the
accumulated costs by cost center to Worksheet B, column 1.
Column 2.--If you do not directly assign the depreciation on movable equipment and expenses
pertaining to movable equipment, e.g., insurance, interest and rent, as part of your normal
accounting systems, you must accumulate the expenses in this cost center. Allocate all expenses
(e.g., interest, personal property tax) for movable equipment to the appropriate cost centers on the
basis of square feet of area occupied or dollar value.
Column 3.--The salary statistics used for employee health and welfare cost allocation must be
reconcilable to total salaries and salary by department shown on Worksheet A, column 1.
Adjustments are necessary to take into account salaries reclassified in column 5 of Worksheet A
and the salaries adjusted in column 7 of Worksheet A.
Rev. 1
45-33
4511
FORM CMS-2088-17
05-18
Column 4.--Allocate the administrative and general expenses on the basis of accumulated cost.
Therefore the amount entered in Worksheet B-1, column 4 is the sum of Worksheet B, columns 1
through 3, lines as applicable.
A negative cost center balance in the statistics for allocating administrative and general expenses
causes an improper distribution of this overhead cost center. Exclude negative balances from the
allocation statistics.
Worksheet B-1, Column 4A.--Enter the costs attributable to the difference between the total
accumulated cost reported on Worksheet B, column 3A, line 101, and the accumulated cost
reported on Worksheet B-1, column 4, line 4. Enter any amounts reported on Worksheet B,
column 3A for (1) any service provided under arrangements to program patients that is not grossed
up and (2) negative balances. Including these costs in the statistics for allocating administrative
and general expenses causes an improper distribution of overhead. In addition, report on line 4
the administrative and general costs reported on Worksheet B, column 4, line 4, since these costs
are not included on Worksheet B-1, column 4 as an accumulated cost statistic.
For subscripted A&G cost centers, the accumulated cost center line number must match the
reconciliation column number. Include in the column number the alpha character "A", i.e., if the
accumulated cost center for A&G is line 4 (A&G), the reconciliation column designation must be
4A.
Worksheet B-1, Column 4.--The administrative and general expenses are allocated on the basis of
accumulated costs. Therefore, the amount entered on Worksheet B-l, column 4, line 4, is the
difference between the amounts entered on Worksheet B, column 3A and Worksheet B-1,
column 4A. A negative cost center balance in the statistics for allocating administrative and
general expenses causes an improper distribution of this overhead cost center. Exclude negative
balances from the allocation statistics.
4511.
WORKSHEET C - APPORTIONMENT OF PATIENT SERVICE COSTS
To determine the allowable costs applicable to the Medicare program, apportion the costs between
the Medicare beneficiaries and the other patients. The basis of the apportionment is the gross
amount of charges for each reimbursable cost center.
Column 1.--Enter the total cost of each cost center as computed on Worksheet B, column 14,
corresponding lines. Do not bring forward any cost center with a credit balance from Worksheet B,
column 14.
Column 2.--Enter on each line (from your records) the gross total patient charges for each cost
center.
45-34
Rev. 1
01-21
FORM CMS-2088-17
4512
Column 3.--Divide the cost for each cost center in column 1 by the corresponding gross charges
in column 2 to determine the ratio of cost to charges for each cost center. Carry the ratio out to six
decimal places.
Column 4.--Enter, from your records or PS&R, the Medicare program charges for eachcost center.
If you charge some patients less than the customary charges for services rendered because of the
patients’ inability to pay or for any other reason, those charges are increased (for apportionment
purposes) to reflect the gross amounts.
Thus, for computing reimbursable costs on this worksheet, the individual amounts applicable to
Medicare program patients must not differ from the amounts applicable to all other patients for the
same services.
When certain services by a provider are furnished under arrangements and an adjustment is made
on Worksheet A-8 to gross up costs, the related charges entered on Worksheet C are also grossed
up in accordance with CMS Pub. 15-1, chapter 23, §2314.
Column 5.--Calculate the Medicare cost by multiplying the cost to charge ratio from column 3 by
the Medicare charges in column 4 for each reimbursable cost center listed for lines 23 through
line 32.
Line 50.--Enter the total of lines 23 through 32.
4512.
WORKSHEET D - CALCULATION OF REIMBURSEMENT SETTLEMENT FOR
COMMUNITY MENTAL HEALTH CENTERS - TITLE XVIII
Worksheet D applies to title XVIII only and provides for the reimbursement calculation of CMHC
services rendered to Medicare beneficiaries.
Line Descriptions
Line 1.--Enter the gross APC/PPS payments (includes deductible and coinsurance).
Line 2.--Enter the amount of outlier payments.
Line 3.--Enter the outlier reconciliation amount from line 54.
Line 4.--Enter the sum of lines 1 through 3.
Line 5.--Enter the amounts paid or payable by primary payers when Medicare liability is secondary
to that of the primary payer.
Rev. 2
45-35
4512 (Cont.)
FORM CMS-2088-17
01-21
Line 6.--Enter the total amount of deductibles billed to program patients (do not include
coinsurance).
Line 7.--Enter in the applicable the column the gross coinsurance amount billed to Medicare
beneficiaries.
Line 8.--Enter the sum of line 4 minus lines 5, 6, and 7.
Line 9.--Enter the gross reimbursable bad debts, net of bad debt recoveries, applicable to any
Medicare deductibles and coinsurance. The amount entered applicable to CMHC PPS must not
exceed the discounted coinsurance applicable to Medicare beneficiaries.
Line 10.--Enter the adjusted Medicare bad debt, line 9 (including negative amounts) times 65
percent.
Line 11.--Enter the reimbursable bad debts for dual eligible beneficiaries. This amount is reported
for informational purposes and is a subset of the amount reported on line 9.
Line 12.--Enter the result of line 8 plus line 10.
Line 13.--Enter any other adjustments. Enter increases to costs as a positive amount and decreases
as a negative amount.
Line 14.--Enter all demonstration payment adjustment amounts before sequestration.
Line 15.--Amount due before sequestration (line 12, minus lines 13 and 14).
Line 16.--Enter the sequestration adjustment amount as follows: (2 percent times (total days in the
cost reporting period that occur during the sequestration period, divided by total days in the entire
cost reporting period, rounded to four decimal places) times line 15). (Note: In accordance with
§3709 of the CARES Act, updated with §102 of the Consolidated Appropriations Act, 2021, do
not apply the sequestration adjustment to the period of May 1, 2020, through March 31, 2021.)
Line 17.--Enter all demonstration payment adjustment amounts after sequestration.
increases to costs as a positive amount and decreases to costs as a negative amount.
Enter
Line 18.--Amount due after sequestration (line 15, minus lines 16 and 17).
Line 19.--Enter the total interim payments applicable to this cost reporting period from
Worksheet D-1, line 4.
Line 20.--For contractor final settlement, report the amount from Worksheet D-1, line 5.99.
45-36
Rev. 2
01-21
FORM CMS-2088-17
4513
Line 21.--Enter the amount from line 18 minus the amounts on lines 19 and 20. This represents
the amount due to or from the provider. Transfer this amount to Worksheet S, Part III, line 1.
Line 22.--Enter protested amounts.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET D, LINES 50 THROUGH
54 ARE FOR CONTRACTOR USE ONLY.
Line 50.--Enter the original outlier amount from line 2.
Line 51.--Enter the outlier reconciliation adjustment
CMS Pub. 100-04, chapter 4, §§10.7.2.2 through 10.7.2.4.
amount
in
accordance
with
Line 52.--Enter the rate used to calculate the time value of money. (See CMS Pub. 100-04,
chapter 4, §§10.7.2.2 through 10.7.2.4.)
Line 53.--Enter the time value of money.
Line 54.--Enter sum of lines 51 and 53.
4513.
WORKSHEET D-1 - ANALYSIS OF PAYMENTS TO COMMUNITY MENTAL
HEALTH CENTERS FOR SERVICES RENDERED TO PROGRAM
BENEFICIARIES
Complete this worksheet for Medicare interim payments only. (See 42 CFR §413.64.)
Complete lines 1 through 4. The remainder of the worksheet is completed by your contractor.
Line Descriptions
Line 1.--Enter the total Medicare interim payments paid to the CMHC. Include all Prospective
Payment System (PPS) payments for CMHC services. Do not include payments received for
services reimbursed on a fee schedule basis. The amount entered reflects the sum of all interim
payments paid on individual bills (net of adjustment bills) for services rendered in this cost
reporting period. The amount entered must include amounts withheld from the CMHC’s interim
payments due to an offset against overpayments to the CMHC applicable to prior cost reporting
periods. It does not include any retroactive lump sum adjustment amounts based on a subsequent
revision of the interim rate or tentative or net settlement amounts; nor does it include interim
payments payable. If the CMHC is reimbursed under the periodic interim payment method of
reimbursement, enter the periodic interim payments received for this cost reporting period.
Rev. 2
45-37
4514
FORM CMS-2088-17
01-21
Line 2.--Enter the total Medicare interim payments payable on individual bills. Since the cost in
the cost report is on an accrual basis, this line represents the amount of services rendered in the
cost reporting period, but not paid as of the end of the cost reporting period, and does not include
payments reported on line 1.
Line 3.--Enter the amount of each retroactive lump sum adjustment and the applicable date.
Line 4.--Enter the total amount of the interim payments (sum of lines 1, 2, and 3.99). Transfer
these totals to Worksheet D, line 19.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET D-1.
LINES 5
THROUGH 7 ARE FOR CONTRACTOR USE ONLY.
(EXCEPTION: IF
WORKSHEET S, PART I, LINE 5, IS “5” (AMENDED COST REPORT), THE
PROVIDER MAY COMPLETE THIS SECTION.)
Line 5.--List separately each tentative settlement payment after desk review together with the date
of payment. If the cost report is reopened after the Notice of Program Reimbursement (NPR) has
been issued, report all settlement payments prior to the current reopening settlement on line 5.
Line 6.--Enter the net settlement amount (balance due to the provider or balance due to the
program) for the NPR, or, if this settlement is after a reopening of the NPR, for this reopening.
NOTE: On lines 3, 5, and 6, when 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.
Line 7.--Enter the sum of the amounts on lines 4, 5.99, and 6.
Worksheet D, line 18.
The amount must equal
Line 8.--Enter the contractor’s name, the contractor number, and NPR date in columns 1, 2, and 3,
respectively.
