CMS-2552-10. Instructions

Hospitals and Health Care Complex Cost Report (CMS-2552-10)

CMS-2552-10. Instructions

OMB: 0938-0050

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CHAPTER 40
HOSPITAL AND HOSPITAL
HEALTH CARE COMPLEX COST REPORT
FORM CMS-2552-10
Section
General ............................................................................................................................... 4000
Rounding Standards for Fractional Computations.................................................... 4000.1
Acronyms and Abbreviations ................................................................................... 4000.2
Recommended Sequence for Completing Form CMS-2552-10 ........................................ 4001
Sequence of Assembly ....................................................................................................... 4002
Sequence of Assembly for Hospital and Hospital Health Care Complex Providers
Participating in Medicare .......................................................................................... 4002.1
Worksheet S - Hospital and Hospital Health Care Complex Cost Report
Certification and Settlement Summary ..................................................................... 4003
Part I - Cost Report Status ........................................................................................ 4003.1
Part II - Certification by a Chief Financial Officer or Administrator of
Provider(s)........................................................................................................ 4003.2
Part III - Settlement Summary .................................................................................. 4003.3
Worksheet S-2 - Hospital and Hospital Health Care Complex Identification Data .......... 4004
Part I - Hospital and Hospital Health Care Complex Identification Data................. 4004.1
Part II - Hospital and Hospital Heath Care Complex Reimbursement
Questionnaire ................................................................................................... 4004.2
Worksheet S-3 - Hospital and Hospital Health Care Complex Statistical Data and
Hospital Wage Index Information ............................................................................ 4005
Part I - Hospital and Hospital Health Care Complex Statistical Data ...................... 4005.1
Part II - Hospital Wage Index Information ............................................................... 4005.2
Part III - Hospital Wage Index Summary ................................................................. 4005.3
Part IV - Hospital Wage Related Cost ...................................................................... 4005.4
Part V - Hospital and Health Care Complex Contract Labor and Benefit Cost ....... 4005.5
Worksheet S-4 - Hospital-Based Home Health Agency Statistical Data .......................... 4006
Worksheet S-5 - Hospital Renal Dialysis Department Statistical Data ............................. 4007
Worksheet S-6 - Hospital-Based Outpatient Rehabilitation Provider Data......... .............. 4008
Worksheet S-7 - Prospective Payment for Skilled Nursing Facilities Statistical Data ...... 4009
Worksheet S-8 - Hospital-Based RHC/FQHC Statistical Data ..........................................4010
Worksheet S-11 - Hospital-Based FQHC Identification Data ........................................... 4010.1
Part I - Hospital-Based FQHC Identification Data ................................................... 4010.2
Part II - Hospital-Based FQHC Consolidated Cost Report Participant
Identification Data ........................................................................................... 4010.3
Part III - Hospital-Based FQHC Statistical Data ...................................................... 4010.4
Worksheet S-9 - Hospital-Based Hospice Identification Data .......................................... 4011
Part I - Enrollment Days for Cost Reporting Periods Beginning Before
October 1, 2015 ................................................................................................ 4011.1
Part II - Census Data for Cost Reporting Periods Beginning Before
October 1, 2015 ................................................................................................ 4011.2
Part III - Enrollment Days for Cost Reporting Periods Beginning On or
After October 1, 2015 ...................................................................................... 4011.3
Part IV - Contracted Statistical Data for Cost Reporting Periods Beginning
On or After October 1, 2015 ............................................................................ 4011.4
Worksheet S-10 - Hospital Uncompensated and Indigent Care Data................................ 4012
Part I - Hospital and Hospital Complex Data .......................................................... 4012.1
Part II - Hospital Data .............................................................................................. 4012.2

Rev.

40-1

CHAPTER 40
Section
Worksheet A - Reclassification and Adjustment of Trial Balance of Expenses................ 4013
Worksheet A-6 - Reclassifications..................................................................................... 4014
Worksheet A-7 - Analysis of Capital Assets ..................................................................... 4015
Part I - Analysis of Changes in Capital Asset
Balances............................................ ............................................................... 4015.1
Part II - Reconciliation of Amounts from Worksheet A, Column 2, Lines 1
and 2................................................................................................................. 4015.2
Part III - Reconciliation of Capital Cost Centers ...................................................... 4015.3
Worksheet A-8 - Adjustments to Expenses ....................................................................... 4016
Worksheet A-8-1 - Statement of Costs of Services from Related Organizations
and Home Office Costs ............................................................................................. 4017
Worksheet A-8-2 - Provider-Based Physician Adjustments .............................................. 4018
Worksheet A-8-3 - Reasonable Cost Determination for Therapy Services
Furnished by Outside Suppliers for Cost Based Providers ....................................... 4019
Part I - General Information...................................................................................... 4019.1
Part II - Salary Equivalency Computation ................................................................ 4019.2
Part III - Standard Travel Allowance and Standard Travel Expense
Computation Provider Site .............................................................................. 4019.3
Part IV - Standard Travel Allowance and Standard Travel Expense - Off
Site Services..................................................................................................... 4019.4
Part V - Overtime Computation ................................................................................ 4019.5
Part VI - Computation of Therapy Limitation and Excess Cost Adjustment ........... 4019.6
Worksheet B, Part I - Cost Allocation - General Service Cost and
Worksheet B-1 - Cost Allocation - Statistical Basis ................................................. 4020
Worksheet B, Part II - Allocation of Capital-Related Costs and Worksheet B ................. 4021
Worksheet B-2 - Post Step-down Adjustments ................................................................. 4022
Worksheet C - Computation of Ratio of Cost to Charges and Outpatient Capital
Reduction .................................................................................................................. 4023
Part I - Computation of Ratio of Costs to Charges ................................................... 4023.1
Part II - Calculation of Outpatient Service Cost-to-Charge Ratios Net of
Reductions for Medicaid Only......................................................................... 4023.2
Worksheet D - Cost Apportionment .................................................................................. 4024
Part I - Apportionment of Inpatient Routine Service Capital Costs ......................... 4024.1
Part II - Apportionment of Inpatient Ancillary Service Capital Costs ..................... 4024.2
Part III - Apportionment of Inpatient Routine Service Other Pass-Through
Costs ................................................................................................................ 4024.3
Part IV - Apportionment of Inpatient/Outpatient Ancillary Service Other
Pass-Through Costs ......................................................................................... 4024.4
Part V - Apportionment of Medical and Other Health Services Costs ..................... 4024.5
Worksheet D-1 - Computation of Inpatient Operating Cost .............................................. 4025
Part I - All Provider Components ............................................................................. 4025.1
Part II - Hospital and Subproviders Only ................................................................. 4025.2
Part III - Skilled Nursing Facility and Other Nursing Facility Only ........................ 4025.3
Part IV - Computation of Observation Bed Cost ...................................................... 4025.4

40-2

Rev.

CHAPTER 40
Section
Worksheet D-2 - Apportionment of Cost of Services Rendered by Interns and
Residents .................................................................................................................. 4026
Part I - Not in Approved Teaching Program ............................................................. 4026.1
Part II - In Approved Teaching Program (Title XVIII, Part B Inpatient
Routine Costs Only) ......................................................................................... 4026.2
Part III - Summary for Title XVIII ........................................................................... 4026.3
Worksheet D-3 - Inpatient Ancillary Service Cost Apportionment................................... 4027
Worksheet D-4 - Computation of Organ Acquisition Costs and Charges for a
Transplant Hospital With a Medicare-Certified Transplant Program....................... 4028
Part I - Computation of Organ Acquisition Costs (Inpatient Routine and
Ancillary Services)........................................................................................... 4028.1
Part II - Computation of Organ Acquisition Costs (Other Than Inpatient
Routine and Ancillary Service Costs) .............................................................. 4028.2
Part III - Summary of Costs and Charges ................................................................. 4028.3
Part IV - Statistics ..................................................................................................... 4028.4
Worksheet D-5 - Apportionment of Cost for Physicians’ Services in a Teaching
Hospital ..................................................................................................................... 4029
Part I - Reasonable Compensation Equivalent Computation for Cost
Reporting Periods Ending Before June 30, 2014 ............................................. 4029.1
Part II - Apportionment of Cost for Physicians’ Services in a Teaching
Hospital for Cost Reporting Periods Ending Before June 30, 2014 ................ 4029.2
Part III - Reasonable Compensation Equivalent Computation for Cost
Reporting Periods Ending On or After June 30, 2014 ..................................... 4029.3
Part IV - Apportionment of Cost for Physicians’ Services in a Teaching
Hospital for Cost Reporting Periods Ending On or After June 30, 2014 ........ 4029.4
Worksheet D-6 - Computation of Cellular Therapy Acquisition Costs ............................. 4029.5
Part I - Inpatient Routine and Ancillary Services Cellular Therapy
Acquisition Costs ............................................................................................. 4029.6
Part II - Interns and Residents not in an Approved Program Cellular
Therapy Acquisition Costs ............................................................................... 4029.7
Part III - Summary of Cellular Therapy Acquisition Costs and Charges................. 4029.8
Part IV - Statistics ..................................................................................................... 4029.9
Worksheet E - Calculation of Reimbursement Settlement ................................................ 4030
Part A - Inpatient Hospital Services Under the PPS ................................................. 4030.1
Part B - Medical and Other Health Services ............................................................. 4030.2
Worksheet E-1 - Analysis of Payments to Providers for Services Rendered .................... 4031
Part I - Analysis of Payments to Providers for Services Rendered........................... 4031.1
Part II - Calculation of reimbursement Settlement for Health Information
Technology ...................................................................................................... 4031.2
Worksheet E-2 - Calculation of Reimbursement Settlement - Swing Beds ...................... 4032
Worksheet E-3 - Calculation of Reimbursement Settlement ............................................. 4033
Part I - Calculation of Medicare Reimbursement Settlement Under TEFRA .......... 4033.1
Part II - Calculation of Medicare Reimbursement Settlement Under IPF PPS ........ 4033.2
Part III - Calculation of Medicare Reimbursement Settlement Under IRF
PPS ................................................................................................................... 4033.3
Part IV - Calculation of Medicare Reimbursement Settlement Under
LTCH PPS ....................................................................................................... 4033.4
Part V - Calculation of Reimbursement Settlement for Medicare Part A
Services - Cost Reimbursement ....................................................................... 4033.5
Part VI - Calculation of Reimbursement Settlement - Title XVIII Part A PPS
SNF Services .................................................................................................... 4033.6
Part VII - Calculation of Reimbursement Settlement - All Other Health
Services for Titles V or XIX Services ............................................................. 4033.7
Worksheet E-4 - Direct Graduate Medical Education and ESRD Outpatient Direct
Medical Education Costs .......................................................................................... 4034
Worksheet E-5 - Outlier Reconciliation at Tentative Settlement ....................................... 4035
Rev.

40-3

CHAPTER 40
Section
Financial Statements Worksheets ...................................................................................... 4040
Worksheet G - Balance Sheet ................................................................................... 4040.1
Worksheet G-1- Statement of Changes in Fund Balances ........................................ 4040.2
Worksheet G-2, Parts I and II - Statement of Patient Revenues and Operating
Expenses .......................................................................................................... 4040.3
Worksheet G-3 - Statement of Revenues and Expenses ........................................... 4040.4
Worksheet H - Analysis of Hospital-Based Home Health Agency Costs ......................... 4041
Worksheet H-1 - Cost Allocation HHA Statistical Basis .................................................. 4042
Worksheet H-2 - Allocation of General Service Costs to HHA Cost Centers................... 4043
Part I - Allocation of General Service Costs to HHA Cost Centers ......................... 4043.1
Part II - Allocation of General Service Cost to HHA Cost Centers - Statistical
Basis ................................................................................................................. 4043.2
Worksheet H-3 - Apportionment of Patient Service Costs ................................................ 4044
Part I - Computation of Lesser of Aggregate Medicare Cost Aggregate
Medicare Limitation Cost, or Per Beneficiary Cost Limitation ...................... 4044.1
Part II - Apportionment of Cost of HHA Services Furnished by Shared
Hospital Departments....................................................................................... 4044.2
Worksheet H-4 - Calculation of HHA Reimbursement .................................................... 4045
Part I - Computation of Lesser of Reasonable Cost or Customary Charges ............. 4045.1
Part II - Computation of HHA Reimbursement Settlement ...................................... 4045.2
Worksheet H-5 - Analysis of Payments to Hospital-Based HHAs for Services
Rendered to Program Beneficiaries ......................................................................... 4046
Worksheet I - Analysis of Renal Dialysis Department Costs ............................................ 4047
Worksheet I-1 - Analysis of Renal Dialysis Department Costs ......................................... 4048
Worksheet I-2 - Allocation of Renal Department Costs to Treatment Modalities ............ 4049
Worksheet I-3 - Direct and Indirect Renal Dialysis Cost Allocation - Statistical
Basis .......................................................................................................................... 4050
Worksheet I-4 - Computation of Average Cost Per Treatment for Outpatient Renal
Dialysis ..................................................................................................................... 4051
Worksheet I-5 - Calculation of Reimbursable Bad Debts - Title XVIII, Part B ................ 4052

40-4

Rev.

CHAPTER 40
Section
Worksheet J-1 - Allocation of General Service Costs to CMHC Cost Centers ................. 4053
Part I - Allocation of General Service Costs to CMHC Cost Centers ...................... 4053.1
Part II - Allocation of General Service Costs to CMHC Cost Centers Statistical Basis ................................................................................................ 4053.2
Worksheet J-2 - Computation of CMHC Provider Costs .................................................. 4054
Part I - Apportionment of CMHC Cost Centers ....................................................... 4054.1
Part II - Apportionment of Cost of CMHC Provider Services Furnished by
Shared Hospital Departments .......................................................................... 4054.2
Worksheet J-3 - Calculation of Reimbursement Settlement - CMHC Provider
Services ..................................................................................................................... 4055
Worksheet J-4 - Analysis of Payments to Hospital-Based CMHC for Services
Rendered to Program Beneficiaries .......................................................................... 4056
Worksheet K - Analysis of Hospital-Based Hospice Costs ............................................... 4057
Worksheet K-1 - Compensation Analysis - Salaries and Wage ........................................ 4058
Worksheet K-2 - Compensation Analysis - Employee Benefits (Payroll Related) ........... 4059
Worksheet K-3 - Compensation Analysis - Contracted Services/Purchased Services ...... 4060
Worksheet K-4 - Part I - Cost Allocation - General Service Costs and Part II - Cost
Allocation - Statistical Basis ..................................................................................... 4061
Worksheet K-5 - Allocation of General Service Costs to Hospice Cost Centers .............. 4062
Part I - Allocation of General Service Costs to Hospice Cost Centers ..................... 4062.1
Part II - Allocation of General Service Costs to Hospice Cost Centers Statistical Basis ................................................................................................ 4062.2
Part III - Computation of the Total Hospice Shared Costs ....................................... 4062.3
Worksheet K-6 - Calculation of Per Diem Cost ................................................................ 4063

Rev. 17

40-5

CHAPTER 40
Section
Worksheet L - Calculation of Capital Payment ................................................................. 4064
Part I - Fully Prospective Method ............................................................................. 4064.1
Part II - Payment Under Reasonable Cost ................................................................ 4064.2
Part III - Computation of Exception Payments ......................................................... 4064.3
Worksheet L-1 ................................................................................................................... 4065
Part I - Allocation of Allowable Capital Costs for Extraordinary
Circumstances .................................................................................................. 4065.1
Part II - Computation of Program Inpatient Ancillary Service Capital Costs for
Extraordinary Circumstances ........................................................................... 4065.2
Part II - Computation of Program Inpatient Routine Service Capital Costs for
Extraordinary Circumstances ........................................................................... 4065.3
Worksheet M-1 - Analysis of Hospital-Based RHC/FQHC Costs .................................... 4066
Worksheet M-2 - Allocation of Overhead to Hospital-Based RHC/FQHC Services ........ 4067
Worksheet M-3 - Calculation of Reimbursement Settlement for Hospital-Based
RHC/FQHC Services ................................................................................................ 4068
Worksheet M-4 - Computation of Hospital-Based RHC/FQHC Vaccine Cost ................. 4069
Worksheet M-5 - Analysis of Payments to Hospital-Based RHC/FQHC Services
Rendered to Program Beneficiaries .......................................................................... 4070
Worksheet N-1 - Reclassification and Adjustment of Trial Balance of Expenses for
Hospital-Based FQHC .............................................................................................. 4071
Worksheet N-2 - Calculation of Hospital-Based FQHC Cost Per Visit ............................ 4071.1
Worksheet N- 3 - Computation of Hospital-Based FQHC Vaccine Cost .......................... 4071.2
Worksheet N-4 - Calculation of Hospital-Based FQHC Reimbursement Settlement ....... 4071.3
Worksheet N-5 - Analysis of Payments to Hospital-Based FQHC for Services
Rendered ................................................................................................................... 4071.4
Worksheet O - Analysis of Hospital-Based Hospice Costs ............................................... 4072
Worksheets O-1, O-2, O-3, and O-4 - Analysis of Hospital-Based Hospice Costs........... 4072.1
Worksheet O-1 - Analysis of Hospital-Based Hospice Costs Hospice
Continuous Home Care
Worksheet O-2 - Analysis of Hospital-Based Hospice Costs Hospice Routine
Home Care
Worksheet O-3 - Analysis of Hospital-Based Hospice Costs Hospice Inpatient
Respite Care
Worksheet O-4 - Analysis of Hospital-Based Hospice Costs Hospice General
Inpatient Care
Worksheet O-5 - Determination of Hospital-Based Hospice Net Expenses for
Allocation.................................................................................................................. 4072.2
Worksheet O-6 - Part I - Cost Allocation - Hospital-Based Hospice General Service
Costs.......................................................................................................................... 4072.3
Worksheet O-6 - Part II - Cost Allocation - Hospital-Based Hospice General
Service Costs Statistical Basis .................................................................................. 4072.3
Worksheet O-7 - Apportionment of Hospital-Based Hospice Shared Service Costs
by Level of Care........................................................................................................ 4072.4
Worksheet O-8 - Calculation of Hospital-Based Hospice Per Diem Cost......................... 4072.5
Electronic Reporting Specifications for Form CMS-2552-10 ........................................... 4095
Form CMS-2552-10 Worksheets ....................................................................................... 4096

40-6

Rev. 17

DRAFT
4000.

FORM CMS-2552-10

4000

GENERAL

The Paperwork Reduction Act of 1995 requires that you be informed why information is collected
and what the information is used for by the government. In accordance with §§1815(a), 1833(e),
and 1861(v)(1)(A) of the Social Security Act (the Act), providers of service participating in the
Medicare program are required to submit annual information to achieve settlement of costs for
health care services rendered to Medicare beneficiaries. In accordance with these provisions, all
hospital and hospital health care complexes must complete Form CMS-2552-10 with a valid Office
of Management and Budget (OMB) control number in order to determine program payment. In
addition to determining program payment, the data submitted on the cost report support
management of the federal programs, e.g., data extraction in developing cost limits, data extraction
in developing and updating various prospective payment systems. The information reported on
Form CMS-2552-10 must conform to the requirements and principles set forth in 42 CFR 412,
42 CFR 413, and in the Provider Reimbursement Manual, Part 1 (CMS Pub. 15-1). The filing of
the cost report is mandatory, and failure to do so results in all payments for the cost reporting
period being deemed overpayments and up to 100 percent withhold of subsequent payments until
the cost report is received. (See Provider Reimbursement Manual, Part 2 (CMS Pub. 15-2),
chapter 1, §100.) The Medicare cost report information is considered public record under the
Freedom of Information Act, 45 CFR Part 5. The Form CMS-2552-10 is effective for hospitals
and hospital health care complexes with cost reporting periods beginning on or after May 1, 2010.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-0050 (expires XX/XX/XXXX). The time required
to complete this information collection is estimated to average 674 hours per response, including
the time to review instructions; search existing data resources; gather the data needed; and
complete and review the information collection. Direct any comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form to:
Center for Medicare and Medicaid Services
Attn: PRA Report 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.
Worksheets are provided on an as needed basis dependent on the needs of the hospital. Not all
worksheets are needed by all hospitals. The following are a few examples of conditions for which
worksheets are needed:
•

Reimbursement is claimed for hospital swing beds;

•

Reimbursement is claimed for a hospital-based inpatient rehabilitation facility (IRF) or
inpatient psychiatric facility (IPF);

•

Reimbursement is claimed for a hospital-based community mental health center (CMHC);

•

The hospital has physical therapy services furnished by outside suppliers (applicable for
cost reimbursement and Tax Equity and Fiscal responsibility Act of 1982 (PL97248)
(TEFRA providers, not PPS); or

•

The hospital is a certified transplant center (CTC).

Rev.

40-7

4000 (Cont.)

FORM CMS-2552-10

DRAFT

Section 4007(b) of the Omnibus Budget Reconciliation Act (OBRA 1987) states that effective
with cost reporting periods beginning on or after October 1, 1989, you are required to submit your
cost report electronically unless you receive an exemption from CMS. The legislation allows CMS
to delay or waiver implementation if the electronic submission results in financial hardship (in
particular for providers with only a small percentage of Medicare volume). Exemptions are
granted on a case-by-case basis (see 42 CFR 413.24(h)).
In addition to Medicare reimbursement, these forms also provide for the computation of
reimbursement applicable to titles V and XIX to the extent required by individual State programs.
Generally, the worksheets and portions of worksheets applicable to titles V and XIX are completed
only to the extent these forms are required by the State program. However, Worksheets S-3 and
D-1 must always be completed with title XIX data.
Each electronic system provides for the step-down method of cost finding. This method provides
for allocating the cost of services rendered by each general service cost center to other cost centers,
which utilize the services. Once the costs of a general service cost center have been allocated, that
cost center is considered closed. Once closed, it does not receive any of the costs subsequently
allocated from the remaining general service cost centers. After all costs of the general service
cost centers have been allocated to the remaining cost centers, the total costs of these remaining
cost centers are further distributed to the departmental classification to which they pertain, e.g.,
hospital general inpatient routine, subprovider.
This cost report is designed to accommodate a hospital health care complex with multiple entities.
If a hospital health care complex has more than one entity reporting (except skilled nursing
facilities and nursing facilities which cannot exceed more than one hospital-based facility), add
additional lines for each entity by subscripting the appropriate line designation.
In completing the worksheets, show reductions in expenses in parentheses ( ) unless otherwise
indicated.
4000.1 Rounding Standards for Fractional Computations.--Throughout the Medicare cost report,
required computations result in fractions. The following rounding standards must be employed
for such computations. When performing multiple calculations, round after each calculation.
However,
1. Round to 2 decimal places:
a. Percentages
b. Averages, standard work week, payment rates, and cost limits
c. Full time equivalent (FTE) employees
d. Per diems, hourly rates
2. Round to 3 decimal places:
a. Payment to cost ratio
3. Round to 4 decimal places:
a. Wage adjustment factor
b. Medicare SSI ratio
c. Disproportionate patient percentage
d. EHR Medicare Share

40-8

Rev.

DRAFT

FORM CMS-2552-10

4000.2

4. Round to 5 decimal places:
a. Payment reduction (e.g., capital reduction, outpatient cost reduction)
5. Round to 6 decimal places:
a. Ratios (e.g., unit cost multipliers, cost/charge ratios, days to days)
6. Round to 9 decimal places:
a. Uncompensated care factor 3
Where a difference exists within a column as a result of computing costs using a fraction or
decimal, and the sum of the parts do not equal the whole, the highest amount in that column must
either be increased or decreased by the difference. If there are two high numbers equaling the
same amount, adjust the first high number from the top of the worksheet for which it applies.
4000.2 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.
ACA
A&G
AHSEA
AKI
ARRA
ASC
BBA
BBRA
BIPA
CAH
CAPD
CAP-REL
CBSA
CCN
CCPD
CCU
CFR
CHIP
CMHC
CMS
CNA
COL
CORF
CRNA
CT
CTC
DEFRA
DRA
DRG
DSH
EACH
ECR
EHR
ESRD
FFY
FQHC
FR
FTE

Rev.

Affordable Care Act
Administrative and General
Adjusted Hourly Salary Equivalency Amount
Acute Kidney Injury
American Recovery and Reinvestment Act of 2009
Ambulatory Surgical Center
Balanced Budget Act
Balanced Budget Reform Act
Benefits Improvement and Protection Act
Critical Access Hospitals
Continuous Ambulatory Peritoneal Dialysis
Capital-Related
Core Based Statistical Areas
CMS Certification Number
Continuous Cycling Peritoneal Dialysis
Coronary Care Unit
Code of Federal Regulations
Children’s Health Insurance Program
Community Mental Health Center
Centers for Medicare & Medicaid Services
Certified Nursing Assistant
Column
Comprehensive Outpatient Rehabilitation Facility
Certified Registered Nurse Anesthetist
Computer Tomography
Certified Transplant Center
Deficit Reduction Act of 1984
Deficit Reduction Act of 2005
Diagnostic Related Group
Disproportionate Share
Essential Access Community Hospital
Electronic Cost Report
Electronic Health Records
End Stage Renal Disease
Federal Fiscal Year (October 1 through September 30)
Federally Qualified Health Center
Federal Register
Full Time Equivalent

40-9

4000.2 (Cont.)

FORM CMS-2552-10

GME
HCERA
HCHC
HCPCS
HCRIS
HFS
HGIP
HIRC
HRHC
HRSA
HHA
HIT
HMO
HSR
I&Rs
ICF/IID
ICU
IME
INPT
IOM
IPF
IPPS
IRF
KPMG
LCC
LDP
LIP
LOC
LOS
LPN
LTCH
LVN
MA
MAO
M+C

MCP
MDH
MED-ED
MIPPA
MMA
MMEA
MPS
MRI
MS-DRG
MSP
NAH
NF
NPI
NPR
OBRA
OLTC
OOT
OPD
OPO
OPPS

40-10

DRAFT

Graduate Medical Education
Health Care and Education Reconciliation Act of 2010
Hospice Continuous Home Care
Healthcare Common Procedure Coding System
Healthcare Cost Report Information System
Health Financial Systems
Hospice General Inpatient Care
Hospice Inpatient Respite Care
Hospice Routine Home Care
Health Resources and Services Administration
Home Health Agency
Health Information Technology
Health Maintenance Organization
Hospital Specific Rate
Interns and Residents
Intermediate Care Facility for Individuals with Intellectual Disabilities
Intensive Care Unit
Indirect Medical Education
Inpatient
Internet Only Manual
Inpatient Psychiatric Facility
Inpatient Prospective Payment System
Inpatient Rehabilitation Facility
Klynveld, Peat, Marwick, & Goerdeler
Lesser of Reasonable Cost or Customary Charges
Labor, Delivery and Postpartum
Low Income Patient
Level of Care
Length of Stay
Licensed Practical Nurse
Long Term Care Hospital
Licensed Vocational Nurse
Medicare Advantage (previously known as M+C)
Medicare Advantage organization (also referred to as MA organization)
Medicare + Choice (also known as Medicare Part C, Medicare Advantage and
Medicare HMO)
Monthly Capitation Payment
Medicare Dependent, Small Rural Hospital
Medical Education
Medicare Improvements for Patients and Providers Act of 2008
Medicare Prescription Drug Improvement and Modernization Act of 2003
Medicare and Medicaid Extenders Act of 2010
Median Payer-Specific
Magnetic Resonance Imaging
Medicare Severity Diagnosis-Related Group
Medicare Secondary Payer
Nursing and Allied Health
Nursing Facility
National Provider Identifier
Notice of Program Reimbursement
Omnibus Budget Reconciliation Act
Other Long Term Care
Outpatient Occupational Therapy
Outpatient Department
Organ Procurement Organization
Outpatient Prospective Payment System

Rev.

DRAFT
OPT
OSP
ORF
PCR
PCRE
PBP
PHE
PPS
PRF
PRM
PRA
PS&R
PT
PTO
RCE
RHC
RN
RPCH
RT
RUG
SCH
SNF
SSI
TEFRA
THC
TOPPS
TPA
UPIN
WKST

FORM CMS-2552-10
-

4000.3

Outpatient Physical Therapy
Outpatient Speech Pathology
Outpatient Rehabilitation Facility
Payment to Cost Ratio
Primary Care Residency Expansion Program
Provider-Based Physician
Public Health Emergency
Prospective Payment System
Provider Relief Fund
Provider Reimbursement Manual
Per Resident Amount
Provider Statistical and Reimbursement Report (or System)
Physical Therapy
Paid Time Off
Reasonable Compensation Equivalent
Rural Health Clinic
Registered Nurse
Rural Primary Care Hospitals
Respiratory Therapy
Resource Utilization Group
Sole Community Hospitals
Skilled Nursing Facility
Supplemental Security Income
Tax Equity and Fiscal Responsibility Act of 1982
Teaching Health Center
Transitional Corridor Payment for Outpatient Prospective Payment System
Third Party Administrator
Unique Physician Identification Number
Worksheet

NOTE: In this chapter, TEFRA refers to §1886(b) of the Act and not to the entire Tax Equity and
Fiscal Responsibility Act.
4000.3 Instructional, Regulatory and Statutory Effective Dates.--Throughout the Medicare cost
report instructions, various effective dates implementing instructions, regulations and/or statutes
are utilized.
Where applicable, at the end of select paragraphs and/or sentences the effective date(s) is indicated
in parentheses ( ) for cost reporting periods ending on or after that date, i.e., (12/31/2010). Dates
followed by a “b” are effective for cost reporting periods beginning on or after the specified date,
i.e., (9/30/2010b). Dates followed by an “s” are effective for services rendered on or after the
specified date, i.e., (4/1/2010s). Instructions not followed by an effective date are effective
retroactive back to cost reporting periods beginning on or after 5/1/2010 (transmittal 1).

Rev.

40-11

4001

FORM CMS-2552-10

DRAFT

4001.

RECOMMENDED SEQUENCE FOR COMPLETING FORM CMS-2552-10
Part I - Statistics, Departmental Cost Adjustments and Cost Allocations

Step

Worksheet

Instructions

S-2, Parts I and II

Read §§4004.1 and 4004.2.
worksheet.

S-3, Parts I, II, III, IV, and V

Read §§4005 through 4005.5. Complete entire
worksheets.

S-4

Read §4006.
applicable.

Complete entire worksheet, if

S-5

Read §4007.
applicable.

Complete entire worksheet, if

S-6

Read §4008.
applicable.

Complete entire worksheet, if

S-7

Read §4009.
applicable.

Complete entire worksheet, if

S-8

Read §4010.
applicable.

Complete entire worksheet, if

S-9

Read §4011. Complete portions of worksheet, as
applicable.

S-11, Parts I, II, and III

Read §§4010.1 through 4010.4. Complete entire
worksheet, if applicable.

Read §4013. Complete columns 1 through 3,
lines 1 through 200.

A-6

Read §4014. Complete, if applicable.

Read §4013. Complete columns 4 and 5, lines 1
through 200.

A-7, Parts I, II, and III

Read §4015. Complete entire worksheet.

A-8-1

Read §4017. Complete Parts A and B.

A-8-2

Read §4018. Complete, if applicable.

A-8-3, Parts I, II, III, IV, V, and VI

Read §§4019 through 4019.6.
applicable.

40-12

Complete entire

Complete, if

Rev.

11-16

FORM CMS-2552-10

4001 (Cont.)

Part I - Statistics, Departmental Cost Adjustments and Cost Allocations (Cont.)
Step

Worksheet

Instructions

A-8

Read §4016. Complete entire worksheet.

Read §4013. Complete columns 6 and 7, lines 1
through 200.

B, Part I and B-1

Read §4020.
column 26.

B, Part II

Read §4021. Complete entire worksheet.

B-2

Read §4022. Complete, if applicable.

L-1, Part I

Read §§4065 and 4065.1.
applicable.

Rev. 10

Complete all columns through

Complete, if

40-13

4001 (Cont.)

FORM CMS-2552-10

11-16

Part II - Departmental Cost Distribution and Cost Apportionment
Step

Worksheet

Instructions

Read §§4023 and 4023.1. Complete entire
worksheet, except for line 92.

D, Part I

Read §§4024 and 4024.1.
worksheet.

D, Part III

Read §§4024 and 4024.3. Complete entire
worksheet.

L-1, Part II

Read §4065.2. Complete, if applicable.

D-1, Parts I and IV

Read §§4025, 4025.1 and 4025.4. Complete both
parts.

Read §4023.1. Complete line 92.

D, Part II

Read §§4024 and 4024.2. Complete entire
worksheet. A separate worksheet must be
completed for each applicable healthcare
program for each hospital and subprovider
subject to PPS or TEFRA provisions.

D, Part IV

Read §§4024 and 4024.4. Complete entire
worksheet. A separate worksheet must be
completed for each applicable health care
program for each hospital and subprovider
subject to PPS or TEFRA provisions.

L-1, Part III

Read §4065.3. Complete, if applicable.

D, Part V

Read §§4024 and 4024.5. Complete entire
worksheet. A separate worksheet must be
completed for each applicable health care
program for each applicable provider
component.

D-3

Read §4027. Complete entire worksheet. A
separate copy of this worksheet must be
completed for each applicable health care
program for each applicable provider
component.

D-1, Parts I and II

Read §§4025 through 4025.2. All providers must
complete Part I. The hospital and subprovider(s)
must complete Part II, lines 38 through 49, and
lines 64 through 69.

40-14

Complete entire

Rev. 10

DRAFT

FORM CMS-2552-10

4001 (Cont.)

Part II - Departmental Cost Distribution and Cost Apportionment (Cont.)
Step

Worksheet

Instructions

D-1, Parts III and IV

Read §§4025, 4025.3 and 4025.4. Only the
hospital-based SNF and hospital-based NF must
complete Part III, lines 70 through 86. All
providers must complete Part IV.

D-2, Parts I through III

Read §§4026 through 4026.3. Complete only
those parts that are applicable. Do not complete
Part III unless both Parts I and II are completed.

L, Parts I through III

Read §4064. Complete applicable parts.

D-5, Parts I and II, or Parts III and IV Read §§4029 through 4029.4.
applicable parts.

D-4, Parts I through IV

Read §§4028 through 4028.4. Complete only if
hospital is a transplant hospital with a Medicarecertified transplant program.

D-6, Parts I through III

Read §4029.5 through 4029.8. Complete entire
worksheet, if applicable.

Rev.

Complete

40-15

4001 (Cont.)

FORM CMS-2552-10

DRAFT

Part III - Calculation and Apportionment of Hospital-Based Facilities
A. Title XVIII - For SNF Only Reimbursed Under PPS.-Step

Worksheet

Instructions

E-3, Part VI

Read §4033.6. If applicable, complete lines 1 through 15 for
title XVIII SNF PPS services.

E-1, Part I

Read §4031.1. Complete this worksheet for title XVIII
services corresponding to Worksheet E-3, Part VI.

E-3, Part VI

Complete the remainder of this worksheet, lines 16 through
19.

B. Titles V and XIX - For Hospital, Subprovider(s), NF and ICF/IIDs.-Step

Worksheet

Instructions

E-3, Part VII

Read §4033.7. If applicable, complete entire worksheet for
titles V and XIX services. Use a separate worksheet for each
title.

C. Title XVIII - For Swing Bed-SNF and Titles V and XIX - For Swing Bed-NF.-Step

Worksheet

Instructions

E-2

Read §4032. Complete a separate copy of this worksheet
(lines 1 through 19) for each applicable health care program
for each applicable provider component. Only entries
applicable to title XVIII are made in column 2. Complete
lines 9, 13, and 17 of column 1 for titles V and XIX, and
columns 1 and 2 for title XVIII.

E-1, Part I

Read §4031.1. Complete this worksheet for title XVIII
services corresponding to Worksheet E-2 title XVIII
swing-bed SNF only.

E-2

Complete the remainder of this worksheet, lines 20 through
23.

40-16

Rev.

11-16

FORM CMS-2552-10

4001 (Cont.)

Part III - Calculation and Apportionment of Hospital-Based Facilities (Cont.)
D. Title XVIII Only - For Home Health Agency (HHA).-Step

Worksheet

Instructions

Read §4041. Complete entire worksheet, if applicable.

H-1, Parts I and II

Read §4042. Complete entire worksheet, if applicable.

H-2, Parts I and II

Read §§4043 through 4043.2. Complete entire worksheet, if
applicable.

H-3, Parts I and II

Read §§4044 through 4044.2. Complete entire worksheet, if
applicable.

H-4, Parts I and II

Read §§4045 through 4045.2. Complete entire worksheet, if
applicable.

H-5

Read §4046. Complete entire worksheet, if applicable.

E. Title XVIII- For ESRD.-Step

Worksheet

Instructions

I-1

Read §§4047 through 4048. Complete a separate worksheet
for renal dialysis department(s) and a separate worksheet for
home program dialysis department(s), if applicable.

I-2

Read §4049. Complete a separate worksheet for renal
dialysis department(s) and a separate worksheet for home
program dialysis department(s), if applicable.

I-3

Read §4050. Complete a separate worksheet for renal
dialysis department(s) and a separate worksheet for home
program dialysis department(s), if applicable.

I-4

Read §§4051. Complete a separate worksheet for renal
dialysis department(s) and a separate worksheet for home
program dialysis department(s), if applicable.

I-5

Read §4052. Complete only one worksheet combining all
renal dialysis departments and home program dialysis
departments, if applicable.

Rev. 10

40-17

4001 (Cont.)

FORM CMS-2552-10

11-16

Part III - Calculation and Apportionment of Hospital-Based Facilities (Cont.)
F. Title XVIII - For CMHC.-Step

Worksheet

Instructions

J-1, Parts I and II

Read §§4053 through 4053.2. Complete entire worksheet, if
applicable.

J-2, Part I

Read §§4054 and 4054.1. Complete entire worksheet, if
applicable.

J-2, Part II

Read §4054.2. Complete entire worksheet, if applicable.

J-3

Read §4055. Complete entire worksheet, if applicable.

J-4

Read §4056. Complete lines 1 through 4 for title XVIII
only.

G. Titles XVIII and XIX - For Provider Based-Hospice.-Step

Worksheet

Instructions

K-1

Read §4058. Complete entire worksheet, if applicable.

K-2

Read §4059. Complete entire worksheet, if applicable.

K-3

Read §4060. Complete entire worksheet, if applicable.

Read §4057. Complete entire worksheet, if applicable.

K-4, Parts I and II

Read §4061. Complete both worksheets, if applicable.

K-5, Parts I, II, and III

Read §§4062 through 4062.3. Complete all worksheets, if
applicable.

K-6

Read §4063. Complete entire worksheet, if applicable.

40-18

Rev. 10

DRAFT

FORM CMS-2552-10

4001 (Cont.)

Part III - Calculation and Apportionment of Hospital-Based Facilities (Cont.)
H. Titles V, XVIII, and XIX - For Hospital-Based RHC/FQHC.-Step

Worksheet

Instructions

M-1

Read §4066. Complete entire worksheet, if applicable.

M-2

Read §4067. Complete entire worksheet, if applicable.

M-3

Read §4068. Complete entire worksheet, if applicable.

M-4

Read §4069. Complete entire worksheet, if applicable.

M-5

Read §4070. Complete entire worksheet, if applicable, for
title XVIII only.

I. Titles V, XVIII, and XIX - For Hospital-Based FQHC.-Step

Worksheet

Instructions

N-1

Read §4071. Complete entire worksheet, if applicable.

N-2

Read §4071.1. Complete entire worksheet, if applicable.

N-3

Read §4071.2. Complete entire worksheet, if applicable.

N-4

Read §4071.3. Complete entire worksheet, if applicable.

N-5

Read §4071.4. Complete entire worksheet, if applicable, for
title XVIII only.

J. Titles V, XVIII, and XIX - For Hospital-Based Hospice.-Step

Worksheet

Instructions

O-1, O-2, O-3, O-4

Read §4072.1. Complete entire worksheet, if applicable.

Read §4072. Complete entire worksheet, if applicable.

O-5

Read §4072.2. Complete entire worksheet, if applicable.

O-6, Parts I and II

Read §4072.3. Complete both worksheets in entirety, if
applicable.

O-7

Read §4072.4. Complete entire worksheet, if applicable.

O-8

Read §4072.5. Complete entire worksheet, if applicable.

Rev.

40-19

4001 (Cont.)

FORM CMS-2552-10

DRAFT

Part IV - Calculation of Reimbursement Settlement
Step

Worksheet

Instructions

E, Part A

Read §§4030 and 4030.1. Complete lines 1 through 51 for
title XVIII for each applicable provider component subject
to IPPS.

E, Part B

Read §4030.2. Complete lines 1 through 27 for title XVIII
for each applicable provider component.

E-4

Read §4034. Complete entire worksheet.

E, Part A

Read §§4030 and 4030.1. Complete lines 52 through 71 for
title XVIII for each applicable provider component subject
to IPPS.

E-1, Part I

Read §4031.1. Complete this worksheet for title XVIII
services corresponding to Worksheet E, Part A.

E, Part A

Complete the remainder of this worksheet, lines 72 through
75.

E, Part B

Read §4030.2. Complete lines 28 through 40 for title XVIII
for each applicable provider component.

E-1, Part I

Read §4031.1. Complete this worksheet for title XVIII
services corresponding to Worksheet E, Part B.

E, Part B

Complete the remainder of this worksheet, lines 41 through
44.

E-3, Part I

Read §§4033 and 4033.1. If applicable, complete lines 1
through 18 for title XVIII for each applicable provider
component subject to TEFRA.

E-1, Part I

Read §4031.1. Complete this worksheet for title XVIII
services corresponding to Worksheet E-3, Part I.

E-3, Part I

Complete the remainder of this worksheet, lines 19 through
22.

E-3, Part II

Read §4033.2. If applicable, complete lines 1 through 31 for
title XVIII IPF PPS.

E-1, Part I

Read §4031.1. Complete this worksheet for title XVIII
services corresponding to Worksheet E-3, Part II.

E-3, Part II

Complete the remainder of this worksheet, lines 32 through
35.

40-20

Rev.

DRAFT

FORM CMS-2552-10

4001 (Cont.)

Part III - Calculation and Apportionment of Hospital-Based Facilities (Cont.)
Step

Worksheet

Instructions

E-3, Part III

Read §4033.3. If applicable, complete lines 1 through 32 for
title XVIII IRF PPS.

E-1, Part I

Read §4031.1. Complete this worksheet for title XVIII
services corresponding to Worksheet E-3, Part III.

E-3, Part III

Complete the remainder of this worksheet, lines 33 through
36.

E-3, Part IV

Read §4033.4. If applicable, complete lines 1 through 22 for
title XVIII LTCH PPS.

E-1, Part I

Read §4031.1. Complete this worksheet for title XVIII
services corresponding to Worksheet E-3, Part IV.

E-3, Part IV

Complete the remainder of this worksheet, lines 23 through
26.

E-3, Part V

Read §4033.5. If applicable, complete lines 1 through 30 for
title XVIII reasonable cost reimbursed providers.

E-1, Part I

Read §4031.1. Complete this worksheet for title XVIII
services corresponding to Worksheet E-3, Part V.

E-3, Part V

Complete the remainder of this worksheet, lines 31 through
34.

E-3, Part VI

Read §4033.6. If applicable, complete lines 1 through 15 for
title XVIII reasonable cost reimbursed providers.

E-1, Part I

Read §4031.1. Complete this worksheet for title XVIII
services corresponding to Worksheet E-3, Part VI.

E-3, Part VI

Complete the remainder of this worksheet, lines 16 through
19.

E-3, Part VII

Read §4033.7. If applicable, complete the entire worksheet
for titles V and XIX providers.

Rev.

40-21

4001 (Cont.)

FORM CMS-2552-10

DRAFT

Part V - Additional Data
Step

Worksheet

Instructions

Read §4040.
All providers maintaining fund type
accounting records must complete this worksheet.
Nonproprietary providers which do not maintain fund type
records complete the General Fund column only.

G-1

Read §4040.1. Complete entire worksheet.

G-2, Parts I and II

Read §4040.2. Complete entire worksheet.

G-3

Read §4040.3. Complete entire worksheet.

S-10, Parts I and II

Read §4012 through 4012.2. Acute care hospitals and CAHs
complete this worksheet.

S-12

Read §4012.20.
worksheet.

E-1, Part II

Read §4031.2 Acute care hospitals and CAHs complete this
worksheet.

S, Parts I, II, and III

Read §§4003.1 through 4003.3. Complete Part III, then
complete Parts I and II.

E-5

Read §4035. Contractors complete this worksheet.

40-22

Acute care hospitals complete this

Rev.

DRAFT
4002.

FORM CMS-2552-10

4002.1

SEQUENCE OF ASSEMBLY

The following examples of assembly of worksheets are provided so all providers are consistent in
the order of submission of their annual cost report. All providers using Form CMS-2552-10 must
adhere to this sequence. If worksheets are not completed because they are not applicable, do not
include blank worksheets in the assembly of the cost report.
4002.1 Sequence of Assembly for Hospital and Hospital Health Care Complex Providers
Participating in Medicare.--Cost report worksheets are assembled in alpha-numeric sequence
starting with the "S" series, followed by A, B, C, etc.
WorkForm CMS sheet Part
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10

Rev.

S
S-2
S-3
S-4
S-5
S-6
S-7
S-8
S-9
S-10
S-11
A
A-6
A-7
A-8
A-8-1
A-8-2
A-8-3
B
B
B-1
B-2
C
C
C
D
D
D
D
D
D
D
D
D
D
D
D
D
D

Health Care
Program (Title)

I - III
I and II
I, II, III, IV, and V

Component

Hospital-Based HHA
Renal Dialysis Department
Hospital-Based CMHC
Hospital-Based SNF
Hospital-Based RHC/FQHC
Hospital-Based Hospice
Hospital & CAH
Hospital-Based FQHC

I and II
I, II, and III
I, II, and III
I, II, III, IV, V, and VI
I
II
I
II
II
I
II
III
IV
V
II
V
I
II
III
IV
V
II
III

V
XIX
V
V
V
V
V
V
V
XVIII
XVIII
XVIII
XVIII
XVIII
XVIII
XVIII

Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Subprovider
Subprovider
Hospital
Hospital
Hospital
Hospital
Hospital
Subprovider
Subprovider

40-23

4002.1 (Cont.)

FORM CMS-2552-10

WorkForm CMS sheet Part

Health Care
Program (Title)

2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10

XVIII
XVIII
XVIII
XIX
XIX
XIX
XIX
XIX
XIX
XIX
V
V
V
V
XVIII
XVIII
XVIII
XIX
XIX
XIX
XIX
V, XVIII, and XIX
XVIII
XVIII
V
V
V
V
V
V
XVIII
XVIII
XVIII
XIX
XIX
XIX
XIX
XIX
XIX
XVIII
V, XVIII, and XIX
V, XVIII, and XIX
V, XVIII, and XIX
XVIII
XVIII
XVIII
XVIII
XVIII
XVIII
XVIII
XVIII
XVIII

40-24

D
D
D
D
D
D
D
D
D
D
D-1
D-1
D-1
D-1
D-1
D-1
D-1
D-1
D-1
D-1
D-1
D-2
D-2
D-2
D-3
D-3
D-3
D-3
D-3
D-3
D-3
D-3
D-3
D-3
D-3
D-3
D-3
D-3
D-3
D-4
D-5
D-5
D-5
D-6
E
E
E-1
E-1
E-1
E-1
E-1
E-1

V
III
III
I
II
III
IV
V
II
V
I, II, and IV
I, II, and IV
I and III
I and III
I, II, and IV
I, II, and IV
I and III
I, II, and IV
I, II, and IV
I and III
I and III
I
II
III

I, II, III, IV
I
II
II
I, II, III
A
B
Part I
Part I
Part I
Part I
Part I
Part I

DRAFT
Component
Subprovider
Swing Bed SNF
SNF
Hospital
Hospital
Hospital
Hospital
Hospital
Subprovider
Subprovider
Hospital
Subprovider
SNF
NF, ICF/IID
Hospital
Subprovider
SNF
Hospital
Subprovider
SNF
NF, ICF/IID
Hospital
Subprovider
Swing Bed SNF
Swing Bed NF
SNF
NF, ICF/IID
Hospital
Subprovider
Swing Bed SNF
Hospital
Subprovider
Swing Bed SNF
Swing Bed NF
SNF
NF, ICF/IID
Hospital
Subprovider
Hospital
Hospital
Hospital
IPF-Subprovider
IRF-Subprovider
Subprovider
Swing Bed SNF
SNF

Rev.

DRAFT

FORM CMS-2552-10

4002.1 (Cont.)

WorkForm CMS sheet Part

Health Care
Program (Title)

Component

HIT
V
V
XVIII
XIX
XIX
XVIII
XVIII
XVIII
XVIII
V and XIX
V and XIX
V and XIX
V and XIX
V and XIX
XVIII
XVIII

Hospital and CAH
Swing Bed SNF
Swing Bed NF
Swing Bed SNF
Swing Bed SNF
Swing Bed NF
Hospital
Subprovider
LTCH
SNF
Hospital
Subprovider - IPF
Subprovider - IRF
NF, ICF/IID
SNF
Hospital
Hospital

Rev.

E-1
II
E-2
E-2
E-2
E-2
E-2
E-3
I through V
E-3
II and III
E-3
IV
E-3
VI
E-3
VII
E-3
VII
E-3
VII
E-3
VII
E-3
VII
E-4
E-5
G
G-1
G-2
G-3
H
H-1 I and II
H-2 I and II
H-3 I and II
H-4 I and II
H-5
I-1 - I-5
I-1 - I-5
J-1 - J-2
J-3
J-4
K
K-1
K-2
K-3
K-4 I and II
K-5 I, II, and III
K-6
L
I, II and III
L
I, II and III
L-1
I
L-1
II
L-1
III
L-1
III
M-1
M-2
M-3
M-4
M-5
N-1
N-2
N-3
N-4
N-5

V, XVIII, and XIX
V, XVIII, and XIX
XVIII
I and II
V, XVIII, and XIX
XVIII

XVIII, XIX
V, XVIII, and XIX
V, XVIII, and XIX
V, XVIII, and XIX
V, XVIII, and XIX
V, XVIII, and XIX
V, XVIII, and XIX
V, XVIII, and XIX
XVIII
XVIII
XVIII
XVIII
XVIII

Hospital-based HHA
Hospital-based HHA
Hospital-based HHA
Hospital-based HHA
Hospital-based HHA
Hospital-based HHA
Renal Dialysis
Home Program Dialysis
CMHC
CMHC
CMHC
Hospital-based Hospice
Hospital-based Hospice
Hospital-based Hospice
Hospital-based Hospice
Hospital-based Hospice
Hospital-based Hospice
Hospital-based Hospice
Hospital
Subprovider
Hospital
Hospital
Hospital
Subprovider
Hospital-based RHC/FQHC
Hospital-based RHC/FQHC
Hospital-based RHC/FQHC
Hospital-based RHC/FQHC
Hospital-based RHC/FQHC
Hospital-based FQHC
Hospital-based FQHC
Hospital-based FQHC
Hospital-based FQHC
Hospital-based FQHC
40-25

4002.1 (Cont.)

FORM CMS-2552-10

WorkForm CMS sheet Part
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10

40-25.1

O
O-1
O-2
O-3
O-4
O-5
O-6
O-7
O-8

I and II

Health Care
Program (Title)

DRAFT
Component
Hospital-based Hospice
Hospital-based Hospice
Hospital-based Hospice
Hospital-based Hospice
Hospital-based Hospice
Hospital-based Hospice
Hospital-based Hospice
Hospital-based Hospice
Hospital-based Hospice

Rev.

01-22

FORM CMS-2552-10

4002.1 (Cont.)

This page is reserved for future use.

Rev. 17

40-25.2

4003
4003.

FORM CMS-2552-10

01-22

WORKSHEET S - HOSPITAL AND HEALTH CARE COMPLEX COST REPORT
CERTIFICATION AND SETTLEMENT SUMMARY

4003.1 Part I - Cost Report Status.--This section is to be completed by the provider and
contractor as indicated on the worksheet.
Lines 1 through 3, column 1-- The provider must check the appropriate box to indicate on line 1
or 2, whether this cost report is prepared electronically or manually. 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. For electronically prepared cost reports, indicate on
line 1, the date and time corresponding to the creation of the electronic file. The date and time
remain identifiers for the file by the contractor and are archived accordingly. This file is your
original submission and is not to be modified. If this is an amended cost report, enter on line 3 the
number of times the cost report has been amended.
Line 4, column 1--The provider must enter an “F” if this is a full cost report or an “L” for a low
Medicare utilization (requires prior contractor approval, see CMS Pub. 15-2, chapter 1, §110).
Line 5, column 1--The contractor enters the Healthcare Cost Report Information System (HCRIS)
cost report status code on line 5, column 1, that corresponds to the filing 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--The contractor enters the date (mm/dd/yyyy) an accepted cost report was
received from the provider.
Line 7, column 2--The contractor enters the 5-position contractor number.
Lines 8 and 9, column 2--If this is an initial cost report, enter “Y” for yes in the box on line 8. If
this is a final cost report, enter “Y” for yes in the box on line 9. If neither, enter “N”.
An initial report is the very first cost report for a particular provider CCN. A final cost report is a
terminating cost report for a particular provider CCN.
If the cost report is both initial and terminating in the same year (for example, the provider started
Medicare and decided to leave the program in the same year), and the cost report is a full Medicare
utilization report, the contractor must submit to HCRIS an as submitted and a final settled report.
The as submitted extract is the initial report, and the final settled is the final report.
If the cost report is both initial and terminating in the same year, and the cost report is a No or Low
Medicare utilization, the contractor must only submit to HCRIS a final settled with or without
audit report. This is the only situation in which a HCRIS extract would be both initial and final.
Line 10, column 3--The contractor enters the Notice of Program Reimbursement (NPR) date
(mm/dd/yyyy). The NPR date must be present if the cost report status code is 2 or 3.
Line 11, column 3--Enter software vendor code of the cost report software used by the contractor
to process this HCRIS cost report file. Use “4” for HFS or “3” for KPMG.
Line 12, column 3--If this is a reopened cost report (response to line 5, column 1 is “4”), the
contractor enters the number of times the cost report has been reopened.

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Rev. 17

DRAFT

FORM CMS-2552-10

4003.3 (Cont.)

4003.2 Part II - Certification by a Chief Financial Officer or Administrator.--The signatory,
either a chief financial officer (CFO) or administrator of the hospital, reads, prepares, and signs
this certification after cost report completion.
Line 1.--The signatory (administrator or Chief Financial Officer) must:
• when signing electronically through the ECR software, sign in column 1 as provided in
42 CFR 413.24(f)(4)(iv)(C)(1); and in column 2, enter “Y” (for yes) to check the
electronic signature checkbox to transmit the cost report electronically with an electronic
signature; or
• when signing outside the ECR software, sign in column 1 as provided in
42 CFR 413.24(f)(4)(iv)(C)(1); and enter a check mark 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.
4003.3 Part III - Settlement Summary.--Enter the balance due to or due from the applicable
program for each applicable component of the hospital or hospital healthcare complex. Transfer
settlement amounts as follows:
Hospital/
Hospital Component
Hospital

Hospital- PARHM

Title V
Wkst. E-3,
Part VII,
line 42

Title XVIII
Part A
Wkst. E,
Part A,
line 74
or
Wkst. E-3,
Part I,
line 21
or
Wkst. E-3,
Part II,
line 34
or
Wkst. E-3,
Part III,
line 35
or
Wkst. E-3,
Part IV,
line 25
or
Wkst. E-3,
Part V,
line 33
Wkst. E,
Part A,
Line 74.01

FROM
Title XVIII
Part B
Wkst. E,
Part B,
line 43

HIT
Wkst. E-1,
Part II,
line 32

Title XIX
Wkst. E-3,
Part VII,
line 42

Wkst. E,
Part B,
Line 43.01

Wkst. E-3,
Part V,
Line 33.01

Rev.

40-27

4003.3 (Cont.)

FORM CMS-2552-10

DRAFT

FROM
Hospital/
Hospital Component

Title V

Title XVIII
Part A

Title XVIII
Part B

Subprovider-IPF

Wkst. E-3,
Part VII,
line 42

Wkst. E-3,
Part II,
line 34

Wkst. E
Part B,
line 43

Wkst. E-3,
Part VII,
line 42

Subprovider-IRF

Wkst. E-3
Part VII,
line 42

Wkst. E-3,
Part III,
line 35

Wkst. E
Part B,
line 43

Wkst E-3,
Part VII
line 42

Wkst. E-2,
col. 1,
line 22

Wkst. E-2,
col. 2,
line 22

Wkst. E-2,
col. 1,
line 22

col. 1,
line 22.01

Wkst. E-2,
col. 2,
line 22.01

HIT

Title XIX

Subprovider-Other
Swing Bed - SNF
Swing-Bed-PARHM

Wkst. E-2,

Swing Bed - NF

Wkst. E-2,
col. 1,
line 22

N/A

Wkst. E-2
col. 1,
line 22

SNF

Wkst. E-3,
Part VII,
line 42

Wkst. E-3,
Part VI,
line 18

Wkst. E,
Part B,
line 43

Wkst. E-3,
Part VII,
line 42

NF, ICF/IID

Wkst. E-3,
Part VII,
line 42

N/A

Wkst. E-3,
Part VII
line 42

Home Health
Agency

Wkst. H-4,
Part II,
sum of
cols.1&2,
line 34

Wkst. H-4,
Part II,
col. 1,
line 34

Wkst. H-4,
Part II,
col. 2,
line 34

Wkst. H-4,
Part II,
sum of
cols.1 & 2,
line 34

Outpatient
Rehabilitation
Providers

Wkst.
J-3,
line 29

N/A

Wkst.
J-3,
line 29

Hospital-Based
RHC/FQHC*

Wkst.
M-3,
line 29

N/A

Wkst.
M-3,
line 29

N/A

Wkst.
N-4,
line 19

Hospital-based
FQHC**

*For hospital-based FQHCs for cost reporting periods beginning prior to October 1, 2014.
**For hospital-based FQHCs for cost reporting periods beginning on and after October 1, 2014.

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Rev.

01-22

FORM CMS-2552-10

4004.

4004.1

WORKSHEET S-2 - HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX
IDENTIFICATION DATA

This worksheet consists of two parts:
Part I - Hospital and Hospital Health Care Complex Identification Data
Part II - Hospital and Hospital Health Care Complex Reimbursement Questionnaire
4004.1 Part I - Hospital and Hospital Health Care Complex Identification Data.--The
information required on this worksheet is needed to properly identify the provider. The responses
to all lines are Yes or No unless otherwise indicated.
Line descriptions
Lines 1 and 2--Enter the street address, post office box (if applicable), the city, state, ZIP code,
and county of the hospital.
Lines 3 through 17--Enter on the appropriate lines and columns indicated the component names,
CMS certification numbers (CCN), core based statistical area (CBSA) codes of the physical
location of the provider’s primary operations (non-CBSA (rural) codes are assembled by placing
the digits “999” in front of the two digit state code, e.g., for the State of Maryland the non-CBSA
code is 99921), provider type, and certification dates of the hospital and its various components,
if any. Indicate for each health care program (titles V, XVIII, or XIX), the payment system
applicable to the hospital and its various components by entering P, T, O, or N in the appropriate
column to designate PPS, TEFRA, OTHER, or NOT APPLICABLE, respectively. The “PPS”
payment systems include the Inpatient Prospective Payment System (IPPS), the Inpatient
Psychiatric Facility Prospective Payment System (IPF PPS), the Long Term Care Hospital
Prospective Payment System (LTCH PPS) and the Inpatient Rehabilitation Facility Prospective
Payment System (IRF PPS). The “TEFRA” payment system includes long term care hospitals
(LTCH) classified as extended neoplastic disease care hospitals (previously referred to as
“subclause (II)” LTCHs), children’s hospitals, cancer hospitals, Religious Non-Medical Health
Care Institutions (RNHCIs), and hospitals located outside the 50 States, the District of Columbia,
and Puerto Rico (i.e., hospitals located in the U.S. Virgin Islands, Guam, the Northern Mariana
Island, and American Samoa). The “OTHER” payment system includes cost reimbursed hospitals
such as critical access hospitals (CAHs) and new TEFRA hospitals exempt from the rate of
increase limits.
Column 4--Indicate, as applicable, the number listed below which best corresponds with the type
of services provided.
1
2
3
4
5
6

= General Short Term (includes CAHs)
= General Long Term
= Cancer
= Psychiatric
= Rehabilitation
= Religious Non-Medical Health Care Institution

7
8
9
10
11

= Children
= Reserved for future use
= Other
= Extended Neoplastic Disease Care
= Indian Health Services

If your hospital services various types of patients, indicate "General - Short Term" or "General Long Term," as appropriate.
NOTE: LTCHs are hospitals organized to provide long term treatment programs with average
lengths of stay greater than 25 days. Some hospitals may be certified as other than
LTCHs, but also have average lengths of stay greater than 25 days.
If your hospital cares for only a special type of patient (such as cancer patients), indicate the special
group served. If you are not one of the hospital types described in items 1 through 8 above,
indicate 9 for "Other".
Rev. 17

40-29

4004.1 (Cont.)

FORM CMS-2552-10

01-22

Line 3--This is an institution which meets the requirements of §1861(e) or §1861(mm)(1) of
the Act and participates in the Medicare program or is a federally controlled institution approved
by CMS.
Line 4--The distinct part IPF is a portion of a hospital which has been issued a subprovider CCN
because it offers a clearly different type of service from the remainder of the hospital with such
services reimbursed under inpatient psychiatric PPS. Effective for cost reporting periods
beginning on or after October 1, 2019, an IPF is permitted to have an IRF subunit, however, an
IPF may not have an IPF subunit. (See 42 CFR 412.25(d).)
Line 5-- The distinct part IRF is a portion of a hospital which has been issued a subprovider CCN
because it offers a clearly different type of service from the remainder of the hospital with such
services reimbursed under inpatient rehabilitation PPS. Effective for cost reporting periods
beginning on or after October 1, 2019, an IRF is permitted to have an IPF subunit, however, an
IRF may not have an IRF subunit. (See 42 CFR 412.25(d).)
Line 6--This is a portion of a general hospital defined as non-Medicare certified and not included
in lines 4 through 18, which offers a clearly different type of service from the remainder of the
hospital.
Line 7--Medicare swing-bed services are paid under the SNF PPS system (indicate payment
system as “P”). CAHs are reimbursed on a cost basis for swing-bed services and should indicate
“O” as the payment system. Rural hospitals with fewer than 100 beds may be approved by CMS
to use these beds interchangeably as hospital and skilled nursing facility beds with payment based
on the specific care provided, as authorized by §1883 of the Act. (See CMS Pub. 15-1, chapter 22,
§§2230-2230.6.)
Line 8--Swing bed-NF services are not payable under the Medicare program but are payable under
State Medicaid programs if included in the Medicaid State plan. Rural hospitals with fewer than
100 beds that have a Medicare swing-bed agreement approved by CMS and that are approved by
the State Medicaid agency to use these beds interchangeably as hospital and other nursing facility
beds, with payment based on the specific level of care provided, as authorized by §1913 of the Act.
Line 9--This is a distinct part skilled nursing facility that has been issued an SNF identification
number and which meets the requirements of §1819 of the Act. A hospital complex cannot contain
more than one hospital-based SNF (includes a composite distinct part) or hospital-based NF. (See
42 CFR 483.5(2)(v).)
Line 10--This is a distinct part nursing facility which has been issued a separate identification
number and which meets the requirements of §1905 of the Act. (See 42 CFR 441.400 for standards
for other nursing facilities, for other than facilities for individuals with intellectual disabilities, and
for facilities for individuals with intellectual disabilities.) If your State recognizes only one level
of care, i.e., skilled, do not complete any lines designated as NF and report all activity on the SNF
line for all programs. The NF line is used by facilities having two levels of care, i.e., either 100 bed
facility all certified for NF and partially certified for SNF or 50 beds certified for SNF only and
50 beds certified for NF only. The contractor will reject a cost report attempting to report more
than one nursing facility.
If the facility operates an intermediate care facility for individuals with intellectual disabilities
(ICF/IID), subscript line 10 to 10.01 and enter the data on that line. Note: Subscripting is allowed
only for the purpose of reporting an ICF/IID.
Line 11--This is any other hospital-based long term care facility not listed above. The beds in this
unit are not certified for titles V, XVIII, or XIX. The data on this line cannot be used for Medicare
reimbursement. Treat this as a non-reimbursable cost center since it is not part of the Medicare
certified hospital.

40-30

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FORM CMS-2552-10

4004.1 (Cont.)

Line 12--This is a distinct part HHA that has been issued an HHA identification number and which
meets the requirements of §§1861(o) and 1891 of the Act. If you have more than one hospitalbased HHA, subscript this line, and report the required information for each HHA.
Line 13--This is a distinct entity that operates exclusively for the purpose of providing surgical
services to patients not requiring hospitalization and which meets the conditions for coverage in
42 CFR 416, Subpart B. The ambulatory surgery center (ASC) operated by a hospital must be a
separately identifiable entity which is physically, administratively, and financially independent
and distinct from other operations of the hospital. (See 42 CFR 416.30(f).) Under this restriction,
hospital outpatient departments providing ambulatory surgery (among other services) are not
eligible. (See 42 CFR 416.120(a).)
Line 14--This is a distinct part hospice and separately certified component of a hospital which
meets the requirements of §1861(dd) of the Act. No payment designation is required in columns 6,
7, and 8.
Lines 15 and 16--Enter the applicable information for hospital-based rural health clinics (RHCs)
on line 15 and for hospital-based federally qualified health centers (FQHCs) on line 16. These
lines are used by hospital-based RHCs and/or FQHCs which have been issued a CCN and meet
the requirements of §1861(aa) of the Act. If you have more than one hospital-based RHC, report
them on subscripts of line 15. If you have more than one hospital-based FQHC, report them on
subscripts of line 16. Report the required information in the appropriate column for each.
Hospital-based RHCs and FQHCs may elect to file a consolidated cost report pursuant to
CMS Pub. 100-02 (Medicare Claims Processing Manual), chapter 13, §80.2. Do not subscript
lines 15 or 16 to report RHCs or FQHCs affiliated with the consolidated group that elects to file
under the consolidated cost reporting method; report only the hospital-based primary RHC and/or
hospital-based primary FQHC of the consolidated group on lines 15 and/or 16, as applicable. A
new RHC/FQHC that begins after the start of a cost reporting period cannot be added to the
consolidated worksheets until the subsequent full cost reporting period. A written request to
consolidate the new RHC/FQHC must be submitted to the contractor in advance of the reporting
period and must be approved by the contractor prior to the start of the reporting period to be
reported as consolidated. In order to qualify for consolidated reporting, all RHCs/FQHCs in the
group must be owned, leased, or through any other device, controlled by one organization. Once
the election to use a consolidated cost report is made, the RHC/FQHC may not revert to individual
reporting without the prior approval of the contractor. See §§4010 and 4010.1 for further
instructions.
Line 17--This line is used by hospital-based community mental health centers (CMHCs).
Subscript this line as necessary to accommodate multiple CMHCs (lines 17.00 through 17.09).
Also subscript this line to accommodate CORFs (lines 17.10-17.19), OPTs (lines 17.20 through
17.29), OOTs (lines 17.30 through 17.39) and OSPs (line 17.40 through 17.49). (See §4095,
Exhibit 2, Table 4, Part III.)
Line 18--If this facility operates a renal dialysis facility (CCN XX-2300 through XX-2499), a renal
dialysis satellite (CCN XX-3500 through XX-3699), and/or a special purpose renal dialysis facility
(CCN XX-3700 through XX-3799), enter in column 2 the applicable CCN. Subscript this line as
applicable.
Line 19--For any component type not identified on lines 3 through 18, enter the required
information in the appropriate column.
Line 20--Enter the inclusive dates covered by this cost report.
In accordance with
42 CFR 413.24(f), you are required to submit periodic reports of your operations which generally
cover a consecutive 12-month period of your operations. (See CMS Pub. 15-2, chapter 1,
§§102.1-102.3, for situations where you may file a short period cost report.)

Rev. 17

40-31

4004.1 (Cont.)

FORM CMS-2552-10

01-22

Line 21--Indicate the type of control under which the hospital operates:
1 = Voluntary Nonprofit, Church
2 = Voluntary Nonprofit, Other
3 = Proprietary, Individual
4 = Proprietary, Corporation
5 = Proprietary, Partnership
6 = Proprietary, Other
7 = Governmental, Federal

8
9
10
11
12
13

= Governmental, City-County
= Governmental, County
= Governmental, State
= Governmental, Hospital District
= Governmental, City
= Governmental, Other

Line 22--Does your facility qualify and is it currently receiving payments for disproportionate
share (DSH) hospital adjustment, in accordance with 42 CFR 412.106? Enter in column 1, “Y”
for yes or “N” for no. Is this facility subject to the provisions of 42 CFR 412.106(c)(2)
(Pickle Amendment hospitals)? Enter in column 2, “Y” for yes or “N” for no.
Line 22.01--For cost reporting periods that overlap or begin on or after October 1, 2013, did this
hospital receive interim uncompensated care payments? Enter in column 1, “Y” for yes or “N”
for no, for the portion of the cost reporting period prior to October 1. Enter in column 2, “Y” for
yes or “N” for no, for the portion of the cost reporting period beginning on or after October 1. For
cost reporting periods that begin on October 1, enter “N” for no in column 1 and complete
column 2; however, when the cost reporting period begins on October 1 and overlaps October 1
of the subsequent year, complete column 1 for the first period (October 1 through September 30)
and complete column 2 for the remainder of the cost reporting period.
Line 22.02--Is this a newly merged hospital that requires final uncompensated care payments to
be determined at cost report settlement? Enter in column 1, “Y” for yes or “N” for no, for the
portion of the cost reporting period prior to October 1. Enter in column 2, “Y” for yes or “N” for
no, for the portion of the cost reporting period on and after October 1. For a newly merged hospital
as defined in the IPPS FY 2015 final rule, 79 FR 50022 (August 22, 2014), the final Factor 3
would be recalculated based on the Medicaid days and SSI days reported on the cost report used
for the applicable fiscal year since the Factor 3 that was published in the final rule did not reflect
the merger. For example, for a newly merged hospital that merged in FY 2015, the numerator of
its Factor 3 would be recalculated based on the FY 2015 SSI days and the Medicaid days reported
on its 2015 cost report. See 79 FR 50021 (August 22, 2014).
For the purpose of this question, a merger is defined as an acquisition where the Medicare provider
agreement of one hospital is subsumed into the provider agreement of the surviving provider. We
would not consider a merger to be an acquisition where a new owner voluntarily terminates the
provider agreement of the hospital it purchased by rejecting assignment of the previous owner’s
provider agreement.
Line 22.03--For cost reporting periods ending on or after October 1, 2014, and before
October 1, 2016, 42 CFR 412.102 provides for a 2-year transition to a rural DSH payment amount
from an urban DSH payment amount, for hospitals that received a geographic reclassification from
urban to rural under the OMB standards for delineating statistical areas adopted by CMS in
FY 2015. Impacted hospitals whose DSH payment adjustment exceeds 12 percent will receive 2/3
of the difference between the urban and rural operating DSH for FY 2015 and 1/3 of the difference
between the urban and rural operating DSH for FY 2016. Did this hospital receive a geographic
reclassification from urban to rural as a result of the OMB standards for delineating statistical areas
adopted by CMS in FY 2015? Enter in column 1, “Y” for yes or “N” for no for the portion of the
cost reporting period prior to October 1. Enter in column 2, "Y" for yes or "N" for no for the
portion of the cost reporting period occurring on or after October 1. Does this hospital contain at
least 100, but not more than 499 beds (as counted in accordance with 42 CFR 412.105)? Enter in
column 3, “Y” for yes or “N” for no.
Line 22.04--For cost reporting periods ending on or after October 1, 2020, and before
October 1, 2022, the FY 2021 IPPS final rule (CMS-1735-F; 85 FR 58746, September 18, 2020)
provides for a 2-year transition (in accordance with 42 CFR 412.102) to a rural DSH payment
40-31.1

Rev. 17

DRAFT

FORM CMS-2552-10

4004.1 (Cont.)

amount from an urban DSH payment amount, for hospitals that received a geographic
reclassification from urban to rural under the OMB standards for delineating statistical areas
adopted by CMS in FY 2021. Impacted hospitals whose DSH payment adjustment exceeds
12 percent will receive 2/3 of the difference between the urban and rural operating DSH for
FY 2021 and 1/3 of the difference between the urban and rural operating DSH for FY 2022. Did
this hospital receive a geographic reclassification from urban to rural as a result of the OMB
standards for delineating statistical areas adopted by CMS in FY 2021? Enter in column 1, “Y”
for yes or “N” for no for the portion of the cost reporting period prior to October 1. Enter in
column 2, “Y” for yes or “N” for no for the portion of the cost reporting period occurring on or
after October 1. Does this hospital contain at least 100, but not more than 499 beds (as counted in
accordance with 42 CFR 412.105)? Enter in column 3, “Y” for yes or “N” for no.
Line 23--Indicate in column 1 the method used to capture Medicaid (title XIX) days reported on
lines 24 and/or 25 of this worksheet during the cost reporting period by entering a “1” if days are
based on the date of admission, “2” if days are based on census days (also referred to as the day
count), or “3” if days are based on the date of discharge. Is the method of identifying the days in
the current cost reporting period different from the method used in the prior cost reporting period?
Enter in column 2, “Y” for yes or “N” for no.
NOTE FOR LINES 24 AND 25: Columns 1 through 6 are mutually exclusive. For example, if
patient days are entered in column 1, those days may not be entered in any other columns.
Effective for cost reporting periods beginning on or after October 1, 2018, a cost report
will be rejected when submitted without listings supporting the DSH eligible days
reported on lines 24 and 25 (42 CFR 413.24(f)(5)). Exhibit 3A presents the standardized
format for the information required for cost reporting periods beginning on or after
October 1, 2022, to support the DSH eligible days reported (see exhibit for instructions
and listing presented at the end of §4004.1.) Submit separate listings for the DSH eligible
days reported on lines 24 and 25. Report days for each column as follows:
Column 1: Enter the number of in-state Medicaid paid days. An in-state Medicaid paid
day is an in-state day of inpatient care furnished to a patient eligible for
inpatient benefits under an approved State Medicaid plan or eligible for
inpatient benefits, or regarded as such, under a waiver authorized under
section 1115(a)(2) of the Act on that day and for which the hospital received
payment from Medicaid. This patient cannot also be entitled to Medicare
Part A.
Column 2: Enter the number of in-state Medicaid eligible unpaid days. An in-state
Medicaid eligible unpaid day is an in-state day of inpatient care furnished to a
patient eligible for inpatient benefits under an approved State Medicaid plan
or eligible for inpatient benefits, or regarded as such, under a waiver
authorized under section 1115(a)(2) of the Act on that day and for which the
hospital has not received payment from Medicaid. This patient cannot also be
entitled to Medicare Part A. Reasons for non-payment could be related to the
provider not billing timely, days that are beyond the number of days for which
a State will pay, days that are utilized by a Medicaid beneficiary prior to an
admission approval but for which a valid enrollment is determined within the
prescribed period, and days for which payment is made by a third party.
Column 3: Enter the number of out-of-state Medicaid paid days. An out-of-state Medicaid
paid day is an out-of-state day of inpatient care furnished to a patient eligible
for inpatient benefits under an approved State Medicaid plan or eligible for
inpatient benefits, or regarded as such, under a waiver authorized under
section 1115(a)(2) of the Act on that day and for which the hospital received
payment from Medicaid. This patient cannot also be entitled to Medicare
Part A.

Rev.

40-31.2

4004.1 (Cont.)

FORM CMS-2552-10

DRAFT

Column 4: Enter the number of out-of-state Medicaid eligible unpaid days. An out-of-state
Medicaid eligible unpaid day is an out-of-state day of inpatient care furnished
to a patient eligible for inpatient benefits under an approved State Medicaid
plan or eligible for inpatient benefits, or regarded as such, under a waiver
authorized under section 1115(a)(2) of the Act on that day and for which the
hospital has not received payment from Medicaid. This patient cannot also be
entitled to Medicare Part A. Reasons for non-payment could be related to the
provider not billing timely, days that are beyond the number of days for which
a State will pay, days that are utilized by a Medicaid beneficiary prior to an
admission approval but for which a valid enrollment is determined within the
prescribed period, and days for which payment is made by a third party.
Column 5: Enter the number of Medicaid health maintenance organization (HMO) days,
both in-state and out-of-state. A Medicaid HMO day is a paid and/or eligible
but unpaid day of inpatient care furnished to a Medicaid beneficiary who is
eligible for Medicaid under a State plan approved under title XIX through a
HMO or a managed care organization (MCO). This patient cannot also be
entitled to Medicare Part A.
Column 6: Enter other Medicaid days. Other Medicaid days are only labor and delivery
days reported on Worksheet S-3, Part I, column 7, line 32.
Line 24--If line 23, column 1, is “3” and this is an IPPS provider, enter the in-state Medicaid paid
days in column 1 (report these days on Worksheet S-3, Part I, column 7, line 1, and lines 8
through 13, as applicable), the in-state Medicaid eligible but unpaid days in column 2 (report these
days on Worksheet S-3, Part I, column 7, line 2, for adult and pediatric patients and line 13 for
nursery patients, as applicable), the out-of-state Medicaid paid days in column 3 (report these days
on Worksheet S-3, Part I, column 7, line 2, for adult and pediatric patients and line 13 for nursery
patients, as applicable), the out-of-state Medicaid eligible but unpaid days in column 4 (report
these days on Worksheet S-3, Part I, column 7, line 2, for adult and pediatric patients and line 13,
for nursery patients, as applicable), the in-state and out-of-state Medicaid HMO paid and in-state
and out-of-state Medicaid HMO eligible but unpaid days in column 5 (report these days on
Worksheet S-3, Part I, column 7, line 2, for adult and pediatric patients and line 13, for nursery
patients, as applicable). Enter only labor and delivery days (reported on Worksheet S-3, Part 1,
column 7, line 32) as “Other Medicaid days” in column 6. If line 23, column 1, is “1” or “2”, enter
the Medicaid days based on each column description; however, these days may not equal the
Medicaid days reported by discharge on Worksheet S-3, Part I. Do not include swing-bed,
observation or hospice days in any columns on this line. See 42 CFR 412.106(a)(1)(ii) and
412.106(b)(4).
Line 25--If line 23, column 1, is “3” and this provider is an IRF or contains an IRF unit, enter the
in-state Medicaid paid days in column 1, (report IRF days on Worksheet S-3, Part I, column 7,
line 1 or IRF unit days on Worksheet S-3, Part I, column 7, line 17), the in-state Medicaid eligible
but unpaid days in column 2 (report IRF days on Worksheet S-3, Part I, column 7, line 2, or IRF
unit days on Worksheet S-3, Part I, column 7, line 4), the out-of-state Medicaid paid days in
column 3 (report IRF days on Worksheet S-3, Part I, column 7, line 2, or IRF unit days on
Worksheet S-3, Part I, column 7, line 4), the out-of-state Medicaid eligible but unpaid days in
column 4 (report IRF days on Worksheet S-3, Part I, column 7, line 2, or IRF unit days on
Worksheet S-3, Part I, column 7, line 4), the in-state and out-of-state Medicaid HMO paid and
in-state and out-of-state Medicaid HMO eligible but unpaid days in column 5 (report IRF days on
Worksheet S-3, Part I, column 7, line 2, or IRF unit days on Worksheet S-3, Part I, column 7,
line 4). Do not enter any days in column 6 for cost reporting periods beginning on or after
October 1, 2012. If line 23, column 1, is “1” or “2”, enter the Medicaid days based on each column
description; however, these days may not equal the Medicaid days reported by discharge on
Worksheet S-3, Part I. Do not include swing-bed, observation or hospice days in any columns on
this line.
Line 26--For the Standard geographic classification (not wage), what is your status at the
beginning of the cost reporting period. Enter “1” for urban or “2” for rural.
40-31.3

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FORM CMS-2552-10

4004.1 (Cont.)

