CMS-2552-10. Crosswalk

FORM CMS-2552-10 HOSPITAL AND HOSPITAL HEALTHCARE COMPLEX
FORMS AND INSTRUCTIONS
The Form CMS-2552-10, Hospital and Hospital Healthcare Complex Cost Report, updates the existing Form CMS-2552-10. The overall burden for the Hospital
and Hospital Healthcare Complex Cost Report increased to 674 hours. Changes to the revised cost report forms, effective for reporting periods beginning on or
after October 1, 2022, include:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

#
1.

Revised Worksheet S-2, Part I, and instructions; and Part II, and instructions.
Revised Worksheet S-3, Part I, and instructions.
Revised Worksheet S-10 instructions.
Revised Worksheets A and instructions.
Revised Worksheets B, Parts I and II; B-1; C, Parts I and II; and D, Parts II, IV, and V.
Revised Worksheet D-1 and instructions.
Revised Worksheet D-3.
Revised Worksheet D-4 and instructions.
Revised Worksheet D-5, Part IV, and instructions.
Added Worksheet D-6 and instructions.
Revised Worksheet E, Part A, and instructions.
Added Worksheet E-5 and instructions.
Revised Worksheet G-3 and instructions.
Revised Worksheet L-1, Part I, and instructions.
FORM
CMS-2552-10
CURRENTLY
APPROVED
Worksheet S-2,
Part I

PROPOSED FORM CMS-2552-10
WORKSHEET
INSTRUCTIONS
WORKSHEET
Worksheet S-2,
Part I

PAGE #
40-504 40-508

SECTION #
§4004.1

PAGE #
40.20 40-38.4

REASON FOR THE CHANGE /
APPLICATION OF THE
INSTRUCTIONS AND
ACCOMPANYING WORKSHEETS
Revised worksheet and instructions to add
lines 88 and 89 to record permanent
adjustments to the TEFRA target amount
per discharge and to add line 123 to report
certain purchased services. Revised
instructions for lines 24 and 25 to add
Exhibit 3A, Listing of Medicaid Eligible
Days for DSH Eligible Hospital, pursuant
to providers’ requests for a standardized
format (83 FR 41681-41685
(August 17, 2018)) to report information
required to support DSH eligible Medicaid
days reported on Worksheet S-2, Part I,
lines 24 and 25.

BURDEN
EFFECT
N/A

FORM
CMS-2552-10
CURRENTLY
APPROVED
Worksheet S-2,
Part II

WORKSHEET
Worksheet S-2,
Part II

PAGE #
40-509 40-510

SECTION #
§4004.2

PAGE #
40-39 40-53

3.

Worksheet S-3,
Part I

Worksheet S-3,
Part I

40-511

§4004.2

40-54 40-58.1

4.

Worksheet S-10

Schedule S-10,
Part I and Part II

40-523 40-523.1

§4012 §4012.2

40-76.2 40-80.12

5.

Worksheet A

Worksheet A

40-524 40-526

§4013

40-81 40-98

6.

Worksheet B,
Parts I & II;
Worksheet B-1

Worksheet B,
Parts I & II;
Worksheet B-1

40-535 40-561

§§4020 - 4021

40-116 - 40-125

#
2.

PROPOSED FORM CMS-2552-10
WORKSHEET
INSTRUCTIONS

REASON FOR THE CHANGE /
APPLICATION OF THE
INSTRUCTIONS AND
ACCOMPANYING WORKSHEETS
Revised instructions for line 12 to add
Exhibit 2A, Listing of Medicare Bad
Debts, pursuant to providers’ requests for a
standardized format (83 FR 41681-41685
(August 17, 2018)) to report information
required to support Medicare bad debt
claimed on the Medicare cost report.
Added line 34 to report temporary
expansion COVID-19 PHE acute care
information.
Designated the Worksheet S-10 as
Worksheet S-10, Part I, and revised Part I
instructions to exclude charges for services
for which the hospital received payment
from the Provider Relief Fund; to apply
the cost-to-charge ratio (CCR) to charity
care given to uninsured patients and
insured patients not covered for the entire
hospital stay; to recognize an inferred
contractual relationship between an insurer
and a provider; to add Worksheet S-10,
Part II, report uncompensated care for the
general short-term hospital inpatient and
outpatient services billable under the
hospital CCN; and to add Exhibits 3B
and 3C, pursuant to providers’ requests for
standardized formats (83 FR 41681-41685
(August 17, 2018)) to report information
required to support uncompensated care
reported on the Worksheet S-10.
Revised instructions to clarify line 77 for
allogeneic hematopoietic stem cell
transplant (HSCT) hospital acquisition
costs. Revised the worksheet and
instructions to add line 78 for chimeric
antigen receptor T-cell (CAR T-cell)
immunotherapy costs and to add line 102
for Opioid Treatment Program.
Revised the worksheets to add line 78 for
CAR T-cell immunotherapy costs and to
add line 102 for Opioid Treatment
Program.