4514.
FINANCIAL STATEMENT WORKSHEET
Prepare this worksheet from the CMHC accounting books and records. Cost reports received with
an incomplete Worksheet F are returned to you for completion. If you do not follow this procedure,
you are considered as having failed to file a cost report.
4514.1 Worksheet F - Statement of Revenues and Expenses.--This worksheet requires the
reporting of total revenues for the entire facility and total operating expenses for the entire facility.
If cost report total revenues and total expenses differ from those on your filed financial statements,
submit a reconciliation report with the cost report submission.
Line 1 - Total Patient Revenue.--Enter on this line total patient revenues.
45-38
Rev. 2
01-21
FORM CMS-2088-17
4514.1 (Cont.)
Line 2 - Less: Allowance and Discounts on Patient’s Accounts.--Enter on this line total patient
revenues not received. This includes:
Provision for Bad Debts,
Contractual Adjustments,
Charity Discounts,
Teaching Allowances,
Policy Discounts,
Administrative Adjustments, and
Other Deductions from Revenue
Line 3 - Net Patient Revenues.--Line 1 minus line 2.
Line 4 - Less: Total Operating Expenses.--Transfer from Worksheet A, column 4, line 100.
Line 5 - Net Income from Service to Patients.--Line 3 minus line 4.
Lines 6 through 22.--Enter on the appropriate line 6 through 19 all other revenue not reported on
line 1. Obtain these amounts from your accounting books and/or records.
Line 20 - Other (Specify).--Enter all other revenue not reported on lines 6 through 19. Obtain this
from your accounting books and/or records. Subscript this line as necessary.
Line 20.50--COVID-19 PHE Funding--Enter the aggregate revenue received for COVID-19
Public Health Emergency (PHE) funding including both Provider Relief Fund and Small Business
Association Loan Forgiveness amounts.
Line 21 - Total Other Income.--Enter the sum of lines 6 through 20.
Line 22 - Total.--Enter the sum of lines 5 and 21.
Lines 23 through 25.--Enter on the appropriate lines 23 through 25, expenses from your books and
records.
Line 26 - Other Expenses (Specify).--Enter all other expenses not reported on lines 23 through 25.
Subscript this line as necessary.
Line 27 - Total Other Expenses.--Enter the sum of line 23 through 26.
Line 28 - Net Income (or Loss) for the Period.--Enter the result of line 22 minus line 27.
Rev. 2
45-39
4514.1 (Cont.)
FORM CMS-2088-17
01-21
THIS PAGE IS RESERVED FOR FUTURE USE.
45-40
Rev. 2
01-21
FORM CMS-2088-17
4590
Form CMS-2088-17 Worksheets
The following is a listing of the Form CMS-2088-17 worksheets and the page number location.
Rev. 2
Worksheets
Page(s)
Wkst. S, Parts I-III
Wkst. S-1, Part I and II
Wkst. S-2
Wkst. A
Wkst. A-6
Wkst. A-8
Wkst. A-8-1
Wkst. A-8-2
Wkst. B
Wkst. B-1
Wkst. C
Wkst. D
Wkst. D-1
Wkst. F
45-303
45-304
45-305
45-306
45-307
45-308
45-309
45-310
45-311 - 45-312
45-313 - 45-314
45-315
45-316
45-317
45-318
45-301
4590 (Cont.)
FORM CMS-2088-17
01-21
THIS PAGE IS RESERVED FOR FUTURE USE.
45-302
Rev. 2
01-21
FORM CMS-2088-17
4595
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE OF CONTENTS
Topic
Page(s)
Table 1:
Record Specifications
45-502 - 45-509
Table 2:
Worksheet Indicators
45-510 - 45-511
Table 3:
List of Data Elements With Worksheet, Line, and
Column Designations
45-512 - 45-530
Table 3A:
Worksheets Requiring No Input
45-530
Table 3B:
Table for Worksheet S-1, Part I
45-530
Table 3C:
Lines That Cannot Be Subscripted
45-531
Table 4:
Reserved for future use
Table 5:
Cost Center Coding
Table 6:
Edits:
Rev. 2
45-531 - 45-535
Level 1 Edits
45-536 - 45-542
Level 2 Edits
45-543 - 45-544
45-501
4595 (Cont.)
FORM CMS-2088-17
01-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 1 - RECORD SPECIFICATIONS
Table 1 specifies the standard record format required for the four types of records in an ECR file.
Type 1 records contain information for identifying the provider, for processing the cost report, and
for vendor validation. Type 2 records contain the line and column labels. Type 3 records contain
data necessary to calculate the Community Mental Health Center (CMHC) cost report. Table 3
provides specifications for the layout of type 3 records. Type 4 records contain the ECR file
encryption coding, records 1, 1.01, and 1.02.
The medium for transferring ECR files to contractors is CD, flash drive, or the CMS approved
Medicare Cost Report E-filing (MCREF) portal, [URL: https://mcref.cms.gov]. ECR files must
comply with CMS specifications. Providers must seek approval from their contractors regarding
the method of submission to ensure that the method of transmission is acceptable.
The following are requirements for all records:
1.
2.
3.
All alpha characters must be in upper case.
For micro systems, the end of record indicator must be a carriage return and line feed,
in that sequence.
No record may exceed 60 characters.
Below is an example of a set of type 1 records with a narrative description of their meaning.
1
2
3
4
5
6
123456789012345678901234567890123456789012345678901234567890
1
1
146000201727420182732A99P00120190362017274
1
2
2088-17
1
4
14:30
Record #1:
This is a cost report file submitted by CCN 146000 for the period from
October 1, 2017 (2017274) through September 30, 2018 (2018273). It is filed on
Form CMS-2088-17. It is prepared with vendor number A99’s PC based system,
version number 1. Position 38 changes with each new test case and/or re-approval
and is an alpha character. Positions 39 and 40 remain constant for approvals issued
after the first test case. This file is prepared by the CMHC on February 05, 2019
(2019036). The electronic cost report specifications, dated October 1, 2017
(2017274), were used to prepare this file.
FILE NAMING CONVENTION
Name each cost report ECR file in the following manner:
CMNNNNNN.YYLC, where
1. CM (CMHC Cost Report) is constant;
2. NNNNNN is the 6 digit CMS Certification Number;
3. YY is the year in which the provider's cost reporting period ends; and
4. L is a character variable (A-Z) to enable separate identification of files from CMHCs
with two or more cost reporting periods ending in the same calendar year.
5. C is the number of times this original cost report is being filed
45-502
Rev. 2
01-21
FORM CMS-2088-17
4595 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 1 - RECORD SPECIFICATIONS
Name each cost report PI file in the following manner:
PINNNNNN.YYLC, where
1. PI (Print Image) is constant;
2. NNNNNN is the 6 digit CMS Certification Number;
3. YY is the year in which the provider's cost reporting period ends; and
4. L is a character variable (A-Z) to enable separate identification of files from CMHCs
with two or more cost reporting periods ending in the same calendar year.
5. C is the number of times this original cost report is being filed
RECORD NAME: Type 1 Records - Record Number 1
Size
Usage
Loc.
Remarks
1.
Record Type
1
X
1
Constant “1”
2.
For Future Use
10
9
2-11
Alpha numeric
3.
Spaces
1
X
12
4.
Record Number
1
X
13
5.
Spaces
3
X
14-16
6.
CMHC CCN
6
9
17-22
Field must have 6 numeric characters.
7.
Fiscal Year
Beginning Date
7
9
23-29
YYYYDDD - Julian date; first day
covered by this cost report
8.
Fiscal Year
Ending Date
7
9
30-36
YYYYDDD - Julian date; last day
covered by this cost report
9.
MCR Version
1
9
37
Constant “2” (for FORM CMS-208817)
10.
Vendor Code
3
X
38-40
To be supplied upon approval. Refer
to page 45-502.
11.
Vendor Equipment
1
X
41
P = PC; M = Main Frame
12.
Version Number
3
X
42-44
Version of extract software, e.g.,
001=1st, 002=2nd, etc. or 101=1st,
102=2nd. The version number must be
incremented by 1 with each recompile
and release to client(s).
Rev. 2
Constant “1”
45-503
4595 (Cont.)
FORM CMS-2088-17
01-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 1 - RECORD SPECIFICATIONS
RECORD NAME: Type 1 Records - Record Number 1 (Cont.)
Size
Usage
Loc.
Remarks
13.
Creation Date
7
9
45-51
YYYYDDD - Julian date; date on
which the file was created (extracted
from the cost report)
14.
ECR Spec. Date
7
9
52-58
YYYYDDD - Julian date; date of
electronic cost report specifications
used in producing each file. Valid for
cost reporting periods ending on
2020366 (12/31/2020). Prior
approvals: 2018273.
RECORD NAME: Type 1 Records - Record Numbers 2 - 99
Size
Usage
Loc.
1.
Record Type
1
9
1
2.
Spaces
10
X
2-11
3.
Record Number
2
9
12-13
Remarks
Constant "1"
#2 - Cost report iteration identifier is
2088-17 in positions 21 through 27.
#3 - Vendor information; optional
record for use by vendors. Left
justified in positions 21 through 60.
#4 - The time that the cost report is
created. This is represented in military
time as alpha numeric. Use positions
21 through 25. Example: 2:30PM is
expressed as 14:30.
#5 to #99 - Reserved for future use.
4.
Spaces
7
X
14-20
Spaces (Optional)
5.
ID Information
40
X
21-60
Left justified to position 21.
45-504
Rev. 2
01-21
FORM CMS-2088-17
4595 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 1 - RECORD SPECIFICATIONS
RECORD NAME: Type 2 Records for Labels
Size
Usage
Loc.
Remarks
1.
Record Type
1
9
1
Constant “2”
2.
Wkst. Indicator
7
X
2-8
Alphanumeric. Refer to Table 2.
3.
Spaces
2
X
9-10
4.
Line Number
3
9
11-13
Numeric
5.
Subline Number
2
9
14-15
Numeric
6.
Column Number
3
X
16-18
Alphanumeric
7.
Sub-column
Number
2
9
19-20
Numeric
8.
Cost Center Code
4
9
21-24
Numeric. Refer to Table 5 for
appropriate cost center codes.
9.