Line 27--For the Standard geographic classification (not wage), what is your status at the end of
the cost reporting period. Enter “1” for urban or “2” for rural. If applicable, enter the effective
date of the geographic reclassification in column 2.
Lines 28 through 34--Reserved for future use.
Line 35--If this is a sole community hospital (SCH), enter the number of periods (0, 1, or 2) within
this cost reporting period that SCH status was in effect.
Line 36--Enter the beginning and ending dates of SCH status during this cost reporting period.
Subscript line 36 if more than one period is identified for this cost reporting period and enter
multiple dates. Multiple dates are created where there is a break in the date between SCH status,
i.e., for calendar year provider SCH status dates are 1/1/2010 through 6/30/2010 and 9/1/2010
through 12/31/2010.
Line 37--If this is a Medicare-dependent, small rural hospital (MDH), enter the number of periods
within this cost reporting period that MDH status was in effect.
Line 37.01--Did this hospital lose their MDH status because they are no longer in a rural area due
to the implementation of the new OMB delineations in FY 2015, and they did not reclassify from
urban to rural under the regulations at §412.103 before January 1, 2016? Enter “Y” for yes or “N”
for no. If yes, calculate the MDH transition payment on Worksheet E, Part A, for portions of the
current cost reporting period that overlap or fall within January 1, 2016, and September 30, 2017.
Do not respond to this question for cost reporting periods that begin on or after October 1, 2017.
Line 38--If line 37 is 1, enter the beginning and ending date of MDH status during this cost
reporting period. If line 37 is greater than 1, subscript this line and enter the applicable beginning
and ending dates accordingly.

Rev.

40-31.4

4004.1 (Cont.)

FORM CMS-2552-10

DRAFT

Line 39--For cost reporting periods that overlap or begin on or after October 1, 2010, does the
hospital qualify for the inpatient hospital adjustment for low-volume hospitals for a portion of the
cost reporting period? Enter in column 1 “Y” for yes or “N” for no. If column 1 is “Y”, does the
facility meet the mileage requirements in accordance with 42 CFR 412.101(b)(2)(i), (ii), or (iii)?
Enter in column 2, “Y” for yes or “N” for no. Hospitals are required to request low-volume status
in writing to their contractor and provide documentation that they meet the mileage criteria.
The response to these questions determines the completion of the low-volume calculation
adjustment.
NOTE: 42 CFR 412.101(c)(1) provides for a low-volume adjustment for qualifying
hospitals for federal fiscal years (FFYs) 2005 through 2010, and FFY 2023 and subsequent
federal fiscal years. Qualifying hospitals, those hospitals more than 25 road miles from the
nearest subsection (d) hospital and with fewer than 200 total discharges, receive a payment
adjustment of an additional 25 percent for each Medicare discharge.
42 CFR 412.101(c)(2) provides for a temporary change in the low-volume adjustment for
qualifying hospitals for FFYs 2011 through 2018:
•Those hospitals with 200 or fewer Medicare discharges will receive an adjustment of
an additional 25 percent for each Medicare discharge; and,
•Those with more than 200 and fewer than 1,600 Medicare discharges will receive an
adjustment of an additional percentage for each Medicare discharge. This adjustment
is calculated using the formula [(4/14) - (Medicare discharges/5600)].
To qualify as a low-volume hospital, the hospital must meet both of the following criteria:
•Be more than 15 road miles from the nearest subsection (d) hospital; and,
•Have fewer than 1,600 Medicare discharges based on the latest available Medicare
Provider Analysis and Review (MedPAR) data as determined by CMS.
42 CFR 412.101(c)(3) provides for a temporary change in the low-volume adjustment for
qualifying hospitals for FFYs 2019 through 2022 as follows:
•Those hospitals with 500 or fewer total discharges will receive an adjustment of an
additional 25 percent for each Medicare discharge; and,
•Those with more than 500 and fewer than 3,800 total discharges will receive an
adjustment of an additional percentage for each Medicare discharge. This adjustment
is calculated using the formula [(95/330) - (total discharges/13,200)].
To qualify as a low-volume hospital, the hospital must meet both of the following criteria:
•Be more than 15 road miles from the nearest subsection (d) hospital; and,
•Have fewer than 3,800 total discharges based on the hospital’s most recently submitted
cost report.

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FORM CMS-2552-10

4004.1 (Cont.)

Line 40--Section 3008 of the Affordable Care Act (ACA 2010) established the Hospital Acquired
Condition (HAC) Reduction Program, beginning in FFY 2015. Enter in column 1, “Y” for yes or
“N” for no if your hospital is subject to the HAC reduction adjustment for discharges occurring
prior to October 1. For cost reporting periods that overlap October 1, 2014, enter “N” in column 1.
Enter in column 2, “Y” for yes or “N” for no if your hospital is subject to the HAC reduction
adjustment for discharges occurring on or after October 1.
Lines 41 through 44--Reserved for future use.
Line 45--Does your facility qualify and receive capital payments for disproportionate share in
accordance with 42 CFR 412.320? Enter “Y” for yes and "N" for no.
Line 46--Are you eligible for the exception payment for extraordinary circumstances pursuant to
42 CFR 412.348(f)? Enter “Y” for yes or “N” for no. If yes, complete Worksheets L, Part III, and
L-1.
Line 47--Is this a new hospital under 42 CFR 412.300(b) (PPS capital)? Enter “Y” for yes or “N”
for no for the respective programs.
Line 48--If line 47 is yes, do you elect full federal capital payment? Enter “Y” for yes or “N” for
no for the respective programs.
Lines 49 through 55--Reserved for future use.
NOTE: CAHs complete question 107 in lieu of question 57.
Line 56--Is this a hospital involved in training residents in approved graduate medical education
(GME) programs? Enter “Y” for yes or “N” for no in column 1. The BBRA provided that
payments that are made to teaching hospitals for costs of direct GME associated with services to
Medicare Advantage (MA) enrollees will be reduced by an estimated percentage in each calendar
year (CY). For column 2, if the response to column 1 is “Y”, or if this hospital was involved in
training residents in approved GME programs in the prior year or penultimate year, and you are
impacted by CR 11642 (or applicable CRs) MA direct GME payment reduction, enter “Y” for yes;
otherwise, enter “N” for no in column 2.
Line 57--If line 56 is yes, is this the first cost reporting period in which you are training residents
in approved programs? Enter “Y” for yes or “N” for no in column 1. If column 1 is yes, were
residents training during the first month of the cost reporting period? Enter “Y” for yes or “N” for
no in column 2. If column 2 is yes, complete Worksheet E-4. If column 2 is “N”, complete
Worksheets D, Parts III and IV, and D-2, Part II, if applicable.
Line 58--If line 56 is “Y” for yes, did you elect cost reimbursement for physician direct medical
and surgical services as defined in 42 CFR 415.160 and CMS Pub. 15-1, chapter 21, §2148? Enter
“Y” for yes or “N” for no. If yes, complete Worksheet D-5.
Line 59--Are you claiming costs of interns and residents (I&R) in unapproved programs on
Worksheet A, column 7, line 100? Enter “Y” for yes or “N” for no. If yes, complete
Worksheet D-2, Part I.

Rev.

40-31.6

4004.1 (Cont.)

FORM CMS-2552-10

DRAFT

Line 60--Are you claiming nursing and allied health education (NAHE) costs for any programs
approved in accordance with 42 CFR 413.85(e)? Enter “Y” for yes or “N” for no in column 1. If
your hospital does not have an approved NAHE program that meets the criteria in
42 CFR 413.85(e), or if all the NAHE costs are for educational activities treated as normal
operating costs as defined in 42 CFR 413.85(h)(6), enter “N” for no. Additionally, 42 CFR 413.87
provides for additional payments to hospitals for costs of NAHE services to MA enrollees. If the
response to column 1 is “Y”, are you impacted by CR 11642 (or applicable CRs) NAHE MA
payment adjustment? Enter “Y” for yes or “N” for no in column 2. If the response to line 60 is
no, do not complete subscripts for line 60.
Effective for cost reporting periods ending on or after September 30, 2017, if the response to
line 60, column 1, is yes, subscript this line for each program, beginning with line 60.01. Enter in
column 2, the Worksheet A line number on which the costs of the NAHE program were reported.
Enter in column 3, the appropriate code that identifies the criterion under which the NAHE
program costs qualify for pass-through payment or are treated as normal operating costs. Select
from the following list:
(1) - NAHE program is a provider operated program that meets the
criteria under 42 CFR 413.85(f).
(2) - NAHE program is a non-provider operated program that meets the
criteria under 42 CFR 413.85(g)(2).
However, under
42 CFR 413.85(g)(2)(iii), the pass-through costs are limited to the
percentage of total allowable provider cost attributable to NAHE
clinical training costs reported in the most recent cost reporting
period ending on or before October 1, 1989.
(3) - NAHE program is a non-provider operated program that meets the
criteria under 42 CFR 413.85(g)(3).
(4) - NAHE program is a non-provider operated program where costs
are treated as normal operating costs under 42 CFR 413.85(h)(6).
For each subscript of line 60 beginning with line 60.01, if the entry in column 3 is “1”, “2”, or “3”,
report the NAHE program costs in the applicable column of Worksheet D, Parts III, and IV, to
separately identify nursing school and allied health education costs from all other medical
education costs. For any subscript of line 60 where the entry in column 3 is “4”, do not transfer
the costs to Worksheet D, Part III, or Part IV.
Requirements During Five Year Period Following Implementation of Increases to Hospitals’ FTE
Resident Caps Under Section 5503 of the ACA, Line 61 and Subscripts--Section 5503 of the ACA
states that a hospital that receives an increase to its FTE resident cap under section 5503 shall
ensure, during the 5-year period beginning on July 1, 2011, that:
(I) The number of FTE primary care residents is not less than the average number of FTE
primary care residents during the three most recent cost reporting periods ending prior to
the date of enactment of section 5503; and,
(II) Not less than 75 percent of the positions attributable to such increase are in a primary
care or general surgery residency.
Failure to comply with either of these two requirements, known as the 3-year primary care average
requirement (I) and the 75 percent test (II), means permanent removal of all section 5503 slots
from the earliest applicable cost reporting period under the regulations at 42 CFR 413.79(n)(2).

40-32

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FORM CMS-2552-10

4004.1 (Cont.)

Line 61--Did your hospital receive FTE slots under section 5503 of the ACA? Enter “Y” for yes
or “N” for no in column 1. If “Y”, enter the number of IME section 5503 slots awarded in column 4
and direct GME section 5503 slots awarded in column 5. The number of IME and/or direct GME
slots entered here should be the amounts on the award letter from CMS. Complete the subscripts
of line 61 for portions of cost reporting periods occurring on or after July 1, 2011, and before
July 1, 2016. If “N” for no, do not complete columns 4 or 5 and subscripts of line 61.
NOTE: Effective for portions of cost reporting periods occurring on or after July 1, 2011, do not
complete line 61, columns 2 and 3. This information is now reported on line 61.01,
columns 2 and 3.
Line 61.01--Effective for portions of cost reporting periods occurring on or after July 1, 2011, and
before July 1, 2016, enter the average unweighted number of primary care FTE residents from the
hospital’s three most recent cost reports ending and submitted to the contractor before
March 23, 2010. See 42 CFR 413.75(b) for the definition of “primary care resident”. Enter the
3-year primary care average for IME in column 2. The source of the primary care IME FTE
residents is the rotation schedules submitted by the provider to support its cost reports for the three
most recent cost reports ending and submitted to the contractors prior to March 23, 2010. Any
audit adjustments to these IME primary care FTE residents must be taken into account in
computing the 3-year average. Exclude OB/GYN and general surgery FTE residents. This
primary care average is based on the hospital’s total primary care FTE count that would otherwise
be allowable if not for the FTE resident cap for each year in the 3-year period. If any of the three
cost reports is not a 12-month cost report, enter the 12-month equivalent FTE count.
Enter the average unweighted number of primary care FTE residents for direct GME in column 3.
This primary care average is based on the hospital’s total unweighted primary care FTE count that
would otherwise be allowable if not for the FTE resident cap for each year in the 3-year period. If
the hospital did not train any OB/GYN residents in its three most recent cost reports ending and
submitted prior to March 23, 2010, convert the weighted primary care FTE counts from line 3.19
of Worksheet E-3, Part IV, of Form CMS-2552-96, to unweighted FTE counts, compute a 3-year
average, and report the average in column 3. If the hospital did train OB/GYN FTE residents in
its three most recent cost reports ending and submitted prior to March 23, 2010, subtract the
OB/GYN FTE counts from line 3.19 of Worksheet E-3, Part IV, of Form CMS-2552-96, convert
the remaining primary care FTE counts to unweighted FTE counts, compute a 3-year average, and
report the average in column 3. Exclude general surgery FTE residents. If any of the three cost
reports is not a 12-month cost report, enter the 12-month equivalent FTE count.
Line 61.02--Enter the current cost reporting period total unweighted primary care FTE count
(excluding obstetrics and gynecology and general surgery), which is used to determine compliance
with the 3-year primary care average requirement. In accordance with section 5503 of the ACA,
which states that the 3-year primary care average requirement must be met by “excluding any
additional positions” added as a result of the section 5503 FTE cap increase, also exclude from
this unweighted primary care FTE count any primary care FTEs added in the current cost reporting
period specific to new or expanded programs under section 5503 (see 75 FR 72198-72199 dated
November 24, 2010). Enter the unweighted IME FTE count in column 2 and the direct GME FTE
count in column 3. If the current cost report is not a 12-month cost report, enter the 12-month
equivalent FTE count. These current cost reporting period unweighted primary care FTE counts
are compared to the 3-year primary care average amounts in line 61.01.

Rev.

40-33

4004.1 (Cont.)

FORM CMS-2552-10

DRAFT

Line 61.03--Enter the baseline FTE count for primary care and/or general surgery residents that is
used for determining compliance with the 75 percent requirement. These primary care and/or
general surgery FTEs would be a part of the unweighted allopathic and osteopathic FTE count
from the hospital’s 12-month (or prorated equivalent) cost report that immediately precedes the
cost report that includes July 1, 2011. Report the IME primary care and/or general surgery baseline
FTE count in column 2 and the direct GME baseline primary care and/or general surgery FTE
count in column 3. (For example, the baseline cost report for June 30 providers would be
July 1, 2010 through June 30, 2011; for December 31 providers, this would be January 1, 2010
through December 31, 2010; for September 30 providers, this would be October 1, 2009 through
September 30, 2010). (On the Form CMS-2552-96, the baseline FTE primary care and/or general
surgery count is included and commingled in the allopathic and osteopathic FTEs reported on
line 3.08 of Worksheet E, Part A, and on line 3.05 of Worksheet E-3, Part IV. On the
Form CMS-2552-10, the baseline primary care and/or general surgery FTE count is included and
commingled in the allopathic and osteopathic FTEs reported on line 10 of Worksheet E, Part A,
and on line 6 of Worksheet E-4). Use the rotation schedules from the hospital’s 12-month (or
prorated equivalent) cost report that immediately precedes the cost report that includes
July 1, 2011, as the source for the primary care and/or general surgery FTEs.
Line 61.04--Enter the total number of unweighted primary care and/or general surgery allopathic
and/or osteopathic FTEs in the current cost reporting period. If the cost report is not a 12-month
cost report, enter the 12-month equivalent FTE count. Exclude OB/GYN FTEs. (These FTEs are
part of the current year FTE count, and are included on Form CMS-2552-10, line 10 of
Worksheet E, Part A, and line 6 of Worksheet E-4). Report the unweighted IME FTE count in
column 2 and the direct GME FTE count in column 3.
Line 61.05--Determination of Compliance with 75 Percent Requirement--For portions of cost
reporting periods occurring on or after July 1, 2011, and before July 1, 2016, enter the difference
between the baseline primary care and/or general surgery FTE counts and the current year primary
care and/or general surgery FTE counts (line 61.04 minus line 61.03). Report the IME FTE count
difference in column 2 and the direct GME FTE count difference in column 3. (If the difference
is less than or equal to zero, enter a zero).
The section 5503 FTE cap slots reported on Worksheet E, Part A, line 8.01 (for IME), and
Worksheet E-4, line 4.01 (direct GME), are dependent upon this difference on line 61.05 (for
portions of cost reporting periods occurring on or after July 1, 2011, and before July 1, 2016),
because of the requirement that 75 percent of the section 5503 FTE cap award be used for primary
care and/or general surgery FTEs in new or expanded programs. If the difference on line 61.05 is
greater than zero, then it must be at least 75 percent of the section 5503 FTE cap award to be
reported on Worksheet E, Part A, line 8.01 (for IME), and Worksheet E-4, line 4.01 (for direct
GME). For example, if a hospital was awarded a total of 10 slots, but the difference reported on
line 61.05 is 5, then the section 5503 FTE slots reported on Worksheet E, Part A, line 8.01 (for
IME), and Worksheet E-4, line 4.01 (for direct GME), cannot be more than 6.67 (that is, 5 divided
by 75 percent). Therefore, determine that the difference on line 61.05 is at least 75 percent of the
section 5503 award amount that is reported on Worksheet E, Part A, line 8.01 (for IME), and
Worksheet E-4, line 4.01 (for direct GME).

40-33.1

Rev.

DRAFT

FORM CMS-2552-10

4004.1 (Cont.)

Line 61.06--Enter the amount of the ACA section 5503 award FTEs that are being used for cap
relief, if any, and/or that are nonprimary care or non-general surgery FTEs. Report the IME
amount in column 2 and the direct GME amount in column 3. For portions of cost reporting
periods occurring on or after July 1, 2011, and before July 1, 2016, the amount reported on this
line can be no more than 25 percent of the section 5503 FTE cap slots reported on Worksheet E,
Part A, line 8.01 (for IME), and Worksheet E-4, line 4.01 (for direct GME). If the amount on
line 61.05, columns 2 or 3, is greater than or equal to the section 5503 cap award reported on
line 61, columns 4 or 5, respectively, report zero on this line.
If the amount on line 61.05 is less than the section 5503 cap award, and the hospital either is
training FTE residents over its existing FTE cap or has added nonprimary care and non-general
surgery FTEs in the current cost reporting period, report on this line the difference of the
section 5503 cap slots on Worksheet E, Part A, line 8.01 (for IME), and Worksheet E-4, line 4.01
(for direct GME), and the amount reported on line 61.05. For example, if a hospital was awarded
a total of 10 slots, and 5 is reported on line 61.05, and the section 5503 FTE slots reported on
Worksheet E, Part A, line 8.01 (for IME), and Worksheet E-4, line 4.01 (for direct GME) is 6.67
FTEs, then the amount reported on line 61.06 cannot exceed 1.67 FTEs which is the difference
between the amount on line 61.05, and the amount reported on Worksheet E, Part A, line 8.01 (for
IME), and Worksheet E-4, line 4.01 (for direct GME). If 10 is reported on line 61.05, then
report 0 (zero) on line 61.06. If 8 is reported on line 61.05 and the hospital added 2 or more
nonprimary care FTEs in the current cost reporting period, then report 2 on this line.
Lines 61.07 through 61.09--Reserved for future use.
Line 61.10--Of the FTEs in line 61.05, specify each new primary care or general surgery program
specialty, if any, and the number of FTE residents for each new program. Use subscripted
lines 61.11 through 61.19 for each additional new program. Enter in column 1 the program name,
enter in column 2 the program code, enter in column 3 the IME FTE unweighted count and enter
in column 4 the direct GME FTE unweighted count.
Line 61.20--Of the additional FTEs in line 61.05, specify each expanded primary care or general
surgery program specialty, if any, and the number of FTE residents for each program expansion.
Use subscripted lines 61.21 through 61.29 for each additional program expansion. Enter in
column 1 the program name, enter in column 2 the program code, enter in column 3 the IME FTE
unweighted count and enter in column 4 the direct GME FTE unweighted count.
Lines 62 and 62.01--ACA Provisions Affecting the Health Resources and Services Administration
(HRSA)--These provisions are effective for a five year period for the Health Resources and
Services Administration (HRSA) Primary Care Residency Expansion (PCRE) program and the
Teaching Health Center (THC) program.
Line 62--Effective for services rendered during September 30, 2010 through September 29, 2015,
enter the number of FTE residents that your hospital trained in this cost reporting period for which
your hospital received HRSA PCRE funding. (Sections 4002 and 5301 of the ACA.)
Line 62.01--Effective for services rendered during October 1, 2010, through September 30, 2015,
enter the number of FTE residents that rotated from a THC into your hospital during this cost
reporting period under the HRSA THC program. (Section 5508 of the ACA.)
Line 63--Has your facility trained residents in a non-provider setting during this cost reporting
period? Enter “Y” for yes or “N” for no in column 1. (See 75 FR 72139-72140
(November 24, 2010).) If column 1 is “Y” for yes, complete lines 64 through 67 and applicable
subscripts. If “N” for no, but your facility trained residents in a non-provider setting during the
base year period (cost reporting period that begins on or after July 1, 2009 and before
June 30, 2010), complete lines 64 and 65, and applicable subscripts effective for cost reporting
periods beginning on or after July 1, 2010.

Rev.

40-33.2

4004.1 (Cont.)

FORM CMS-2552-10

DRAFT

Lines 64 and 65--Section 5504 of the ACA Base Year FTE Residents in Nonprovider Settings-The base year is your cost reporting period that begins on or after July 1, 2009 and before
June 30, 2010.
Line 64--If line 63 is yes or your facility trained residents in the base year period, enter in
column 1, for cost reporting periods that begins on or after July 1, 2009, and before June 30, 2010,
the number of unweighted nonprimary care FTE residents attributable to rotations that occurred in
all nonprovider settings. Enter in column 2, the number of unweighted nonprimary care FTE
residents that trained in your hospital. Include unweighted OB/GYN, dental and podiatry FTEs
on this line. Enter in column 3, the ratio of column 1 divided by the sum of columns 1 and 2.
Line 65--If line 63 is yes or your facility trained residents in the base year period, enter from your
cost reporting period that begins on or after July 1, 2009, and before June 30, 2010, the number of
unweighted primary care FTE residents for each primary care specialty program in which you train
residents. (See 42 CFR 413.75(b) for the definition of “primary care resident.”) Use subscripted
lines 65.01 through 65.50 for each additional primary care program. Enter in column 1, the
program name. Enter in column 2, the program code. Enter in column 3, the number of
unweighted primary care FTE residents attributable to rotations that occurred in nonprovider
settings for each applicable program. Enter in column 4, the number of unweighted primary care
FTE residents in your hospital for each applicable program. Enter in column 5, the ratio of
column 3 divided by the sum of columns 3 and 4. If you operated a primary care program that did
not have FTE residents in a nonprovider setting, enter zero in column 3 and complete all other
columns for each applicable program.
NOTE: The sum of the FTE counts on line 64, columns 1 and 2, and line 65, columns 3 and 4,
should approximate the sum of the FTE counts on Form CMS-2552-96, Worksheet E-3,
Part IV, lines 3.05 and 3.11, for your cost reporting period that begins on or after
July 1, 2009 and before June 30, 2010.
Lines 66 and 67--Section 5504 of the ACA Current Year FTE Residents in Nonprovider
Settings--Effective for cost reporting periods beginning on or after July 1, 2010.
Line 66--If line 63 is yes, enter in column 1, the unweighted number of nonprimary care FTE
residents attributable to rotations occurring in all non-provider settings. Enter in column 2, the
number of unweighted nonprimary care FTE residents in your hospital. Include unweighted
OB/GYN, dental and podiatry FTEs on this line. Enter in column 3, the ratio of column 1 divided
by the sum of columns 1 and 2.
Line 67--If line 63 is yes, then, for each primary care residency program in which you are training
residents, enter in column 1, the program name. Enter in column 2, the program code. Enter in
column 3, the number of unweighted primary care FTE residents attributable to rotations that
occurred in nonprovider settings for each applicable program. Enter in column 4, the number of
unweighted primary care FTE residents in your hospital for each applicable program. Enter in
column 5, the ratio of column 3 divided by the sum of columns 3 and 4. Use subscripted
lines 67.01 through 67.50 for each additional primary care program.
If you operated a primary care program that did not have FTE residents in a nonprovider setting,
enter zero in column 3 and complete all other columns for each applicable program.
NOTE: The sum of the FTE counts on line 66, columns 1 and 2, and line 67, columns 3 and 4,
should approximate the sum of the FTE counts on Worksheet E-4, lines 6 and 10, for this
current cost reporting period.
Lines 68 and 69--Reserved for future use.
Line 70--Are you an IPF or do you contain an IPF subprovider? Enter in column 1 “Y” for yes or
“N” for no.
40-33.3

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FORM CMS-2552-10

4004.1 (Cont.)

Line 71--For column 1, if this facility is an IPF or contains an IPF subprovider (response to line 70,
column 1, is “Y” for yes), did the facility train residents in graduate medical education programs
in the most recent cost report filed on or before November 15, 2004? Enter “Y” for yes or “N”
for no.
For column 2, did the facility train residents in a new graduate medical education program in the
current cost reporting period, or in a prior cost reporting period, in accordance with
42 CFR 412.424(d)(1)(iii)(D)? Enter in column 2, “Y” for yes or “N” for no. (Note: If column 1
is “Y,” then column 2 must be “N.” Columns 1 and 2 cannot be “Y” simultaneously; however,
columns 1 and 2 can be “N” simultaneously.)
For column 3, if column 2 is yes, indicate which program year began in this cost reporting period.
New programs that began before October 1, 2012, have a 3-year new program growth period for
the first new program, while new programs that began on or after October 1, 2012, have a 5-year
new program growth period for the first new program. For new programs that began before
October 1, 2012 (see 42 CFR 413.79(e)(1)), enter a 1, 2, or 3, in column 3 to correspond to the
I&R academic year in the first 3 program years of the first new program’s existence that began
during the current cost reporting period, or enter a 6 to indicate this cost reporting period includes
the beginning of the program year following the 3-year new program growth period of the first
new program, or the program is beyond the new program growth period. For new programs that
began on or after October 1, 2012 (see 42 CFR 413.79(e)(1)), enter a 1, 2, 3, 4, or 5, in column 3
to correspond to the I&R academic year in the first 5 program years of the first new program’s
existence that began during the current cost reporting period, or enter a 6 to indicate this cost
reporting period includes the beginning of the program year following the 5-year new program
growth period of the first new program, or the program is beyond the new program growth period.
If column 2 is no, make no entry in column 3.
Lines 72 through 74--Reserved for future use.
Line 75--Are you an IRF or do you contain an IRF subprovider? Enter in column 1 “Y” for yes
or “N” for no.
Line 76--For column 1, if this facility is an IRF or contains an IRF subprovider (response to
line 75, column 1, is “Y” for yes), did the facility train residents in graduate medical education
programs in the most recent cost reporting period ending on or before November 15, 2004?
Enter “Y” for yes or “N” for no.
For column 2, did the facility train residents in a new graduate medical education program in the
current cost reporting period, or in a prior cost reporting period, in accordance with 70 FR 47929
(August 15, 2005)? Enter in column 2, “Y” for yes or “N” for no. (Note: If column 1 is “Y”, then
column 2 must be “N.” Columns 1 and 2 cannot be “Y” simultaneously; however, columns 1 and
2 can be “N” simultaneously.)
For column 3, if column 2 is yes, indicate which program year began in this cost reporting period.
New programs that began before October 1, 2012, have a 3-year new program growth period for
the first new program, while new programs that began on or after October 1, 2012, have a 5-year
new program growth period for the first new program. For new programs that began before
October 1, 2012 (see 42 CFR 413.79(e)(1)), enter a 1, 2, or 3, in column 3 to correspond to the
I&R academic year in the first 3 program years of the first new program’s existence that began
during the current cost reporting period, or enter a 6 to indicate this cost reporting period includes
the beginning of the program year following the 3-year new program growth period of the first
new program, or the program is beyond the new program growth period. For new programs that
began on or after October 1, 2012 (see 42 CFR 413.79(e)(1)), enter a 1, 2, 3, 4, or 5, in column 3
to correspond to the I&R academic year in the first 5 program years of the first new program’s
existence that began during the current cost reporting period, or enter a 6 to indicate this cost
reporting period includes the beginning of the program year following the 5-year new program
growth period of the first new program, or the program is beyond the new program growth period.
If column 2 is no, make no entry in column 3.
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Lines 77 through 79--Reserved for future use.
Line 80--Are you a freestanding LTCH? Enter in column 1 “Y” for yes or “N” for no. LTCHs
can only exist as independent/freestanding facilities. To be considered as independent or a
freestanding facility, a LTCH located within another hospital must meet the separateness (from
the host/co-located provider) requirements identified in 42 CFR 412.22(e.)
Line 81--Are you an independent or freestanding LTCH located within another hospital, subject
to the special payment provisions of 42 CFR 412.534? Enter “Y” for yes or “N” for no. To be
considered as independent or a freestanding facility, a LTCH located within another hospital must
meet the separateness (from the host/co-located provider) requirements identified in
42 CFR 412.22.
Lines 82 through 84--Reserved for future use.
Line 85--Is this a new hospital under 42 CFR 413.40(f)(1)(i) (TEFRA)? Enter “Y” for yes or “N”
for no.
Line 86--Have you established a new “Other” subprovider (excluded unit) under
42 CFR 413.40(f)(1)(ii)? Enter “Y” for yes or “N” for no in column 1. If there is more than one
subprovider, subscript this line. Do not complete this line.
Line 87--Is this hospital a LTCH classified under section 1886(d)(1)(B)(vi) (referred to as
extended neoplastic disease care hospitals)? Enter “Y” for yes or “N” for no.
Line 88--Is this provider approved for a permanent adjustment to the TEFRA target amount per
discharge? Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, in column 2, enter
the number of approved permanent adjustments, and complete line 89. See CMS Pub. 15-1,
chapter 30, §3004.1 and §3004.2, for clarification on permanent adjustments.
Line 89--If line 88, column 1, is yes, complete columns 1, 2, and 3, for the earliest (first) approved
permanent adjustment. In column 1, enter the Worksheet A line number upon which the approval
of the permanent adjustment to the TEFRA target amount per discharge was based; in column 2,
enter the cost reporting period beginning date that the permanent adjustment to the TEFRA target
amount per discharge was effective, if available; and in column 3, enter the amount of the
approved permanent adjustment to the TEFRA target amount per discharge approved as of the
date in column 2. If the number on line 88, column 2, is greater than one (the hospital received
multiple approvals for permanent adjustments to the TEFRA target amount per discharge),
subscript this line consecutively as necessary to report each additional approved permanent
adjustment in chronological order. Report the earliest (first) approved permanent adjustment on
line 89, and report each subsequently approved permanent adjustment on lines 89.01, 89.02, etc.
See CMS Pub. 15-1, chapter 30, §3004.1 and §3004.2, for clarification on permanent adjustments.
Lines 90--Do you provide title V and/or XIX inpatient hospital services? Enter “Y” for yes or “N”
for no in the applicable column.
Line 91--Is this hospital reimbursed for title V and/or XIX through the cost report in full or in part?
Enter “Y” for yes or “N’ for no in the applicable column.
Line 92--If all of the nursing facility beds were certified for title XIX, and there were also
title XVIII certified beds (dual certified), were any of the title XVIII beds occupied by title XIX
patients during the cost reporting period? Enter “Y” for yes or “N” for no in the applicable column.
Complete a separate Worksheet D-1 for title XIX for each level of care.

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Line 93--Do you operate an ICF/IID facility for purposes of title XIX? Enter “Y” for yes or “N”
for no.
Line 94--Does title V and/or XIX reduce capital costs? Enter “Y” for yes or “N” for no in the
applicable column.
Line 95--For each column, if line 94 is “Y” for yes, enter the percentage by which capital costs are
reduced.
Line 96--Does title V and/or XIX reduce operating costs? Enter “Y” for yes or “N” for no in the
applicable column.
Line 97--For each column, if line 96 is “Y” for yes, enter the percentage by which operating costs
are reduced.
Line 98--Does title V or XIX follow Medicare for the interns and residents post step-down
adjustments on Worksheet B, Part I, column 25? Enter “Y” for yes or “N” for no in column 1 for
title V, and in column 2 for title XIX.
Line 98.01--Does title V or XIX follow Medicare for the reporting of charges on Worksheet C,
Part I? Enter “Y” for yes or “N” for no in column 1 for title V, and in column 2 for title XIX.
Line 98.02--Does title V or XIX follow Medicare for the calculation of observation bed costs on
Worksheet D-1, Part IV, line 89? Enter “Y” for yes or “N” for no in column 1 for title V, and in
column 2 for title XIX.
Line 98.03--Does title V or XIX follow Medicare for a CAH reimbursed 101% of cost for inpatient
services? Enter “Y” for yes or “N” for no in column 1 for title V, and in column 2 for title XIX.
Line 98.04--Does title V or XIX follow Medicare for a CAH reimbursed 101% of cost for
outpatient services? Enter “Y” for yes or “N” for no in column 1 for title V, and in column 2 for
title XIX.
Line 98.05--Does title V or XIX follow Medicare and add back the reasonable compensation
equivalent (RCE) disallowance on Worksheet C, Part I, column 4? Enter “Y” for yes or “N” for
no in column 1 for title V, and in column 2 for title XIX.
Line 98.06--Does title V or XIX follow Medicare when cost reimbursed for Worksheet D, Parts I
through IV? Enter “Y” for yes or “N” for no in column 1 for title V, and in column 2 for title XIX.
Lines 99 through 104--Reserved for future use.
Line 105--If this hospital qualifies as a CAH, enter “Y” for yes in column 1. Otherwise, enter “N”
for no, and skip to line 108. (See 42 CFR 485.606ff.)
Line 106--If line 105 is yes, has this CAH elected the all-inclusive method of payment for
outpatient services? Enter “Y” for yes or “N” for no. If yes, an adjustment for the professional
component is still required on Worksheet A-8-2.
NOTE: If the facility elected the all-inclusive method for outpatient services, professional
component amounts are excluded from deductible and coinsurance amounts and are not
included on Worksheet E-1.

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DRAFT

Line 107--If line 105 is yes, is this CAH eligible for 101 percent reasonable cost reimbursement
for I&R in approved training programs? Enter a “Y” for yes or an “N” for no in column 1. If
column 1 is yes, the GME elimination is not made on Worksheet B, Part I, column 25, and the
program is cost reimbursed. If yes, complete Worksheet D-2, Part II.
If column 1 is yes and line 70 and/or line 75 is yes, do I&Rs in approved medical education
programs train in the CAH’s excluded IPF and/or IRF unit? Enter a “Y” for yes or an “N” for no
in column 2. If column 2 is yes, complete Worksheet E-4, to calculate GME reimbursement for
CAH subproviders.
Line 108--Is this a rural hospital qualifying for an exception to the certified registered nurse
anesthetist (CRNA) fee schedule? (See 42 CFR 412.113(c).) Enter “Y” for yes or “N” for no, in
column 1.
Line 109--If this hospital qualifies as a CAH (response to line 105 is yes) or is a cost reimbursed
provider, are therapy services provided by outside suppliers? Enter “Y” for yes or “N” for no
under the corresponding physical, occupational, speech and/or respiratory therapy services as
applicable.
Line 110--Did this facility participate in the Rural Community Hospital Demonstration Project
(also known as the §410A Demo) for the current cost reporting period? Enter “Y” for yes or “N”
for no. If “Y”, complete Worksheet E, Part A, lines 200 through 218, and Worksheet E-2, line 200
through 215, as applicable.
Line 111--If this facility qualifies as a CAH, did it participate in the Frontier Community Health
Integration Project (FCHIP) demonstration for this cost reporting period? Enter “Y” for yes or
“N” for no in column 1. If the response in column 1 is “Y”, enter in column 2, the integration
prong of the FCHIP demonstration in which this CAH is participating. Enter all that apply: “A”
for ambulance services reimbursed at 101% of reasonable costs; “B” for additional beds used only
for SNF and/or NF level of care; and/or “C” for tele-health services reimbursed at 101% of
reasonable costs.
NOTE FOR LINE 111: If the entry in column 2 is “C”, a telemedicine cost center must exist on
Worksheet A, line 93 (Other Outpatient Service (specify)), or a subscript thereof, to report
the telehealth originating site cost and/or telehealth destination site cost of CAHs
participating in the FCHIP demonstration with a cost center code of “04050” (see §4095,
Table 5).

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Line 112--Did this hospital participate in the Pennsylvania Rural Health Model (PARHM)
demonstration for any portion of the cost reporting period? In column 1, enter “Y” for yes or “N”
for no. If column 1 is “Y”, in column 2, enter the beginning date for the portion of the cost
reporting period the hospital began participation in the PARHM demonstration; and, in column 3,
enter the ending date for the portion of the cost reporting period the hospital ceased participation
in the PARHM demonstration, when applicable. If the hospital participated in the PARHM
demonstration for the entire cost reporting period enter the beginning and ending dates
accordingly. The PARHM demonstration is effective for outpatient services and inpatient
discharges ending on or after January 29, 2019.
If column 1 is “Y” and the hospital participated in the PARHM demonstration for the entire cost
reporting period, complete all hospital worksheets by selecting the “PARHM Demonstration”
indicator box at the top of each worksheet.
If column 1 is “Y” and any portion of the cost
reporting period the hospital did not participate in the PARHM demonstration, complete the
hospital worksheets as “Hospital” for the period of non-participation and complete a separate set
of hospital worksheets as “PARHM Demonstration” for the period of participation.
Lines 113 through 114--Reserved for future use.
Line 115--Is this an all-inclusive rate provider (see instructions in CMS Pub. 15-1, chapter 22,
§2208). Enter “Y” for yes or “N” for no in column 1. If yes, enter the applicable method (A, B,
or E only) in column 2. If column 2 is “E”, enter the inpatient Medicare calculation percentage in
column 3. Enter “93” for short-term hospitals where over 50 percent of all patients admitted stay
less than 30 days or “98” for long-term hospitals where over 50 percent of all patients stay 30 days
or more. (See CMS Pub. 15-1, chapter 22, §2208.1.E.)
Line 116--Are you classified as a referral center? Enter “Y” for yes or “N” for no. See
42 CFR 412.96.
Line 117--Are you legally required to carry malpractice insurance? Enter “Y” for yes or “N” for
no. Malpractice insurance, sometimes referred to as professional liability insurance, is insurance
purchased by physicians and hospitals to cover the cost of being sued for malpractice.
Line 118--Is the malpractice insurance 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 covers an incident occurring while
the policy is in force regardless of when the claim arising out of that incident is filed. If the policy
is claims-made, enter 1. If the policy is occurrence, enter 2.
Line 118.01--Enter the total amount of malpractice premiums paid in column 1, enter the total
amount of paid losses in column 2, and enter the total amount of self-insurance paid in column 3.
Line 118.02--Indicate if malpractice premiums and paid losses are reported in a cost center other
than the Administrative and General (A&G) cost center. If yes, provide a supporting schedule and
list the amounts applicable to each cost center.
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 protects providers for excess protection that may be
unavailable or cost-prohibitive at the primary level.
Line 119--This question is eliminated and this line must not be used.
Rev.

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DRAFT

Line 120--If this is an SCH (or EACH), that qualifies for the outpatient hold harmless provision in
accordance with ACA section 3121, enter “Y” for yes or “N” for no in column 1. If this is a rural
hospital with 100 or fewer beds, that qualifies for the outpatient hold harmless provision in
accordance with ACA section 3121, enter “Y” for yes or “N” for no in column 2. The ACA §3121
was amended by the Medicare and Medicaid Extenders Act (MMEA) of 2010, §108; the
Temporary Payroll Tax Cut Continuation Act of 2011, §308; and the Middle Class Tax Relief and
Job Creation Act of 2012, §3002. Note that for SCHs and EACHs, the outpatient hold harmless
provision is effective for services rendered from January 1, 2010 through February 29, 2012,
regardless of bed size, and from March 1, 2012 through December 31, 2012, for SCHs and EACHs
with 100 or fewer beds. Rural hospitals with 100 or fewer beds are also extended through
December 31, 2012. These responses impact the TOPs calculation on Worksheet E, Part B, line 8.
Line 121--Did this facility incur and report costs (direct or indirect) in the “Implantable Devices
Charged to Patients” (line 72) cost center as indicated in the 73 FR 48462 (August 19, 2008),
bearing the revenue codes established by the National Uniform Billing Committee (NUBC) for
high cost implantable devices? Enter “Y” for yes or “N” for no.
Line 122--Does the cost report contain health care related taxes as defined in §1903(w)(3) of
the Act? Enter “Y” for yes or “N” for no in column 1. If the answer in column 1 is “Y”, enter in
column 2 the Worksheet A line number where these taxes are included.
Line 123--Did the facility and/or its subproviders (if applicable) purchase professional services,
e.g., legal, accounting, tax preparation, bookkeeping, payroll, and/or management/consulting
services, from an unrelated organization? In column 1, enter "Y" for yes or "N" for no. If column 1
is yes, were the majority of the expenses, i.e., greater than 50% of the total professional services
expenses, for services purchased from unrelated organizations located outside of the main
hospital’s local area labor market? In column 2, enter “Y” for yes or “N” for no.
Line 124--Reserved for future use.
Line 125--Is this facility a Medicare-certified transplant center? Enter “Y” for yes or “N” for no
in column 1. If yes, enter the certification date and, if applicable, the termination date on lines 126
through 132, as applicable.
Line 126--If this is a Medicare-certified kidney transplant program, enter the certification date in
column 1, and, if applicable, the termination date in column 2. Also complete Worksheet D-4.
Line 127--If this is a Medicare-certified heart transplant program, enter the certification date in
column 1, and, if applicable, the termination date in column 2. Also complete Worksheet D-4.
Line 128--If this is a Medicare-certified liver transplant program, enter the certification date in
column 1, and, if applicable, the termination date in column 2. Also complete Worksheet D-4.
Line 129--If this is a Medicare-certified lung transplant program, enter the certification date in
column 1, and, if applicable, the termination date in column 2. Also, complete Worksheet D-4.
Line 130--If Medicare pancreas transplants are performed, enter the more recent date of
July 1, 1999, (coverage of pancreas transplants) or the certification date for kidney transplants in
column 1 and, if applicable, the termination date in column 2. Also, complete Worksheet D-4.
Line 131--If this is a Medicare-certified intestinal transplant program, enter the certification date
in column 1, and, if applicable, the termination date in column 2. Also, complete Worksheet D-4.

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4004.1 (Cont.)

Line 132--If this is a Medicare-certified islet transplant program enter the certification date in
column 1, and, if applicable, the termination date in column 2. Also, complete Worksheet D-4.
Line 133--Removed and reserved.
Line 134--If this hospital operates a hospital-based organ procurement organization (OPO), enter
the OPO CCN in column 1, and termination date, if applicable, in column 2.
Lines 135 through 139--Reserved for future use.
Line 140--Are there any related organization or home office costs claimed as defined in
CMS Pub. 15-1, chapter 10? Enter “Y” for yes or “N” for no in column 1. If yes, complete
Worksheet A-8-1. If this facility is part of a chain and you are claiming home office costs, enter
in column 2, the home office chain number and complete lines 141 through 143. See
CMS Pub. 15-1, chapter 21, §2150, for a definition of a chain organization.
Line 141--Enter the name of the chain home office in column 1, the home office contractor name
in column 2, and the home office contractor number in column 3.
Line 142--Enter the street address and P. O. Box (if applicable) of the home office.
Line 143--Enter the city, State, and ZIP code, of the home office.
Line 144--Are provider based physicians' costs included in Worksheet A? Enter “Y” for yes or
“N” for no. If yes, complete Worksheet A-8-2.
Line 145--If costs for renal dialysis services are claimed on Worksheet A, line 74, are the costs for
inpatient services only? Enter “Y” for yes or “N” for no in column 1. If column 1 is no, does the
dialysis facility include Medicare utilization for this cost reporting period? Enter “Y” for yes or
“N” for no in column 2. No response is required in column 1 or column 2 unless Worksheet A,
column 7, line 74, is greater than zero. If column 1 is yes, or column 2 is no, do not complete
Worksheet S-5 or the Worksheet I series for renal dialysis services.
Line 146--Have you changed your cost allocation methodology from the previously filed cost
report? Enter “Y” for yes or “N” for no. If yes, enter the approval date in column 2.
Line 147--Was there a change in the statistical basis? Enter “Y” for yes or “N” for no.
Line 148--Was there a change in the order of allocation? Enter “Y” for yes or “N” for no.
Line 149--Was there a change to the simplified cost finding method? Enter “Y” for yes or “N” for
no.
Lines 150 through 154--Reserved for future use.
Lines 155 through 161--If you are a hospital (public or non-public) that qualifies for an exemption
from the application of the lower of cost or charges principle as provided in 42 CFR 413.13,
indicate the component and/or services for titles V, XVIII and XIX that qualify for the exemption
by entering in the corresponding box a “Y” for yes, if you qualify for the exemption, or an “N” for
no, if you do not qualify for the exemption. Subscript as needed for additional components. For
title XVIII providers, a response of “Y” does not subject the provider to the LCC principle.
Lines 162 through 164--Reserved for future use.
Line 165--Is the hospital part of a multi-campus hospital that has one or more campuses in different
CBSAs? Enter “Y” for yes or “N” for no. (For purposes of this question, only answer yes if the
main campus and the off-site campus(es) are classified as section 1886(d) hospitals, or they are
located in Puerto Rico).
Rev.

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DRAFT

Line 166--If you responded “Y” for yes to question 165, enter information for each campus
(including the main campus) as follows: name in column 0, county in column 1, State in column 2,
ZIP code in column 3, geographic CBSA in column 4, and the FTE count for this campus in
column 5. If additional campuses exist, subscript this line as necessary. Enter the information in
columns 0 through 5 for the main campus first, and then enter the information in each column for
the subordinate campuses, in any order. For example, for the main campus, enter on line 166 the
name, county, state, ZIP code, geographic CBSA, and FTEs per campus. For the first subordinate
campus, enter on line 166.01 the name, county, state, ZIP code, geographic CBSA, and FTEs per
campus. Report only FTE information associated with IPPS areas and not the FTE information
for excluded areas, i.e., hospital-based IPF and hospital-based IRF.
Line 167--Is this hospital/campus a meaningful user of electronic health record (EHR) technology
in accordance §1886(n) of the Social Security Act as amended by the section 4102 of the American
Recovery and Reinvestment Act (ARRA) of 2009 or the Consolidated Appropriations Act of 2016,
Division O, Title VI, §602 (CAA 2016)? Enter “Y” for yes or “N” for no. A CAH that is not a
meaningful user beginning in FFY 2015 is subject to a payment adjustment as defined in
42 CFR 413.70(a)(6)(i). A CAH may, on a case-by-case basis, be granted an exception from this
adjustment if CMS or its Medicare contractor determines, on an annual basis, that a significant
hardship exists, such as in the case of a CAH in a rural area without sufficient internet access.
However, in no case may a CAH be granted an exception for more than 5 years.
Line 168--If this provider is a CAH (line 105 is “Y” for yes) and is also a meaningful EHR
technology user (line 167 is “Y” for yes), enter, if applicable, the reasonable acquisition cost
incurred for EHR assets either purchased or initially rented under a virtual purchase lease (see
42 CFR 413.130(b)(5) and (8), and CMS Pub. 15-1, chapter 1, §110.B.1.b) in the current cost
reporting period. If applicable, also enter the un-depreciated cost (i.e., net book value), as of the
beginning of the current cost reporting period, for assets purchased or initially rented under a
virtual purchase lease in prior cost reporting period(s) which were used for EHR purposes in the
current cost reporting period. Do not enter on this line any cost for EHR assets which was already
claimed for the same assets in previous cost reporting period(s). The reasonable acquisition cost
incurred is for depreciable assets such as computers and associated hardware and software
necessary to administer certified EHR technology. (See 75 FR 44461 (July 28, 2010) and
42 CFR 495.106(a) and (c)(2).)
Additionally, if the amount on this line is greater than zero, submit a listing of the EHR assets
showing the following information for each asset: (1) nature of each asset and acquisition
cost; (2) an annotation whether the asset was purchased or leased under a virtual purchase lease
(42 CFR 413.130(b)(8)); (3) date of purchase or date the virtual purchase lease was
initiated; (4) name(s) of original purchaser (e.g., CAH, CAH’s home office, group of unrelated
providers); (5) information regarding the asset’s use (i.e., indication whether the asset (hardware
of software) will be shared with CAH’s non-EHR systems); and, (6) tag number and location
(department unit). For cost reporting periods beginning on or after October 1, 2016, do not
complete this line.
Line 168.01--If this provider is a CAH (line 105 is “Y”) and is not a meaningful user (line 167 is
“N”), does this provider qualify for a hardship exception under 42 CFR 413.70(a)(6)(ii)? Enter
“Y” for yes or “N” for no. If no, the CAH is subject to a payment adjustment. The CAH’s
reasonable costs in providing inpatient services are adjusted as defined in 42 CFR 413.70(a)(6)(i)
for cost reporting periods that begin in or after FFY 2015. Specifically, sections 1814(l)(4)(A) and
(B) of the Act provide that, if a CAH does not demonstrate meaningful use of certified EHR
technology for an applicable EHR reporting period, then for a cost reporting period beginning in
FFY 2015, the CAHs reasonable costs shall be adjusted from 101 percent to 100.66 percent. For
a cost reporting period beginning in FFY 2016, the CAH’s reasonable costs shall be adjusted to
100.33 percent. For a cost reporting period beginning in FFY 2017 and each subsequent FFY, the
CAH’s reasonable costs shall be adjusted to 100 percent.

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Line 169--If this is a §1886(d) provider that responded “N” for no to question 105 and “Y” for yes
to question 167, enter the transition factor to be used in the calculation of your EHR incentive
payment. For cost reporting periods where the transition factor is zero, enter “9.99” for software
programming purposes. For hospitals that qualify for the EHR incentive payment under
ARRA 2009, §4120, this question is not applicable for cost reporting periods beginning on or after
October 1, 2016. For Puerto Rico hospitals that qualify for the EHR incentive payment under
CAA 2016, §602, this question is not applicable for cost reporting periods beginning on or after
October 1, 2021.
See 75 FR 44458-44460 (July 28, 2010) and CAA 2016, §602. The transition factor equals:
If a subsection (d) hospital first becomes a meaningful EHR user in fiscal year 2011,
2012 or 2013; or if a subsection (d) Puerto Rico hospital first becomes a meaningful
EHR user in fiscal year 2016, 2017, or 2018:
• The first year transition factor is 1.00
• The second year transition factor is 0.75
• The third year transition factor is 0.50
• The fourth year transition factor is 0.25
• Any succeeding transition year is 0
If a subsection (d) hospital first becomes a meaningful EHR user in fiscal year 2014;
or if a subsection (d) Puerto Rico hospital first becomes a meaningful EHR user in
fiscal year 2019:
• The first year transition factor is 0.75
• The second year transition factor is 0.50
• The third year transition factor is 0.25
• Any succeeding transition year is 0
If a subsection (d) hospital first becomes a meaningful EHR user in fiscal year 2015;
or if a subsection (d) Puerto Rico hospital first becomes a meaningful EHR user in
fiscal year 2020:
• The first year transition factor is 0.50
• The second year transition factor is 0.25
• Any succeeding transition year is 0
Line 170--If line 167 is “Y”, enter the EHR reporting period. Enter in column 1, the reporting
period beginning date and, in column 2, the ending date in accordance with 42 CFR 495.4. The
EHR reporting period may be a full federal fiscal year or, if this is the first payment year, any
continuous 90-day period within a federal fiscal year. If the EHR reporting period ending date is
on or after April 1, 2013, the EHR incentive payment will be subject to the 2 percent sequestration
adjustment. The response to this question impacts the sequestration calculation on Worksheet E-1,
Part II, line 9. For cost reporting periods beginning on or after October 1, 2016, do not complete
this line except for Puerto Rico hospitals.
Line 171--If this provider is a meaningful EHR technology user (line 167 is “Y”), the days
associated with individuals enrolled in section 1876 Medicare cost plans must be included in the
calculation of the incentive payment. Indicate if you have section 1876 days included in the days
reported on Worksheet S-3, Part I, line 2, column 6, by entering “Y” for yes or “N” for no in
column 1. If column 1 is yes, enter the number of section 1876 Medicare days in column 2.

Rev.

40-38.1

4004.1 (Cont.)

FORM CMS-2552-10

DRAFT

Exhibit 3A -- Listing of Medicaid Eligible Days for a DSH Eligible Hospital
If reporting Medicaid days on Worksheet S-2, Part I, line 24, or line 25, for a cost reporting period
beginning on or after October 1, 2022, complete a separate Exhibit 3A listing for each CCN. If a
SCH is eligible to receive a DSH payment adjustment but Worksheet E, Part A, line 48, is greater
than line 47, do not complete an Exhibit 3A listing; however, if Worksheet E, Part A, line 47, is
greater than line 48, the SCH must submit an Exhibit 3A listing. Enter dates in the MM/DD/YYYY
format.
Enter the provider name, CCN, CRP beginning and ending dates, the line number of
Worksheet S-2, Part I, that the listing supports, the sum of the days for columns 10 and 12, and
the sum of the days for column 11.
Columns 1 through 6--From the Medicaid patient’s claim, enter the patient name, dates of service,
patient account or identification number, and, patient medical record number that correlate to the
Medicaid eligible days reported in columns 10 and 11, in columns 1 through 6, respectively.
Column 7--Enter the Medicaid recipient identification number that correlates to the Medicaid
eligible days reported in columns 10 and 11. For a newborn baby born to a Medicaid eligible
mother, enter the mother’s Medicaid identification number that correlates to the Medicaid eligible
days reported in columns 10 and 12.
Column 8--Enter the applicable State plan eligibility code number, if available. To report more
than one code, report the additional State plan eligibility codes in column 18.
Column 9--For each entry in columns 10 and 12, or column 11, enter the Worksheet S-2, Part I,
column number where the days were reported.
Column 10--Enter the number of Medicaid eligible days during the dates of service entered in
columns 3 and 4, including the number of days for a newborn baby remaining in the hospital after
the Medicaid eligible mother’s date of discharge (see column 12 instructions for reporting
newborn baby days prior to the Medicaid eligible mother’s date of discharge). (See §4004.1 “Note
for lines 24 and 25” for definitions of the eligible Medicaid days.) The sum of the days in this
column must equal the sum of the days reported on Worksheet S-2, Part I, line 24 or 25, as
applicable, columns 1 through 5. In addition, the sum of the days summarized by each column
reported in column 9 must equal the days reported in the respective column on Worksheet S-2,
Part I, line 24 or 25, as applicable. For example, if the listing supports days for Worksheet S-2,
Part I, line 24, then the sum of the days reported in column 10 of the exhibit must equal the days
reported on Worksheet S-2, Part I, line 24, sum of columns 1 through 5; and, if the days reported
on Worksheet S-2, Part I, line 24, column 3, equals 25, then the sum of the days entered in
column 10 where column 9 is 3, must equal 25.
Column 11--Enter the number of labor and delivery days, defined as days during which a
maternity patient is in the labor/delivery room ancillary area at midnight at the time of census
taking; the maternity patient is not included in the census count of the inpatient routine care area
because the patient has not occupied an inpatient routine bed at some time before admission (see
CMS Pub. 15-1, chapter 22, §2205.2). The days reported in this column must equal the number
of days reported on Worksheet S-2, Part I, line 24, column 6.
Column 12--Enter the number of newborn baby days occurring prior to the Medicaid eligible
mother’s date of discharge for a baby born to a Medicaid eligible mother. These newborn baby
days are in addition to the mother’s days reported in column 10. If the Medicaid eligible mother
was discharged and the newborn baby remained in the hospital, do not report the newborn baby
days occurring after the date of the mother’s discharge in this column; report the days on a
separate line in column 10.

40-38.2

Rev.

DRAFT

FORM CMS-2552-10

4004.1 (Cont.)

Columns 13 and 14--Enter in column 13 the name of the insurance company or other payer with
primary responsibility for paying the claim. If applicable, enter in column 14 the name of the
insurer or other payer with secondary responsibility.
Column 15--Enter either “A” or “B” to indicate the patient’s Medicare eligibility during the dates
of service in columns 3 and 4; otherwise, if the patient was eligible for neither Part A nor Part B,
leave the column blank. If the patient was eligible for Medicare, enter “A” or “B” as follows:
•
•
•

if eligible for only Medicare Part A, enter “A”
if eligible for both Part A and Part B, enter “A”
if eligible for only Medicare Part B, enter “B”

Columns 16 and 17--If the entry in column 15 is either “A” or “B”, enter the date that the patient’s
Medicare eligibility started in column 16 and, if applicable, enter the date that the patient’s
Medicare eligibility ended in column 17.
Column 18--Enter optional comments and/or additional information as needed. To decrease
patients’ vulnerability to identity theft, do not report a patient’s date of birth or social security
number.

Rev.

40-38.3

4004.1 (Cont.)

FORM CMS-2552-10

DRAFT

EXHIBIT 3A
TITLE

MEDICAID ELIGIBLE DAYS FOR A DSH ELIGIBLE HOSPITAL

PROVIDER NAME
CCN
CRP BEGINNING DATE
CRP ENDING DATE
WS S-2, PT. I, LINE #
PREPARED BY
DATE PREPARED
TOTAL COLUMNS 10 &12
TOTAL COLUMN 11

PATIENT
LAST
NAME
1

WKST S-2,
PART I
COLUMN
NUMBER
9

40-38.4

PATIENT
FIRST
NAME
2

PATIENT CLAIM INFORMATION
DATE OF
DATE OF
SERVICE SERVICE FROM
TO
3
4

MEDICAID DAYS
ELIGIBLE
DAYS
10

LABOR &
DELIVERY
ROOM DAYS
11

NEWBORN
BABY DAYS
12

PATIENT
ACCOUNT
NUMBER
5

MEDICAL
RECORD
NUMBER
6

INSURANCE OR
OTHER PAYER NAME
PRIMARY
13

SECONDARY
14

MEDICAID
NUMBER
7

STATE
ELIGIBILITY
CODE
8

MEDICARE ELIGIBILITY
A/B
INDICATOR
15

START DATE
16

END DATE
17

COMMENTS
18

Rev.

01-22

FORM CMS-2552-10

4004.2

4004.2 Part II - Hospital and Hospital Health Care Complex Reimbursement Questionnaire.-The information required on Part II of this worksheet (formerly Form CMS-339) must be
completed by all hospitals submitting cost reports to the Medicare contractor under title XVIII of
the Social Security Act. Its purpose is to assist you in preparing an acceptable cost report, to
minimize the need for direct contact between you and your contractor, and to expedite review and
settlement of cost reports. It is designed to answer pertinent questions about key reimbursement
concepts displayed in the cost reports and to gather information necessary to support certain
financial and statistical entries on the cost report. The questionnaire is a tool used in arriving at a
prompt and equitable settlement of your cost report.
Where the instructions for this worksheet direct you to submit documentation/information, mail or
otherwise transmit to the contractor immediately after submission of the ECR. The contractor has
the right under §§1815(a) and 1883(e) of the Act to request any missing documentation required
to complete the desk review.
To the degree that the information in the questionnaire constitutes commercial or financial
information which is confidential and/or is of a highly sensitive personal nature, the information
will be protected from release under the Freedom of Information Act. If there is any question
about releasing information, the contractor should consult with the CMS Regional Office.
Line Descriptions
NOTE: The responses on all lines are Yes or No unless otherwise indicated. If, in accordance
with the following instructions, you are requested to submit documentation, indicate the
line number for each set of documents you submit.
Lines 1 through 21 are required to be completed by all hospitals.
Line 1--Indicate whether the hospital has changed ownership immediately prior to the beginning
of the cost reporting period. 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 hospital 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 hospital is involved in business transactions, including management
contracts, with individuals or entities (e.g., chain home offices, drug or medical supply companies)
that are related to the provider or its officers, medical staff, management personnel, or members
of the board of directors through ownership, control, or family and other similar relationships.
Enter “Y” for yes or “N” for no. If “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.)

Rev. 17

40-39

4004.2 (Cont.)

FORM CMS-2552-10

01-22

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 you answer “Y” in column 1, 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) 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 no 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 filed financial statements. Enter “Y” for yes or “N” for no. If “Y”, submit a
reconciliation with the cost report.
Line 6--Indicate whether costs were claimed for a nursing program. Enter “Y” for yes or “N” for
no in column 1. If you answer “Y” in column 1, enter “Y” for yes or “N” for no in column 2 to
indicate whether the provider is the legal operator of the program.
Line 7--Indicate whether costs were claimed for allied health programs. Enter “Y” for yes or “N”
for no. If “Y”, submit a list of the program(s) with the cost report and annotate for each whether
the provider is the legal operator of the program.
NOTE FOR LINES 6 and 7: For purposes of lines 6 and 7, the provider is the legal operator of
a nursing program and/or allied health program if it meets the criteria in
42 CFR 413.85(f)(1) or (f)(2).
Line 8--Indicate whether approvals and/or renewals were obtained during the cost reporting period
for nursing program and/or allied health programs. Enter “Y” for yes or “N” for no. If “Y”, submit
a list of the program(s), and copies of the approvals and/or renewals with the cost report.
Line 9--Indicate whether costs for interns and residents in approved GME programs were claimed
on the current cost report. Enter “Y” for yes or “N” for no. If “Y”, submit the current year InternResident Information System (IRIS) with the cost report in a password-encrypted file on a CD or
flash drive, or by a contractor-approved means such as electronic mail or a secure website.
Line 10--Indicate whether intern and resident approved GME program(s) have been initiated or
renewed during the cost reporting period. Enter “Y” for yes or “N” for no. If “Y”, submit copies
of the certification(s)/program approval(s) with the cost report. (See 42 CFR 413.79(l) for the
definition of a new program.)
Line 11--Indicate whether GME costs were directly assigned to cost centers other than the InternResident Services in an Approved Teaching Program on Worksheet A. Enter “Y” for yes or “N”
for no. If “Y”, submit a listing of the cost centers and amounts with the cost report.

40-40

Rev. 17

DRAFT

FORM CMS-2552-10

4004.2 (Cont.)

Line 12--Indicate whether you are seeking reimbursement for bad debts resulting from Medicare
deductible and coinsurance amounts that are uncollectible from Medicare beneficiaries. (See
42 CFR 413.89 for the criteria for an allowable Medicare bad debt.) Enter “Y” for yes or “N” for
no in column 1. If you answer “Y” in column 1, submit listings supporting the bad debts claimed
in the cost report. Effective for cost reporting periods beginning on or after October 1, 2018, a
cost report will be rejected when submitted without listings that correspond to the amount of bad
debt claimed (42 CFR 413.24(f)(5)). Exhibit 2 (for cost reporting periods beginning prior to
October 1, 2022) and Exhibit 2A (for cost reporting periods beginning on or after
October 1, 2022) present the information required to support the bad debt claimed. (See exhibits
and instructions presented at the end of §4004.2.) If applicable, submit separate exhibits for each
provider number in a hospital health care complex.
[Exhibit 2 and instructions moved to the end of §4004.2 with Exhibit 2A and instructions.]
Line 13--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 you answer “Y” in column 1, submit a
copy of the policy with the cost report.
Line 14--Indicate whether patient deductibles and/or coinsurance amounts were waived. Enter
“Y” for yes or “N” for no in column 1. If you answer “Y” in column 1, do not include the
deductibles and/or coinsurance amounts that were waived on the bad debt listing (i.e., Exhibit 2
or Exhibit 2A).

Rev.

40-41

4004.2 (Cont.)

FORM CMS-2552-10

DRAFT

Line 15--Indicate whether total available beds have changed from the prior cost reporting period.
Enter “Y” for yes or “N” for no in column 1. If you answer “Y” in column 1, provide an analysis
of available beds and explain any changes that occurred during the cost reporting period.
NOTE FOR LINE 15: For purposes of line 15, available beds are provider beds that are
permanently maintained for lodging inpatients. They must be available for use and housed
in patient rooms or wards (i.e., do not include beds in corridors or temporary beds). (See
CMS Pub. 15-1, chapter 22, §2200.2.C., CMS Pub. 15-2, chapter 40, §4005.1, and
42 CFR 412.105(b).)
Line 16--Indicate whether the cost report was prepared using the Provider Statistical &
Reimbursement Report (PS&R) only. Use columns 1 and 2 for Part A and columns 3 and 4 for
Part B. Enter “Y” for yes or “N” for no in columns 1 and 3. If either column 1 or 3 is “Y” enter
the paid-through date of the PS&R in columns 2 and/or 4. Also, submit a crosswalk between
revenue codes and charges found on the PS&R to the cost center groupings on the cost report.
This crosswalk will reflect a cost center to revenue code match only.
Line 17--Indicate whether the cost report was prepared using the PS&R for totals and provider
records for allocation. Use columns 1 and 2 for Part A and columns 3 and 4 for Part B. Enter
“Y” for yes or “N” for no in columns 1 and 3. If either column 1 or 3 is “Y”, enter the paid through
date of the PS&R used to prepare this cost report in columns 2 and/or 4. Also, submit a detailed
crosswalk between revenue codes, departments and charges on the PS&R to the cost center
groupings on 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 workpapers 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.
Line 18--If you entered “Y” on either line 16 or 17, columns 1 and/or 3, 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 columns 1
and 3. If either column 1 or 3 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 19--If you entered “Y” on either line 16 or 17, columns 1 and/or 3, 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 columns 1 and 3. If either column 1 or 3 is “Y”, submit a detailed
explanation and documentation which provides an audit trail from the PS&R to the cost report.
Line 20--If you entered “Y” on either line 16 or 17, columns 1 and/or 3, indicate whether other
adjustments were made to the PS&R data. Enter “Y” for yes or “N” for no in columns 1 and 3. If
either column 1 or 3 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 21--Indicate whether the cost report was prepared using provider records only. Enter “Y” for
yes or “N” for no in columns 1 and 3. If either column 1 or 3 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.

40-42

Rev.

DRAFT

FORM CMS-2552-10

4004.2 (Cont.)

The minimum requirements are:
•

Copies of input tables, calculations, or charts supporting data elements for PPS
operating rate components, capital PPS rate components and other PRICER
information covering the cost reporting period.

•

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.

•

Reconciliation of remittance totals to the provider’s internal records.

•

Include the name of the system used and indicate how the system was maintained
(vendor or provider). If the provider maintained the system, include date of last
software update.

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.
Lines 22 through 40 are required to be completed by cost-reimbursed and TEFRA hospitals only.
Line 22--Indicate whether assets have been re-lifed for Medicare purposes. Enter “Y” for yes or
“N” for no in column 1. If column 1 is “Y”, submit a detailed listing of these specific assets, by
class, as shown in the Fixed Asset Register with the cost report.
NOTE: “Class” means those depreciable asset groupings you use (e.g., land improvements,
moveable equipment, buildings, fixed equipment).
Line 23--Indicate whether changes occurred in the Medicare depreciation expense due to
appraisals made 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 Appraisal Report and Appraisal Summary by class of asset
with the cost report.
Line 24--Indicate whether new leases and/or amendments to existing leases were entered into
during the cost reporting period. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”,
submit a listing of the new leases and/or amendments to existing leases if the annual rental cost of
each of these leases is $50,000 or greater with the cost report. The listing should include the
following information:
•
•
•
•
•

Identify if the lease is new or a renewal.
Parties to the lease.
Period covered by the lease.
Description of the asset being leased.
Annual charge by the lessor.

NOTE: Providers are required to submit copies of the lease, or significant extracts, upon
request from the contractor.

Rev.

40-43

4004.2 (Cont.)

FORM CMS-2552-10

DRAFT

Line 25--Indicate whether new capitalized leases were entered into during the cost reporting
period. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a list of the
individual assets by class, the department assigned to, and respective dollar amounts if the annual
rental cost of these leases is $50,000 or greater with the cost report.
Line 26--Indicate whether assets subject to §2314 of DEFRA were acquired during the cost
reporting period. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a
computation of the basis with the cost report.
Line 27--Indicate whether your capitalization 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 with the cost
report.
Line 28--Indicate whether new loans, mortgage agreements, or letters of credit were entered into
during the cost reporting period. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”,
submit copies of the debt documents and amortization schedules with the cost report. Also, state
the purpose of the borrowing.
Line 29--Indicate whether you have a funded depreciation account and/or bond funds (Debt
Service Reserve Fund) treated as a funded depreciation account. Enter “Y” for yes or “N” for no
in column 1. If column 1 is “Y”, submit a detailed analysis of the funded depreciation account for
the cost reporting period with the cost report. (See CMS Pub. 15-1, chapter 2, §226, and
42 CFR 413.153.)
Line 30--Indicate whether existing debt has been replaced prior to its scheduled maturity with new
debt. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a copy of the new
debt document and a schedule calculating the allowable cost. (See CMS Pub. 15-1, chapter 2,
§233.3, for description of allowable cost.)
Line 31--Indicate whether debt has been recalled before its scheduled maturity without the
issuance of new debt. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a
detailed analysis supporting the debt cancellation costs and treatment of these expenses on the cost
report. (See CMS Pub. 15-1, chapter 2, §215, for description and treatment of debt cancellation
costs.)
Line 32--Indicate whether you have entered into new agreements or if changes occurred in patient
care services furnished through contractual arrangements with suppliers of service. Enter “Y” for
yes or “N” for no in column 1. If column 1 is “Y”, submit copies of the contracts in those instances
where the cost of the individual’s services exceeds $25,000 per year with the cost report.
Where you do not have written agreements for purchased services, submit a description listing the
following information:
•
•
•
•

Duration of the arrangement.
Description of services.
Financial arrangement.
Name(s) of parties to the agreement furnishing the services.

Line 33--If you answered “Y” on line 32, were the requirements of CMS Pub. 15-1, chapter 21,
§2135.2, pertaining to competitive bidding applied? Enter “Y” for yes or “N” for no in column 1.
If column 1 is “N”, submit an explanation with the cost report.
Line 34--Indicate whether services were furnished at your facility under an arrangement with
provider-based physicians. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”,
submit Exhibit 1 (exhibit and instructions presented at the end of §4004.2), where applicable.

40-44

Rev.

DRAFT

FORM CMS-2552-10

4004.2 (Cont.)

You may submit computer generated substitutes for these schedules provided they contain, at a
minimum, the same information as in Exhibit 1. (This includes the signature on a substitute
Exhibit 1.)
Allocation agreements (Exhibit 1) are required if physician compensation is attributable to both
direct patient care and provider services. Allocation agreements are also required if all of the
provider-based physician’s compensation is attributable to provider services (i.e., departmental
supervision and administration, quality control activities, teaching and supervision of InternsResidents and/or Allied Health Students, and in the case of teaching hospitals electing cost
reimbursement for teaching physicians’ services, for compensation attributable to direct medical
and surgical services furnished to individual patients, and the supervision of intern and residents
furnishing direct medical and surgical services to individual patients. However, Exhibit 1 is not
required if all of the provider-based physician’s compensation is attributable to direct medical and
surgical services to individual patients.
Physicians’ compensation information is considered to be confidential, and therefore, qualifies for
exemption from disclosure under the Freedom of Information Act, and specifically under
5 U.S.C. 552(b)(4). The compensation information also qualifies for exemption from disclosure
under 5 U.S.C. 552(b)(6) which covers “personnel and medical files, the disclosure of which
would constitute a clearly unwarranted invasion of personal privacy.” An individual’s
compensation is a personal matter and its release would be an invasion of privacy. Accordingly,
CMS will not release, or make available to the public, compensation information collected.
[Instructions for Exhibit 1 and sample form moved to the end of §4004.2.]
Line 35--If you answered “Y” on line 34, indicate whether new agreements or amendments to
existing agreements were entered into during the cost reporting period. Enter “Y” for yes or “N”
for no in column 1. If column 1 is “Y”, submit copies of the new agreements or the amendments
to existing agreements with the cost report.
Line 36--Indicate whether home office costs are claimed on the cost report. Enter “Y” for yes or
“N” for no in column 1.
Line 37--If you answered “Y” on line 36, indicate whether a home office cost statement was
prepared by the home office. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”,
submit a schedule displaying the entire chain’s direct, functional, and pooled costs as provided to
the designated home office contractor as part of the home office cost statement.
Line 38--If you answered “Y” on line 36, indicate whether the fiscal year end of the home office
is different from that of the provider. Enter “Y” for yes or “N” for no in column 1. If column 1 is
“Y”, enter the fiscal year end of the home office in column 2.
Line 39--If you answered “Y” on line 36, indicate whether the provider renders services to other
components of the chain. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit
a schedule listing the names of the entities, the services provided, and cost incurred to provide
these services with the cost report.
Line 40--If you answered “Y” on line 36, indicate whether the provider renders services to the
home office. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a schedule
listing the services provided, and cost incurred to provide these services with the cost report.
Line 41--Enter the first name, last name and the title/position held by the cost report preparer in
columns 1, 2, and 3, respectively.
Line 42--Enter the employer/company name of the cost report preparer.
Line 43--Enter the telephone number and email address of the cost report preparer.
Rev.

40-45

4004.2 (Cont.)

FORM CMS-2552-10

DRAFT

Exhibit 1 - Allocation of Physician Compensation Hours Instructions and Form
Complete this exhibit in accordance with CMS Pub. 15-1, chapter 21, §2182.3. The data elements
shown are physicians’ hours of service providing a breakdown between the professional and
provider component.
Prepare a physician time allocation for each physician by department, who receives payment
directly from you or a related organization for services rendered. This includes physicians paid
through affiliated agreements. A weighted average for the entire department may be used where
all physicians in the department are in the same specialty. Where a weighted average is submitted,
individual time allocations need not be submitted. The physician or department head supplying
this information must sign the schedule.
EXHIBIT 1
Allocation of Physician
Compensation: Hours

Cost Reporting Year:
Basis of Allocation:

Provider Name:
CCN:
Department:
Physician Name:
Beginning:

Time Study

Ending:
Other

Describe:
Total
Hours

Services
1.

Provider Services - Teaching and Supervision of I/R's and other GME Related Functions.

1A. Provider Services - Teaching and Supervision of Allied Health Students
1B. Provider Services - Non Teaching Reimbursable Activities such as Departmental
Administration, Supervision of Nursing, and Technical Staff, Utilization Review, etc.
1C. Provider Services - Emergency Room Physician Availability (Do not include
minimum guarantee arrangements for Emergency Room Physicians.)
1D. Sub-Total - Provider Administrative Services (Lines 1, 1A, 1B, 1C).
2.

Physician Services: Medical and Surgical Services to Individual Patients

Non-Reimbursable Activities: Research, Teaching of I/R's in Non-Approved
Programs, Teaching and Supervision of Medical Students, Writing for Medical
Journals, etc.

Total Hours: (Lines 1D, 2, and 3)

Professional Component Percentage (Line 2 / Line 4)

Provider Component Percentage - (Line 1D / Line 4)
Signature: Physician or Physician Department Head

40-46

Date

Rev.

DRAFT

FORM CMS-2552-10

4004.2 (Cont.)

Exhibit 2 - Listing of Medicare Bad Debts and Appropriate Supporting Data Instructions and
Form
If seeking reimbursement for bad debts resulting from Medicare deductible and coinsurance
amounts that are uncollectible from Medicare beneficiaries (Worksheet S-2, Part II, line 12, is Y),
for a cost reporting period beginning prior to October 1, 2022, complete Exhibit 2, or internal
schedules that provide the same level of information as is requested on the exhibit, to support the
bad debts claimed. If claiming bad debts for inpatient and outpatient services, complete a separate
exhibit or internal schedule for each (one schedule for inpatient and one schedule for outpatient).
Exhibit 2 requires the following information:
Columns 1, 2, and 3 - Patient Names, Health Insurance Claim 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, health insurance claim number (HICN) or Medicare Beneficiary
Identifier (MBI), and dates of service that correlate to the filed bad debt. (See 42 CFR 413.89.)
Column 4--Indigency/Medicaid Beneficiary--If the patient included in column 1 has been deemed
indigent (either by virtue of being dual eligible for Medicare and Medicaid, or otherwise), place a
check in the “yes” section of this column. If the patient included in this column has a valid
Medicaid number, also include this number in the “Medicaid Number” section of this column. See
the criteria in 42 CFR 413.89 for guidance on the billing requirements for indigent and Medicaid
beneficiaries.
Columns 5 and 6--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, HIC number, and dates of service shown in columns 1, 2, and 3 of this exhibit. The date in
column 6 represents the date that the unpaid account is deemed worthless, whereby all collection
efforts, both internal and by an outside entity, ceased and there is no likelihood of recovery of the
unpaid account. (See CFR 413.89(f).)
Column 7--Remittance Advice Dates--Enter in this column the remittance advice dates that
correlate with the beneficiary name, HIC No., and dates of service shown in columns 1, 2, and 3
of this exhibit.
Columns 8 and 9--Deductibles & Coinsurance--Record in these columns the beneficiary’s unpaid
deductible and coinsurance amounts that relate to covered services.
Column 10--Total Medicare Bad Debts--Enter on each line of this column, the sum of the amounts
in columns 8 and 9. Calculate the total bad debts by summing up the amounts on all lines of
column 10. This total must agree with the bad debts claimed on the cost report. Attach additional
supporting schedules, if necessary, for bad debt recoveries.

