Final Cost Report

Revisions Crosswalk (Form 276-22)
Final Cost Report
Note: In Changes to the Application column, the quoted words are what are to be entered. Example in issue #1 is “276-22”; do not enter the words that
explain the change and that are outside of the quotations.

Issue
#
1.

Page #

Section

Worksheet S

Row 59

2.

Worksheet S

Row 68

3.

Worksheet D

Row 73

4.

Worksheet D

Row 147

5.

Worksheet D

Row 223

6.

Worksheet D

Row 303

7.

Worksheet G

8.

Worksheet N

Part II
Column 1,
Lines 1-23,
25, 26, 28
Column K

9.

Worksheet N

10.
11.

Worksheet N
Worksheet N

Columns
1,2,3
Worksheet
Line 9d

Action to be
performed
Change form
number
Remove

Changes to the Application
Changed form number 276-19 to “276-22”.
Remove Form Expiration Date: 8/31/2022

Change form
number
Change form
number
Change form
number
Change form
number
Formatting

Changed form name and number HCFA 27619 to “CMS 276-22”.
Changed form name and number HCFA 27619 to “CMS 276-22”.
Changed form name and number HCFA 27619 to “CMS 276-22”.
Changed form number 276-19 to “276-22”.

Formatting

Removed line numbers in column K

Formatting

Shaded cells with “XXXXX”

Formatting
Change formula

Updated font and format
Changed formula from =H33/I10 to
=ROUND(H33/J10,4)

Shaded Column 1

Reason for the Change
To reflect the most recent change in the
form number/year.
This date is not determined until approval
of the PRA package renewal.
To reflect the most recent change in the
form number/year.
To reflect the most recent change in the
form number/year.
To reflect the most recent change in the
form number/year.
To reflect the most recent change in the
form number/year.
To be consistent with other columns not
being used.

To remove duplicative line numbers
already in column B.
To be consistent with other worksheets.
To be consistent with other worksheets.
To round calculation to 4 decimal places.

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