Labels/Headings
36
X
25-60
Alphanumeric, left justified
10
b. Column
Headings
Statistical Basis
& Code
X
21-30
Alphanumeric, left justified
a. Line Labels
The type 2 records contain text which appears on the printed cost report. Of these, there are three
groups: (1) Worksheet A cost center names (labels); (2) column headings for step down entries;
and (3) other text appearing in various places throughout the cost report.
A Worksheet A cost center label must be furnished for every cost center with cost or charge data
anywhere in the cost report. The line and subline numbers for each label must be the same as the
line and subline numbers of the corresponding cost center on Worksheet A. The columns and
sub-column numbers are always set to zero.
Column headings for the General Service cost centers on Worksheets B and B-1 are supplied once,
consisting of one to three records. The statistical basis shown on Worksheet B-1 is also reported.
The statistical basis consists of one or two records (lines 4 and 5). Statistical basis code is supplied
only to Worksheet B-1 columns and is recorded as line 6 and only for capital cost centers,
columns 1 and 2 and subscripts as applicable. The statistical code must agree with the statistical
bases indicated on lines 4 and 5, i.e., code 1 = square footage, code 2 = dollar value, and code 3 =
all others. Refer to Table 2 for the special worksheet identifier to be used with column headings
and statistical basis and to Table 3 for line and column references.
Rev. 2
45-505
4595 (Cont.)
FORM CMS-2088-17
01-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 1 - RECORD SPECIFICATIONS
Use the following type 2 cost center descriptions for all Worksheet A standard cost center lines.
Line
Description
1
2
3
4
5
6
7
8
9
10
11
12
23
24
25
26
27
28
29
30
31
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
45-506
CAP REL COSTS - BLDG & FIXT
CAP REL COSTS - MVBLE EQUIP
EMPLOYEE BENEFITS
ADMINISTRATIVE & GENERAL
MAINTENANCE & REPAIRS
OPERATION OF PLANT
LAUNDRY & LINEN SERVICE
HOUSEKEEPING
CAFETERIA
CENTRAL SERVICES & SUPPLY
MEDICAL RECORDS & LIBRARY
PRO ED & TRAINING (APPROVED)
DRUGS & BIOLOGICALS
OCCUPATIONAL THERAPY
BEHAVIORAL HEALTH TREATMENT/SVCS
INDIVIDUAL THERAPY
GROUP THERAPY
ACTIVITY THERAPY
FAMILY THERAPY
PSYCHIATRIC TESTING
EDUCATION TRAINING
SHELTERED WORKSHOPS
RECREATIONAL PROGRAMS
RESIDENT DAY CAMPS
DIAGNOSTIC CLINICS
PHYSICIANS’ PRIVATE OFFICES
FUND RAISING
COFFEE SHOPS & CANTEEN
RESEARCH
INVESTMENT PROPERTY
ADVERTISING
FRANCHISE FEES & OTHER ASSESSMENTS
PRO ED & TRAINING (NOT APPROVED)
MEALS & TRANSPORTATION
ACTIVITY THERAPIES
PSYCHOSOCIAL PROGRAMS
VOCATIONAL TRAINING
Rev. 2
01-21
FORM CMS-2088-17
4595 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 1 - RECORD SPECIFICATIONS
Type 2 records for Worksheet B-1, columns 1 through 12, for lines 1 through 5, and line 6, for
columns 1 and 2 only (capital cost center columns), are listed below. The numbers running vertical
to line 1 descriptions are the general service cost center line designations.
1
CAP REL
CAP REL
EMPLOYEE
ADMINISMAINOPERATION
LAUNDRY
HOUSECAFETERIA
CENTRAL
MEDICAL
PROF.
1
2
3
4
5
6
7
8
9
10
11
12
2
BLDGS &
MOVABLE
BENEFITS
TRATIVE &
TENANCE &
OF PLANT
& LINEN
KEEPING
SERVICES &
RECORDS &
EDUCATION
LINE
3
FIXTURES
EQUIPMENT
GENERAL
REPAIRS
SERVICE
SUPPLY
LIBRARY
& TRAINING
4
SQUARE
DOLLAR
GROSS
ACCUM.
SQUARE
SQUARE
POUNDS OF
HOURS OF
MEALS
COSTED
TIME
ASSIGNED
6
5
FEET
VALUE
SALARIES
COST
FEET
FEET
LAUNDRY
SERVICE
SERVED
REQUIS.
SPENT
TIME
1
2
Examples of type 2 records are below. Either zeros or spaces may be used in the line, sub line,
column, and sub column number fields (positions 11through 20). Spaces are preferred. (See first
two lines of the example.)* Refer to Table 6 for additional cost center code requirements.
Examples:
Worksheet A line labels with embedded cost center codes:
*
*
2A000000
1
0100CAP REL COSTS-BLDG & FIXT
2A0000000000000020000000200CAP REL COSTS-MVBLE EQUIP
2A000000
8
0800HOUSEKEEPING
2A000000
30
3000PSYCHIATRIC TESTING
2A000000
45
4500DIAGNOSTIC CLINICS
Examples of column headings for Worksheets B-1 and B; statistical bases used in cost allocation
on Worksheet B-1, and statistical codes used for Worksheet B-1 (line 6) are displayed below.
Examples of column headings:
2B10000*
2B10000*
2B10000*
2B10000*
2B10000*
2B10000*
Rev. 2
1
2
3
4
5
6
1
1
1
1
1
1
CAP REL
BLDGS &
FIXTURES
SQUARE
FEET
1
45-507
4595 (Cont.)
FORM CMS-2088-17
01-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 1 - RECORD SPECIFICATIONS
RECORD NAME: Type 3 Records for Non-label Data
Size
Usage
Loc.
Remarks
1.
Record Type
1
9
1
2.
Worksheet
Indicator
7
X
2-8
3.
Spaces
2
X
9-10
4.
Line Number
3
9
11-13
Numeric
5.
Sub-line Number
2
9
14-15
Numeric
6.
Column Number
3
X
16-18
Alphanumeric
7.
Sub-column
Number
2
9
19-20
Numeric
8.
Field Data
a. Alpha Data
36
X
21-56
Left justified. (Y or N for yes/no
answers; dates must use
MM/DD/YYYY format - slashes, no
hyphens.) Refer to Table 6 for
additional requirements for alpha data.
Spaces
4
X
57-60
Spaces (optional).
16
9
21-36
Right justified. May contain
embedded decimal point. Leading
zeros are suppressed; trailing zeros to
the right of the decimal point are not.
Positive values are presumed; no “+”
signs are allowed. Use leading minus
to specify negative values. Express
percentages as decimal equivalents,
i.e., 8.75% is expressed as .087500.
All records with zero values are
dropped. Refer to Table 6 for
additional requirements regarding
numeric data.
b. Numeric Data
Constant “3”
Alphanumeric. Refer to Table 2.
A sample of type 3 records and a number line for reference are below.
1
2
3
4
5
6
123456789012345678901234567890123456789012345678901234567890
3A000000
3
1
36393
3A000000
3
2
5599
3A000000
25
1
47750
3A000000 100
1
167922
45-508
Rev. 2
01-21
FORM CMS-2088-17
4595 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 1 - RECORD SPECIFICATIONS
The line numbers are numeric. In several places throughout the cost report (see list below), the
line numbers themselves are data. The placement of the line and sub line numbers as data must be
uniform.
Worksheet A-6, columns 3 and 7
Worksheet A-8, column 4
Worksheet A-8-1, Part I, column 1
Examples of records (*) with a Worksheet A line number as data and a number line for reference
are listed below. Example of grand total record for Worksheet A-6 (**).
**
**
*
*
*
1
2
3
4
5
6
123456789012345678901234567890123456789012345678901234567890
3A600000 100
4
225321
3A600000 100
7
225321
3A6000G0
13
0 RENTAL EXPENSE
3A6000G0
13
1 G
3A6000G0
13
3
1.00
3A6000G0
13
4
221409
3A6000G0
13
7
51.00
3A6000G0
13
8
225321
3A6000G0
14
0 RENTAL EXPENSE
3A6000G0
14
1 G
3A6000G0
14
3
4.00
3A6000G0
14
4
3912
3A800000
3A800000
3A800000
* 3A800000
3A800000
3A800000
3A800000
* 3A800000
18
18
18
18
19
19
19
19
0
1
2
4
0
1
2
4
* 3A810001
3A810001
3A810001
3A810001
1
3
4
5
1
1
1
1
IRS PENALTY
B
-935
4.00
MISC INCOME
A
-114525
4.00
9.00
KITCHEN
3352
1122
RECORD NAME: TYPE 4 RECORDS
File Encryption and Date and Tape Stamp
This type 4 record consists of 3 records: 1, 1.01, and 1.02. These records are created at the point
in which the ECR file has been completed and saved to an electronic medium to ensure the integrity
of the file.
Rev. 2
45-509
4595 (Cont.)
FORM CMS-2088-17
01-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 2 - WORKSHEET INDICATORS
This table contains the worksheet indicators that are used for electronic cost reporting.
A
worksheet indicator is provided for only those worksheets for which data are to be provided.
The worksheet indicator consists of seven characters in positions 2 through 8 of the record
identifier. The first two characters of the worksheet indicator (positions 2 and 3 of the record
identifier) always show the worksheet. The third character of the worksheet indicator (position 4
of the record identifier) is used as part of the worksheet, e.g., A-8-1. The fourth character of the
worksheet indicator (position 5 of the record identifier) is not used. Except for Worksheets A-6
and A-8-2, (if there is a need for extra lines on multiple worksheets), the fifth and sixth characters
of the worksheet indicator (positions 6 and 7 of the record identifier) identify worksheets required
by a Federal program (18 = title XVIII, 05 =title V, or 19 = title XIX) or worksheets required for
the facility (00 = Universal). The seventh character of the worksheet indicator (position 8 of the
record identifier) represents the worksheet part.
Worksheets That Apply to the Community Mental Health Center Cost Report
Worksheet
45-510
Worksheet Indicator
S, Part I
S000001
S, Part II
S000002
S, Part III
S000003
S-1, Part I
S100001
S-1, Part II
S100002
S-2
S200000
A
A000000
A-6
A600?A0
A-8
A800000
A-8-1, Parts I and II
A810000
A-8-2
A820000
B-1 (For use in
column headings)
B10000*
B
B000000
B-1
B100000
C
C000000
D
D000000
D-1
D100000
F
F000000
(b)
(a)
Rev. 2
01-21
FORM CMS-2088-17
4595 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 2 - WORKSHEET INDICATORS
FOOTNOTES:
(a) Worksheets with Multiple Parts Using Identical Worksheet Indicator
While this worksheet have several parts, the lines are numbered sequentially. This worksheet
identifier is used with all lines from this worksheet regardless of the worksheet part. This
differs from the Table 3 presentation which still identifies each worksheet and part as they
appear on the printed cost report. This affects Worksheet A-8-1.