Rev.

40-47

4004.2 (Cont.)

FORM CMS-2552-10

DRAFT

EXHIBIT 2
LISTING OF MEDICARE BAD DEBTS AND APPROPRIATE SUPPORTING DATA
PROVIDER NAME
CCN
FYE

PREPARED BY
DATE PREPARED
INPATIENT
OUTPATIENT
(3)
DATES OF
SERVICE

(1)
Patient Name

(2)
HICN / MBI

FROM

(4)
INDIGENCY &
MEDICAID
BENEFICIARY
(CK IF APPL)
YES

MEDICAID
NUMBER

(5)
DATE
FIRST
BILL
SENT TO
BENEFICIARY

(6)
DATE
COLLECTION
EFFORTS
CEASED

(7)
MEDICARE
REMITTANCE
ADVICE
DATES

(8)*
DEDUCT

(9)*
CO-INS

(10)
TOTAL

* THESE AMOUNTS MUST NOT BE CLAIMED UNLESS THE PROVIDER BILLS FOR THESE SERVICES WITH THE INTENTION OF PAYMENT.
SEE INSTRUCTIONS FOR COLUMN 4 - INDIGENCY/MEDICAID BENEFICIARY, FOR POSSIBLE EXCEPTION.

40-48

Rev.

DRAFT

FORM CMS-2552-10

4004.2 (Cont.)

Exhibit 2A -- Listing of Medicare Bad Debts Instructions and Form
If seeking reimbursement for bad debts resulting from Medicare deductible and coinsurance
amounts that are uncollectible from Medicare beneficiaries (Worksheet S-2, Part II, line 12, is Y)
for a cost reporting period beginning on or after October 1, 2022, complete Exhibit 2A to support
the bad debts claimed. Complete separate exhibits for bad debts resulting from inpatient services
and outpatient services. A hospital healthcare complex claiming bad debts for multiple
components must complete separate exhibits for each CCN. Enter dates in the MM/DD/YYYY
format.
Exhibit 2A requires the following information:
Enter the provider name, CCN, subprovider CCN (if applicable), cost reporting period (CRP)
beginning and ending dates, whether the listing represents Medicare bad debts for inpatient or
outpatient services, the name of the preparer, the date prepared, the total of Medicare allowable
bad debts (sum of column 24), and the total of dual-eligible Medicare bad debts (sum of amounts
entered in column 24 where column 7 has an entry).
Columns 1, 2, 3, 4, 5, and 6--From the Medicare beneficiary’s bill, enter the beneficiary’s name,
dates of service, patient account or identification number, and MBI or HICN, that correlate to the
claimed bad debt. (See 42 CFR 413.89(f).)
Column 7--Enter the Medicare beneficiary’s Medicaid number if the beneficiary was dually
eligible (eligible for Medicare and some category of Medicaid benefits).
Column 8--Enter “Y” for yes if the Medicare beneficiary was not eligible for Medicaid but the
provider deemed them to be indigent; otherwise, enter “N” for no. (See 42 CFR 413.89(e)(2)(ii).)
Column 9--Enter the Medicare remittance advice date for the Medicare beneficiary information
in columns 1 through 6.
Column 10--Enter the Medicaid remittance advice date or, when the provider does not receive a
Medicaid remittance advice, enter “AD” for alternate documentation used to determine state
liability (42 CFR 413.89(e)(2)(iii)(B)), that corresponds to the Medicare beneficiary information
in columns 1 through 7.
Column 11--Enter the date a remittance advice was received from a secondary payer, if
applicable.
Column 12--Enter the amount of coinsurance and deductible for which the Medicare beneficiary
is responsible. If the beneficiary is a qualified Medicare beneficiary (QMB), enter “QMB.” For
a Medicare beneficiary who is dually eligible for Medicaid (not a QMB), enter the amount the
beneficiary is required to pay under the state cost sharing agreement (42 CFR 413.89(e)(2)(iii)).
For a Medicare beneficiary deemed indigent by the provider (column 8 is “Y”), enter zero.
Column 13--Enter the date that the first bill was sent to the Medicare beneficiary. If the
beneficiary is a QMB, enter “QMB.”

Rev

40-49

4004.2 (Cont.)

FORM CMS-2552-10

DRAFT

NOTE FOR COLUMNS 14 THROUGH 17: The dates reported in column 14 (the date that the
Medicare beneficiary's liability was written off of the provider's accounts receivable),
column 15 (the date that the collection agency ceased collection effort), column 16 (the
date that all collection efforts ceased), and column 17 (the date that deductible and
coinsurance amounts were written off as a Medicare bad debt), may be the same date.
Column 14--Enter the date the Medicare beneficiary’s liability was written off of the accounts
receivable (A/R) in the provider’s financial accounting system. The date entered in this column
may be the same as, or earlier than, the date the account was deemed worthless (written off as a
Medicare bad debt).
Columns 15A and 15--In column 15A, enter “Y” for yes if the account was sent to a collection
agency; otherwise, enter “N” for no. If column 15A, is “Y”, in column 15, enter the date the
collection agency returned the account (i.e., the date that the collection agency ceased collection
effort on the account).
Column 16--Enter the date all collection efforts ceased, both internal and external, including
efforts to collect from Medicaid and/or from a state for its cost sharing liability.
Column 17--Enter the date the deductible and coinsurance amounts were written off as a Medicare
bad debt, i.e., the amount must have been written off as a bad debt against the A/R in the provider’s
financial accounting system; all collection effort, internal and external, against the Medicare
beneficiary and/or other third parties ceased; and a Medicaid remittance advice was received
from the state for Medicaid patients or alternate documentation exists as permitted under
42 CFR 413.89(e)(2)(iii)(B).
Column 18--Enter the amount of recoveries for amounts previously written off as an allowable
Medicare bad debt in this or a prior cost reporting period. The amount reported in this column
includes any payments received on an account after the account was written off as a bad debt,
including payments received in the same year the account was written off when the payment was
received after the date of the write off. (See 42 CFR 413.89(f).)
Column 19--If an amount is reported in column 18, enter the fiscal year end of the cost reporting
period in which the Medicare bad debt (to which the recovery applies) was claimed and
reimbursed. This column is optional; however, the date assists in identifying recovery amounts
that must be offset. The fiscal year end entered in this column is a prior cost reporting period
unless the write-off and recovery both occurred during this cost reporting period.
Column 20--Enter the Medicare deductible from the Medicare remittance advice (before any
payments received from any party).
Column 21--Enter the Medicare coinsurance amount from the Medicare remittance advice (before
any payments received from any party).
Column 22--Enter the amount of any payments received from the Medicare beneficiary, their
estate, third party insurance, etc., during this cost reporting period, before the account was written
off, for any amounts reported in column 20 and/or column 21. For example, when a beneficiary
has a liability for a deductible $2,500 and makes a payment of $1,500, the payment is reported in
column 22, leaving the remaining $1,000 eligible as an allowable bad debt.
Column 23--If an amount is reported in column 22, enter the payment source, or sources if
multiple payers, e.g., Medicare beneficiary, estate, third party insurance, etc.. Do not create
separate lines to enter each payment source.

40-50
DRAFT

FORM CMS-2552-10

Rev.
4004.2 (Cont.)

Column 24--Enter the allowable Medicare bad debt amount. This amount must be less than or
equal to the sum of the amounts in columns 20 and 21, less any payments in columns 18 and 22.
If the fiscal year end in column 19 is prior to this cost reporting period, enter the recovery amount
(reported in column 18) as a negative amount in this column. For each CCN, the sum of the
amounts entered in this column on each listing, (inpatient and outpatient), as applicable, must
equal the bad debts claimed for that CCN on the Medicare cost report. For example,
CCN ##-0001, an inpatient acute care hospital, reported bad debts of $24,000 on the Exhibit 2A
for inpatient and indicated that $12,000 on the Exhibit 2A for Medicaid eligible. The amount
reported on Worksheet E, Part A, line 64, must equal $24,000. The amount reported on
Worksheet E, Part A, line 66, must equal $12,000 (dual eligible).
Column 25--This column is for informational purposes. Enter any comments or additional
information as needed.

Rev.

40-51

4004.2 (Cont.)

FORM CMS-2552-10

DRAFT

EXHIBIT 2A
TITLE

MEDICARE BAD DEBTS

PROVIDER NAME
CCN
SUBPROVIDER CCN
CRP BEGINNING DATE
CRP ENDING DATE
INPATIENT / OUTPATIENT
PREPARED BY
DATE PREPARED
TOTAL COLUMN 24
TOTAL DUAL ELIGIBLE

PATIENT
NAME
LAST
1

PATIENT
NAME
FIRST
2

DATE OF
SERVICE:
FROM
3

DATE OF
SERVICE:
TO
4

PATIENT
ACCOUNT
NUMBER
5

A/R
WRITE
OFF DATE
14

SENT TO
COLLECTION
AGENCY
(Y/N)
15A

RETURN
FROM
COLLECTION
AGENCY
DATE
15

COLLECTION
EFFORT
CEASED
DATE
16

MEDICARE
WRITE
OFF DATE
17

MBI OR
HICN
6

MEDICAID
NUMBER
7

DEEMED
INDIGENT
8

MEDICARE
REMITTANCE
ADVICE
DATE
9

RECOVERIES ONLY:
AMOUNT
RECEIVED
18

RECOVERIES ONLY:
MCR FYE
DATE
19

MEDICARE DEDUCTIBLE
AMOUNT*
20

MEDICARE COINSURANCE
AMOUNT*
21

MEDICAID
REMITTANCE
ADVICE
DATE
10

SECONDARY
PAYER RA
RECEIVED
DATE
11

BENEFICIARY
RESPONSIBILITY
AMOUNT
12

DATE
FIRST
BILL SENT
TO BENE
13

CURRENT
YEAR PAYMENTS
RECEIVED
AMOUNT
22

CURRENT
YEAR PAYMENTS
RECEIVED
SOURCE
23

ALLOWABLE
BAD
DEBTS
AMOUNT
24

COMMENTS
25

* Report deductible and coinsurance amounts only when the provider billed the patient with the expectation of payment. See column 8 instructions for possible
exception.

40-52

Rev.

DRAFT

FORM CMS-2552-10

4004.2 (Cont.)

This page is reserved for future use.

Rev.

40-53

4005
4005.

FORM CMS-2552-10

DRAFT

WORKSHEET S-3 - HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX
STATISTICAL DATA AND HOSPITAL WAGE INDEX INFORMATION

This worksheet consists of five parts:
Part I
Part II
Part III
Part IV
Part V

Hospital and Hospital Health Care Complex Statistical Data
Hospital Wage Index Information
Hospital Wage Index Summary
Hospital Wage Related Costs
Hospital Contract Labor and Benefit Costs

4005.1 Part I - Hospital and Hospital Health Care Complex Statistical Data.--This part collects
statistical data regarding beds, days, FTEs, and discharges.
Column Descriptions
Column 1--Enter the Worksheet A line number that corresponds to the Worksheet S-3 component
line description.
Column 2--Refer to 42 CFR 412.105(b) and 69 FR 49093-49098 (August 11, 2004) to determine
the facility bed count. Indicate the number of beds available for use by patients at the end of the
cost reporting period.
A bed means an adult bed, pediatric bed, portion of inpatient labor/delivery/postpartum (LDP)
room (also referred to as birthing room) bed when used for services other than labor and delivery,
or newborn ICU bed (excluding newborn bassinets) maintained in a patient care area for lodging
patients in acute, long term, or domiciliary areas of the hospital. Beds in post-anesthesia, postoperative recovery rooms, outpatient areas, emergency rooms, ancillary departments (however,
see exception for labor and delivery department), nurses' and other staff residences, and other such
areas that are regularly maintained and utilized for only a portion of the stay of patients (primarily
for special procedures or not for inpatient lodging) are not termed a bed for these purposes. (See
CMS Pub. 15-1, chapter 22, §2205.)
For cost reporting periods beginning prior to October 1, 2012, beds in distinct ancillary labor and
delivery rooms and the proportion of LDP room (birthing room) beds used for labor and delivery
services are not a bed for these purposes. (See 68 FR 45420 (August 1, 2003).)
For cost reporting periods beginning on or after October 1, 2012, in accordance with 77 FR 5341153413 (August 31, 2012), beds in distinct labor and delivery rooms, when occupied by an inpatient
receiving IPPS-level acute care hospital services or when unoccupied, are considered to be part of
a hospital’s inpatient available bed count in accordance with 42 CFR 412.105(b) and are to be
reported on line 32. Furthermore, the proportion of the inpatient LDP room (birthing room) beds
used for ancillary labor and delivery services is considered part of the hospital’s available bed
count.
Column 3--Enter the total bed days available. Bed days are computed by multiplying the number
of beds available throughout the period in column 2 by the number of days in the reporting period.
If there is an increase or decrease in the number of beds available during the period, multiply the
number of beds available for each part of the cost reporting period by the number of days for which
that number of beds was available.

40-54

Rev.

04-20

FORM CMS-2552-10

4005.1

Column 4--CAHs accumulate the aggregate number of hours all CAH patients spend in each
category on lines 1 and 8 through 12. This data is for informational purposes only.
Columns 5 through 7--Enter the number of inpatient days or visits, where applicable, for each
component by program. Do not include HMO days except where required (lines 2 through 4,
columns 6 and 7; line 13, column 7), organ acquisition, or observation bed days in these columns.
Nursery days (all the days during which a newborn infant occupies a nursery) are reported on
line 13, column 7, and include the in-state paid Medicaid days; in-state Medicaid eligible but
unpaid days; out-of-state Medicaid paid days; out-of-state Medicaid eligible but unpaid days paid;
and Medicaid HMO paid and eligible but unpaid days. Observation bed days are reported in
columns 5 (title V), 7 (title XIX) and 8 (total), line 28. For LTCH, enter in column 6, on the
applicable line, the number of covered Medicare days (from the PS&R) and enter in column 6,
line 33, the number of non-covered days (from provider’s books and records) for Medicare
patients. See line 33 for further discussion.
For a hospital that participated in the PARHM demonstration during this cost reporting period,
subscript column 6 and report the program days associated with discharges occurring during the
period of non-participation in column 6, and program days occurring during the PARHM
demonstration in column 6.01. All PARHM demonstration program days are determined and
reported based the on the discharge date. For instance, the hospital began participation in the
PARHM demonstration for discharges occurring on or after January 29, 2019. A patient was
admitted on January 26, 2019 and discharged on February 1, 2019. The patient’s discharge date
was on or after January 29, 2019; therefore, all the program days associated with the discharge are
reported as PARHM demonstration days in column 6.01
Report the program days for PPS providers (acute care hospital, IPF, IRF, and LTCH) in the cost
reporting period in which the discharge is reported. This also applies to providers under the
TEFRA/PPS blend. TEFRA providers should report their program days in the reporting period in
which they occur.
NOTE: Medicaid days for Medicaid recipients who are members of an HMO as well as out-ofstate days, Medicaid secondary payer patient days, Medicaid eligible days for which no
payment was received, and nursery days are reported on lines 2, 3, 4, or 13, in accordance
with 42 CFR 412.106(b)(4)(ii). Therefore, Medicaid patient days reported on line 1,
column 7, do not include days for Medicaid patients who are also members of an HMO,
out-of-State Medicaid days, Medicaid secondary payer patient days, Medicaid eligible
days for which no payment was received, and nursery days.
Column 8--Enter the number of inpatient days for all classes of patients for each component.
Include organ acquisition and HMO days in this column. This amount will not equal the sum of
columns 5 through 7, when the provider renders services to other than titles V, XVIII, or XIX
patients.
Column 9--Enter the number of intern and resident FTEs in an approved program, determined in
accordance with 42 CFR 412.105(f), for the indirect medical education adjustment. The FTE
residents reported by an IPF PPS facility or an IRF PPS facility (whether freestanding or a unit
reported on line 16 or 17, respectively, of an IPPS hospital’s cost report) shall be determined in
accordance with 42 CFR 412.424(d)(1)(iii) for IPFs, and in accordance with the 70 FR 4792947930 (August 15, 2005) for IRFs.
Columns 10 and 11--The average number of FTE employees for the period may be determined
either on a quarterly or semiannual basis. When quarterly data are used, add the total number of
hours worked by all employees on the first week of the first payroll period at the beginning of each
quarter, and divide the sum by 160 (4 times 40). When semiannual data are used, add the total
number of paid hours on the first week of the first payroll period of the first and seventh months
of the period. Divide this sum by 80 (2 times 40). Enter the average number of paid employees
in column 10, and the average number of nonpaid workers in column 11, for each component, as
applicable.
Rev. 16

40-55

4005.1 (Cont.)

FORM CMS-2552-10

04-20

Columns 12 through 14--Enter the number of discharges including deaths (excluding newborn and
DOAs) for each component by program. A patient discharge, including death, is a formal release
of a patient. (See 42 CFR 412.4.) Enter the title XVIII Medicare Advantage (MA) discharges in
column 13, line 2. For cost reporting periods ending on or after June 30, 2014, enter the title XIX
managed care discharges in column 14, line 2. For columns 13 and 14, lines 2 and 33 are a subset
of column 15, line 1. For cost reporting periods ending on or after October 1, 2014, enter the
title XIX managed care discharges in column 14, lines 3 and 4, for the IPF and IRF subproviders.
For column 14, lines 3 and 4 are subsets of column 15, line 16 and 17, respectively. Lines 2
through 4, column 14, are collected for informational purposes only. For LTCH, enter in
column 13, line 1, the number of covered Medicare discharges (from the PS&R) and enter in
column 13, line 33, the number of discharges associated with non-covered Medicare days (from
provider’s books and records). See line 33 for further discussion.
Column 15--Enter the number of discharges including deaths (excluding newborn and DOAs) for
all classes of patients for each component.
Line Descriptions
Line 1--For cost reporting periods beginning before October 1, 2012, exclude from column 2 the
portion of LDP room (birthing room) beds used for ancillary labor and delivery services, but
include on this line beds used for routine adult and pediatric services (postpartum). In accordance
with the instructions in 68 FR 45420 (August 1, 2003), compute this proportion (off the cost
report) by multiplying the total number of occupied and unoccupied available beds in the LDP
room by the percentage of time these beds were used for ancillary labor and delivery services. An
example of how to calculate the “percentage of time” would be for a hospital to determine the
number of hours for the cost reporting period during which each LDP room maternity patient
received labor and delivery services and divide the sum of those hours for all such patients by the
sum of the total hours (for both, ancillary labor and delivery services and for routine postpartum
services) that all maternity patients spent in the LDP room during that cost reporting period.
Alternatively, a hospital could calculate an average percentage of time maternity patients received
ancillary labor and delivery services in an LDP room during a typical month.
For cost reporting periods beginning on or after October 1, 2012, include all the available LDP
room (birthing room) beds in the available bed count in column 2. (See 77 FR 53411-53413
(August 31, 2012).) The proportion of available LDP room beds related to the ancillary labor and
delivery services must not be excluded from column 2 for those cost reporting periods.
In columns 5, 6, 7 and 8, enter the number of adult and pediatric hospital days excluding the SNF
and NF swing-bed, observation bed, and hospice days. In columns 6 and 7, also exclude HMO
days. Do not include in column 6 Medicare Secondary Payer/Lesser of Reasonable Cost
(MSP/LCC) days. Include these days only in column 8. However, do not include employee
discount days in column 8.
Labor and delivery days (as defined in the instructions for Worksheet S-3, Part I, line 32) must not
be included on this line.
Line 2--Enter in column 6, the title XVIII MA days and days for individuals enrolled in Medicare
cost plans (§1876 of the Act). Enter in column 7 the title XIX Medicaid HMO days and other
Medicaid eligible days not included on line 1, column 7.
Line 3--Enter in column 6, the title XVIII MA days and days for individuals enrolled in Medicare
cost plans (§1876 of the Act) that pertain to IPF subprovider patients. Enter in column 7 the
title XIX Medicaid HMO days and other Medicaid eligible days not included on line 16, column 7.

40-56

Rev. 16

DRAFT

FORM CMS-2552-10

4005.1 (Cont.)

Line 4--Enter in column 6, the title XVIII MA days and days for individuals enrolled in Medicare
cost plans (§1876 of the Act) that pertain to IRF subprovider patients. Enter in column 7 the
title XIX Medicaid HMO days and other Medicaid eligible days not included on line 17, column 7.
Line 5--Enter the Medicare covered swing-bed days (which are considered synonymous with SNF
swing-bed days) for all title XVIII programs where applicable. (See 42 CFR 413.53(a)(2).)
Exclude all MA days from column 6, include the MA days in column 8.
Line 6--Enter the non-Medicare covered swing-bed days (which are considered synonymous with
NF swing-bed days) for all programs where applicable. (See 42 CFR 413.53(a)(2).)
Line 7--Enter the sum of lines 1, 5, and 6.
Lines 8 through 13--Enter the appropriate statistic applicable to each discipline for all programs.
Line 14--Enter the sum of lines 7 through 13 for columns 2 through 8, and for columns 12 through
15, enter the amount from line 1. For columns 9 through 11, enter the total for each from your
records. Labor and delivery days (as defined in the instructions for Worksheet S-3, Part I, line 32)
must not be included on this line.
Line 15--Enter the number of outpatient visits for CAHs by program and total. An outpatient CAH
visit is defined in 42 CFR 413.70(b)(3)(iii).
Line 16--Enter the applicable data for the IPF subprovider.
Line 17--Enter the applicable data for the IRF subprovider.
Line 18--Enter the applicable data for other than IPF or IRF subproviders. If you have more than
one subprovider, subscript this line. Treat this area as a nonreimbursable cost center for Medicare
since it is not part of the Medicare certified hospital.
Line 19--If your State recognizes one level of care, complete this line for titles V, XVIII, and XIX,
however, do not complete line 20. If you answered yes to line 92 of Worksheet S-2, Part I,
complete all columns.
Line 20--Enter nursing facility days if you have a separately certified nursing facility for title XIX
or you answered yes to line 92 of Worksheet S-2, Part I. Make no entry if your State recognizes
only SNF level of care. If you operate an ICF/IID, subscript this line to 20.01 and enter the ICF/IID
days. Do not report any nursing facility data on line 20.01.
Line 21--Enter data for an other long term care facility. Treat this area as a nonreimbursable cost
center for Medicare since it is not part of the Medicare certified hospital.
Line 22--If you have more than one hospital-based HHA, subscript this line.
Line 23--Enter data for an ASC. If you have more than one ASC, subscript this line.
Line 24--Enter days applicable to hospice patients in a distinct part hospice.
Line 24.10--Effective for cost reporting periods beginning on or after October 1, 2011, enter in
column 8, the days applicable to hospice patients currently under a valid hospice election who
occupy general inpatient routine beds under a contractual arrangement between the hospital and
hospice to provide general inpatient hospice and/or respite care services.

Rev.

40-57

4005.1 (Cont.)

FORM CMS-2552-10

DRAFT

Line 25--CMHCs enter the number of partial hospitalization days as applicable. For reporting of
multiple facilities follow the same format used on Worksheet S-2, Part I, line 17.
Line 26--Enter the number of outpatient visits for FQHC and RHC. If you have both a hospitalbased FQHC and a hospital-based RHC, or multiples of either one, subscript this line as follows:
Report the first through twenty-fifth hospital-based RHCs on subscripted line numbers 26
through 26.24 and the twenty-sixth through thirty-sixth hospital-based RHCs on
subscripted line numbers 26.50 through 26.60.
Report the first through twenty-fifth hospital-based FQHCs on subscripted line
numbers 26.25 through 26.49 and the twenty-sixth through thirty-sixth hospital-based
FQHCs on subscripted line numbers 26.61 through 26.71.
If the RHC/FQHC is approved to file a consolidated cost report, all data is reported in aggregate
as a single provider. Report the consolidated primary RHC data on line 26 and consolidated
primary FQHC data on subscripted line 26.25.
Line 28--Enter the total observation bed days in column 8. Divide the total number of observation
bed hours by 24 and round up to the nearest whole day. These total hours should include the hours
for observation of patients who are subsequently admitted as inpatients but only the hours up to
the time of admission as well as the hours for observation of patients who are not subsequently
admitted as inpatients but only the hours up to the time of discharge from the facility. Observation
bed days only need to be computed if the observation bed patients are placed in a routine patient
care area. The bed days are needed to calculate the cost of observation beds since it cannot be
separately costed when the routine patient care area is used. If, however, you have a distinct
observation bed area, it must be separately costed (as are all other outpatient cost centers), and this
computation is not needed.
Line 29--Enter in column 6, the total number of ambulance trips, as defined by §4531(a)(1) of the
BBA. Do not subscript this line.
Line 30--Enter in column 8, the employee discount days if applicable. These days are used on
Worksheet E, Part A, line 31, in the calculation of the DSH adjustment and Worksheet E-3,
Part III, line 3, in the calculation of the LIP adjustment. The days reported on this line must reflect
hospital services provided in the beds reported on line 14, column 2.
Line 31--Enter in column 8, the employee discount days, if applicable, for IRF subproviders.
Line 32--Effective for cost reporting periods beginning on or after October 1, 2012, enter in
column 2, the total number of available beds located in the distinct ancillary labor and delivery
rooms. In accordance with 42 CFR 412.105(b) and 77 FR 53411-53413 (August 31, 2012),
distinct ancillary labor and delivery room beds, when occupied by an inpatient receiving
IPPS-level acute care hospital services or when unoccupied, are considered to be part of a
hospital’s inpatient available bed count. These beds are not included in the inpatient routine beds
reported on line 1. Note that the available bed days reported in column 3 are reduced on
Worksheet E, Part A, by the equivalent of outpatient labor and delivery days from line 32.01.
Effective for cost reporting periods beginning on or after October 1, 2013, enter in column 6, the
number of labor/delivery inpatient days for title XVIII.
(See 78 FR 50730-50733
(August 19, 2013).)
Effective for cost reporting periods beginning on or after October 1, 2009, enter in column 7, the
number of labor/delivery inpatient days for title XIX, and in column 8, the total number of
labor/delivery inpatient days for the entire hospital. (See 74 FR 43899-43901 (August 27, 2009).)

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For the purposes of reporting on this line, labor and delivery days are defined as days during which
a maternity patient is in the labor/delivery room ancillary area at midnight at the time of census
taking, and is not included in the census of the inpatient routine care area because the patient has
not occupied an inpatient routine bed at some time before admission (see CMS Pub. 15-1,
chapter 22, §2205.2). Maternity patients must be admitted to the hospital as an inpatient for their
labor and delivery days to be included on line 32. These days must not be reported on
Worksheet S-3, Part I, line 1 or line 14. In the case where the maternity patient is in a single
multipurpose labor/delivery/postpartum (LDP) room (also referred to as a birthing room), hospitals
must determine the proportion of each inpatient stay that is associated with ancillary services (labor
and delivery) versus routine adult and pediatric services (postpartum) and report the days
associated with the labor and delivery portion of the stay on this line. An example of this would
be for a hospital to determine the percentage of each stay associated with labor/delivery services
and apply that percentage to the stay to determine the number of labor and delivery days of the
stay. Alternatively, a hospital could calculate an average percentage of time maternity patients
receive ancillary services in an LDP room during a typical month, and apply that percentage
through the rest of the year to determine the number of labor and delivery days to report on line 32.
Line 32.01--Effective for cost reporting periods beginning on or after October 1, 2012, enter in
column 8, the equivalent days for the entire hospital that are attributable to outpatient services
provided in the distinct ancillary labor and delivery room. Calculate the number of days by
dividing the total number of hours attributable to the outpatient services by 24, and round to the
nearest whole day. These total outpatient hours include the hours for outpatients occupying the
distinct ancillary labor and delivery room until they are admitted as inpatients or are discharged
from the hospital. For example, one patient is admitted as an inpatient after first occupying the
distinct ancillary labor and delivery room bed for 8 hours. Therefore, for this patient, 8 hours
would be included in the sum of the total hours used to compute equivalent days to be entered on
line 32.01. Another patient is admitted to the distinct ancillary labor and delivery room for
monitoring of possible labor or for a sonogram. After spending 6 hours in this department (room),
this patient is discharged from the hospital without being admitted as an inpatient. Therefore, for
this patient, 6 hours would be included in the sum of the total hours used to compute the equivalent
days to be entered on line 32.01. These outpatient labor and delivery days are used on
Worksheet E, Part A, to reduce the available bed days reported on line 32 so that only those distinct
ancillary labor and delivery room beds which are occupied by inpatients or are unoccupied are
ultimately counted as “beds.”
Line 33--Enter in column 6, the number of LTCH non-covered Medicare days (from the provider’s
books and records). These LTCH non-covered Medicare days are a subset of total patient days
reported in column 8, line14, and may be part of a covered or non-covered stay for Medicare
covered services. Enter in column 13, the number of LTCH discharges for Medicare stays
comprised exclusively of non-covered Medicare days (from the provider’s books and records).
These LTCH discharges are a subset of discharges reported in column 15, line 1, and do not
include discharges for a covered stay, where a portion of the stay is non-covered and the discharge
is already included in column 13, line 1, and reflected in the PS&R.
Line 33.01--Enter the LTCH site neutral days in column 6, and the LTCH site neutral discharges
in column 13. NOTE: The data entered on this line is a subset of the data reported on line 1.
Line 34--Effective March 1, 2020, through the end of the COVID-19 public health emergency
(PHE), enter the number of temporary expansion COVID-19 PHE acute care beds in column 2
and the number of bed days available for temporary expansion COVID-19 PHE acute care beds
in column 3. In columns 5, 6, 7, and 8, enter the number of inpatient days for temporary expansion
COVID-19 PHE acute care beds for title V, title XVIII, title XIX, and all patients, respectively.
The beds and days entered on this line are a subset of the beds and days that must be entered on
line 1 and lines 8 through 12. The temporary expansion COVID-19 PHE acute care bed days
available are excluded from the calculation of the IPPS hospital inpatient bed days available on
Worksheet E, Part A, line 4.

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4005.2 Part II - Hospital Wage Index Information.--This worksheet provides for the collection
of hospital wage data which is needed to update the hospital wage index applied to the laborrelated portion of the national average standardized amounts of the PPS. It is important for
hospitals to ensure that the data reported on Worksheet S-3, Parts II, III, and IV, are accurate.
Beginning October 1, 1993, the wage index must be updated annually. (See §1886(d)(3)(E) of
the Act.) Congress also indicated that any revised wage index must exclude data for wages
incurred in furnishing SNF services. Complete Worksheet S-3, Parts II, III, and IV, for IPPS
hospitals (see §1886(d)), any hospital with an IPPS subprovider, or any hospital that would be
subject to the IPPS if not granted a waiver.
NOTE: Any line reference for Worksheets A and A-6 includes all subscripts of that line. For
Worksheet A-6 reclassifications, see instructions for column 3 of this worksheet.
NOTE: Lines 4 and 22 apply to physician’s Part A administrative costs.
NOTE: Capitalized labor costs (salaries, hours, and wage-related costs) including, but not limited
to, capital projects associated with lines 1 and 2 of Worksheet A must not be included on
Worksheet S-3, Parts II, and III.
Column 2
General instructions for completing column 2:
1. For each line item (except for wage-related costs on lines 17 through 25 or as otherwise
indicated), report in column 2, the direct salaries and wages, including amounts for
related paid vacation, holiday, sick leave, other paid-time-off (PTO), severance pay,
and bonus pay for personnel associated with the line item.
2. Paid vacation, holiday, sick leave, other PTO, severance pay, and bonus pay must be
reported in column 2, with related direct salaries and wages to be considered an
allowable cost for the wage index.
3. Paid vacation, holiday, sick leave, other PTO, severance pay, and bonus pay must be
reported in the same cost center as the related direct salaries and wages. For example,
do NOT report the direct salaries and wages of an employee in one cost center and
report the employee’s paid vacation in a different cost center.
4. To be considered an allowable salary cost (i.e., direct salaries and wages plus paid
vacation, holiday, sick leave, other PTO, and severance pay), the associated hours must
also be reported in column 5. (See exceptions in column 5 instructions for bonus pay
and overtime pay. Also, for wage-related costs, there are no associated hours.)
5. Bonus pay includes award pay and vacation, holiday, and sick pay conversion (pay in
lieu of time off).
NOTE: Methodology for including and accruing direct salaries, paid vacation, paid holiday, paid
sick, and other PTO in the wage index:
Salary cost--The required source for costs on Worksheet A is the general ledger (see §4013
and 42 CFR 413.24(e)). Worksheet S-3, Part II, (wage index) data are derived from
Worksheet A; therefore, the proper source for costs for the wage index is also the general
ledger. A hospital’s current year general ledger includes both costs that are paid during the
current year and costs that are expensed in the current year but paid in the subsequent year
(current year accruals). Include on Worksheet S-3, Part II, the current year costs incurred
from the general ledger; that is, both the current year costs paid and the current year
accruals. (Costs that are expensed in the prior year but paid in the current year (prior year
accruals) are not included on a hospital’s current year general ledger; do not include on the
hospital's current year Worksheet S-3, Part II.)
Hours--The source for paid hours on Worksheet S-3, Part II, is the provider’s payroll
report. Hours are included on the payroll report in the period the associated expense is
paid. Include on Worksheet S-3, Part II, the hours from the current year payroll report,
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including hours associated with costs expensed in the prior year but paid in the current
year. The payroll report time period must cover the weeks that best match the provider’s
cost reporting period. (Hours associated with costs expensed in the current year but not
paid until the subsequent year (current year accrual) are not included on the current year
payroll report; do not include on the hospital’s current year Worksheet S-3, Part II.)
Although this methodology does not provide a perfect match between paid costs and paid
hours for a given year, it approximates a match between costs and hours.
NOTE: The above methodology is recommended by CMS but does not preclude using a different
approach that would produce a more accurate finding for purposes of the wage index. A
hospital must obtain approval from its contractor to use a different methodology. For
example, when the hospital is unable to match the general ledger and payroll report direct
salaries and hours within the exact dates of its cost reporting period, they may request
approval to accrue salaries and hours on Worksheet S-3, Part II (up to 15 days before the
cost reporting period beginning date or 15 days after the cost reporting period ending
date in order to include 365 or 366 days, depending on the year). Accrued costs must
have associated hours and must be excluded from the subsequent Worksheet S-3, Part II.
Regardless of the methodology used, costs and hours reported must be consistent. That is, accrued
costs must have associated hours reported in the same cost center and in the same cost reporting
period. The hospital must ensure that supporting documentation for both salaries and hours are
based on actual data maintained in a form that permits validation by the contractor. For example,
the hospital must be able to provide a payroll report that is summarized by individual employee
and type of pay (i.e., vacation, holiday, sick, etc.) so that the Medicare contractor can validate the
hours reported. The use of estimates for these amounts is unacceptable for the wage index.
Line 1--Enter from Worksheet A, column 1, line 200, the direct salaries and wages, including the
amounts for related paid vacation, holiday, sick leave, other PTO, severance pay, and bonus pay,
paid to hospital employees. See Worksheet A instructions (§4013).
Lines 2 through 10--The amounts reported must be adjusted for vacation, holiday, sick, other paid
time off, severance, and bonus pay if not already included. Do not include in lines 2 through 8 the
salaries for employees associated with excluded areas lines 9 and 10.
Line 2--Enter the salaries for directly-employed Part A non-physician anesthetist (for rural
hospitals that have been granted CRNA pass-through) to the extent these salaries are included in
line 1. Add to this amount the costs for CRNA Part A services furnished under contract to the
extent hours can be accurately determined. Report only the personnel costs associated with these
contracts. DO NOT include costs for equipment, supplies, travel expenses, and other
miscellaneous or overhead items. DO NOT include costs applicable to excluded areas reported on
lines 9 and 10. Additionally, contract CRNA cost must be included on line 11. Report in
column 5, the hours that are associated with the costs in column 4 for directly employed and
contracted Part A CRNAs.
Line 3--Enter the non-physician anesthetist salaries included in line 1, subject to the fee schedule
and paid under Part B by the contractor. Do not include salary costs for physician assistants,
clinical nurse specialists, nurse practitioners, and nurse midwives.
Line 4--Enter the physician Part A administrative salaries, (excluding teaching physician salaries),
that are included in line 1. Also do not include I & R salary on this line. Report I & R salary on
line 7. In accordance with 42 CFR 415.55(a) and 415.60, reasonable ER physician availability
cost can be considered Part A services.
Line 4.01-- Enter the Part A teaching physician salaries that are included in line 1.

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Line 5--Enter the total physician, physician assistant, nurse practitioner and clinical nurse
specialist on-call salaries and salaries associated with services that are billable under Part B that
are included in line 1. Under Medicare, these services are related to direct patient care and can be
billed separately under Part B. Also include physician salaries for patient care services reported
for rural health clinics (RHC) and FQHCs included on Worksheet A, column 1, lines 88 and/or 89,
as applicable. Do not include on this line amounts that are included on lines 9 and 10 for the SNF
or excluded area salaries. Refer to CMS Pub. 15-1, §§2313.2.E. and 2182.3.E., for instructions
related to keeping time studies to track time spent in Part A versus Part B activities. However,
although §2313.2.E.2. states that, “A minimally acceptable time study must encompass at least
one full week per month of the cost reporting period,” the contractor makes the final determination
on the adequacy of the records maintained. A 2-week semi-annual (every 6 months) time study
can be adequate unless the contractor believes that a significant change in the pattern of physician
time is likely to occur from one quarter to the next, in which case, the contractor may require more
frequent time studies. Adequate documentation must be maintained to support total hours in a
manner that is verifiable, and to serve as a condition of payment under Part A. In the absence of
a written allocation agreement, the contractor assumes that 100 percent of the physician
compensation cost is allocated to Part B services. Include non-allowable services that are neither
Part A nor Part B services (e.g., stand-by time, physician availability services, time spent in
research activities) with the time spent in Part B activities. Non-allowable services that are neither
Part A nor Part B services (for example, research, teaching of residents in non-approved programs,
teaching and supervision of medical students, writing for medical journals, reasonable availability
services in departments/cost centers other than emergency room, etc.) are reported as nonreimbursable activities in the designated non-reimbursable cost centers (for example,
Worksheet A, lines 190 through 194, see 42 CFR 415.60(b)(3)). Reasonable availability services
for emergency rooms can be considered Part A in certain circumstances (see CMS Pub. 15-1,
chapter 21, §2109.3.A. through C. for instances when emergency department physician
availability services costs are allowable, and for the associated required documentation).
Line 6--Report on line 6 the non-physician on-call salaries and salaries reported for hospital-based
RHC and FQHC services included on Worksheet A, column 1, lines 88 and/or 89, as applicable.
Do not include on this line amounts that are included on lines 9 and 10 for the SNF or excluded
area salaries.
Line 7--Enter from Worksheet A the salaries reported in column 1 of line 21 for interns and
residents. Subscript this line and report salaries for contracted interns and residents in an approved
program on line 7.01. Report only the personnel costs associated with these contracts. DO NOT
include cost for equipment, supplies, travel expenses, and other miscellaneous or overhead items.
DO NOT include costs applicable to excluded areas reported on lines 9 and 10. Additionally,
contract intern and resident costs must be included on line 11. DO NOT include contract intern
and residents costs on line 13. Report in column 5, the hours that are associated with the costs in
column 4 for directly employed and contract interns and residents.
Line 8--If you are a member of a home office or related organization as defined in CMS Pub. 15-1,
chapter 21, §2150, enter from your records, the wages and salaries for home office and/or related
organization personnel that are included in line 1. Wage related costs are not included on this line.
Lines 9 and 10--Enter on line 9 the amount reported on Worksheet A, column 1, for line 44 for the
SNF. On line 10, enter from Worksheet A, column 1, the sum of lines 20, 23, 40 through 42, 45,
45.01, 46, 94, 95, 98 through 101, 105 through 112, 114, 115 through 117, and 190 through 194.
DO NOT include on lines 9 and 10 any salaries for general service personnel (e.g., housekeeping)
which, on Worksheet A, column 1, may have been included directly in the SNF and the other cost
centers detailed in the instructions for line 10.
General Instructions for Contract Labor:
Only contract labor costs reported on the provider’s trial balance and, therefore, on Worksheet A,
column 2, are included on Worksheet S-3, Part II. Do not include contract labor wages and hours
on Worksheet S-3, Part II, line 1. Contract labor costs not reported in the proper cost center are
disallowed from the wage index calculation. If hours cannot be accurately determined, the
contract labor costs must not be included in the wage index. In general, for contract labor, the
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minimum requirement for supporting documentation is the contract itself. If the wage costs,
hours, and non-labor costs are not clearly specified in the contract, other supporting
documentation is required, such as a representative sample of invoices that specify the wage
costs, hours, and non-labor costs. Attestations or declarations from the vendor or hospital are not
acceptable in lieu of supporting documentation for wages, hours, wage-related costs, and
non-labor costs. Hospitals must be able to provide such documentation when requested by the
contractor. Report only personnel costs associated with the contract. DO NOT include cost for
equipment, supplies, travel expenses, and other miscellaneous or overhead items (non-labor
costs).
Workers who are contracted solely for the purpose of providing services on-call can only be
included on Worksheet S-3 when they actually work the on-call schedule. That is, they are
actually delivering patient care at the hospital, or are at the hospital so as to be available to deliver
patient care. If either of these latter two scenarios occur, then both the wages and associated hours
actually worked must be included in the appropriate contract labor line on Worksheet S-3. For
contractors that work a regular schedule in addition to being on-call, report the on-call wages, but
not the hours associated with the time the contractors are on-call. Do not include wages or hours
associated with Par B services.
Line 11--Enter the amount paid for services furnished under contract, rather than by employees,
for direct patient care, as defined below. Do not include costs applicable to excluded areas reported
on line 9 and 10. Include costs for contract CRNA and intern and resident services (these costs
are also to be reported on lines 2 and 7.01, respectively). DO NOT include the costs for patient
care services from the home office allocation and/or from related organizations. Include on this
line contract pharmacy and laboratory wage costs as defined below.
Direct patient care services include, but are nto limited to, nursing, diagnostic, therapeutic, and
rehabilitative services. Report only personnel costs associated with these contracts. DO NOT
apply the guidelines for contracted therapy services under §1861(v)(5) of the Act and
42 CFR 413.106. Direct patient care contracted labor, for purposes of this worksheet, DOES NOT
include the following: services paid under Part B: (e.g., physician clinical services, physician
assistant services), management and consultant contracts, billing services, legal and accounting
services, clinical psychologist and clinical social worker services, housekeeping services, security
personnel, planning contracts, independent financial audits, or any other service not directly related
to patient care.
Contract pharmacy and laboratory services are furnished under contract, rather than by
employees. These services include, but are not limited to, pharmacist, pharmacy assistant, medical
technologist, laboratory technologist, laboratory technician, and other services directly related to
patient care. These services exclude pathologist Part A. Instead, contract pathologist Part A
services must be reported on line 13. DONOT include the following services paid under Part B
(e.g., physician clinical services, physician assistant services), management and consultant
contracts, clerical and billing services, legal and accounting services, housekeeping services,
security personnel, planning contracts, independent financial audits, or any other service not
directly related to patient care. Report only personnel costs associated with the contracts.
If you have no contracts for direct patient care as defined above, enter a zero in column 2. If you
are unable to accurately determine the number of hours associated with contracted labor, enter a
zero in column 2.

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Line 12--Enter the amount paid for contracted top level management services, and other
contract management and administrative services furnished under contract, rather than by
employees. Include on this line contract management and administrative services associated
with cost centers other than those listed on lines 26 through 43 (and their subscripts) of this
worksheet that are included in the wage index.
Contracted Top Level Management: Include the amount paid for top level management
services, as defined below, furnished under contract rather than by employees. Contract
management is limited to the personnel costs for those individuals who are working at the
hospital facility in the capacity of chief executive officer, chief operating officer, chief financial
officer, or nursing administrator. The titles given to these individuals may vary from the titles
indicated above. However, the individual should be performing those duties customarily given
these positions.
For purposes of this worksheet, contract top level management services DO NOT include the
following: physician Part A services, consultative services, clerical and billing services, legal and
accounting services, unmet physician guarantees, physician services, planning contracts,
independent financial audits, or any services other than the top level management contracts listed
above. Per instructions on Worksheet S-2, Part II, for top level management contracts, submit to
your Medicare contractor the aggregate wages and hours.
Other Contract Management and Administrative Services: Examples of other contract
management and administrative services that would be reported on line 12 include department
directors, administrators, managers, ward clerks, and medical secretaries. Report only those
personnel costs associated with the contract. DO NOT include on line 12 any contract labor costs
associated with lines 26 through 43 and subscripts for these lines.
Line 13--Enter from your records the amount paid under contract (in accordance with the general
instructions for contract labor) for Part A physician services - administrative, excluding teaching
physician services. DO NOT include contract I & R services (to be included on line 7). DO
NOT include the costs for Part A physician services from the home office allocation and/or from
related organizations (to be reported on line 15). Do not include wages or hours associated with
Part B services. As stated in the General Instructions for Contract Labor, “the minimum
requirement for supporting documentation is the contract itself. If the wage costs, hours, and nonlabor costs are not clearly specified in the contract, other supporting documentation is required,
such as a representative sample of invoices that specify the wage costs, hours, and non-labor
costs.” Refer to CMS Pub. 15-1, §§2313.2E and 2182.3.E, for instructions related to keeping time
studies to track time spent in Part A versus Part B activities. Adequate documentation must be
maintained to support total hours in a manner that is verifiable. Total hours worked by the
physicians cannot be imputed. In the absence of a written allocation agreement, the contractor
assumes that 100 percent of the physician compensation cost is allocated to Part B services.
Services that are neither Part A nor Part B services (for example, research, non-allowable teaching
of residents in non-approved programs, teaching and supervision of medical students, writing for
medical journals, reasonable availability services in departments/cost centers other than
emergency room, etc.) are not reported on line 13. Reasonable availability services for emergency
rooms can be considered Part A in certain circumstances (see CMS Pub. 15-1, chapter 21,
§2109.3.A. through C. for instances when emergency department physician availability services
costs are allowable, and for the associated required documentation).
Line 14--For cost reporting periods beginning before October 1, 2015, enter the salaries and wagerelated costs (as defined on lines 17 and 18) paid to personnel who are affiliated with a home office
and/or related organization, who provide services to the hospital, and whose salaries are not
included on Worksheet A, column 1. In addition, add the home office/related organization salaries
included on line 8 and the associated wage-related costs. This amount must be based on
recognized methods of allocating an individual's home office/related organization salary to the

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hospital. Obtain this information from the home office cost statement to report wages and hours
for your hospital. Report only wages and hours associated with your hospital. If no home
office/related organization exists or if you cannot accurately determine the hours associated with
the home office/related organization salaries that are allocated to the hospital, then enter a zero in
column 2. All costs for any related organization (as defined in CMS Pub. 15-1, chapter 10;
42 CFR 413.17; and CMS Pub. 15-1, chapter 21, §2150ff through §2153ff), must be shown as the
cost to the related organization. For cost reporting periods beginning on or after October 1, 2015,
do not use this line but use lines 14.01 and/or 14.02.
Line 14.01--For cost reporting periods beginning on or after October 1, 2015, enter the salaries
paid to personnel affiliated with a home office, who provide services to the hospital, and whose
salaries are not included on Worksheet A, column 1, but are included in Worksheet A, column 2,
column 4 (if reported on Worksheet A-6), and/or column 6 (if reported on Worksheet A-8-1). In
addition, add the home office salaries included on line 8. The amounts reported on this line must
be based on recognized methods of allocating an individual's home office salary to the hospital.
Obtain this information from the home office cost statement to report wages and hours for your
hospital. Report only wages and hours associated with your hospital (and not other providers in
the chain). If no home office exists or if you cannot accurately determine the hours associated
with the home office salaries that are allocated to the hospital, then enter a zero in column 2. All
costs for any home office (as defined in 42 CFR 413.17; and CMS Pub. 15-1, chapter 21, §2150ff
through §2153ff), must be shown as the cost to the home office. Report only home office salary
costs on this line; report home office wage-related costs on line 25.50.
Line 14.02--For cost reporting periods beginning on or after October 1, 2015, enter the salaries
paid to personnel affiliated with a related organization (other than home office), who provide
services to the hospital, and whose salaries are not included on Worksheet A, column 1, but are
included in Worksheet A, column 2, column 4 (if reported on Worksheet A-6), and/or column 6
(if reported on Worksheet A-8-1). In addition, add the related organization salaries, other than a
home office, included on line 8. The amounts reported on this line must be based on recognized
methods of allocating an individual’s related organization salary to the hospital. If no related
organization exists or if you cannot accurately determine the hours associated with the related
organization salaries that are allocated to the hospital, then enter a zero in column 2. All costs for
any related organization (as defined in CMS Pub. 15-1, chapter 10; and 42 CFR 413.17), must be
shown as the cost to the related organization. Report only related organization salary costs on this
line; report related organization wage-related costs on line 25.51.
NOTE: Do not include any costs for Part A physician services from the home office allocation
and/or related organizations. These amounts are reported on line 15. Do not report any
wages, wage-related costs, or hours associated with excluded areas (lines 9 and 10).
Report the cost of home office services, whether employee or contract labor, in the most
closely matched cost centers on Worksheet A (lines 4 through 17), column 2, and on the
corresponding lines of Worksheet S-3, Part II (lines 26 through 43). Report allowable
contract labor costs, if applicable, in accordance with instructions on lines 28, 33, or 35.
If a wage related cost associated with the home office is not “core” (as described in the
Worksheet S-3, Part IV) and is not a category included in “other” wage related costs on
line 18 (see Worksheet S-3, Part IV, and line 18 instructions below), the cost cannot be,
included on line 14, or subscripts. For example, if a hospital’s employee parking cost
does not meet the criteria for inclusion as a wage-related cost on line 18, any parking cost
associated with home office staff cannot be included on line 14, or subscripts.
Line 15--For cost reporting periods beginning before October 1, 2015, enter from your records the
salaries and wage-related costs, and amount paid under contract for Part A physician services administrative, excluding teaching physician Part A services, from the home office allocation
and/or related organizations. For cost reporting periods beginning on and after October 1, 2015,
report only the salary costs and amount paid under contract on this line and report the wage-related
costs (as defined on lines 17 and 18) on line 25.52.
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Line 16--For cost reporting periods beginning before October 1, 2015, enter from your records the
salaries and wage-related costs for teaching physician Part A services from the home office
allocation and/or related organizations. Also report on this line Part A teaching physicians’
salaries under contract.
For cost reporting periods beginning on and after October 1, 2015 and before October 1, 2017, for
teaching physician Part A services from the home office allocation and/or related organizations,
report only the salary costs on this line and report the wage-related costs (as defined on lines 17)
on line 25.53. For Part A teaching physicians’ salaries under contract, continue to report salaries
and wage related costs on this line. Do not complete this line effective for cost reporting periods
beginning on or after October 1, 2017.
Line 16.01--For cost reporting periods beginning on or after October 1, 2017, enter from your
records the salaries for teaching physician Part A services from the home office allocation and/or
related organizations. Report the wage-related costs (as defined on lines 17) on line 25.53.
Line 16.02--For cost reporting periods beginning on or after October 1, 2017, enter from your
records the salaries for Part A teaching physicians under contract.
Lines 17 through 25 and 25.50 through 25.53--In general, the amount reported for wage-related
costs must meet the “reasonable cost” provisions of Medicare. For pension and executive deferred
compensation costs see the instructions below in Part IV. NOTE: Wage-related costs on
lines 25.50 through 25.53 are not tied to wage-related costs reported on Worksheet S-3, Part IV.
For those wage-related costs that are not covered by Medicare reasonable cost principles, a hospital
shall use generally accepted accounting principles (GAAP). For example, for purposes of the wage
index, disability insurance cost should be developed using GAAP. Hospitals are required to
complete Worksheet S-3, Part IV, a reconciliation worksheet to aid hospitals and contractors in
implementing GAAP when developing wage-related costs. Upon request by the contractor or
CMS, hospitals must provide a copy of the GAAP pronouncement, or other documentation,
showing that the reporting practice is widely accepted in the hospital industry and/or related field
as support for the methodology used to develop the wage-related costs. If a hospital does not
complete Worksheet S-3, Part IV, or, if the hospital is unable, when requested, to provide a copy
of the standard used in developing the wage-related costs, the contractor may remove the cost from
the hospital’s Worksheet S-3 due to insufficient documentation to substantiate the wage-related
cost relevant to GAAP.
NOTE: All costs for any related organization must be shown as the cost to the related
organization. (For Medicare cost reporting principles, see CMS Pub. 15-1, chapter 10,
§1000. For GAAP, see FASB 57.) If a hospital’s consolidation methodology is not in
accordance with GAAP or if there are any amounts in the methodology that cannot be
verified by the contractor, the contractor may apply the hospital’s cost-to-charge ratio to
reduce the related party expenses to cost.
NOTE: All wage-related costs, including FICA, workers compensation, and unemployment
compensation taxes, associated with physician services are to be allocated according to
the services provided; that is, those taxes and other wage-related costs attributable to
Part A administrative services must be placed on line 22, to Part A teaching services must
be placed on line 22.01, and to Part B (patient care services) must be placed on line 23.
Line 17 must not include wage-related costs that are associated with physician services.
Line 17--Enter the core wage-related costs from Worksheet S-3, Part IV, line 24. (See note below
for costs that are not to be included on line 17). Only the wage-related costs reported on
Worksheet S-3, Part IV, line 24, are reported on this line. (Wage-related costs are reported in
column 2, not column 1, of Worksheet A.)

40-61.1

Rev. 17

01-22

FORM CMS-2552-10

4005.2 (Cont.)

NOTE: Do not include wage-related costs applicable to the excluded areas reported on
lines 9 and 10. Instead, these costs are reported on line 19. Also, do not include the wagerelated costs for physicians Parts A and B, non-physician anesthetists Parts A and B,
interns and residents in approved programs, and home office/related party personnel. (See
lines 14, 15, and 20 through 25, and 25.50 through 25.53.)
Health Insurance and Health-Related Wage Related Costs:
The following are the allowable health insurance and health-related costs for the wage index.
1) Purchased Health Insurance:
• Premium costs.
• Costs paid to external organizations for plan administration.
2) Self (or Self-Funded) Health Insurance:
• Costs paid to external organizations for plan administration.
• Without a Third-Party Administrator (TPA).
• Costs the hospital incurs in providing services under the plan to its employees.
(Domestic claim charges must be reduced to cost. Costs must also exclude any
copayments and deductibles paid by employees.) Employee withholdings and
contributions are employee costs, not hospital costs. Hospitals are not permitted to
treat as hospital wage-related costs the amounts that their employees incur for their
health insurance benefits.
• Hospital’s payment to unrelated health care providers for services rendered, under
the plan, to hospital’s employees.
• With a TPA.
• Amount the TPA pays to the hospital or other health care providers for services
rendered under the plan. (For domestic claims, the hospital must provide
documentation from its TPA to demonstrate that payments for services rendered to
employees are based on a discount from full charges. Also, the payments must
be reasonable; that is, the costs included for domestic claims must not exceed
the amount that commercial insurers pay the hospital for the same services rendered
to non-employees.) Employee withholdings and contributions are employee costs,
not hospital costs. Hospitals are not permitted to treat as hospital wage-related
costs the amounts that their employees incur for their health insurance benefits.
Hospitals cannot claim additional net wage-related costs for employee claims not
fully reimbursed by the TPA payment.
NOTE: Hospitals and contractors are not required to remove from domestic claims costs,
the personnel costs that are associated with hospital staff who deliver the services to
employees. Regardless of whether self-funded insurance is with or without a TPA, where
hospitals provide healthcare services to their employees, hospitals cannot claim as a wagerelated cost the amount by which the hospitals reduce copays or deductibles of employees
receiving the health care services.
3) Health-Related Services: Inpatient and outpatient health services that are not covered under the
hospital’s health insurance plan, but are provided to employees at no cost or at a discount, for
example, employee physicals, flu shots, smoking cessation, and weight control programs, are to
be included as a core wage-related cost. (Domestic claim charges must be reduced to cost. Costs
must also exclude any copayments and deductibles paid by employees.)
NOTE: Hospitals and contractors are not required to remove from domestic claims costs,
the personnel costs that are associated with hospital staff who deliver the services to
employees.

Rev. 17

40-61.2

4005.2 (Cont.)

FORM CMS-2552-10

01-22

Line 18--Enter the total of “other” wage-related costs. Line 18, column 4, must equal the sum of
Worksheet S-3, Part IV, line 25, and its subscripts. Complete instructions for Worksheet S-3,
Part IV, line 25, are below in §4005.4. Do not complete this line effective for cost reporting
periods beginning on or after October 1, 2015.
NOTE: Do not include wage-related costs applicable to the excluded areas reported on lines 9
and 10. Instead, these costs are reported on line 19. Also, do not include the wagerelated costs for physician Parts A and B, non-physician anesthetists Parts A and B,
interns and residents in approved programs, and home office personnel.

40-62

Rev. 17

04-20

FORM CMS-2552-10

4005.2 (Cont.)

Line 19--Enter the total (core and other) wage-related costs applicable to the excluded areas
reported on lines 9 and 10.
Lines 20 through 25, and 25.50 through 25.53--Enter from your records the core wage-related
costs for each category of employee listed. Do not include the other wage-related costs reported
on Worksheet S-3, Part II, line 18, and Worksheet S-3, Part V, line 25. Do not include wagerelated costs for excluded areas reported on line 19. Subscript line 22, and report the wagerelated costs for Part A teaching physicians reported on line 4.01, on line 22.01. On line 23, do
not include wage-related costs related to non-physician salaries reported for hospital-based
RHCs and FQHCs services included on Worksheet A, column 1, lines 88 and/or 89, as
applicable. These wage-related costs are reported separately on line 24.
Line 25.50--For cost reporting periods beginning on or after October 1, 2015, enter the core
wage-related costs (as defined on line 17) paid to personnel who are affiliated with a home office
whose salaries are reported on line 14.01.
Line 25.51--For cost reporting periods beginning on or after October 1, 2015, enter the core
wage-related costs (as defined on line 17) paid to personnel who are affiliated with a related
organization (other than home office) whose salaries are reported on line 14.02.
Line 25.52--For cost reporting periods beginning on or after October 1, 2015, enter the core
wage-related costs (as defined on line 17) for Part A physician services - administrative,
excluding teaching physicians Part A services, from the home office allocation and/or related
organizations, whose salaries are reported on line 15.
Line 25.53--For cost reporting periods beginning on or after October 1, 2015, enter the core
wage-related costs (as defined on line 17) for teaching physicians Part A services from the home
office allocation and/or related organizations, whose salaries are reported on line 16, or for cost
reporting periods beginning on or after October 1, 2017, line 16.01.
NOTE: For cost reporting periods beginning prior to October 1, 2015, other wage related costs
associated with the home office are reported on Worksheet S-3, Part II, line 18, and on
Worksheet S-3, Part IV, line 25, and its subscripts. For lines 25.50 through 25.53 of
Worksheet S-3, Part II, if a wage-related cost associated with the home office is not
“core” (as described in the Worksheet S-3, Part IV), the cost must not be included on
line 14 and its subscripts, or on line 25 and its subscripts.
Lines 26 through 43--These lines provide for the collection of hospital wage data for overhead
costs to properly allocate the salary portion of the overhead costs to the appropriate service areas
for excluded units. Enter the direct salary and wages with related salary amounts for paid vacation,
holiday, sick, other PTO, severance, and bonus pay from Worksheet A, column 1, for lines 26, 27,
29 through 32, 34, and 36 through 43. Enter the contract labor costs from Worksheet A, column 2,
for lines 28, 33, and 35.
Line 26--Salaries and hours reported on this line correlate to the salaries reported on line 4,
column 1, of Worksheet A, for the personnel working in the Employee Benefit Department, or
the Human Resources Department. Do not report costs or hours associated with other hospital
employees on this line.

Rev. 16

40-63

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FORM CMS-2552-10

04-20

Lines 28, 33, and 35--Enter the amount paid for services performed under contract (in
accordance with the general contract labor instructions above), rather than by employees, for
A&G, housekeeping, and dietary services, respectively. Continue to report on the standard lines
(line 27, 32, and 34), the amounts paid for services rendered by employees not under contract.
Only contract labor costs reported on Worksheet A, column 2, column 4 (if reported on
Worksheet A-6), and/or column 6 (if reported on Worksheet A-8-1), are included on these lines.
Contract labor costs not reported in the proper cost center on Worksheet A, are excluded from the
wage index.
Line 28--Administrative and General (A&G) costs are expenses a hospital incurs in carrying out
its administrative and/or general management functions. Include on line 28, the contract services
that are included on Worksheet A, line 5, and subscripts, columns 2, 4 and/or 6 (“Administrative
and General”). Contract information and data processing services, legal, tax preparation, cost
report preparation, and purchasing services are examples of contract labor costs that would be
included on this line and must not be reported on lines 11 or 12. Do not include on line 28 the
costs for top level management contracts (these costs are reported on line 12). Do not include on
this line contract labor which is more closely matched to another overhead cost center, such as,
but not limited to, contract housekeeping or dietary services, which must be reported on line 33 or
line 35.
Lines 32 through 35--All hospitals must incur costs for housekeeping and dietary services, either
direct, under contract, or both. It is not acceptable to report zeroes for housekeeping or dietary
services. Report wages and hours for housekeeping services on either line 32 (direct) or line 33
(contract), and for dietary services, on either line 34 (direct) or line 35 (contract). See 79 FR 49965
(August 22, 2014). Hospitals are encouraged to ensure that their contracts clearly specify the salaries,
wages, and hours related to all of their contract labor. If, in rare instances, hours for these services
cannot be determined exactly from the contract, determine the hours based on a reasonable estimation.
Examples of reasonable estimates are regional average hourly rates, including an average of the wages
and hours for dietary and housekeeping services of other hospitals in the same CBSA. Hospitals also
may conduct time studies to determine hours worked. If regional averages or time studies cannot be
used, data from the Bureau of Labor Statistics may be used to obtain average wages and hours for
housekeeping and dietary services.
Column 3--Enter on each line, as appropriate, the salary and wages portion (as defined in
column 2 instructions) of any reclassifications made on Worksheet A-6. NOTE: Adjust the hours
in column 5 associated with the reclassified salary and wages. See the NOTE for column 5 below.
Column 4--Enter on each line the result of column 2 plus or minus column 3.
Column 5--Enter on each line the number of paid hours corresponding to the amounts reported
in column 4. Paid hours include regular hours (including paid lunch hours), overtime hours, paid
holiday, vacation and sick leave hours, paid time-off hours, and hours associated with severance
pay. For Part II, lines 1 through 15 (including subscripts), lines 26 through 43 (including
subscripts), and Part III, line 7, if the hours cannot be determined, then the associated salaries
must not be included in columns 2 through 4.
NOTE: The hours reported in column 5 must reflect any changes to salaries reported in
column 3. Report the on-call wages for employees and contractors that work a regular
schedule in addition to being on-call (not present at the hospital but off-site and ready to
be called in if needed); however, do not report the on-call hours. Report both the wages
and hours for on-call employees and contractors when they are called in to work. Overtime
hours are calculated as one hour when an employee is paid time and a half. No hours are
required for bonus pay. The intern and resident hours associated with the salaries reported
on line 7 must be based on 2080 hours per year for each full time intern and resident
employee. The hours reported for salaried employees who are paid a fixed rate are
recorded as 40 hours per week or the number of hours in your standard work week.

40-64

Rev. 16

04-20

FORM CMS-2552-10

4005.4

NOTE: Workers who are contracted solely for the purpose of providing services on-call
can only be included on Worksheet S-3 when they actually work the on-call schedule; that
is, they are actually delivering patient care at the hospital, or are at the hospital so as to be
available to deliver patient care. If either of these latter two scenarios occur, then both the
wages and associated hours actually worked must be included in the appropriate contract
labor line on Worksheet S-3. Do not include wages or hours associated with Part B
services.
Column 6--Enter on all lines (except lines 17 through 25) the average hourly wage resulting from
dividing column 4 by column 5.
4005.3 Part III - Hospital Wage Index Summary.--This worksheet provides for the calculation
of a hospital’s average hourly wage (without overhead allocation, occupational mix adjustment,
and inflation adjustment) as well as analysis of the wage data.
Columns 1 through 6--Follow the same instructions discussed in Part II, except for column 6,
line 5.
Line 1--From Part II, enter the result of line 1 minus the sum of lines 2, 3, 4.01, 5, 6, 7, 7.01, and
8. Add to this amount lines: 28, 33, and 35.
Line 2--From Part II, enter the sum of lines 9 and 10.
Line 3--Enter the result of line 1 minus line 2.
Line 4--From Part II, enter the sum of lines 11, 12, 13, 14, 14.01, 14.02, and 15. (Line 16 is omitted
from Part III, line 4, because physicians' teaching services are excluded from the wage index.)
Line 5--For cost reporting periods beginning prior to October 1, 2015, from Part II, enter the sum
of lines 17, 18, 22, 25.50, 25.51, and 25.52. Enter on this line in column 6 the wage-related cost
percentage computed by dividing Part III, column 4, line 5, by Part III, column 4, line 3. Round
the result to 2 decimal places.
For cost reporting periods beginning on or after October 1, 2015, from Part II, enter the sum of
lines 17, 22, 25.50, 25.51, and 25.52. Enter on this line in column 6 the wage-related cost
percentage computed by dividing Part III, column 4, line 5, by Part III, column 4, line 3. Round
the result to 2 decimal places.
Line 6--Enter the sum of lines 3 through 5.
Line 7--Enter from Part II above, the sum of lines 26 through 43. If the hospital’s ratio for
excluded area salaries to net salaries is greater than 5 percent, the hospital must complete all
columns for this line. (See instructions in Part II, lines 26 through 43 for calculating the
percentage.)
4005.4 Part IV - Wage Related Costs.--The hospital must provide the contractor with a complete
list of all core wage related costs included in Part II (§4005.2), lines 17 and 19 through 25. This
worksheet provides for the identification of such costs.
For lines 1 through 23, for wage related costs not covered by Medicare reasonable cost principles
(excluding the reporting of certain defined benefit pension costs; see instructions below), a
hospital shall use GAAP in reporting wage related costs. In addition, some costs such as payroll
taxes, which are reported as a wage related cost(s) on Worksheet S-3, Part IV, are not considered
fringe benefits for Medicare cost finding.
See instructions for line 25 on including “other” wage related costs in the wage index that are not
a core wage related cost reported on lines 1 through 23.
Rev. 16

40-65

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FORM CMS-2552-10

04-20

Enter on each line as applicable the corresponding amount from your accounting books and/or
records.
Line 3--Report pension cost for defined benefit pension plans that do not meet the applicable
requirements for a qualified pension plan under section 401(a) of the Internal Revenue Code.
The policy adopted in the FFY 2012 IPPS final rule (CMS-1518--F; 76 FR 51586-51590,
August 18, 2011) does not change the reporting basis for these costs.
NOTE: These plans generally are not funded by a funding vehicle that is for exclusive benefit of
employees or their beneficiaries and do not qualify for special tax benefits, such as tax
deferral of employer contributions. For such unfunded defined benefit plans, the costs
of these plans are reported on a cash basis which recognizes benefit payments made
during the current period. Typically, these plans supplement the basic qualified defined
benefit plan or provide benefits to a select class of employees, such as executives.
Line 4--Commencing with cost reporting periods used for the FFY 2013 wage index, report
pension cost for defined benefit pension plans which meet the applicable requirements for a
qualified pension plan under §401(a) of the Internal Revenue Code for the wage index. The
allowable pension costs to be reported for these defined benefit pension plans shall be determined
in accordance with the policy adopted in the FY 2012 IPPS final rule (CMS-1518-F; 76 FR 5158651590, August 18, 2011), modified in the FY 2016 IPPS final rule (CMS 1632-F; 80 FR 4950549508, August 17, 2015) and as discussed below. Enter the pension costs from your records or
from the Wage Index Pension Cost Schedule available for download from the CMS website at
www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Wage-IndexFiles.html. (See CMS Pub. 15-1, chapter 21, §2142.)
Policy
Defined Benefit Pension Plan: A defined benefit pension plan is a type of deferred compensation
plan, which is established and maintained by the employer primarily to provide systematically for
the payment of definitely determinable benefits to its employees usually over a period of years, or
for life, after retirement. Pension plan benefits are generally measured by, and based on, such
factors as age of employees, years of service, and compensation received by employees. This
section applies only to defined benefit pension plans which meet the applicable requirements for
a qualified pension plan under §401(a) of the Internal Revenue Code. A qualified pension plan is
for the exclusive benefit of employees or their beneficiaries and qualifies for special tax benefits,
such as tax deferral of employer contributions.
Pension Contributions: Pension costs for a defined benefit pension plan are allowable only to the
extent that costs are actually incurred by the provider Such costs are found to have been incurred
only if paid directly to participants or beneficiaries under the terms of the plan or paid to a pension
fund which meets the applicable tax qualification requirements under §401(a) of the Internal
Revenue Code. For purposes of the wage index, provider pension payments shall be measured on
a cash-basis without regard to CMS Pub. 15-1, chapter 23, §2305. Payment must be made by
check or other negotiable instrument, cash, or legal transfer of assets such as stocks, bonds, and
real property. A contribution payment shall be deemed to occur on the date it is credited to the
fund established for the pension plan, or for provider payments made directly to a plan participant
or beneficiary, on the date the provider’s account is debited. Contributions made under a pension
plan that covers multiple providers or employers shall be allocated on a basis consistent with plan
records. If the plan records do not show a separate accounting of the actuarially determined cost
estimates, contribution deposits, and/or assets attributable to each participating provider or
employer, the allocation basis must represent a reasonable approximation of the funding
attributable to each employer.

40-65.1

Rev. 16

11-16

FORM CMS-2552-10

4005.4 (Cont.)

Source of Documentation for Pension Contributions: Providers are required to obtain contribution
data from the pension trustee, insurance carrier, Schedule B or SB of IRS Form 5500, and if
applicable, from accounting records showing the allocation of total plan contributions to each
participating provider. These records must be maintained as needed for subsequent periods.
Reasonable Compensation: In order for pension costs to be allowable, the benefits payable under
the plan (attributable to employer contributions) together with all other compensation paid to the
employee must be reasonable in amount.
Defined Benefit Pension Plan Costs for the Wage Index: The annual pension to be included in the
wage index shall be the average annual employer contributions made by or on behalf of the
provider (on a cash basis) to all defined benefit plans covered under this section during the
averaging period. Contribution payments must satisfy the allowability requirements outlined
above; see “Pension Contributions” and “Reasonable Compensation” above. A reversion of plan
assets shall be treated as a negative contribution payment and a negative pension cost resulting
from a reversion of plan assets shall offset a provider’s other wage related costs.
In the FY 2016 IPPS final rule and effective with the FY 2017 wage index, the averaging period
used to compute the average defined benefit pension cost for the wage index was modified. Prior
to this modification, the averaging period was generally the 36 consecutive calendar month period
centered on the midpoint of the cost reporting period used for the wage index (the cost reporting
period used for the wage index shall hereafter be referred to as the wage index cost reporting
period). Beginning with the FY 2017 wage index, generally, the averaging period is based on the
base cost reporting period, plus the prior two cost reporting years (36 months).
A provider who adopts a new defined benefit pension plan and has no other defined benefit plan
in existence during the averaging period may elect to exclude from the averaging period all cost
reporting periods ending prior to the date the new plan was adopted. No defined benefit pension
cost is reportable for a wage index cost reporting period that is excluded from the averaging period
in accordance with this paragraph. An election to claim costs for a newly adopted plan based on
an averaging period of less than 36 months must be applied on a consistent basis for all wage index
cost reporting periods for which the 36-month averaging period contains the plan effective date.
If the wage index cost reporting period does not represent a 12-month period, the annual pension
cost otherwise determined in accordance with this section shall be prorated to reflect the number
of months in the wage index cost reporting period.
For the FY 2013 through FY 2022 wage index only, a provider may include a prefunding
installment as a component of pension cost regardless of whether or not the plan(s) which gave
rise to the prefunding balance are still in existence. The annual prefunding installment shall equal
1/10th of the prefunding balance. A prefunding installment that is not reflected in the pension cost
for a wage index cost reporting period may not be reassigned and added to the pension cost
reported for wage index purposes in any subsequent period. The prefunding balance equals the
excess, if any, of (i) provider contributions made (on a cash-basis) to its defined benefit pension
plans during the look-back period over (ii) the pension costs included in the wage-index for the
same look-back period. A provider’s share of the total contributions made under a pension plan
that covers multiple providers or employers shall be determined on a basis consistent with the
methodology used to determine the wage index pension costs for the cost reporting periods
included in the prefunding balance. The look-back period shall consist of consecutive provider
cost reporting periods commencing no earlier than October 1, 2002 and ending with the provider’s
cost reporting period immediately prior to the FY 2013 wage index cost reporting period. The
look-back period may not include any cost reporting period for which the provider is unable to
provide documentation of the contributions made or the pension costs included in the wage index;

Rev. 10

40-65.2

4005.4 (Cont.)

FORM CMS-2552-10

11-16

all prior cost reporting periods must also be excluded in order to satisfy the requirement that the
look-back period consist of consecutive cost reporting periods. A provider who establishes a
prefunding balance must submit documentation to the Medicare contractor to support the
calculation of the prefunding balance and annual prefunding installment. A prefunding worksheet
with complete instructions is available for download from the CMS website at
www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Wage-IndexFiles.html.
Pension Plan with Multiple Entities: If a hospital participates in a pension plan or retirement
system that also covers other entities, the hospital must report its respective 3-year average pension
cost (or prefunding balance) reflecting only the hospital's allocated share of total plan
contributions, and not including any share of pension costs of other entities. For each hospital,
this is accomplished by first determining the hospital's allocated portion of pension contribution
for each year of the 3-year average, and then computing the 3-year average for that hospital based
only on that hospital's respective allocated pension contributions. This is consistent with the
regulations at 42 CFR 413.24(a), which state, in pertinent part, that providers must provide
adequate cost data based on their financial and statistical records. Therefore, a provider may not
claim as an allowable cost the costs of services associated with another entity. It is not appropriate
to compute the 3-year average (or prefunding balance) based on the total contributions made to the
plan by all participating entities and then determine a hospital's allocated portion of the 3-year
average cost (or prefunding balance) because there are instances in which the 3-year average could
be skewed because a hospital may be including pension costs from another entity in its 3-year
average. Specifically, if the allocated percentage of total plan contributions for one or more of the
participating entities changes during the 3-year average, the average will be skewed. The allocated
percentage to each entity can change due to mergers, changes in plan coverage, or other factors.
We also note that the allocation of contributions between the various entities participating in a
pension plan or pension system should agree with the methodology used for plan reporting
purposes and/or financial statement purposes, and the methodology used should be applied
consistently over time. Furthermore, if wage index reporting is required for two or more hospitals
covered under the same pension plan or retirement system, those hospitals must ensure that the
allocation of plan contributions for each reporting period is determined on a consistent basis to
avoid duplicate reporting of costs.
Examples
Example 1 (prefunding balance and prefunding installment):
•

40-65.3

Provider’s FY 2017 wage index cost reporting period is 01/01/2013-12/31/2013. The
look-back period ends with the cost reporting period immediately prior to the cost
reporting period used for the FY 2013 wage index. Since the FY 2013 wage index
was based on the providers 1/1/2009-12/31/2009 cost reporting period, the look-back
period ends on 12/31/2008. Assuming the provider has always reported costs on a
calendar year basis, the earliest possible cost reporting period in the look-back period
is the period commencing 01/01/2003 (first cost reporting period commencing on or
after 10/01/2002).

Rev. 10

11-16

FORM CMS-2552-10
•

4005.4 (Cont.)

The provider is able to document its pension contributions (on a cash basis) and the
pension costs included in the wage index for all cost reporting periods except for the
2004 year. Therefore, 2004 and all prior cost reporting periods must be excluded from
the look-back period. The data for 2005 through 2008 is as follows:
Cost Reporting Year Cash Basis Contributions
2005
2006
2007
2008

$400,000
$800,000
$0
$650,000

Wage-Index Pension Costs
$500,000
$0
$600,000
$700,000

•

Because the pension cost reported in the wage index for 2005 was higher than the cash
contributions made during that same period, the provider may elect to drop 2005 (and
all prior periods) from the look-back period.

•

Although the contributions made in 2007 were also less than the pension cost reported
for that same period, the provider cannot exclude 2007 without also excluding 2006
(look-back period must consist of consecutive cost reporting periods).

•

Although the contributions made in 2008 were less than the pension cost reported in
that same period, the provider cannot exclude 2008 since the look-back period must
end with 2008 because that is the cost reporting period immediately prior to the
FY 2013 wage index cost reporting period.

•

The prefunding balance based on a 2006-2008 look-back period is $150,000
($1,450,000 [$800,000+$0+$650,000] total contributions - $1,300,000 [$0 + $600,000
+ $700,000] in wage index pension costs reported for the same period). The annual
prefunding installment is $15,000 (1/10th of $150,000).

Example 2 (pension cost for a 12-month wage index cost reporting period):
•

Provider’s FY 2017 wage index cost reporting period is 12 months (01/01/2013 12/31/2013); the 36-month averaging period is 01/01/2011 to 12/31/2013, which
includes the wage index cost reporting year and the prior two cost reporting periods.

•

Contributions made during 01/01/2011 - 12/31/2011 = $500,000.

•

Contributions made during 01/01/2012 - 12/31/2012 = $300,000.

•

Contributions made in wage index cost reporting period 01/01/2013 - 12/31/2013 =
$600,000.