BURDEN
EFFECT
N/A

N/A
Increase

N/A

N/A

#
7.

8.

9.

FORM
CMS-2552-10
CURRENTLY
APPROVED
Worksheet C,
Parts I & II

WORKSHEET
Worksheet C,
Parts I & II

PAGE #
40-563 40-567

SECTION #
§§4023 - 4024.1

PAGE #
40-127 40-133

Worksheet D,
Parts II, IV, & V

Worksheet D,
Parts II, IV, & V

40-568;
40-570 - 40-570.1;
40-572

§4024.2; §4024.4;
§4024.5

Worksheet D-1

40-573 40-575

§§4025.2 - 4025.4

40-133 40-134;
40-135 - 40-137;
40-138 - 40-140.2;
40-141 40-152

Worksheet D-1

PROPOSED FORM CMS-2552-10
WORKSHEET
INSTRUCTIONS

10.

Worksheet D-3

Worksheet D-3

40-578

§4027

11.

Worksheet D-4

Worksheet D-4

49-579 40-581

§§4028 - 4028.4

12.

Worksheet D-5,
Part IV

Worksheet D-5,
Part IV

40-583.2

§§4029.4

40-168.2 40-168.3

13.

Worksheet D-6

Worksheet D-6

40-583.3 40-583.4

§§4029.5 - 4029.8

40-168.4 40-168.6

14.

Worksheet E-3,
Part V
Worksheet E-5

Worksheet E-3,
Part V
Worksheet E-5

40-595

§4033.5

40-202 - 40-205.2

40-599.1

§4035

40-216.5

15.

40-158 40-160
40-161 40-165.3

REASON FOR THE CHANGE /
APPLICATION OF THE
INSTRUCTIONS AND
ACCOMPANYING WORKSHEETS
Revised the worksheets to add line 78 for
CAR T-cell immunotherapy costs and to
add line 102 for Opioid Treatment
Program.
Revised the worksheets to add line 78 for
CAR T-cell immunotherapy costs.
Revised the worksheet and instructions to
add lines 55.01 and 55.02, for permanent
and temporary adjustments to the TEFRA
target amount per discharge, to properly
calculate the TEFRA limit for inpatient
costs.
Revised the worksheet to add line 78 for
CAR T-cell immunotherapy costs.
Revised instructions to clarify counting
organs, including total usable organs,
Medicare usable organs, organs for
Medicare Advantage patients, and organs
when there is a primary and secondary
payer.
Revised the worksheet to add lines 17.01
and 31.01 for inpatient allogeneic HSCT
acquisition; and lines 17.02 and 31.02 for
outpatient allogeneic HSCT acquisition,
respectively.
Added Worksheet D-6, Computation of
Acquisition Costs, and instructions, to
calculate the inpatient routine, ancillary,
and other costs associated with the
acquisition of allogeneic HSCT as required
under Section 108 of the Further
Consolidated Appropriations Act, 2020
(Pub. L. 116-94).
Added line 3.01 and instructions for
cellular therapy acquisition cost.
Added Worksheet E-5, Outlier
Reconciliation at Tentative Settlement, and
instructions, for contractor use, to report
the outlier reconciliation amount during
cost report tentative settlement.

BURDEN
EFFECT
N/A

N/A

N/A

N/A
N/A

N/A

Increase

N/A
N/A

#
16.

FORM
CMS-2552-10
CURRENTLY
APPROVED
Worksheet L-1,
Part I

PROPOSED FORM CMS-2552-10
WORKSHEET
INSTRUCTIONS
WORKSHEET
Worksheet L-1,
Part I

PAGE #
40-647 - 40-655

SECTION #
§4065.1

PAGE #
40-277 - 40-278

REASON FOR THE CHANGE /
APPLICATION OF THE
INSTRUCTIONS AND
ACCOMPANYING WORKSHEETS
Revised the worksheet to add line 78 for
CAR T-cell immunotherapy costs and to
add line 102 for Opioid Treatment
Program.

BURDEN
EFFECT
N/A