(b) Worksheet A-6
For Worksheet A-6, include in the worksheet identifier the reclassification code as the 5th and
6th digits (6th and 7th of the record). For example, 3A6000A0 or 3A6000B0, 3A6000C0,
3A600AA0, 3A600AB0, or 3A600ZZ0. Additionally, for Worksheet A-6 include in the
worksheet identifier “00” in the 5th and 6th digits (6th and 7th of the record) (3A600000) to
identify grand total reclassification increases and grand total reclassification decreases.
Rev. 2
45-511
4595 (Cont.)
FORM CMS-2088-17
01-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
This table identifies the collection of all data elements from all worksheets in the CMHC cost
report. This includes data elements necessaryto calculate a CMHC cost report, informational data,
and calculation data. These calculated fields (e.g., Worksheet B, column 6) are needed to verify
the mathematical accuracy of the raw data elements and to isolate differences between the file
submitted by the CMHC and the report produced by the contractor. Where an adjustment is made,
that record must be present in the electronic data file. For explanations of the adjustments required,
refer to the cost report instructions.
Table 3 "Usage" column is used to specify the format of each data item as follows:
9
Numeric, greater than or equal to zero.
-9
Numeric, may be either greater than, less than, or equal to zero.
9(x).9(y) Numeric, greater than zero, with x or fewer significant digits to the left of the
decimal point, a decimal point, and exactly y digits to the right of the decimal point.
X
Character.
Consistency in line numbering (and column numbering for general service cost centers) for each
cost center is essential. The sequence of some cost centers does change among worksheets.
Table 3 refers to the data elements needed from a standard cost report. When a standard line is
subscripted, the subscripted lines must be numbered sequentially with the first subline number
displayed as "01" or "1" (with a space preceding the 1) in field locations 14 and 15. It is
unacceptable to format in a series of 10, 20, or skip subline numbers (i.e., 01, 03, except for
skipping subline numbers for prior year cost center(s) deleted in the current period or initially
created cost center(s) no longer in existence after cost finding). Exceptions are specified in this
manual. For “Other (specify)” lines, i.e., any other nonstandard cost center lines, all subscripted
lines should be in sequence and consecutively numbered beginning with subscripted sub line “01”.
Automated systems should reorder these numbers where the provider skips or deletes a line
number in the series.
Drop all records with zero values from the file. Any record absent from a file is treated as if it
were zero.
All numeric values are presumed positive. Leading minus signs may only appear in data with
values less than zero that are specified in Table 3 with a usage of "-9". Amounts that are within
preprinted parentheses on the worksheets, indicating the reduction of another number, are reported
as positive values.
45-512
Rev. 2
FORM CMS-2088-17
01-21
4595 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Description
Line(s)
Column(s)
Field
Size
Usage
WORKSHEET S
Part I: Cost Report Status
Provider Use Only
Electronically prepared cost report
Manually prepared cost report
If this is an amended report enter the number
of times the provider resubmitted this cost
report
Medicare Utilization - Enter “F” for full, “L”
for low, or “N” for no.
Contractor Use Only
Cost Report Status
Enter the cost report status code: 1 for as
submitted, 2 for settled without audit, 4 for
reopened, or 5 for amended.
Date received (mm/dd/yyyy)
Contractor Number
Initial report for this Provider CCN
Final report for this Provider CCN
Notice of Program Reimbursement (NPR) date
(mm/dd/yyyy)
Enter contractor’s vendor code (ADR)
If line 5, column 1, is 4: enter the number of
times reopened = 0-9
Part II - Certification
Signature of chief financial officer or
administrator
Checkbox (enter “Y” if electronic signature;
otherwise, leave blank)
Printed Name
Title
Signature date (mm/dd/yyyy)
Part III: Settlement Summary
Balances due provider or program:
Title XVIII
Rev. 2
1
2
3
1
1
1
1
1
1
X
X
9
4
1
1
X
5
1
1
X
6
7
8
9
10
2
2
2
2
3
10
5
1
1
10
X
X
X
X
X
11
12
3
3
1
1
X
9
1
1
36
X
1
2
1
X
2
3
3
1
1
1
36
36
10
X
X
X
1
1
11
-9
45-513
4595 (Cont.)
FORM CMS-2088-17
01-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Description
Line(s)
Column(s)
Field
Size
Usage
WORKSHEET S-1, PART I
Part I: Identification Data
Site Name
Provider CCN (xxxxxx)
CBSA number (xxxxx)
Date Certified (mm/dd/yyyy)
Type of control (see Table 3B)
Street
P.O. Box
City
State
ZIP Code
County
Cost reporting period beginning date
(mm/dd/yyyy)
Cost reporting period ending date
(mm/dd/yyyy)
Is this CMHC part of a HO/CO as defined in
§2150 of CMS Pub. 15-1 that claims
HO/CO in a home office cost statement?
(Y/N) If yes, enter the chain organization’s
information below.
Name of HO/CO
Street
P.O. Box
HO/CO CCN
City
State
ZIP Code
45-514
1
1
1
1
1
2
2
3
3
3
3
4
1
2
3
4
5
1
2
1
2
3
4
1
36
6
5
10
2
36
9
36
2
10
36
10
X
X
X
X
X
X
X
X
X
X
X
X
4
2
10
X
5
1
1
X
6
7
7
7
8
8
8
1
1
2
3
1
2
3
36
36
9
6
36
2
10
X
X
X
X
X
X
X
Rev. 2
05-18
FORM CMS-2088-17
4595 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Description
Line(s)
Column(s)
Field
Size
Usage
WORKSHEET S-1, PART I (Cont.)
Medical Malpractice
Is this CMHC legally required to carry
malpractice insurance? (Y/N)
9
1
1
X
If line 9 is “Y”, is the malpractice insurance a
claims-made or occurrence policy? Enter
“1” for claims-made or “2” for occurrence
policy.
10
1
1
X
List malpractice premiums in column 1, paid
losses in column 2 and self-insurance in
column 3.
11
1-3
11
9
12
1
1
X
13
1
1
X
If column 1 is “Y”, enter the type of
demonstration in column 2. If CMHC
participated in more than one
demonstration, subscript this line
accordingly.
13
2
36
X
Are there any costs included in Worksheet A
that resulted from transactions with related
organizations as defined in CMS Pub. 15-1,
chapter 10? If “Y”, complete
Worksheet A-8-1.
14
1
1
X
Are malpractice premiums, paid losses, or
self-insurance reported in a cost center other
than the Administrative and General cost
center? (Y/N) If yes, submit supporting
schedule listing cost centers and amounts.
Miscellaneous
Did this facility participate in any payment
demonstration during this cost reporting
period? (Y/N)
Rev. 1
45-515
4595 (Cont.)
FORM CMS-2088-17
05-18
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Description
Line(s)
Column(s)
Field
Size
Usage
WORKSHEET S-1, PART II
Part II: Statistical Data
Reimbursable Cost Centers:
Number of Visits by:
Medicare Patients
2-10
1
11
9
Other Patients
Total Visits
2-10
2
11
9
2-10
3
11
9
Medicare Patients
1-10
4
11
9
Other Patients
1-10
5
11
9
1-10
6
11
9
Staff Therapists
1-10
7
6
9(3).99
Physicians
1-10
8
6
9(3).99
Social Workers
Others
1-10
9
6
9(3).99
1-10
10
6
9(3).99
Total
11
1-6
11
9
Total
11
7-10
6
9(3).99
Medicare Patients
12
4
9
9(6).99
Other Patients
12
5
9
9(6).99
Total Patient Days
12
6
9
9(6).99
Number of Patient Days:
Total Patient Days
FTE (Full-time Equivalent Employees)
on Payroll
Unduplicated Census: Patient Days
45-516
Rev. 1
05-18
FORM CMS-2088-17
4595 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Description
Column(s)
Field
Size
Usage
1
1
1
X
1
2
10
X
2
1
1
X
2
2
10
X
2
3
1
X
3
1
1
X
4
1
1
X
4
2
1
X
4
3
10
X
5
1
1
X
Line(s)
WORKSHEET S-2
Provider Organization and Operation
Has the provider changed ownership
immediately prior to the beginning of the
cost reporting period? (Y/N) (see
instructions)
If yes, enter the date of the change in
column 2. (mm/dd/yyyy)
Has the provider terminated participation in
the Medicare program? (Y/N)
If yes, enter in column 2 the termination date.
(mm/dd/yyyy)
If yes, enter in column 3 “V” for voluntary or
“I” for involuntary.
Is the provider involved in business
transactions, including management
contracts, with individuals or entities that
were related to the provider or its officers,
medical staff, management personnel, or
members of the board of directors through
ownership, control, or family and other
similar relationships? (Y/N) (see
instructions)
Financial Data and Reports
Were the financial statements prepared by a
certified public accountant? (Y/N)
If yes, enter in column 2 “A” for audited, “C”
for compiled or “R” for reviewed.
Submit a complete copy of financial
statements or enter date available in
column 3. (mm/dd/yyyy)
Are the cost report total expenses and total
revenues different from those on the filed
financial statements? (Y/N)
Rev. 1
45-517
4595 (Cont.)
FORM CMS-2088-17
05-18
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Description
Column(s)
Field
Size
Usage
6
1
1
X
7
1
1
X
8
1
1
X
9
1
1
X
9
2
10
X
10
1
1
X
10
2
10
X
11
1
1
X
12
1
1
X
13
1
1
X
13
14
0
1
36
1
X
X
Line(s)
WORKSHEET S-2
Bad Debts
Is the provider seeking reimbursement for bad
debts? (Y/N)
If line 6 is yes, did the provider’s bad debt
collection policy change during the cost
reporting period? (Y/N)
If line 6 is yes, were patient deductibles and/or
co-payments waived? (Y/N)
PS&R Report Data
Was the cost report prepared using the PS&R
report only? (Y/N)
If yes, enter in column 2 the paid-through date
of the PS&R report used to prepare the cost
report. (mm/dd/yyyy)
Was the cost report prepared using the PS&R
report for totals and the provider’s records
for allocation? (Y/N)
If yes, enter in column 2 the paid-through date
of the PS&R report. (mm/dd/yyyy)
If line 9 or 10 is yes, were adjustments made to
the PS&R Report data for additional claims
that have been billed but are not included on
the PS&R Report used to file the cost report?