•

Total contributions made during the 36-month averaging period = $1,400,000.

•

The provider has no prefunding balance or prefunding installment.

•

The pension cost for the FY 2017 wage index cost reporting period is $466,667
($1,400,000 total contributions divided by 36 months in the averaging period
multiplied by 12 months in the wage index cost reporting period).

Rev. 10

40-65.4

4005.4 (Cont.)

FORM CMS-2552-10

11-16

Example 3 (pension cost for a 7-month wage index cost reporting period):
•

Provider’s FY 2017 wage index cost reporting period is 7 months (01/01/2013 07/31/2013); the 36-month averaging period is 8/01/2010 to 07/31/2013 (begins
29 months prior to the Fiscal Year Begin Date of the wage index cost reporting period
for a total of 36 months).

•

Contributions made during 08/01/2010 - 12/31/2010 = $300,000.

•

Contributions made during 01/01/2011 - 12/31/2011 = $500,000.

•

Contributions made during 01/01/2012 - 12/31/2012 = $400,000.

•

Contributions made in wage index cost reporting period 01/01/2013 - 07/31/2013 =
$200,000.

•

Total contributions made during the 36-month averaging period = $1,400,000.

•

The provider has documented a prefunding balance of $1,000,000; the annual
prefunding installment is therefore $100,000 (1/10th of prefunding balance).

•

The pension cost for the FY 2017 wage index cost reporting period is $330,555
($272,222 average pension cost [$1,400,000 total contributions divided by 36 months
in the averaging period multiplied by 7 months in the in wage index cost reporting
period] plus $58,333 pro-rata prefunding installment [$100,000 annual prefunding
installment multiplied by 7/12ths to reflect a 7-month wage index cost reporting
period]).

Example 4 (pension cost for a new plan):
•

•

The provider adopted a new pension plan effective 07/01/2012 and had no other
pension plan in effect prior to that date; therefore, there is no prefunding balance or
prefunding installment.

•

Contributions made during 01/01/2011 - 12/31/2011 = $0 (no plan in existence)

•

Contributions made during 01/01/2012 - 12/31/2012 = $500,000.

•

Contributions made in the wage index cost reporting period 01/01/2013 - 12/31/2013
= $1,200,000.

•

Total contributions during the 36-month averaging period = $1,700,000.

•

The provider did not report a pension cost attributable to the new plan based on a
36-month averaging period during any prior wage index cost reporting period;
therefore, it may elect to exclude cost reporting periods ending prior to the 07/01/2012
plan effective date from the averaging period; the 36-month averaging period is,
therefore, shortened to 24 months and excludes the period 01/01/2011 to 12/31/2011.
The pension cost for the FY 2017 wage index cost reporting period would then be
$850,000 ($1,700,000 total contributions divided by 24 months in the averaging period
multiplied by 12 months in the wage index reporting period).

40-65.5

Rev. 10

04-20

FORM CMS-2552-10

4005.4 (Cont.)

Lines 8, 8.01, 8.02, and 8.03--Effective for cost reporting periods beginning prior to
October 1, 2015, complete line 8 if the hospital has purchased or self-funded insurance. Effective
for cost reporting periods beginning on or after October 1, 2015, complete line 8.01 if the hospital
has self-funded insurance without a TPA. Complete line 8.02 if the hospital has self-funded
insurance with a TPA. Complete line 8.03 if the hospital purchases health insurance. (See the
instructions under Worksheet S-3, Part II, regarding health insurance as a wage-related cost for the
wage index).
Line 21--Report costs of executive deferred compensation plans and awards for executives. The
policy adopted in the FFY 2012 IPPS final rule; 76 FR 51586-51590 (August 18, 2011) does not
change the reporting basis for these costs. Examples of executive deferred compensation include
special stock option or bonus plans and sum certain postemployment awards that are not available
to other employees.
NOTE: Costs reported on line 21 excludes costs of executive deferred compensation that are
defined contribution pension plans, tax-sheltered annuity plans, nonqualified defined
benefit plans and qualified defined benefit plans that are available to other employees
that are reportable on lines 1 through 4, respectively.
Line 25--Enter each wage related cost that is considered an “other” wage related cost separately.
Subscript this line for each “other” wage related cost in accordance with the following criteria.
For line 25 and subscripts specify the type of each “other” wage related cost. The total of line 25
and its subscripts is reported on Worksheet S-3, Part II, line 18, column 4. Do not complete this
line effective for cost reporting periods beginning on or after October 1, 2015.
A hospital may report an “other” wage related cost (defined as the value of the benefit) if it meets
all of the following criteria:
•

The costs are not listed on lines 1 through 23 “Wage Related Costs Core” of this worksheet
or included in salaries reported on Worksheet S-3, Part II, column 4, line 17.

•

The “other” wage related cost is greater than one (1) percent of total salaries after the direct
excluded salaries are removed. Line 25 and each subscript must independently meet this
1 percent test. See below for instructions to calculate the 1 percent test.

•

The wage related cost is a fringe benefit as described by the IRS and is reported to the IRS
on an employee’s or contractor’s W-2 or 1099 as taxable income.

•

The wage related cost is not being furnished for the convenience of the provider or
otherwise excludable from income as a fringe benefit (such as a working condition fringe).

NOTE: Direct salaries and wages, including amounts related to paid vacation, holiday, sick
leave, etc., reported on line 1 of Worksheet S-3, Part II, must not be included as other
wage related costs on this line, nor on line 18 of Worksheet S-3, Part II.
NOTE: Do not include wage related costs applicable to the excluded areas reported on
Worksheet S-3, Part II, lines 9 and 10. Instead, these costs are reported on Worksheet S3, Part II, line 19. Also, do not include on this line the wage related costs for physician
Parts A and B, non-physician anesthetists Parts A and B, interns and residents in
approved programs, and home office personnel.

Rev. 16

40-65.6

4005.4 (Cont.)

FORM CMS-2552-10

04-20

Calculate the 1 percent test by dividing each individual category of the other wage related cost
(that is, the numerator) by the sum of Worksheet S-3, Part III, lines 3 and 4, column 4, (that is, the
denominator). The other wage related costs associated with contract labor and home office/related
organization personnel are included in the numerator because these other wage related costs are
allowed in the wage index (in addition to other wage related costs for direct employees), assuming
the requirements for inclusion in the wage index are met. For example, if a hospital is including
parking garage costs as an other wage related cost that is reported on the W-2 or 1099 form, when
running the 1 percent test, include in the numerator all the parking garage other wage related cost
for direct salary employees, contracted employees, and home office employees, and divide by the
sum of Worksheet S-3, Part III, lines 3 and 4, column 4.
Calculate the 1 percent test only one time for a category of other wage related costs, inclusive of
other wage related costs for employees, contracted employees, and home office employees.

40-65.7

Rev. 16

11-16

FORM CMS-2552-10

4005.5

4005.5 Part V - Contract Labor and Benefit Costs.--This section identifies the contract labor
costs and benefit costs for the entire hospital and hospital healthcare complex including all
applicable subproviders and units. This section must be completed by all hospitals (e.g., IPPS
hospitals, CAHs, IPFs, IRFs, cancer hospitals, children’s hospitals, LTCHs, and RNHCIs).
Definitions:
Contract Labor Costs--Enter the amount paid for services furnished under contract, rather than by
employees, for direct patient care, as defined in the instructions for Worksheet S-3, Part II, line 11.
The amount of contract labor reported on S-3, Part II, line 11, should agree with the amount
reported on S-3, Part V, line 2. This is only for the hospital (not including excluded areas). The
remainder of Worksheet S-3, Part V, should reflect contract labor as defined on Worksheet S-3,
Part II, line 11 (direct patient care for all of the excluded areas), with the aggregate total reported
on line 1.
Benefit Costs--Enter the amount of employee benefit costs, also referred to as wage-related costs.
Worksheet S-3, Part IV, provides a list of core wage-related costs. The core wage-related costs
reported on S-3, Part IV, line 24, which is spread on Worksheet S-3, Part II, lines 17, and 19
through 25, must be reported by component on Worksheet S-3, Part V. The amount reported on
Worksheet S-3, Part V, line 1, must agree to the allowable amount reported on Worksheet S-3,
Part IV, line 24. Worksheet S-3, Part V, line 2, must agree to the amount reported on
Worksheet S-3, Part II, line 17. Each excluded area must contain their share of wage-related costs
so that lines 19 through 25 on Worksheet S-3, Part II, will agree to Worksheet S-3, Part V, lines 3
through 18.
Identify the contract labor costs and benefit costs for each component on the applicable line.

Rev. 10

40-65.8

4006
4006.

FORM CMS-2552-10

11-16

WORKSHEET S-4 - HOSPITAL-BASED HOME HEALTH AGENCY STATISTICAL
DATA

In accordance with 42 CFR 413.20(a), 42 CFR 413.24(a), and 42 CFR 413.24(c), you are required
to maintain statistical records for proper determination of costs payable under titles V, XVIII, and
XIX. The statistics required on this worksheet pertain to a hospital-based HHA. The data
maintained is dependent upon the services provided by the agency, number of program home
health aide hours, total agency home health aide hours, program unduplicated census count, and
total unduplicated census count. In addition, FTE data are required by employee staff, contracted
staff, and total. Complete a separate Worksheet S-4 for each hospital-based HHA.
Line 1--Enter the number of hours applicable to home health aide services.
Line 2--Enter the unduplicated count of all individual patients and title XVIII patients receiving
home visits or other care provided by employees of the agency or under contracted services during
the reporting period. Count each individual only once. However, because a patient may be
covered under more than one health insurance program, the total census count (column 5, line 2)
may not equal the sum of columns 1 through 4, line 2. For purposes of calculating the unduplicated
census, if a beneficiary has received healthcare in more than one CBSA, you must prorate the
count of that beneficiary so as not to exceed a total of (1). A provider is to also query the
beneficiary to determine if he or she has received healthcare from another provider during the year,
e.g., Maine versus Florida for beneficiaries with seasonal residence.
Lines 3 through 18--Lines 3 through 18 provide statistical data related to the human resources of
the HHA. The human resources statistics are required for each of the job categories specified in
lines 3 through 18.
Enter the number of hours in your normal work week.
Report in column 1 the FTE employees on the HHA’s payroll. These are staff for which an
IRS Form W-2 is used.
Report in column 2 the FTE contracted and consultant staff of the HHA.
Compute staff FTEs for column 1 as follows: Add all hours for which employees were paid and
divide by 2080 hours. Round to two decimal places, e.g., .04447 is rounded to .04. Compute
contract FTEs for column 2 as follows. Add all hours for which contracted and consultant staff
worked and divide by 2080 hours.
If employees are paid for unused vacation, unused sick leave, etc., exclude these paid hours from
the numerator in the calculations.
Line 19--Enter in column 1 the number of CBSAs that you serviced during this cost reporting
period.
Line 20--Enter each 5-digit CBSA and/or non-CBSA (rural) code where the reported HHA visits
were performed. Subscript the line to accommodate the number of CBSAs you service. 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.
PPS Activity Data--Applicable for Medicare Services.
In accordance with 42 CFR 413.20 and §1895 of the Social Security Act, HHAs transitioned from
a cost-based reimbursement system to a PPS effective for home health services rendered on or
after October 1, 2000.

40-66

Rev. 10

09-15

FORM CMS-2552-10

4006 (Cont.)

The statistics required on this worksheet pertain to home health services furnished on or after
October 1, 2000. The data to be maintained, depending on the services provided by the agency,
includes the number of aggregate program visits furnished in each episode of care payment
category for each covered discipline, the corresponding aggregate program charges imposed in
each episode of care payment category for each covered discipline, total visits and total charges
for each episode of care payment category, total number of episodes and total number of outlier
episodes for each episode of care payment category, and total medical supply charges for each
episode of care payment category.
HHA Visits--See CMS Pub. 15-2, chapter 32, §3205, for the definition of an HHA visit.
Episode of Care--Under home health PPS the 60-day episode is the basic unit of payment where
the episode payment is specific to one individual beneficiary. Beneficiaries are covered for an
unlimited number of non-overlapping episodes. The duration of a full-length episode will be
60 days. An episode begins with the start of care date and must end by the 60th day from the start
of care.
Less than a full Episode of Care--When four or fewer visits are provided by the HHA in a 60-day
episode period, the result is a low utilization payment adjustment (LUPA). In this instance, the
HHA will be reimbursed based on a standardized per visit payment.
An episode may end before the 60th day in the case of a beneficiary elected transfer, or a discharge
and readmission to the same HHA (including for an intervening inpatient stay). This type of
situation results in a partial episode payment (PEP) adjustment.
Use lines 21 through 32 to identify the number of visits and the corresponding visit charges for
each discipline for each episode payment category. Lines 33 and 35 identify the total number of
visits and the total corresponding charges, respectively, for each episode payment category.
Line 36 identifies the total number of episodes completed for each episode payment category.
Line 37 identifies the total number of outlier episodes completed for each episode payment
category. Outlier episodes do not apply to 1) Full Episodes without Outliers and 2) LUPA
Episodes. Line 38 identifies the total medical supply charges incurred for each episode payment
category. Column 5 displays the sum total of data for columns 1 through 4. The statistics and data
required on this worksheet are obtained from the PS&R report.
When an episode of care is initiated in one fiscal year and concludes in the subsequent fiscal year,
all statistical data (i.e., cost, charges, counts, etc.,) associated with that episode of care will appear
on the PS&R of the fiscal year in which the episode of care is concluded. Similarly, all data
required in the cost report for a given fiscal year must only be associated with services rendered
during episodes of care that conclude during the fiscal year. Title XVIII visits reported on this
worksheet will not agree with the title XVIII visits reported on Worksheet H-3, sum of columns 2
and 3, line 14.
Columns 1 through 4--Enter data pertaining to title XVIII patients only. Enter, as applicable, in
the appropriate columns 1 through 4, lines 21 through 32, the number of aggregate program visits
furnished in each episode of care payment category for each covered discipline and the
corresponding aggregate program visit charges imposed for each covered discipline for each
episode of care payment category. The visit counts and corresponding charge data are mutually
exclusive for all episode of care payment categories. For example, visit counts and the
corresponding charges that appear in column 4 (PEP only Episodes) will not include any visit
counts and corresponding charges that appear in column 3 (LUPA Episodes) and vice versa. This
is true for all episode of care payment categories in columns 1 through 4.

Rev. 8

40-67

4006 (Cont.)

FORM CMS-2552-10

09-15

Line 33--Enter in columns 1 through 4 for each episode of care payment category, the sum total of
visits from lines 21, 23, 25, 27, 29 and 31.
Line 34--Enter in columns 1 through 4 for each episode of care payment category, the charges for
services paid under PPS and not identified on any previous lines.
Line 35--Enter in columns 1 through 4 for each episode of care payment category, the sum total of
visit charges from lines 22, 24, 26, 28, 30, 32 and 34.
Line 36--Enter in columns 1 through 4 for each episode of care payment category, the total number
of episodes (standard/non-outlier) of care rendered and concluded in the provider’s fiscal year.
Line 37--Enter in columns 2 and 4 for each episode of care payment category identified, the total
number of outlier episodes of care rendered and concluded in the provider’s fiscal year. Outlier
episodes do not apply to columns 1 and 3 (Full Episodes without Outliers and LUPA Episodes,
respectively).
NOTE: Line 36 and 37 are mutually exclusive.
Line 38--Enter in columns 1 through 4 for each episode of care payment category, the total nonroutine medical supply charges for services rendered and concluded in the provider’s fiscal year.
Column 5--Enter on lines 21 through 37, the sum total of amounts from columns 1 through 4.

40-68

Rev. 8

11-16
4007.

FORM CMS-2552-10

4007

WORKSHEET S-5 - HOSPITAL RENAL DIALYSIS DEPARTMENT STATISTICAL
DATA

In accordance with 42 CFR 413.20(a), 42 CFR 413.24(a), and 42 CFR 413.24(c), you are required
to maintain statistical records for proper determination of costs payable under the Medicare
program. The statistics reported on this worksheet pertain to the renal dialysis department. The
data maintained, depending on the services provided by the hospital, includes patient data, the
number of treatments, number of stations, and home program data.
If you have more than one renal dialysis department, submit one Worksheet S-5 combining all of
the renal dialysis departments’ data. You must also have on file (as supporting documentation), a
Worksheet S-5 for each renal dialysis department and the appropriate workpapers. File this
documentation with exception requests in accordance with CMS Pub. 15-1, chapter 27, §2720.
Also enter on the combined Worksheet S-5 the applicable data for each renal dialysis satellite for
which you are separately certified (that is, a satellite for which you were issued a satellite CCN).
Section 153(b) of MIPPA amended section 1881(b) of the Act to require the implementation of an
ESRD bundled payments system effective January 1, 2011. This new payment system is
effectuated on Worksheets I-4 and I-5 (sections 4051 and 4052).
Column Descriptions
Columns 1 and 2--Include in these columns information regarding outpatient hemodialysis
patients. Do not include information regarding intermittent peritoneal dialysis. In column 2,
report information if you are using high flux dialyzers.
Columns 3 through 6--Report information concerning the provider’s training and home programs.
Do not include intermittent peritoneal dialysis information in columns 3 and 5.
Line Descriptions
Line 1--Enter the number of patients receiving dialysis at the end of the cost reporting period.
Line 2--Enter the average number of times patients receive dialysis per week. For CAPD and
CCPD patients, enter the number of exchanges per day.
Line 3--Enter the average time for furnishing a dialysis treatment.
Line 4--Enter the average number of exchanges for CAPD.
Line 5--Enter the number of days dialysis is furnished during the cost reporting period.
Line 6--Enter the number of stations used to furnish dialysis treatments at the end of the cost
reporting period.
Line 7--Enter the number of treatments furnished per day per station. This number represents the
number of treatments that the facility can furnish not the number of treatments actually furnished.
Line 8--Enter your utilization. Compute this number by dividing the number of treatments
furnished by the product of lines 5, 6, and 7. This percentage cannot exceed 100 percent.
Line 9--Enter the number of times your facility reuses dialyzers. This number is the average
number of times patients reuse a dialyzer. If none, enter zero.
Line 10--Enter the percentage of patients that reuse dialyzers.

Rev. 10

40-69

4007 (Cont.)

FORM CMS-2552-10

11-16

Line 10.01--Indicate whether your facility qualified and was approved as a low-volume facility for
this cost reporting period. CMS adjusts the base rate for low-volume ESRD facilities. In order to
receive this low-volume adjustment, a facility must attest in accordance with 42 CFR 413.232(f).
Effective for cost reporting periods ending on or after June 30, 2015, if you operate multiple renal
dialysis departments or home program dialysis departments and one of those facilities is eligible
for low-volume, respond yes to this question and complete line 23.
Line 10.02--Indicate if your facility elected 100 percent PPS effective January 1, 2011. Enter “Y”
for yes or “N” for no. This election must have been received by the ESRD facility’s contractor by
November 1, 2010. Requests received after this date will not be accepted regardless of postmark
or delivery date.
New providers: ESRD facilities certified for Medicare participation on or after January 1, 2011,
are paid based on 100 percent of the ESRD PPS payment. ESRD facilities certified for Medicare
participation on or after January 1, 2011, enter “Y” for yes.
Line 10.03--If your facility did not elect to be paid based on 100 percent of the ESRD PPS payment
and your cost reporting period is a December 31 fiscal year end, enter the transition period in
column 2 as follows: For the fiscal year ending December 31, 2011, enter 1; for the fiscal year
ending December 31, 2012, enter 2; for the fiscal year ending December 31, 2013, enter 3; and,
for the fiscal year ending December 31, 2014, enter 4 for 100 percent ESRD PPS payment.
Column 1 will be blank.
If your cost reporting period ends on a date other than December 31, indicate in column 1 the
transition period effective for the portion of the cost reporting period prior to January 1. Indicate
in column 2 the transition period effective for the portion of the cost reporting period on and after
January 1. For example, a cost reporting period with a fiscal year ending October 31 would
indicate the applicable transition periods as follows:
Fiscal year ending October 31, 2011:
Leave column 1 blank as this would be prebundled ESRD PPS, and enter 1 in column 2 for the period of January 1, 2011, through
October 31, 2011.
Fiscal year ending October 31, 2012:
Enter 1 in column 1 for the period of
November 1, 2011, through December 31, 2011, and enter 2 in column 2 for the period of
January 1, 2012, through October 31, 2012.
Fiscal year ending October 31, 2013:
Enter 2 in column 1 for the period of
November 1, 2012, through December 31, 2012, and enter 3 in column 2 for the period of
January 1, 2013, through October 31, 2013.
Fiscal year ending October 31, 2014:
Enter 3 in column 1 for the period of
November 1, 2013, through December 31, 2013, and enter 4 in column 2 for the period of
January 1, 2014, through October 31, 2014.
For all cost reporting periods beginning on or after January 1, 2014, enter 4 in column 2 for
100 percent ESRD PPS payment. Column 1 will be blank.
Payments during the transition period 1 are a blend of 25 percent case-mix adjusted ESRD PPS
and 75 percent basic case-mix adjusted composite rate (25/75). Payments during the transition
period 2 are a blend of 50 percent case-mix adjusted ESRD PPS and 50 percent basic case-mix
adjusted composite rate (50/50). Payments during the transition period 3 are a blend of 75 percent
case-mix adjusted ESRD PPS and 25 percent basic case-mix adjusted composite rate (75/25).
Payments for services rendered on and after January 1, 2014 are 100 percent ESRD PPS.
Line 11--Enter the number of patients who are awaiting a transplant at the end of the cost reporting
period.
Line 12--Enter the number of patients who received a transplant during the fiscal year.

40-70

Rev. 10

11-16

FORM CMS-2552-10

4007 (Cont.)

Line 13--Enter the direct product cost net of discount and rebates for Epoetin (EPO). Include all
EPO cost for patients receiving outpatient, home (Method I or II (claims that would have been
processed as Method II are processed as Method I for services rendered on or after
January 1, 2011)), or training dialysis treatments. This amount includes EPO cost furnished in the
renal department or any other department if furnished to an end stage renal disease dialysis patient.
Report on this line the amount of EPO cost included in line 74 of Worksheet A. Effective for cost
reporting periods ending after December 31, 2012, do not use this line; report these costs on line 22
(and subscripts), column 2.
Line 14--Based on the instructions contained on line 13, enter the amount of EPO included on
line 94 (home dialysis program) from Worksheet A. Effective for cost reporting periods ending
after December 31, 2012, do not use this line; report these costs on line 22 (and subscripts),
column 3.
Erythropoiesis-Stimulating Agents (ESA) Statistics--Effective January 1, 2005 and prior to
January 1, 2011, Medicare paid for ESAs based on the Average Sales Price Drug Pricing File.
Effective January 1, 2011, payment for ESAs is included in the ESRD PPS payment.
Line 15--Enter the number of EPO units furnished relating to the renal dialysis department.
Effective for cost reporting periods ending after December 31, 2012, do not use this line; report
the number of ESA units furnished on line 22 (and subscripts), column 4.
Line 16--Enter the number of EPO units furnished relating to the home dialysis program. Effective
for cost reporting periods ending after December 31, 2012, do not use this line; report the number
of ESA units furnished on line 22, (and subscripts), column 5.
Line 17--Enter the direct product cost net of discount and rebates for darbepoetin alfa (Aranesp).
Include all Aranesp cost for patients receiving outpatient, home (Method I or II (claims that would
have been processed as Method II are processed as Method I for services rendered on or after
January 1, 2011)), or training dialysis treatments. This amount includes Aranesp cost furnished in
the renal department or any other department if furnished to an end stage renal disease dialysis
patient. Report on this line the amount of Aranesp cost included in line 74 of Worksheet A.
Effective for cost reporting periods ending after December 31, 2012, do not use this line; report
these costs on line 22 (and subscripts), column 2.
Line 18--Based on the instructions contained on line 17, enter the dollar amount of Aranesp
included on line 94 (home dialysis program) from Worksheet A. Effective for cost reporting
periods ending after December 31, 2012, do not use this line; report these costs on line 22 (and
subscripts), column 3.
Line 19--Enter the number of micrograms of Aranesp furnished relating to the renal dialysis
department. Effective for cost reporting periods ending after December 31, 2012, do not use this
line; report the number of ESA units furnished on line 22 (and subscripts), column 4.
Line 20--Enter the number of micrograms of Aranesp furnished relating to the home dialysis
program. Effective for cost reporting periods ending after December 31, 2012, do not use this line;
report the number of ESA units furnished on line 22 (and subscripts), column 5.
Line 21--Identify how physicians are paid for medical services provided to Medicare beneficiaries.
Under the monthly capitation payment (MCP) methodology, contractors pay physicians for their
Part B medical services. Under the initial method, the renal facility pays for physicians’ Part B
medical services. The facility’s payment rate is increased in accordance with 42 CFR 414.313.
There are a limited number of facilities electing this method.
Line 22--Identify each ESA separately on line 22 and subscripts. Complete this line effective for
cost reporting periods ending after December 31, 2012. Enter in column 1, the name of the ESA

Rev. 10

40-70.1

4007 (Cont.)

FORM CMS-2552-10

11-16

administered to renal dialysis patients. Enter in column 2, the direct product cost net of discounts
and rebates for ESAs administered to renal dialysis patients. These costs are included in line 74
of Worksheet A. Include all ESA costs for patients receiving outpatient, home, or training dialysis
treatments. This amount includes ESA costs furnished in the renal department or any other
department if furnished to an end stage renal disease dialysis patient. Enter in column 3 the direct
product cost net of discounts and rebates for ESAs administered to home dialysis patients. These
costs are included in line 94 of Worksheet A.
Include all ESA costs for patients receiving self-care home dialysis treatments. This amount
includes ESA costs furnished in the home dialysis program for an end stage renal disease dialysis
patient. Enter in column 4, the total ESA units furnished to renal dialysis department patients
during the cost reporting period. Enter in column 5, the total ESA units furnished to home program
dialysis patients during the cost reporting period.
Line 23--If line 10.01 is yes, for cost reporting periods ending on or after June 30, 2015, enter on
this line, and any applicable subscripts, the CCN and treatments for each renal facility. If this
facility operates a renal dialysis facility (CCN XX-2300 through XX-2499), a renal dialysis
satellite (CCN XX-3500 through XX-3699), and/or a special purpose renal dialysis facility
(CCN XX-3700 through XX-3799), subscript this line and enter in column 1 each CCN from
Worksheet S-2, Part I, line 18, and its subscripts. Enter in column 2, the total treatments
corresponding to each CCN identified in column 1. The sum of all treatments reported on this line
and its subscripts, column 2, must equal the total treatments reported on Worksheet I-4, line 12,
column 1, for the renal dialysis department, plus the total treatments reported on Worksheet I-4,
line 12, column 1, for the home program dialysis department.

40-70.2

Rev. 10

04-20
4008.

FORM CMS-2552-10

4008

WORKSHEET S-6 - HOSPITAL-BASED COMMUNITY MENTAL HEALTH
CENTER AND OTHER OUTPATIENT REHABILITATION PROVIDER
STATISTICAL DATA

In accordance with 42 CFR 413.20(a), 42 CFR 413.24(a), and 42 CFR 413.24(c), maintain
statistical records for proper determination of costs payable under the Medicare program. The
statistics reported on this worksheet pertain to hospital-based community mental health centers
(CMHCs), comprehensive outpatient rehabilitation facilities (CORFs), outpatient rehabilitation
facilities (ORFs) which generally furnishes outpatient physical therapy (OPT), outpatient
occupational therapy (OOT), or outpatient speech pathology (OSP). If you have more than one
hospital-based component, complete a separate worksheet for each facility.
Additionally, only CMHCs are required to complete the corresponding Worksheet J series.
However, all CMHCs, CORFs, ORFs, OPTs, OOTs, and OSPs must complete the applicable
Worksheet A cost center for the purpose of overhead allocation.
This worksheet provides statistical data related to the human resources of the community mental
health center. FTE data is required by employee staff, contracted staff, and total. The human
resources statistics are required for each of the job categories specified on lines 1 through 17. Enter
any additional categories needed on line 18.
Enter the number of hours in your normal work week in the space provided.
Report in column 1 the FTE employees on the CMHC or outpatient rehabilitation provider's
payroll. These are staff for which an IRS Form W-2 was issued.
Report in column 2 the FTE contracted and consultant staff of the CMHC or outpatient
rehabilitation provider.
Compute staff FTEs for column 1 as follows: Add hours for which employees were paid divided
by 2080 hours, and round to two decimal places, e.g., round .04447 to .04. Compute contract FTEs
for column 2 as follows. Add all hours for which contracted and consultant staff worked divided
by 2080 hours, and round to two decimal places.
If employees are paid for unused vacation, unused sick leave, etc., exclude the paid hours from the
numerator in the calculations.

Rev. 16

40-71

4009
4009.

FORM CMS-2552-10

04-20

WORKSHEET S-7 - PROSPECTIVE PAYMENT FOR SKILLED NURSING
FACILITIES STATISTICAL DATA

In accordance with 42 CFR 413.20(a), 42 CFR 413.24(a), and 42 CFR 413.24(c), you are required
to maintain statistical records for proper determination of costs payable under the Medicare
program. Public Law 105-33 (Balanced Budget Act of 1997) requires that all SNFs be reimbursed
under PPS for cost reporting periods beginning on and after July 1, 1998.
NOTE: Do not complete this worksheet for cost reporting periods ending on or after
October 1, 2019.
Line 1--If this facility contains a hospital-based SNF, if all patients were covered under managed
care or if there was no Medicare utilization, enter “Y” for yes. If the response is yes, do not
complete the rest of this worksheet.
Line 2--Does this hospital have an agreement under either section 1883 or 1913 of the Act for
swing beds? Enter “Y” for yes or “N” for no in column 1. If yes, enter arrangement date
(mm/dd/yyyy) in column 2.
Column Descriptions for Lines 3 through 200
Column 1--The case mix resource utilization group (RUGs) designations are already entered in
this column.
Column 2--Enter the number of days associated with SNF services. All SNF payment data will be
reported as a total amount paid under the RUG PPS payment system on Worksheet E-3, Part VI,
line 1, and will be generated from the PS&R or your records.
Column 3--Enter the number of days associated with the swing beds. All swing-bed SNF payment
data will be reported as a total amount paid under the RUG PPS payment system on
Worksheet E-2, line 1, and will be generated from the PS&R or your records.
Column 4--Enter the sum total of columns 2 and 3.
Line 201--Enter in column 1, the CBSA code in effect at the beginning of the cost reporting period.
Enter in column 2, the CBSA code in effect on or after October 1 of the current cost reporting
period, if applicable.
Lines 202 through 206--A notice published in the 68 FR 46036-46072 (August 4, 2003), provided
for an increase in RUG payments to hospital based SNFs for payments on or after October 1, 2003.
Congress expects this increase to be used for direct patient care and related expenses. Lines 202
through 206 are identified as following: 202 - Staffing, 203 - Recruitment, 204 - Retention of
Employees, 205 - Training, and 206 - Other. Enter in column 1 the direct patient care expenses
and related expenses in accordance with the above referenced Federal Register citation. Enter in
column 2, the ratio, expressed as a percentage, of total expenses for each category to total SNF
revenue from Worksheet G-2, Part I, line 7, column 3. For each line, indicate in column 3,
whether the increased RUG payments received reflects increases associated with direct patient
care and related expenses by responding “Y” for yes. Indicate “N” for no if there was no increase
in spending in any of these areas. If the increased spending is in an area not previously identified
in areas one through four, identify on the “Other (Specify)” line(s), the cost center(s) description
and the corresponding information as indicated above.

40-72

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4010.

WORKSHEET S-8 - HOSPITAL-BASED RHC/FQHC STATISTICAL DATA

4010

In accordance with 42 CFR 413.20(a), 42 CFR 413.24(a), and 42 CFR 413.24(c), you are required
to maintain separate statistical records for proper determination of costs payable under the
Medicare program. The statistics reported on this worksheet pertain to hospital-based
RHCs/FQHCs. If you have more than one of these clinics/centers, complete a separate worksheet
for each. Hospital-based RHCs/FQHCs may elect to file a consolidated cost report pursuant to
CMS Pub. 100-02, chapter 13, §80.2. Effective for cost reporting periods beginning on and after
October 1, 2014, hospital-based FQHCs no longer complete Worksheet S-8 and must complete
Worksheet S-11 to report statistical data.
Lines 1 and 2--Enter the full address of the hospital-based RHC/FQHC.
Line 3--For hospital-based FQHCs only, enter your appropriate designation of “R” for rural or “U”
for urban. See CMS Pub. 100-04, chapter 9, §20.6.2 for information regarding urban and rural
designations. If you are uncertain of your designation, contact your contractor. Hospital-based
RHCs do not complete this line.
Lines 4 through 9--In column 1, enter the applicable grant award number(s). In column 2, enter
the date(s) awarded.
Line 10--If the facility provides other than hospital-based RHC or FQHC services (e.g., laboratory
or physician services), answer “Y” for yes and enter the type of operation on subscripts of line 11,
otherwise enter “N” for no.
Line 11--Enter in columns 1 through 14 the starting and ending hours in the applicable columns
for the days that the facility is available to provide hospital-based RHC/FQHC services. Enter the
starting and ending hours in the applicable columns 1 through 14 for the days that the facility is
available to provide other than hospital-based RHC/FQHC services. When entering time, do so
as military time, e.g., 2:00 p.m. is 1400.
Line 12--Have you received an approval for an exception to the productivity standards? Enter a
“Y” for yes or an “N” for no.
Line 13--Is this a consolidated cost report as defined in CMS Pub. 100-02, chapter 13, §80.2? If
yes, enter in column 2, the number of providers included in this report, complete line 14, and
complete only one worksheet series M for the consolidated group. If no, complete a separate
Worksheet S-8 for each component accompanied by a corresponding Worksheet M series.
Line 14--Identify clinic/center name and CCN number filing the consolidated cost report.

Rev. 10

40-73

4010.1

FORM CMS-2552-10

4010.1

WORKSHEET S-11 - HOSPITAL-BASED FQHC IDENTIFICATION DATA

11-16

In accordance with 42 CFR 413.20(a), 42 CFR 413.24(a), and 42 CFR 413.24(c), you are required
to maintain statistical records for proper determination of costs payable under the Medicare
program. The statistics reported on this worksheet pertain to hospital-based FQHCs and are
effective for cost reporting periods beginning on or after October 1, 2014. Hospital-based FQHCs
may elect to file a consolidated cost report pursuant to CMS Pub. 100-02, chapter 13, §80.2. If
you have more than one hospital-based FQHC reported on Worksheet S-2, Part I, line 16, and its
subscripts, complete a separate Worksheet S-11, Part I, for each, unless you have contractor
approval to file a consolidated cost report.
This worksheet consists of three parts:
Part I - Hospital-Based FQHC Identification Data
Part II - Hospital-Based FQHC Consolidated Cost Report Participant Identification Data
Part III - Hospital-Based FQHC Statistical Data
4010.2 Part I - Hospital-Based FQHC Identification Data.--The information required on this
worksheet is needed to properly identify the hospital-based FQHC(s) listed on Worksheet S-2,
Part I, line 16, and its subscripts, or in the case of a consolidated cost report, the primary hospitalbased FQHC. In the case of a consolidated cost report, only the primary FQHC completes the
entire Worksheet S-11, Part I. All other hospital-based FQHCs filing under a consolidated cost
report must be listed on line 9, and its subscripts, and must complete a separate Worksheet S-11,
Part II.
Line 1--Enter the hospital-based FQHC site name in column 1. Indicate the type of control under
which the hospital-based FQHC operates by entering a number from the list below in column 2.
1
2
3
4
5
6

= Voluntary Nonprofit, Corporation
= Voluntary Nonprofit, Other
= Proprietary, Individual
= Proprietary, Corporation
= Proprietary, Partnership
= Proprietary, Other

7
8
9
10
11

= Governmental, Federal
= Governmental, State
= Governmental, County
= Governmental, City
= Governmental, Other

Enter the date the hospital-based FQHC terminated its participation in the Medicare program (if
applicable) in column 3. In column 4, enter a “V” for a voluntary termination or an “I” for an
involuntary termination.
If the hospital-based FQHC changed ownership immediately prior to the beginning of the cost
reporting period enter the date of the change of ownership in column 5. Also submit the name and
address of the new owner and a copy of the sales agreement with the cost report.
Line 2--Enter the Hospital-based FQHC’s street address in column 1 and the post office box in
column 2 (if applicable).
Line 3--Enter the city in column 1, state in column 2, ZIP code in column 3, county in column 4,
and the appropriate designation (“U” for urban or “R” for rural) in column 5. See
CMS Pub. 100-04, chapter 9, §20.6.2, for information regarding urban and rural designations. If
you are uncertain of your designation, contact your contractor.

40-73.1

Rev. 10

11-16

FORM CMS-2552-10

4010.2 (Cont.)

Line 4--Indicate whether this hospital-based FQHC is owned, leased or controlled by an entity that
operates multiple FQHCs. Enter a “Y” for yes or an “N” for no. If yes, complete lines 5 through
7. Otherwise, skip to line 8.
Lines 5 through 7--Enter the name of the entity that owns, leases or controls the hospital-based
FQHC, the street address, post office box (if applicable), HRSA grant award number assigned to
the organization, city, state, and ZIP code.
Line 8--Indicate whether this hospital-based FQHC is filing a consolidated cost report under
CMS Pub. 100-02, chapter 13, §80.2. Enter “Y” for yes or “N” for no. If yes, enter in column 2,
the date the hospital-based FQHC requested approval to file a consolidated cost report, in
column 3, the date the contractor approved the hospital-based FQHCs request to file a consolidated
cost report, and in column 4, the number of FQHCs included in this consolidated cost report other
than the primary FQHC
Line 9--If the response to line 8, column 1, is yes, list on the subscripts of line 9, each
hospital-based FQHC that is part of this consolidated cost report, excluding the primary hospitalbased FQHC listed on line 1. Enter in column 1, the site name; column 2, the CCN; column 3, the
CBSA; column 4, the date the hospital-based FQHC requested approval to file as part of a
consolidated cost report; and column 5, the date the contractor approved the hospital-based FQHCs
request to file as part of a consolidated cost report. Each hospital-based FQHC listed on the
subscripts of line 9 must complete a separate Worksheet S-11, Part II.
Line 10--There are 3 types of organizations that are eligible to enroll in Medicare as a
hospital-based FQHC. Indicate in column 1, the type of organization this hospital-based FQHC is
by entering a number from the list below. If your response in column 1 is “1” or “3”, enter any or
all of the alpha character (s) associated with the response in column 2. For example, if you entered
“1” in column 1, enter in column 2, “A”, “B”, “C” and/or “D.” An organization receiving a grant
under §330 of the Public Health Service (PHS) Act or an outpatient health program/facility can
operate as any or all of the subcategories listed under the respective numeric options presented
below.
1) An organization receiving a grant(s) under §330 of the PHS Act:
A) Community Health Centers
B) Migrant and Seasonal Agricultural Workers Health Centers
C) Health Care for the Homeless Health Centers
D) Health Centers for Residents of Public Housing
2) Health Center Program Look-Alikes; Organizations that have been identified by HRSA as
meeting the definition of “Health Center” under §330 of the PHS Act, but not receiving grant
funding under §330; or,
3) Outpatient health program/facility operated by:
A) A tribe or tribal organization under the Indian Self-Determination Act
B) An urban Indian organization under title V of the Indian Health Care Improvement Act
C) Other
Line 11--Indicate if your hospital-based FQHC received a grant under §330 of the PHS Act during
this cost reporting period. If this is a consolidated cost report, did the primary hospital-based
FQHC reported on line 1, column 1, receive a grant under §330 of the PHS Act during this cost
reporting period? Enter “Y” for yes or “N” for no.

Rev. 10

40-73.2

4010.2 (Cont.)

FORM CMS-2552-10

11-16

Line 12--If the response to line 11 is yes, indicate in column 1, the type of grant that was awarded
from the list below. Enter the date of the grant award in column 2, and enter the grant award
number in column 3. If you received more than one grant subscript this line accordingly.
1 = Community Health Center (§330(e), PHS Act)
2 = Migrant and Seasonal Agricultural Workers Health Center (§330(g), PHS Act)
3 = Health Care for the Homeless Health Centers (§330(h), PHS Act)
4 = Health Centers for Residents of Public Housing (§330(i), PHS Act)
5 = Other
Line 13--Indicate if your hospital-based FQHC submitted an initial deeming or annual redeeming
application for medical malpractice coverage to HRSA under the Federal Tort Claims Act (FTCA).
Enter “Y” for yes or “N” for no in column 1. If column 1 is yes, enter the effective date of coverage
in column 2.
Line 14--Indicate if the hospital-based FQHC received a THC development grant authorized under
Part C of title VII of the PHS Act from HRSA for the purpose of establishing new accredited or
expanded primary care residency programs. Enter “Y” for yes or “N” for no in column 1. If yes,
enter the number of FTE residents your hospital-based FQHC trained using THC funding in
column 2, and the total number of visits performed by such residents in column 3, during this cost
reporting period.
4010.3 Part II - Hospital-Based FQHC Consolidated Cost Report Participant Identification
Data--For each hospital-based FQHC that is included on Worksheet S-11, Part I, line 9, and its
subscripts, a separate Worksheet S-11, Part II, must be completed in the identical sequence that
the consolidated hospital-based FQHCs are reported on Worksheet S-11, Part I, line 9, and its
subscripts. Do not complete this worksheet for the primary hospital-based FQHC reported on
Worksheet S-11, Part I, line 1.
Line 1--Enter the hospital-based FQHC site name in column 1 and the certification date in
column 2. Indicate the type of control under which the hospital-based FQHC operates by entering
a number from the list below in column 3.
1
2
3
4
5
6

= Voluntary Nonprofit, Corporation
= Voluntary Nonprofit, Other
= Proprietary, Individual
= Proprietary, Corporation
= Proprietary, Partnership
= Proprietary, Other

7
8
9
10
11

= Governmental, Federal
= Governmental, State
= Governmental, County
= Governmental, City
= Governmental, Other

Enter the date the hospital-based FQHC terminated its participation in the Medicare program (if
applicable) in column 4. In column 5, enter a “V” for a voluntary termination or an “I” for an
involuntary termination.
If the hospital-based FQHC changed ownership immediately prior to the beginning of the cost
reporting period enter the date of the change of ownership in column 6. Also submit the name and
address of the new owner and a copy of the sales agreement with the cost report.
Line 2--Enter the hospital-based FQHC’s street address in column 1 and the post office box in
column 2 (if applicable).

40-73.3

Rev. 10

11-16

FORM CMS-2552-10

4010.3 (Cont.)

Line 3--Enter the city in column 1, state in column 2, ZIP code in column 3, county in column 4,
and the appropriate designation (“U” for urban or “R” for rural) in column 5. See
CMS Pub. 100-04, chapter 9, §20.6.2, for information regarding urban and rural designations. If
you are uncertain of your designation, contact your contractor.
Line 4--There are three types of organizations that are eligible to enroll in Medicare as a hospitalbased FQHC. Indicate in column 1, the type of organization this hospital-based FQHC is by
entering a number from the list below. If your response in column 1 is “1” or “3”, enter any or all
of the alpha characters associated with the response in column 2. For example, if you entered “1”
in column 1, enter in column 2, “A”, “B”, “C” and/or “D”. An organization receiving a grant
under §330 of the PHS Act or an outpatient health program/facility can operate as any or all of the
subcategories listed under the respective numeric options below.
1) An organization receiving a grant(s) under §330 of the PHS Act:
A) Community Health Centers
B) Migrant and Seasonal Agricultural Workers Health Centers
C) Health Care for the Homeless Health Centers
D) Health Centers for Residents of Public Housing
2) Health Center Program Look-Alikes; Organizations that have been identified by HRSA as
meeting the definition of “Health Center” under §330 of the PHS Act, but not receiving grant
funding under §330; or,
3) Outpatient health program/facility operated by:
A) A tribe or tribal organization under the Indian Self-Determination Act
B) An urban Indian organization under title V of the Indian Health Care Improvement Act
C) Other
Line 5--Indicate if your hospital-based FQHC received a grant under §330 of the PHS Act during
this cost reporting period. Enter “Y” for yes or “N” for no.
Line 6--If the response to line 5 is yes, indicate in column 1, the type of grant that was awarded
from the list below. Enter the date of the grant award in column 2 and enter the grant award
number in column 3. If you received more than one grant subscript this line accordingly.
1 = Community Health Center (§330(e), PHS Act)
2 = Migrant and Seasonal Agricultural Workers Health Center (§330(g), PHS Act)
3 = Health Care for the Homeless Health Center (§340(d), PHS Act)
4 = Health Centers for Residents of Public Housing ((§330(i), PHS Act)
5 = Other
Line 7--Indicate if this hospital-based FQHC submitted an initial deeming or annual redeeming
application for medical malpractice coverage to HRSA under the FTCA. Enter “Y” for yes or “N”
for no in column 1. If column 1 is yes, enter the effective date of coverage in column 2.
Line 8--Indicate if the hospital-based FQHC received a THC development grant authorized under
Part C of title VII of the PHS Act from HRSA for the purpose of establishing new accredited or
expanded primary care residency programs. Enter “Y” for yes or “N” for no in column 1. If yes,
enter the number of FTE residents your FQHC trained using THC funding in column 2.

Rev. 10

40-73.4

4010.4

FORM CMS-2552-10

11-16

4010.4 Part III - Hospital-Based FQHC Statistical Data.--This part collects statistical data
regarding the number and types of visits by title. If you have more than one hospital-based FQHC
reported on Worksheet S-2, Part I, line 16, and its subscripts, complete a separate Worksheet S-11,
Part III, for each. If you elected to file consolidated, complete one Worksheet S-11, Part III, for
the primary hospital-based FQHC and all subcomponents.
Only those visits that qualify as a face to face encounter associated with a beneficiary receiving
services under the Medicare fee for service program are included in column 2. However, visits
attributable to beneficiaries enrolled in a Medicare Advantage plan must be included in column 4.
For the purposes of the Medicare program, a beneficiary who receives care at a hospital-based
FQHC can be seen for three types of visits:
•

•
•

Medical Visit - A face to face encounter between an FQHC patient and one of the
following: a physician, physician assistant, nurse practitioner, certified nurse midwife,
visiting registered nurse, visiting licensed practical nurse, registered dietician, or certified
DSMT/MNT educator.
Medical Visit for Subsequent Illness or Injury
Mental Health Visit - A face to face encounter between an FQHC patient and one the of
the following: a clinical psychologist, clinical social worker, or a physician, physician
assistant, nurse practitioner, certified nurse midwife, visiting registered nurse, visiting
licensed practical nurse for mental health services.

Column 0--Use this column only when you are filing a consolidated cost report to identify each
hospital-based FQHC listed on Worksheet S-11, Part I, line 9, and subscripts in the exact same
order.
Columns 1 through 4--Enter the number of medical visits and mental health visits for each
program (title V, title XVIII and title XIX) and visits paid by all other payers (i.e., private pay).
Include dually eligible (Medicare/Medicaid) beneficiaries in column 2.
Line 1--Enter the number of medical visits applicable to columns 1 through 4. Each visit to the
hospital-based FQHC by the beneficiary counts as a single visit, even in the case where a
beneficiary returns to the hospital-based FQHC in the same day for a subsequent illness or injury.
If you are filing under a consolidated cost report, line 1 must contain the medical visits exclusively
for the primary CCN and you must subscript line 1 to report the number of medical visits for each
additional hospital-based FQHC included in this consolidated cost report. Each subscript of line 1,
column 0, must contain a corresponding CCN from Worksheet S-11, Part I, line 9, and subscripts,
in the exact same order. Enter the number of medical visits applicable to columns 1 through 4, for
each hospital-based FQHC listed on line 1 and its subscripts.
Line 2--Enter the total number of medical visits (sum of line 1 and its subscripts) for each
applicable column.
Line 3--Enter the number of mental health visits applicable to columns 1 through 4. Each visit to
the hospital-based FQHC by the beneficiary counts as a single visit, even in the case where a
beneficiary returns to the hospital-based FQHC in the same day for a subsequent illness or injury.
If you are filing under a consolidated cost report, line 3 must contain the mental health visits
exclusively for the primary CCN and you must subscript line 3 to report the number of mental
health visits for each additional hospital-based FQHC included in this consolidated cost report.
Each subscript of line 3, column 0, must contain a corresponding CCN from Worksheet S-11,
Part I, line 9, and subscripts, in the exact same order. Enter the number of mental health visits
applicable to columns 1 through 4, for each hospital-based FQHC listed on line 3, and its
subscripts.

40-73.5

Rev. 10

11-16

FORM CMS-2552-10

4010.4 (Cont.)

Line 4--Enter the total number of mental health visits (sum of line 3 and its subscripts) for each
applicable column.
Column 5--Enter the sum of the total medical and mental health visits included in columns 1
through 4.

Rev. 10

40-73.6

4011
4011.

FORM CMS-2552-10

11-16

WORKSHEET S-9 - HOSPITAL-BASED HOSPICE IDENTIFICATION DATA

In accordance with 42 CFR 418.310 hospice providers of service participating in the Medicare
program are required to submit annual information for health care services rendered to Medicare
beneficiaries. Also, 42 CFR 413.24(f) requires cost reports from providers on an annual basis.
The data submitted on the cost reports supports management of Federal programs. The statistics
required on this worksheet pertain to a hospital-based hospice. Complete a separate Worksheet S-9
for each hospital-based hospice.
4011.1

Part I - Enrollment Days for Cost Reporting Periods Beginning Before October 1, 2015.--

NOTE: Columns 1 and 2 contain the days identified in column 3 and 4. Column 3 and 4 identify
the SNF and NF days out of the total for titles XVIII and XIX.
Lines 1 through 4--Enter on lines 1 through 4 the enrollment days applicable to each level of care
(LOC). Enrollment days are unduplicated days of care received by a hospice patient. A day is
recorded for each day a hospice patient receives one of four levels of care. Where a patient moves
from one LOC to another, count only one day of care for that patient for the last type of care
rendered. For line 4, an inpatient care day should be reported only where the hospice provides or
arranges to provide the inpatient care.
Line 5--Enter the total of columns 1 through 6 for lines 1 through 4.
For the purposes of the Medicare and Medicaid hospice programs, a patient electing hospice can
receive only one of the following four types of care per day:
Hospice Continuous Home Care (HCHC) Day - A HCHC day is a day on which the hospice
patient is not in an inpatient facility, and receives continuous care during a period of crisis in order
to maintain the individual at home. A day consists of a minimum of 8 hours and a maximum of
24 hours of predominantly nursing care. For each day a beneficiary received 8 or more hours of
predominantly nursing care, count the day as one HCHC day. Note: Do not count days by dividing
the total hours by 24.
Hospice Routine Home Care (HRHC) Day - A HRHC day is a day on which the hospice patient
is at home and not receiving HCHC.
Hospice Inpatient Respite Care (HIRC) Day - An HIRC day is a day on which the hospice patient
receives care in an approved inpatient facility, to provide respite for the individual’s family or
other persons caring for the individual at home.
Hospice General Inpatient Care (HGIP) Day - A HGIP day is a day on which the hospice patient
receives care in a Medicare certified hospice facility, hospital or SNF for pain control or acute or
chronic symptom management which cannot be managed in other settings.
Column Descriptions
Column 1--Enter only the unduplicated Medicare days applicable to the four types of care. Enter
on line 5 the total unduplicated Medicare days.
Column 2--Enter only the unduplicated Medicaid days applicable to the four types of care. Enter
on line 5 the total unduplicated Medicaid days.
Column 3--Enter only the unduplicated days applicable to the four types of care for all Medicare
hospice patients residing in a skilled nursing facility. Enter on line 5 the total unduplicated days.

40-74

Rev. 10

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FORM CMS-2552-10

4011.2

Column 4--Enter only the unduplicated days applicable to the four types of care for all Medicaid
hospice patients residing in a nursing facility. Enter on line 5, the total unduplicated days.
Column 5--Enter in column 5, only the days applicable to the four types of care for all other nonMedicare or Medicaid hospice patients. Enter on line 5 the total unduplicated days.
Column 6--Enter the total days for each type of care, (i.e., sum of columns 1, 2, and 5). The
amount entered in column 6, line 5, should represent the total days provided by the hospice.
NOTE: Convert continuous home care hours into days so that column 6, line 5, reflects the actual
total number of days provided by the hospice.
4011.2

Part II - Census Data for Cost Reporting Periods Beginning Before October 1, 2015.--

NOTE: Columns 1 and 2 contain the days identified in columns 3 and 4. Columns 3 and 4
identify the SNF and NF days out of the total for titles XVIII and XIX.
Line 6--Enter the total number of patients receiving hospice care within the cost reporting period
for the appropriate payer source.
The total under this line should equal the actual number of patients served during the cost reporting
period for each program. Thus, if a patient’s total stay overlapped two reporting periods, the stay
should be counted once in each reporting period. The patient who initially elects the hospice
benefit, is discharged or revokes the benefit, and then elects the benefit again within a reporting
period is considered to be a new admission with a new election and should be counted twice.
A patient transferring from another hospice is considered to be a new admission and would be
included in the count. If a patient entered a hospice under a payer source other than Medicare and
then subsequently elects Medicare hospice benefit, count the patient once for each pay source.
The difference between line 6 and line 9 is that line 6 should equal the actual number of patients
served during the reporting period for each program, whereas under line 9, patients are counted
once, even if their stay overlaps more than one reporting period.
Line 7--Enter the total title XVIII Unduplicated Continuous Care hours billable to Medicare.
When computing the Unduplicated Continuous Care hours, count only one hour regardless of
number of services or therapies provided simultaneously within that hour.
Line 8--Enter the average length of stay for the reporting period. Include only the days for which
a hospice election was in effect. The average length of stay for patients with a payer source other
than Medicare and Medicaid is not limited to the number of days under a hospice election. Line 5
divided by line 6.
The statistics for a patient who had periods of stay with the hospice under more than one program
is included in the respective columns. For example, patient A enters the hospice under Medicare
hospice benefit, stays 90 days, revokes the election for 70 days (and thus goes back into regular
Medicare coverage), then reelects the Medicare hospice benefits for an additional 45 days, under
a new benefit period and dies (patient B).

Rev. 10

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4011.2 (Cont.)

FORM CMS-2552-10

11-16

Medicare patient C was in the program on the first day of the year and died on January 29 for a
total length of stay of 29 days. Patient D was admitted with private insurance for 27 days, then
their private insurance ended and Medicaid covered an additional 92 days. Patient E, with private
insurance, received hospice care for 87 days. The average length of stay (LOS) (assuming these
are the only patients the hospice served during the cost reporting period) is computed as follows:
Medicare Days (90 & 45 & 29)
Patient (A, B & C)
Medicare Patients
Average LOS Medicare
Medicaid Days Patient D (92)
Medicaid Patient
Average LOS Medicaid
Other (Insurance) Days (87 & 27)
Other Payments (D & E)
Average LOS (Other)

164 days
/3
-------------54.67 Days
92 Days
1
92 Days
114 Days
2
54 Days

All Patients (90+45+29+92+87+27)
370 Days
Total number of patients
6
Average LOS for all patients
61.67 Days
Enter the hospice’s average length of stay, without regard to payer source, in column 6, line 8.
Line 9--Enter the unduplicated census count of the hospice for all patients initially admitted and
filing an election statement with the hospice within a reporting period for the appropriate payer
source. Do not include the number of patients receiving care under subsequent election periods
(see CMS Pub. 100-02, chapter 9, §20). However, the patient who initially elects the hospice
benefit, is discharged or revokes the benefits, and elects the benefit again within the reporting
period is considered a new admission with each new election and should be counted twice.
The total under this line should equal the unduplicated number of patients served during the
reporting period for each program. Thus, you would not include a patient if their stay was counted
in a previous cost reporting period. If a patient enters a hospice source other than Medicare and
subsequently becomes eligible for Medicare and elects the Medicare hospice benefit, then count
that patient only once in the Medicare column, even though he/she may have had a period in
another payer source prior to the Medicare election. A patient transferring from another hospice
is considered to be a new admission and is included in the count.

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DRAFT

FORM CMS-2552-10

4011.4

4011.3 Part III - Enrollment Days for Cost Reporting Periods Beginning On or After
October 1, 2015.--This section collects unduplicated days data.
Lines 10 through 13--Enter the enrollment days applicable to each LOC in columns 1 through 3.
Include dually eligible (Medicare/Medicaid) beneficiaries in column 1. Enrollment days are
unduplicated days of care received by a hospice patient. Report a day for each day a hospice
patient received one of four levels of care -- HCHC, HRHC, HIRC, or HGIP. When a patient was
transferred from one LOC to another, count the day of transfer as one day of care at the LOC billed.
Report an HIRC day on line 12, only when the hospice provided or arranged to provide the
inpatient respite care.
Enter the total unduplicated days by LOC (sum of columns 1 through 3) in column 4.
Line 14--Enter the total unduplicated days (sum of lines 10 through 13) in each column, as
applicable.
4011.4 Part IV - Contracted Statistical Data for Cost Reporting Periods Beginning On or After
October 1, 2015.--This section collects unduplicated days data for inpatient services at a contracted
facility. The days reported in Part IV are a subset of the days reported in Part III.
Lines 15 and 16--Enter the contracted inpatient service enrollment days applicable to each LOC
in columns 1 through 3. Include dually eligible (Medicare/Medicaid) beneficiaries in column 1.
Enrollment days are unduplicated days of care received by a hospice patient. Report a day for
each day a hospice patient received HIRC or HGIP care at a contracted facility. When a patient
was transferred from one LOC to another, count the day of transfer as one day of care at the LOC
billed. Enter the total unduplicated days by LOC (sum of columns 1 through 3) in column 4.

Rev.

40-76.1

4012
4012.

FORM CMS-2552-10

DRAFT

WORKSHEET S-10 - HOSPITAL UNCOMPENSATED AND INDIGENT CARE
DATA

Section 112(b) of the Balanced Budget Refinement Act (BBRA) requires that short-term acute
care hospitals (§1886(d) of the Act) submit cost reports containing data on the cost incurred by the
hospital for providing inpatient and outpatient hospital services for which the hospital is not
compensated. Worksheet S-10 provides for the collection of the required data. Charity care charge
data, as referenced in section 4102 of American Recovery and Reinvestment Act of 2009, may be
used to calculate the EHR technology incentive payments made to §1886(d) hospitals and CAHs.
Section 1886(n)(6)(B) of the Act, as added by section 602 of Consolidated Appropriations
Act, 2016, adds subsection (d) Puerto Rico hospitals as eligible hospitals under the EHR incentive
program. In addition, section 1886(r)(2) of the Act, as added by section 3133 of the ACA, requires
an additional payment for uncompensated care for 1886(d) DSH eligible hospitals. Charity care
charges, discounts given to uninsured patients that meet the hospital's written financial assistance
policy/uninsured discount policy (hereinafter referred to as “financial assistance policy” or FAP),
non-Medicare bad debt, and non-reimbursed Medicare bad debt may be used in the calculation of
the uncompensated care payment. CMS does not mandate the eligibility criteria that a hospital
uses under its financial assistance policy. Section 1886(d) hospitals and CAHs are required to
complete this worksheet.
Worksheet S-10 provides for the collection of uncompensated and indigent care data for the entire
hospital complex. Effective for cost reporting periods beginning on or after October 1, 2022,
Worksheet S-10 is Worksheet S-10, Part I; and, effective for cost reporting periods beginning on
or after October 1, 2022, Worksheet S-10, Part II, provides for the collection of uncompensated
and indigent care data for inpatient and outpatient services billable under the hospital CCN. The
data reported on Part II is a subset of the data reported on Part I.
For additional information on uncompensated care and completing the Worksheet S-10, see
MLN Matters SE17031 and the CMS Questions and Answers for Worksheet S-10, available on the
CMS web site (cms.gov).
Definitions.-Charity Care and Uninsured Discounts--Charity care and uninsured discounts result from a
hospital's policy to provide all or a portion of medically necessary health care services free of
charge to patients who meet the hospital’s charity care policy or FAP. Charity care and uninsured
discounts can include full or partial discounts. If a patient is not eligible for discounts under the
hospital’s charity care policy or FAP, then any discounts or reductions given to the standard
managed care rate must not be accounted for as charity care or an uninsured discount. Discounts
given to patients for prompt payment must not be included as charity care. For Medicare purposes,
charity care is not reimbursable and unpaid amounts associated with charity care are not considered
as an allowable Medicare bad debt. A hospital cannot claim as charity care amounts of unpaid
deductibles and co-insurance for which it has received reimbursement from Medicare (reimbursed
Medicare bad debt). (Additional guidance provided in the instruction for line 20.) Hospitals that
received HRSA-administered Uninsured Provider Relief Fund (PRF) payments, as authorized by
the CARES Act (Pub. L. 116-136), for services provided to uninsured COVID-19 patients, must
not include the patient charges for those services. Under the terms and conditions of the PRF,
payments are considered payment in full for such care or treatment.
Courtesy Allowances--Courtesy allowances are reductions in charges by a provider in the form of
allowances to persons such as physicians, clergy, members of religious orders, and others as may
be approved by the governing body of the provider, for services received from the provider.
Courtesy allowances also include discounts for prompt payment, friends and family discounts, and
employee discounts. Courtesy allowances are not charity care charges, nor are they Medicare
bad debts, and must not be included on this worksheet. Reductions in charges made as employee
fringe benefits, such as hospitalization and personnel health programs, are not courtesy
allowances or charity care and must not be included on this worksheet.
40-76.2

Rev.

DRAFT

FORM CMS-2552-10

4012 (Cont.)

Inferred contractual relationship--For Worksheet S-10 purposes, a contractual relationship
between an insurer and a provider will be inferred where a provider accepts an amount from an
insurer as payment, or partial payment, on behalf of an insured patient (for example, payments
from workman’s compensation funds, payments from an automobile insurer for medical benefits,
or payments from an insurer for out-of-network services).
Medicare bad debt--When furnishing services to a Medicare beneficiary, a provider incurs costs
in furnishing such covered services. A Medicare beneficiary may be responsible for paying a share
of those costs as part of their applicable deductible and/or coinsurance amounts. When a Medicare
beneficiary, or other responsible party, fails to pay the deductible and/or coinsurance amounts, the
provider has incurred costs of furnishing services that are unrecovered. If the unpaid deductible
and coinsurance amounts meet the criteria of 42 CFR 413.89, then these amounts may be allowable
as Medicare bad debt. Amounts reimbursed as a Medicare bad debt cannot be claimed as charity
care.
Non-Medicare bad debt--Charges for health services for which a hospital determines the
non-Medicare patient has a financial responsibility to pay, but the non-Medicare patient does not
pay. These amounts are subject to the cost-to-charge ratio (CCR). (Additional guidance provided
in the instructions for lines 28 and 29.)
Non-reimbursable Medicare bad debt--The amount of allowable Medicare coinsurance and
deductibles considered to be uncollectible but not reimbursed by Medicare under the requirements
of 42 CFR 413.89(h). (Additional guidance provided in the instructions for lines 27 and 27.01.)
Net revenue--Actual payments received or expected to be received from a payer (including
coinsurance payments from the patient) for services delivered during this cost reporting period.
Net revenue will typically be charges (gross revenue) less contractual allowance. (Applies to
lines 2, 9, and 13.)
Public Programs--Federal, State, and/or local government programs paying, in full or in part, for
health care (e.g., Medicare, Medicaid, CHIP and/or other Federal, State, or locally operated
programs).
Uncompensated care--Consists of charity care and uninsured discounts, non-Medicare bad debt,
and non-reimbursable Medicare bad debt. Uncompensated care does not include courtesy
allowances, discounts given to patients that do not meet the hospital’s charity care policy, or
discounts given to uninsured patients that do not meet the hospital's FAP, or bad debt reimbursed
by Medicare.

Rev.

40-77

4012.1 (Cont.)
4012.1

FORM CMS-2552-10

DRAFT

Part I - Hospital and Hospital Health Care Complex.--

Uncompensated and Indigent Care Cost-to-Charge Ratio-Line 1--Enter the CCR resulting from Worksheet C, Part I, line 202, column 3, divided by
Worksheet C, Part I, line 202, column 8.
For all inclusive rate no-charge-structure providers, enter your ratio as calculated in accordance
with CMS Pub. 15-1, chapter 22, §2208.
Medicaid--The amounts reported on lines 2 through 8 are mutually exclusive of the amounts
reported on lines 17 and 18.
Line 2--Enter the inpatient and outpatient payments received or expected for title XIX covered
services delivered during this cost reporting period. Include payments for an expansion Children’s
Health Insurance Program (CHIP) program, that covers recipients who would have been eligible
for coverage under title XIX. Include payments for all covered services except physician or other
professional services, and include payments received from Medicaid managed care programs. If
not separately identifiable, disproportionate share (DSH) and supplemental payments are included
in this line. For these payments, report the amount received or expected for the cost reporting
period, net of associated provider taxes or assessments.
Line 3--Enter “Y” for yes if you received or expect to receive any DSH or supplemental payments
from Medicaid relating to this cost reporting period. Otherwise enter “N” for no.
Line 4--If you answered yes to question 3, enter “Y” for yes if all of the DSH and/or supplemental
payments you received from Medicaid are included in line 2. Otherwise, enter “N” for no and
complete line 5.
Line 5--If you answered no to question 4, enter the DSH and/or supplemental payments the
hospital received or expects to receive from Medicaid relating to this cost reporting period that
were not included in line 2, net of associated provider taxes or assessments.
Line 6--Enter all charges (gross revenue) for title XIX covered services delivered during this cost
reporting period. These charges relate to the services for which payments were reported on line 2.
Line 7--Calculate the Medicaid cost by multiplying line 1 by line 6.
Line 8--Enter the difference between net revenue and costs for Medicaid by subtracting the sum
of lines 2 and 5 from line 7. If line 7 is less than the sum of lines 2 and 5, then enter zero.
Children’s Health Insurance Program--The amounts reported on lines 9 through 12 are mutually
exclusive of the amounts reported on lines 17 and 18.
Line 9--Enter all payments received or expected for services delivered during this cost reporting
period that were covered by a stand-alone CHIP program. Stand-alone CHIP programs cover
recipients who are not eligible for coverage under title XIX. Include payments for all covered
services except physician or other professional services, and include any payments received from
CHIP managed care programs.
Line 10--Enter all charges (gross revenue) for services delivered during this cost reporting period
that were covered by a stand-alone CHIP program. These charges relate to the services for which
payments were reported on line 9.
Line 11--Calculate the stand-alone CHIP cost by multiplying line 1 by line 10.
Line 12--Enter the difference between net revenue and costs for stand-alone CHIP by subtracting
line 9 from line 11. If line 11 is less than line 9, then enter zero.
40-78

Rev.

DRAFT

FORM CMS-2552-10

4012.1 (Cont.)

Other state or local indigent care program--The amounts reported on lines 13 through 16 are
mutually exclusive of the amounts reported on lines 17 and 18.
Line 13--Enter all payments received or expected for services delivered during this cost reporting
period for patients covered by a state or local government indigent care program (other than
Medicaid or CHIP), where such payments and associated charges are identified with specific
patients and documented through the provider's patient accounting system. Include payments for
all covered services except physician or other professional services, and include payments from
managed care programs.
Line 14--Enter all charges (gross revenue) for services delivered during this cost reporting period
for patients covered by a state or local government program, where such charges and associated
payments are documented through the provider's patient accounting system. These charges should
relate to the services for which payments were reported on line 13.
Line 15--Calculate the costs for patients covered by a state or local government program by
multiplying line 1 by line 14.
Line 16--Calculate the difference between net revenue and costs for patients covered by a state or
local government program by subtracting line 13 from line 15. If line 15 is less than line 13, then
enter zero.
Grants, donations and total unreimbursed cost for Medicaid, CHIP, and state/local indigent
care--The amounts reported on lines 17 and 18 are mutually exclusive of the amounts reported on
lines 2 through 16.
Line 17--Enter the value of all non-government grants, gifts and investment income received
during this cost reporting period that were restricted to funding uncompensated or indigent care.
Include interest or other income earned from any endowment fund for which the income is
restricted to funding uncompensated or indigent care.
Line 18--Enter all grants, appropriations or transfers received or expected from government
entities for this cost reporting period for purposes related to operation of the hospital, including
funds for general operating support as well as for special purposes (including but not limited to
funding uncompensated care). Include funds from the Federal Section 1011 program, if
applicable, which helps hospitals finance emergency health services for undocumented aliens.
While Federal Section 1011 funds were allotted for federal fiscal years 2005 through 2008, any
unexpended funds will remain available after that time period until fully expended even after
federal fiscal year 2008. If applicable, report amounts received from charity care pools net of
related provider taxes or assessments. Do not include funds from government entities designated
for non-operating purposes, such as research or capital projects.
Line 19--Calculate the total unreimbursed cost for Medicaid, CHIP, and state and local indigent
care programs by entering the sum of lines 8, 12, and 16.

Rev.

40-79

4012.1 (Cont.)

FORM CMS-2552-10

DRAFT

Uncompensated care cost-Line 20--Enter the charity care charges and uninsured discount amounts determined in
accordance with the hospital’s charity care criteria/policy or FAP for the cost reporting period as
described in A, B, or C. Do not reduce charges in columns 1 or 2 by any payments made for the
patient liability (see instructions for line 22 to report payment amounts). All amounts reported on
line 20, columns 1 and 2, other than amounts for deductible, coinsurance, or co-payment for
hospital services, are subject to the CCR on line 1 when calculating costs on line 21. Do not
include in columns 1 or 2:
•
•
•
•
•

amounts that do not meet the hospital’s charity care policy of FAP;
Medicaid shortfalls, contractual allowances, or amounts for patients given courtesy
allowances;
deductible and coinsurance amounts claimed as Medicare bad debts;
charges for physician and other professional services; and
charges reported in a previous cost reporting period.

Effective for cost reporting periods beginning on or after October 1, 2018, a cost report is rejected
when submitted without listings supporting the charity care amounts claimed on line 20
(42 CFR 413.24(f)(5)). Exhibit 3B presents the standard format for the information required to
support the charity care amounts claimed and must be submitted with cost reports for periods
beginning on or after October 1, 2022. (See exhibit and instructions presented at the end of
§4012.7.)
A. For cost reporting periods beginning prior to October 1, 2016, and for subsection (d)
Puerto Rico hospitals under §1886(n)(6)(B) for cost reporting periods beginning on or after
October 1, 2016, enter the total initial payment obligation, measured at full charges, for patients,
including uninsured patients, who are given a full or partial discount based on the hospital’s charity
care policy or FAP for medically necessary health care services delivered during this cost reporting
period for the entire facility.
Column 1 (Uninsured Patients): Enter the sum of charges for:
• uninsured patients; and
• patients with coverage from an entity/insurer that does not have a contractual
relationship with the provider; and
• insured patients that were determined uninsured for the entire hospital stay; and
• non-covered services provided to patients eligible for Medicaid or other indigent care
programs, if such inclusion is specified in the hospital’s charity care policy or FAP
and the patient meets the hospital's policy criteria.
Column 2 (Insured Patients): Enter the sum of:
• amounts for deductible and coinsurance required by the payer for insured patients
covered by a public program or private insurer with which the provider has a
contractual relationship that were written off to charity care; and
• non-covered charges for days exceeding a length-of-stay limit for patients covered by
Medicaid or other indigent care programs, if such inclusion is specified in the
hospital’s charity care policy or FAP and the patient meets the hospital's policy criteria
(such amounts must also be included on line 25).
Column 3: Enter the sum of columns 1 and 2.

40-80

Rev.

DRAFT

FORM CMS-2552-10

4012.1 (Cont.)

B. For cost reporting periods beginning on or after October 1, 2016, and for
subsection (d) Puerto Rico hospitals under §1886(n)(6)(B) beginning on or after October 1, 2020,
through cost reporting periods beginning prior to October 1, 2022, enter the actual charge
amounts for the entire facility for patients, including uninsured patients who were given full or
partial discounts that were determined in accordance with the hospital’s charity care criteria/policy
or FAP, and written off during this cost reporting period, regardless of when the services were
provided.
Column 1 (Uninsured Patients): Enter the sum of:
• total charges, or the portion of the total charges for uninsured patients; and
• total charges, or the portion of total charges for patients with coverage from an
entity/insurer that does not have a contractual relationship with the provider; and
• total charges, or the portion of total charges for insured patients that were determined
uninsured for the entire hospital stay; and
• charges for non-covered services provided to patients eligible for Medicaid or other
indigent care programs, if such inclusion is specified in the hospital’s charity care
policy or FAP and the patient meets the hospital's policy criteria.
NOTE FOR COLUMN 1: The total charges or the portion of total charges is the amount
the patient is not responsible for paying (e.g., 100% of charges if the patient qualified for
100% discount or 70% of charges if the patient qualified for a 70% discount).
Column 2 (Insured Patients): Enter the sum of amounts written off to charity care for:
• deductible and coinsurance required by the payer for insured patients covered by a
public program or private insurer with which the provider has a contractual
relationship; and
• non-covered charges for days exceeding a length-of-stay limit for patients covered by
Medicaid or other indigent care programs, if such inclusion is specified in the
hospital’s charity care policy or FAP and the patient meets the hospital's policy criteria
(such amounts must also be included on line 25).
Column 3: Enter the sum of columns 1 and 2.
C. For cost reporting periods beginning on or after October 1, 2022, including
subsection (d) Puerto Rico hospitals under §1886(n)(6)(B), enter the actual charges for the entire
facility for patients, including uninsured patients, who were given full or partial discounts that
were written off during this cost reporting period, regardless of when the services were provided.
Column 1 (Uninsured Patients): Enter amounts written off to charity care for:
• total charges, or the portion of total charges, for uninsured patients; and
• total charges, or the portion of total charges, for patients with coverage from an
entity/insurer that does not have a contractual or inferred contractual relationship
with the provider; and
• total charges, or the portion of total charges, for insured patients that were
determined uninsured for the entire hospital stay; and
• charges for non-covered services provided to patients eligible for Medicaid or
other indigent care programs, if such inclusion is specified in the hospital’s charity
care policy or FAP and the patient meets the hospital's policy criteria.
NOTE FOR COLUMN 1: The total charges or the portion of total charges is the amount
the patient is not responsible for paying (e.g., 100% of charges if the patient qualified for
100% discount or 70% of charges if the patient qualified for a 70% partial discount).

Rev.

40-80.1

4012.1 (Cont.)

FORM CMS-2552-10

DRAFT

Column 2 (Insured Patients): Enter amounts written off to charity care for:
• deductible, coinsurance, and co-payment amounts for hospital services required by
the payor for insured patients covered by a public program or private insurer with
which the provider has a contractual or inferred contractual relationship; and
• non-covered charges for days exceeding a length-of-stay limit for patients covered
by Medicaid or other indigent care programs, if such inclusion is specified in the
hospital’s charity care policy or FAP and the patient meets the hospital's policy
criteria (such amounts are subject to the CCR and must be included on line 25);
and
• charges, or the portion of charges, other than deductible, coinsurance, and copayment amounts that represent the insured patient’s liability for medically
necessary hospital services (such amounts are subject to the CCR, and must be
included on line 25.01). These charges include a patient’s liability from a
contractual or inferred contractual relationship between a public program or
private insurer and the provider.
Column 3: Enter the sum of columns 1 and 2.
Line 21--Calculate the cost for charity care and uninsured discounts. In column 1, calculate the
cost of uninsured patients approved for charity care and uninsured discounts by multiplying
line 20, column 1, by the CCR on line 1. In column 2, calculate the cost of insured patients
approved for charity care in accordance with A or B. In column 3, enter the sum of columns 1
and 2.
A. For cost reporting periods beginning prior to October 1, 2022: enter the sum of the
deductibles and coinsurance not subject to the CCR on line 1 for insured patients approved
for charity care (line 20, column 2, minus line 25) plus the non-covered charges for insured
patients for days exceeding a length-of-stay limit that are subject to the CCR on line 1
(line 25 multiplied by line 1).
B. For cost reporting periods beginning on or after October 1, 2022, enter the sum of the
deductibles and coinsurance not subject to the CCR on line 1 for insured patients approved
for charity care (line 20, column 2, minus lines 25 and 25.01) plus the non-covered
charges for insured patients for days exceeding a length-of-stay limit and charges for
insured patients’ liability that are subject to the CCR on line 1 (lines 25 and 25.01,
multiplied by line 1).
Line 22--Enter payments received from patients for amounts previously written off as charity care.
Payments entered on this line must not exceed charity care or uninsured discount amounts written
off in the cost reporting period. Do not include:
•
•
•
•

payments from payers;
grants or other mechanisms of funding for charity care;
payments for physician or other professional services; and
payments received that represent a patient’s liability, or amounts that were not
previously written off on line 20 as charity care or uninsured discounts.

A. For cost reporting periods beginning prior to October 1, 2016, and for subsection (d)
Puerto Rico hospitals under §1886(n)(6)(B) beginning on or after October 1, 2016, enter the sum
of payments received and payments expected to be received for the entire facility from patients
who have been approved for charity care or uninsured discounts for health care services delivered
during this cost reporting period. In column 1, enter payments from uninsured patients and patients
with coverage from an entity that does not have a contractual relationship with the provider. In
column 2, enter payments from patients covered by a public program or private insurer with which
the provider has a contractual relationship. In column 3, enter the sum of columns 1 and 2.

40-80.2

Rev.

DRAFT

FORM CMS-2552-10

4012.1 (Cont.)