(Y/N). If yes, see instructions.
If line 9 or 10 is yes, were adjustments made to
the PS&R Report data for corrections of
other PS&R Report information? (Y/N) If
yes, see instructions.
If line 9 or 10 is yes, were adjustments made to
the PS&R Report data for Other? (Y/N)
If yes, describe the other adjustments.
Was the cost report prepared only using the
provider’s records? (Y/N) If yes, see
instructions.
45-518
Rev. 1
05-18
FORM CMS-2088-17
4595 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Column(s)
Field
Size
Usage
1
2
3
1
1
2
36
36
36
36
36
36
X
X
X
X
X
X
3-13, 2332, 42-58
1
11
-9
100
1
11
9
1-13, 2332, 42-58
2
11
-9
100
2
11
9
3-13, 2332, 42-58
3
11
-9
100
3
11
9
1-13, 2332, 42-58
4
11
-9
100
4
11
9
Reclassifications by department
1-13, 2332, 42-58
5
11
-9
Reclassified trial balance by department
1-13, 2332, 42-58
6
11
-9
100
6
11
9
Description
Line(s)
WORKSHEET S-2
Cost Report Preparer Contact Information
Enter the preparer’s information:
First Name
Last Name
Title
Employer
Telephone Number
Email Address
15
15
15
16
17
17
WORKSHEET A
Salaries by department
Total salaries
Other costs by department
Total other costs
Contracted purchased services by department
Total contracted purchased services
Total (column 1 through column 3) by
department
Total (column 1 through column 3)
Total reclassified trial balance
Rev. 1
45-519
4595 (Cont.)
FORM CMS-2088-17
05-18
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Description
Column(s)
Field
Size
Usage
1-13, 2332, 42-58
7
11
-9
100
7
11
-9
1-13, 2332, 42-58
8
11
-9
100
8
11
9
Line(s)
WORKSHEET A
Adjustments by department
Total adjustments
Net expenses for allocation by department
Total expenses for allocation
WORKSHEET A-6
For each expense reclassification:
Explanation
1-99
0
36
X
Reclassification identification code
1-99
1
2
X
Worksheet A cost center
1-99
2
36
X
Worksheet A line number
1-99
3
5
99.99
Reclassification salary
1-99
4
11
9
Reclassification non-salary
1-99
5
11
9
Worksheet A cost center
1-99
6
36
X
Worksheet A line number
1-99
7
5
99.99
Reclassification salary
1-99
8
11
9
Reclassification non-salary
1-99
9
11
9
100*
4, 5, 8, 9
11
9
Total Reclassification Increases
100*
4, 5
11
9
Total Reclassification Decreases
100*
8, 9
11
9
Increases:
Decreases:
Total
*See footnote “b” in “Table 2 - Worksheet Indicators” for appropriate worksheet indicators.
45-520
Rev. 1
01-21
FORM CMS-2088-17
4595 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Column(s)
Field
Size
Usage
1-49
0
36
X
4, 7, 911, 1314, 17-49
1
1
X
1-49
2
11
-9
Worksheet A cost center
3-6, 1014, 17-49
3
36
X
Worksheet A line number +
3-6, 1014, 17-49
4
5
99.99
50
2
11
-9
Description
Line(s)
WORKSHEET A-8
Description of adjustment
Basis (A or B)*
Amount
Total
* These include subscripts of lines 17 through 49. Requiring records for columns 1 and 2. These
subscripts should occur based on Worksheet A layout.
+ Do not include preprinted lines 1, 2, 7, 8, 9. Include only subscripts of those lines, if activated
by an entry in either columns 1 or 2.
Rev. 2
45-521
4595 (Cont.)
FORM CMS-2088-17
01-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Description
Line(s)
Column(s)
Field
Size
Usage
WORKSHEET A-8-1
Part I - For costs incurred and adjustments
required as a result of transactions with related
organization(s):
Worksheet A line number
1-4
1
5
99.99
Cost center
1-4
2
36
X
Expense item(s)
1-4
3
36
X
Amount allowable in cost
1-4
4
11
-9
Amount included in Worksheet
1-4
5
11
-9
Net adjustment(s)
1-4
6
11
-9
5
4-6
11
-9
Type of interrelationship (A through G)
6-10
1
1
X
If type is G, specify description of relationship
6-10
0
36
X
Name of individual or partnership with
interest in provider and related organization(s)
6-10
2
36
X
Percent of ownership in provider
Name of related organization
6-10
3
6
9(3).99
6-10
4
36
X
Percent ownership of related organization
6-10
5
6
9(3).99
Type of business
6-10
6
36
X
Total
Part II - For each related organization:
45-522
Rev. 2
01-21
FORM CMS-2088-17
4595 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Description
Line(s)
Column(s)
Field
Size
Usage
WORKSHEET A-8-2
By each cost center or physician:
Worksheet A line number
1-99
1, 10
5
99.99
Physician identifier and aggregate only
1-99
2, 11
36
X
Total physicians’ remuneration
1-99
3
11
9
Physicians’ remuneration - professional
component
1-99
4
11
9
Physicians’ remuneration - provider
component
1-99
5
11
9
RCE amount
1-99
6
11
9
Number of physicians’ hours - provider
component
1-99
7
11
9
Unadjusted RCE limit
1-99
8
11
9
5 Percent of unadjusted RCE limit
1-99
9
11
9
Cost of membership and continuing
education
1-99
12
11
9
Provider component share of column 12
1-99
13
11
9
Physician cost of malpractice insurance
1-99
14
11
9
Provider component share of column 14
1-99
15
11
9
Adjusted RCE limit
1-99
16
11
9
RCE disallowance
1-99
17
11
9
Adjustment
1-99
18
11
9
100
3-5, 7-9,
12-18
11
9
In total for the facility (sum of lines 1-99)
Total
Rev. 2
45-523
4595 (Cont.)
FORM CMS-2088-17
01-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Description
Line(s)
Column(s)
Field
Size
Usage
WORKSHEETS B and B-1 Headings *
*
Column heading (cost center name)
1-3 *
1-3, 4-13
10
X
Statistical basis
4, 5 *
1-3, 4-13
10
X
Refer to Table 1 for specifications and Table 2 for the worksheet identifier for column
headings. There may be up to five type 2 records (3 for cost center name and 2 for the
statistical basis) for each column. However, for any column that has less than five type 2
record entries, blank records or the word “blank” is not required to maximize each column
record count.
WORKSHEET B
1-13,
23-32,
42-58
0
11
9
100
0
11
9
Costs after cost finding by department
1-13,
23-32,
42-58, 99
1-3, 4-13
11
-9
Subtotal
4-13,
23-32,
42-58, 99
3A
11
-9
Total costs after cost finding by department
23-32,
42-58, 99
14
11
-9
Total costs after cost finding
100
1-14
11
Total of the subtotal
100
3A
11
Net expenses (from Worksheet A, column 8)
Total expenses (from Worksheet A, column 8)
45-524
9
9
Rev. 2
01-21
FORM CMS-2088-17
4595 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Column(s)
Field
Size
Usage
0
1-13
1
X
All cost allocation statistics
1-13, 2332, 42-58
1-13 *
11
9
Reconciliation
4-13, 2332, 42-58
4A-13A
11
-9
Cost to be allocated
101
1-13 +
11
9
Unit cost multiplier
102
1-13
8
9.9(6)
Description
Line(s)
WORKSHEET B-1
For each cost allocation using accumulated
costs as the statistic, include a record
containing an X.
*
In each column using accumulated costs as the statistical basis for allocating costs, identify
each cost center that is to receive no allocation with a negative 1 (-1) placed in the accumulated
cost column. Providers may elect to indicate total accumulated cost as a negative amount in the
reconciliation column. Cost centers that are not to receive an allocation cannot have entries in
both the reconciliation and accumulated cost columns when the accumulated cost statistic is offset
to zero.
For those cost centers that are to receive partial allocation of costs, provide only the cost to be
excluded from the statistic as a negative amount on the appropriate line in the reconciliation
column. This will result in entries in both the reconciliation column and accumulated cost column
simultaneously on the same line where a partial accumulated cost statistic is offset. If line 4 is
fragmented, line 4 must be deleted and subscripts of line 4 must be used.
+ Include any column which uses accumulated cost as its basis for allocation.
Rev. 2
45-525
4595 (Cont.)
FORM CMS-2088-17
01-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Column(s)
Field
Size
Usage
23-32
1
11
9
50
1
11
9
23-32
2
11
9
50
2
11
9
Ratio of cost to charges
23-32
3
8
9.9(6)
Medicare program charges by cost center
23-32
4
11
9
50
4
11
9
23-32
5
11
9
50
5
11
9
Description
Line(s)
WORKSHEET C
From Worksheet B, column 14, reimbursable
cost centers
Total
Total patient charges by cost center
Total patient charges
Total Medicare program charges
Medicare cost by cost center
Total Medicare cost
WORKSHEET D
Gross APC/PPS payments
1
1
11
9
Outlier payments
2
1
11
9
Outlier reconciliation amount (transfer from
line 54)
3
1
11
9
Gross reimbursement (sum of lines 1
through 3)
4
1
11
9
Primary payer payments
5
1
11
9
Deductibles billed to program payments (do
not include coinsurance)
6
1
11
9
Coinsurance billed to program patients (see
instructions)
7
1
11
9
Subtotal (line 4 minus lines 5, 6, and 7)
8
1
11
9
45-526
Rev. 2
01-21
FORM CMS-2088-17
4595 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Description
Line(s)
Column(s)
Field
Size
Usage
WORKSHEET D (Cont.)
Reimbursable bad debts (see instructions)
9
1
11
-9
Adjusted reimbursable bad debts
10
1
11
-9
Reimbursable bad debts for dual eligible
beneficiaries (see instructions)
11
1
11
-9
Subtotal (line 8 plus line 10)
12
1
11
-9
Other adjustments (specify) (see instructions)
13
0
36
X
Other adjustments (specify) (see instructions)
13
1
11
-9
Other demonstration payment adjustment
amount before sequestration
14
1
11
-9
Amount due prior to the sequestration
adjustment (see instructions)
15
1
11
-9
Sequestration adjustment (see instructions)
16
1
11
9
Other demonstration payment adjustment after
sequestration
17
1
11
-9
Amount due after sequestration adjustment
(see instructions)
18
1
11
-9
Interim payments
19
1
11
9
Tentative settlement (for contractor use only)
20
1
11
-9
Balance due provider/program (line 18 minus
lines 19 and 20) (indicate overpayment in
brackets)
21
1
11
-9
Protested amounts (nonallowable cost report
items) in accordance with CMS Pub. 15-2,
chapter 1, §115.2
22
1
11
-9
Rev. 2
45-527
4595 (Cont.)
FORM CMS-2088-17
01-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Description
Line(s)
Column(s)
Field
Size
Usage
WORKSHEET D (Cont.)
To Be Completed By Contractor:
Original outlier amount (see instructions)
50
1
11
-9
Outlier reconciliation adjustment amount (see
instructions)
51
1
11
-9
The rate used to calculate the Time Value of
Money
52
1
11
9(8).9(2)
Time Value of Money (see instructions)
53
1
11
-9
Total (sum of lines 51 and 53)
54
1
11
-9
WORKSHEET D-1
Total interim payments paid to CMHC
1
2
11
9
Interim payments payable
2
2
11
9
3.01-3.98
1
10
X
Program to provider
3.01-3.49
2
11
9
Provider to program
3.50-3.98
2
11
9
3.99
2
11
9
4
2
11
9
Date of each retroactive lump sum adjustment
(mm/dd/yyyy)
Amount of each retroactive lump sum
adjustment:
Subtotal (sum of lines 3.01-3.49 minus sum of
lines 3.50 through 3.98)
Total interim payments
45-528
Rev. 2
01-21
FORM CMS-2088-17
4595 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Description
Line(s)
Column(s)
Field
Size
Usage
WORKSHEET D-1 (Cont.)
To Be Completed By Contractor:
Date of each tentative settlement payment
(mm/dd/yyyy)
5.01-5.98
1
10
X
Program to provider
5.01-5.49
2
11
9
Provider to program
5.50-5.98
2
11
9
5.99
2
11
9
6.01-6.02
1
10
X
Program to provider
6.01
2
11
9
Provider to program
6.02
2
11
9
7
8
2
1
11
36
9
X
Enter Contractor’s number
8
2
5
X
Enter the date of the NPR
8
3
11
X
Amount of each tentative settlement payment:
Subtotal (sum of lines 5.01-5.49 minus sum of
lines 5.50-5.98)
Date of net settlement amount (balance due)
Net settlement amount (balance due):
Total Medicare program liability
Enter name of the Contractor
WORKSHEET F
Total patient revenues
1
1
11
9
Less: Allowance and discounts on patients’
accounts
2
1
11
9
Net patient revenues (line 1 minus line 2)
3
1
11
9
Less: Total operating expenses
4
1
11
9
Net income from service to patients (line 3
minus line 4)
5
1
11
9
6-20
1
11
9
Other revenues
Rev. 2
45-529
4595 (Cont.)
FORM CMS-2088-17
01-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Column(s)
Field
Size
Usage
20
0
36
X
20.50
1
11
9
Total other income (sum of lines 6 through
20)
21
1
11
9
Total (line 5 plus line 21)
22
1
11
9
Other expenses
23-26
1
11
9
Other (specify)
26
0
36
X
Total other expenses (sum of lines 23 through
26)
27
1
11
9
Net income (or loss) for the period (line 22
minus line 27)
28
1
11
-9
Description
Line(s)
WORKSHEET F (Cont.)
Other (specify)
COVID-19 PHE funding
TABLE 3A - WORKSHEETS REQUIRING NO INPUT
Worksheet S, Part III
Worksheet B
TABLE 3B - TABLE TO WORKSHEET S-1, Part I
Type of Control
1
2
3
4
=
=
=
=
5
6
7
=
=
=
45-530
Voluntary Nonprofit, Church
Voluntary Nonprofit, Other
Proprietary, Individual
Proprietary, Corporation
District
Proprietary, Partnership
Proprietary, Other
Governmental, Federal
8
9
10
11
=
=
=
=
12 =
13 =
Governmental,
Governmental,
Governmental,
Governmental,
City-County
County
State
Hospital
Governmental, City
Governmental, Other
Rev. 2
05-18
FORM CMS-2088-17
4595 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 3C - LINES THAT CANNOT BE SUBSCRIPTED
(BEYOND THOSE PREPRINTED)
Worksheet
Lines
S, Parts I, II, & III
ALL
S-1, Part I
1-12, 14
S-1, Part II
1-9, 11, 12
S-2
A
ALL
1-12, 23-31, 42-57, 100
A-6
ALL
A-8
1-16, 50
A-8-1, Part I
1-3, 5
A-8-1, Part II
6-9
A-8-2
ALL
B
SAME AS WORKSHEET A
B-1
SAME AS WORKSHEET A
C
23-31, 50
D
ALL, except line 13
ALL, except lines 3.01-3.98 and lines
5.01-5.98
D-1
F
ALL, except lines 20 and 26
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 5 - COST CENTER CODING
INSTRUCTIONS FOR PROGRAMMERS
Cost center coding is required because there are thousands of unique cost center names in use by
providers. Many of these names are exclusive to the reporting provider and give no hint as to the
actual function being reported. Using codes to standardize meanings makes practical data analysis
possible. The method to accomplish this must be rigidly controlled to assure accuracy.
For any added cost center names (the preprinted cost center labels must be precoded), the preparer
must be presented with the allowable choices for that line or range of lines from the lists of standard
and nonstandard descriptions. They will then select a description that best matches their added
label. The code associated with the matching description, including increments due to choosing
the same description more than once, will then be appended to the user’s label by the software.
Rev. 1
45-531
4595 (Cont.)
FORM CMS-2088-17
05-18
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 5 - COST CENTER CODING
Additional guidelines are:
•
•
•
•
•
•
•
•
Any pre-existing codes for the line must not be allowed to carry over.
All “Other . . .” lines must not be pre-coded.
The order of choice is standard first, followed by specific nonstandard, and lastly the
nonstandard “Other . . ." cost centers.
When the nonstandard "Other . . ." is chosen, the preparer must be prompted with “Is this the
most appropriate choice?" and offered a chance to answer yes or to select another description.
The cost center coding process must be able to be edited for purposes of making corrections.
A separate list showing the preparer’s added cost center name on the left with the chosen
standard or nonstandard description and code on the right must be printed for review.
The number of times a description can be selected on a given report must be displayed on the
screen next to the description and this number must decrease with each usage to show the
remaining number available. The number of times a description can be selected is shown on
the standard and nonstandard cost center tables.
Standard cost center lines, descriptions and codes are not to be changed. The acceptable format
for these are displayed listed in the STANDARD COST CENTER DESCRIPTIONS AND
CODES listed on page 45-533. The proper line number is the first two digits of the cost center
code. Change all “Other” nonstandard lines to the appropriate cost center name.
INSTRUCTIONS FOR PREPARERS
Coding of Cost Center Labels
Cost center coding is a methodology for standardizing the meaning of cost center labels as used
by the CMHC on the Medicare cost report. The use of this coding methodology allows the CMHC
to use their labels for cost centers that have meaning within the institution.
The four digit codes that are required and must be associated with each cost center
label/descriptions. The codes provide standardized meaning for data analysis. The preparer must
code all added cost center labels/descriptions. Standard labels/descriptions are automatically coded
by CMS approved cost report software.
Additional cost center descriptions have been identified through analysis of provider labels. The
meanings of these additional descriptions were sufficiently different when compared to the
standard labels to warrant their use. These additional descriptions are hereafter referred to as the
nonstandard labels. Included with the nonstandard descriptions are "Other . . ." designations to
provide for situations where no match in meaning can be found. Refer to Worksheet A, line 13,
32, and 58. Both the standard and nonstandard cost center descriptions, along with their cost center
codes, are shown on Table 5. The “USE” column on that table indicates the number of times that
a given code can be used on one cost report. Compare your added cost center labels/descriptions
to the standard and nonstandard table and select the appropriate cost center code. CMS approved
software provides an automated process for selecting an appropriate code to properly match with
your added cost center label/description.
45-532
Rev. 1
01-21
FORM CMS-2088-17
4595 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 5 - COST CENTER CODING
Additional Guidelines
Categories
You must make your selection from the proper category such as general service description for
general service cost center lines, special purpose cost center descriptions for special purpose cost
center lines, etc.
Use of a Cost Center Coding Description More Than Once
Often a description from the standard or nonstandard tables applies to more than one of the labels
being added or changed by the preparer. In the past, it was necessary to determine which code
was to be used and then increment the code number upwards by one for each subsequent use. This
was done to provide a unique code for each cost center label. Now, most approved software
associate the proper code, including increments as required, once a matching description is
selected. Remember to use your label. You are matching to CMS’s description only for coding
purposes.
Cost Center Coding and Line Restrictions
Cost center codes may only be used in designated lines in accordance with the classification of
cost center(s), i.e., lines 1 through 13 may only contain cost center codes within the CMHC
services cost center category of both standard and nonstandard coding. For example, in the general
service cost center category for “Other (specify)” cost, line 13 and subscripts must contain cost
center codes of 1300 through 1309 which are identified as nonstandard cost center codes. This
logic must hold true for all other cost center categories, i.e., reimbursable cost centers and
nonreimbursable cost centers.
Rev. 2
45-533
4595 (Cont.)