B. For cost reporting periods beginning on or after October 1, 2016, (except subsection (d)
Puerto Rico hospitals under §1886(n)(6)(B) as those hospitals continue to follow the instructions
in A), through cost reporting periods beginning prior to October 1, 2022, enter all payments for
the entire facility received from patients during this cost reporting period, regardless of when the
services were provided, for amounts previously written off on line 20 as charity care or uninsured
discounts. In column 1, enter payments received from uninsured patients and patients with
coverage from an entity that does not have a contractual relationship with the provider. In
column 2, enter payments received from patients covered by a public program or a private insurer
with which the provider has a contractual relationship. In column 3, enter the sum of columns 1
and 2.
C. For cost reporting periods beginning on or after October 1, 2022, enter the sum of
payments received from patients during this cost reporting period for the entire facility for
amounts previously written off on line 20 as charity care or uninsured discounts. In column 1,
enter payments received from uninsured patients and patients with coverage from an entity that
does not have a contractual or inferred contractual relationship with the provider. In column 2,
enter payments received from patients covered by a public program or a private insurer with which
the provider has a contractual or inferred contractual relationship. Payments entered on this line
must not exceed charity care or uninsured discount amounts written off in the cost reporting
period. In column 3, enter the sum of columns 1 and 2.
Line 23--Calculate the cost of charity care for columns 1 and 2 by subtracting line 22 from line 21.
In column 1, enter the cost for uninsured patients and patients with coverage from an entity that
does not have a contractual relationship (or an inferred contractual relationship for cost reporting
periods beginning on or after October 1, 2022) with the provider. In column 2, enter the cost for
patients covered by a public program or private insurer with which the provider has a contractual
relationship (or an inferred contractual relationship for cost reporting periods beginning on or
after October 1, 2022). For columns 1 and 2, if the amount on line 22 is greater than line 21, enter
zero. In column 3, enter the sum of columns 1 and 2.
Line 24--Enter “Y” for yes if any charges for patient days beyond a length-of-stay limit imposed
on patients covered by Medicaid or other indigent care program are included in the amount
reported on line 20, column 2, and complete line 25. Otherwise, enter “N” for no.
Line 25--If you answered yes to question 24, enter charges for patient days beyond a length-of-stay
limit imposed on patients covered by Medicaid or other indigent care program, if such inclusion is
specified in the hospital’s charity care policy or FAP and the patient meets the hospital's policy
criteria, for services delivered during this cost reporting period. The charges entered on this line
are subject to the CCR and must also be reported in the amount on line 20, column 2.
Line 25.01--For cost reporting periods beginning on or after October 1, 2022, enter the charges
that represent the insured patient’s liability for medically necessary hospital services, other than
deductible, coinsurance, and co-payment amounts. The charges entered on this line are subject
to the CCR and must also be reported in the amount on line 20, column 2.

Rev.

40-80.3

4012.1 (Cont.)

FORM CMS-2552-10

DRAFT

Line 26--For cost reporting periods beginning prior to October 1, 2022, enter the amount of bad
debts (Medicare bad debts and non-Medicare bad debts), net of recoveries, written off during this
cost reporting period on balances owed by patients for the entire facility regardless of the date of
service. Do not include:
•
•
•

bad debts for physician and other professional services; and
amounts from line 20; and
amounts for privately insured patients that were the obligation of an insurer rather than
the patient.

For cost reporting periods beginning on or after October 1, 2022, enter the amount of Medicare
and non-Medicare bad debts/implicit price concessions (pursuant to the Accounting Standards
Update, Topic 606) written off during this cost reporting period, net of recoveries, that relate to
balances owed by patients, regardless of the date of service, for the entire facility. Submit
Exhibit 3C to support the bad debt amount claimed. Do not include:
•
•
•

bad debts for physician and other professional services; and
amounts from line 20; and
amounts for privately insured patients that were the obligation of an insurer rather
than the patient.

Line 27--Enter the Medicare reimbursable (also referred to as adjusted) bad debts, for the entire
facility, including PARHM demonstration, pursuant to 42 CFR 413.89(h). The amount must be
the sum of the amounts reported on Worksheets E, Part A, line 65; E, Part B, line 35; E-2, line 17,
columns 1 and 2 (line 17.01, columns 1 and 2, for cost reporting periods that begin on or after
October 1, 2012); E-3, Part I, line 12; E-3, Part II, line 24; E-3, Part III, line 25; E-3, Part IV,
line 15; E-3, Part V, line 26; E-3, Part VI, line 10; I-5, line 11; J-3, line 21 (line 22 for cost
reporting periods that begin on or after October 1, 2012); M-3, line 23 (line 23.01 for cost
reporting periods that begin on or after October 1, 2012); and N-4, line 10.
Line 27.01-- Enter the Medicare allowable bad debts, for the entire facility, including PARHM
demonstration. The amount must be the sum of the amounts reported on Worksheets E, Part A,
line 64; E, Part B, line 34; E-2, line 17, columns 1 and 2; E-3, Part I, line 11; E-3, Part II, line 23;
E-3, Part III, line 24; E-3, Part IV, line 14; E-3, Part V, line 25; E-3, Part VI, line 8; I-5, line 5.05,
column 2; J-3, line 21; M-3, line 23; and N-4, line 9.
Line 28--For cost reporting periods beginning before October 1, 2013, calculate the non-Medicare
bad debt amount by subtracting line 27 from line 26. For cost reporting periods beginning on or
after October 1, 2013, calculate the non-Medicare bad debt amount by subtracting line 27.01 from
line 26.
Line 29--Calculate the non-Medicare and non-reimbursable Medicare bad debt amount.
A. For cost reporting periods beginning before October 1, 2013, calculate the
non-Medicare and non-reimbursable Medicare bad debt amount by multiplying line 28 by the CCR
on line 1.
B. For cost reporting periods beginning on or after October 1, 2013, calculate the
non-Medicare and non-reimbursable Medicare bad debt amount as the sum of:
•
•

non-Medicare bad debt amount on line 28 multiplied by the CCR on line 1, plus
non-reimbursable Medicare bad debt amount calculated by subtracting line 27
from line 27.01 (this amount is not multiplied by the CCR on line 1).

Line 30--Calculate the cost of uncompensated care by entering the sum of line 23, column 3, and
line 29.
Line 31--Calculate the cost of unreimbursed and uncompensated care as the sum of lines 19
and 30.
40-80.4

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FORM CMS-2552-10

4012.2

4012.2 Part II - Hospital.--This part provides for the collection of uncompensated and indigent
care data only for inpatient and outpatient services billable under the hospital CCN. The data
reported on this part is a subset of the data reported on Part I. For a cost reporting period
beginning on or after October 1, 2022, an §1886(d) hospital, including a subsection (d) Puerto
Rico hospital under §1886(n)(6)(B), reports uncompensated and indigent care data for the
hospital CCN only. Do not include data for services provided by any other part of the hospital
complex, e.g., psychiatric unit, SNF, HHA, ESRD, etc.
Uncompensated and Indigent Care Cost-to-Charge Ratio-Line 1--Enter the CCR resulting from Worksheet C, Part I, line 202, column 3, minus lines 40, 41,
42, 44, 45, 46, 88, 89, 94, 99, 101, 115, and 116, column 3; divided by Worksheet C, Part I,
line 202, column 8, minus lines 40, 41, 42, 44, 45, 46, 88, 89, 94, 99, 101,115, and 116, column 8.
For all inclusive rate no-charge-structure providers, enter your ratio as calculated in accordance
with CMS Pub. 15-1, chapter 22, §2208.
Lines 2 through 19--Do not complete.
Uncompensated care cost-Line 20--Enter, in columns 1 and 2, the portion of the charity care charges and uninsured discount
amounts reported on Worksheet S-10, Part I, line 20, for the general short-term hospital inpatient
and outpatient services billed under the hospital CCN. In column 3, enter the sum of columns 1
and 2.
Line 21--Calculate the cost for charity care and uninsured discounts. In column 1, calculate the
cost of uninsured patients approved for charity care and uninsured discounts by multiplying
line 20, column 1, by the CCR on line 1. In column 2, enter the cost of insured patients approved
for charity care calculated as the sum of the deductibles and coinsurance not subject to the CCR
on line 1 for insured patients approved for charity care (line 20, column 2, minus lines 25
and 25.01) plus the non-covered charges for insured patients for days exceeding a length-of-stay
limit and charges for insured patients’ liability that are subject to the CCR on line 1 (lines 25
and 25.01, multiplied by line 1). In column 3, enter the sum of columns 1 and 2.
Line 22--Enter, in columns 1 and 2, the portion of the payments reported on Worksheet S-10,
Part I, line 22, for the general short-term hospital inpatient and outpatient services billed under
the hospital CCN. In column 3, enter the sum of columns 1 and 2.
Line 23--Calculate the cost of charity care for columns 1 and 2 by subtracting line 22 from line 21.
For columns 1 and 2, if the amount on line 22 is greater than line 21, enter zero. In column 3,
enter the sum of columns 1 and 2.
Line 24--Enter “Y” for yes if any charges for patient days beyond a length-of-stay limit imposed
on patients covered by Medicaid or other indigent care program are included in the amount
reported on line 20, column 2, and complete line 25. Otherwise, enter “N” for no.
Line 25--If you answered yes to question 24, enter the portion of the charges reported on
Worksheet S-10, Part I, line 25, for the general short-term hospital inpatient and outpatient
services billed under the hospital CCN. The charges entered on this line are subject to the CCR
and must also be reported in the amount on line 20, column 2.

Rev

40-80.5

4012.2 (Cont.)

FORM CMS-2552-10

DRAFT

Line 25.01--Enter the portion of the charges reported on Worksheet S-10, Part I, line 25.01, for
the general short-term hospital inpatient and outpatient services billed under the hospital CCN.
The charges entered on this line are subject to the CCR and must also be reported in the amount
on line 20, column 2.
Line 26--Enter the portion of the charges reported on Worksheet S-10, Part I, line 26, for the
general short-term hospital inpatient and outpatient services billed under the hospital CCN.
Line 27--Enter the Medicare reimbursable (also referred to as adjusted) bad debts, including
PARHM demonstration, pursuant to 42 CFR 413.89(h). The amount reported must be the sum of
the amounts reported on the hospital Worksheet E, Part A, line 65; PARHM demonstration
Worksheet E, Part A, line 65; the hospital Worksheet E, Part B, line 35; and PARHM
demonstration Worksheet E, Part B, line 35.
Line 27.01--Enter the Medicare allowable bad debts, including PARHM demonstration. The
amount reported must be the sum of the amounts reported on the hospital Worksheet E, Part A,
line 64; the PARHM demonstration Worksheet E, Part A, line 64; the hospital Worksheet E,
Part B, line 34; and the PARHM demonstration Worksheet E, Part B, line 34.
Line 28--Calculate the non-Medicare bad debt amount by subtracting line 27.01 from line 26.
Line 29--Calculate the non-Medicare and non-reimbursable Medicare bad debt amount as the sum
of:
•
•

non-Medicare bad debt amount on line 28 multiplied by the CCR on line 1, plus
non-reimbursable Medicare bad debt amount calculated by subtracting line 27 from
line 27.01 (this amount is not multiplied by the CCR on line 1).

40-80.6

Rev.

DRAFT

FORM CMS-2552-10

4012.2 (Cont.)

Exhibit 3B -- Charity Care Listing Instructions and Form
Exhibit 3B presents the charity care listing information required to support the charity care
amounts claimed on Worksheet S-10, line 20, and must be submitted with cost reports for cost
reporting periods beginning on or after October 1, 2022. For each CCN in the hospital healthcare
complex, submit a listing of patients, identified as uninsured or insured, that received charity care.
Enter dates in the MM/DD/YYYY format.
If a SCH is eligible to receive a DSH payment adjustment but Worksheet E, Part A, line 48, is
greater than line 47, do not complete an Exhibit 3B listing; however, if Worksheet E, Part A,
line 47, is greater than line 48, the SCH must submit an Exhibit 3B listing.
The sum of column 20 amounts for uninsured patients (insurance status code 1 or 2) on charity
care listings for all of the hospital and hospital healthcare complex CCNs must equal
Worksheet S-10, Part I, line 20, column 1. The sum of column 20 amounts for insured patients
(insurance status code 3) on charity care listings for all of the hospital and hospital healthcare
complex CCNs must equal Worksheet S-10, Part I, line 20, column 2. The sum of column 20
amounts for uninsured patients on the charity care listing for the hospital CCN must equal
Worksheet S-10, Part II, line 20, column 1; and the sum of column 20 amounts for insured patients
must equal Worksheet S-10, Part II, line 20, column 2.
Enter the provider name, hospital CCN and component CCN (only if the listing presents the
charity care for a component of the hospital), CRP beginning and ending dates, the name of the
preparer and the date prepared. Also enter the sum of the uninsured amounts (insurance status 1
or 2) in column 20, and the sum of the insured amounts (insurance status 3) in column 20.
Columns 1, 2, 3, 4, and 5--From the patient’s bill, enter the patient’s last name, first name, dates
of service, and patient account or identification number that correlate to the claimed charity care
charges.
Column 6--Enter 1, 2, or 3, to indicate the patient’s insurance status at the time services were
provided, as follows:
•
•

•

Enter 1 to indicate the patient was uninsured (did not have any insurance coverage).
Enter 2 to indicate the patient was insured but not covered when the patient:
o had insurance coverage through an insurance company with which you do not
have a contractual relationship,
o had insurance coverage and the services provided were medically necessary but
not covered,
o had insurance coverage and the patient had exhausted their benefits, or
o had general coverage through Medicaid but was not covered for this particular
stay due to exhausted benefits or noncoverage.
Enter 3 to indicate the patient was insured.

Column 7--For insured patients, enter the name of the primary payor, e.g., Medicaid, HMO
Medicaid, BCBS, Aetna, State Farm, etc., regardless of whether you have a contractual (or
inferred contractual) relationship with the insurer.
Column 8--For insured patients, enter the name of the secondary payor (e.g., Medicaid, HMO
Medicaid, BCBS, Aetna, State Farm, etc.), regardless of whether you have a contractual (or
inferred contractual) relationship with the insurer.

Rev

40-80.7

4012.2 (Cont.)

FORM CMS-2552-10

DRAFT

Column 9--Enter the total charges (excluding physician/professional charges) for the claim that
correlates to the claimed charity care charges.
Column 10--If the total charges in column 9 include amounts for physician/professional charges,
enter those physician/professional charges in this column.
Column 11--Enter the amount of deductible, coinsurance, and copayment owed by the patient
according to their medical insurance coverage, if applicable.
Column 12--Enter the total amounts received from third party payors (any entity paying medical
claims on behalf of the insured such as goveryment agencies, insurance companies, and HMOs).
Column 13--Complete this column only for insured patients; do not complete this column for
uninsured patients. Enter the amount of the contractual allowance for the insured patient, i.e., the
difference between the hospital’s billed charges and the amount contractually paid by an insurer
after deductible and coinsurance for an insured patient, if applicable. Report the sum of
contractual allowance amounts for primary and secondary payors, if applicable.
Column 14--Enter the amount of non-covered charges for services not medically necessary and/or
not included in the hospital’s written charity care policy or FAP.
Column 15--Enter all payments received from patients (or individuals responsible for payment).
(Charity care is determined as column 9 minus columns 10, 11, 12, 13, 14, 15, and 16, and is
reported in column 17, 18, or 19).
Column 16--Enter the amounts written off as a patient bad debt, i.e., written off as a bad debt or
implicit price concession against the A/R (considered a reduction in revenue) in the provider’s
financial accounting system, regardless of the date, for this claim.
Column 17--Complete this column only for uninsured patients; do not complete this column for
insured patients. Enter the amount of the uninsured discount given to the uninsured patient
pursuant to the hospital’s written charity care policy or FAP.
Column 18--For insured patients, enter the portion of the medically necessary non-covered
charges considered for charity care, if such inclusion is specified in the hospital’s written charity
care policy or FAP and the patient meets the hospital’s policy criteria, as follows:
•
•
•

enter the charges for non-covered services provided to patients eligible for Medicaid
or other indigent care programs.
enter the charges for non-covered days exceeding a length-of-stay limit for patients
covered by Medicaid or other indigent care programs.
enter the portion of charges where the patient has exhausted their benefits.

Column 19--Enter any other allowable charges (not reported in column 17 or column 18) and
written off as charity care pursuant to the provider’s written charity care policy or FAP.
Column 20--Enter the sum of the amounts in columns 17, 18, and 19.
Column 21-- Enter the date the charity care amount or uninsured discount was written off.

40-80.8

Rev.

DRAFT

FORM CMS-2552-10

4012.2 (Cont.)

EXHIBIT 3B
TITLE

CHARITY CARE CHARGES

PROVIDER NAME
HOSPITAL CCN
COMPONENT CCN
CRP BEGINNING DATE
CRP ENDING DATE
PREPARED BY
DATE PREPARED
UNINSURED COLUMN 20
INSURED COLUMN 20

PATIENT
NAME LAST
1

TOTAL
THIRD
PARTY
PAYMENTS
12

Rev.

PATIENT CLAIM INFORMATION
PATIENT
DATE OF
DATE OF
NAME SERVICE SERVICE FIRST
FROM
TO
2
3
4

INSURED
CONTRACTUAL
ALLOWANCE
AMOUNT
13

NONCOVERED
CHARGES
14

TOTAL
PATIENT
PAYMENTS
15

PATIENT
ACCOUNT
NUMBER
5

AMOUNTS
WRITTEN
OFF AS
BAD DEBT
16

INSURANCE
STATUS
6

PRIMARY
PAYOR
7

SECONDARY
PAYOR
8

UNINSURED
DISCOUNT
AMOUNTS
17

CHARITY
CARE
NONCOVERED
CHARGES
18

OTHER
CHARITY
CARE
CHARGES
19

TOTAL
CHARGES
FOR
CLAIM
9

PHYSICIAN /
PROFESSIONAL
CHARGES
10

AMOUNTS
WRITTEN OFF TO
CHARITY CARE
AND UNINSURED
DISCOUNTS
20

DEDUCTIBLE /
COINSUR /
COPAY
AMOUNTS
11

WRITE OFF
DATE
21

40-80.9

4012.2 (Cont.)

FORM CMS-2552-10

DRAFT

Exhibit 3C -- Listing of Total Bad Debts Instructions and Form
For cost reporting periods beginning on or after October 1, 2022, IPPS hospitals eligible for DSH
and UCC must complete an Exhibit 3C listing to support the amount of Medicare and nonMedicare bad debts, or implicit price concessions, reported on Worksheet S-10, line 26.
If a SCH is eligible to receive a DSH payment adjustment but Worksheet E, Part A, line 48, is
greater than line 47, do not complete an Exhibit 3C listing; however, if Worksheet E, Part A,
line 47, is greater than line 48, the SCH must submit an Exhibit 3C listing.
Complete a separate exhibit for the hospital and each component of the hospital complex (each
CCN) and, on each listing, report only the data related to inpatient and outpatient services billed
under that CCN. The sum of the amounts in column 17 for all the CCNs of the hospital complex
bad debt listings must correspond to the amount reported on Worksheet S-10, Part I, line 26. The
sum of the amounts in column 17 for the hospital CCN bad debt listing must correspond to the
amount reported on Worksheet S-10, Part II, line 26. The bad debt of a Medicare beneficiary may
be included on this listing even when their unpaid deductible and coinsurance amounts do not
meet the Medicare bad debt criteria for inclusion on the Medicare bad debt listing (not included
on Worksheet E, Parts A or B) for this cost reporting period.
Enter dates in the MM/DD/YYYY format.
Exhibit 3C requires the following information:
Enter the provider name, hospital CCN (even when the listing presents the bad debts for a
component of the hospital), component CCN (only if the listing presents the bad debts for the
component of the hospital), CRP beginning and ending dates, name of the preparer, date prepared,
and sum of the amounts in column 17.
Columns 1, 2, 3, 4, and 5--From the patient’s bill, enter the patient’s last name, first name, dates
of service, and patient account or identification number that correlate to the claimed bad debt.
Column 6--Enter 1, 2, or 3, to indicate the patient’s insurance status at the time services were
provided, as follows:
•
•

•

Enter 1 to indicate the patient was uninsured (did not have any insurance coverage).
Enter 2 to indicate the patient was insured but not covered when the patient:
o had insurance coverage through an insurance company with which you
do not have a contractual relationship,
o had insurance coverage and the services provided were medically
necessary but not covered, or
o had insurance coverage and the patient had exhausted their benefits.
Enter 3 to indicate the patient was insured.

Column 7--Enter the patient’s primary payor at the time services were provided, e.g., BCBS,
AARP, or Medicare.
Column 8--Enter the patient’s secondary payor at the time services were provided, e.g., BCBS,
AARP, or Medicare.
Column 9--Enter IP for inpatient or OP for outpatient to indicate the type of service provided to
the patient.
Column 10--Enter the total charges for services provided to the patient.

40-80.10
DRAFT

FORM CMS-2552-10

Rev.
4012.2 (Cont.)

Column 11----If the total charges in column 10 include amounts for physician/professional
charges, enter those physician/professional charges in this column.
Column 12-- Enter all payments received from patients (or individuals responsible for payment),
for amounts currently or previously written off to bad debt.
Column 13--Enter the total amounts received from third party payors, including amounts for
Medicare cross-over claims for dual eligible beneficiaries.
Columns 14--Enter the portion of the patient’s charges written off to charity care. For charity
care determined in a year prior to the bad debt determination, ensure that the amount reported in
this column relates to the charges reported in column 10, regardless of the charity care write off
date.
Column 15--Enter contractual allowances, and other amounts such as insurance write-offs,
courtesy discounts, and employee discounts. These amounts are not charity care or bad debt but
must be included in determining the amount of allowable bad debt.
Column 16--Enter the date the amounts were written off as a bad debt, i.e., written off as a bad
debt or implicit price concession against the A/R (reduction in revenue) in the provider’s financial
accounting system.
Column 17--Calculate the net patient bad debt amount by computing the ratio of total charges to
total charges plus physician/professional charges (column 10 divided by the sum of columns 10
and 11). Apply the ratio to the total payments, discounts, and allowances (columns 12 through 15)
and subtract the resulting amount from total charges (column 10).

Rev.

40-80.11

4012.2 (Cont.)

FORM CMS-2552-10

DRAFT

EXHIBIT 3C
TITLE

TOTAL BAD DEBTS

PROVIDER NAME
HOSPITAL CCN
COMPONENT CCN
CRP BEGINNING DATE
CRP ENDING DATE
PREPARED BY
DATE PREPARED
TOTAL COLUMN 17

PATIENT LAST
NAME
1

SERVICE
INDICATOR
(IP / OP)
9

40-80.12

PATIENT CLAIM INFORMATION
PATIENT FIRST
DATE OF
DATE OF
NAME
SERVICE - FROM
SERVICE - TO
2
3
4

PATIENT ACCT
NUMBER
5

INSURANCE
STATUS
6

PRIMARY
PAYOR
7

SECONDARY
PAYOR
8

TOTAL PHYSICIAN / PROFESSIONAL CHGS
11

TOTAL
THIRD PARTY
PAYMENTS
13

PATIENT
CHARITY CARE
AMOUNT
14

CONTRACTUAL
ALLOWANCE /
OTHER AMOUNT
15

A/R
WRITE OFF
DATE
16

TOTAL
CHARGES
10

TOTAL
PATIENT
PAYMENTS
12

PATIENT BAD
DEBT WRITE
OFF AMOUNT
17

Rev.

10-18
4013.

FORM CMS-2552-10

4013

WORKSHEET A - RECLASSIFICATION AND ADJUSTMENT OF TRIAL
BALANCE OF EXPENSES

In accordance with 42 CFR 413.20, the methods of determining costs payable under title XVIII
involve using data available from the institution's basic accounts, as usually maintained, to arrive
at equitable and proper payment for services. Worksheet A provides for recording the trial balance
of expense accounts from your accounting books and records. It also provides for the necessary
reclassifications and adjustments to certain accounts. The cost centers on this worksheet are listed
in a manner that facilitates the transfer of the various cost center data to the cost finding worksheets
(e.g., on Worksheets A, B, C, and D, the line numbers are consistent). While providers are
expected to maintain their accounting books and general ledger in a manner consistent with the
standard cost centers/departments identified on this worksheet, not all of the cost centers listed
apply to all providers using these forms. For example, IPPS providers may contain a Burn
Intensive Care Unit, where CAHs may not furnish this type of service.
Do not include on this worksheet items not claimed in the cost report because they conflict with
the regulations, manuals, or instructions but which you wish nevertheless to claim and contest.
Enter amounts on the appropriate settlement worksheet (Worksheet E, Part A, line 75;
Worksheet E, Part B, line 44; Worksheet E-2, line 23; and Worksheet E-3, Parts I, II, III, IV, V,
VI, and VII, lines 22, 35, 36, 26, 34, 19, and 43, respectively). For provider based-facilities, enter
the protested amounts on line 35 of Worksheet H-4, Part II, for HHAs; line 30 of Worksheet J-3
for CMHCs; and line 30 of Worksheet M-3 for RHC/FQHC providers.
If the cost elements of a cost center are separately maintained on your books, maintain a
reconciliation of the costs per the accounting books and records to those on this worksheet. This
reconciliation is subject to review by your contractor.
Standard (i.e., preprinted) CMS line numbers and cost center descriptions cannot be changed. If
you need to use additional or different cost center descriptions, 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 7 and 8, identify them as lines 7.01 and 7.02. If additional lines
are added for general service cost centers, add corresponding columns for cost finding. Lines 24
through 29, 47 through 49, 78 through 87, 102 through 104, 119 through 189, and 195 through
199, are reserved for future use; do not use these lines.
Also, 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.

Rev. 15

40-81

4013 (Cont.)

FORM CMS-2552-10

10-18

Cost center coding is a methodology for standardizing the meaning of cost center labels as used
by health care providers on the Medicare cost reports. Form CMS-2552-10 provides 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.
Additionally, nonstandard cost center descriptions have been identified through analysis of
frequently used labels.
The use of this coding methodology allows providers to continue to use labels for cost centers that
have meaning within the individual institution. The five-digit cost center codes that are associated
with each provider-assigned cost center label in their electronic file provide standardized meaning
for data analysis. You are required to compare any added or changed label to the descriptions
offered on the standard or nonstandard cost center tables. A description of cost center coding and
the table of cost center codes are in §4095, Table 5.
Columns 1, 2, and 3--The expenses listed in these columns must be the same as listed in your
accounting books and records and/or trial balance.
Enter on the appropriate lines in columns 1, 2, and 3, the total expenses incurred during the cost
reporting period. These expenses are detailed between salaries (column 1) and other than salaries
(column 2).
Column 1--Report in each cost center only direct salaries and wages plus related salary amounts
for paid vacation, holiday, sick, other paid-time-off (PTO), severance, and bonus pay. Refer to
the instructions at Worksheet S-3, Part II, column 2, line 1, for the definition of bonus pay and
PTO salary cost.
NOTE: Paid vacation, holiday, sick, other PTO, severance, and bonus pay must be reported with
related direct salaries or wages in column 1. Do not report wage-related costs, as defined
in §4005.4, in column 1.
Column 2--Report in each cost center all other costs other not reported in column 1, including both
wage and wage-related contract labor cost for services contracted by the hospital, the home office,
or related organizations. If necessary, reclassify contract labor costs to the cost center benefiting
from the contract labor services (see column 4 instructions).
Column 3--For each line, enter the sum of column 1 plus column 2. The sum of column 1 plus the
sum of column 2 equals the sum of column 3. Record any needed reclassifications and/or
adjustments in columns 4 and 6, as appropriate.
Column 4--With the exception of the reclassification of capital-related costs which are reclassified
via Worksheet A-7, all reclassifications in this column are made via Worksheet A-6.
Worksheet A-6 need not be completed by all providers and is completed only to the extent that the
reclassifications are needed and appropriate in the particular circumstance. Show reductions to
expenses as negative numbers.
The net total of the entries in column 4 must equal zero on line 200.
Column 5--Adjust the amounts entered in column 3 by the amounts in column 4 (increase or
decrease) and extend the net balances to column 5. Column 5, line 200, must equal column 3,
line 200.
Column 6--Enter on the appropriate lines in column 6 the amounts of any adjustments to expenses
indicated on Worksheet A-8, column 2. The total on Worksheet A, column 6, line 200, equals
Worksheet A-8, column 2, line 50.

40-82

Rev. 15

11-16

FORM CMS-2552-10

4013 (Cont.)

Column 7--Adjust the amounts in column 5 by the amounts in column 6 (increase or decrease),
and extend the net balances to column 7. Transfer the amounts in column 7 to the appropriate lines
on Worksheet B, Part I, column 0.
Line Descriptions
The trial balance of expenses is broken down into general service, inpatient routine service,
ancillary service, outpatient service, other reimbursable, special purpose, and nonreimbursable
cost center categories to facilitate the transfer of costs to the various worksheets. The line numbers
on Worksheet A are used on subsequent worksheets, for example, the categories of ancillary
service cost centers, outpatient service cost centers, and other reimbursable cost centers appear on
Worksheet C, Part I, using the same line numbers as on Worksheet A.
NOTE: The category titles do not have line numbers. Only cost centers, data items, and totals
have line numbers.
Lines 1 through 23--These lines are for the general service cost centers. These costs are expenses
incurred in operating the facility 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 charges, computer hardware and software costs, etc. General service cost centers furnish
services to both general service areas and to other cost centers in the provider.
Lines 1 and 2--The capital cost centers on lines 1 and 2 include depreciation, leases and rentals for
the use of facilities and/or equipment, and interest incurred in acquiring land or depreciable assets
used for patient care.
NOTE: Do not include in these cost centers costs incurred for the repair or maintenance of
equipment or facilities; amounts specifically included in rentals or lease payments for
repair and/or maintenance agreements; 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 insurance or any other form of insurance to provide
protection other than the replacement of depreciable assets; or taxes other than those
assessed on the basis of some valuation of land or depreciable assets used for patient care.
However, if no amount of the lease payment is identified in the lease agreement for
maintenance, you are not required to carve out a portion of the lease payment to represent
the maintenance portion. Thus, the entire lease payment is considered a capital-related
cost subject to the provisions of 42 CFR 413.130(b).
When you are dealing with a related organization, you are essentially dealing with yourself and
Medicare considers the costs to you equal to the cost to the related organization. Therefore, for
costs applicable to services, facilities, and supplies furnished by organizations related by common
ownership or control (see 42 CFR 413.17 and CMS Pub. 15-1, chapter 10), the reimbursable cost
includes the costs for these items at the cost to the supplying organization unless the exception
provided in 42 CFR 413.17(d) and CMS Pub. 15-1, chapter 10, §1010, is applicable, not to exceed
the price of comparable services, facilities, or supplies that could be purchased elsewhere in the
open market.

Rev. 10

40-83

4013 (Cont.)

FORM CMS-2552-10

11-16

The policy of cost incurred from related organizations applies to capital-related and noncapital-related costs. If you include costs incurred by a related organization on your cost report,
the nature of the costs (e.g., capital-related or operating costs) do not change. Treat capital-related
costs incurred by the related organization as capital-related costs to you.
If the price of comparable services, facilities, or supplies that could be purchased elsewhere in the
open market is lower than the cost to the supplying related organization; if the exception in
CFR 413.17(d) and CMS Pub. 15-1, chapter 10, §1010, applies; or if the supplying organization
is not related to you, then no part of the charge to you is a capital-related cost unless the services,
facilities, or supplies are capital-related in nature.
In the case of leased equipment, the fact that the lease or rental is for a depreciable asset is sufficient
for consideration as a capital-related item, but a distinction must be made between the lease of
equipment and the purchase of services. A lease of equipment is considered a capital-related cost
while a purchase of service is considered an operating cost. Generally, for the agreement to be
considered a lease or rental (and therefore a capital-related cost), the agreement must convey to
the provider the possession, use, and enjoyment of the asset. Each agreement must be examined
on its own merits. Factors that would weigh in favor of treating a particular agreement as a lease
of equipment include the following:
•

The equipment is operated by personnel employed by the provider or an organization
related to the provider within the meaning of CMS Pub. 15-1, chapter 10.

•

The physicians who perform the services with or interpret the tests from the equipment are
associated with the provider.

•

The agreement is memorialized in one document rather than in two or more documents
(e.g., one titled a "Lease Agreement" and one titled a "Service Agreement").

•

The document memorializing the agreement is titled a “lease agreement.” If one or more
of the documents memorializing the agreement are titled “Service Agreements,” this
indicates a purchase of services.

•

The provider holds the certificate of need (CON) for the services furnished with the
equipment.

•

The basis for determining the lease payment is units of time and is not volume sensitive
(e.g., numbers of scans).

•

The provider attends to such matters as utilization review, quality assurance, and risk
management for the services involving the equipment.

•

The provider schedules the patients for services involving the equipment.

•

The provider furnishes any supplies required to be used with the equipment.

•

The provider’s access to the equipment is not subject to interruption without notice or
interruption on very short notice.

If the supplying organization is not related to you (see 42 CFR 413.17), no part of the charge to
you is a capital-related cost unless the services, facilities, or supplies are capital-related in nature.

40-84

Rev. 10

09-15

FORM CMS-2552-10

4013 (Cont.)

Under certain circumstances, costs associated with minor equipment are considered capital-related
costs. See CMS Pub. 15-1, chapter 1, §106, for three methods of writing off the cost of minor
equipment. Amounts treated as expenses under method (a) are not capital-related costs because
they are treated as operating expenses. Amounts included in expense under method (b) are capitalrelated costs because such amounts represent the amortization of the cost of tangible assets over a
projected useful life. Amounts determined under method (c) are capital-related costs because
method (c) is a method of depreciation.
Section 1886(g) of the Act, as implemented by 42 CFR 412, Subpart M, requires that the
reasonable cost-based payment methodology for hospital inpatient capital-related costs be replaced
with an inpatient prospective payment methodology for hospitals paid under the IPPS, effective
for cost reporting periods beginning on or after October 1, 1991. Hospitals and hospital distinct
part units (IPFs, IRFs, and LTCH) excluded from the IPPS pursuant to 42 CFR 412, Subpart B,
are paid for capital-related costs under their respective PPS payment systems. Also, CAHs are
reimbursed on a reasonable cost basis under 42 CFR 413.70.
Lines 1 and 2--Capital costs are defined as all allowable capital-related costs for land and
depreciable assets, with additional recognition of costs for capital-related items and services that
are legally obligated by an enforceable contract. (See CMS Pub. 15-1, chapter 28, §2800.)
Betterment or improvement costs related to capital are included in capital assets. (See
42 CFR 412.302.) Capital costs incurred as a result of extraordinary circumstances are included
in capital. (See 42 CFR 412.348(g).) Direct assignment of capital costs must be done in
accordance with CMS Pub. 15-1, chapter 23, §§2307 and 2313.
Capital costs include the following:
1. Allowable depreciation on assets based on the useful life guidelines used to determine
depreciation expense in the hospital’s base period, which cannot be subsequently
changed.
2. Allowable capital-related interest expense. Except as provided in subsections a through
c below, the amount of allowable capital-related interest expense recognized as capital
is limited to the amount the hospital was legally obligated to pay.
a. An increase in interest expense is recognized if the increase is due to periodic
fluctuations of rates in variable interest rate loans or to periodic fluctuations of rates
at the time of conversion from a variable rate loan to a fixed rate loan when no other
changes in the terms of the loan are made.
b. If the terms of a debt instrument are revised, the amount of interest recognized
associated with the original capital cannot exceed the amount that would have been
recognized during the same period prior to the revision of the debt instrument.
c. Investment income (excluding income from funded depreciation accounts and other
exclusions from investment income offset cited in CMS Pub. 15-1, chapter 2,
§202.2) is used to reduce capital interest expense based in each cost reporting
period.

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3. Allowable capital-related lease and rental costs for land and depreciable assets.
a. The cost of lease renewals and the acquisition of assets continuously leased (e.g.,
capitalized leases) are recognized provided that the same asset remains in use, the
asset has a useful life of at least 3 years, and the annual lease payment is $1,000 or
more for each item or service.
b. If a hospital-owned asset is sold or given to another party and that same asset is
then leased back by the hospital, the amount of allowable capital-related costs
recognized as capital costs is limited to the amount allowed for that asset in the last
cost reporting period during which it was owned by the hospital.
4. The appropriate portion of the capital-related costs of related organizations under
42 CFR 413.17 that would be recognized as capital costs if these costs had been
incurred directly by the hospital.
Unless there is a change of ownership, the hospital must continue the same cost finding methods
for capital costs. This includes its practices for the direct assignment of capital-related costs and
its cost allocation bases in. If there is a change of ownership, the new owners may request that the
contractor approve a change in order to be consistent with their established cost finding practices.
If a hospital desires to change its cost finding method for the direct assignment of capital costs, the
request for change must be made in writing to the contractor prior to the beginning of the cost
reporting period for which the change is to apply. The request must include justification as to why
the change will result in more accurate and more appropriate cost finding. The contractor does not
approve the change unless it determines that there is reasonable justification for the change.
Line 3--In accordance with 42 CFR 412.302(b)(4), enter all other capital-related costs, including
but not limited to taxes, insurance, and license and royalty fees on depreciable assets. This line
also includes any directly allocated home office other capital cost. After reclassifications in
column 4 and adjustments in column 6, the balance in column 7 must equal zero. This line cannot
be subscripted.
PPS providers paid 100 percent Federal complete line 3, column 2, and Worksheet A-7, Parts I (if
applicable), II, and III.

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Line 4--Enter in column 1, the direct salaries and salary amounts for paid vacation, holiday, sick,
other paid-time-off (PTO), severance, and bonus pay incurred only for employees in the employee
benefits department and/or the human resources department. In accordance with CMS Pub. 15-1,
chapter 23, §2307, if your accounting system directly allocates employee benefits to individual
cost centers, enter in column 2 the employee benefits cost of employees in the employee benefits
and/or human resources department. If your accounting system does not directly allocate all or a
portion of the employee benefits to all the individual cost centers, then enter in column 2 the total
employee benefits cost and/or residual employee benefits costs of all hospital employees.
Line 5--Enter A&G costs on this line. A&G includes a wide variety of provider administrative
costs such as but not limited to cost of executive staff, legal and accounting services, facility
administrative services (not already included in other general service cost centers), etc. If this line
is componentized into more than one cost center, eliminate line 5. Componentized A&G lines
must begin with subscripted line 5.01 and continue in sequential and consecutive order except
where this manual specifies otherwise.
Line 6--Maintenance and repairs are any activity to maintain the facility and grounds such as, but
not limited to, costs of routine painting, plumbing and electrical repairs, mowing, and snow
removal.
Line 7--Operation of plant includes the cost such as, but not limited to, the internal hospital
environment including air conditioning (both heating and cooling systems and ventilation) and
other mechanical systems.
Line 8--Laundry and linen services includes the cost of routine laundry and linen services whether
performed in-house or by outside contractors.
Line 9--Housekeeping includes the cost of routine housekeeping activities such as mopping,
vacuuming, cleaning restrooms, lobbies, waiting areas and otherwise maintaining patient and nonpatient care areas.
Line 10--Dietary includes the cost of preparing meals for patients.
Line 11--Cafeteria includes the cost of preparing food for provider personnel, physicians working
at the provider, visitors to the provider.
Line 12--Maintenance of personnel includes the cost of room and board furnished to employees.
(See CMS Pub. 15-1, chapter 7, §704.3.)
Line 13--Nursing administration normally includes only the cost of nursing administration. The
salary cost of direct nursing services, including the salary cost of nurses who render direct service
in more than one patient care area, is directly assigned to the various patient care cost centers in
which the services were rendered. Direct nursing services include gross salaries and wages of
head nurses, registered nurses, licensed practical and vocational nurses, aides, orderlies, and ward
clerks.
However, if your accounting system fails to specifically identify all direct nursing services to the
applicable patient care cost centers, then the salary cost of all direct nursing service is included in
this cost center.
Line 14--Central services and supply includes the costs of supplies and services which are
requested by departments throughout the provider, including medical supplies charged to patients.

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Line 15--Pharmacy includes the cost of drugs and pharmacy supplies requested by patient care
departments and drugs charged to patients.
Line 16--Medical records and medical records library includes the direct costs of the medical
records cost center including the medical records library. The general library and the medical
library are not included in this cost center but are reported in the A&G cost center.
Line 17--Social service includes the cost of explaining health care resources and policies to
patients, family and professional staff; assistance in planning for post-hospital patient needs;
assisting patients and families receive needed follow-up care by referral to health care resources
and providing advocacy through appropriate organizations.
Line 19--The services of a nonphysician anesthetist generally are paid for by the Part B contractor
based on a fee schedule rather than on reasonable cost basis through the cost report. As such, the
salary and fringe benefit costs included on line 19 generally are not reimbursed through the cost
report.
NOTE: Any costs are included on this line are limited to salary and employee benefit costs.
However, payment for the nonphysician anesthetists on a fee basis may not apply to a qualified
rural hospital or CAH if the facility employed or contracted with not more than one FTE
(2080 hours) nonphysician anesthetist and, if (1) the hospital had 800 or fewer surgical procedures
(including inpatient and outpatient procedures) requiring anesthesia services, and (2) each
nonphysician employed by or under contract with the hospital has agreed not to bill under Part B
of title XVIII for professional services furnished. (See 42 CFR 412.113(c)(2)(i))
Payment under the fee schedule applies to qualified hospitals and CAHs unless the hospital
establishes, before the beginning of each calendar year, that it did not exceed 800 surgical
procedures requiring anesthesia in the previous year. (See 42 CFR 412.113(c)(2)(ii))
Hospitals which do not qualify for the exception and are therefore subject to the fee schedule
payment method must remove the salary and fringe benefit costs from line 19. The total amount
is reported on Worksheet A-8, line 28 and in column 6, line 19, of this worksheet. This removes
these costs from the cost reported in column 7.

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Lines 20 and 23--If you have an approved nursing or allied health education program that meets
the criteria of 42 CFR 413.85(e), classroom and clinical portions of the costs may be allowable as
pass-through costs as defined in 42 CFR 413.85(d)(2).
Classroom costs are those costs associated with formal, didactic instruction on a specific topic or
subject in a classroom that meets at regular, scheduled intervals over a specific time period (e.g.,
semester or quarter) and for which a student receives a grade. (See 42 CFR 413.85(c).)
Clinical training is defined as involving the acquisition and use of the skills of a nursing or allied
health profession or trade in the actual environment in which these skills will be used by the student
upon graduation. While it may involve occasional or periodic meetings to discuss or analyze cases,
critique performance, or discuss specific skills or techniques, it involves no classroom instruction.
(See 42 CFR 413.85(c).)
If your program is a nonprovider-operated program under 42 CFR 413.85(g)(2), the classroom
portion of the costs is not allowable as a pass-through cost and must not be reported on these lines.
The clinical portions of these nonprovider-operated program costs are allowable as pass-through
costs if the following conditions as set forth in 42 CFR 413.85(g)(2) are met:
1. The hospital must have claimed and have been paid for clinical costs (described above)
during its latest cost reporting period that ended on or before October 1, 1989. (See
42 CFR 413.85(g)(2)(ii).)
2. In any cost reporting period, the pass-through costs are limited to the percentage of
total allowable provider costs attributable to allowable clinical training costs reported
in the provider’s most recent cost reporting period ending on or before October 1, 1989.
(See 42 CFR 413.85(g)(2)(iii).)
3. The hospital receives a benefit for the support it furnishes to the education program
through the provision of clinical services by nursing and allied health students
participating in the program. (See 42 CFR 413.85(g)(2)(iv).)
4. The clinical training costs must be incurred by the provider or by an educational
institution related to the provider by common ownership or control as defined by
42 CFR 413.17(b) and CMS Pub. 15-1, chapter 10, §1002 (cost to related
organizations). Costs incurred by a third party, regardless of its relationship to either
the provider or the educational institution, are not allowed.
(See
42 CFR 413.85(g)(2)(v).)
5. The costs incurred by the hospital for the program do not exceed the costs that would
have been incurred by the hospital if the program had been operated by the hospital.
(See 42 CFR 413.85(g)(2)(vi).)
6. The clinical training must occur on the premises of the hospital; i.e., in the hospital
itself or in the physical area immediately adjacent to the hospital buildings or in other
areas and structures located within 250 yards of the main buildings. (See
42 CFR 413.85(g)(2)(i).)
If your nonprovider-operated program was originally a provider operated program and you
continued incurring the costs after the program was transferred to a wholly-owned subsidiary
educational institution prior to October 1, 2003, the clinical training costs and classroom costs are
eligible for pass-through payment under 42 CFR 413.85(g)(3)(ii) and (g)(3)(iii) if all of the
following conditions in 42 CFR 413.85(g)(3) are met:
1. The program must have originally been provider-operated according to the criteria set
forth in 42 CFR 413.85(f). (See 42 CFR 413.85(g)(3)(i).)

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2. The program was transferred to a wholly owned subsidiary educational institution in
order to meet accreditation standards prior to October 1, 2003.
(See
42 CFR 413.85(g)(3)(i).)
3. The hospital has continuously incurred the costs of both the classroom and clinical
training portions of the program at the educational institution.
(See
42 CFR 413.85(g)(3)(i).)
4. The hospital received Medicare reasonable cost payment for the NAHE program both
prior and subsequent to the date the hospital transferred operation of the program to its
wholly owned subsidiary educational institution (and the program ceased to be
provider-operated according to the criteria under 42 CFR 413.85(f).
(See
42 CFR 413.85(g)(3)(ii).)
Line 20--Establish a separate cost center for each nursing program that meets the requirements of
42 CFR 413.85(e) by subscripting line 20 for each nursing school program. If the direct costs of
a nursing program are not included in the costs on line 20, column 3, or applicable subscripts,
reclassify the costs to line 20, or applicable subscripts, through a Worksheet A-6 reclassification.
Line 21--Enter the cost of intern and resident salaries and salary-related fringe benefits. Do not
include salary and salary-related fringe benefits applicable to teaching physicians which are
included in line 22.
Line 22--Enter the other costs applicable to interns and residents in an approved teaching program.
Line 23--Establish a separate cost center for each allied health/paramedical education program that
meets the requirements of 42 CFR 413.85(e) (e.g., one for pharmacy, another for pastoral
education, etc.) by subscripting line 23 for each allied health education program. If the direct costs
of an allied health education program are not included in the costs on line 23, column 3, or
applicable subscripts, reclassify the costs to line 23, or applicable subscripts, through a
Worksheet A-6 reclassification.
Lines 24 through 29--Reserved for future use.
Lines 30 through 46--These lines are for the inpatient routine service cost centers.
Line 30--The purpose of this cost center is to accumulate the incurred routine service cost
applicable to adults and pediatrics (general routine care) in a hospital. Do not include incurred
costs applicable to subproviders or any other cost centers which are treated separately.
Lines 31 through 35--Use lines 31 through 35 to record the cost applicable to intensive care type
inpatient hospital units. (See 42 CFR 413.53(b) and (d) and CMS Pub. 15-1, chapter 22, §2202.7.)
Label line 35 appropriately to indicate the purpose for which it is being used.
Lines 36 through 39--Reserved for future use.

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Line 40--Use this line to record the IPF service costs of a subprovider. Hospital units that are
excluded units from the IPPS are treated as subproviders for cost reporting purposes.
Line 41--Use this line to record the IRF service costs of a subprovider. Hospital units that are
excluded units from the IPPS are treated as subproviders for cost reporting purposes.
Line 42--Use this line to record the inpatient routine service costs of other subproviders as
applicable.
Line 43--Use this line to record the costs associated with the nursery.
Line 44--Use this line to record the costs of SNFs certified for titles V, XVIII, or XIX if your State
accepts one level of care.
Line 45--Use this line to record the cost of NFs certified for title V or title XIX but not certified as
an SNF for title XVIII. Subscript this line to record the cost of ICF/IID. Do not report nursing
facility costs on this subscripted line.
Line 46--Use this cost center to accumulate the direct costs incurred in maintaining long term care
services not specifically required to be included in other cost centers. A long term care unit refers
to a unit where the average length-of-stay for all patients is greater than 25 days. The beds in this
unit are not certified for title XVIII. Treat this area as a non-reimbursable cost center for Medicare
since it is not part of the Medicare certified hospital.
Lines 47 through 49--Reserved for future use.
Lines 50 through 78--Use for ancillary service cost centers.
Line 57--Use this line to record direct costs associated with computed tomography (CT) services.
Line 58--Use this line to record direct costs associated with magnetic resonance imaging (MRI)
services.
Line 59--Use this line to record direct costs associated with cardiac catheterization services.
Line 60--Use this line to record direct costs associated with laboratory services.
Line 61--Use this line to record costs when a pathologist continues to bill non-program patients
for clinical laboratory tests and is compensated by you for services related to such tests for program
beneficiaries. When you pay the pathologist an amount for administrative and supervisory duties
for the clinical laboratory for program beneficiaries only, include the cost in this cost center.
NOTE: No overhead expenses are allocated to this cost center since it relates to services for
program beneficiaries only. The cost reporting treatment is similar to that of services
furnished under arrangement to program beneficiaries only. (See CMS Pub. 15-1,
chapter 23, §2314.) These costs are apportioned among the various programs on the
basis of program charges for provider clinical laboratory tests for all programs for which
you reimburse the pathologist.
Line 62--Include the direct expenses incurred in obtaining blood directly from donors as well as
obtaining whole blood and packed red blood cells from suppliers. Do not include in this cost
center the processing fee charged by suppliers. The processing charge is included in the blood
storing, processing, and transfusion cost center. Identify this line with the appropriate cost center
code (06250) (Table 5 - Electronic Reporting Specifications) for the cost of administering blood
clotting factors to hemophiliacs. (See §4452 of BBA 1997, OBRA 1989 & 1993.)

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Line 63--Include the direct expenses incurred for processing, storing, and transfusing whole blood,
packed red blood cells, and blood derivatives. Also include the processing fee charged by
suppliers.
Line 71--Include on this line medical supplies charged to patients other than the high cost
implantable devices reported on line 72. Obtain the expense amounts from your records as follows
depending on how you accumulate these expenses in your general ledger (GL). (1) If the expenses
for chargeable medical supplies are accumulated together with non-chargeable medical supplies
in the “Central Services” GL account and are reported in that cost center (line 14 on Worksheet A),
do not include the chargeable medical supplies expenses on Worksheet A, line 71. Rather, allocate
the costs in column 14 of Worksheet B to line 71 (and other lines) using the recommended “costed
requisitions” statistics. (2) If the expenses for chargeable medical supplies are reported in a
separate GL account, include these expenses on Worksheet A, line 71, column 2. (3) If the
expenses for chargeable medical supplies are reported in a specific subaccount(s) under the GL
accounts for various routine and ancillary departments (i.e., operating room, adults and pediatrics,
or clinic), report the sum of the balances in that subaccount(s) on Worksheet A, line 71, column 2.
If you reported the total balance (i.e., including the amounts for chargeable medical supplies) of
the various GL accounts (i.e., operating room, adults and pediatrics, or clinic), in those respective
cost centers in column 2 of Worksheet A, reclassify the cost of the chargeable medical supplies
from those cost centers to the “medical supplies charged to patients” cost center (line 71). (See
CMS Pub. 15-1, chapter 22, §2200.1, and 42 CFR 413.53(a)(1).)
Line 72--Include on this line high cost implantable devices charged to patients bearing the revenue
codes established by the NUBC as indicated in the 73 FR 48462 (August 19, 2008), and not
reported on line 71. Obtain the expense amounts from your records as follows depending on how
you accumulate these expenses in your general ledger (GL). (1) If the expenses for chargeable
implantable devices are accumulated together with non-chargeable implantable devices in the
“Central Services” GL account and are reported in that cost center (line 14 on Worksheet A), do
not include the high cost chargeable implantable devices expenses on Worksheet A, line 72.
Rather, allocate the costs in column 14 of Worksheet B to line 72 (and other lines) using the
recommended “costed requisitions” statistics. (2) If the expenses for high cost chargeable
implantable devices are reported in a separate GL account, include these expenses on
Worksheet A, line 72, column 2. (3) If the expenses for high cost chargeable implantable devices
are reported in a specific subaccount(s) under the GL accounts for various routine and ancillary
departments (i.e., operating room, adults and pediatrics, or clinic), report the sum of the balances
in that subaccount(s) on Worksheet A, line 72, column 2. If you reported the total balance (i.e.,
including the amounts for high cost chargeable implantable devices) of the various GL accounts
(i.e., operating room, adults and pediatrics, or clinic), in those respective cost centers in column 2
of Worksheet A, reclassify the cost of the high cost chargeable implantable devices from those
cost centers to the “implantable devices charged to patients” cost center (line 72). (See
CMS Pub. 15-1, chapter 22, §2200.1, and 42 CFR 413.53(a)(1).)
Line 73--This cost center includes the costs of drugs charged to patients. Such costs are generally
allocated from general service cost centers (e.g., pharmacy, A&G, etc.) through the allocation
process on Worksheet B, or are reclassified from other cost centers on Worksheet A. Include all
costs for drugs and vaccines provided to patients including the cost of osteoporosis drugs
pneumococcal, influenza, and COVID-19 vaccines and monoclonal antibody products for
treatment of COVID-19 not subject to deductibles and coinsurance.

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Line 74--If you furnish renal dialysis treatments, account for such costs by establishing this
separate ancillary service cost center. In accumulating costs applicable to the cost center, include
no other ancillary services even though they are routinely administered during the course of the
dialysis treatment. However, if you physically perform a few minor routine laboratory services
associated with dialysis in the renal dialysis department, such costs remain in the renal dialysis
cost center. Outpatient maintenance dialysis services are reimbursed under the composite rate
reimbursement system. For purposes of determining overhead attributable to ESAs, include the
cost of the drug in this cost center. The drug costs will be removed on Worksheet B-2 after
stepdown.
Effective for services rendered on or after January 1, 2011, ESRD services are paid under the
ESRD PPS.
NOTE: ESRD physician supervisory services are not included as your costs under the composite
rate reimbursement system or ESRD PPS. Supervisory services are included in the
physician’s monthly capitation rate.
Line 75--Enter the cost of ASCs that are not separately certified as a distinct part but which have
a separate surgical suite. Do not include the costs of the ancillary services provided to ASC
patients. Include only the surgical suite costs (i.e., those used in lieu of operating or recovery
rooms).
Line 77--Effective for services rendered on or after January 1, 2017, enter the hospital acquisition
costs for allogeneic (stem cells obtained from a donor other than the recipient) hematopoietic stem
cell transplants (HSCT) as defined in CMS Pub. 100-04, chapter 3, §90.3.1, and
CMS Pub. 100-04, chapter 4, §231.11. This includes costs of services purchased under
arrangements and registry fees for national donor registries (42 USC 274k), if applicable. Do not
reclassify costs from the routine and ancillary cost centers; rather compute the acquisition costs
on Worksheet D-6, Part I, including acquisition costs associated with services intended for transplant
but not resulting in transplant, i.e., due to death of the intended recipient or other causes. Do not
include costs for allogeneic HSCT on this line. Do not include any costs related to autologous
(stem cells obtained from the recipient) hematopoietic stem cell acquisition or transplants on this
line (CMS Pub. 100-04, chapter 3, §90.3.2, and 100-04, chapter 4, §231.10).
Line 78--Effective for cost reporting periods beginning on or after October 1, 2022, enter the
hospital costs for procuring, storing, and processing chimeric antigen receptor T-cells
(CAR T-cell) for immunotherapy infusion (FDA-approved CAR T-cell immunotherapies only).
This includes the cost of the CAR T-cell manufactured biologic, i.e., the cost paid to the
manufacturer. Do not include costs for CAR T-cell immunotherapy transplants or the medication
cost of the non-CAR T-cell drugs used for CAR T-cell immunotherapy complications, e.g., cytokine
release syndrome, on this line.
Lines 79 through 87--Reserved for future use.

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Lines 88 through 93--Use these lines for outpatient service cost centers.
NOTE: For lines 88 through 90 and 93, any ancillary service billed as clinic, RHC, and FQHC
services must be reclassified to the appropriate ancillary cost center, e.g., radiologydiagnostic, laboratory.
Line 88--Use this line to report the costs of hospital-based RHCs. If more than one is maintained,
subscript the line. See Table 5 in §4095 for the proper cost center code for hospital-based RHCs.
In accordance with CMS Pub. 100-04, chapter 9, §40A, compensation paid to a physician for RHC
services rendered in a hospital-based RHC is cost-reimbursed. Where the physician agreement
compensates for RHC services as well as non-RHC services, or services furnished in the hospital,
the related compensation must be eliminated on Worksheet A-8 and billed to the Part B contractor.
If not specified in the agreement, a time study must be used to allocate the physician compensation.
Line 89--Use this line to report the costs of hospital-based FQHCs. If more than one is maintained,
subscript the line. See Table 5 in §4095 for the proper cost center code for FQHCs.
In accordance with CMS Pub. 100-04, chapter 9, §40, compensation paid to a physician for FQHC
services rendered in a hospital-based FQHC is cost-reimbursed. Where the physician agreement
compensates for FQHC services as well as non-FQHC services, or services furnished in the
hospital, the related compensation must be eliminated on Worksheet A-8 and billed to the Part B
contractor. If not specified in the agreement, a time study must be used to allocate the physician
compensation.
Line 90--Enter the cost applicable to the clinic not included on lines 88 and 89. If you have two
or more clinics which are separately costed, separately report each such clinic. Subscript this line
to report each clinic. If you do not separately cost each clinic, you may combine the cost of all
clinics on the clinic line.
Line 91--Enter the costs of the emergency room cost center.
Line 92--Do not use this line on this worksheet. If you have a distinct part area specifically
designated for observation (e.g., where observation patients are not placed in a general acute care
area bed), report this on a subscripted line 92.01.
NOTE: It is possible to have both a distinct observation bed area and a non-distinct area (for
example, where your distinct part observation bed area is only staffed from 7:00 a.m. to
10:00 p.m. Patients entering your hospital needing observation bed care after 10:00 p.m.
and before 7:00 a.m. are placed in a general inpatient routine care bed). If patients
entering the distinct part observation bed area are charged differently than the patients
placed in the general inpatient routine care bed, separate the costs into distinct
observation bed costs and non-distinct observation bed costs. However, if the charge is
the same for both patients, report all costs and charges as distinct part observation beds.
Line 93--Use this line to report the costs of other outpatient services not previously identified on
lines 88 through 90. If more than one other service is offered, subscript the line. See Table 5 in
§4095 for the proper cost center code for this line.
Line 93.99--Effective for cost reporting periods ending on or after September 30, 2017, enter the
costs of providing hospital-based partial hospitalization program (PHP) services as defined in
the Act §1861(ff).

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Lines 94 through 98 and 100--Use these lines for other reimbursable cost centers (other than HHA
and CMHC).
Line 94--Use this line to accumulate the direct costs incurred for self-care home dialysis. For
purposes of determining overhead attributable ESAs, include the cost of the drug in this cost center.
The drug costs will be removed on Worksheet B-2 after stepdown.
A Medicare beneficiary dialyzing at home has the option to deal directly with the Medicare
program and make individual arrangements for securing the necessary supplies and equipment to
dialyze at home. Under this arrangement, the beneficiary is responsible for dealing directly with
the various suppliers and the Medicare program to arrange for payment. The beneficiary is also
responsible to the suppliers for the deductible and 20 percent Medicare coinsurance requirement.
You do not receive composite rate payment for a patient who chooses this option. However, if
you provide any direct home support services to a beneficiary who selects this option, you are
reimbursed on the same reasonable cost basis for these services as for other outpatient services.
These costs are entered on line 93 and are notated as cost reimbursed. You may service Medicare
beneficiaries who elect this option and others who deal directly with you. In this case, set up two
home program dialysis cost centers (using a subscript for the second cost center) to properly
classify costs between the two categories of beneficiaries (those subject to cost reimbursement and
those subject to the composite rate).
Effective for services rendered on or after January 1, 2011, ESRD services are paid under the
ESRD PPS.
Line 95--Report all ambulance costs on this line for both owned and operated services and services
under arrangement. No subscripting is allowed for this line.
Lines 96 and 97--Use these lines to report durable medical equipment (DME) rented or sold,
respectively. Enter the direct expenses incurred in renting or selling DME items to patients. Also,
include all direct expenses incurred by you in requisitioning and issuing DME to patients.
For a hospital-based SNF, report support surfaces by subscripting line 97, and use the proper cost
center code.
Line 99--This cost center accumulates the direct costs for outpatient rehabilitation providers
(CORFs and OPTs) and CMHCs. However, only CMHCs complete the J series worksheets. Use
lines 99 through 99.09 for CMHCs, lines 99.10 through 99.19 for CORFs, lines 99.20 through
99.29 for OPTs, lines 99.30 through 99.39 for OOTs, and lines 99.40 through 99.49 for OSPs. If
you have multiple components, subscript this line using the proper cost center code.
Line 100-- Use this line if your hospital operates an intern and resident program not approved by
Medicare. For the services of a resident who is not in an approved GME program, payment is
made to the hospital on a Part B reasonable cost basis regardless of whether the services are
furnished to hospital inpatients or outpatients. (See 42 CFR 415.202.) Enter the costs of residents’
services; however, do not include other costs such as administrative costs related to teaching
activities of a physician as these costs are not allowable.
Line 101--This cost center accumulates costs specific to HHA services. If you have more than one
certified hospital-based HHA, subscript line 101 for each HHA.
Provider-based HHAs are operated and managed in a variety of ways within the context of the
health care complexes of which they are components. In some instances, there are discrete
management and administrative functions pertaining to the HHA, the cost of which is readily
identifiable from the books and records.
Hospital-based HHAs are operated and managed in a variety of ways within the context of the
health care complexes of which they are components. In some instances, there are discrete
management and administrative functions pertaining to the HHA, the cost of which is readily
identifiable from the books and records.
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In other instances, the administration and management of the hospital-based HHA is integrated
with the administration and management of the health care complex to such an extent that the cost
of administration and management of the HHA can be neither identified nor derived from the
books and records of the health care complex. In other instances, the cost of administration and
management of the HHA is integrated with the administration and management of the health care
complex, but the cost of the HHA administration and management can be derived through cost
finding. However, in most cases, even when the cost of HHA administration and management can
be either identified or derived, the extent to which the costs are applicable to the services furnished
by the hospital-based HHA is not readily identifiable.
Even when the costs of administration and management of a provider-based HHA can be identified
or derived, such costs do not generally include all of the general service costs (i.e., overhead costs)
applicable to the HHA. Therefore, allocation of general service costs through cost finding is
necessary for the determination of the full costs of the hospital-based HHA.
When the hospital-based HHA can identify discrete management and administrative costs from its
books and records, these costs are included on line 101.
Similar situations occur for the services furnished by the hospital-based HHA. For example, in
some instances, physical therapy services are furnished by a discrete HHA physical therapy
department. In other instances, physical therapy services are furnished to the patient of the
hospital-based HHA by an integrated physical therapy department of a hospital health care
complex in such a manner that the direct costs of furnishing the physical therapy services to the
patients of the hospital-based HHA cannot be readily identified or derived. In other instances,
physical therapy services are furnished to patients of the hospital-based HHA by an integrated
physical therapy department of a hospital health care complex in such a manner that the costs of
physical therapy services furnished to patients of the hospital-based HHA can be readily identified
or derived.
When you maintain a separate therapy department for the HHA apart from the hospital therapy
department furnishing services to other patients of the hospital health care complex or when you
are able to reclassify costs from an integrated therapy department to an HHA therapy cost center,
make a reclassification entry on Worksheet A-6 to the appropriate HHA therapy cost center. Make
a similar reclassification to the appropriate line for other ancillaries when the HHA costs are
readily identifiable.
NOTE: This cost report provides separate HHA cost centers for all therapy services. If services
are provided to HHA patients from a shared hospital ancillary cost center, make the cost
allocation on Worksheet H-1, Part II.
Line 102--Effective for cost reporting periods ending on or after January 1, 2022, enter the cost
of providing services for the treatment of Opioid Use Disorder furnished by the hospital’s
Medicare-enrolled opioid treatment program as defined in the Act §1861(jjj) and as described in
CMS Pub. 100-02, Medicare Benefit Policy Manual, chapter 17.
Lines 103 and 104--Reserved for future use.
Lines 105 through 117--Use these lines for special purpose cost centers. Special purpose cost
centers include kidney, heart, liver, lung, pancreas, intestinal, and islet acquisition costs as well as
costs of other organ acquisitions which are nonreimbursable but which CMS requires for data
purposes, cost centers which must be reclassified but which require initial identification, and ASC
and hospice costs which are needed for rate setting purposes.
NOTE: Prorate shared acquisition costs (e.g., coordinator salaries, donor awareness programs)
among the type of organ acquisitions. Generally, this is done based on the number of
organs procured. Further, if multiple organs have been procured from a community
hospital or an independent organ procurement organization, prorate the cost among the
type of acquisitions involved.
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These cost centers include the cost of services purchased under arrangement or billed directly to
the hospital in connection with the acquisition of organs. Such direct costs include but are not
limited to:
•
•
•
•
•
•

Fees for physician services (preadmission for transplant donor and recipient tissuetyping and all tissue-typing services performed on cadaveric donors);
Cost for organs acquired from other providers or organ procurement organizations;
Transportation costs of organs;
Organ recipient registration fees;
Surgeons' fees for excising cadaveric donor organs; and
Tissue-typing services furnished by independent laboratories.

NOTE: No amounts or fees paid to a donor, their estate, heirs, or assigns in exchange for an organ
or for the right to remove or transplant an organ are included in organ acquisition costs.
Also, such amounts or fees are not included in any other revenue producing or general
service cost center.
Only hospitals which are certified transplant centers are reimbursed directly by the
Medicare program for organ acquisition costs. All such costs are accumulated on
Worksheet D-4.
Hospitals which are not certified transplant centers are not reimbursed by the Medicare program
for organ acquisition costs. Such hospitals sell any organs excised to a certified transplant center
or an organ procurement organization. The costs are accumulated in the applicable organ
acquisition cost center and flow through cost finding to properly allocate overhead costs to this
cost center. However, only a certified transplant center completes Worksheet D-4.
Line 105--Record any costs in connection with kidney acquisitions. This cost center flows through
cost finding and accumulates any appropriate overhead costs.
Line 106--Record any costs in connection with heart acquisitions. This cost center flows through
cost finding and accumulates any appropriate overhead costs.
Line 107--Record any costs in connection with liver acquisitions. This cost center flows through
cost finding and accumulates any appropriate overhead costs.
Line 108--Record any costs in connection with lung acquisitions. This cost center flows through
cost finding and accumulates any appropriate overhead costs.
Line 109--Record any costs in connection with pancreas acquisitions. This cost center flows
through cost finding and accumulates any appropriate overhead costs.
Line 110--Record any costs in connection with intestinal acquisitions. This cost center flows
through cost finding and accumulates any appropriate overhead costs.
Line 111--Record the costs associated with the acquisition of the pancreas that is used to isolate
the islet cells that are used for transplant. Do not include in this cost any costs associated with the
isolation of the islet cells as these costs will be included as an add-on to the DRG payment. (See
change request (CR) 5505, dated March 2, 2007).
Line 112--Record any costs related to organ acquisitions, which are not already recorded on
lines 105 through 111 and subscripts. This cost center flows through cost finding and accumulates
any appropriate overhead costs.

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Line 113--Enter all interest paid by the facility. After reclassifications in column 4 and
adjustments in column 6, the balance in column 7 must equal zero. This line cannot be subscripted.
NOTE: If capital-related and working capital interest are commingled on this line, reclassify
working capital interest to A&G expense. Reclassify capital-related interest to lines 1
and 2, as appropriate, in accordance with the instructions for those lines.
Line 114--Include only utilization review costs of the hospital-based SNF. All costs are either
reclassified or adjusted in total depending on the scope of the review. If the scope of the review
covers all patients, all allowable costs are reclassified in column 4 to A&G expenses (line 5). If
the scope of the review covers only Medicare patients or Medicare, title V, and title XIX patients,
then (1) in column 4, reclassify to A&G expenses all allowable costs other than physicians'
compensation and (2) deduct in column 6 the compensation paid to the physicians for their
personal services on the utilization review committee. The amount reported on Worksheet E-2,
column 1, line 7, must equal the amount adjusted on Worksheet A-8.
Line 115--Enter the direct costs of an ASC as defined in 42 CFR 416.2. An ASC operated by a
hospital must be a separately identifiable entity, physically, administratively, and financially
independent and distinct from other operations of the hospital. In addition, the ASC must have an
agreement with CMS as required by 42 CFR 416.25. Under this restriction, hospital outpatient
departments providing ambulatory surgery (among other services) are not eligible to be classified
as ASCs. Those ASCs which meet the definition in 42 CFR 416.2 and are currently treated as an
outpatient cost center on the hospital’s Medicare cost report are reimbursed through a
prospectively determined standard overhead amount. For cost reporting purposes, an eligible ASC
is treated as a nonreimbursable cost center to ensure that overhead costs are properly allocated
since the cost is not reimbursable in this cost report.
Line 116--Record the costs applicable to hospice care for terminally ill Medicare beneficiaries who
elect to receive care from a participating hospice. If you have a contractual arrangement with a
hospice for the use of general inpatient routine beds, do not to report those costs on this line.
Rather, report the contractual arrangement costs on line 30, Adults and Pediatrics (General Routine
Care). Additionally, report amounts received under the contract with the hospice on
Worksheet A-8, line 30.99, and enter the applicable days on Worksheet S-3, Part I, line 24.10.
Line 117--Enter other special purpose cost centers not previously identified. Review Table 5 in
§4095 for the proper cost center code.
Lines 119 through 189--Reserved for future use.
Lines 190 through 194--Record 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 nonallowable cost area
is so insignificant as not to warrant establishment of a nonreimbursable cost center, these expenses
are adjusted on Worksheet A-8. (See CMS Pub. 15-1, chapter 23, §2328.)
Line 194--Establish a nonreimbursable cost center to accumulate the cost incurred by you for
services related to the physicians’ private practice. Such costs include 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. Do not include costs applicable to services rendered to hospital
patients by hospital-based physicians since such costs may be included in hospital costs.
Lines 195 through 199--Reserved for future use.
Line 200--Sum of lines 118 through 199.
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4014.

4014

WORKSHEET A-6 - RECLASSIFICATIONS

This worksheet provides for the reclassification of certain costs to effect proper cost allocation
under cost finding. For each reclassification adjustment, assign an alpha character in column 1 to
identify each reclassification entry, e.g., A, B, C. DO NOT USE NUMERIC DESIGNATIONS.
All reclassification entries must have a corresponding Worksheet A line number reference in
columns 3 and 7. In column 10, indicate the column of Worksheet A-7 impacted by the
reclassification, where applicable. If more than one column on Worksheet A-7 is impacted by one
reclassification, report each entry as a separate line to properly report each column impacted on
Worksheet A-7. If you directly assign the capital-related costs, i.e., insurance, taxes, and other,
reclassify these costs to line 3. Do not reclassify other capital-related costs reported or reclassified
to line 3 of Worksheet A back to the capital lines 1 or 2, of Worksheet A. This is accomplished
through Worksheet A-7.
Submit with the cost report copies of any workpapers used to compute the reclassifications effected
on this worksheet.
Identify any reclassifications made as salary and other costs in the appropriate column. However,
when transferring to Worksheet A, transfer the sum of the two columns.
NOTE: Salary amounts paid to an employee in addition to direct salaries or wages (such as paid
vacation, holiday, sick, other paid-time-off (PTO), severance, and bonus pay) must be
reported on Worksheet A, column 1, of the same cost center as the employees direct
salaries and wages. For example, if the indirect salaries (such as paid vacation, holiday,
sick, other paid-time-off (PTO), severance, and bonus pay) are reported in the “Employee
Benefits” cost center or in column 2 of the cost where the related direct salary and wages
are reported, a reclassification entry must be made to reclassify them to column 1 of the
cost center(s) in which the related direct salaries and wages are reported.
If there is any reclassification to general service cost centers for compensation of provider-based
physicians, make the appropriate adjustment for RCE limitation on Worksheet A-8-2. (See §4018.)
Examples of reclassifications that may be needed are:
•

Reclassification of related organization rent expenses included in the A&G cost center
which are applicable to lines 1 and 2 of Worksheet A. See instructions for
Worksheet A-8-1 for treatment of rental expenses for related organizations.

•

Reclassification of interest expense included on Worksheet A, column 3, line 113,
which is applicable to funds borrowed for A&G purposes (e.g., operating expenses) or
for the purchase of buildings and fixtures or movable equipment. Allocate interest on
funds borrowed for operating expenses with A&G expenses.

•

Reclassification of employee benefits expenses (e.g., employee health service,
hospitalization insurance, workers compensation, employee group insurance, social
security taxes, unemployment taxes, annuity premiums, past service benefits, and
pensions) included in the A&G cost center.

•

Reclassification of utilization review cost applicable to the hospital-based SNF to A&G
costs. If the scope of the utilization review covers the entire population, reclassify the
total allowable utilization review cost included on Worksheet A, column 3, line 114.
However, if the scope of the utilization review in the hospital-based SNF covers only
Medicare patients or Medicare and title XIX patients, only the allowable utilization
review costs included on Worksheet A, column 3, line 114 (other than the
compensation of physicians for their personal services on utilization review
committees), are reclassified to A&G costs.

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11-17

The appropriate adjustment for physicians’ compensation is made on Worksheet A-8. For further
explanations concerning utilization review in skilled nursing facilities, see CMS Pub. 15-1,
chapter 21, §2126.2.
•

Reclassification of any dietary cost included in the dietary cost center which is
applicable to the cafeteria, nursery, and to any other cost centers such as gift, flower,
coffee shops, and canteen.

•

Reclassification of any direct expenses included in the central service and supply cost
center which are directly applicable to other cost centers such as intern-resident service,
intravenous therapy, and oxygen (inhalation) therapy.

•

Reclassification of any direct expenses included in the laboratory cost center which are
directly applicable to other cost centers such as whole blood and packed red blood cells
or electrocardiology.

•

Reclassification of any direct expenses included in the radiology-diagnostic cost center
which are directly applicable to other cost centers such as radiology-therapeutic,
radioisotope, or electrocardiology.

•

When you purchase services (e.g., physical therapy) under arrangements for Medicare
patients but do not purchase such services under arrangements for non-Medicare
patients, your books reflect only the cost of the Medicare services. However, if you do
not use the grossing up technique for purposes of allocating overhead and if you incur
related direct costs applicable to both Medicare and non-Medicare patients (e.g.,
paramedics or aides who assist a physical therapist in performing physical therapy
services), reclassify the related costs on Worksheet A-6 from the ancillary service cost
center. Allocate them as part of A&G expense. However, when you purchase services
that include performing administrative functions such as completion of medical
records, training, etc., as described in CMS Pub. 15-1, chapter 14, §1412.5, the overall
charge includes the provision of these services. Therefore, for cost reporting purposes,
these related services are NOT reclassified to A&G.

•

If a beneficiary receives outpatient renal dialysis for an extended period of time and
you furnish a meal, the cost of this meal is not an allowable cost for Medicare. Make
an adjustment on Worksheet A-8. However, the dietary counseling cost attributable to
a dialysis patient is an allowable cost. Reclassify this cost from the dietary cost center,
line 10, to the renal dialysis cost center, line 74.

•

When interns and residents are employed to replace anesthetists, you must reclassify
the related direct costs from the intern and resident cost center to the anesthesiology
cost center. (See 49 FR 208 (January 3, 1984).)
NOTE: These interns and residents do not qualify for the IME adjustment and must
be excluded for the intern and resident FTE for that purpose. (See
42 CFR 412.113(c).)

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•

If you incur costs for an unpaid guarantee for emergency room physician availability,
attach a separate worksheet showing the computation of the necessary reclassification.
(See CMS Pub. 15-1, chapter 21, §2109.)

•

Reclassification of the costs of malpractice insurance premiums, self-insurance fund
contributions, and uninsured malpractice losses incurred either through deductible or
coinsurance provisions, as a result of an award in excess of reasonable coverage limits,
or as a government provider to the A&G cost center.

Rev. 12

11-17
4015.

FORM CMS-2552-10

4015.1

WORKSHEET A-7 - RECONCILIATION OF CAPITAL COST CENTERS

This worksheet consists of three parts:
Part I
Analysis of Changes in Capital Asset Balances.
Part II Reconciliation of amounts from Worksheet A, column 2, lines 1 and 2.
Part III Reconciliation of Capital Cost Centers.
See the instructions for Worksheet A for a definition of capital. All providers must complete
Parts I, II, and III.
NOTE: Include assets which are directly allocated to the provider from the home office or related
organization and the related other capital costs in Parts I and II of this worksheet.
The intent of Worksheet A-7, Part I, is to reflect assets which relate to the hospital.
However, examine the cost finding elections made at the time you submit the cost report
to consider the cost finding treatment of SNF, HHA, hospice, subproviders, CORF,
CMHC, the physician office building, and any other nonallowable cost centers.
Where you have elected to cost find any of these areas through the cost report, related
assets must be included in Worksheet A-7, Part I, as appropriate, to properly allocate the
related insurance, taxes, etc.
4015.1 Part I - Analysis of Changes in Capital Asset Balances.--This part enables the Medicare
program to analyze the changes that occurred in your capital asset balances during the current
reporting period. Complete this worksheet only once for the entire hospital complex (certified and
non-certified components). However, only include in Part I assets that relate to hospital services
or are commingled and cannot be separated.
Columns 1 and 6--Enter the balance recorded in your books of accounts at the beginning of your
cost reporting period (column 1) and at the end of your cost reporting period (column 6). You
must submit a reconciliation demonstrating that the amount reported on Part I, column 6, line 10,
agrees with the total fixed assets on Worksheet G, plus any directly allocated assets from the home
office or related organization, less any assets not allocated through the cost finding method on
Worksheet B. Include fully depreciated assets still used for patient care.
Columns 2 through 4--Enter the cost of capital assets acquired by purchase in column 2 and the
fair market value at date acquired of donated assets in column 3. Enter the sum of columns 2 and
3 in column 4.
NOTE: The amounts in Part I, column 2, must also include transfers of assets from a change of
ownership.
Column 5--Enter the cost or other approved basis of all capital assets sold, retired, or disposed of
in any other manner during your cost reporting period.
Column 6--Enter the sum of columns 1 and 4, minus column 5.
Column 7--Enter the initial acquisition cost of fully depreciated assets for each category. An asset
that is fully depreciated and continues to be used in the facility must be recorded in this column.
There will be no depreciation expense recorded after the asset is fully depreciated.

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Line Descriptions
Line 7--If you acquired certified health information technology (HIT) assets and are an EHR
technology meaningful user (Worksheet S-2, Part I, line 167, is yes) in accordance with
ARRA 2009, §4102, and CAA 2016, §602, enter the corresponding amounts on this line.
Line 9--If you have included in lines 1 through 7 of Part I any of the following, enter those amounts
on line 9.
•

Capitalized a lease in accordance with generally accepted accounting principles (GAAP)
and included it in the assets reported on Worksheet G,

•

Excess of amounts paid for the acquisition of assets over their fair values or the amount
recognized under §2314 of DEFRA for transactions after July 18, 1984, or

•

Construction in progress at the end of the cost reporting period.

Line 10--Enter line 8 minus line 9.
4015.2 Part II - Reconciliation of Amounts From Worksheet A, Column 2, Lines 1 and 2.--The
purpose of this worksheet is to segregate and specifically identify the depreciation and capitalrelated costs which are directly assigned to Worksheet A, column 2, lines 1 and 2.
Columns 9 through 14--Enter in columns 9 through 14, the depreciation and other capital-related
costs. (Do not report in columns 12 through 14 any amounts previously reported in Part III,
columns 5 through 7). The sum of columns 9 through 14 of this part, which is reported in
column 15, lines 1 and 2, must agree with the amounts reported on Worksheet A, column 2, lines 1
and 2.
4015.3 Part III - Reconciliation of Capital Cost Centers.--Use this part to allocate allowable
insurance, taxes, and other capital expenditures (not including depreciation, lease, and interest
expense) to the capital-related cost centers. This part also summarizes the amounts in the capitalrelated cost centers on Worksheet A, lines 1 and 2, column 7.
Lines 1 and 2--The allowable costs for other capital-related expenses (including but not limited to
taxes, insurance, and license and royalty fees on depreciable assets) are apportioned by applying
the ratio of the hospital's capital related building and fixtures and capital related movable
equipment gross asset value to total asset value in each cost reporting period. These lines compute
the appropriate gross asset ratios used in allocating other capital-related costs in columns 5 through
7.
Line 3--Enter the sum of lines 1 and 2. Column 4 must equal 1.000000.
Columns 1 through 4, Lines 1 and 2--Use these columns and lines to compute ratios of
capital related building and fixtures and capital related movable equipment gross asset values to
total gross asset values. Use these ratios on columns 5 through 7 to allocate other capital costs
(insurance, taxes, and other) to the capital-related cost center lines (Worksheet A, lines 1 and 2).
Column 1--Enter on line 1 your gross asset value (asset value before accumulated depreciation)
for buildings and fixtures (which also includes old land and land improvements). Enter on line 2
your gross asset value for movable equipment.
NOTE: Part III, column 1, line 3, must agree with the sum of Part I, column 6, line 8.
Column 2--Enter in column 2, line as appropriate, any amounts that you have included in
column 1, lines 1 and 2, and which were reported on line 8 of Part I, as appropriate.
Column 3--Enter column 1 less column 2.
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Column 4--Enter on lines 1 and 2 the amount in column 3, lines as applicable, divided by the
amount in column 3, line 3. Round the resulting ratio to six decimal places.
Columns 5 through 7--These columns provide for the allocation of other capital-related costs
(taxes, insurance, and other) to the capital-related cost center lines (Worksheet A, lines 1 and 2).
Line 3--Enter in column 5 capital expenditures relating to insurance. Enter in column 6 capital
expenditures relating to State and local taxes on property and equipment. Enter in column 7 other
capital expenditures (not including taxes, insurance, depreciation, lease, and interest expense).
Enter in column 8, the sum of the amounts reported in columns 5 through 7.
Lines 1 and 2--Apply the ratios developed in column 4, line as applicable, to allocate the other
capital costs reported in line 3.
Column 8--Line 3 must be equal to or less than the amount on Worksheet A, line 3, column 3. The
amount reported becomes the reclassification entry on Worksheet A, column 4, which will zeroout the balance on line 3. If you directly assign other capital-related costs, see Part II for proper
disclosure of these costs.
Columns 9 through 15--These lines summarize the amounts in the capital-related cost centers
(Worksheet A, lines 1 and 2, column 7).
NOTE: The amount entered in these columns must be net of reclassifications and adjustments
identified on Worksheets A-6, A-8 and A-8-1.
Column 9--Enter the amount reported in Part II above, from column 9, lines 1 and 2, adjusted by
the amounts identified on Worksheets A-6, A-8 and A-8-1.
Column 10--Enter the amount reported in Part II, column 10, lines 1 and 2, relating to
capital-related lease expense, adjusted by the amounts identified on Worksheets A-6, A-8, and
A-8-1. (See CMS Pub. 15-1, chapter 28, §2806.1.) Report insurance, taxes, and license and
royalty fees associated with leased assets in columns 12, 13, and 14 of this worksheet, respectively.
Column 11--Enter the amount reported in Part II, column 11, lines 1 and 2, relating to
capital-related interest expense, adjusted by the amounts identified on Worksheets A-6, A-8, and
A-8-1.
Column 12--Enter the amount from column 5 plus any additional amounts reported in Part II,
column 12 adjusted by amounts identified on Worksheets A-6, A-8, and A-8-1.
Column 13--Enter the amount from column 6 plus any additional amounts reported in Part II,
column 13 adjusted by amounts identified on Worksheets A-6, A-8, and A-8-1.
Column 14--Enter the amount from column 7 plus any additional amounts reported in Part II,
column 14 adjusted by amounts identified on Worksheets A-6, A-8, and A-8-1.
Column 15--Enter the sum of columns 9 through 14. The amounts from column 15, lines 1 and 2,
must equal the amounts on Worksheet A, column 7, lines 1 and 2.
4016.

WORKSHEET A-8 - ADJUSTMENTS TO EXPENSES WORKSHEET

In accordance with 42 CFR 413.9(c)(3), if your operating costs include amounts not related to
patient care, these amounts are not reimbursable under the program. If your operating costs include
amounts 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.

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11-17

This worksheet provides for the adjustments in support of those listed on Worksheet A, column 6.
These adjustments, required under the Medicare principles of reimbursement, are made on the
basis of cost or amount received (revenue) only if the cost (including direct cost and all applicable
overhead) cannot be determined. If the total direct and indirect cost can be determined, enter the
cost. Submit with the cost report a copy of any work papers used to compute a cost adjustment.
Once an adjustment to an expense is made on the basis of cost, you may not determine the required
adjustment to the expense on the basis of revenue in future cost reporting periods. Enter the
following symbols in column 1 to indicate the basis for adjustment: "A" for cost or "B" for amount
received. Line descriptions indicate the more common activities which affect allowable costs or
result in costs incurred for reasons other than patient care and, thus, require adjustments.
Types of adjustments entered on this worksheet include (1) those needed to adjust expenses to
reflect actual expenses incurred; (2) those items which constitute recovery of expenses through
sales, charges, fees, etc.; (3) those items needed to adjust expenses in accordance with the Medicare
principles of reimbursement; and (4) those items which are provided for separately in the cost
apportionment process.
If an adjustment to an expense affects more than one cost center, record the adjustment to each
cost center on a separate line on Worksheet A-8.
NOTE: When adjustments affect capital, they must be appropriately identified as impacting
capital related building and fixtures or capital related movable equipment. If these
adjustments affect other capital-related costs, indicate in column 5, the capital-related
cost category shown on Worksheet A-7, Part III, columns 9 through 14.
Enter additional costs as positive amounts. Enter reductions of cost as a negative number. Enter a
net total (if a reduction of cost) as a negative number.
Line Descriptions
Lines 1 through 3--Enter the investment income to be applied against interest expense. (See
CMS Pub. 15-1, chapter 2, §202.2, for an explanation.)
Line 7--For patient telephones, make an adjustment on this line or establish a nonreimbursable
cost center. When this line is used, base the adjustment on cost. Revenue is not used. (See
CMS Pub. 15-1, chapter 23, §2328.)
Line 10--Enter the total provider-based physician adjustments for personal patient care services
and RCE limitations. Obtain this amount from Worksheet A-8-2, column 18, sum of all lines.
NOTE: Make the adjustment to Worksheet A, column 6, for each applicable cost center from
Worksheet A-8-2, column 18, line as appropriate.
Line 12--Obtain this amount from section A, column 6 of Worksheet A-8-1.
NOTE: Worksheet A-8-1 represents the detail of the various cost centers on Worksheet A which
must be adjusted.
Line 19--For each NAHE program on Worksheet A, line 20, and its subscripts, and Worksheet A,
line 23, and its subscripts, enter the revenue adjustments (for tuition, fees, books, etc.) to be applied
against total allowable costs that are directly related to the approved NAHE activities. Subscript
this line to separately report the revenue offset for each NAHE program reported on line 20 and
line 23. (See CMS Pub. 15-1, chapter 4, §414, and 42 CFR 413.85(d)(2)(i).)

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Line 21--Enter the cash received from the imposition of interest, finance, or penalty charges on
overdue receivables. Use this income to offset the allowable administration and general costs.
(See CMS Pub. 15-1, chapter 21, §2110.2.)
Line 22--Enter the interest expense imposed by the contractor on Medicare overpayments. Also,
enter interest expense on borrowing made to repay Medicare overpayments.
Line 23--Enter, if applicable, the amount from Worksheet A-8-3, line 65.
Line 24--Enter, if applicable, the amount from Worksheet A-8-3, line 65.
Line 25--This line pertains to the hospital-based SNF only. When the utilization review covers
only Medicare patients or Medicare and title XIX patients, allocate 100 percent of the reasonable
compensation paid to the physicians for their services on utilization review committees to the
health care programs. Apportion all other allowable costs applicable to utilization review which
cover only health care program patients among all users of the hospital-based SNF. Reclassify
such other costs on Worksheet A-6. Enter the physicians’ compensation for service on utilization
review committees which cover only health care program patients in the hospital-based SNF. The
amount entered equals the amount shown on Worksheet A, column 6, line 114. (See
CMS Pub. 15-1, chapter 21, §2126.2.) If the utilization review costs pertain to more than one
program, the amount entered on Worksheet E-2, column 1, line 7, must equal the amount adjusted
on Worksheet A-8.
Lines 26 and 27--When depreciation expense computed in accordance with the Medicare
principles of reimbursement differs from depreciation expenses per your books, enter the
difference on lines 26 and 27, as applicable. Use line 26 capital related buildings and fixtures costs
and line 27 for new capital related movable equipment costs. Personal use of assets requires
adjustment to depreciation expense, e.g., automotive used 50% for business and 50% personal.
Line 28--This adjustment is required for salaries and fringe benefits paid to non-physician
anesthetists reimbursed on a fee schedule. (See the instructions for Worksheet A, line 19.)
Line 29--Sections 1861(s)(2)(K), 1842(b)(6)(C), and 1842(b)(12) of the Act provide for coverage
of and separate payment for services performed by a physician assistant. The physician assistant
is an employee of the hospital and payment is made to the employer of the physician assistant.
Make an adjustment on Worksheet A-8 for any payments made directly to the physician assistant
for services rendered. This avoids any duplication of payments.
Line 30--Enter, if applicable, the amount from Worksheet A-8-3, line 65, for occupational therapy
services rendered.
Line 31--Enter, if applicable, the amount from Worksheet A-8-3, line 65, for speech pathology
services rendered.
Line 32--For CAHs, where applicable in accordance with ARRA of 2009, section 4102, remove
the current year depreciation expense associated with purchased assets for which the total cost or
remaining un-depreciated cost was reimbursed either in the current or prior cost reporting period
as EHR incentive payment if such depreciation was included on Worksheet A, line 2
(capital-related movable equipment), or any other line. This includes the depreciation expense for
EHR assets purchased in the current cost reporting period, as well as depreciation expense related
to the remaining net book value (i.e., un-depreciated basis) of EHR assets purchased in prior cost
reporting periods which were not fully depreciated at the beginning of the current cost reporting
period.
Also, use this line to remove that portion of the annual rent/lease expense applicable to EHR assets
leased under a virtual purchase lease which equals the depreciation expense for this asset since the
total cost of the asset (or the un-depreciated cost if the lease was initiated in a prior cost reporting
period), was claimed as EHR incentive payment. Also remove any portion of the total
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rental charge which exceeds the actual cost of ownership of the EHR asset. (See CMS Pub. 15-1,
chapter 1, §110.B.2.) In accordance with CMS Pub. 15-1, chapter 1, §110.B.2, the actual cost of
ownership of an asset leased under a virtual purchase lease includes not only the depreciation
expense, but insurance and interest as well. For example, if the depreciation for the asset is
$50,000 per year, the insurance is $3,000 per year, the interest is $10,000 per year, and the rental
charge is $70,000 per year, the rental expense must be limited to the cost of ownership which in
this example is $63,000. Since the adjustment to limit the rent expense to the cost of ownership is
$7,000, the actual adjustment on this line will be to reduce the allowable rent expense for this EHR
asset by $57,000 (i.e., $50,000 depreciation portion and $7,000 excess rental charge over the cost
of ownership).
Lines 33 through 49--Enter any additional adjustments which are required under the Medicare
principles of reimbursement. Label the lines appropriately to indicate the nature of the required
adjustments. If the number of blank lines is not sufficient, subscript lines 33 through 49. The
grossing up of costs in accordance with provisions of CMS Pub. 15-1, chapter 23, §2314, is an
example of an adjustment entered on these lines and is explained below.
If you furnish ancillary services to health care program patients under arrangements with others
but simply arrange for such services for non-health care program patients and do not pay the nonhealth care program portion of such services, your books reflect only the costs of the health care
program portion. Therefore, allocation of indirect costs to a cost center which includes only the
cost of the health care program portion results in excessive assignment of indirect costs to the
health care programs. Since services were also arranged for the non-health care program patients,
allocate part of the overhead costs to those groups.
In the foregoing situation, do not allocate indirect costs to the cost center unless your contractor
determines that you are able to gross up both the costs and the charges for services to non-health
care program patients so that both costs and charges for services to non-health care program
patients are recorded as if you had provided such services directly. See the instructions for
Worksheet C, Part I, for grossing up of your charges.
Meals furnished by you to an outpatient receiving dialysis treatment also require an adjustment.
These costs are nonallowable for title XVIII reimbursement. Therefore, the cost of these meals
must be adjusted.
In accordance with CMS Pub. 100-04, chapter 9, §40, compensation paid to a physician for RHC
services rendered in a hospital-based RHC is cost reimbursed. Where the physician agreement
compensates for RHC services as well as non-RHC services, or services furnished in the hospital,
the related compensation must be eliminated on Worksheet A-8 and billed to the Part B contractor.
If not specified in the agreement, a time study must be used to allocate the physician compensation.
If the hospital performs ESRD services and costs are reported on either line 74, 94, or both, these
costs should include the cost of all ESAs. Do not report the cost of these drugs claimed in any
other cost center. These costs will be removed later on Worksheet B-2.
If the hospital pays membership dues to an organization that performs lobbying and political
activities, the portion of the dues associated with these non-allowable activities must be removed
from costs.
Line 30.99 (hardcoded)--When the hospital enters into a contractual arrangement with a hospice
for the use of general inpatient routine beds, enter the amount received under contract from the
hospice. This amount must be used to offset general inpatient routine care costs on Worksheet A,
line 30.
Line 50--Enter the sum of lines 1 through 49. Transfer the amounts in column 2 to the appropriate
lines on Worksheet A, column 6.

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4017

WORKSHEET A-8-1 - STATEMENT OF COSTS OF SERVICES FROM RELATED
ORGANIZATIONS AND HOME OFFICE COSTS

In accordance with 42 CFR 413.17, costs 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 organization, except for the exceptions outlined in
42 CFR 413.17(d). This worksheet provides for the computation of any needed adjustments to
costs applicable to services, facilities, and supplies furnished to the hospital by organizations
related to you or costs associated with the home office. In addition, it shows certain information
concerning the related organizations with which you have transacted business as well as home
office costs. (See CMS Pub. 15-1, chapter 10, and §2150, respectively.)
Part A--Cost applicable to home office costs, services, facilities, and supplies furnished 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. Costs for services provided by a home office or related party, including
employee or contract labor, must be assigned to the most closely matched cost centers on
Worksheet A (lines 4 through 17). When portions of home office or related party costs, including
employee or contract labor costs, pertain to more than A&G, assign the applicable costs to the
corresponding most closely matched cost centers on lines 4 through 17 of Worksheet A. For
example, if the home office cost included contracted housekeeping services, the contract labor
costs must be reported on Worksheet A, line 9, and reflected on Worksheet A-8-1, referencing
Worksheet A, line 9, in column 1.
Columns 1, 2, and 3--Enter in columns 1 and 3, respectively, the Worksheet A line number and
specific expense category from your books and/or records associated with the acquisition of
services, facilities, and/or supplies from related organizations. Column 2 (Worksheet A cost
center description) is automatically completed based on the cost center in column 1.
Column 4--Enter the allowable cost from the books and/or records of the related organization
which includes only the actual cost incurred by the related organization for services, facilities,
and/or supplies and excludes any markup, profit or amounts that otherwise exceed the acquisition
cost of such items.
Column 5--Enter the amount included on Worksheet A for services, facilities, and/or supplies
acquired from related organizations.
Column 6--Enter the result of column 4 minus column 5.
Column 7--Enter the specific column of Worksheet A-7, Part III, columns 9 through 14, impacted
by the adjustment.
Part B--Use this part to show your relationship to organizations for which transactions were
identified in Part A. 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, in columns 1 through 6, as appropriate.
Complete only those columns which are pertinent to the type of relationship which exists.
Columns 1 and 2--Enter in column 1, the appropriate symbol which describes your relationship to
the related organization. If the symbol A, D, E, F, or G is entered in column 1, enter the name of
the related individual in column 2.
Column 3--If the individual indicated in column 2 or the organization indicated in column 4 has a
financial interest in you, enter the percent of ownership as a ratio.
Column 4--Enter the name of the related corporation, partnership, or other organization.
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Column 5--If you or the individual indicated in column 2 has a financial interest in the related
organizations, 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).
4018.

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 or which represent
availability services in a hospital emergency room under specified conditions.
(See
42 CFR 415.150 and 42 CFR 415.164 for an exception for teaching physicians under certain
circumstances.) 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). Effective for cost reporting periods ending on or after
October 1, 2021, any nonreimbursable services such as research must be reported in the designated
nonreimbursable cost center and not included on this worksheet. Effective for cost reporting
periods ending prior to October 1, 2021, if nonreimbursable costs such as research are included in
column 3 those costs must also be included in column 4 as professional services in order to be
properly removed from Worksheet A. Only provider services are reimbursable to you through the
cost report. This worksheet also provides for the computation of the 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.
Enter the total provider-based physician adjustment for personal care services and RCE limitations
applicable to the compensation of provider-based physicians directly assigned to or reclassified to
general service cost centers. RCE limits are not applicable to a medical director, chief of medical
staff, or to the compensation of a physician employed in a capacity not requiring the services of a
physician, e.g., controller. RCE limits also do not apply to CAHs; however, the professional
component must still be removed on this worksheet. CAHs need only complete columns 1 through
5 and 18.
NOTE: 42 CFR 415.70(a)(2) provides that limits established under this section do not apply to
costs of physician compensation attributable to furnishing inpatient hospital services paid
for under the PPS implemented under 42 CFR 412.
Limits established under this section apply to inpatient services subject to the TEFRA rate of
increase ceiling (see 42 CFR 413.40), outpatient services for all titles, and to title XVIII, Part B
inpatient services.
Since the methodology used in this worksheet applies the RCE limit in total, make the adjustment
required by 42 CFR 415.70(a)(2) on Worksheet C, Part I. Base this adjustment on the RCE
disallowance amounts entered in column 17 of Worksheet A-8-2.
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.
NOTE: The RCEs are not applied to Medicare non-reimbursable or Medicare non-certified areas
of the hospital and the adjustments generated from this worksheet for physician
compensation are limited to the cost centers on Worksheet A, lines 4 through 41, 43, 50
through 78, 90 through 99, 105 through 111, and 115, and subscripts as allowed.

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Column Descriptions
Columns 1 and 10--Enter the line numbers from Worksheet A for each cost center that contained
compensation for physicians who are subject to RCE limits.
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 each successive line below for each additional
physician in that cost center.
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, etc. However, the
identity of the physician must be made available to your contractor/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 you for each cost center. Physician
compensation means 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 you or other
organizations furnish a physician in return for the physician's services. (See 42 CFR 415.60(a).)
Include the compensation in column 3 of Worksheet A or, if necessary, through appropriate
reclassifications on Worksheet A-6 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 applicable to the
physician's services to individual patients (professional component). These services are
reimbursed on a reasonable charge basis by the Part B contractor 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 3, 4 or 5.
Column 6--For each line of data, enter the RCE limit applicable to the physician's compensation
included in that cost center. Obtain the RCE limit from the applicable chart in the Federal Register
as listed below. If the physician specialty is not identified in the chart, use the RCE for the “Total”
category (from the same chart).
Cost Reporting Period
Beginning On or After
January 1, 2004

Federal Register
68 FR 45459 (August 1, 2003)

Note
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.

January 1, 2015

79 FR 50162 (August 22, 2014)

Not applicable.

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Column 7--Enter for each line of data, 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 in this column. The hours entered are the actual hours for which
the physician is compensated by you for furnishing services of a general benefit to your patients.
If the physician is paid for unused vacation, unused sick leave, etc., exclude the hours so paid from
the hours entered. Time records or other documentation that supports this allocation must be
available for verification by your 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--Enter for each line of data five percent of the amounts entered in column 8.
Column 12--You may adjust 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 you.
Enter for each line of data the actual amounts of these expenses paid by you.
Column 13--Enter for each line of data the result of multiplying column 5 by column 12, and
dividing that amount by column 3.
Column 14--You may also adjust upward the computed RCE limit in column 8 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--Enter for each line of data the result of multiplying column 5 by column 14, and
dividing that amount by column 3.
Column 16--Enter for each line of data the sum of columns 8 and 15, plus the lesser of column 9
or 13.
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. Transfer the amounts for each cost center to Worksheet C, Part I, column 4, for all
hospitals subject to PPS. (See 42 CFR 412.)
Column 18--The adjustment for each cost center entered represents the PBP elimination from costs
entered on Worksheet A-8, column 2, line 10, and on Worksheet A, column 6, to each cost center
affected. 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. For CAHs, transfer the amount from column 4
(professional component remuneration) to column 18.
NOTE: If you incur cost for unpaid guarantee for emergency room physician availability, attach
a separate worksheet showing the computation of the necessary reclassification. (See
CMS Pub. 15-1, chapter 21, §2109.)
Line Descriptions
Line 200--Enter the total of lines 1 through 11 for columns 3 through 5, 7 through 9, and 12
through 18.

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4019.

4019.1

WORKSHEET A-8-3 - REASONABLE COST DETERMINATION FOR THERAPY
SERVICES FURNISHED BY OUTSIDE SUPPLIERS

This worksheet provides for the computation of any needed adjustments to costs applicable to
therapy services furnished by outside suppliers in CAHs. Therapy services rendered by non-CAH
providers are either subject to fee schedule reimbursement or the corresponding PPS
reimbursement. Consequently, only CAHs complete this worksheet. The information required on
this worksheet provides, in the aggregate, all data for therapy services furnished by all outside
suppliers in determining the reasonableness of therapy costs.
If you contract with an outside supplier for therapy services, the potential for limitation and the
amount of payment you receive depend on several factors:
•

An initial test to determine whether these services are categorized as intermittent part-time
or full-time services;

•

The location where the services are rendered, i.e., at your site or an alternate site.

•

Whether detailed time and mileage records are maintained by the outside supplier;

•

Add-ons for supervisory functions, aides, overtime, equipment and supplies; and

•

Contractor determinations of reasonableness of rates charged by the supplier compared
with the going rates in the area.

4019.1 Part I - General Information.--This part provides for furnishing certain information
concerning therapy services furnished by outside suppliers.
Line 1--Enter the number of weeks that services were performed on site. Count only those weeks
during which a supervisor, therapist or an assistant was on site. (See CMS Pub. 15-1, chapter 14.)
Line 2--Multiply the amount on line 1 by 15 hours per week. This calculation is used to determine
whether services are full-time or intermittent part-time.
Line 3--Enter the number of days in which the supervisor or therapist (only report the therapists
for respiratory therapy) was on site. Count only one day when both the supervisor and therapist
were at the site during the same day.
Line 4--Enter the number of days in which the therapy assistant (PT, OT, or SP only) was on site.
Do not include days when either the supervisor or therapist was also at the site during the same
day.
NOTE: Count an unduplicated day for each day the contractor has at least one employee on site.
For example, if the contractor furnishes a supervisor, therapist and assistant on one day,
count one therapist day. If the contractor provides two assistants on one day (and no
supervisors or therapists), count one assistant day.
Line 5--Enter the number of unduplicated visits made by the supervisor or therapist. Count only
one visit when both the supervisor and therapist were present during the same visit.
Line 6--Enter the number of unduplicated visits made by the therapy assistant. Do not include in
the count the visits when either the supervisor or therapist was present during the same visit.
Line 7--Enter the standard travel expense rate applicable. (See CMS Pub. 15-1, chapter 14.)

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Line 8--Enter the optional travel expense rate applicable. (See CMS Pub. 15-1, chapter 14.) Use
this rate only for services for which time records are available.
Line 9--Enter in the appropriate columns the total number of hours worked for each category.
Line 10--Enter in each column the appropriate adjusted hourly salary equivalency amount
(AHSEA). This amount is the prevailing hourly salary rate plus the fringe benefit and expense
factor described in CMS Pub. 15-1, chapter 14. This amount is determined on a periodic basis for
appropriate geographical areas and is published as an exhibit at the end of CMS Pub. 15-1,
chapter 14. Use the appropriate exhibit for the period of this cost report.
Enter in column 1 the supervisory AHSEA, adjusted for administrative and supervisory
responsibilities. Determine this amount in accordance with the provisions of CMS Pub. 15-1,
chapter 14, §1412.5. Enter in columns 2, 3, and 4 (for therapists, assistants, aides, and trainees
respectively), the AHSEA from either the appropriate exhibit found in CMS Pub. 15-1, chapter 14
or from the latest publication of rates. If the going hourly rate for assistants in the area is
unobtainable, use no more than 75 percent of the therapist AHSEA. The cost of services of a
therapy aide or trainee is evaluated at the hourly rate, not to exceed the hourly rate paid to your
employees of comparable classification and/or qualification, e.g., nurses' aides.
(See
CMS Pub. 15-1, chapter 14, §1412.2.)
Line 11--Enter the standard travel allowance equal to one half of the AHSEA. Enter in columns 1
and 2, one half of the amount in column 2, line 10. Enter in column 3, one half of the amount in
column 3, line 10. (See CMS Pub. 15-1, chapter 14, §1402.4.)
Lines 12 and 13--Enter the number of travel hours and number of miles driven, respectively, if
time records of visits are kept. (See CMS Pub. 15-1, chapter 14, §§1402.5 and 1403.1.) Subscript
this line into two categories of provider site and provider offsite as necessary. For example, report
line 12 - provider site and line 12.01 - provider offsite.
NOTE: There is no travel allowance for aides employed by outside suppliers.
4019.2 Part II - Salary Equivalency Computation.--This part provides for the computation of the
full-time or intermittent part-time salary equivalency.
When you furnish therapy services from outside suppliers to health care program patients but
simply arrange for such services for non-health care program patients and do not pay the nonhealth care program portion of such services, your books reflect only the cost of the health care
program portion. Where you can gross up costs and charges in accordance with provisions of
CMS Pub. 15-1, chapter 23, §2314, complete Part II, lines 14 through 20, and 23, in all cases and
lines 21 and 22, where appropriate. See §4016 and CMS Pub. 15-1, chapter 23, §2314 for
instructions regarding grossing up costs and charges. However, where you cannot gross up costs
and charges, complete lines 14 through 20, and 23.
Line 14 through 20--To compute the total salary equivalency allowance amounts, multiply the
total hours worked (line 9) by the adjusted hourly salary equivalency amount for supervisors,
therapists, assistants, aides and trainees (for respiratory therapy only).
Line 17--Enter the sum of lines 14 and 15 for respiratory therapy, or sum of lines 14 through 16
for all others.
Line 20--Enter the sum of lines 17 through 19 for respiratory therapy, or sum of lines 17 and 18
for all other.

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Lines 21 and 22--If the sum of hours in columns 1 and 2 for respiratory therapy, or 1 through 3 for
all others, line 9, is less than or equal to the product found on line 2, complete these lines. (See
the exception above where you cannot gross up costs and charges, and services are provided to
program patients only.)
Line 21--Enter the result of line 17 divided by the sum of columns 1 and 2, line 9, for respiratory
therapy, or columns 1 through 3, line 9, for all others.
Line 22--Enter the result of line 2 times line 21.
Line 23--If there are no entries on lines 21 and 22, enter the amount on line 20. Otherwise, enter
the sum of the amounts on lines 18, 19, and 22 for respiratory therapy, or lines 18 and 22 for all
others.
4019.3 Part III - Standard and Optional Travel Allowance and Travel Expense Computation Provider Site.--This part provides for the computation of the standard and optional travel
allowance and travel expense for services rendered on site.
Lines 24 through 28--Complete these lines for the computation of the standard travel allowance
and standard travel expense for therapy services performed at your site. One standard travel
allowance is recognized for each day an outside supplier performs skilled therapy services at your
site. For example, if a contracting organization sends three therapists to you each day, only one
travel allowance is recognized per day. (See CMS Pub. 15-1, chapter 14, §1403.1, for a discussion
of standard travel allowance and §1412.6 for a discussion of standard travel expense.)
Line 24--Include the standard travel allowance for supervisors and therapists. This standard travel
allowance for supervisors does not take into account the additional allowance for administrative
and supervisory responsibilities. (See CMS Pub. 15-1, chapter 14, §1402.4.)
Line 25--Include the standard travel allowance for assistants for physical therapy, occupational
therapy, and speech pathology.
Line 26--Enter the amount from line 24 for respiratory therapy, or the sum of lines 24 and 25 for
physical therapy, occupational therapy, or speech pathology.
Line 27--Enter the result of line 7 times line 3 for respiratory therapy, or line 7 times the sum of
lines 3 and 4 for all others.
Lines 29 through 35--Complete these lines for computing the optional travel allowance and
expense when proper records are maintained.
Line 31--Enter the amount on line 29 for respiratory therapy or the sum of lines 29 and 30 for all
others.
Line 32--Enter the result of line 8 times the sum of columns 1 and 2, line 13, for respiratory
therapy, or columns 1, 2, and 3, line 13, for all other.
Lines 33 through 35--Enter an amount in one of these lines depending on the method utilized.
4019.4 Part IV - Standard and Optional Travel Allowance and Standard Travel Expense
Computation - Services outside Provider Site.--This part provides for the computation of the
standard travel allowance, the standard travel expense, the optional travel allowance, and the
optional travel expense. (See CMS Pub. 15-1, chapter 14, §§1402ff, 1403.1, and 1412.6.)

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Lines 36 through 39--Complete these lines for the computation of the standard travel allowance
and standard travel expense for therapy services performed in conjunction with offsite visits. Only
use these lines if you do not use the optional method of computing travel. A standard travel
allowance is recognized for each visit to a patient’s residence. If services are furnished to more
than one patient at the same location, only one standard travel allowance is permitted, regardless
of the number of patients treated.
Lines 40 through 43--Complete the optional travel allowance and optional travel expense
computations for physical therapy, occupational therapy, and speech pathology services in
conjunction with home health services only. Compute the optional travel allowance on lines 40
through 42. Compute the optional travel expense on line 43.
Lines 44 through 46--Choose and complete only one of the options on lines 44 through 46.
However, use lines 45 and 46 only if you maintain time records of visits. (See CMS Pub. 15-1,
chapter 14, §1402.5.)
4019.5 Part V - Overtime Computation.--This part provides for the computation of an overtime
allowance when an individual employee of the outside supplier performs services for you in excess
of your standard work week. No overtime allowance is given to a therapist who receives an
additional allowance for supervisory or administrative duties. (See CMS Pub. 15-1, chapter 14,
§1412.4.)
Line 47--Enter in the appropriate columns the total overtime hours worked. Where the total hours
in column 5 are either zero or, equal to or greater than 2080, the overtime computation is not
applicable. Make no further entries on lines 48 through 55 (If there is a short period prorate the
hours). Enter zero in each column of line 56. Enter in column 5 the sum of the hours recorded in
columns 1, 3 and 4 for respiratory therapy, and columns 1 through 3 for physical therapy, speech
pathology, and occupational therapy.
Line 48--Enter in the appropriate column the overtime rate (the AHSEA from line 10, column as
appropriate, multiplied by 1.5).
Line 50--Enter the percentage of overtime hours by class of employee. Determine this amount by
dividing each column on line 47 by the total overtime hours in column 5, line 47.
Line 51--Use this line to allocate your standard work year for one full-time employee. Enter the
numbers of hours in your standard work year for one full-time employee in column 5. Multiply
the standard work-year in column 5 by the percentage on line 50 and enter the result in the
corresponding columns.
Line 52--Enter in columns 1 through 3 for physical therapy, speech pathology, and occupational
therapy the AHSEA from Part I, line 10, columns 2 through 4, as appropriate. Enter in columns 1,
3, and 4, the AHSEA from Part I, line 10, columns 2, 4, and 5, for respiratory therapy.
Line 56--Enter in column 5, the sum of the amounts recorded in columns 1, 3, and 4, for respiratory
therapy, and columns 1 through 3, for physical therapy, speech pathology, and occupational
therapy.
4019.6 Part VI - Computation of Therapy Limitation and Excess Cost Adjustment.--This part
provides for the calculation of the adjustment to the therapy service costs in determining the
reasonableness of therapy cost.
Line 58--Enter the amount reported on lines 33, 34, or 35.
Line 59--Enter the amount reported on lines 44, 45, or 46.

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4019.6 (Cont.)

Lines 61 and 62--When the outside supplier provides the equipment and supplies used in
furnishing direct services to your patients, the actual cost of the equipment and supplies incurred
by the outside supplier (as specified in CMS Pub. 15-1, chapter 14, §1412.1) is considered an
additional allowance in computing the limitation.
Line 64--Enter the amounts paid and/or payable to the outside suppliers for the hospital, if
applicable, for therapy services rendered during the period as reported in the cost report. This
includes any payments for supplies, equipment use, overtime, or any other expenses related to
supplying therapy services for you. Add all subscripted lines together for purposes of calculating
the amount to be entered on this line.
Line 65--Enter the excess cost over the limitation, i.e., line 64 minus line 63. If the amount is
negative, enter a zero. Transfer this amount to Worksheet A-8, line 23, for respiratory therapy;
line 24, for physical therapy; line 30, for occupational therapy; and line 31, for speech pathology.

Rev.

40-115

4020
4020.

FORM CMS-2552-10

DRAFT

WORKSHEET B, PART I - COST ALLOCATION - GENERAL SERVICE COSTS
AND WORKSHEET B-1 - COST ALLOCATION - STATISTICAL BASIS

Base cost data on an approved method of cost finding and on the accrual basis of accounting except
where government institutions operate on a cash basis of accounting. (See 42 CFR 413.24(a).)
Cost data based on such basis of accounting is acceptable subject to appropriate treatment of capital
expenditures. Cost finding is the process of recasting the data derived from the accounts ordinarily
kept by you 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. The various cost finding
methods recognized are outlined in 42 CFR 413.24. Worksheets B, Part I, and B-1 have been
designed to accommodate the stepdown method of cost finding.
The provider can elect to change the order of allocation and/or allocation statistics, as appropriate,
for the current cost reporting period if a request is received by the contractor, in writing, 90 days
prior to the end of that reporting period. The contractor has 60 days to make a decision and notify
the provider of that decision or the change is automatically accepted. The change must be shown
to more accurately allocate the overhead or should demonstrate simplification in maintaining the
changed statistics. If a change in statistics is requested, the provider must maintain both sets of
statistics until an approval is made. If both sets are not maintained and the request is denied, the
provider reverts back to the previously approved methodology. The provider must include with
the request all supporting documentation and a thorough explanation of why the alternative
approach should be used. (See CMS Pub. 15-1, chapter 23, §2313.)
Simplified Cost Allocation Methodology
As an alternative approach to the cost finding methods identified in CMS Pub. 15-1, chapter 23,
§2306, the provider may request a simplified cost allocation methodology. This methodology
reduces the number of statistical bases a provider maintains. It may result in reducing Medicare
reimbursement. A comparison is recommended if the possible loss reimbursement is surpassed by
the reduced costs of maintaining voluminous statistics. The following statistical bases must be
used for purposes of allocating overhead cost centers. There can be no deviation of the prescribed
statistics and it must be utilized for all the following cost centers.
Cost Center

Statistical Basis

Buildings and Fixtures
Movable Equipment
Maintenance and Repairs
Operation of Plant
Housekeeping
Employee Benefits
Cafeteria*
Administrative and General
Laundry and Linen
Dietary**
Social Service
Maintenance of Personnel

Square Footage
Square Footage
Square Footage
Square Footage
Square Footage
Salaries
Salaries
Accumulated Costs
Patient Days
Patient Days
Patient Days
Eliminated and moved to A&G for simplified cost
finding
Nursing Salaries
Costed Requisitions
Costed Requisitions
Gross Patient Revenue
Assigned Time
Assigned Time
Assigned Time
100 percent to Anesthesiology

Nursing Administration
Central Services and Supply
Pharmacy
Medical Records and Library
Nursing Program*
Interns and Residents
Paramedical Education
Nonphysician Anesthetists

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Rev.

03-18

FORM CMS-2552-10

4020 (Cont.)

NOTE: The election of the alternative method discussed above cannot result in inappropriately
shifting costs.
*Contract labor is not included and is not grossed up.
**If this is a meals on wheels program, a Worksheet A-8 adjustment is required.
Once the simplified method is elected, the provider must continue to use this method for no less
than 3 years, unless a change of ownership occurs.
The 90-day and 60-day rule previously discussed in this section still applies (CMS Pub. 15-1,
chapter 23, §2313).
Continuation of the Standard Allocation Methodology Instructions
Worksheet B, Part I, provides for the allocation of the expenses of each general service cost center
to those cost centers which receive the services. The cost centers serviced by the general service
cost centers include all cost centers within your organization, other general service cost centers,
inpatient routine service cost centers, ancillary service cost centers, outpatient service cost centers,
other reimbursable cost centers, special purpose cost centers, and nonreimbursable cost centers.
Obtain the total direct expenses from Worksheet A, column 7.
All direct GME costs (inpatient and outpatient in approved programs) are reimbursed based on a
specific amount per resident as computed on Worksheet E-4. Costs applicable to interns and
residents must still be allocated in columns 21 and 22. These costs are, however, eliminated from
total costs in column 25, unless you qualify for an exception. See the instructions for column 25
for a more detailed explanation.
Worksheet B-l provides for the proration of the statistical data needed to equitably allocate the
expenses of the general service cost centers on Worksheet B, Part I. To facilitate the allocation
process, the general format of Worksheets B, Part I, and B-1 is identical. Each general service
cost center has the same line number as its respective column number across the top. Also, the
column and line numbers for each general service cost center are identical on the two worksheets.
In addition, the line numbers for each routine service, ancillary outpatient service, other
reimbursable, special purpose, and nonreimbursable cost center are identical on the two
worksheets. The cost centers and line numbers are also consistent with Worksheet A. If you have
subscripted any lines on Worksheet A, subscript the same lines on these worksheets.
NOTE: General service columns 1 through 23 and subscripts thereof must be consistent on
Worksheets B, Parts I and II; H-2, Part I; J-1, Part I; K-5, Part I; and L-1, Part I.
The statistical basis shown at the top of each column on Worksheet B-1 is the recommended basis
of allocation of the cost center indicated which must be used by all providers completing this form.
If a different basis of allocation is used, you must indicate the basis of allocation actually used at
the top of the column subject to the applicable provisions of CMS Pub. 15-1, chapter 23, §2313.
Additionally, the following overhead cost center statistics can be substituted for the recommended
statistics printed on Worksheet B-1 subject to the applicable provisions of CMS Pub. 15-1,
chapter 23, §2313.
Cost Center

Statistical Basis

Housekeeping
Cafeteria
Maintenance of Personnel
Medical Records

Square Footage
FTEs
Eliminate and move to A&G
Gross Patient Revenue

Rev. 14

40-117

4020 (Cont.)

FORM CMS-2552-10

03-18

Most cost centers are allocated on different statistical bases. However, for those cost centers with
the same basis (e.g., square feet), the total statistical base over which the costs are allocated differs
because of the prior elimination of cost centers that have been closed.
The general service cost centers are ordered sequentially such that the cost centers that render the
most services to and receive the least services from other cost centers are listed first. When closing
the general service cost centers, first close the cost centers that render the most services to and
receive the least services from other cost centers. List the cost centers in this sequence from left
to right on the worksheets. However, your circumstances may be such that a more accurate result
is obtained by allocating to certain cost centers in a sequence different from that followed on these
worksheets.
NOTE: General service cost centers are not allocated to provider-based physician (PBP) clinical
lab service (line 61) because this cost center is treated as a purchased service under
arrangements provided only to program beneficiaries.
If the amount of any cost center on Worksheet A, column 7, has a credit balance, show this amount
as a credit balance on Worksheet B, Part I, column 0. Allocate the costs from the applicable
overhead cost centers in the normal manner to the cost center showing a credit balance. After
receiving costs from the applicable overhead cost centers, if a general service cost center has a
credit balance at the point it is allocated, do not allocate the general service cost center. Rather,
enter the credit balance in parentheses on line 201 as well as on the first line of the column and on
line 202. This enables column 24, line 202, to crossfoot to columns 0 and 4A, line 202, if the
provider has intern & resident costs or a post step-down adjustment in column 25. However,
column 26 will cross foot to columns 0 and 4A if the provider has no interns and residents costs
or a post step-down adjustment in column 25. After receiving costs from the applicable overhead
cost centers, if a revenue producing cost center has a credit balance on Worksheet B, Part I,
column 26, do not carry forward a credit balance to any worksheet.
On Worksheet B-1, enter on the first line in the column of the cost center being allocated the total
statistical base over which the expenses are allocated (e.g., in column 1,
capital-related cost - building and fixtures, enter on line 1 the total square feet of the building on
which depreciation was taken). For all cost centers to which the capital-related cost is allocated,
enter that portion of the total statistical base applicable to each. The sum of the statistical base
applied to each cost center receiving the services rendered must equal the total base entered on the
first line. Use accumulated cost for allocating A&G expenses.
Do not include any statistics related to services furnished under arrangements except if:
•

Both Medicare and non-Medicare costs of arranged for services are recorded in your
records; or

•

Your contractor determines that you are able to (and do) gross up the costs and charges
for services to non-Medicare patients so that both cost and charges are recorded as if
you had furnished such services directly to all patients. (See CMS Pub. 15-1,
chapter 23, §2314.)

Enter on line 202 of Worksheet B-l the total expenses of the cost center being allocated. Obtain
this amount from Worksheet B, Part I, from the same column and line number used to enter the
statistical base on Worksheet B-1. (In the case of capital-related costs - buildings and fixtures, this
amount is on Worksheet B, Part I, column 1, line 1.)
Divide the amount entered on line 202 by the total statistic entered in the same column on the first
line. Enter the resulting unit cost multiplier on line 203. Round the unit cost multiplier to six
decimal places.

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FORM CMS-2552-10

4020 (Cont.)

Multiply the unit cost multiplier by that portion of the total statistics applicable to each cost center
receiving the services rendered. Enter the result of each computation on Worksheet B, Part I, in
the corresponding column and line. (See §4000.1 for rounding standards.)
After applying the unit cost multiplier to all the cost centers receiving the services rendered, the
total cost (line 202) of all the cost centers receiving the allocation on Worksheet B, Part I, 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, Part I, and
B-1 before proceeding to the column for the next cost center.
If a general service cost center has a credit balance at the point it is allocated on Worksheet B,
Part I, do not allocate the general service cost centers. However, display the statistic
departmentally, but do not calculate a unit cost multiplier for lines 203 and 205 on Worksheet B-1.
Use line 204 of Worksheet B-1 in conjunction with the allocation of capital-related costs on
Worksheet B, Part II. Complete line 204 for all columns after Worksheets B, Part I, and B-1 are
completed and the amount of direct and indirect capital-related cost is determined on Worksheet B,
Part II, column 2A. Use line 205 for all columns in allocating the direct and indirect capital-related
cost on Worksheet B, Part II. Compute the unit cost multiplier (after the amount entered on
line 204 has been determined) by dividing the capital-related costs recorded on line 204 by the
total statistic entered in the same column on the first line. Round the unit cost multipliers to six
decimal places. (See instructions for Worksheet B, Part II, for the complete methodology and
exceptions.)
Do not use line 200 to allocate costs on Worksheet B, Part I.
Since intern and resident costs are segregated into two cost centers, properly allocate general
service costs applicable to each center. A listing of general service cost centers which may be
applicable and the appropriate allocation to the separate cost centers for the intern and resident
costs is presented below.
Cost Center
Capital Related Costs - Bldgs. & Fixtures
Capital Related Costs - Movable Equipment
Employee Benefits
Administrative and General
Maintenance and Repair
Operation of Plant
Housekeeping
Cafeteria
Maintenance of Personnel

Rev.

Salary &
Salary Related
Fringe Benefits
X
X
X

Other
X
X
X
X
X
X
X
X
X

40-119

4020 (Cont.)

FORM CMS-2552-10

DRAFT

After the costs of the general service cost center have been allocated on Worksheet B, Part I, enter
in column 24, the sum of the costs in columns 4A through 23, for lines 30 through 201. Once
overhead is allocated to these cost centers, they are closed and the costs are not further allocated
to the revenue producing cost centers.
Since costs applicable to direct GME costs (inpatient and outpatient in approved programs) are
reimbursed based on a specific amount per resident, exclude these costs from the total costs in
column 26. Enter on each line in column 25 the sum of the amounts shown on each line in
columns 21 and 22. If you qualify for the exception (cost reimbursed hospital such as CAHs do
not offset I&R costs), enter only the amounts from Worksheet B-2.
In addition, when an adjustment to expenses is required after cost allocation, enter the amount
applicable to each cost center in column 25 of Worksheet B, Part I. Corresponding adjustments to
Worksheet B, Part II, may be applicable for capital-related cost adjustments. Submit a supporting
worksheet showing the computation of the adjustments in addition to completing Worksheet B-2.
NOTE: The amount reported in column 25 must equal both the sum of the amounts shown in
columns 21 and 22, unless you qualify for the exception and the amounts on
Worksheet B-2, excluding adjustments with a worksheet code of “4.” See the
instructions for column 25 for a more detailed explanation.
Other examples of adjustments to expenses which may be required after cost allocation are (1) the
allocation of available costs between the certified portion and the non-certified portion of a distinct
part provider, and (2) costs attributable to unoccupied beds in a hospital with a restrictive
admission policy. (See CMS Pub. 15-1, chapter 23, §§2342-2344.3.)
After the adjustments have been entered on Worksheet B, Part I, column 25, subtract the amounts
in column 25 from the amounts in column 24, and enter the resulting amounts in column 26 for
each line. The cost subtotal entered in column 24, line 202, must equal the total costs entered in
column 0, line 202.
Transfer the totals in column 26, lines 30 through 46 (inpatient routine service cost centers),
lines 50 through 78 (ancillary service cost centers), lines 88 through 93 (outpatient service cost
centers), lines 94 through 101 (other reimbursable cost centers), and lines 105 through 117 (special
purpose cost centers) to Worksheet C, Parts I and II, column l, lines 30 through 117. For cost
reporting periods beginning before October 1, 2014, hospital-based RHC/FQHCs transfer the total
costs from column 26, lines 88 and 89, respectively, to Worksheet M-2. For cost reporting periods
beginning on or after October 1, 2014, hospital-based RHCs transfer the total costs from
column 26, line 88, to Worksheet M-2. For cost reporting periods beginning on or after
October 1, 2014, hospital-based FQHCs see instructions for Worksheet N-2, column 4.

40-120

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FORM CMS-2552-10

4020 (Cont.)

Transfer the total cost in column 26, line 100 (intern/resident services not in approved teaching
program) to Worksheet D-2, Part I, column 2, line 1.
The total outpatient rehabilitation costs in column 26, line 93, and subscripts, must agree with
Worksheet J-1, Part I, column 26, line 22, for each provider type.
Do not transfer ASC costs from column 26, line 115. Do not transfer the nonreimbursable cost
center totals (lines 190 through 193).
NOTE: Do not transfer negative numbers.
Column Descriptions
Column 1--Include only capital costs for building and fixtures. See the instructions for
Worksheet A, line 1, for a discussion capital-related costs for building and fixtures.
Column 2--Include only capital costs for movable equipment. See the instructions for
Worksheet A, line 2, for a discussion capital-related costs for movable equipment.
Column 20--All nursing program costs that are considered normal operating costs in
42 CFR 413.85(h)(6) (and identified as criterion code 4 in column 3 of Worksheet S-2, Part I,
subscripts of line 60) do not transfer to Worksheet D, Part III, and Part IV.
Column 23--All paramedical/allied health costs that are considered normal operating costs in
42 CFR 413.85(h)(6) (and identified as criterion code 4 in column 3 of Worksheet S-2, Part I,
subscripts of line 60) do not transfer to Worksheet D, Part III, and Part IV.
Worksheet B, Part I, Column 25--Hospitals other than CAHs--Accumulate in this column the
costs for interns and residents. Except as provided in 42 CFR 413.77(e)(1), the costs of interns
and residents (direct GME costs for inpatient and outpatient in approved programs) for PPS and
TEFRA hospitals are paid on a per resident amount (PRA) through Worksheet E-4. In order to
avoid duplicate payments of interns and residents costs, enter the sum of the amounts reported on
each line in columns 21 and 22 in the appropriate line of column 25. When an adjustment to
expenses is required after cost allocation, enter on the appropriate lines in this column the amounts
from Worksheet B-2, excluding adjustments with a worksheet code of “4.” The total of
columns 21 and 22 and the applicable lines on Worksheet B-2, must equal the total of column 25.
NOTE: In accordance with 42 CFR 413.77(e), if a hospital did not have any approved medical
residency programs or did not participate in Medicare during the base period but either
condition changes in a cost reporting period beginning on or after October 1, 2006 and
the residents are not on duty during the first month of the cost reporting period in which
the hospital first begins to train residents, the contractor establishes a PRA using
information from the first cost reporting period immediately following the cost reporting
period during which the hospital participates in Medicare and residents began training at
the hospital. Any interns and residents costs incurred during the cost reporting period,
prior to the base period used to calculate the PRA, are reimbursed as pass-through costs
based on reasonable costs on Worksheets D, Parts III and IV, and D-2, Part II, if
applicable. If Worksheet S-2, Part I, line 57, column 1, is “Y” and column 2 is “N”, do
not include in column 25 the interns and residents costs from columns 21 and 22.
If Worksheet S-2, Part I, line 57, column 1, contains an “N” or column 2 contains a “Y”,
include in column 25 the interns and residents in approved programs costs from
columns 21 and 22 because these costs will be reimbursed on a PRA basis through
Worksheet E-4.
CAHs--If you are CAH and responded “Y” to Worksheet S-2, Part I, line 107 (indicating that you
have an I&R training program), the GME elimination is not performed. Consequently, do not
include in column 25 the intern and resident costs from columns 21 and 22.
Rev.

40-121

4020 (Cont.)

FORM CMS-2552-10

DRAFT

Worksheet B-1, Column 5A--Enter the costs attributable to the difference between the total
accumulated cost reported on Worksheet B, Part I, column 4A, line 202, and the accumulated cost
reported on Worksheet B-1, column 5, line 5. Enter any amounts reported on Worksheet B, Part I,
column 4A, for (1) any service provided under arrangements to program patients and which is not
grossed up and (2) negative balances. Enter a negative one (-1) in the accumulated cost column
to identify the cost center which should be excluded from receiving any A&G costs.
If some of the costs from that cost center are to receive A&G costs then enter in the reconciliation
column the amount not to receive A&G costs to assure that only those costs to receive overhead
receive the proper allocation. For example, organ acquisition cost centers must exclude from the
accumulated cost statistic those costs associated with organs purchased from an OPO or another
transplant hospital as these costs already include A&G costs. Likewise, exclude costs associated
with the CAR T-cell manufactured biologic. Including a statistical cost which does not relate to
the allocation of A&G expenses causes an improper distribution of overhead (see
42 CFR 413.24(d)(6). In addition, report on line 5 the A&G costs reported on Worksheet B, Part I,
column 5, line 5, since these costs are not included on Worksheet B-1, column 5, as an
accumulated cost statistic.
For componentized 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 5.03 (Other A&G), the reconciliation column designation
must be 5A.03.
Worksheet B-1, Column 5--The A&G expenses are allocated on the basis of accumulated costs.
Therefore, the amount entered on Worksheet B-l, column 5, line 5, is the difference between the
amounts entered on Worksheet B, Part I, column 4A and Worksheet B-1, column 5A. A negative
cost center balance in the statistics for allocating A&G expenses causes an improper distribution
of this overhead cost center. Exclude negative balances from the allocation statistics.
Worksheet B-1, Column 20--Enter the appropriate statistics for each nursing program based on
assigned time. Nursing program costs reported on line 20, and its subscripts, may not be allocated
to another program listed on line 20, or its subscripts.
Worksheet B-1, Column 23--Enter the appropriate statistics for each paramedical education/allied
health program based on assigned time. If, however, the use of assigned time is not appropriate
for that paramedical education program (i.e., a non-direct patient care cost center), a different
statistical basis may be used. For example, if you have a paramedical education program for
hospital administration, using assigned time as the statistical basis may be inappropriate. Use
accumulated costs as the statistical basis for allocating hospital administrative paramedical
education program costs. Paramedical education/allied health program costs reported on line 23,
and its subscripts, may not be allocated to another program listed on line 23, or its subscripts.
Worksheet B-1, Columns 20 and 23, Lines 206 (NAHE Adjustment Amount to be Allocated)
and 207 (NAHE Unit Cost Multiplier)--For each line on Worksheet B-2, where column 2, is “4”
(indicating a post stepdown adjustment for nursing program education costs and/or allied
health/paramedical education costs), enter on line 206 in the corresponding column 20 and/or 23,
and applicable subscripts, the adjustment amount (as a positive number) from the corresponding
line of Worksheet B-2, column 4.
Enter on line 207 the NAHE unit cost multiplier by dividing the adjustment amount on line 206,
by the total statistic at the top of the applicable column. Calculate the NAHE post step-down
adjustment by multiplying the NAHE unit cost multiplier by the applicable cost center statistic and
enter the resulting amount in the corresponding cost center on Worksheet D, Part III, columns 1A
and 2A, and Worksheet D, Part IV, columns 2A and 3A, as appropriate. Since the NAHE
adjustment columns on Worksheets D, Parts III and IV, are not subscriptable, combine the NAHE
adjustment amounts on Worksheet D, Part III columns 1A and 2A, respectively, and Worksheet D,
Part IV, columns 2A and 3A, respectively, when Worksheet B-1, columns 20 and/or 23, are
subscripted. See the instructions for Worksheets D, Parts III and IV, for further information.
40-122

Rev.

11-16
4021.

FORM CMS-2552-10

4021

WORKSHEET B, PART II - ALLOCATION OF CAPITAL-RELATED COSTS

This worksheet provides for the determination of direct and indirect capital-related costs allocated
to those cost centers which receive the services. The cost centers serviced by the general service
cost centers include all cost centers within your organization, other general service cost centers,
inpatient routine service cost centers, ancillary service cost centers, outpatient service cost centers,
other reimbursable cost centers, special purpose cost centers, and nonreimbursable cost centers.
Hospitals receiving 100 percent Federal rate for IPPS capital payments complete Worksheet B,
Part II in its entirety.
NOTE: Unless there is a change in ownership or the provider has elected the alternative method
described in §4017, the hospital must continue the same cost finding methods (including
its cost finding bases) in effect in the hospital's prior cost reporting period. If there is a
change in ownership, the new owners may request that the contractor approve a change
in order to be consistent with their established cost finding practices. (See
CMS Pub. 15-1, chapter 23, §2313.)
Part II is completed by all IPPS hospitals and IPPS excluded hospitals which were part of a
complex subject to IPPS. Freestanding hospitals excluded from IPPS are not required to complete
Part II.
See the instructions for Worksheet A, lines 1 and 2, for a discussion of capital-related costs.
Use these worksheets in conjunction with Worksheets B, Part I and B-1. The format and allocation
process employed are identical to that used on Worksheets B, Part I, and B-1. Any cost centers,
subscripted lines, and/or columns added to Worksheet A are also added to Worksheet B, Part II,
in the same sequence.
Column 0--Where capital-related costs have been directly assigned to specific cost centers on
Worksheet A, column 7, in accordance with CMS Pub. 15-1, chapter 23, §2307, enter in this
column those amounts directly assigned from your records. Where you include cost incurred by a
related organization, the portion of these costs that are capital-related costs is considered directly
assigned capital-related costs of the applicable cost center. For example, if you are part of a chain
organization that includes some costs incurred by the home office of the chain organization in your
A&G cost center, the amount so included represents capital-related costs included in this column.
Columns l and 2--Obtain the amounts entered in columns l and 2, lines 4 through 199, from the
corresponding columns and lines on Worksheet B, Part I.
Column 2A--Enter the sum of columns 0 through 2 for each line.
Enter on line 204 of Worksheet B-l for each column the capital-related costs allocated. Report
these costs on the first line of each column on Worksheet B, Part II. (See exceptions below.)
Complete a unit cost multiplier for each column by dividing the amount on line 204 of
Worksheet B-l by the statistic reported on the first line of the same column. Enter the unit cost
multiplier on line 205 and round to six decimal places, e.g., .0622438 is rounded to .062244. The
allocation process on Worksheet B, Part II, is identical to that used on Worksheets B, Part I,
and B-l.
Multiply the unit cost multipliers on line 205 by the portion of the total statistic on Worksheet B-1
applicable to each cost center. Enter the result of each computation on Worksheet B, Part II,
respectively, in the corresponding column and line.

Rev. 10

40-123

4021 (Cont.)

FORM CMS-2552-10

11-16

After the unit cost multipliers have been applied to all the cost centers, the total cost on
Worksheet B, Part II, line 202, of all the cost centers receiving the allocation must equal the
amount allocated on the first line of the column. However, this is not true in circumstances
described in the second paragraph of exceptions below. Perform these procedures for each general
service cost center. Complete the column for each cost center on Worksheets B-1 and B, Part II,
before proceeding to the column for the next cost center.
EXCEPTIONS: When a general service cost center is not allocated on Worksheet B, Part I,
because it has a negative balance at the point it is to be allocated, the
capital-related cost for the same general service cost center on Worksheet B,
Part II, is not allocated. Enter the total capital-related cost on line 201, the
negative cost center line. This enables column 2A, line 202, to cross foot to
column 26, line 202, if no intern and resident cost or post step-down
adjustments are identified in column 25. Otherwise column 2A, line 202, will
crossfoot to line 24.
When a general service cost center has a negative direct cost balance on
Worksheet B, Part I, column 0, and the negative balance becomes positive
through the cost allocation process, adjust the amount of capital-related cost
determined on Worksheet B, Part II, for that general cost center to reflect the
amount allocated on Worksheet B, Part I. Determine the adjusted amounts of
capital related cost allocated on Worksheet B, Part II, by dividing the
capital related cost by the total indirect cost allocated to the specific cost center
on Worksheet B, Part I. (Do not include the negative direct cost.) Then
multiply that ratio by the net amount allocated on Worksheet B, Part I, for that
specific cost center. For cross footing purposes, enter the adjusted
capital-related costs on the first line of the column and the differences between
the total capital-related cost and the adjusted capital-related cost on line 201 of
Worksheet B, Part II. This enables column 2A, line 202, to cross foot to
column 26, line 202, if no intern and resident cost or post step-down
adjustments are identified in column 25. Otherwise column 2A, line 202, will
crossfoot to line 24.
After all the capital-related costs of the general service cost centers have been allocated on
Worksheet B, Part II, enter in column 24, the sum of columns 2A through 23, for lines 30
through 201.
When an adjustment to expenses is required after cost allocation, show the amount applicable to
each cost center in column 25 of Worksheet B, Part II. Submit a supporting worksheet showing
the computation of the adjustment in addition to completing Worksheet B-2.
Adjustments to expenses which may be required after cost allocation include (1) the allocation of
available costs between the certified portion and the noncertified portion of a distinct part provider,
and (2) costs attributable to unoccupied beds of a hospital with a restrictive admission policy. (See
CMS Pub. 15-1, chapter 23, §§2342-2344.3.)
After the adjustments have been entered on Worksheet B, Part II, column 25, subtract the amounts
in column 25 from the amounts in column 24, and enter the resulting amounts in column 26 for
each line. The total costs entered in column 26, line 202, must equal the total costs entered in
column 2A, line 202, if no intern and resident cost or post step-down adjustments are identified in
column 25, otherwise column 2A, line 202, will equal line 24.
On Worksheet B, Part II, columns 19 through 23, lines 30 through 194, are shaded because the full
amount of nonphysician anesthetists and medical education costs is obtained from Worksheet B,
Part I, columns 19 through 23. Enter these amounts on line 200 for cross footing purposes. If
column 20 is subscripted for additional education cost centers qualifying as educational
pass-through costs (see the instructions for Worksheet A, lines 20 through 23), the subscripted
column(s) must be shaded similarly to column 20.
40-124

Rev. 10

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FORM CMS-2552-10

4021 (Cont.)

Since capital-related cost, non-physician anesthetists, and approved education programs are not
included in the operating cost per discharge, columns 19 through 23, lines 30 through 194, are
shaded on Worksheet B, Part II, for all lines except lines 19 through 23, 200, 201, and 202. These
are the only lines and columns where an approved educational cost center can be shown. For
purposes of this paragraph only, the statistic for line 200 is the sum of the statistics on lines 30
through 117 and lines 190 through 194 on Worksheet B-1 for the same column. Enter these
amounts on line 200 for cross footing purposes. Use line 200 of Worksheet B-1, columns 19
through 23, for this purpose in the allocation of capital-related cost on Worksheet B, Part II. Use
the statistic on line 200 together with the statistics on lines 19 through 23 of Worksheet B-1 to
allocate columns 19 through 23 of Worksheet B, Part II. If column 20 is subscripted for additional
education cost centers qualifying as educational pass-through costs (see the instructions for
Worksheet A, lines 20 through 23), the subscripted column(s) must be shaded similarly to
columns 20 through 23.
The total for each column includes lines 200 and 201 for cross footing purposes.
Transfer:

Rev.

From Worksheet B, Part II, Column 26

To Worksheet D, Part I

Line 30 - Adults and Pediatrics

Column l, line 30 for the hospital

Lines 31 through 35 - Intensive Care
Type Inpatient Hospital Units
Line 40 - IPF Subprovider

Column 1, lines 31 through 35

Line 41 - IRF Subprovider

Column l, line 41

Line 42 - Subprovider

Column l, line 42

Line 43 - Nursery

Column 1, line 43 for titles V and XIX

From Worksheet B, Part II, Column 26

To Worksheet D-l, Part III

Line 44 - SNF

Line 75 for the SNF

Sum of lines 44 and 45

Line 75 for the NF

From Worksheet B, Part II, Column 26

To Worksheet D, Part II

Lines 50 through 78 - Ancillary Services

Column l, lines 50 through 78

Lines 90, 91, 92 and its subscripts, and
93 - Outpatient Service Cost and its
subscripts
Lines 94, 95, and 98 - Other
Reimbursable Cost Centers

Column l, lines 90, 91, 92 and its
subscripts, and 93 and its subscripts

From Worksheet B, Part II, Column 26

To Worksheet C, Part II, Column 2

Lines 50 through 98

Column l, line 40

Column l, lines 94, 95, and 98

40-125

4022
4022.

FORM CMS-2552-10

DRAFT

WORKSHEET B-2 - POST STEP-DOWN ADJUSTMENTS

This worksheet provides an explanation of the post step-down adjustments reported in column 25
of Worksheets B, Parts I and II; D, Parts III and IV; and L-1, Part I.
Column Descriptions
Column 1--Enter a brief description of the post step-down adjustment.
Column 2--Make post step-down adjustments on Worksheets B, Parts I and II; D, Parts III and IV;
and L-1, Part I. Enter the worksheet code to which the post step-down adjustment applies. For
lines 74 and/or 94, remove the amount for ESAs (i.e., Epoetin and Aranesp) reported on
Worksheet S-5, lines 13, 14, 17, 18, and subscripts of line 22, columns 2 and 3.
Use the codes below to identify the worksheet in which the adjustment applies:
Code
1
2
3
4

Worksheet
B, Part I
B, Part II
L-1, Part I
D, Part III and D, Part IV

Column 3--Enter the worksheet line number to which the adjustment applies.
Column 4--Enter the amount of the adjustment. Transfer these amounts to the appropriate lines
on Worksheets B, Parts I and II, or L-1, Part I, column 25.
Line Descriptions
Line 1--Enter the amount of the EPO adjustment for the renal dialysis inpatient department from
Worksheet S-5, line 13. Do not use this line effective for cost reporting periods ending after
December 31, 2012.
Line 2--Enter the amount of the EPO adjustment for the home dialysis program from
Worksheet S-5, line 14. Do not use this line effective for cost reporting periods ending after
December 31, 2012.
Line 3--Enter the amount of the Aranesp adjustment for the renal dialysis inpatient department
from Worksheet S-5, line 17. Do not use this line effective for cost reporting periods ending after
December 31, 2012.
Line 4--Enter the amount of the Aranesp adjustment for the home dialysis program from
Worksheet S-5, line 18. Do not use this line effective for cost reporting periods ending after
December 31, 2012.
Line 5--Enter the amount of the ESA adjustment for the renal dialysis inpatient department from
Worksheet S-5, sum of the subscripts of line 22, column 2. Complete this line effective for cost
reporting periods ending after December 31, 2012.
Line 6--Enter the amount of the ESA adjustment for the home dialysis program from
Worksheet S-5, sum of the subscripts of line 22, column 3. Complete this line effective for cost
reporting periods ending after December 31, 2012.

40-126

Rev.

01-22

FORM CMS-2552-10

4022 (Cont.)

Lines 7 through 59--Enter any additional adjustments that are required under the Medicare
principles of reimbursement. Label the lines appropriately to indicate the nature of the required
adjustments. If the number of blank lines is not sufficient, use additional Worksheets B-2.
For cost reporting periods ending on or after September 30, 2017, report a post step-down
adjustment, if applicable, for each non-provider operated NAHE program identified on
Worksheet S-2, subscripts of line 60, with a code of “2” or “3” in column 3:
1. for the portion of program cost that exceeds the percentage of total allowable provider
cost attributable to NAHE clinical training costs reported in the most recent cost
reporting period ending on or before October 1, 1989, as defined in
42 CFR 413.85(g)(2)(iii).
2. for the portion of program costs that the provider did not incur for courses that were
included in the program as defined in 42 CFR 413.85(g)(3)(iii);
For each non-provider operated NAHE program, enter a brief description of the post step-down
adjustment in column 1. Enter in column 2 the worksheet code “4.” These post step-down
adjustments are applied to Worksheet D, Parts III, and IV. Enter the Worksheet A line number of
the NAHE program being adjusted in column 3. Column 3 must be either nursing program
(line 20, or a subscript of line 20) or paramedical education/allied health (line 23, or a subscript of
line 23). Enter the post step-down adjustment amount in column 4.
For example: The provider qualifies for pass-through payment under 42 CFR 413.85(g)(2) for a
non-provider operated nursing program reported on Worksheet A, line 20. The pass-through cost
for the program is limited to a percentage of allowable cost attributable to the clinical training cost
in the provider’s most recent cost reporting period ending on or before October 1, 1989. The
provider’s capped percentage in the current cost reporting period, based on the cost reporting
period ending on or before October 1, 1989, is 10 percent, calculated in accordance with
42 CFR 413.85(g)(2)(iii). The post step-down adjustment would be calculated as follows:
Current year total allowable costs (W/S A, col. 7, line 118):
Times 10 percent (1989 cap):
Current year nursing program clinical training costs
(W/S A, col. 7, line 20):
Current year cost in excess of cap ($180,000-$150,000):
Percentage of cost in excess of cap ($30,000/$180,000):
Current year nursing program clinical training costs
(W/S B, Part I, col. 20, line 20):
W/S B-2 post step-down adjustment needed ($225,000 x 17%):

$1,500,000
$150,000
$180,000
$30,000
17%
$225,000
$38,250

NOTE: Do not use this worksheet to reduce the total allowable costs that are directly related to
the NAHE programs by the revenue received from tuition and student fees. Use
Worksheet A-8 to offset NAHE program costs by tuition and student fees
(42 CFR 413.85(d)(2)(i)). Do not use a post step-down adjustment.

Rev. 17

40-126.1

4022 (Cont.)

FORM CMS-2552-10

01-22

This page is reserved for future use.

40-126.2

Rev. 17

DRAFT
4023.

FORM CMS-2552-10

4023.1

WORKSHEET C - COMPUTATION OF RATIO OF COST TO CHARGES AND
OUTPATIENT CAPITAL REDUCTION

4023.1 Part I - Computation of Ratio of Cost to Charges.--This worksheet computes the ratio of
cost to charges for inpatient services, ancillary services, outpatient services, and other reimbursable
services. All charges entered on this worksheet must comply with CMS Pub. 15-1, chapter 22,
§§2202.4 and 2203. This ratio is used on Worksheet D, Part V, for titles V and XIX, and for
title XVIII; Worksheet D-3; Worksheet D-4; Worksheet H-3, Part II; and Worksheet J-2, Part II,
to determine the program's share of ancillary service costs in accordance with 42 CFR 413.53.
This worksheet is also needed to determine the adjusted total costs used on Worksheet D-1 because
of your status as IPPS, TEFRA, or other.
42 CFR 413.106(f)(3) provides that the costs of therapy services furnished under arrangements to
a hospital inpatient are exempt from the guidelines for physical therapy and respiratory therapy if
such costs are subject to the provisions of 42 CFR 413.40 (rate of increase ceiling) or 42 CFR 412
(inpatient prospective payment). However, therapy services furnished under arrangements to
CAHs are subject to the provisions of 42 CFR 413.106.
42 CFR 415.70(a)(2) provides that RCE limits do not apply to the costs of physician compensation
attributable to furnishing inpatient hospital services (provider component) paid for under
42 CFR 412ff.
To facilitate the cost finding methodology, apply the therapy limits and RCE limits to total
departmental costs. This worksheet provides the mechanism for adjusting the costs after cost
finding to comply with 42 CFR 413.106(f)(3) and 42 CFR 415.70(a)(2). This is done by
computing a series of ratios in columns 9 through 11. In column 9, a ratio referred to as the “cost
or other ratio” is computed based on the ratio of total reasonable cost to total charges. This ratio
is used by you or your components not subject to the IPPS or TEFRA (e.g., hospital-based SNFs
and CAHs). Also use this ratio for Part B services still subject to cost reimbursement. In
column 10, compute a TEFRA inpatient ratio. This ratio reflects the add-back of respiratory
therapy/physical therapy (RT/PT) limitations to total cost since TEFRA inpatient costs are not
subject to these limits. (TEFRA inpatient services are subject to RCE limits.) In column 11,
compute an IPPS inpatient ratio. This ratio reflects the add-back of RT/PT and RCE limitations
to total cost since inpatient hospital services covered by the IPPS are not subject to any of these
limitations.
Column Descriptions
The following provider components may be subject to 42 CFR 413.40 or 42 CFR 412.1(a)ff:
•
•
•
•

Hospital Part A inpatient services for title XVIII,
Hospital subprovider Part A inpatient services for title XVIII,
Hospital inpatient services for titles V and XIX, and
Hospital subprovider services for titles V and XIX.

All components or portions of components not subject to IPPS, IPF PPS, IRF PPS, LTC PPS, or
TEFRA, e.g., CAH services, are classified as “Cost or Other.”
The following matrix summarizes the columns completed for Cost or Other, TEFRA Inpatient,
and IPPS:
Columns
Type of Service Inpatient
Inpatient routine service cost centers (lines 30-46)

Rev.

Cost or
Other
1-3

TEFRA
Inpatient
1-3

IPPS,
IPF-PPS,
IRF-PPS
1-5

40-127

4023.1 (Cont.)

FORM CMS-2552-10

DRAFT
Columns

Type of Service Inpatient (Cont.)
Inpatient ancillary (lines 50-93)

Cost or
Other
1, 8, 9

TEFRA
Inpatient
1-3, 8-10

IPPS,
IPF-PPS,
IRF-PPS
1-9, 11

Other Reimbursable (lines 94-98)

1, 8, 9

1-3, 8-10

1-9, 11

Other Reimbursable (lines 99-101)

1, 8

1-3, 8

1-8

Special Purpose (lines 105-117)

1, 8

1-3, 8

1-8

Column 1--Enter on each line the amount from the corresponding line of Worksheet B, Part I,
column 26. Transfer the amount on line 92 from Worksheet D-1, Part IV, line 89, if you do not
have a distinct observation bed area. If you have a distinct observation bed area, subscript line 92
into line 92.01, and transfer the appropriate amount from Worksheet B, Part I, column 26. In a
complex comprised of an acute care hospital with an excluded unit(s) (excluded from the IPPS),
only the acute care hospital may report observation bed costs. Any services provided by the
RHC/FQHC outside the benefits package for those clinics are reported by the hospital in its
appropriate ancillary cost center, but not in the RHC/FQHC cost center lines 88 and 89. Do not
bring forward any cost center with a credit balance from Worksheet B, Part I, column 26.
Column 2--Enter the amount of therapy limits applied to the cost center on lines 65 to 68. Obtain
these amounts from Worksheet A-8, lines 23, 24, 30, and 31 respectively.
NOTE: Complete this column only when the hospital or subprovider is subject to PPS or TEFRA
rate of increasing ceiling (see 42 CFR 412, Subparts N and P, and 42 CFR 413.40,
respectively). If the hospital and all subproviders have correctly indicated that their
payment system is in the “other” category on Worksheet S-2, do not complete columns 2
through 5, 10, and 11.
Column 3--Enter on each cost center line the sum of columns 1 and 2.
Column 4--Only complete this section if you or your subproviders are subject to IPPS, IPF PPS,
IRF PPS, or LTC PPS. Enter on each line the amount of the RCE disallowance. Obtain these
amounts from the sum of the amounts for the corresponding line on Worksheet A-8-2, column 17.
Column 5--Complete this section only if you or your subproviders are subject to a PPS. Enter on
each cost center line the sum of the amounts entered in columns 3 and 4.
Columns 6 and 7--Enter on each cost center line the total inpatient and outpatient gross patient
charges including charges for charity care patients and, where applicable, standard customary
charges for items reimbursed on a fee schedule (e.g., DME, oxygen, prosthetics, and orthotics).
Also include the total inpatient and outpatient gross charges for cost centers which have a credit
balance on Worksheet B, Part I, column 26, and, therefore, do not contain “cost” in column 1 of
Worksheet C, Part I.
Total charges on Worksheet C, Part I, for each department are for provider services only.
Therefore, Medicare charges on Worksheets D, Parts II and IV, D-2, D-3, and D-4, must also
include provider services only. When reporting charges for a complex, e.g., hospital, subprovider,
SNF, charges for like services must be uniform. (See CMS Pub. 15-1, chapter 22, §2203.)

40-128

Rev.

03-18

FORM CMS-2552-10

4023.1 (Cont.)

When certain services are furnished under arrangements and an adjustment is made on
Worksheet A-8 to gross up costs, gross up the related charges entered on Worksheet C, Part I, in
accordance with CMS Pub. 15-1, chapter 23, §2314. If no adjustment is made on Worksheet A-8,
show only the charges you actually billed on Worksheet C, Part I.
NOTE: Any cost center that includes CRNA charges must exclude these charges unless the
hospital qualifies for the rural exception as outlined in §4013. All cost centers for which
CRNA costs are excluded on Worksheet A-8 must also exclude the charges associated
with these costs.
NOTE: Any charges for ancillary services provided to clinic, RHC and FQHC patients must be
reclassified to the appropriate ancillary cost center, e.g., radiology-diagnostic, laboratory.
A similar adjustment must be made to program charges.
Report on line 92 all charges for observation bed services provided in the inpatient
routine care area of the hospital. The charges relate to all payer classes and include those
observation bed charges for patients released as outpatients and those patients admitted
as inpatients. If you have a distinct observation bed unit, report your gross charges on
line 92.01 (which was subscripted on Worksheet A).
Column 8--Enter the total of columns 6 and 7.
Column 9 through 11--Cost to charge ratios are not calculated for lines 99 through 117. The
corresponding locations on Worksheet C, Part I, are shaded.
Column 9, lines 50 through 98--Always complete this column. Divide the cost for each cost center
in column 1 by the total charges for the cost center in column 8 to determine the ratio of total cost
to total charges (referred to as the "Cost or Other" ratio) for that cost center. Enter the resultant
departmental ratios in this column. Round ratios to 6 decimal places.
Column 10, lines 50 through 98--Complete this section only when the hospital or its subprovider
is subject to the TEFRA rate of increase ceiling. (See 42 CFR 413.40.) Divide the amount
reported in column 3 (which represents the total cost adjusted for the add-back of amounts
excluded on Worksheet A-8 for the RT/PT limits) for each cost center by the total charges for the
cost center in column 8.
This computation determines the RT/PT adjusted ratio of cost to charges (referred to as the TEFRA
inpatient ratio) for each cost center. Enter the resultant departmental ratio. Round ratios to 6
decimal places.
Column 11, lines 50 through 98--Complete this section only when the hospital is subject to the
IPPS or the LTC PPS or when its subprovider is subject to its respective PPS reimbursement
methodology. (See 42 CFR 412.1(a) through 412.125, and 42 CFR 412, Subparts O, N, and P,
respectively). Divide the amount reported in column 5 (which represents the total cost adjusted
for the add-back of amounts excluded on Worksheet A-8 for the RT/PT and the RCE limits) for
each cost center by the total charges for the cost center in column 8.
This computation determines the RCE/RT/PT adjusted ratio of cost to charges (referred to as the
PPS inpatient ratio) for each cost center. Enter the resultant departmental ratio. Round ratios to 6
decimal places.
Line Descriptions
Lines 30 through 117--These cost centers have the same line numbers as the respective cost centers
on Worksheets A, B, and B-1. This design facilitates referencing throughout the cost report.