FORM CMS-2088-17
01-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 5 - STANDARD COST CENTER DESCRIPTIONS AND CODES
CODE
USE
GENERAL SERVICE
COST CENTERS
Cap Rel Costs-Bldgs & Fixt
Cap Rel Costs-Mvble Equip
Employee Benefits
Administrative & General
Maintenance & Repairs
Operation of Plant
Laundry & Linen Service
Housekeeping
Cafeteria
Central Services & Supply
Medical Records & Library
Pro Ed & Training
(Approved)
45-534
USE
Sheltered Workshops
Recreational Programs
Resident Day Camps
Diagnostic Clinics
Physicians’ Private Offices
Fund Raising
Coffee Shops & Canteen
Research
Investment Property
Advertising
Franchise Fees & Other
Assessments
4200
4300
4400
4500
4600
4700
4800
4900
5000
5100
5200
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
Pro Ed & Training
(Not Approved)
Meals & Transportation
Activity Therapies
Psychosocial Programs
Vocational Training
5300
(01)
5400
5500
5600
5700
(01)
(01)
(01)
(01)
NONREIMBURSABLE
SERVICES
0100
0200
0300
0400
0500
0600
0700
0800
0900
1000
1100
1200
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
REIMBURSABLE
COST CENTERS
Drugs & Biologicals
Occupational Therapy
Behavioral Health
Treatment/Svcs
Individual Therapy
Group Therapy
Activity Therapy
Family Therapy
Psychiatric Testing
Education Training
CODE
2300
2400
2500
(01)
(01)
(01)
2600
2700
2800
2900
3000
3100
(01)
(01)
(01)
(01)
(01)
(01)
Rev. 2
01-21
FORM CMS-2088-17
4595 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 5 - NONSTANDARD COST CENTER DESCRIPTIONS AND CODES
CODE
USE
1300
(10)
3200
(10)
5800
(10)
GENERAL SERVICE COST CENTERS
Other (specify)
REIMBURSABLE SERVICES
Other (specify)
NONREIMBURSABLE COST CENTERS
Other (specify)
Rev. 2
45-535
4595 (Cont.)
FORM CMS-2088-17
01-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 6 - EDITS
Medicare cost reports submitted electronically must meet a variety of edits. These include
mathematical accuracy edits, certain minimum file requirements, and other data edits. Any vendor
software which produces an ECR file for Medicare CMHCs must automate all of these edits.
Failure to properly implement these edits may result in the suspension of a vendor's system
certification until corrective action is taken. The vendor’s software should provide meaningful
error messages to notify the CMHC of the cause of every exception. The edit message generated
by the vendor systems must contain the related 4 digit and 1 alpha character, where indicated,
reject/edit code specified below. Any file submitted by a provider containing a level 1 edit will be
rejected by the contractors. Notification must be made to CMS for any exceptions.
The edits are applied at two levels. Level 1 edits (1000 series reject codes) test the format of the
data to identify error conditions that must be corrected or they will result in a cost report rejection.
These edits also test for critical data elements specified in Table 3. Vendor programs must prevent
CMHCs from generating an ECR file when the cost report violates any level 1 edits. Level 2 edits
(2000 series edit codes) identify potential inconsistencies and missing data items. These items
should be resolved at the CMHC site and supporting documentation (such as worksheets or data)
should be submitted with the cost report. Failure to submit the appropriate data with your cost
report may result in payments being withheld pending resolution of the issue(s).
The vendor requirements (above) and the edits (below) reduce both contractor processing time and
unnecessary rejections. Vendors should develop their programs to prevent their client CMHCs
from generating an ECR file where level 1 edit conditions exist. In addition, ample warnings
should be given to the CMHC where level 2 edit conditions are violated.
Level 1 edit conditions are to be applied against title XVIII services only. However, any
inconsistencies or omissions that would cause a level 1 condition for non-title XVIII services
must be resolved prior to acceptance of the cost report. [09/30/2018]
NOTE: The date in brackets [ ] at the end of each edit indicates effective date of the edit. A date
without an alpha suffix, such as [10/01/2017], indicates the edit is effective for cost reporting
ending on or after the date in brackets. A date followed by a “b,” such as [09/30/2018b], indicates
the edit is effective for cost reporting periods beginning on or after the date in brackets. A date
followed by an “s,” such as [10/01/2017s], indicates the edit is effective for services rendered on
or after the date in brackets.
I. Level 1 Edits (Minimum File Requirements)
Edit
Condition
1000
The first digit of every record must be either 1, 2, 3, or 4 (encryption code only).
[09/30/2018]
1005
No record may exceed 60 characters. [09/30/2018]
1010
All alpha characters must be in upper case. This is exclusive of the vendor
information, type 1 record, record number 3 and the encryption code, type 4
record, record numbers 1, 1.01, and 1.02. [09/30/2018]
1015
For micro systems, the end of record indicator must be a carriage return and
line feed, in that sequence. [09/30/2018]
45-536
Rev. 2
01-21
FORM CMS-2088-17
4595 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 6 - EDITS
I. Level 1 Edits (Minimum File Requirements)
Edit
Condition
1020
The CMHC provider number (record #1, positions 17 through 22) must be valid
and numeric. [09/30/2018]
1025
All calendar format dates must be edited for 10 character format,
e.g., 10/01/2017 (MM/DD/YYYY). [09/30/2018]
1030
All dates (record #1, positions 23 through 29, 30 through 36, 45 through 51,
and 52 through 58) must be in Julian format and a possible date. [09/30/2018]
1035
The fiscal year beginning date (record #1, positions 23 through 29) must be less
than the fiscal year ending date (record #1, positions 30 through 36).
[09/30/2018]
1036
The fiscal year ending date (record #1, positions 30 through 36) must be 30 days
greater than the fiscal year beginning date (record #1, positions 23 through 29)
and the fiscal year ending date (record #1, positions 30 through 36) must be less
than 458 days greater than the fiscal year beginning date (record #1,
positions 23 through 29). [09/30/2018]
1040
The vendor code (record #1, positions 38 through 40) must be a valid code.
[09/30/2018]
1045
The type 1 record #1 must be correct and the first record in the file. [09/30/2018]
1050
All record identifiers (positions 1 through 20) must be unique. [09/30/2018]
1055
Only a Y or N is valid for fields which require a yes/no response. [09/30/2018]
1060
Variable columns (Worksheet B and Worksheet B-1) must have a
corresponding type 2 record (Worksheet A label) with a matching line number.
[09/30/2018]
All line, sub-line, column, and sub-column numbers (positions 11 through 13,
14 through 15, 16 through 18, and 19 through 20, respectively) must be numeric,
except that each cost center using accumulated cost as the statistical basis must
have a Worksheet B-1 reconciliation column numbered the same as the
Worksheet A line number followed by an “A” as part of the line number
followed by the sub-line number. [09/30/2018]
The cost center code (positions 21 through 24 in type 2 records) must be a code
from Table 5, Cost Center Coding, and each cost center code must be unique.
[09/30/2018]
1065
1067
Rev. 2
45-537
4595 (Cont.)
FORM CMS-2088-17
01-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 6 - EDITS
I. Level 1 Edits (Minimum File Requirements - Cont.)
Edit
Condition
1070
The following standard cost centers listed below must be reported on the lines
as indicated and the corresponding cost centers codes may only appear on the
lines as indicated. No other cost center codes may be placed on these lines.
[09/30/2018]
Cost Center
Cap Rel Costs-Bldg & Fixt
Cap Rel Costs-Mvble Equip
Employee Benefits
Administrative & General
Maintenance & Repairs
Operation of Plant
Laundry & Linen Services
Housekeeping
Cafeteria
Central Services & Supply
Medical Records & Library
Pro Ed & Training (Approved)
Drugs & Biologicals
Occupational Therapy
Behavioral Health Treatment/Svcs
Individual Therapy
Group Therapy
Activity Therapy
Family Therapy
Psychiatric Testing
Education Training
Sheltered Workshops
Recreational Programs
Resident Day Camps
Diagnostic Clinics
Physicians’ Private Offices
Fund Raising
Coffee Shops & Canteen
Research
Investment Property
Advertising
Franchise Fees & Other Assessments
45-538
Line
1
2
3
4
5
6
7
8
9
10
11
12
23
24
25
26
27
28
29
30
31
42
43
44
45
46
47
48
49
50
51
52
Code
0100
0200
0300
0400
0500
0600
0700
0800
0900
1000
1100
1200
2300
2400
2500
2600
2700
2800
2900
3000
3100
4200
4300
4400
4500
4600
4700
4800
4900
5000
5100
5200
Rev. 2
01-21
FORM CMS-2088-17
4595 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 6 - EDITS
I. Level 1 Edits (Minimum File Requirements - Cont.)
Edit
Condition
1070 (Cont.)
Pro Ed & Training (Not Approved)
53
5300
Meals & Transportation
54
5400
Activity Therapies
55
5500
Psychosocial Programs
56
5600
Vocational Training
57
5700
Cost center integrity for variable worksheets must be maintained throughout the
cost report. For subscripted lines, the relative position must be consistent
throughout the cost report. [09/30/2018]
1075
1080
For every line used on Worksheets A, B, B-1, and C, there must be a
corresponding type 2 record. [09/30/2018]
1085
Fields requiring numeric data (charges, visits, costs, FTEs, etc.) may not contain
any alpha characters. [09/30/2018]
1090
A numeric field (except unit cost multipliers) cannot exceed more than
11 positions. Unit cost multipliers cannot exceed 13 positions. [09/30/2018]
1095
In all cases where the file includes both a total and the parts that comprise that
total, each total must equal the sum of its parts. [09/30/2018]
1100
All dates must be possible, e.g., no “00”, no “30” or “31” of February and cannot
be greater than the current date, except for Worksheet S-2, column 3, line 4, and
column 2, line 9. [09/30/2018]
1000S
Worksheet S-1, Part I, lines 1 through 3, must contain: the CMHC site name in
column 1, line 1; the CMHC street address in column 1, line 2; the CMHC city
name in column 1, line 3; the CMHC 2-letter state abbreviation in column 2,
line 3; the CMHC ZIP code (formatted as XXXXX) or the CMHC ZIP+4 code
(formatted as XXXXX-XXXX) in column 3, line 3; and the CMHC CCN in
column 2, line 1. [09/30/2018]
1002S
Worksheet S-1, Part I, column 3, line 1, must be completed with a valid
five-position alphanumeric CBSA code. [09/30/2018]
The cost report beginning date (Worksheet S-1, Part 1, column 1, line 4) must be
on or after October 1, 2017, and the cost report ending date (Worksheet S-1,
Part I, column 2, line 4) must be on or after September 30, 2018. [09/30/2018]
1005S
1010S
1020S
The type of control (Worksheet S-1, Part I, column 5, line 1) must have a value
of 1 through 13. (See Table 3B) [09/30/2018]
The cost report period beginning date (Worksheet S-1, Part I, column 1, line 4)
must precede the cost report ending date (Worksheet S-1, Part I, column 2, line 4).