Rev. 14

40-129

4023.1 (Cont.)

FORM CMS-2552-10

03-18

Therefore, if you have subscripted any lines on those worksheets, you must subscript the same
lines on this worksheet.
NOTE: The worksheet line numbers start at line 30 because of the line referencing feature.
Line 200--For each of the columns 1 through 5 (total costs), respectively, enter the sum of lines 30
through 199 for all unshaded lines in accordance with Worksheet C, Part I.
For each of the columns 6, 7, and 8 (total charges), respectively, enter the sum of lines 30 through
60, and 62 through 199, for all unshaded lines in accordance with Worksheet C, Part I. Since the
charges on line 61 are also included on line 60 (laboratory), the charges on line 61 must be
excluded to avoid overstating total charges.
Line 201--Enter the amounts from line 92 for columns 1, 3, and 5. Calculate the observation bed
cost on line 92 using the routine cost per diem from Worksheet D-1 because it is part of routine
costs and as such has been included in the amounts reported on line 30 for the hospital. Therefore,
in order to arrive at the total allowable costs, subtract this cost to avoid reporting these costs twice.
Line 201, columns 6, 7, and 8, are shaded.
Line 202--For columns 1, 3, and 5, subtract line 201 from line 200, and enter the result.
Transfer Referencing
Costs--The costs of the inpatient routine service cost centers are transferred:
From Worksheet C, Column 1, 3, or 5:
Line 30
Lines 31 through 35
Line 40, 41, 42 and subscripts
Line 43 (titles V and XIX only)
Line 44 (title XVIII only)
Line 45 and subscripts (titles V and XIX only)

To
Wkst. D-1, Part I, line 21
Wkst. D-1, Part II, lines 43 through 47
Separate Wkst. D-1, Part I, line 21
Wkst. D-1, Part II, line 42
Separate Wkst. D-1, Part I, line 21
Separate Wkst. D-1, Part I, line 21

Charges--Transfer the total charges for each of lines 50 through 98, column 8, to Worksheet D,
Part IV, column 7, lines as appropriate.
Ratios
Cost or Other Ratios--The “Cost or Other” ratio is transferred from column 9:
For
To
Inpatient ancillary services for titles V, XVIII, Wkst. D-3, column 1, for each cost
Part A, and XIX furnished by the hospital,
center
subprovider, SNF, NF, swing-bed SNF, and
swing-bed NF
Ancillary services furnished by the hospitalWkst. H-3, Part II, column 1, line as
based HHA
appropriate
Hospital-based CMHC (titles V, XVIII, and
XIX) shared ancillary services

40-130

Wkst. J-2, Part II, column 3, line as
appropriate

Rev. 14

04-20

FORM CMS-2552-10

4023.2

TEFRA Inpatient Ratio--Transfer the TEFRA inpatient ratio on lines 50 through 94 and 96
through 98 from column 10 for hospital or subprovider components for titles V; XVIII, Part A;
and XIX; inpatient services subject to the TEFRA rate of increase ceiling (see 42 CFR 413.40) to
Worksheet D-3, column 1, for each cost center.
PPS Inpatient Ratio--Transfer the PPS inpatient ratio on lines 50 through 94 and 96 through 98
from column 11, for hospital or subprovider components for titles V; XVIII, Part A; and XIX;
inpatient services subject to the IPPS (see 42 CFR 412.1(a) through 412.125) to Worksheet D-3,
column 1, for each cost center. The transfer of the PPS inpatient ratio also applies when the facility
is an IPF subject to IPF PPS, a LTCH subject to LTCH PPS, or an IRF subject to IRF PPS (see
42 CFR 412, Subparts N, O, and P, respectively).
4023.2 Part II - Calculation of Outpatient Services Cost-to-Charge Ratios Net of Reductions for
Medicaid Only.--This worksheet is not applicable for title XVIII. It is only applicable for select
state Medicaid programs. This worksheet computes the outpatient cost-to-charge ratios reflecting
the following:
•

The percentage of capital reduction as identified on Worksheet S-2, Part I, line 95, the
applicable column.

•

The reduction in reasonable costs of hospital outpatient services (other than the capitalrelated costs of such services (also known as operating reduction)) is based upon the
percentage entered on Worksheet S-2, Part I, line 97, the applicable column.

Column Descriptions
Column 1--Enter the amounts for each cost center from Worksheet B, Part I, column 26, as
appropriate. Transfer the amount on line 92 from Worksheet D-1, Part IV, line 89, for the hospital
and if you use inpatient routine beds as observation beds. If you have a distinct observation bed
area, add subscripted line 92.01 and transfer the appropriate amount from Worksheet B, Part I,
column 26. Do not bring forward costs in any cost center with a credit balance from Worksheet B,
Part I, column 26.
Column 2--Enter the sum of the amounts for each cost center from Worksheet B, Part II, as
appropriate. Do not bring forward costs in any cost center with a credit balance on Worksheet B,
Part I, or Worksheet B, Part II. For line 92, enter the amounts from Worksheet D-1, Part IV,
column 5, line 90. Combine the hospital and subprovider amounts if applicable.
Column 3--For each line, subtract column 2 from column 1, and enter the result.
Column 4--Multiply column 2 by the appropriate capital reduction percentage, and enter the result.
Column 5--Multiply column 3 by the outpatient reasonable cost reduction percentage, and enter
the result.
Column 6--Subtract columns 4 and 5 from column 1, and enter the result.
Column 7--Enter the total charges from Worksheet C, Part I, column 8.
Column 8--Divide column 6 by column 7, and enter the result.

Rev. 16

40-131

4024
4024.

FORM CMS-2552-10

04-20

WORKSHEET D - COST APPORTIONMENT

Worksheet D consists of the following five parts:
Part I
Part II
Part III
Part IV

Part V

Apportionment of Inpatient Routine Service Capital Costs
Apportionment of Inpatient Ancillary Service Capital Costs
Apportionment of Inpatient Routine Service Other Pass-Through Costs
Apportionment of Inpatient/Outpatient Ancillary Service Other
Pass-Through Costs
Apportionment of Medical and Other Health Services Costs

At the top of each part, indicate by checking the appropriate boxes the health care program,
provider component or PARHM Demonstration, and the payment system, as applicable, for which
the part is prepared.
If Worksheet S-2, Part I, line 112, column 1, is Y and (1) the hospital participated in the PARHM
demonstration for the entire cost reporting period, select the “PARHM Demonstration” box only
and complete Worksheet D, Parts I through IV; or (2) the hospital participated in the PARHM
demonstration for a portion of the cost reporting period, select the “PARHM Demonstration” box
and complete Worksheet D, Parts I through IV, for the portion of the cost reporting period,
included in the demonstration. Select the “Hospital” box and complete a separate set of
Worksheet D, Parts I through IV, for the portion of the cost reporting period not included in the
demonstration. See §4024.5 for specific instructions for Worksheet D, Part V.
NOTE: Only hospital components subject to PPS (including the PARHM Demonstration) or
TEFRA complete Worksheet D, Parts I through IV. New children’s and new cancer
hospitals complete only Worksheet D, Parts III and IV (line 85 of Worksheet S-2, Part I,
has a “Y” response). CAHs do not complete Parts I through IV. Hospital-based SNF
and NF providers are added to the Worksheet D, Part III, and will also complete a
separate Worksheet D, Part IV. Effective for cost reporting periods beginning on or after
April 1, 2019 (see CR10962, dated November 2, 2018), complete a separate
Worksheet D, Part IV, for swing-bed SNFs that claim cost reimbursement for CRNA
services.
Line Descriptions for Parts I through V
Lines 30 through 43 (for Parts I and III), lines 44 and 45 (for Part III), and lines 50 through 98 (for
Parts II, IV, and V)--These cost centers have the same line numbers as the respective cost centers
on Worksheets A, B, B-1, and C. This design facilitates referencing throughout the cost report.
Therefore, any lines subscripted on those worksheets, must subscripted on this worksheet.
4024.1 Part I - Apportionment of Inpatient Routine Service Capital Costs--This part computes
the amount of capital-related costs applicable to hospital inpatient routine service costs. Complete
only one Worksheet D, Part I (*), for each title. Report hospital and subprovider information on
the same worksheet, lines as appropriate. Complete this part for all payment methods.
* Hospitals that participated in the PARHM demonstration must complete Worksheet D, Part I for
the portion of the cost reporting period not included in the PARHM demonstration and a separate
Worksheet D, Part I for the portion of the cost reporting period included in the PARHM
demonstration.
Column 1--Enter on each line the capital-related cost for each cost center, as appropriate. Obtain
this amount from Worksheet B, Part II, column 26.
Column 2--Compute the amount of the swing-bed adjustment. If you have a swing-bed agreement
or have elected the swing-bed optional method of reimbursement, determine the amount for the
cost center in which the swing-beds are located by multiplying the amounts in column 1 by the
ratio of the amount entered on Worksheet D-1, line 26, to the amount entered on Worksheet D-1,
Part I, line 21.
40-132

Rev. 16

01-22

FORM CMS-2552-10

4024.2

Column 3--For each line, subtract the amount, if any, in column 2 from the amount in column 1,
and enter the result.
Column 4--Enter on each line the total patient days, excluding swing-bed days, for that cost center.
For line 30, enter the total days reported on Worksheet S-3, Part I, column 8, the sum of lines 1
and 28. For lines 31 through 43, enter the days from Worksheet S-3, Part I, column 8, lines 8
through 12, 13, and 16 through 18 (as applicable).
Column 5--Divide the capital costs of each cost center in column 3 by the total patient days in
column 4 for each line to determine the capital per diem cost. Enter the resultant per diem cost in
column 5.
Column 6--Enter the program inpatient days for the applicable cost centers. For line 30, enter the
days reported on Worksheet S-3, Part I, columns 5, 6, or 7, as appropriate, line 1. For lines 31
through 43, enter the days from Worksheet S-3, Part I, columns 5, 6, or 7, as appropriate, lines 8
through 12, 13, and 16 through 18 (as applicable), respectively.
For the PARHM demonstration, complete column 6 as follows: For line 30, enter the days reported
on Worksheet S-3, Part I, columns 5, 6.01, or 7, as appropriate, line 1. For lines 31 through 35,
and line 43, enter the days from Worksheet S-3, Part I, columns 5, 6.01, or 7, as appropriate, lines 8
through 12, and line 13, respectively.
NOTE: When you place overflow general care patients temporarily in an intensive care type
inpatient hospital unit because all beds available for general care patients are occupied,
count the days as intensive care type inpatient hospital days for purposes of computing
the intensive care type inpatient hospital unit per diem. However, count the program
days as general routine days in computing program reimbursement.
(See
CMS Pub. 15-1, chapter 22, §2217.) Add any program days for general care patients of
the component who temporarily occupied beds in an intensive care or other special care
unit to line 30, and decrease the appropriate intensive care or other special care unit by
those days.
Column 7--Multiply the per diem in column 5 by the inpatient program days in column 6 to
determine the program’s share of capital costs applicable to inpatient routine services, as
applicable.
4024.2 Part II - Apportionment of Inpatient Ancillary Service Capital Costs.--This part computes
the amount of capital costs applicable to hospital (*) inpatient ancillary services for titles V; XVIII,
Part A; and XIX. Complete a separate copy of this worksheet for each subprovider for titles V;
XVIII, Part A; and XIX; as applicable.
* Hospitals that participated in the PARHM demonstration must complete Worksheet D, Part II
for the portion of the cost reporting period not included in the PARHM demonstration and a
separate Worksheet D, Part II for the portion of the cost reporting period included in the PARHM
demonstration.
Make no entries on this worksheet for any cost centers with a negative balance on Worksheet B,
Part I, column 26.
Column 1--Enter on each line the capital-related costs for each cost center, as appropriate. Obtain
this amount from Worksheet B, Part II, column 26. For the hospital component or subprovider, if
applicable, enter on line 92 the amount from Worksheet D-1, Part IV, column 1, line 90.

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Column 2--Enter on each line the total charges applicable to each cost center as shown on
Worksheet C, Part I, column 8.
Column 3--Divide the capital cost of each cost center in column 1 by the charges in column 2 for
each line to determine the cost-to-charge ratio. Round the ratios to six decimal places, e.g.,
round 0321514 to .032151. Enter the resultant departmental ratio in column 3.
Column 4--Enter on each line the appropriate title V; XVIII, Part A; or XIX, inpatient charges
from Worksheet D-3, column 2. For title XVIII, enter on line 92, the observation bed charges
applicable to title XVIII patients subsequently admitted after being treated in the observation area.
Enter on line 96, the Medicare charges for medical equipment rented by an inpatient. The charges
are reimbursed under the DRG. However, you are entitled to the capital-related cost pass-through
applicable to this medical equipment.
NOTE: Program charges for PPS providers are reported in the cost reporting period in which the
discharge is reported. TEFRA providers report charges in the cost reporting period in
which they occur.
Do not include in Medicare charges any charges identified as MSP/LCC.
Column 5--Multiply the capital ratio in column 3 by the program charges in column 4 to determine
the program’s share of capital costs applicable to titles V; XVIII, Part A; or XIX, inpatient ancillary
services, as appropriate.
4024.3 Part III - Apportionment of Inpatient Routine Service Other Pass-Through Costs.--This
part computes the amount of pass-through costs other than capital applicable to hospital inpatient
routine service costs. Complete only one Worksheet D, Part III, for each title (*). Report hospital,
subprovider, hospital-based SNF and NF/ICF-IID (if applicable) information on the same
worksheet, lines as appropriate.
* Hospitals that participated in the PARHM demonstration must complete Worksheet D, Part III
for the portion of the cost reporting period not included in the PARHM demonstration and a
separate Worksheet D, Part III for the portion of the cost reporting period included in the PARHM
demonstration.
Column 1A--For each cost center, enter the amount of the applicable nursing program post
step-down adjustments from Worksheet B-2. Apportion the post step-down adjustments using the
respective program allocation statistics and unit cost multiplier reported on Worksheet B-1,
column 20, or its subscripts. Do not complete this column if the response on Worksheet S-2, Part I,
line 60, is no.
Column 1--For each applicable line, transfer the nursing program cost from Worksheet B, Part I,
the sum of column 20, and its subscripts, minus post step-down adjustments reported in
column 1A, if applicable, when Worksheet S-2, Part I, line 60, is yes, except do not transfer
subscripts of line 60 with a criterion code of “4” in column 3. Do not transfer the costs if the
response on Worksheet S-2, Part I, line 60, is no.
Column 2A--For each cost center, enter the amount of the applicable allied health/paramedical
education program post step-down adjustments from Worksheet B-2. Apportion the post stepdown adjustments using the respective program allocation statistics and unit cost multiplier
reported on Worksheet B-1, column 23, or its subscripts. Do not complete this column if the
response on Worksheet S-2, Part I, line 60, is no.

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4024.4

Column 2--For each applicable line, transfer the allied health/paramedical education program cost
from Worksheet B, Part I, the sum of column 23, and its subscripts, minus post step-down
adjustments reported in column 2A, if applicable, when Worksheet S-2, Part I, line 60, is yes,
except do not transfer subscripts of line 60 with a criterion code of “4” in column 3. Do not transfer
the costs if the response on Worksheet S-2, Part I, line 60, is no.
Column 3--Transfer from Worksheet B, Part I, the sum of columns 21 and 22, for each applicable
line, plus or minus post step-down adjustments (reported on Worksheet B-2), the applicable
medical education costs for interns and residents when Worksheet S-2, Part I, line 57, column 1,
is yes, and column 2, is no. Otherwise do not transfer the costs.
NOTE: If you qualify for the exception in 42 CFR 413.77(e)(1), because this is the first cost
reporting period in which you are training residents in approved programs and the
residents were not on duty during the first month of this cost reporting period, then all
direct GME costs are reimbursed as a pass-through based on reasonable cost.
Column 4--Compute the amount of the swing-bed adjustment. If you have a swing-bed agreement,
determine the amount for the cost center in which the swing-beds are located by multiplying the
sum of the amounts in columns 1 through 3 by the ratio of the amount entered on Worksheet D-1,
Part I, line 26, to the amount entered on Worksheet D-1, Part I, line 21.
Column 5--Enter the sum of columns 1, 2, and 3, minus column 4.
Column 6--Enter on each line the total patient days, excluding swing-bed days, for that cost center.
Transfer these amounts from the appropriate Worksheet D, Part I, column 4. For SNFs enter total
patient days from Worksheet S-3, Part I, column 8, line 19.
Column 7--Enter the per diem cost for each line by dividing the cost of each cost center in
column 5 by the total patient days in column 6.
Column 8--Enter the program inpatient days for the applicable cost centers. Transfer these
amounts from the appropriate Worksheet D, Part I, column 6. For SNF (line 44), enter the
program days from Worksheet S-3, Part I, column 6, line 19.
For a provider that participated in the PARHM demonstration during this cost reporting period
complete a separate Worksheet D, Part III for the portion of the cost reporting period the provider
participated in the PARHM demonstration. For the PARHM demonstration transfer from the
appropriate Worksheet D, Part I, column 6, lines 30 through 35, and line 43, respectively.
Column 9--Multiply the per diem cost in column 7 by the inpatient program days in column 8 to
determine the program's share of pass-through costs applicable to inpatient routine services, as
applicable. Transfer the sum of the amounts on lines 30 through 35 and 43 to Worksheet D-1,
Part I, line 50, for the hospital or PARHM demonstration as applicable. If you are a title XVIII
hospital paid under the IPPS, also transfer this sum to Worksheet E, Part A, line 57, accordingly.
Transfer the amounts on lines 40 through 42 to the appropriate Worksheet D-1, line 50, for the
subprovider. Also transfer the amount on line 40 to Worksheet E-3, Part II, line 28, and the
amount on line 41, to Worksheet E-3, Part III, line 29. For hospital-based SNF, NF or ICF/IID
that follow Medicare principles, transfer the amount in column 9, line 44, to Worksheet E-3,
Part VI, line 2, or for NF or ICF/IID to Worksheet E-3, Part VII, line 26, as applicable.
4024.4 Part IV - Apportionment of Inpatient/Outpatient Ancillary Service Other Pass-Through
Costs.--This part computes the amount of pass-through costs other than capital applicable to
hospitals, SNFs, NFs, ICF/IIDs, and effective for cost reporting periods beginning on or after
April 1, 2019, CRNA pass-through costs for swing-bed SNFs. Hospitals and subprovider
components subject to the IPPS and/or the Outpatient Prospective Payment System (OPPS) must
exclude direct medical education costs as these costs are reimbursed separately. TEFRA hospitals

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are subject to the TEFRA rate of increase limitation for inpatient operating costs. In order to
determine inpatient operating costs, it is necessary to exclude capital-related and medical education
costs as these costs are reimbursed separately.
Complete a separate copy of this Worksheet D, Part IV for the hospital (*), each subprovider, the
SNF, NF and ICF/IID. For CRNA pass-through costs for IPPS hospital swing-bed SNFs complete
columns 1, 7, 8, 10, and 11 only.
* Hospitals that participated in the PARHM demonstration must complete Worksheet D, Part IV
for the portion of the cost reporting period not included in the PARHM demonstration and a
separate Worksheet D, Part IV for the portion of the cost reporting period included in the PARHM
demonstration.
Make no entries on this worksheet for any cost centers with a negative balance on Worksheet B,
Part I, column 26.
Column 1--Transfer from Worksheet B, Part I, column 19, for each applicable line (plus or minus
any adjustments reported on Worksheet B-2, if applicable) the nonphysician anesthetist’s costs
which qualify for a reasonable cost payment in accordance with 42 CFR 412.113(c). (See also
§4013, line 19, description for more information.)
Column 2A--For each cost center, enter the amount of the applicable nursing program post
step-down adjustments from Worksheet B-2. Apportion the post step-down adjustment using the
respective program allocation statistics and unit cost multiplier reported on Worksheet B-1,
column 20, or its subscripts. Do not complete this column if the response on Worksheet S-2, Part I,
line 60, is no.
Column 2--For each applicable line, transfer the nursing program cost from Worksheet B, Part I,
the sum of column 20, and its subscripts, minus post step-down adjustments reported in
column 2A, if applicable, when Worksheet S-2, Part I, line 60, is yes, except do not transfer
subscripts of line 60 with a criterion code of “4” in column 3. Do not transfer the costs if the
response on Worksheet S-2, Part I, line 60, is no. For the hospital only, enter on line 92,
observation beds, the amount from Worksheet D-1, Part IV, column 5, line 91.
Column 3A--For each cost center, enter the amount of the applicable allied health/paramedical
education program post step-down adjustments from Worksheet B-2. Apportion the post
step-down adjustments using the respective program allocation statistics and unit cost multiplier
reported on Worksheet B-1, column 23, or its subscripts. Do not complete this column if the
response on Worksheet S-2, Part I, line 60, is no.
Column 3--For each applicable line, transfer the allied health/paramedical education program cost
from Worksheet B, Part I, the sum of column 23, and its subscripts, minus post step-down
adjustments reported in column 3A, if applicable, when Worksheet S-2, Part I, line 60, is yes,
except do not transfer subscripts of line 60 with a criterion code of “4” in column 3. Do not transfer
the costs if the response on Worksheet S-2, Part I, line 60, is no. For the hospital component only,
enter on line 92, the observation bed amount from Worksheet D-1, Part IV, column 5, line 92.
Column 4--Transfer from Worksheet B, Part I, the sum of columns 21 and 22, for each applicable
line, (plus or minus post step-down adjustments made on Worksheet B-2, if applicable), the
applicable medical education costs for interns and residents when Worksheet S-2, Part I, line 57,
column 1, is yes and column 2, is no, otherwise do not transfer the costs. For the hospital only,
enter on line 92, observation beds, the amount from Worksheet D-1, Part IV, column 5, line 93.
NOTE: If you qualify for the exception in 42 CFR 413.77(e)(1) because this is the first cost
reporting period in which you are training residents in approved programs and the
residents were not on duty during the first month of this cost reporting period, then all
direct GME costs for interns and residents in approved programs are reimbursed as a
pass-through based on reasonable cost.
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4024.4

Column 5--This column represents total inpatient other pass-through costs. Enter on each
appropriate line the sum of the amounts entered on the corresponding lines in columns 1, 2, 3, and
4.
Column 6--This column represents outpatient other pass-through costs. Enter on each appropriate
line the sum of the amounts entered on the corresponding lines in columns 2, 3, and 4.
Column 7--Enter on each line the charges applicable to each cost center as shown on Worksheet C,
Part I, column 8.
Column 8--Divide the cost of each cost center in column 5 by the charges in column 7, to
determine the cost/charge ratio for each cost center. For CRNA IPPS hospital swing-bed SNF
pass through costs, divide the cost of each cost center in column 1 by the charges in column 7, to
determine the cost/charge ratio for each cost center. Round the ratios to six decimal places, e.g.,
round 0321514 to .032151.
Column 9--This column computes the outpatient ratio of cost to charges. Divide the cost of each
cost center in column 6 by the charges in column 7, for each line, to determine the cost/charge
ratio. Round the ratios to six decimal places, e.g., round .0321514 to .032151. Enter the resultant
departmental ratio in column 9.
Column 10--Enter on each line titles V; XVIII, Part A; or XIX; inpatient charges from
Worksheet D-3. For a hospital that participated in the PARHM demonstration during this cost
reporting period complete a separate Worksheet D, Part IV. For the portion of the cost reporting
period the provider participated in the PARHM demonstration enter the inpatient charges
applicable to the PARHM demonstration period from Worksheet D-3.
Do not include in Medicare charges any charges identified as MSP/LCC.
Column 11--Multiply the ratio in column 8 by the charges in column 10 to determine the program's
share of pass-through costs applicable to titles V; XVIII, Part A; or XIX; inpatient ancillary
services, as appropriate.
For hospitals and subproviders, transfer column 11, line 200, to Worksheet D-1, Part II, column 1,
line 51. If you are an IPPS hospital, also transfer this amount to Worksheet E, Part A, line 58. If
you are an IPF or IPF subprovider, also transfer this amount to Worksheet E-3, Part II, line 28. If
you are an IRF or IRF subprovider, also transfer this amount to Worksheet E-3, Part III, line 29.
For SNFs, for title XVIII transfer the amount on line 200 to Worksheet E-3, Part VI, line 3; for
SNFs, NFs and ICF/IIDs for titles V and XIX, transfer the amount on line 200 to E-3, Part VII,
line 26, as applicable. If you are an IPPS hospital swing-bed SNF, for title XVIII transfer the
amount on line 200 to Worksheet E-2, line 3.
Column 12--Enter on each line titles XVIII, Part B; V; or XIX (if applicable); outpatient charges
from Worksheet D, Part V, column 2, and applicable subscripts. For a hospital that participated
in the PARHM demonstration during this cost reporting period complete a separate Worksheet D,
Part IV. For the portion of the cost reporting period the hospital participated in the PARHM
demonstration enter the outpatient charges applicable to the PARHM demonstration period from
Worksheet D, Part V, column 2.
Do not include in Medicare charges any charges identified as MSP/LCC.
Column 13--Multiply the ratio in column 9 by the charges in column 12 to determine the program's
share of pass-through costs applicable to titles XVIII, Part B; V; or XIX (if applicable); outpatient
ancillary services, as appropriate.
For providers subject to the OPPS, transfer column 13, line 200, to Worksheet E, Part B, line 9.

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4024.5 Part V - Apportionment of Medical and Other Health Services Costs.--This part provides
for the apportionment of costs applicable to hospital outpatient services reimbursable under
titles V, XVIII, and XIX. Complete a separate copy of this Worksheet D, Part V for the hospital
(*), each subprovider, the SNF, NF and ICF/IID, and the Swing-bed SNF (**) and Swing-bed NF.
* Hospitals including CAHs that (1) participated in the PARHM demonstration for the entire cost
reporting period, select the “PARHM Demonstration” box only and complete Worksheet D, Part
V; or (2) participated in the PARHM demonstration for a portion of the cost reporting period,
select the “PARHM Demonstration” box and complete Worksheet D, Part V, for the portion of the
cost reporting period, included in the demonstration. Select the “Hospital” box and complete a
separate Worksheet D, Part V, for the portion of the cost reporting period not included in the
demonstration.
** CAH swing-bed SNFS that (1) participated in the PARHM demonstration for the entire cost
reporting period, select the “PARHM Demo Swing-bed SNF” box only and complete Worksheet
D, Part V; or (2) participated in the PARHM demonstration for a portion of the cost reporting
period, select the “PARHM Demo Swing-bed SNF” box and complete Worksheet D, Part V, for
the portion of the cost reporting period, included in the demonstration. Select the “Swing-bed
SNF” box and complete a separate Worksheet D, Part V, for the portion of the cost reporting period
not included in the demonstration.
Enter in the appropriate cost center the program charges from the PS&R or from provider records.
Providers exempt from outpatient PPS (i.e., CAHs), complete columns 3, 4, 6, and 7. All other
providers subscript columns 2 and 5 as necessary. Include charges for vaccine, i.e., pneumococcal,
influenza, COVID-19, monoclonal antibody products for treatment of COVID-19, hepatitis, and
osteoporosis as indicated on line 73 below.
Exclude charges for which costs were excluded on Worksheet A-8. For example, CRNA costs
reimbursed on a fee schedule are excluded from total cost on Worksheet A-8. For titles V and
XIX, enter the appropriate outpatient service charges.
NOTE: Do not enter CORF, OPT, OSP, OOT, or CMHC charges on Worksheet D, Part V.
Report only charges for CMHCs on Worksheet J-2.
For title XVIII, complete a separate Worksheet D, Part V, for each provider component as
applicable. Enter the applicable component number in addition to the hospital provider number.
Make no entries in columns 5 through 7 of this worksheet for any cost centers with a negative
balance on Worksheet B, Part I, column 26. However, complete columns 1 through 4 for such
cost centers.
In accordance with ACA, section 3121, as amended by the Medicare and Medicaid Extenders Act
(MMEA) of 2010, section 108; the Temporary Payroll Tax Cut Continuation Act of 2011,
section 308; and, the Middle Class Tax Relief and Job Creation Act of 2012, section 3002; hold
harmless payments are extended for rural hospitals with 100 or fewer beds through
December 31, 2012; SCHs and EACHs regardless of bed size through February 29, 2012; and
SCHs and EACHs with 100 or fewer beds through December 31, 2012. As such, rural hospitals
and SCHs or EACHs that qualify and whose cost reporting period overlaps the effective date,
(Worksheet S-2, Part I, line 120, column 1 or 2, is yes), must subscript column 2 and enter the
applicable charges that correspond to the respective portion of the cost reporting period.
In accordance with ACA 2010, section 3138, cancer hospitals must utilize a predetermined
payment-to-cost ratio (PCR) to calculate the corresponding transitional outpatient payment
effective for services rendered beginning January 1, 2012. The PCR may be revised each calendar
year. Where the cost reporting period overlaps a PCR revision date, subscript column 2 and the
corresponding column 5 to represent the portion of the cost reporting period that corresponds to
each unique PCR. See section 4030.2 for further instruction/information.
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Column 1--Enter on each line in column 1 the ratio from the corresponding line on Worksheet C,
column 9.
Columns 2 through 4--Do not include in Medicare charges any charges identified as MSP/LCC.
Column 2--PPS Reimbursed Services--Enter the charges for services rendered which are subject
to PPS. These charges should not include services paid under the fee schedule such as physical
therapy, speech pathology or occupational therapy. Create separate subscripted column (e.g. 2.01,
2.02) when a cost reporting period overlaps the effective dates for the various transitional corridor
payments and/or when a provider experiences a geographic reclassification from urban to rural.
However, no subscripting is required when a provider geographically reclassifies from rural to
urban. The subscripting of this column will directly correspond to the subscripts of Worksheet E,
Part B, lines 2 through 8.
Do not include in any column services excluded from the OPPS because they are paid under
another fee schedule, e.g., rehabilitation services and clinical diagnostic lab.
Column 3--Cost Reimbursed Services Subject to Deductibles and Coinsurance--Enter the charges
for services rendered which are subject to cost reimbursement. This includes services rendered by
CAHs.
Include the charges for drugs and supplies related to ESRD dialysis (excluding ESAs, and any
drugs or supplies paid under the composite rate or ESRD PPS bundled payment rate), and corneal
tissue on line 72.
Column 4--Cost Reimbursed Services Not Subject to Deductibles and Coinsurance--Vaccine Cost
Apportionment--This column provides for the apportionment of costs which are not subject to
deductible and coinsurance i.e., pneumococcal, influenza, COVID-19, monoclonal antibody
products for treatment of COVID-19, hepatitis B, and osteoporosis. Enter such charges for
services which are not subject to deductible and coinsurance.
Column 5--Multiply the charges in column 2, and subscripts, if necessary, by the ratios in
column 1, and enter the result. Line 200 equals the sum of lines 50 through 98.
Column 6--Multiply the charges in column 3 by the ratios in column 1, and enter the result.
Line 200 equals the sum of lines 50 through 98.
Column 7--Multiply the charges in column 4 by the ratios in column 1, and enter the result.
Line 200 equals the sum of lines 50 through 98.
Line Descriptions
Line 60--Generally, for title XVIII, Medicare outpatient covered clinical laboratory services are
paid on a fee basis, and should not be included on this line. Outpatient CAH clinical laboratory
services will be paid on a reasonable cost basis not subject to deductibles and coinsurance. In
addition, hospital outpatient laboratory testing by a hospital laboratory with fewer than 50 beds in
a qualified rural area will also be paid on a reasonable cost basis not subject to deductibles and
coinsurance, for cost reporting periods beginning on or after July 1, 2010, but before July 1, 2012
(Patient Protection and Affordable Care Act of 2010, §3122, amended by the MMEA, §109). For
title V and XIX purposes, follow applicable State program instructions.
For CAHs, outpatient clinical laboratory diagnostic tests are paid at 101 percent of reasonable
costs, and the beneficiary is not required to be physically present in the CAH at the time the
specimen is collected. As such, enter the corresponding charges on this line. See MIPPA 2008,
§148 and CR 6395, transmittal 1729, dated May 8, 2009.

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Line 61--Enter the program charges for provider clinical laboratory tests for which the provider
reimburses the pathologist. See §4013 for a more complete description on the use of this cost
center. For title XVIII, do not include charges for outpatient clinical diagnostic laboratory services.
For titles V and XIX purposes, follow applicable State program instructions.
NOTE: Since the charges on line 61 are also included on line 60, laboratory, reduce the total
charges to prevent double counting. Make this adjustment on line 201.
Line 71--Enter in columns 2 and 3, the charges for medical supplies charged to patients which are
not paid on a fee schedule. Do not report the charges for prosthetics and orthotics.
Line 72--Enter in columns2 and 3, the charges for implantable devices charged to patients which
are not paid on a fee schedule. Do not report the charges for prosthetics and orthotics.
Line 73--Enter the program charges for drugs charged to patients. Enter in column 2, charges for
vaccines and drugs reimbursed at 100 percent under the OPPS. Include in column 3, charges for
drugs paid at 80 percent of cost subject to deductibles and coinsurance, such as osteoporosis drugs
and drugs paid under the OPPS such as hepatitis vaccines. Include in column 4, vaccine charges
for vaccines reimbursed at 100 percent of cost such as pneumococcal, influenza, and COVID-19
vaccines, and monoclonal antibody products for treatment of COVID-19, not subject to
deductibles and coinsurance.
Line 74--The only renal dialysis services entered on this line are for inpatients that are not
reimbursed under the composite rate regulations. (See 42 CFR 413.170.) Therefore, include only
inpatient Part B charges on this line in column 3. Enter the related costs in column 6.
Line 75--Enter in column 3 the outpatient ASC facility charges and Part B charges for the hospital
non-distinct part ASC. These charges represent the ASC facility charge only (i.e., in lieu of
operating or recovery room charges), and do not include charges for the ancillary services provided
to the patient.
Line 77--Enter the Medicare charges billed under revenue code 0815 (acquisition charges) for
allogeneic HSCT. Using your internal logs, these charges must be reported by ancillary cost
center on Worksheet D-6.
Line 78--For CAR T-cell immunotherapy, enter the Medicare charges billed under revenue
codes 0871, 0872, 0873, 0874, and 0891, as described in CMS Pub. 100-04. chapter 32, §400.2.2.
Lines 88 through 93--Use these lines for outpatient service cost centers.
NOTE: For lines 88, 89, and 90, any ancillary service billed as clinic, RHC, or FQHC services
must be reclassified to the appropriate ancillary cost center, e.g., radiology-diagnostic,
PBP clinical lab services - program only. A similar adjustment must be made to program
charges.
Line 92--Enter in column 2 the title XVIII Part B charges for observation beds. These are the
charges for patients who were treated in the non-distinct observation beds and released. These
patients were not admitted as inpatients.
Line 94--The only home program dialysis services which are cost reimbursed are those rendered
to beneficiaries who have elected the option to deal directly with Medicare. Home program
dialysis services reimbursed under the composite rate regulation (see 42 CFR 413.170) are not
included on this line. This line includes costs applicable to equipment-related expenses only.
Line 95--Only CAHs eligible for cost reimbursement for ambulance services complete this line.
Report charges for ambulance services from your records or the PS&R report type 85C in
column 3. Multiply column 1 times column 3 and enter the result in column 6. All other hospital
provider types are reimbursed under the ambulance fee schedule and do not complete this line.
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Lines 96 and 97--For title XVIII, DME is paid on a fee schedule through the contractor and,
therefore, is not paid through the cost report.
Line 200--Enter the sum of lines 50 through 98.
Line 201--Enter in columns 3 and 4 program charges for provider clinical laboratory tests where
the physician bills the provider for program patients only. Obtain this amount from line 61.
Line 202--Enter in columns 3, 4, 6, and 7, and subscripts, the amount on line 200 plus or minus
the amounts on line 201, if applicable.
Transfer Referencing: For title XVIII, transfer the sum of the amounts in columns 3 and 4, and
applicable subscripts, line 202 to Worksheet E, Part B, line 12 (ancillary services charges). Make
no transfers of swing bed charges to Worksheet E-2 since no LCC comparison is made.
For titles V and XIX (other than IPPS), transfer the sum of the amounts in columns 2, 3, and /or 4,
plus subscripts as applicable, line 202, plus the amount from Worksheet D-3, column 2, line 202,
to the appropriate Worksheet E-3, Part VII, line 9.
For titles V and XIX (under IPPS), transfer the amount in columns 2, 3, and /or 4, plus subscripts
as applicable, line 202, to the appropriate Worksheet E-3, Part VII, line 9.
NOTE: If the amount on line 202 includes charges for professional patient care services of
provider-based physicians, eliminate the amount of the professional component charges
from the total charges, and transfer the net amount as indicated. Submit a schedule
showing these computations with the cost report.
Transfer To References
From Wkst. D, Part V

Title XVIII,
Part B Swing Bed

Titles V or XIX,
Title XVIII, Part B

Column 6, line 202 and column 7,
line 73, and subscripts

N/A

Wkst. E, Part B, col. 1 (and
subscripts), line 1

Columns 5, line 202

N/A

Wkst. E, Part B, col. 1 (and
subscripts), line 2

Sum of columns 2, 3, and 4, as
applicable (SNF only), line 202

N/A

Wkst. E, Part B, line 12,
or Wkst. E-3, Part VII, col. 1,
line 9, for titles V or XIX

Sum of column 6 and 7 (SNF only),
line 202

Wkst E-2,
col. 2, line 3

Wkst. E, Part B, line 1,
or Wkst. E-3, Part VII, col. 1,
line 2, for titles V or XIX

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This page is reserved for future use.

40-140.2

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FORM CMS-2552-10

4025.

WORKSHEET D-1 - COMPUTATION OF INPATIENT OPERATING COST

4025

This worksheet provides for the computation of hospital inpatient operating cost in accordance
with 42 CFR 413.53 (determination of cost of services to beneficiaries), 42 CFR 413.40 (ceiling
on rate of hospital cost increases), and 42 CFR 412.1 through 412.125 (prospective payment). All
providers must complete this worksheet.
Complete a separate copy of this worksheet for the hospital (*) (including CAH), each subprovider,
hospital-based SNF, and hospital-based other nursing facility. Also, complete a separate copy of
this worksheet for each health care program under which inpatient operating costs are computed.
When this worksheet is completed for a component, show both the hospital and component
numbers.
At the top of each page, indicate by checking the appropriate line the health care program, provider
component, and the payment system for which the page is prepared.
Worksheet D-1 consists of the following four parts:
Part I
Part II
Part III
Part IV

All Provider Components
Hospital and Subproviders Only
Skilled Nursing Facility, Other Nursing Facility, and ICF/IID Only
Computation of Observation Bed Pass-Through Cost

NOTE: If you have made a swing-bed election for your certified SNF, treat the SNF costs and
patient days as though they were hospital swing-bed SNF-type costs and patient days on
Parts I and II of this worksheet. Do not complete Part III for the SNF. (See
CMS Pub. 15-1, chapter 22, §2230.9B.)
* Hospitals including CAHs that (1) participated in the PARHM demonstration for the entire cost
reporting period, select the “PARHM Demonstration” box only and complete Worksheet D-1,
Parts I and II; or (2) participated in the PARHM demonstration for a portion of the cost reporting
period, select the “PARHM Demonstration” box and complete Worksheet D-1, Parts I and II, for
the portion of the cost reporting period, included in the demonstration. Select the “Hospital” box
and complete a separate Worksheet D-1, Parts I and II, for the portion of the cost reporting period
not included in the demonstration.
Definitions
The following definitions apply to days used on this worksheet.
Inpatient Day--The number of days of care charged to a beneficiary for inpatient hospital services
is always documented in units of full days. A day begins at midnight and ends 24 hours later. Use
the midnight to midnight method in reporting the days of care for beneficiaries even if the hospital
uses a different definition for statistical or other purposes.
A part of a day, including the day of admission, counts as a full day. However, do not count the
day of discharge or death, or a day on which a patient begins a leave of absence, as a day. If both
admission and discharge or death occur on the same day, consider the day a day of admission and
count it as one inpatient day.
Include a maternity patient in the labor/delivery room ancillary area at midnight in the census of
the inpatient routine (general or intensive) care area only if the patient has occupied an inpatient

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routine bed at some time since admission. Count no days of inpatient routine care for a maternity
inpatient who is discharged (or dies) without ever occupying an inpatient routine bed. However,
once a maternity patient has occupied an inpatient routine bed, at each subsequent census include
the patient in the census of the inpatient routine care area to which she is assigned, even if the
patient is located in an ancillary area (labor/delivery room or another ancillary area) at midnight.
In some cases, a maternity patient may occupy an inpatient bed only on the day of discharge if the
day of discharge differs from the day of admission. For purposes of apportioning the cost of
inpatient routine care, count this single day of routine care as the day of admission (to routine care)
and discharge. This day is considered as one day of inpatient routine care. (See CMS Pub. 15-1,
chapter 22, §2205.2.)
When an inpatient is occupying any other ancillary area (e.g., surgery or radiology) at the census
taking hour prior to occupying an inpatient bed, do not record the patient’s occupancy in the
ancillary area as an inpatient day in the ancillary area. However, include the patient in the inpatient
census of the routine care area. When the patient occupies a bed in more than one patient care area
in one day, count the inpatient day only in the patient care area in which the patient was located at
the census taking hour.
Newborn Inpatient Day--Newborn inpatient days are the days that an infant occupies a newborn
bed in the nursery. Include an infant remaining in the hospital after the mother is discharged who
does not occupy a newborn bed in the nursery, an infant delivered outside the hospital and later
admitted to the hospital but not occupying a newborn bed in the nursery, or an infant admitted or
transferred out of the nursery for an illness in inpatient days. Also, include an infant born in and
remaining in the hospital and occupying a newborn bed in the nursery after the mother is
discharged in newborn inpatient days.
Private Room Inpatient Day--Private room inpatient days are the days that an inpatient occupies a
private room. If you have only private rooms, report your days statistic as general inpatient days.
Inpatient private room days are used for computing any private room differential adjustment on
Worksheet D-1, Part I, if you have a mixture of different type rooms to accommodate patients. Do
not count swing-bed SNF or swing-bed NF-type services rendered in a private room as private
room days.
Inpatient Swing-Bed Days--Inpatient swing-bed days are the days applicable to swing-bed SNF or
swing-bed NF-type services. See 42 CFR 413.53(a)(2).
Intensive Care Type Inpatient Days--Intensive care type inpatient days are those days applicable
to services rendered in intensive care type inpatient hospital units. These units must meet the
requirements specified in CMS Pub. 15-1, chapter 22, §2202.7.II.A.
NOTE: When you place overflow general care patients temporarily in an intensive care type
inpatient hospital unit because all beds available for general care patients are occupied,
count the days as intensive care type inpatient hospital days for purposes of computing
the intensive care type inpatient hospital unit per diem. However, count the program
days as general routine days in computing program reimbursement.
(See
CMS Pub. 15-1, chapter 22, §2217.)
Observation Beds--Observation beds, for purposes of this worksheet, are those beds in general
routine areas of the hospital which are not organized as a distinct, separately staffed observation
area and which are used to house patients for observation. These beds need not be used full time
for observation patients. These beds are not to be confused with a subintensive care unit (i.e.,
definitive observation unit, a stepdown from intensive care reported as an inpatient cost center
following surgical intensive care (line 34)). If you have a distinct observation bed unit (an
outpatient cost center), report the costs of this unit on the subscripted line 92.01 on Worksheet A.
4025.1 Part I - All Provider Components.--This part provides for the computation of the total
general inpatient routine service cost net of swing-bed cost and private room cost differential for
each separate provider component. When this worksheet is completed for a component, show both
the hospital and component numbers.
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4025.1 (Cont.)

Line Descriptions
Lines 1 through 16--Inpatient days reported, unless specifically stated, exclude days applicable to
newborn and intensive care type patient stays. Report separately the required statistics for the
hospital, each subprovider, hospital-based SNF, hospital-based other nursing facility and ICF/IID.
Obtain the information from your records and/or Worksheet S-3, Part I, columns and lines as
indicated.
Line 1--Enter the total general routine inpatient days, including private room days, swing-bed
days, and observation bed days, as applicable. Do not include routine care days rendered in an
intensive care type inpatient hospital unit. Enter the total days from Worksheet S-3, Part I,
column 8, for the component and lines as indicated: hospitals from lines 7 and 28; subproviders
from lines 16 through 18, as applicable, and 28, if applicable; SNFs from line 19; and NFs from
line 20. If you answered yes to line 92 of Worksheet S-2, the NF days come from line 19 for the
SNF level of care, and line 20 for the NF level of care, and you will need to prepare a separate
Worksheet D-1 for each level of care for title XIX.
Line 2--Enter the total general routine inpatient days. Include private room days and exclude
swing-bed and newborn days. Hospitals enter the sum of the days entered on Worksheet S-3,
Part I, column 8, lines 1 and 28. Subproviders, SNFs, and NFs enter the days from line 1 of this
worksheet.
Line 3--Enter the total private room days excluding swing-bed private room days and observation
bed days. If you have only private room days, do not complete this line.
Line 4--Enter the result of line 2, minus line 3, minus total observation bed days from
Worksheet S-3, Part I, column 8, line 28. The result will be semi-private room days exclusive of
swing-bed semi-private room days and observation bed days. If you have only private room days,
such days will be included in this line.
NOTE: For purposes of this computation, the program does not distinguish between semi-private
and ward accommodations. (See CMS Pub. 15-1, chapter 22, §2207.3.)
Line 5--Enter the total swing-bed SNF-type inpatient days, including private room days, through
December 31 of your cost reporting period. If you are on a calendar year end, report all swingbed SNF-type inpatient days.
Line 6--Enter the total swing-bed SNF-type inpatient days, including private room days, after
December 31 of your cost reporting period. If you are on a calendar year end, enter zero. The
sum of lines 5 and 6 equals Worksheet S-3 Part I, line 5, column 8.
Line 7--Enter the total swing-bed NF-type inpatient days, including private room days, through
December 31 of your cost reporting period. If you are on a calendar year end, report all swing- bed
NF-type inpatient days. This line includes title V, title XIX, and all other payers.
Line 8--Enter the total swing-bed NF-type inpatient days, including private room days, after
December 31 of your cost reporting period. If you are on a calendar year end, enter zero. This
line includes title V, title XIX, and all other payers. The sum of lines 7 and 8 equals
Worksheet S-3, Part I, line 6, column 8.
NOTE: Obtain the amounts entered on lines 5 and 7 from your records.

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Line 9--Enter the total program general routine inpatient days as follows:
Type of Provider
Hospital
Subprovider
SNF
NF

From
Wkst. S-3, Part I, cols. 5, 6, 6.01 (PARHM only), or 7, line 1
Wkst. S-3, Part I, cols. 5, 6, or 7, line 16, 17, or 18, as applicable
Wkst. S-3, Part I, cols. 5, 6, or 7, line 19
Wkst. S-3, Part I, cols. 5, 6, or 7, for SNF only level of care; line 19.
If line 92 of Wkst S-2, Part I is a “Y”, two D-1s must be
completed for title XIX using line 19 for SNF level of care and
line 20 for the NF level of care; or line 20 only for NF level of
care.

Include private room days and exclude swing-bed and newborn days for each provider component.
Add any program days for general care patients of the component who temporarily occupied beds
in an intensive care or other special care unit. (See CMS Pub. 15-1, chapter 22, §2217.)
NOTE: If Worksheet S-2, line 92, columns 1 or 2, as applicable is “Y” for yes, then
Worksheet D-1 for title XIX (for the SNF and NF component) must be completed. The
results are to be combined and transferred to title XIX SNF, Worksheet E-3, Part VII,
line 1.
Line 10--Enter the title XVIII swing-bed SNF-type inpatient days, including private room days,
through December 31 of your cost reporting period. If you are on a calendar year end, report all
program swing-bed SNF-type inpatient days. Combine titles V and XIX for all SNF lines if your
State recognizes only SNF level of care.
Line 11--Enter the title XVIII swing-bed SNF-type inpatient days, including private room days,
after December 31 of your cost reporting period. If you are on a calendar year end, enter zero.
Line 12--Enter the total titles V or XIX swing-bed NF-type inpatient days, including private room
days, through December 31 of your cost reporting period. If you are on a calendar year end, report
all program swing-bed NF-type inpatient days.
Line 13--Enter the total titles V or XIX swing-bed NF-type inpatient days, including private room
days, after December 31 of your reporting period. If you are on a calendar year end, enter zero.
NOTE: If you are participating in both titles XVIII and XIX, complete, at a minimum, a separate
Worksheet D-1, Part I, for title XIX, lines 9, 12, and 13. If these data are not supplied,
the cost report is considered incomplete and is rejected.
Line 14--Enter the total medically necessary private room days applicable to the program,
excluding swing-bed days, for each provider component.
Line 15--Enter, for titles V or XIX only, the total nursery inpatient days from Worksheet S-3,
Part I, column 8, line 13.
Line 16--Enter, for titles V or XIX only, the total nursery inpatient days applicable to the program
from Worksheet S-3, Part I, columns 5 and 7, respectively, line 13.
Lines 17 through 27--These lines provide for the carve-out of reasonable cost of extended care
services furnished by a swing-bed hospital. Under the carve out method, the total costs attributable
to SNF-type and NF-type routine services furnished to all classes of patients are subtracted from
total general inpatient routine service costs before computing the average cost per diem for general
routine hospital care. The rates on lines 17 through 20 are supplied by your contractor.
Line 17--Enter the Medicare swing-bed SNF rate applicable to the calendar year in which inpatient
days on line 5 occurred. If the swing-bed SNF rate for the prior calendar year is higher, enter that
rate instead. (See CMS Pub. 15-1, chapter 22, §2230ff.) CAHs do not complete this line.
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4025.1 (Cont.)

Line 18--Enter the Medicare swing-bed SNF rate applicable to the calendar year in which inpatient
days on line 6 occurred. If the swing-bed SNF rate for the prior calendar year is higher, enter that
rate instead. (See CMS Pub. 15-1, chapter 22, §2230ff.) CAHs do not complete this line.
Line 19--Enter the average Statewide rate per patient day paid under the State Medicaid plan for
routine services furnished by nursing facilities (other than NFs for individuals with intellectual
disabilities) in that State. This rate is approximated by taking the average rate from the prior
calendar year (i.e. the calendar year preceding the year relating to inpatient days reported on
line 7), updated to approximate the current year rate. Obtain the proper rate from your contractor.
Line 20--Enter the average Statewide rate per patient day paid under the State Medicaid plan for
routine services furnished by nursing facilities (other than NFs for individuals with intellectual
disabilities) in that State. This rate is approximated by taking the average rate from the prior
calendar year (i.e. the calendar year preceding the year relating to inpatient days reported on
line 8), updated to approximate the current year rate. Obtain the proper rate from your contractor.
Line 21--Enter the total general inpatient routine service costs for the applicable provider
component.
For titles V, XVIII, and XIX, enter the amounts from Worksheet C, Part I, line 30, for adults and
pediatrics or lines 40, 41, or 42, as applicable, for the subprovider, as appropriate:
COST or OTHER
TEFRA
PPS

Inpatient - Column 1 (includes CAHs)
Inpatient - Column 3 (includes cancer and children’s hospitals)
Inpatient - Column 5 (includes acute, IPFs, IRFs, & LTCHs)

SNF/NF Inpatient Routine--For title XVIII, transfer this amount from Worksheet C, Part I,
column 5, line 44 (SNF). For titles V and XIX, transfer this amount from Worksheet B, Part I,
column 26, line 45 (NF) or 45.01 (ICF/IID).
Line 22--Enter the product of the days on line 5 multiplied by the amount on line 17.
Line 23--Enter the product of the days on line 6 multiplied by the amount on line 18.
Line 24--Enter the product of the days on line 7 multiplied by the amount on line 19.
Line 25--Enter the product of the days on line 8 multiplied by the amount on line 20.
Line 26--Enter the sum of the amounts on lines 22 through 25. This amount represents the total
reasonable cost for swing-bed SNF-type and NF-type inpatient services.
For CAHs, subtract the sum of lines 24 and 25 from the amount reported on line 21. Divide that
result by the patient days equal to lines 2, 5, and 6 above to arrive at a per diem (retain this amount
for the calculation required on lines 38, 64, and 65). Multiply the per diem by the total days
reported on lines 5 and 6. Add that result to the amounts reported on lines 24 and 25.
Line 27--Subtract the amount on line 26 from the amount on line 21. This amount represents the
general inpatient routine service cost net of swing-bed SNF-type and NF-type inpatient costs.
Lines 28 through 36--All providers must complete lines 28 through 36. PPS providers complete
these lines for data purposes only. However, if line 4 equals line 2 above or if line 3 above is zero,
you are not to complete these lines.
Line 28--Enter the total charges for general inpatient routine services, excluding charges for
swing-bed SNF-type and NF-type inpatient services and observation bed days (from your records).

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Line 29--Enter the total charges for private room accommodations, excluding charges for private
room accommodations for swing-bed SNF-type and NF-type inpatient services and observation
bed days (from your records).
Line 30--Enter the total charges for semi-private room and ward accommodations, excluding semiprivate room accommodation charges for swing-bed SNF-type and NF-type services (from your
records).
Line 31--Enter the general inpatient routine cost-to-charge ratio (rounded to six decimal places)
by dividing the total inpatient general routine service costs (line 27) by the total inpatient general
routine service charges (line 28).
Line 32--Enter the average per diem charge (rounded to two decimal places) for private room
accommodations by dividing the amount on line 29 by the days on line 3.
Line 33--Enter the average per diem charge (rounded to two decimal places) for semi-private
accommodations by dividing the amount on line 30 by the days on line 4.
Line 34--Subtract the average per diem charge for all semi-private accommodations (line 33) from
the average per diem charge for all private room accommodations (line 32) to determine the
average per diem private room charge differential. If a negative amount results from this
computation, enter zero on line 34.
Line 35--Multiply the average per diem private room charge differential (line 34) by the inpatient
general routine cost-to-charge ratio (line 31) to determine the average per diem private room cost
differential (rounded to two decimal places).
Line 36--Multiply the average per diem private room cost differential (line 35) by the private room
accommodation days (excluding private room accommodation days applicable to swing-bed SNFtype and NF-type services) (line 3) to determine the total private room accommodation cost
differential adjustment.
Line 37--Subtract the private room cost differential adjustment (line 36) from the general inpatient
routine service cost net of swing-bed SNF-type and NF-type costs (line 27) to determine the
adjusted general inpatient routine service cost net of swing-bed SNF-type service costs, NF-type
service costs, and the private room accommodation cost differential adjustment. If line 4 equals
line 2, enter the amount from line 27 above.
4025.2 Part II - Hospital and Subproviders Only.--This part provides for the apportionment of
inpatient operating costs to titles V, XVIII, and XIX and the calculation of program excludable
cost for all hospitals (*) and subproviders. CAHs are required to complete this worksheet. For
hospitals reimbursed under TEFRA, it provides for the application of a ceiling on the rate of cost
increase for the hospital and subproviders. When the worksheet is completed for a component,
show both the hospital and component numbers.
* Hospitals including CAHs that (1) participated in the PARHM demonstration for the entire cost
reporting period, select the “PARHM Demonstration” box only and complete Worksheet D-1,
Parts I and II; or (2) participated in the PARHM demonstration for a portion of the cost reporting
period, select the “PARHM Demonstration” box and complete Worksheet D-1, Parts I and II, for
the portion of the cost reporting period, included in the demonstration. Select the “Hospital” box
and complete a separate Worksheet D-1, Parts I and II, for the portion of the cost reporting period
not included in the demonstration.

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Line Descriptions
Line 38--For non-IPPS providers, (includes CAHs), divide the adjusted general inpatient routine
service cost (line 37) by the total general inpatient routine service days including private room
(excluding swing-bed and newborn) days (line 2) to determine the general inpatient routine service
average cost per diem (rounded to two decimal places).
For PPS providers (includes IRFs, IPFs, and LTCHs under 100 percent PPS), divide the sum of
lines 36 and 37, by the inpatient days reported on line 2.
For CAHs the per diem, unless there is an adjustment for private room differential, should be equal
to the per diem calculated in the formula on line 26. If this is a CAH and there is a private room
differential, process as a non-PPS provider.
Line 39--Multiply the total program inpatient days including private room (excluding swing-bed
and newborn) days (line 9) by the adjusted general inpatient routine service average cost per diem
(line 38) to determine the general inpatient service cost applicable to the program.
Line 40--Multiply the medically necessary private room (excluding swing-bed) days applicable to
the program (line 14) by the average per diem private room cost differential (line 35) to determine
the reimbursable medically necessary private room cost applicable to the program. PPS providers
including IRF, IPF and LTCH, reimbursed at 100 percent Federal rate enter zero.
Line 41--Add lines 39 and 40 to determine the total general inpatient routine service cost
applicable to the program.
Line 42--This line is for titles V and XIX only and provides for the apportionment of your inpatient
routine service cost of the nursery, as appropriate.
Column 1--Enter the total inpatient cost applicable to the nursery from Worksheet C, Part I,
line 43.
TEFRA, COST, or OTHER Inpatient
PPS Inpatient, or IPF, IRF, and LTCH PPS

Column 3
Column 5

Column 2--Enter the total inpatient days applicable to the nursery from line 15.
Column 3--Divide the total inpatient cost in column 1 by the total inpatient days in column 2
(rounded to two decimal places).
Column 4--Enter the program nursery days from line 16.
Column 5--Multiply the average per diem cost in column 3 by the program nursery days in
column 4.
Lines 43 through 47--These lines provide for the apportionment of the hospital inpatient routine
service cost of intensive care type inpatient hospital units (excluding nursery) to the program.
Column 1--Enter on the appropriate line the total inpatient routine cost applicable to each of the
indicated intensive care type inpatient hospital units from Worksheet C, Part I, lines 31 through
35, as appropriate.
TEFRA, COST, or OTHER Inpatient
PPS Inpatient, or IPF, IRF and LTCH PPS

Column 3
Column 5

Column 2--Enter on the appropriate line the total inpatient days applicable to each of the indicated
intensive care type inpatient units. Transfer these inpatient days from Worksheet S-3, Part I,
column 8, lines 8 through 12, as appropriate.
Rev.

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DRAFT

Column 3--For each line, divide the total inpatient cost in column 1 by the total inpatient days in
column 2 (rounded to two decimal places).
Column 4--Enter on the appropriate line the Program days applicable to each of the indicated
intensive care type inpatient hospital units. Transfer these inpatient days from Worksheet S-3,
Part I, columns 5, 6, 6.01 (PARHM only) or 7, as appropriate, lines 8 through 12.
NOTE: When you place overflow general care patients temporarily in an intensive care type
inpatient hospital unit because all beds available for general care patients are occupied,
count the days as intensive care type unit days for the purpose of computing the intensive
care type unit per diem. The days are included in column 2. However, count the program
days as general routine days in computing program reimbursement. Enter the program
days on line 9 and not in column 4, lines 43 through 47, as applicable. (See
CMS Pub. 15-1, chapter 22, §2217.)
Column 5--Multiply the average cost per diem in column 3 by the program days in column 4.
Line 48--Enter the total program inpatient ancillary service cost from the appropriate
Worksheet D-3, column 3, line 200.
Line 48.01--Enter the Program inpatient cellular therapy acquisition cost from Worksheet D-6,
Part III, line 10, column 1.
Line 49--Enter the sum of the amounts on lines 41 through 48.01. When this worksheet is
completed for components, neither subject to prospective payment, nor subject to the target rate of
increase ceiling (i.e., "Other" box is checked), transfer this amount to Worksheet E-3, Part V,
line 1, or Part VII, line 1, as appropriate. Do not complete lines 50 through 63.
For all inclusive rate providers (Method E), apply the percentage to the sum of the aforementioned
lines (lines 41 through 48.01) based on the provider type designated on Worksheet S-2, column 4,
line 3 (see CMS Pub. 15-1, chapter 22, §2208).
Lines 50 through 53--These lines compute total program inpatient operating cost less program
capital-related, nonphysician anesthetists, and approved medical education costs. Complete these
lines for all provider components.
Line 50--Enter on the appropriate worksheet the total pass-through costs including capital-related
costs applicable to program inpatient routine services. Transfer capital-related inpatient routine
cost from Worksheet D, Part I, column 7, sum of lines 30 through 35 and line 43 for the hospital,
and line 40, 41, or 42, as applicable, for the subprovider. Add that amount to the other
pass-through costs from Worksheet D, Part III, column 9, sum of lines 30 through 35 and line 43,
for the hospital, and line 40, 41, or 42, as applicable, for the subprovider.
Line 51--Enter the total pass-through costs including capital-related costs applicable to program
inpatient ancillary services. Transfer capital-related inpatient ancillary costs from Worksheet D,
Part II, column 5, line 200. Add that amount to the other pass-through costs from Worksheet D,
Part IV, column 11, line 200.
Line 52--Enter the sum of lines 50 and 51.
Line 53--Enter total program inpatient operating cost (line 49) less program capital-related,
nonphysician anesthetists (if appropriate), and approved medical education costs (line 52).

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FORM CMS-2552-10

4025.2 (Cont.)

Lines 54 through 63--Except for those hospitals specified below, all hospitals (and distinct part
hospital units) excluded from prospective payment and extended neoplastic disease care hospitals
are reimbursed under cost reimbursement principles and are subject to the ceiling on the rate of
hospital cost increases (TEFRA). (See 42 CFR 413.40.) CAHs do not complete these lines as
CAH reimbursement is based on reasonable cost. The following hospitals are reimbursed under
special provisions and, therefore, are not generally subject to TEFRA or prospective payment:
•

Hospitals reimbursed under approved State cost control systems (see 42 CFR 403.300
through 403.322);

•

Nonparticipating hospitals furnishing emergency services to Medicare beneficiaries.

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For your components subject to the PPS or not otherwise subject to the rate of increase ceiling as
specified above, make no entries on lines 54 through 63.
NOTE: A new non-PPS hospital or subprovider (lines 85 and/or 86 of Worksheet S-2 with a “Y”
response) is cost reimbursed for all cost reporting periods through the end of its first
12-month cost reporting period. The 12-month cost reporting period also becomes the
TEFRA base period unless an exemption under 42 CFR 413.40(f) is granted. If such an
exemption is granted, cost reimbursement continues through the end of the exemption
period. The last 12-month period of the exemption is the TEFRA base period.
NOTE: For lines 54 through 63:
In the FFY 2018 IPPS final rule, (82 FR 38298
(August 14, 2017)), CMS created a new category of IPPS excluded hospitals named
“extended neoplastic disease care hospitals” under subsection (d)(1)(B)(vi) of the Act,
for hospitals that were formally classified as “subclause (II) LTCHs, effective for cost
reporting periods beginning on or after January 1, 2015, (that is, calendar year 2015 and
subsequent fiscal years). The payment adjustment is determined based on reasonable
cost, as described at 42 CFR 412.526(c).
Line 54--Enter the number of program discharges including deaths (excluding newborn and
DOAs) for the component from Worksheet S-3, Part I, columns 12 through 14 (as appropriate),
lines 14 and 16 through 18 (as appropriate). A patient discharge, including death, is a formal
release of a patient.

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Line 55--Enter the target amount per discharge as obtained from your contractor. The target
amount establishes a limitation on allowable rates of increase for hospital inpatient operating cost.
The rate of increase ceiling limits the amount by which your inpatient operating cost may increase
from one cost reporting period to the next. (See 42 CFR 413.40.) Ensure the amounts reported
on lines 55.01 and 55.02 are not included on this line.
Line 55.01--If Worksheet S-2, Part I, line 88, column 1, is “Y”, enter the amount of the permanent
adjustment to the TEFRA target amount per discharge from Worksheet S-2, Part I, line 89,
column 3, after applying the proper update factor (see 42 CFR 413.40) as obtained from your
contractor. If the contractor approved more than one permanent adjustment to the TEFRA target
amount per discharge (Worksheet S-2, Part I, line 88, column 2, is greater than 1), enter the sum
of all permanent adjustments, i.e., the sum of the amounts entered on Worksheet S-2, Part I, line 89
and subscripts, column 3, after applying the proper update factors (see 42 CFR 413.40) as
obtained from your contractor.
Line 55.02--This line is for contractor use only. Enter the contractor-approved amount of the
adjustment to the TEFRA target amount per discharge. Do not use this line to report a permanent
TEFRA target rate per discharge adjustment amount; report permanent adjustments on line 55.01.
Line 56--Multiply the number of discharges on line 54, by the sum of the amounts on lines 55,
55.01, and 55.02, to determine the rate of increase ceiling.
Line 57--Subtract line 53 from line 56, to determine the difference between adjusted inpatient
operating cost and the target amount.
Line 58 through 62--New providers and extended neoplastic disease care hospitals do not complete
lines 58 through 62. This line provides incentive payments when your cost per discharge for the
cost reporting period subject to the ceiling is less than the applicable target amount per discharge.
In addition, bonus payments are provided for hospitals who have received PPS exempt payments
for three or more previous cost reporting periods and whose operating costs are less than the target
amount, expected costs (lesser of actual costs or the target amount for the previous year), or trended
costs (lesser of actual operating costs or the target amount in 1996; or for hospitals where its third
full cost reporting period was after 1996 the inpatient operating cost per discharge), updated and
compounded by the market basket. It also provides for an adjustment when the cost per discharge
exceeds the applicable target amount per discharge. If line 57 is zero, enter zero on lines 58
through 62.

Rev.

40-149

4025.3

FORM CMS-2552-10

DRAFT

Line 58--If line 57 is a positive amount (actual inpatient operating cost is less than the target
amount), enter on line 58 the lesser of 15 percent of line 57, or 2 percent of line 56. If line 57 is
negative, do not complete line 58 (leave blank); however, complete line 62 for calculation of any
adjustments to the operating costs.
Line 59--Enter the hospital’s trended cost:
•

•

For a hospital for which its cost reporting period ending during FY 1996 was the third
or subsequent full cost reporting period, trended costs are the lesser of (line 53 divided by
line 54), or the FY 1996 cost report Worksheet D-1, Part II, line 55 (target amount)
compounded forward for each succeeding fiscal year by the market basket.
For all other hospitals, trended costs are the allowable inpatient operating costs per
discharge (line 53 divided by line 54) from its third full cost reporting period
compounded forward for each succeeding fiscal year by the market basket.

Line 60--Enter the hospital’s expected cost, calculated as the lesser of the hospital’s inpatient
operating cost per discharge (line 53 divided by line 54) or the prior year cost report
Worksheet D-1, Part II, sum of lines 55 and 55.01, updated by the market basket.
Line 61--Enter the continuous improvement bonus payment. If (line 53 divided by line 54) is less
than the lowest of the sum of lines 55 and 55.01, or line 59, or line 60, enter the lesser of 50 percent
of the amount by which operating costs (line 53) are less than expected costs (line 54 multiplied
by line 60), or 1 percent of the target amount (line 56); otherwise enter zero. (See
42 CFR 413.40(d)(4)(i).)
Line 62--If line 57 is a negative amount (actual inpatient operating cost is greater than the target
amount) and line 53 is greater than 110 percent of line 56, enter on this line the lesser of (1) or (2):
(1) 50 percent of the result of (line 53 minus 110 percent of line 56) or (2) 10 percent of line 56;
otherwise enter zero. (See 42 CFR 413.40(d)(3).)
Line 63--Allowable Cost Plus Incentive Payment--If line 57 is a positive amount, enter the sum of
lines 52, 53, 58, and 61 (if applicable). If line 57 is a negative amount, enter the sum of lines 52,
56, and 62. If line 57 is zero, enter the sum of lines 52 and 56. New providers and extended
neoplastic disease care hospitals enter the lesser of lines 53 or 56, plus line 52.
Line 64--Enter the amount of Medicare swing-bed SNF-type inpatient routine cost through
December 31 of the cost reporting period. Determine this amount by multiplying the program
swing-bed SNF-type inpatient days on line 10, by the rate used on line 17. For CAHs multiply
line 10, times the per diem calculated on line 38.
Line 65--Enter the amount of Medicare swing-bed SNF-type inpatient routine cost for the period
after December 31 of the cost reporting period. Determine this amount by multiplying the program
swing-bed SNF-type inpatient days on line 11, by the rate used on line 18. For CAHs multiply
line 11, times the per diem calculated on line 38.
Line 66--Enter the sum of lines 64 and 65. For CAHs only transfer this amount to Worksheet E-2,
column 1, line 1.
Line 67--Enter the amount of titles V or XIX swing-bed NF-type inpatient routine cost through
December 31 of the cost reporting period. Determine this amount by multiplying the program
swing-bed NF-type inpatient days on line 12, by the rate used on line 19.
Line 68--Enter the amount of titles V or XIX swing-bed NF-type inpatient routine cost for the
period after December 31 of the cost reporting period. Determine this amount by multiplying the
program swing-bed NF-type inpatient days on line 13, by the rate used on line 20.
Line 69--Enter the sum of lines 67 and 68. Transfer this amount to the appropriate Worksheet E-2,
column 1, line 2. If your state recognizes only one level of care obtain the amount from line 66.
40-150

Rev.

DRAFT

FORM CMS-2552-10

4025.3 (Cont.)

4025.3 Part III - SNF, NF, and ICF/IID Only.--This part provides for the apportionment of
inpatient operating costs to titles V, XVIII, and XIX. Hospital-based SNFs complete lines 70
through 74 and 83 through 86 for data purposes only as SNFs are reimbursed under SNF PPS for
title XVIII. Complete lines 70 through 89 for titles V and XIX. When this worksheet is completed
for a component, show both the hospital and component numbers. Any reference to the nursing
facility will also apply to the ICF/IID unit.
Line Descriptions
Line 70--Enter the hospital-based SNF or other nursing facility routine service cost from Part I,
line 37.
Line 71--Calculate the adjusted general inpatient routine service cost per diem by dividing the
amount on line 70, by inpatient days, including private room days, shown on Part I, line 2.
Line 72--Calculate the routine service cost by multiplying the program inpatient days, including
the private room days in Part I, line 9, by the per diem amount on line 71.
Line 73--Calculate the medically necessary private room cost applicable to the program by
multiplying the days shown in Part I, line 14, by the per diem in Part I, line 35.
Line 74--Add lines 72 and 73 to determine the total reasonable program general inpatient routine
service cost.
Lines 75 through 82--Apportionment of Inpatient Operating Costs for Other Nursing Facilities
(NF)--These lines are used for titles V and/or XIX only. For title XVIII Medicare, skip lines 75
through 82, and continue with line 83.
Line 75--Enter the capital-related cost allocated to the general inpatient routine service cost center.
For titles V and XIX, transfer this amount from Worksheet B, Part II, column 26, line 45 (NF).
Line 76--Calculate the per diem capital-related cost by dividing the amount on line 75 by the days
in Part I, line 2.
Line 77--Calculate the program capital-related cost by multiplying line 76 by the days in Part I,
line 9.
Line 78--Calculate the inpatient routine service cost by subtracting line 77 from line 74.
Line 79--Enter the aggregate charges to beneficiaries for excess costs obtained from your records.
Line 80--Enter the total program routine service cost for comparison to the cost limitation. Obtain
this amount by subtracting line 79 from line 78.
Line 81--Enter the inpatient routine service cost per diem limitation. This amount is provided by
your state contractor.
Line 82--Enter the inpatient routine service cost limitation. Obtain this amount by multiplying the
number of inpatient days shown on Part I, line 9 by the cost per diem limitation on line 81.
Line 83--For titles V and XIX, enter the amount of reimbursable inpatient routine service cost
determined by adding line 77 to the lesser of line 80 or line 82. If you are a provider not subject
to the inpatient routine service cost limit, enter the sum of lines 77 and 80. For title XVIII, enter
the amount from line 74.
Line 84-- Enter the program ancillary service amount from Worksheet D-3, column3, line 200.

Rev.

40-151

4025.4

FORM CMS-2552-10

DRAFT

Line 85--Enter (only when Worksheet D-1 is used for a hospital-based SNF and NF) the applicable
program's share of the reasonable compensation paid to physicians for services on utilization
review committees to an SNF and/or NF. Include the amount eliminated from total costs on
Worksheet A-8, line 25. If the utilization review costs are for more than one program, the sum of
all the Worksheet D-1 amounts reported on this line must equal the amount adjusted on
Worksheet A-8, line 25.
Line 86--Calculate the total program inpatient operating cost by adding the amounts on lines 83
through 85. Transfer this amount to the appropriate Worksheet E-3, Part VII, line 1, except for
SNFs subject to SNF PPS. For NF and ICF/IID, transfer this amount to Worksheet E-3, Part VII,
line 1, for titles V and XIX.
4025.4 Part IV - Computation of Observation Bed Pass-Through Cost.--This part provides for
the computation of the total observation bed costs and the portion of costs subject to reimbursement
as a pass-through cost for observation beds that are only in the general acute care routine area of
the hospital. CAHs are required tp complete this worksheet. For title XIX, insert the amount
calculated for title XVIII for the hospital, if applicable. To avoid duplication of reporting
observation bed costs, do not transfer the title XIX amount to Worksheet C.
Line 87--Transfer the total observation bed days from Worksheet S-3, Part I, column 8, line 28.
NOTE: Observation days are only recognized and reported in the inpatient routine area of the
hospital.
Line 88--Calculate the result of general inpatient routine cost on line 27 divided by line 2.
Line 89--Multiply the number of days on line 87 by the cost per diem on line 88, and enter the
result. Transfer this amount to Worksheet C, Parts I and II, column 1, line 92.
Lines 90 through 93--These lines compute the observation bed costs used to apportion the routine
pass-through costs and capital-related costs associated with observation beds for PPS, TEFRA,
and new children’s and new cancer providers. Lines 90 through 93 correspond to specific medical
education programs reported on Worksheet D, Part III, columns 1, 2, and 3, respectively.
Column 1--For line 90, transfer the amount from Worksheet D, Part I, column 1, line 30, for the
hospital. For line 91 through 93, enter the cost from Worksheet D, Part III, columns 1, 2 and 3,
line 30.
Column 2--Enter on each line the general inpatient routine cost from line 21. Enter the same
amount on each line.
Column 3--Divide column 1 by column 2, for each line, and enter the result. If there are no costs
in column 1, enter 0 in column 3.
Column 4--Enter the total observation cost from line 89. Enter the same amount on each line.
Column 5--Multiply the ratio in column 3 by the amount in column 4. Use this cost to apportion
routine pass-through costs associated with observation beds on Worksheet D, Parts II and IV.
Transfer the amount in column 5:
From
Wkst. D-1, Part IV
Col. 5, line 90
Col. 5, line 91
Col. 5, line 92
Col. 5, line 93

40-152

To
Wkst. D, Part II
Col. 1, line 92

To
Wkst D, Part IV
Col. 2, line 92
Col. 3, line 92
Col. 4, line 92

Rev.

04-20

FORM CMS-2552-10

4026.

4026.1

WORKSHEET D-2 - APPORTIONMENT OF COST OF SERVICES RENDERED BY
INTERNS AND RESIDENTS

4026.1 Part I - Not in Approved Teaching Program.--Use this part only if you have interns and
residents who are not in an approved teaching program. (See CMS Pub. 15-1, chapter 4.) If you
have more than one hospital-based outpatient rehabilitation provider, subscript line 17 to
accommodate reporting data for each.
Column 1--Enter the percentage of time that interns and residents, not in an approved teaching
program, are assigned to each of the indicated patient care areas on lines 1 through 19 and 21
through 26 (from your records).
Column 2--Enter on line 1 the total cost of residents’ services rendered in all patient care areas
from Worksheet B, Part I, column 26, line 100. Multiply the amount in column 1 by the total cost
in column 2, line 1. Enter the resulting amounts on the appropriate lines in column 2.
Inpatient
Column 3--Enter the total inpatient days applicable to the various patient care areas of the complex.
Description

Enter in Col. 3

Inpatient Days From
Worksheet D-1

Adults & Pediatrics
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Intensive Care Type Unit
Nursery
IPF - Inpatient Routine
IPF - Inpatient Routine
Subprovider
SNF
NF

line 2
line 3
line 4
line 5
line 6
line 7
line 8
line 10
line 11
line 12
line 13
line 14

Part I, col. 1, line 1
Part II, col. 2, line 43
Part II, col. 2, line 44
Part II, col. 2, line 45
Part II, col. 2, line 46
Part II, col. 2, line 47
S-3, Part I, col. 8, line 13
Part I, col. 1, line 1
Part I, col. 1, line 1
Part I, col. 1, line 1
Part I, col. 1, line 1
Part I, col. 1, line 1

Column 4--Divide the allocated expenses in column 2 by the inpatient days in column 3 to arrive
at the average per diem cost for each cost center.
For swing bed-SNF or swing bed-NF facilities, transfer the per diem amount in column 4, line 2,
to Worksheet E-2, column 1 (for titles V and XIX) or column 2 (for title XVIII), line 4.

Rev. 16

40-153

4026.1 (Cont.)

FORM CMS-2552-10

04-20

Columns 5, 6, and 7--Enter in the appropriate column the health care program inpatient days for
each patient care area.
Titles V and XIX
Description

Enter in column 5 for
title V or column 7
for title XIX

From Worksheet D-1

Adults & Pediatrics
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Type Unit
Other Intensive Care Type Unit
Nursery
IPF - Inpatient Routine
IRF - Inpatient Routine
Subprovider
SNF
NF

line 2
line 3
line 4
line 5
line 6
line 7
line 8
line 10
line 11
line 12
line 13
line 14

Part I, col. 1, line 9
Part II, col. 4, line 43
Part II, col. 4, line 44
Part II, col. 4, line 45
Part II, col. 4, line 46
Part II, col. 4, line 47
Part II, col. 4, line 42
Part I, col. 1, line 1
Part I, col. 1, line 1
Part I, col. 1, line 1
Part I, col. 1, line 1
Part I, col. 1, line 1

Title XVIII--Enter in column 6, lines 2 through 13, as appropriate, the total number of days in
which beneficiaries were inpatients of the provider and had Medicare Part B coverage. Such days
are determined without regard to whether Part A benefits were available. Submit a reconciliation
with the cost report demonstrating the computation of Medicare Part B inpatient days. The
following reconciliation format is recommended:
Cost
Center

Part A
Inpatient
Days
plus

Part B
Only Days minus

Part A Coverage
But No Part B
Days Coverage =

Medicare
Part B
Days

Part A Inpatient Days--Enter the Medicare Part A inpatient days from Worksheet D-1.
Cost Center

From Worksheet D-1

Adults & Pediatrics
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Type Unit
Surgical Intensive Care Type Unit
Other Intensive Care Type Unit
IPF - Inpatient Routine
IRF - Inpatient Routine
Subprovider
Skilled Nursing Facility

Part I, column 1, line 9
Part II, column 4, line 43
Part II, column 4, line 44
Part II, column 4, line 45
Part II, column 4, line 46
Part II, column 4, line 47
Part I, column 1, line 9
Part I, column 1, line 9
Part I, column 1, line 9
Part I, column 1, line 9

Part B Only Days--Enter the total number of days from your records in which inpatients were
covered under Medicare Part B but did not have Part A benefits available.
No Part B Days--Enter the total number of days from your records in which inpatients were
covered under Medicare Part A but did not have Part B benefits available.