[09/30/2018]
Rev. 2
45-539
4595 (Cont.)
FORM CMS-2088-17
01-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 6 - EDITS
I. Level 1 Edits (Minimum File Requirements - Cont.)
Edit
Condition
1025S
The certification date entered on Worksheet S-1, Part I, column 4, line 1, must be
present and possible. The certification date must be on or before the cost
reporting period beginning date and after 01/01/1966. [09/30/2018]
1030S
The CMHC CCN reported on Worksheet S-1, Part I, column 2, line 1, must be
between XX-1400 through XX-1499, XX-4600 through XX-4799, or XX-4900
through XX-4999, where XX corresponds to the two digit state code.
[09/30/2018]
1040S
On Worksheet S-1, Part I, there must be a “Y” or “N” response for column 1,
lines 5, 9, 12, 13 and 14. [09/30/2018]
1045S
Worksheet S-1, Part I, line 5, is “Y”, then Worksheet S-1, Part I, columns 1, 2,
and 3, as applicable, lines 6 through 8, must be present and valid and vice versa.
[09/30/2018]
1050S
If Worksheet S-1, Part I, line 9, is “Y”, then line 10 must contain a “1” or “2”,
and line 11, sum of columns 1 through 3, must be greater than zero, and vice
versa. [09/30/2018]
1060S
If Worksheet S-1, Part II, columns 1 and 2, lines 2 through 10; and columns 4, 5,
and 7 through 10, lines 1 through 10, must be equal to or greater than zero.
[09/30/2018]
1100S
On Worksheet S-2, there must be a “Y” or “N” response for column 1, lines 1
through 6, 9, 10, and 14. If column 1, line 6, is “Y”, then column 1, lines 7 and 8,
must be “Y” or “N”. If column 1, line 9 or 10, is “Y”, then column 1, lines 11,
12, and 13 must be “Y” or “N”. [09/30/2018]
1105S
If Worksheet S-2, column 1, line 1, is “Y”, then column 2 must contain a valid
date (MM/DD/YYYY), and vice versa. [09/30/2018]
1110S
If Worksheet S-2, column 1, line 2, is “Y”, then column 2 must contain a valid
date (MM/DD/YYYY) and column 3 must contain a “V” or an “I”, and vice
versa. [09/30/2018]
1120S
If Worksheet S-2, column 1, line 3, is “N”, then Worksheet A-8-1 must not be
present. [09/30/2018]
45-540
Rev. 2
01-21
FORM CMS-2088-17
4595 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 6 - EDITS
I. Level 1 Edits (Minimum File Requirements - Cont.)
Edit
Condition
1130S
If Worksheet S-2, column 1, line 3, is “Y”, then Worksheet A-8-1, Part I,
columns 4 or 5, sum of lines 1 through 4, must not be equal zero, and
Worksheet A-8-1, Part II, column 1, any one of lines 6 through 10, must contain
one of the alpha characters A, B, C, D, E, F, or G. [09/30/2018]
1140S
If Worksheet S-2, column 1, line 4, is “Y”, then column 2 must be “A”, “C” or
“R”. If Worksheet S-2, column 1, line 4, is “N”, then column 2 must be blank.
[09/30/2018]
1150S
If Worksheet S-2, column 1, line 9, is “Y”, then column 2 must contain a valid
date (MM/DD/YYYY) and vice versa. [09/30/2018]
1160S
If Worksheet S-2, column 1, line 10, is “Y”, then column 2 must contain a valid
date (MM/DD/YYYY) and vice versa. [09/30/2018]
1000A
Worksheet A, columns 1, 2, and 8, line 100, must be greater than zero.
[09/30/2018]
1010A
For each amount on Worksheet A, column 8, lines 24 through 32, that is greater
than zero, the corresponding total visits on Worksheet S-1, Part II, column 3,
lines 2 through 10, must also be greater than zero, and vice versa. [09/30/2018]
1020A
For reclassifications reported on Worksheet A-6, all increases (column 4 plus
column 5) must equal all decreases (column 8 plus column 9). [09/30/2018]
1025A
For each line on Worksheet A-6, when an entry is present in column 4 or 5, there
must be an entry in columns 1 and 3, and if an entry is present in column 8 or 9,
there must be an entry in columns 1 and 7. All entries in column 1 must be upper
case alpha characters. [09/30/2018]
1032A
Worksheet A-6, column 0, must have an explanation present on the first line for
each reclassification code. [09/30/2018]
1040A
For Worksheet A-8 adjustments on lines 3 through 6, 10 through 14, and 17, if
column 2 has an amount, then column 1 must be either “A” or “B”, and column 4
for that line must have entry, and if lines 17 through 49, column 2, have entries,
then columns 0, 1, and 4, for the corresponding line must have entries.
[09/30/2018]
Rev. 2
45-541
4595 (Cont.)
FORM CMS-2088-17
01-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 6 - EDITS
I. Level 1 Edits (Minimum File Requirements - Cont.)
Edit
Condition
1042A
For Worksheet A-8 adjustments on lines 1, 2, 7, 8, and 9, if column 2 has an
entry, then column 1 of the corresponding lines must be either “A” or “B”.
[09/30/2018]
1045A
Worksheet A-8-1, Part I, columns 1 and 3, must have an entry when there is an
amount in column 4 or 5 for each of lines 1 through 4. [09/30/2018]
1055A
Worksheet A-8-2, column 3, must be equal to or greater than the sum of
columns 4 and 5; and columns 6 and 7 must each be greater than zero if column 5
is greater than zero. [09/30/2018]
1000B
On Worksheet B-1, statistical amounts must be greater than or equal to zero,
except for reconciliation columns. [09/30/2018]
1005B
Worksheet B, column 14, line 100, must be greater than zero. [09/30/2018]
1010B
For each general service cost center with a net expense for cost allocation greater
than zero (Worksheet B-1, columns 1 through 13, line 102), the corresponding
total cost allocation statistics (Worksheet B-1, column 1, line 1; column 2, line 2;
etc.) must also be greater than zero. Exclude from this edit any column that uses
accumulated cost as its basis for allocation and any reconciliation column.
[09/30/2018]
For any column that uses accumulated cost as its basis of allocation
(Worksheet B-1), there may not exist on any statistical line amounts in both the
reconciliation column and the accumulated cost column, including the negative
one, simultaneously. [09/30/2018]
1015B
1000C
On Worksheet C, all amounts must be equal to or greater than zero. [09/30/2018]
1010C
If Worksheet S-1, Part II, column 3, lines 2 through 10, and column 6, lines 1
through 10, are greater than zero, the corresponding line (lines 23 through 32) on
Worksheet C, column 2, must also be greater than zero, and vice versa.
[09/30/2018]
1020C
The total charges on each line of Worksheet C, column 2, must be greater than
or equal to the corresponding line on Worksheet C, column 4. [09/30/2018]
1000D
If Worksheet S-1, Part II, column 1, line 11, is greater than zero, then
Worksheet D, line 12, must be greater than zero. [09/30/2018]
If Worksheet D, line 1, is greater than zero, then Worksheet D-1, column 2, line 1,
must be greater than zero and vice versa. [09/30/2018]
1005D
45-542
Rev. 2
01-21
FORM CMS-2088-17
4595 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 6 - EDITS
II. Level 2 Edits (Potential Rejection Errors)
These conditions are usually, but not always, incorrect. These edit errors should be cleared when
possible through the cost report. When corrections on the cost report are not feasible, provide
additional information in schedules, notes, or any other manner as may be required by your
contractor. Failure to clear these errors in a timely fashion, as determined by your contractor, may
be grounds for withholding payments.
Edit
Condition
2000
All type 3 records with numeric fields and a positive usage must have values
equal to or greater than zero (supporting documentation may be required for
negative amounts). [09/30/2018]
2005
Only elements set forth in Table 3, with subscripts as appropriate, are required in
the file. [09/30/2018]
2015
Standard cost center lines, descriptions, and codes should not be changed. (See
Table 5 for standard descriptions and codes.) This edit applies to the standard
line only and not subscripts of that code. [09/30/2018]
All standard cost center codes must be entered on the designated standard cost
center line and subscripts thereof as indicated in Table 5. [09/30/2018]
2020
2025
Only nonstandard cost center codes within a cost center category may be placed
on lines 13, 32, and 58, and subscripts. [09/30/2018]
2035
Administrative and general standard cost center code 0400 may only appear on
line 4. [09/30/2018]
2000S
The amount due the provider or program (Worksheet S, Part III, column 1, line 1)
should not equal zero. [09/30/2018]
2020S
Worksheet S-2, lines 15 through 17, all columns, must be completed.
[09/30/2018]
2000B
At least one cost center description (lines 1 through 3), at least one statistical
basis label (lines 4 through 5), and one statistical basis code (line 6) (capital cost
center lines only) must be present for each general service cost center with cost
greater than zero (Worksheet B-1, columns 1 through 13, line 101). Exclude any
reconciliation columns from this edit. [09/30/2018]
2005B
The column numbering among these worksheets must be consistent. For
example, data in capital-related costs - buildings and fixtures is identified as
coming from column 1 on all applicable worksheets. [09/30/2018]
2000C
If Worksheet C, column 1, has any costs on any line, then column 2 must have
charges on the corresponding cost center, and vice versa. [09/30/2018]
2000F
Net income or loss on Worksheet F, column 1, line 28, should not equal zero.
[09/30/2018]
Rev. 2
45-543
4595 (Cont.)
FORM CMS-2088-17
01-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-2088-17
TABLE 6 - EDITS
II. Level II Edits (Potential Rejection Errors - Cont.)
Edit
Condition
2050F
Total patient revenue (Worksheet F, column 1, line 1) should be equal to or
greater than total charges (Worksheet C, column 2, line 50). [09/30/2018]
NOTE: CMS reserves the right to require additional edits to correct deficiencies that become
evident after processing the data commences and, as needed, to meet user requirements.
45-544
Rev. 2
| File Type | application/pdf |
| File Title | COMMUNITY MENTAL HEALTH CENTER COST REPORT |
| Subject | COMMUNITY MENTAL HEALTH CENTER COST REPORT |
| Author | CMS |
| File Modified | 2021-01-13 |
| File Created | 2021-01-12 |