40-154

Rev. 16

09-15

FORM CMS-2552-10

4026.1 (Cont.)

Columns 8, 9, and 10--Multiply the average cost per day in column 4 by the health care program
days in columns 5, 6, and 7, respectively. Enter the resulting amounts in columns 8, 9, and 10, as
appropriate, for each cost center.
Outpatient
Column 3--Enter the total charges applicable to each outpatient service area. Obtain the total
charges from Worksheet C, column 8, lines 88 through 93.
Column 4--Compute the total outpatient cost-to-charge ratio by dividing costs in column 2 by
charges in column 3, for each cost center.
Columns 5, 6, and 7--Enter in these columns program charges for outpatient services. Do not
include in Medicare charges any charges identified as MSP/LCC.
Titles V and XIX:
Description

Enter in col. 5 for
title V or col. 7
for title XIX

Sum of
Worksheet D, Part V,
Worksheet D-3, sum of cols. 2 through 4
col. 2
(and applicable subscripts)

RHC
FQHC
Clinic
Emergency
Observation Beds
Other Outpatient

line 21
line 22
line 23
line 24
line 25
line 26

line 88
line 89
line 90
line 91
line 92
line 93

Title XVIII:

line 88
line 89
line 90
line 91
line 92
line 93

Description

Enter in.
col. 6 for
title XVIII

From
Worksheet D, Part V,
Worksheet cols. 2 through 4
D-3, col. 2 (& applicable subscripts)

RHC
FQHC
Clinic
Emergency
Observation Beds
Other Outpatient

line 21
line 22
line 23
line 24
line 25
line 26

line 88
line 89
line 90
line 91
line 92
line 93

plus
plus
plus
plus
plus
plus

line 88
line 89
line 90
line 91
line 92
line 93

Less Part A
Only Charges
minus
minus
minus
minus
minus
minus

From
Provider
Records

NOTE: Submit a reconciliation worksheet with the cost report showing the computations used
for the charges for column 6.
If you have subproviders, the amounts entered in these columns are the sum of the hospital and
subprovider Worksheets D-3 and D, Part V.
Columns 8, 9, and 10, lines 21 through 26--Compute program outpatient costs for titles V; XIX;
and XVIII, Part B; cost by multiplying the cost-to-charge ratio in column 4 by the program
outpatient charges in columns 5, 6, and 7. Enter the resulting amounts in columns 8, 9, and 10, as
appropriate, for each cost center.

Rev. 8

40-155

4026.2

FORM CMS-2552-10

09-15

Transfer program expenses.
From Title V (column 8)/Title XIX (column 10)

Hospital: Sum of lines 9 and 27

Worksheet E-3, Part VII, line 19

Subprovider: lines 10-12, as applicable

Worksheet E-3, Part VII, line 19

Other Nursing Facility: line 14

Worksheet E-3, Part VII, line 19

From Title XVIII (Column 9) (only if
Part II is not utilized)

Hospital: Sum of lines 9 and 27

Worksheet E, Part B, line 22

Subprovider: line 10-12, as applicable

Worksheet E, Part B, line 22

Skilled Nursing Facility: line 13

Worksheet E, Part B, line 22

4026.2 Part II - In An Approved Teaching Program (Title XVIII, Part B Inpatient Routine Costs
Only).--This part provides for reimbursement for inpatient routine services rendered by interns and
residents in approved teaching programs to Medicare beneficiaries who have Part B coverage and
are not entitled to benefits under Part A. (See CMS Pub. 15-1, chapter 4; and chapter 21, §2120.)
Do not complete this section unless you qualify for the new teaching hospital exception for GME
payments in 42 CFR 413.77(e)(1).
Column 1--Enter the amounts allocated in the cost finding process to the indicated cost centers.
Obtain these amounts from Worksheet B, Part I, sum of the amounts in columns 21 and 22, as
adjusted for any post step-down adjustments applicable to interns and residents in approved
teaching programs.
Column 2--Enter the adjustment for interns and residents costs applicable to swing-bed services
but allocated to hospital routine cost. Compute these amounts as follows:
Swing
Inpatient
Bed
Amount

I&R Costs
Allocated to
Adults &
Pediatrics

times

Total
Swing-Bed
Days

divided
by

Total Days

For line 30 (SNF)

Wkst. D-2,
col. 1, line 29

Wkst. D-1,
sum of lines 5
and 6

Wkst. D-1,
line 1

For line 31 (NF)

Wkst. D-2,
col. 1, line 29

Wkst. D-1,
sum of lines 7
and 8

Wkst. D-1,
line 1

The amount subtracted from line 29 must equal the sum of the amounts computed for lines 30
and 31.

40-156

Rev. 8

04-20

FORM CMS-2552-10

4026.3

If you have swing-beds in your IPF subprovider, complete line 38 to adjust for swing-bed costs.
Compute the swing-bed amounts as explained above except that the interns and residents costs
allocated to adults and pediatrics (line 38) comes from Worksheet D-2, column 1, line 38. The
amount subtracted from line 38 must equal the sum of subscripts of line 38, as applicable. If you
have swing-beds in your IRF subprovider, complete line 39 to adjust for swing-bed costs.
Compute the swing-bed amounts as explained above except that the interns and residents costs
allocated to adults and pediatrics (line 39) comes from Worksheet D-2, column 1, line 39. The
amount subtracted from line 39 must equal the sum of subscripts of line 39, as applicable.
Column 3--Enter on lines 29, and 38 through 40, as applicable, the amounts in column 1 minus the
amount in column 2. Enter on line 30 the amount from column 2. Enter on lines 32 through 36,
and 41, the amounts from column 1.
Column 4--Enter the total inpatient days applicable to the various patient care areas of the complex.
(See instructions for Part I, column 3. For line 30, this is from Worksheet D-1, sum of lines 5
and 6.)
Column 5--Divide the allocated expense in column 3 by the inpatient days in column 4 to arrive
at the average per diem cost for each cost center.
Column 6--Enter on lines 29, 30, 32 through 36, and 38 through 41, as applicable, the total number
of days in which inpatients were covered under Medicare Part B but did not have Part A benefits
available.
Column 7--Multiply the average per diem cost in column 5 by the number of inpatient days in
column 6 to arrive at the expense applicable to title XVIII for each cost center. Transfer the
amount on line 30, or lines 38 through 40, if you are a subprovider with a swing-bed, to
Worksheet E-2, column 2, line 6.
For columns 1, 3, and 7, enter on line 37, the sum of the amounts on line 29 plus the sum of the
amounts on lines 32 through 36.
Transfer the expenses on lines 37 through 41, to the appropriate lines on Part III, column 4,
whenever you complete both Parts I and II.
However, when only Part II is completed, transfer the amount entered in column 7, lines 37
through 41, to Worksheet E, Part B, line 22, as appropriate.
4026.3 Part III - Summary for Title XVIII (To be completed only if both Parts I and II are
used).--Do not complete this section unless you qualify for the exception for GME payments in
42 CFR 413.77(e)(1). This part is applicable to Medicare only and is provided to summarize the
amounts apportioned to the program in Parts I and II. This part is completed only if both Parts I
and II are used.
Transfer title XVIII expenses.
Description

From column 6

Hospital
Subprovider
SNF

Line 45
TO Worksheet E, Part B, line 22
Lines 46 through 48 TO Worksheet E, Part B, line 22
Line 49
TO Worksheet E, Part B, line 22

Rev. 16

40-157

4027
4027.

FORM CMS-2552-10
WORKSHEET D-3
APPORTIONMENT

INPATIENT

ANCILLARY

04-20
SERVICE

COST

This worksheet provides for the apportionment of cost applicable to hospital inpatient services
reimbursable under titles V, XVIII and XIX as indicated in 42 CFR 413.53. All hospitals (*) filing
a full cost report, including CAHs (Worksheet S-2, line 105, is “Y”) must complete this worksheet.
Complete a separate copy of this worksheet for each sub-provider, distinct part SNF and NF,
swing-bed SNF and NF, or any other component. Identify the health care program, provider
component, and the payment system by checking the appropriate boxes at the top of the worksheet.
The cost centers on this worksheet have the same line numbers as the respective cost centers on
Worksheets A, B, B-1, and C. This design facilitates referencing throughout the cost report.
* Hospitals that participated in the PARHM demonstration must complete Worksheet D-3, for the
portion of the cost reporting period not included in the PARHM demonstration and a separate
Worksheet D-3, for the portion of the cost reporting period included in the PARHM demonstration.
Column 1--Effective for cost reporting periods ending before September 30, 2018, enter the ratio
of cost to charges developed for each cost center from Worksheet C, lines 50 through 94, and 96
through 98. The ratios in columns 10 and 11 of Worksheet C are used only for hospital or
sub-provider components for titles V, XVIII, and XIX inpatient services subject to the TEFRA
rate of increase ceiling (see 42 CFR 413.40) or PPS (see 42 CFR 412, Subpart N, O, or P),
respectively. Use the ratios in column 9 in all other cases.
Effective for cost reporting periods ending on or after September 30, 2018, enter the ratio of cost
to charges developed for each cost center from Worksheet C, lines 50 through 94, and 96
through 98. The ratios in column 10 of Worksheet C are used for TEFRA providers (see
42 CFR 413.40). TEFRA providers include LTCHs classified as extended neoplastic disease care
hospitals; children’s hospitals; cancer hospitals; RNHCIs; and hospitals located outside the 50
States, the District of Columbia, and Puerto Rico (i.e., hospitals located in the U.S. Virgin Islands,
Guam, the Northern Mariana Islands, and American Samoa.) The ratios in column 11 of
Worksheet C are used for all PPS providers (see 42 CFR 412, Subpart N, O, or P; 42 CFR
413.114(a)(2) for other than CAHs; and 42 CFR 413, Subpart J). Use the ratios in column 9 for
cost reimbursed providers such as CAHs, new TEFRA hospitals exempt from the rate of increase
limits, and post-hospital SNF care furnished in a swing-bed CAH (see 42 CFR 413.114(a)(2)).
Column 2--Enter from the PS&R or your records the inpatient program charges applicable to the
provider component services only (not professional component) in the appropriate cost centers as
detailed below. Also include charges for cost centers with a negative balance on Worksheet B,
Part I, column 26. Do not include Program charges for swing-bed services and Medicare charges
identified as MSP/LCC. Hospitals that participated in the PARHM demonstration must report
PS&R charges for the portion of the cost reporting period included in the PARHM demonstration
and complete a separate worksheet and report PS&R charges for the portion of the cost reporting
period not included in the demonstration.
Lines 30 through 35--Enter the program charges from the PS&R or your records (hospital only).
Lines 40 through 42--Enter in column 2 the inpatient program charges for the sub-providers’
component only. For sub-provider components do not complete lines 30 through 35 and 43. For
a hospital complex, do not complete lines 40 through 42.

40-158

Rev. 16

DRAFT

FORM CMS-2552-10

4027 (Cont.)

Line 43--Enter the charges for your nursery department for which you were reimbursed. Complete
this for Medicaid services only.
Line 61--Enter the program charges for your clinical laboratory tests for which you reimburse the
pathologist. See the instructions for Worksheet A (see §4013) for a more complete discussion on
the use of this cost center.
NOTE FOR LINE 61: Since the charges on line 61 are also included on line 60, laboratory,
you must reduce total charges to prevent double counting. Make this adjustment on
line 201.
Line 73--Enter only the program charges for drugs charged to patients that are not paid a
predetermined amount.
Line 78--For CAR T-cell immunotherapy cost, enter the charges for services for all patients (for
Medicare, these are billed under revenue codes 0871, 0872, 0873, 0874, and 0891).
Lines 88 through 90 and 93--Do not enter on these lines program charges related to any inpatient
ancillary services (e.g., radiology- diagnostic, laboratory) provided in a clinic, RHC, or FQHC and
billed as inpatient services. Instead, reclassify such program charges to the related ancillary cost
centers.
Lines 92 and 92.01--Enter on these lines, as applicable, the program charges for observation bed
services if the patient was subsequently admitted as an inpatient. However, these program charges
can only be reported on the main hospital’s (e.g., acute care hospital, freestanding psychiatric
hospital, freestanding rehabilitation hospital) Worksheet D-3 or PARHM Demonstration
Worksheet D-3. (That is, program charges for observation bed services provided to patients
subsequently admitted as inpatients to an acute hospital’s excluded psychiatric or rehabilitation
unit must be reported on Worksheet D-3 of the acute hospital.)
Lines 96 and 97--Do not enter program charges for oxygen rented or sold as the fee schedule
applies for these services.
Line 200--Enter the total of the amounts in columns 2 and 3, lines 50 through 94, and 96 through
98.
Line 201--Enter in column 2, program charges for your clinical laboratory tests when the physician
bills you for program patients only. Obtain this amount from line 61.
Line 202--Enter in column 2, the amount on line 200 less the amount on line 201.
Transfer the amount in column 2, line 202, as follows:
For title XVIII, Part A (other reimbursement), transfer the amount to Worksheet E-3, Part V,
line 8. Do not transfer this amount if you are reimbursed under PPS or TEFRA. No transfers of
swing-bed charges are made to Worksheet E-2 since no LCC comparison is made. For titles V
and XIX (if not a PPS provider), transfer the amount plus the amount from Worksheet D, Part V,
sum of columns 3 and 4, line 202, to Worksheet E-3, Part VII, column 1, line 9.

Rev.

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FORM CMS-2552-10

DRAFT

Column 3--Multiply the indicated program charges in column 2, by the ratio in column 1, to
determine the program inpatient expenses.
Transfer column 3, line 200, as follows:
Type of Provider
Hospital
Sub-provider
SNF
NF
Swing-Bed SNF
Swing-Bed NF

40-160

TO
Wkst. D-1, Part II, col. 1, line 48
Wkst. D-1, Part II, col. 1, line 48
Wkst. D-1, Part III, col. 1, line 84
Wkst. D-1, Part III, col. 1, line 84
Wkst. E-2, col. 1, line 3
Wkst. E-2, col. 1, line 3

Rev.

DRAFT
4028.

FORM CMS-2552-10

4028.1

WORKSHEET D-4 - COMPUTATION OF ORGAN ACQUISITION COSTS AND
CHARGES FOR A TRANSPLANT HOSPITAL WITH A MEDICARE-CERTIFIED
TRANSPLANT PROGRAM

This worksheet computes organ acquisition costs for a transplant hospital that is a Medicarecertified transplant center (CTC) with a Medicare-approved transplant program (transplant
program) as defined in 42 CFR 482.70. Hospitals that do not have a Medicare-approved
transplant program do not complete this worksheet. (See CMS Pub. 15-1, chapter 31, §3107.)
Complete a separate worksheet for each transplant program (heart, liver, lung, pancreas,
intestine, kidney, or islet) with a certification date on Worksheet S-2, Part I, lines 126 through 132.
Check the applicable box to identify the transplant program for which the worksheet computes
acquisition costs. When a CTC procures multiple organs from a single donor, the CTC must
equitably and reasonably allocate the days and charges related to that procurement among the
organ types procured, and report the days and charges for each organ type on the appropriate
transplant program worksheet (see CMS Pub. 15-1, chapter 31, §3102).
Hospitals that participated in the PARHM demonstration for a portion of the cost reporting period
or the entire cost reporting period DO NOT complete a separate Worksheet D-4. Hospitals
participating in the PARHM demonstration for a portion of the cost reporting period or the entire
cost reporting period complete this worksheet for the hospital for the entire cost reporting period
and see specific instructions on line 69.
An OPO is either a hospital-based OPO or an independent OPO. OPO references throughout this
chapter include both hospital-based and independent OPOs unless differentiation is required for
context.
NOTE: For cost allocation purposes, count organs procured en bloc (two organs procured as
one unit) and transplanted into the same recipient as one organ. This can include, but is
not limited to, en bloc kidneys and en bloc lungs. Count organs procured en bloc and
subsequently separated for transplant as two organs.
Worksheet D-4 consists of the following four parts:
Part I

Part II

Part III
Part IV

Computation of Organ Acquisition Cost (Inpatient Routine and Ancillary
Services)
Computation of Organ Acquisition Cost (Other than Inpatient Routine and
Ancillary Service Costs)
Summary of Costs and Charges
Statistics

4028.1 Part I - Computation of Organ Acquisition Costs (Inpatient Routine and Ancillary
Services).--This worksheet computes the routine and ancillary costs for organ acquisitions,
allocating routine costs based on the per diem cost for each routine cost center and allocating
ancillary costs based on the cost-to-charge ratio for each ancillary cost center.
Lines 1 through 7--These lines provide for the computation of inpatient routine service costs
applicable to organ acquisition and for the accumulation of inpatient routine service charges for
organ acquisition.
Column 1--Enter on lines 1 through 6, as appropriate, the inpatient routine charges applicable to
organ acquisition. Enter on line 7, the sum of the amounts reported on lines 1 through 6.

Rev.

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4028.1 (Cont.)

FORM CMS-2552-10

DRAFT

Column 2--Enter on lines 1 through 6, as appropriate, the average per diem cost from
Worksheet D-1:
Description

To
Worksheet D-4,
Part I, col. 2

From
Worksheet D-1,
Part II

Adults & Pediatrics
Intensive Care
Coronary Care
Burn Intensive Care Type Unit
Surgical Intensive Care Type Unit
Other Intensive Care Type Unit

line 1
line 2
line 3
line 4
line 5
line 6

col. 1, line 38
col. 3, line 43
col. 3, line 44
col. 3, line 45
col. 3, line 46
col. 3, line 47

Column 3--For each cost center, enter total organ acquisition days (Medicare and non-Medicare).
An organ acquisition day is an inpatient day of care rendered to a potential recipient/donor (before
admission for the actual transplant) solely for a medical evaluation for an anticipated organ
transplant; or an organ donor patient who is hospitalized for the surgical removal of an organ; or
a day of care rendered to a cadaver in an inpatient routine service area for the surgical removal of
its organs for transplant. Pro-rate these days proportionally to the number of organs excised. For
example, if a cadaveric donor spent 1 day in the hospital following the declaration of death and
consent to donate, and five organs were excised from the cadaveric donor (e.g., two kidneys, two
lungs, and one liver), the number of organ acquisition days reported as a ratio is computed:
• on Worksheet D-4 (kidney) as 2 kidneys divided by 5 organs total = 0.40 days for kidney;
• on Worksheet D-4 (lung) as 2 lungs divided by 5 organs total = 0.40 days for lung; and
• on Worksheet D-4 (liver) as 1 liver divided by 5 organs total = 0.20 days for liver.
On line 7, enter the sum of lines 1 through 6. (See CMS Pub. 100-02, chapter 11, §§140.4-140.8.)
Column 4--For each cost center, enter the amount in column 2 multiplied by the amount in
column 3. On line 7, enter the sum of lines 1 through 6.
Lines 8 through 40--These lines provide for the computation of ancillary service cost applicable
to organ acquisition. These lines also provide for the accumulation of inpatient and outpatient
organ acquisition ancillary charges.
Column 1--For each cost center, transfer the “cost or other” cost-to-charge ratio from
Worksheet C, column 9.
Column 2--For each cost center, enter inpatient and outpatient organ acquisition ancillary charges
from your records. On line 41, enter the sum of lines 8 through 40. When a CTC procures multiple
organs from a single donor, equitably attribute the ancillary charges to each organ procured. For
example, if the CTC’s operating room charge is $12,000 to procure two kidneys, procured and
transplanted en bloc, and one heart, the CTC reports a $6,000 operating room charge for the en
bloc kidneys on the kidney Worksheet D-4 and a $6,000 operating room charge for the heart on
the heart Worksheet D-4. However, if the CTC’s operating room charge is $12,000 to procure
two kidneys (not en bloc) and one heart, the CTC reports a $4,000 operating room charge for each
kidney on the kidney Worksheet D-4 and a $4,000 operating room charge for the heart on the
heart Worksheet D-4. When attributing the ancillary charges, the CTC may use an alternate basis
for allocation (e.g., number of operating room minutes) if the contractor can verify the alternate
basis results in a more accurate cost per organ.
Column 3--For each cost center, compute the organ acquisition costs by multiplying the ratio in
column 1 by the amount in column 2. On line 41, enter the sum of lines 8 through 40.

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FORM CMS-2552-10

4028.2

4028.2 Part II - Computation of Organ Acquisition Costs (Other Than Inpatient Routine and
Ancillary Service Costs).--This worksheet apportions the cost of I&R not in an approved teaching
program attributable to organ acquisitions.
Lines 42 through 47--These lines apportion the cost of I&R not in an approved teaching program
for inpatient services attributable to organ acquisitions.
Column 1--For each applicable line, transfer the average cost per day of I&R not in an approved
teaching program from Worksheet D-2, Part I, column 4, lines as indicated.
Column 2--Transfer the number of organ acquisition days in each inpatient routine service area
from Part I, column 3, lines 1 through 6, as applicable.
Column 3--For each cost center multiply the average cost per day amount in column 1 by the
number of days in column 2.
Line 48--For columns 2 and 3, enter the sum of lines 42 through 47.
Lines 49 through 54--These lines apportion the cost of I&R not in an approved teaching program
for outpatient services attributable to organ acquisitions.
Column 1--For each applicable line, transfer the organ acquisition charges from the outpatient
service areas on Part I, column 2, lines 35 through 40, as applicable.
Column 2--Transfer the ratio of cost to charges for outpatient costs of I&R not in an approved
teaching program for each outpatient service area from Worksheet D-2, Part I, column 4, lines 21
through 26, as applicable.
Column 3--For each cost center, compute organ acquisition costs by multiplying the charges in
column 1 by the ratios in column 2.
Line 55--For columns 1 and 3, enter the sum of lines 49 through 54.

Rev.

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4028.3

FORM CMS-2552-10

4028.3

DRAFT

Part III - Summary of Costs and Charges.--

Line 56--In column 1, enter the sum of the costs in Part I, column 4, line 7, and column 3, line 41.
In column 3, enter the sum of the charges in Part I, column 1, line 7, and column 2, line 41.
Line 57--In column 1, enter the cost of inpatient services of I&R not in an approved teaching
program from Part II, column 3, line 48. In column 3, enter the charges for the services for which
the cost is entered in column 1. If you do not charge separately for the services of I&R, enter zero
in column 3.
Line 58--In column 1, enter the cost of outpatient services of I&R not in an approved teaching
program from Part II, column 3, line 55. In column 3, enter the charges for the services for which
the cost is entered in column 1. If you do not charge separately for the services of interns and
residents, enter zero in column 3.
Line 59--In column 1, enter the direct organ acquisition costs and allocated general service costs
from Worksheet B, Part I, column 26, lines 105, 106, 107, 108, 109, 110, or 111, whichever is
applicable. In accordance with 42 CFR 413.402(b), direct costs include, but are not limited to, the
cost of services purchased under arrangements or billed directly to you for:
•
•
•
•
•
•

Fees for physician services (preadmission donor and recipient tissue typing),
Costs for organs acquired from other providers or organ procurement organizations,
Transportation costs excluding costs for transporting organs outside of the United
States,
Organ recipient registration fees,
Surgeon’s fees for excising cadaveric organs, and
Tissue typing services furnished by independent laboratories.

In column 3, enter the applicable charges from your schedule of charges. If your facility has no
schedule of charges for the services, enter the cost from column 1.
Line 60--If Worksheet S-2, Part I, line 58, is “Y,” enter the cost of physicians in column 1. For
cost reporting periods ending before June 30, 2014, transfer the amount from Worksheet D-5,
Part II, column 3, lines 24 through 30, as applicable. For cost reporting periods ending on or after
June 30, 2014, transfer the amount from Worksheet D-5, Part IV, lines 24 through 30, as
applicable. In column 3, enter the applicable charges from your schedule of charges. If your
facility has no schedule of charges for the services, enter the cost from column 1.
Line 61--Enter in columns 1 and 3 the sum of lines 56 through 60. This amount must be equal to
or greater than the amount reported on line 66 (revenues for organs sold).
Line 62-- Enter the number of total usable organs excised and purchased minus all unusable or
discarded organs that could not be transplanted (usable organs equals Worksheet D-4, Part IV,
line 74, sum of columns 1 and 2, minus Worksheet D-4, Part IV, line 83, sum of columns 1 and 2).
For islets, enter the number of patients who received islets injections. (See CMS Pub. 100-04,
chapter 32, section 70.4.)

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4028.3 (Cont.)

Line 63--In column 2, enter the number of Medicare usable organs that are included on line 62.
Medicare usable organs include:
• organs transplanted into Medicare beneficiaries (line 75.01);
• kidneys (not including non-renal organs) transplanted into MA beneficiaries effective
for transplants occurring on or after January 1, 2021 (line 75.02);
• organs transplanted into Medicare beneficiaries with partial payments by a primary
insurer in addition to Medicare (line 75.03);
• organs sent to other providers and OPOs; (sum of lines 76, 77, and 78); and,
• kidneys sent to military renal transplant centers (MRTCs) that have a reciprocal sharing
agreement with the hospital-based OPO in effect prior to March 3, 1988, and approved
by the contractor (line 79.01).
NOTE FOR LINE 63: Do not include:
• organs used for research (line 82);
• kidneys sent to MRTCs without a reciprocal sharing agreement with the hospital-based
OPO in effect prior to March 3, 1988, and approved by the contractor and organs sent
to veterans’ hospitals (line 79);
• organs sent or sold outside of the United States (lines 80 and 81); and
• organs transplanted into non-Medicare beneficiaries; organs that were totally paid by
primary insurance other than Medicare; organs that were paid by a MA plan (except for
kidneys transplanted into MA beneficiaries for transplants occurring on or after
January 1, 2021) or a PACE (program of all-inclusive care for the elderly)
organization; and organs procured from a non-certified OPO.
Line 64--Enter the ratio of Medicare usable organs (line 63) to total usable organs (line 62).
Line 65--In column 1, calculate the Medicare costs by multiplying the ratio on line 64 by the total
costs on line 61, column 1. In column 3, calculate the Medicare charges by multiplying the ratio
on line 64, column 2, by the total charges on line 61, column 3.
Line 66--Enter in column 1 (and transfer to column 3), the total revenue applicable to organs
reported on line 63, i.e,:
•

Revenue amounts for organs sent to other providers, organs sent to OPOs, and kidneys sent
to MRTCs with a reciprocal sharing agreement with the hospital-based OPO in effect prior
to March 3, 1988, and approved by the contractor; and

•

For cost reporting periods beginning prior to October 1, 2022, also include on this line
the primary insurer payment amounts applicable to organ acquisition for organs that were
partially reimbursed by primary insurers when Medicare is the secondary payer. When
the primary insurer does not pay in full for the services, that is for the transplant and the
organ acquisition costs, Medicare may have a secondary payer liability for the organ
acquisition costs (see 42 CFR 413.414(c)). When Medicare is the secondary payer and the
primary insurer makes a payment for both the transplant and the organ acquisition costs,
the portion of the payment applicabale to organ acquisition costs must be used to reduce
the Medicare organ acquisition cost. Enter in column 1 (and transfer to column 3) the
amount applicable to the organ acquisition costs by prorating the primary payer payment
amount between the organ acquisition and transplant based on the charges submitted to
the primary insurer. (The amount reported on this line must not be included on
Worksheet E, Part A, line 60.) For cost reporting periods beginning on or after
October 1, 2022, do not include the primary insurer payment amounts applicable to organ
acquisition on this line; instead, report the amounts on line 66.01.

Rev.

40-165

4028.4

FORM CMS-2552-10

DRAFT

Line 66.01-- For cost reporting periods beginning on or after October 1, 2022, enter the primary
insurer payment amounts applicable to organ acquisition for organs included on line 63 and
line 75.03 that were partially reimbursed by primary insurers when Medicare is the secondary
payer. When the primary insurer does not pay in full for the services, that is for the transplant
and the organ acquisition costs, Medicare may have a secondary payer liability for the organ
acquisition costs (see 42 CFR 413.414(c)). When Medicare is the secondary payer and the
primary insurer makes a payment for both the transplant and the organ acquisition costs, the
portion of the payment applicabale to organ acquisition costs must be used to reduce the Medicare
organ acquisition cost. Enter in column 1 (and transfer to column 3) the amount applicable to the
organ acquisition costs by prorating the primary payer payment amount between the organ
acquisition and transplant based on the charges submitted to the primary insurer. (The amount
reported on this line must not be included on Worksheet E, Part A, line 60.)
Line 66.02--For cost reporting periods beginning on or after October 1, 2022, when a nonMedicare primary insurer makes a single payment for a transplant that includes the organ
acquisition cost, report the portion of the payment applicable to the transplant. Enter in column 1
(and transfer to column 3) the amount applicable to the transplant by prorating the amount
received between the organ acquisition and the transplant based on the charges submitted to the
primary insurer. This line is informational to reconcile primary insurer payment amounts. (The
amount reported on this line must remain on Worksheet E, Part A, line 60.)
Line 67--For cost reporting periods beginning prior to October 1, 2022, enter the result of line 65
minus line 66. For cost reporting periods beginning on or after October 1, 2022, enter the result
of line 65 minus the sum of lines 66 and 66.01.
Line 68--Enter in all columns the total amount of organ acquisition charges billed to Medicare
under Part B. This occurs when organs are transplanted into Medicare beneficiaries who, on the
day of transplantation, are not entitled to Part A benefits. This computation reflects an adjustment
between Medicare Part A and Part B costs and charges so that the amount added under Part B is
the same amount subtracted under Part A.
Line 69--For columns 1 and 3 subtract line 68 from line 67. For columns 2 and 4, transfer that
amount from line 68. Hospitals participating in the PARHM demonstration for a portion of the
cost reporting period or the entire cost reporting period must prorate the amount on line 69 using
Medicare patient days and transfer to the appropriate Worksheet E, Part A, line 55. For example,
a hospital with a June 30, 2019, fiscal year end that began participation in the PARHM
demonstration on January 29, 2019, reported Medicare inpatient days on Worksheet S-3, Part I,
column 6, line 14, for the period of July 1, 2018, through January 28, 2019, and reported Medicare
inpatient days on Worksheet S-3, Part I, column 6.01, line 14, for the period of January 29, 2019,
through June 30, 2019. Multiply the amount on line 69 by the ratio of Medicare inpatient days
reported on Worksheet S-3, Part I, column 6, line 14, divided by total Medicare inpatient days
(sum of Worksheet S-3, Part I, columns 6 plus 6.01, line 14) and enter on the “Hospital”
Worksheet E, Part A, line 55. To compute the portion of line 69 applicable to the PARHM
demonstration, multiply the amount on line 69 by the ratio of Medicare inpatient days reported on
Worksheet S-3, Part I, column 6.01, line 14, divided by total Medicare inpatient days (sum of
Worksheet S-3, Part I, columns 6 plus 6.01, line 14) and enter on the “PARHM demonstration”
Worksheet E, Part A, line 55.

40-165.1

Rev.

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FORM CMS-2552-10

4028.4 (Cont.)

4028.4 Part IV - Statistics.--For each organ type, report the statistics applicable to living donors
in column 1, cadaveric donors in column 2, and revenues in column 3. Report in column 1 the
statistics applicable to living donors for kidneys, partial livers, or partial lungs. Do not report in
column 1 any statistics for hearts, pancreata, intestines, whole livers, whole lungs, or islets; report
these statistics in column 2. Count organs as one organ when:
• procured en bloc (two organs procured as one unit) and transplanted into the same
recipient, and
• procured en bloc with the intention of transplanting en bloc as one organ, including, but
not limited to, en bloc kidneys and en bloc lungs.
Line 70--For columns 1 and 2, enter the number of organs excised in the CTC. Do not include
organs excised outside of the CTC, even if a procurement team from your CTC excised the organs.
Line 71--For columns 1 and 2, enter the number of organs purchased from other transplant
hospitals. Include organs excised outside of the CTC by a procurement team from your CTC.
Line 72--For columns 1 and 2, enter the number of organs purchased from non-transplant
hospitals.
Line 73--Enter in column 2 the number of organs purchased from OPOs.
Line 74--For each column, enter the sum of lines 70 through 73.
Line 75--For cost reporting periods beginning prior to October 1, 2022, enter in columns 1 and 2,
the total number of organs transplanted by the CTC. For cost reporting periods beginning on or
after October 1, 2022, line 75 is the sum of lines 75.01, 75.02, 75.03, and 75.04.
NOTE FOR LINES 75.01, 75.02, and 75.03: For cost reporting periods beginning on or after
October 1, 2022, report the organs on these lines on line 63 (Medicare usable organs).
Line 75.01--Enter in columns 1 and 2, the number of organs transplanted by the CTC into
Medicare beneficiaries.
Line 75.02--Enter in columns 1 and 2, the number of kidneys transplanted into MA beneficiaries
on or after January 1, 2021, by the CTC.
Line 75.03-- Enter in columns 1 and 2, the number of organs transplanted by the CTC into patients
with Medicare as a secondary payer where Medicare had a financial responsibility as the
secondary payer. In column 3, enter the amount of revenue received from the primary payer for
organs reported in columns 1 and 2. Where the amount reported in column 3 includes the cost of
acquiring and transplanting the organ, the amount must be split on lines 66.01 and 66.02
accordingly. The amount reported on this line in column 3 must equal the sum of line 66.01,
column 1, and line 66.02, column 1.
Line 75.04--For cost reporting periods beginning on or after October 1, 2022, enter in columns 1
and 2, the number of organs transplanted by the CTC into non-Medicare patients, non-renal MA
beneficiaries, and Medicare beneficiaries where Medicare was secondary payer but had no
financial responsibility as the secondary payer.

Rev.

40-165.2

4028.4 (Cont.)

FORM CMS-2552-10

DRAFT

Line 76--In columns 1 and 2, enter the number of organs sold to other (non-transplant) hospitals.
Enter in column 3 the amount of revenue received for organs reported in columns 1 and 2.
Line 77--In columns 1 and 2, enter the number of organs sold to OPOs. In column 3, enter the
amount of revenue received for organs reported in columns 1 and 2.
Line 78--In columns 1 and 2, enter the number of organs sold to transplant hospitals. In column 3,
enter the amount of revenue received for organs reported in columns 1 and 2.
Line 79--In columns 1 and 2, enter the number of:
• kidneys sold to MRTCs without a reciprocal sharing agreement with the hospital-based
OPO in effect prior to March 3, 1988, and approved by the contractor; and
• organs sold to VA hospitals.
Line 79.01--In columns 1 and 2, enter the number of kidneys sold to MRTCs that have a reciprocal
sharing agreement with the hospital-based OPO in effect prior to March 3, 1988, and approved
by the contractor. In column 3, enter the amount of revenue received for kidneys reported in
columns 1 and 2.
Line 80--In columns 1 and 2, enter the number of organs sold outside of the U.S.
Line 81--In columns 1 and 2, enter the number of organs sent outside of the U.S. with no revenue
received.
Line 82--In columns 1 and 2, enter the number of organs used for research.
Line 83--In columns 1 and 2, enter the number of unusable or discarded organs.
Line 84--In columns 1 and 2, enter the sum of lines 75 through 83, excluding lines 75.01, 75.02,
75.03, and 75.04. In column 3, enter the sum of lines 76 through 78, and line 79.01. The totals
for columns 1 and 2 must equal the totals on line 74, columns 1 and 2, respectively. For cost
reporting periods beginning prior to October 1, 2022, do not complete column 3. For cost
reporting periods beginning on or after October 1, 2022, the total for column 3 must equal the
amount on line 66, column 1.

40-165.3

Rev.

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FORM CMS-2552-10

4028.4 (Cont.)

This page is reserved for future use.

Rev.

40-165.4

4029

FORM CMS-2552-10

4029.

DRAFT

WORKSHEET D-5 - APPORTIONMENT OF COST FOR PHYSICIANS’ SERVICES
IN A TEACHING HOSPITAL

A teaching hospital engaged in an approved GME residency program in accordance with
42 CFR 415.152, may elect to receive payment on a reasonable cost basis for the direct medical
and surgical services of its physicians in lieu of fee schedule payments that might otherwise be
made for these services. These services, and the supervision of interns and residents furnishing
care to individual beneficiaries, are covered as hospital services for which Medicare pays the
hospital on a reasonable cost basis. Teaching hospitals that have elected to be paid for these
services on a reasonable cost basis in accordance with 42 CFR 415.160, are subject to RCEs. This
worksheet provides for the computation of the RCE limits by medical specialty and the
apportionment of reimbursable adjusted cost to titles V, XVIII, and XIX in accordance with
4 CFR 415.162 and CMS Pub. 15-1, chapter 21, §2148.
NOTE: CAHs do not complete this worksheet.
If such election is made, direct medical and surgical services to program patients, including
supervision of interns and residents, rendered in a teaching hospital by physicians on the hospital
staff are reimbursable as provider services on a reasonable cost basis. In addition, certain medical
school costs may be reimbursed. Payments for services donated by volunteer physicians to
program patients are made to a fund designated by the organized medical staff the teaching hospital
or medical school.
Limits on the amount of physician compensation which may be recognized as a reasonable
provider cost are imposed in accordance with 42 CFR 415.70.
Worksheet D-5 consists of four parts:
Part I

Part II

Part III

Part IV

Reasonable Compensation Equivalent Computation for Cost Reporting
Periods Ending Before June 30, 2014
Apportionment of Cost for Physicians’ Services in a Teaching Hospital for
Cost Reporting Periods Ending Before June 30, 2014
Reasonable Compensation Equivalent Computation for Cost Reporting
Periods Ending On or After June 30, 2014
Apportionment of Cost for Physicians’ Services in a Teaching Hospital for
Cost Reporting Periods Ending On or After June 30, 2014

Effective for cost reporting periods ending on or after June 30, 2014, do not complete
Worksheet D-5, Parts I and II, but complete Worksheet D-5, Parts III and IV.
4029.1 Part I - Reasonable Compensation Equivalent Computation for Cost Reporting Periods
Ending Before June 30, 2014.--This part provides for the computation of the RCE limit by medical
specialty of the physician on the hospital staff or physician on the medical school faculty.
Complete separate parts for the hospital staff physicians and for physicians on the medical staff
faculty. This part must be completed by applicable hospitals for cost reporting periods ending
before June 30, 2014.
Where several physicians work in the same specialty, see CMS Pub. 15-1, chapter 21, §2182.6C,
for a discussion of applying the RCE limit in the aggregate for the specialty versus on an individual
basis to each of the physicians in the specialty.

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FORM CMS-2552-10

4029.1 (Cont.)

When RCE limits are applied on an individual basis to each physician in a medical specialty,
prepare a supporting worksheet identical in columnar format to Worksheet D-5, Part I, for each
medical specialty. Enter on the first line under columns 1 and 9, the line number applicable to the
medical specialty (as displayed on Worksheet D-5, Part I). Enter the name of the medical specialty
on the first line in columns 2 and 10. Following the first line, use a separate line to compute the
adjusted cost of physician’s direct medical and surgical services (column 16) for each physician.
Enter the total amount from column 16 of the supporting worksheet in column 16 of the line on
Worksheet D-5, Part I, corresponding to the medical specialty for which the supporting worksheet
is prepared. If the individual physician method is used, list each physician using an individual
identifier that is not the name or social security number of the physician (e.g., Dr. A, Dr. B).
However, the identity of the physician must be made available to your contractor.
NOTE: The method used on Worksheet D-5 (i.e., aggregate or individual physician) must be the
same as the method used on Worksheet A-8-2.
Column Descriptions
Column 3--Enter for each medical specialty the amount of the total cost included in
Worksheet A-8-2, column 3. When the individual physician method is used, enter in column 3 of
the supporting worksheet the amount included on Worksheet A-8-2, column 3, for that physician.
Column 4--Enter for each medical specialty the amount of the cost included in Worksheet A-8-2,
column 4, for the direct medical and surgical services, including the supervision of interns and
residents by physicians on the hospital staff or by physicians on the faculty of a medical school,
as appropriate.
If the individual physician method is used, enter in column 4 of the supporting worksheet the
amount included on Worksheet A-8-2, column 4, for the indicated physician.
Column 5--Enter for each line of data the reasonable compensation equivalent (RCE) limit
applicable to the physician’s compensation. The amount entered is the limit applicable to the
physician specialty. Obtain the RCE applicable to the specialty from the table listed in the
68 FR 45488 (August 1, 2003). 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 6--Enter the physician’s hours allocated to professional services (i.e., professional
component hours) in all components (e.g., hospitals, sub-providers) of the health care complex. If
the physician is paid for unused vacation, unused sick leave, etc., exclude the hours so paid from
the hours entered in this column. Time records or other documentation that supports this allocation
must be available for verification by your contractor upon request. (See CMS Pub. 15-1,
chapter 21, §2182.3E.)
Column 7--Enter the unadjusted RCE limit for each line of data. This amount is the product of the
RCE amount entered in column 5 and the ratio of the physician’s professional component hours
entered in column 6 to 2080 hours.
Column 8--Enter for each line of data five percent of the amounts entered in column 7.

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Column 11--You may adjust upward, up to five percent of the computed limit (column 8), the
computed RCE limit in column 7 to take into consideration the actual costs of membership for
physicians in professional societies and continuing education paid by the provider or medical
school.
Enter for each line of data the actual amounts of these expenses paid by the provider or medical
school.
Column 12--Enter for each line of data, the result of multiplying column 4 by column 11 and
dividing by column 3.
Column 13--You may also adjust upward the computed RCE limit in column 7 to reflect the actual
malpractice expense incurred by the provider or by the medical school, as appropriate, for the
services of a physician or group of physicians to provider patients.
Enter for each line of data the actual amounts of these malpractice expenses paid by the provider
(or medical school, if applicable).
Column 14--Enter for each line of data, the result of multiplying column 4 by column 13, and
dividing by column 3.
Column 15--Enter for each line of data, the sum of columns 7 and 14, plus the lesser of columns 8
or 12.
Column 16--Enter for each line of data, the adjusted cost of direct medical and surgical services,
including the supervision of interns and residents (i.e., the lesser of column 4 or column 15).
Line Descriptions
Line 11--Total the amounts in columns 3 through 8, and 11 through 16.
4029.2 Part II - Apportionment of Cost for Physicians’ Services in a Teaching Hospital for Cost
Reporting Periods Ending Before June 30, 2014.--This part provides for the accumulation and
apportionment of reimbursable cost for titles V, XVIII, and XIX using the aggregate per diem
method of apportionment (see CMS Pub. 15-1, chapter 22, §2218) for the adjusted direct medical
and surgical services, including the supervision of interns and residents, rendered by physicians to
patients in a teaching hospital which makes the election described in CMS Pub. 15-1, chapter 21,
§2148. Complete a separate Part II for the hospital and for each sub-provider for cost reporting
periods ending before June 30, 2014.
Line Descriptions
Line 1--Enter in the appropriate column, the adjusted cost of direct medical and surgical services,
including the supervision of interns and residents, rendered to all patients by physicians on the
hospital staff (column 1) and by physicians on the medical school faculty (column 2), as
determined in accordance with CMS Pub. 15-1, chapter 21, §2148. Transfer these amounts from
Part I, column 16, line 11. Enter the same amount on each component’s Part II.
Line 2--Enter in column 1, the sum of the hospital inpatient days and the hospital outpatient visit
days for all patients in the hospital and each hospital sub-provider. Compute these days in the
manner described in CMS Pub. 15-1, chapter 22, §2218.C. Enter in column 2, the same number
of days as entered in column 1. Make the same entries on each component’s Part II.

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4029.3

Line 3--Enter the result obtained by dividing the cost of services on line 1 by the sum of the days
on line 2 for each category of physicians.
Lines 4 through 16--Enter in column 1, on the appropriate line, the reimbursable days and
outpatient visit days for titles V, XVIII, and XIX for the hospital and each hospital sub-provider,
as applicable. Lines 10 through 16 contain the total of the title XVIII organ acquisition days and
outpatient visit days. Enter in column 2 the same number of days as entered in column 1. Compute
these days from your records in the manner described in CMS Pub. 15-1, chapter 22, §2218.C. Do
not complete lines 10 through 16 for an IRF, IPF or hospital sub-provider(s).
Line 17--Do not use.
Lines 18 through 31--Enter on the appropriate line the result of multiplying the days entered on
lines 4 through 16 by the average cost per diem from line 3. Enter the total of columns 1 and 2 in
column 3 for each line. The total becomes a part of the reimbursement settlement through the
transfers denoted on this worksheet.
4029.3 Part III - Reasonable Compensation Equivalent Computation for Cost Reporting Periods
Ending On or After June 30, 2014.--This part provides for the computation of the RCE limit of the
physician on the hospital staff or physician on the medical school faculty. This part must be
completed by applicable hospitals for cost reporting periods ending on or after June 30, 2014.
Column Descriptions
Columns 1 through 5, 9 through 11, and 13--For each line in columns 1 through 4, transfer the
information from the corresponding columns on Worksheet A-8-2. For each line in column 5,
transfer the amount from Worksheet A-8-2, column 6. For each line in columns 9 and 10, transfer
the information from Worksheet A-8-2, columns 10 and 11, respectively. For each line in
columns 11 and 13, transfer the amounts from Worksheet A-8-2, columns 12 and 14, respectively.
Column 6--For each line, enter the physician’s hours allocated to professional services
(i.e., professional component hours) in all components (e.g., hospitals, sub-providers) of the health
care complex. If the physician is paid for unused vacation, unused sick leave, etc., exclude the
hours so paid from the hours entered in this column. Time records or other documentation
supporting this allocation must be available for verification by your contractor upon request. (See
CMS Pub. 15-1, chapter 21, §2182.3E.)
Column 7--For each line, enter the unadjusted RCE limit calculated by multiplying the RCE
amount in column 5, by the ratio of the physician’s professional component hours entered in
column 6 to 2080 hours (column 5 x (column 6 ÷ 2080)).
Column 8--For each line, enter five percent of the amount entered in column 7.
Column 12--For each line, enter the professional component share of column 11 by multiplying
column 4 by column 11 and dividing by column 3.
Column 14--Enter for each line of data the result of multiplying column 4 by column 13 and
dividing by column 3.
Column 15--For each line, enter the sum of column 7 plus column 14, plus the lesser of column 8
or 12.
Column 16--For each line, enter the lesser of column 4 or column 15.
Line Descriptions
Line 200--Total the amounts in columns 3 through 8, and columns 11 through 16.
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DRAFT

4029.4 Part IV - Apportionment of Cost for Physicians’ Services in a Teaching Hospital for Cost
Reporting Periods Ending On or After June 30, 2014.--This part provides for the accumulation and
apportionment of reimbursable cost for titles V, XVIII, and XIX using the aggregate per diem
method of apportionment (see CMS Pub. 15-1, chapter 22, §2218) for the adjusted direct medical
and surgical services, including the supervision of interns and residents, rendered by physicians to
patients in a teaching hospital which makes the election described in CMS Pub. 15-1, chapter 21,
§2148. Complete a separate Part IV for the hospital and each hospital sub-provider for cost
reporting periods ending on or after June 30, 2014.
Line Descriptions
Line 1--Enter the adjusted cost of direct medical and surgical services, including the supervision
of interns and residents, rendered to all patients by physicians, determined in accordance with
CMS Pub. 15-1, chapter 21, §2148. Transfer these amounts from Part III, column 16, line 200.
When completing this worksheet for multiple components of a health care complex, enter the same
amount on each component’s Part IV worksheet.
Line 2--Enter the sum of the hospital inpatient days and the hospital outpatient visit days for all
patients in the hospital and each hospital sub-provider. Compute these days in the manner
described in CMS Pub. 15-1, chapter 22, §2218.C. When completing this worksheet for the
hospital or hospital sub-provider(s), enter the same amount on each component’s Part IV.
Line 3--Enter the result obtained by dividing the cost of services on line 1 by the sum of the days
on line 2.
Lines 4 through 16--For each line, enter the reimbursable days and outpatient visit days for
titles V, XVIII, and XIX for the hospital and each sub-provider. Lines 10 through 16 contain the
total of the title XVIII organ acquisition days and outpatient visit days. Compute these days from
your records in the manner described in CMS Pub. 15-1, chapter 22, §2218.C.
Line 17.01--Enter the reimbursable inpatient allogeneic HSCT acquisition days for title XVIII for
the hospital for cost reporting periods beginning on or after October 1, 2020. Compute these days
from your records in the manner described in CMS Pub. 15-1, chapter 22, §2218.C.
Line 17.02--Enter the reimbursable outpatient allogeneic HSCT acquisition days for title XVIII
for the hospital for cost reporting periods beginning on or after October 1, 2020. Compute these
days from your records in the manner described in CMS Pub. 15-1, chapter 22, §2218.C.

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FORM CMS-2552-10

4029.4 (Cont.)

Lines 18 through 31.02--For each line, enter the result of multiplying the days entered on lines 4
through 17.02 by the average cost per diem from line 3. The total becomes a part of the
reimbursement settlement through the transfers denoted on this worksheet. Transfer the amounts
as follows:
From Worksheet D-5, Part IV
Sum of lines 18 and line 19
Line 20

Line 21
Sum of lines 22 and line 23
Sum of lines 24 through 30
Sum of lines 31.01 and 31.02

To Worksheet
E-3, Part VII, line 20 (title V hospital or component)
E, Part A, line 56 (Medicare IPPS hospital)
E-3, Part I, line 3 (TEFRA hospital)
E-3, Part II, line 15 (IPF)
E-3, Part III, line 16 (IRF)
E-3, Part IV, line 6 (LTCH)
E-3, Part V, line 17 (Cost reimbursement)
E, Part B, line 23 (Medicare hospital Part B)
E-3, Part VII, line 20 (title XIX hospital or component)
D-4 (for each organ type), Part III, line 60 (see note)
D-6, Part III, line 4 (see note)

NOTE FOR LINES 24 THROUGH 30: Transfer the cost on each line to the Worksheet D-4 for
the organ type as specified (e.g., transfer the cost for physicians’ services in a teaching
hospital applicable to kidney acquisition on Worksheet D-5, Part IV, line 24, to the
kidney acquisition Worksheet D-4, Part III, line 60).
NOTE FOR LINES 31.01 AND 31.02: Transfer the cost on each line to Worksheet D-6 as
follows:
• from Worksheet D-5, Part IV, line 31.01, to Worksheet D-6, Part III, line 4, col. 1.
• from Worksheet D-5, Part IV, line 31.02, to Worksheet D-6, Part III, line 4, col. 2.

Rev.

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FORM CMS-2552-10

4029.5

DRAFT

WORKSHEET D-6 - COMPUTATION OF CELLULAR THERAPY ACQUISITION
COSTS

On the Worksheet D-6, the hospital reports the acquisition costs for allogeneic HSCT. The
worksheet, effective for cost reporting periods beginning on or after October 1, 2020, calculates
the inpatient routine, ancillary, and other costs associated with acquiring allogeneic
hematopoietic stem cells for transplantation, including acquisition costs in cases that do not result
in transplant due to death of the intended recipient or other causes, and reimbursed under reasonable
cost as required under §1886(d)(5)(M) of the Act. Do not include costs for allogeneic HSCT.
See CMS Pub. 100-04, chapter 3, §90.3.1, and CMS Pub. 100-04, chapter 4, §231.11, for costs
that may be included as allogeneic HSCT acquisition costs.
The Worksheet D-6 consists of the following parts:
Part I - Inpatient Routine and Ancillary Services Cellular Therapy Acquisition Costs
Part II - Interns and Residents Not In An Approved Teaching Program Cellular Therapy
Acquisition Costs
Part III - Summary of Cellular Therapy Acquisition Costs and Charges
Part IV - Statistics
4029.6 Part I - Inpatient Routine and Ancillary Services Cellular Therapy Acquisition Costs.-On this part, the hospital calculates the routine and ancillary services costs for allogeneic HSCT
acquisition, allocating routine services costs based on the per diem cost for each routine service
cost center and allocating ancillary services costs based on the cost-to-charge ratio for each
ancillary service cost center.
Lines 1 through 6--These lines calculate inpatient routine services costs applicable to allogeneic
HSCT acquisition days, and provide for reporting the associated inpatient routine services
charges.
Line 7--Enter the sum of the amounts reported on lines 1 through 6.
Column 1--For each cost center, enter the inpatient routine services charges applicable to
allogeneic HSCT acquisition days.
Column 2--For each cost center, transfer the average per diem cost from Worksheet D-1:
Description

From
Worksheet D-1,
Part II

To
Worksheet D-6,
Part I, column 2

Adults & Pediatrics
Intensive Care
Surgical Intensive Care Type Unit
Other Intensive Care Type Unit

col. 1, line 38
col. 3., line 43
col. 3., line 46
col. 3., line 47

line 1
line 2
line 5
line 6

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FORM CMS-2552-10

4029.6 (Cont.)

Column 3--For each cost center, enter the inpatient allogeneic HSCT acquisition days (Medicare
and non-Medicare) for services rendered to:
•
•

an allogeneic HSCT recipient, donor, or potential donor, solely for a medical
evaluation in anticipation of a stem cell transplant; and
an allogeneic HSCT donor in an inpatient routine service area for the collection of
stem cells for transplant.

Column 4--For each cost center, calculate the allogeneic HSCT acquisition costs for routine
services by multiplying the per diem in column 2 by the days in column 3.
Lines 8 through 28--These lines provide for the computation of the inpatient and outpatient
ancillary services acquisition cost.
Column 1--For each cost center, transfer the corresponding “cost or other” cost-to-charge ratio
from Worksheet C, Part I, column 9.
Column 2--For each cost center, using your internal logs, enter the itemized charges for services
furnished to potential transplant donors and recipients (for Medicare, billed under revenue
code 0815), i.e., enter the acquisition charges for inpatient ancillay services for all patients. Also
report acquisition charges for cases that do not result in transplant due to death of the intended
recipient or other causes.
Column 3-- For each cost center, using your internal logs, enter the itemized charges for services
furnished to potential transplant donors and recipients (for Medicare, billed under revenue
code 0815), i.e., enter the acquisition charges for outpatient ancillay services for all patients. Also
report acquisition charges for cases that do not result in transplant due to death of the intended
recipient or other causes.
Column 4--For each cost center, calculate the inpatient ancillary services acquisition costs by
multiplying the ratio in column 1 by the inpatient ancillary charges in column 2.
Column 5--For each cost center, calculate the outpatient ancillary services acquisition costs by
multiplying the ratio in column 1 by the outpatient ancillary services charges in column 3.
Line 28--For each column (2 through 5), enter the sum of lines 8 through 27.

Rev.

40-168.5

4029.7

FORM CMS-2552-10

DRAFT

4029.7 Part II - Interns and Residents not in an Approved Program Cellular Therapy
Acquisition Costs.--On this part, the hospital calculates the cost of interns and residents not in an
approved teaching program attributable to allogeneic HSCT acquisition.
Lines 1 through 6--These lines apportion the cost of interns and residents not in an approved
teaching program for inpatient routine services attributable to allogeneic HSCT acquisition.
Line 7--Enter the sum of lines 1 through 6 in columns 2 and 3.
Column 1--For each cost center, transfer the corresponding average cost per day of I&R not in
an approved teaching program from Worksheet D-2, Part I, column 4.
Column 2--For each cost center, transfer the number of allogeneic HSCT acquisition days in each
inpatient routine service area from Part I, column 3, lines 1 through 6.
Column 3--For each cost center, calculate the allogeneic HSCT I&R not in an approved program
acquisition costs by multiplying the average cost per day in column 1 by the number of days in
column 2.
4029.8 Part III - Summary of Cellular Therapy Acquisition Costs and Charges.--On this part,
the hospital summarizes the costs and charges for allogeneic HSCT acquisition.
Line 1--Transfer the direct acquisition costs and allocated general service costs from
Worksheet B, Part I, line 77, column 26. The direct costs include, but are not limited to, the cost
of services purchased under arrangements or billed directly to you for:
•
•
•
•
•
•
•

National Marrow Donor Program fees, if applicable, for stem cells from an unrelated
donor;
Tissue typing of donor and recipient;
Donor evaluation;
Physician pre-admission/pre-procedure donor evaluation services;
Costs associated with harvesting procedure (e.g., general routine and special care
services, procedure/operating room and other ancillary services, apheresis services,
etc.);
Post-operative/post-procedure evaluation of donor; and
Preparation and processing of stem cells.

Line 2--In column 1, enter the sum of the costs from Part I, line 7, column 4, and Part I, line 28,
column 4. In column 2, enter the cost from Part I, line 28, column 5.
Line 3--In column 1, enter the cost of services of interns and residents not in an approved teaching
program from Part II, line 7, column 3.
Line 4--Apportion the acquisition cost from line 1 between inpatient and outpatient using the ratio
of inpatient transplants (line 7, column 1) to total transplants (line 7, column 3) and outpatient
transplants (line 7, column 2) to total transplants (line 7, column 3).
Line 5--If Worksheet S-2, Part I, line 58, is “Y,” transfer the cost of physicians from
Worksheet D-5, Part IV, line 31.01 and 31.02, to columns 1 and 2, respectively.
Line 6--For each column, enter the sum of lines 2 through 5.
Line 7--Enter the number of inpatient and outpatient allogeneic HSCTs in columns 1 and 2,
respectively. In column 3, enter the sum of columns 1 and 2.

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4029.6 (Cont.)

Line 8-- Enter the number of Medicare inpatient and outpatient allogeneic HSCTs in columns 1
and 2, respectively.
Line 9--Calculate the ratio of Medicare to total by dividing line 8 by line 7.
Line 10--Calculate the Medicare acquisition cost for allogeneic HSCTs by multiplying line 6 by
line 9 for each column. Transfer the HSCT acquisition costs from line 10, column 1, as follows:
IPPS hospital - Inpatient
TEFRA hospital - Inpatient
CAH - Inpatient

to Worksheet E, Part A, line 55.01
to Worksheet D-1, Part II, line 48.01
to Worksheet E-3, Part V, line 3.01

Do not transfer total outpatient acquisition costs for allogeneic HSCTs from column 2 as these
costs are paid under OPPS and not reimbursed under reasonable cost.
4029.9

Part IV - Statistics.--

Line 1--Enter the number of recipients intended to receive an allogeneic hematopoietic stem cell
transplant for whom the acquisition cost was incurred and reported on Worksheet D-6, Part I, but
the transplant did not occur due to death of the intended recipient or other causes.

Rev.

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DRAFT

This page is reserved for future use.

40-168.8

Rev.

04-20

FORM CMS-2552-10

4030.

WORKSHEET E - CALCULATION OF REIMBURSEMENT SETTLEMENT

4030.1

Worksheet E, Parts A and B, calculate title XVIII settlement for inpatient hospital services under
the IPPS (including IPPS hospitals participating in the PARHM demonstration), and title XVIII
(Part B) settlement for medical and other health services. Worksheet E-3 computes title XVIII,
Part A settlement for non-IPPS hospitals, settlements under titles V and XIX, and settlements for
title XVIII SNFs reimbursed under a PPS. Worksheet E-4 computes total direct GME costs.
Worksheet E consists of the following two parts:
Part A - Inpatient Hospital Services Under the IPPS
Part B - Medical and Other Health Services
Application of Lesser of Reasonable Cost or Customary Charges--Worksheet E, Part B, allows for
the computation of the lesser of reasonable costs or customary charges (LCC), where applicable,
for services covered under Part B. Make a separate computation on each of these worksheets. In
addition, make separate computations to determine whether the services on any or all of these
worksheets are exempt from LCC. For example, the provider may meet the nominal charge criteria
for the services on Worksheet E, Part B, and, therefore, be exempt from LCC only for these
services.
For those provider Part B services exempt from LCC for this reason, reimbursement for the
affected services is based on 80 percent of reasonable cost net of the Part B deductible amounts.
4030.1

Part A - Inpatient Hospital Services Under the IPPS.--

For SCH/MDH status change and/or geographical reclassification (see 42 CFR 412.102 and 103),
subscript column 1 for lines 1 through 3, 22, 28, 29, 33, 34, 41, 45, 47, and 48. For SCH/MDH
status changes see additional instructions at line 35.03. If you responded “1” and “2”, or “2” and
“1”, to Worksheet S-2, Part I, questions 26 and 27, respectively, which indicated your facility
experienced a change in geographic classification status during the year, subscript column 1, and
report the payments before the reclassification, and on or after the reclassification in the applicable
column. Effective for cost reporting periods ending on or after June 30, 2018, if a SCH
experienced a change in geographic reclassification (Worksheet S-2, Part I, questions 26 and 27,
answered “1” and “2”, or “2” and “1”, respectively) and the hospital maintained the SCH status
for the entire cost reporting period, do not subscript column 1; report all payments, both before
and after the geographic reclassification, in column 1.
For cost reporting periods that overlap or begin on or after October 1, 2014, if you responded “Y”,
to Worksheet S-2, Part I, line 22.03, column 1 or 2, which indicated your facility experienced a
change in geographic redesignation as a result of the OMB standards for delineating statistical
areas adopted by CMS in FY 2015, subscript column 1, for lines 33 and 34.
For SCH or MDH status change, enter on lines 1 through 3, in column 1, the applicable payment
data for the period applicable to SCH or MDH status. Enter on lines 1 through 3, in column 1.01,
the payment data for the period in which the provider did not retain SCH or MDH status. The data
for lines 1 through 3 must be obtained from the provider's records or the PS&R.
For IPPS hospitals participating in Model 4 of the Bundled Payments for Care Improvement
(BPCI) initiative, IME and disproportionate share hospital (DSH) payments will be calculated
based on the non-discounted base DRG payment that would have been made in the absence of the
model, as will outlier payments and hospital capital payments (see CR 8196, dated
February 15, 2013). Enter on lines 1.03 and 2.02, in column 1, the applicable payment data for
the cost reporting period.

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04-20

For IPPS hospitals participating in the PARHM demonstration during this cost reporting period
and (1) the hospital participated in the PARHM demonstration for the entire cost reporting period,
select the “PARHM Demonstration” box only and complete this worksheet; or (2) the hospital
participated in the PARHM demonstration for a portion of the cost reporting period, select the
“PARHM Demonstration” box and complete Worksheet E, Part A, for the portion of the cost
reporting period, included in the demonstration. Select the “Hospital” box and complete a separate
Worksheet E, Part A, for the portion of the cost reporting period not included in the demonstration.
For hospitals participating in the PARHM demonstration for a portion of this cost reporting period,
enter the applicable data on Worksheet E, Part A, for the PARHM demonstration, lines 1.01, 1.02,
1.03, 1.04, 2, 2.02, 2.03, 2.04, 3, 35.03, 35.04, 35.05, 41.01, 48, 52, 53, 54, 54.01, 55, 56, 60, 62,
63, 64, 66, 68, 70, 70.87, 70.88, 70.89, 70.92, 70.93, 70.94, 70.95, 71.01, 71.02, 72.01,73.01,74.01,
and 92 through 96. The data input in all other applicable lines are the same for the PARHM
participation portion and non-participation portion of the cost reporting period.
Line Descriptions
Line 1--The amount entered on this line is the sum of the federal specific operating portion (DRG
payments) paid for PPS discharges during the cost reporting period and the DRG payments made
for PPS transfers during the cost reporting period. For cost reporting periods overlapping
October 1, 2013, and subsequent years, do not complete line 1, but complete lines 1.01 and 1.02.
Line 1.01--For cost reporting periods that overlap October 1, 2013, and subsequent years, enter
the amount of the federal specific operating portion (DRG payments) paid for PPS discharges and
transfers occurring prior to October 1. For example, a calendar year provider would include DRG
payments for discharges occurring during the period of January 1 through September 30.
Line 1.02--For cost reporting periods that begin or overlap October 1, 2013, and subsequent years,
enter the amount of the federal specific operating portion (DRG payments) paid for PPS discharges
and transfers occurring on or after October 1. For example, a calendar year provider would include
DRG payments for discharges occurring during the period of October 1 through December 31.
Line 1.03--Enter the amount of the federal specific operating portion (DRG payments) for Model 4
bundled payments for care improvement (BPCI) initiative, effective for discharges occurring on
or after October 1, 2013. Effective for cost reporting periods that overlap October 1, 2014, and
subsequent years, enter the amount of the federal specific operating portion (DRG payments) paid
for Model 4 BPCI discharges and transfers occurring prior to October 1.
Line 1.04--Effective for cost reporting periods that begin or overlap October 1, 2014, and
subsequent years, enter the amount of the federal specific operating portion (DRG payments) paid
for Model 4 BPCI discharges and transfers occurring on or after October 1.
Line 2--Enter the amount of outlier payments made for PPS discharges during the cost reporting
period. See 42 CFR 412, Subpart F, for a discussion of these items. For cost reporting periods
that begin on or after October 1, 2018, do not complete line 2, but complete lines 2.03 and 2.04.
Line 2.01--For inpatient PPS services rendered during the cost reporting period, enter the operating
outlier reconciliation amount for operating expenses from line 92.
Line 2.02--Effective for discharges occurring on or after October 1, 2013, enter the amount of
outlier payments made for Model 4 BPCI discharges during the cost reporting period.

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4030.1 (Cont.)

Line 2.03--For cost reporting periods that begin on or after October 1, 2018, enter the amount of
the outlier payments made for PPS discharges occurring prior to October 1 of the cost reporting
period. For example, a calendar year provider would include outlier payments for discharges
occurring during the period of January 1, through September 30.
Line 2.04--For cost reporting periods that begin on or after October 1, 2018, enter the amount of
the outlier payments made for PPS discharges occurring on or after October 1 of the cost reporting
period. For example, a calendar year provider would include outlier payments for discharges
occurring during the period of October 1, through December 31.
Line 3--Hospitals receive payments for IME for managed care patients based on the DRG payment
that would have been made if the service had not been a managed care service. The PS&R will
capture in conjunction with the PPS PRICER the simulated payments. Enter the total managed
care “simulated payments” from the PS&R.
Line 4--Enter the result of dividing the number of bed days available (Worksheet S-3, Part I,
column 3, line 14) by the number of days in the cost reporting period (365, or 366 in case of leap
year). Effective for cost reporting periods beginning on or after October 1, 2012, enter the result
of dividing the number of bed days available (Worksheet S-3, Part I, column 3, line 14, plus
line 32) by the number of days in the cost reporting period (365, or 366 in case of leap year).
NOTE: Reduce the bed days available by: (1) swing-bed days (Worksheet S-3, Part I, column 8,
sum of lines 5 and 6): (2) the number of observation days (Worksheet S-3, Part I,
column 8, line 28); (3) effective for cost reporting periods beginning on or after
October 1, 2011, the number of non-distinct part hospice days (Worksheet S-3, Part I,
column 8, line 24.10); (4) effective for cost reporting periods beginning on or after
October 1, 2012, the number of outpatient ancillary labor and delivery days
(Worksheet S-3, Part I, column 8, line 32.01); and (5) the number of temporary
expansion COVID-19 PHE acute care bed days (Worksheet S-3, Part I, column 3,
line 34).
Indirect Medical Educational Adjustment Calculation for Hospitals--Calculate the IME adjustment
only if you answered “yes” to line 56 on Worksheet S-2, and complete lines 5 through 29.01, as
applicable. In addition, a hospital may be entitled to the IME adjustment if Worksheet S-2, line 56,
is “no” and lines 13 and/or 14 are greater than zero. (See 42 CFR 412.105.) Hospitals that incur
indirect costs for GME programs are eligible for an additional payment as defined in
42 CFR 412.105(d). This section calculates the additional payment by applying the applicable
multiplier of the adjustment factor for such hospitals.
Calculation of the IME adjusted FTE Resident cap in accordance with 42 CFR 412.105(f):
Line 5--Enter the FTE count for allopathic and osteopathic programs for the most recent cost
reporting period ending on or before December 31, 1996, (see 42 CFR 412.105(f)(1)(iv)). Adjust
this count for the 30 percent increase for qualified rural hospitals and also adjust for any increases
due to primary care residents that were on approved leaves of absence (see
42 CFR 412.105(f)(1)(iv) and (xi) respectively). Temporarily reduce the FTE count of a hospital
that closed a program(s), if the regulations at 42 CFR 412.105(f)(1)(ix) are applicable. (Effective
October 1, 2001, see 42 CFR 413.79(h)(3)(ii)).
Line 6--Enter the FTE count for allopathic and osteopathic programs that meet the criteria for an
adjustment to the cap for new programs in accordance with 42 CFR 413.79(e).

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DRAFT

For hospitals qualifying for a cap adjustment under 42 CFR 413.79(e)(1) or (e)(3), the cap is
effective beginning with the fourth program year of the first new program accredited or begun on
or after January 1, 1995, but before October 1, 2012. For urban hospitals that participate in
training residents in a new program for the first time on or after October 1, 2012, under
413.79(e)(1), the cap is effective beginning with the hospital’s cost reporting period that coincides
with or follows the start of the sixth program year of the first new program started (see
79 FR 50110 (August 22, 2014)). For rural hospitals that participate in training residents in a new
program on or after October 1, 2012, under 413.79(e)(3), each new program in which the rural
hospital participates has its own initial years before the rural hospital’s FTE resident cap is adjusted
based on each new program. Therefore, the rural hospital’s FTE resident cap is adjusted for each
new program effective with the hospital’s cost reporting period that coincides with or follows the
start of the sixth program year of each new program started (see 79 FR 50110 (August 22, 2014)).
For hospitals qualifying for a cap adjustment under 42 CFR 413.79(e)(2), the cap for each new
program accredited or begun on or after January 1, 1995, and before August 6, 1997, is reported
on this line and is effective in the fourth program year of each of those new programs (see
66 FR 39881 (August 1, 2001)). The cap adjustment reported on this line should not include any
resident FTEs that were already included in the cap on line 5. Do not report new program FTEs
during the time frame prior to the effective date of the hospital’s FTE cap adjustment on this line.
New program FTEs during the time frame prior to the effective date of the hospital’s FTE cap
adjustment are reported on line 16. For urban hospitals that already have an FTE cap adjustment
on line 5 but start a rural track program in accordance with 42 CFR 413.79(k), enter here the
allopathic or osteopathic FTE count for residents in all years of a rural track program that meet the
criteria for an add-on to the cap under 42 CFR 412.105(f)(1)(x). (If the rural track program is a
new program under 42 CFR 413.79(l) and the hospital qualifies for a cap adjustment under
42 CFR 413.79(e)(1) or (3), do not report FTE residents in the rural track program on this line
during the time frame prior to the effective date of the hospital’s FTE cap).
Line 7--Enter the section 422 reduction amount to the IME cap as specified under
42 CFR §412.105(f)(1)(iv)(B)(1).
Line 7.01--Enter the section 5503 reduction amount to the IME cap as specified under
42 CFR §412.105(f)(1)(iv)(B)(2). If this cost report straddles July 1, 2011, calculate the prorated
section 5503 reduction amount off the cost report and enter the result on this line. (Prorate the cap
reduction amount by multiplying it by the ratio of the number of days from July 1, 2011, to the
end of the cost reporting period to the total number of days in the cost reporting period.) Otherwise
enter the full cap reduction amount.
Line 8--Enter the adjustment (increase or decrease) to the FTE count for allopathic and osteopathic
programs for affiliated programs in accordance with 42 CFR 413.75(b), 413.79(c)(2)(iv) and
64 FR 26340 (May 12, 1998), and 67 FR 50069 (August 1, 2002).
Line 8.01--Enter, as applicable, all of or a portion of the amount of the FTE cap slots the hospital
was awarded under section 5503 of the ACA. The amount of the section 5503 award that is
reported on this line is the amount of the section 5503 award that is being “used” in this cost
reporting period. In the 5-year evaluation period following implementation of section 5503 (that
is, July 1, 2011, through June 30, 2016), at least 75 percent of the slots are to be “used” for
additional primary care and/or general surgery residents, while 25 percent of the amount that is
reported may be (but need not be) “used” for other purposes. During the 5-year evaluation period,
failure to meet the requirements at 42 CFR 413.79(n)(2) of the regulations means loss of a
hospital’s section 5503 slots. Therefore, for portions of cost reporting periods occurring during

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the 5-year evaluation period (July 1, 2011, and before July 1, 2016), do not automatically report
the full amount of the section 5503 award; only enter the amount of the section 5503 award that
equates to at least 75 percent of the FTEs being “used” for additional primary care and/or general
surgery FTEs, and no more than 25 percent being used for other FTEs. If, during the 5-year
evaluation period, your hospital has not added any primary care or general surgery residents in
accordance with receipt of the section 5503 award, leave this line blank and do not report any of
the section 5503 award on this line in this cost reporting period.
For portions of cost reporting periods occurring during the 5-year evaluation period, if the amount
reported on Worksheet S-2, Part I, line 61.02, column 2, is less than the amount on line 61.01,
column 2, then report zero (0) on this line.
Line 8.02--Enter the amount of increase if the hospital was awarded FTE cap slots from a closed
teaching hospital under section 5506 of ACA. Further subscript this line (lines 8.03 through 8.20)
as necessary if the hospital receives FTE cap slot awards on more than one occasion under
section 5506. Refer to the letter from CMS awarding this hospital the slots under section 5506 to
determine the effective date of the cap increase. If the section 5506 award is phased in over more
than one effective date, only report the portions of the section 5506 award as they become effective.
If the effective date of the cap increase is not the same as your fiscal year beginning date, then
prorate the cap increase accordingly. (Prorate the cap increase amount by multiplying it by the
ratio of the number of days from the effective date of the cap increase to the end of the cost
reporting period to the total number of days in the cost reporting period).
Line 9--Adjusted IME FTE Resident Cap--Enter the result of line 5 plus line 6, minus lines 7 and
7.01, plus or minus lines 8, 8.01, and 8.02, and applicable subscripts. However, if the resulting
IME cap is less than zero (0), enter zero (0) on this line.
Calculation of the allowable current year FTEs:
Line 10--Enter the FTE count for allopathic and osteopathic programs in the current year from
your records. Do not include residents in the initial years of the new program, which, for urban or
rural hospitals that participate in training residents in a new program under 42 CFR 413.79(e)(1)
or (e)(3), prior to October 1, 2012, means that the program has not yet completed one cycle of the
program (i.e., “period of years,” or the minimum accredited length of the program). (See
42 CFR 412.105(f)(1)(iv) and/or (f)(1)(v).) For new programs started prior to October 1, 2012,
contact your contractor for instructions on how to complete this line if you have a new program
for which the period of years is less than or more than three years. For urban hospitals that began
participating in training residents in a new program for the first time on or after October 1, 2012,
under 42 CFR 413.79(e)(1), do not include FTE residents in a new program on this line if this cost
reporting period is prior to the cost reporting period that coincides with or follows the start of the
sixth program year of the first new program started (i.e., the initial years, see 79 FR 50110
(August 22, 2014)). For rural hospitals participating in a new program(s) on or after
October 1, 2012, under 42 CFR 413.79(e)(3), each new program in which the rural hospital
participates has its own initial years before the rural hospital’s FTE resident cap is adjusted based
on that new program. Therefore, for rural hospitals, do not include FTE residents in a particular
new program on this line if this cost reporting period is prior to the cost reporting period that
coincides with or follows the start of the sixth program year of that specific new program started
(see 79 FR 50110 (August 22, 2014)). For both urban and rural hospitals, report FTE residents in
the initial years of the new program on line 16. Exclude FTE residents displaced by hospital or
program closure that are in excess of the cap for which a temporary cap adjustment is needed (see
42 CFR 412.105(f)(1)(v)).

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04-20

Line 11--Enter the FTE count for residents in dental and podiatric programs.
Line 12--Enter the result of the lesser of line 9, or line 10 added to line 11.
Line 13--Enter the total allowable FTE count for the prior year, either from Form CMS-2552-96
line 3.14 or from Form CMS-2552-10 line 12, as applicable. Do not include residents in the initial
years of the program that are exempt from the rolling average under 42 FR 412.105(f)(1)(v).
However, if the period of years during which the FTE residents in any of your new training
programs were exempted from the rolling average has expired (see 42 CFR 412.105(f)(1)(v)),
enter on this line the allowable FTE count from line 12 plus the count of previously new FTE
residents in that specific program that were added to line 16 of the prior year’s cost report (line 3.17
if the prior year cost report was the Form CMS-2552-96). If you were not training any residents
in approved teaching programs in the prior year, make no entry.
Line 14--Enter the total allowable FTE count for the penultimate year, either from
Form CMS-2552-96 line 3.14, or Form CMS-2552-10 line 12, as applicable. If you were not
training any residents in approved programs in the penultimate year, make no entry. Do not include
residents in the initial years of the program that are exempt from the rolling average under
42 CFR 412.105(f)(1)(v). However, if the period of years during which the FTE residents in any
of your new training programs were exempted from the rolling average has expired (see
42 CFR 412.105(f)(1)(v)), enter on this line the allowable FTE count from line 12 plus the count
of previously new FTE residents in that specific program that were added to line 16 of the
penultimate year’s cost report (line 3.17 if the prior year cost report was the Form CMS-2552-96).
Line 15--Enter the sum of lines 12 through 14 divided by three.
Line 16--Enter the number of FTE residents in the initial years of the program (see
42 CFR 412.105(f)(1)(v).) This line is reserved for use only by urban hospitals that do not have a
previous FTE cap established on line 5 or line 6, and are first establishing an FTE cap by
participating in training residents in a new allopathic or osteopathic residency program(s) for the
first time in accordance with 42 CFR 413.79(e)(1). (Rural hospitals participating in training
residents in new programs in accordance with 42 CFR 413.79(e)(3) would also report FTE
residents in the initial years of the new program on this line). For a new program started prior to
October 1, 2012, contact your contractor for instructions on how to complete this line if you have
a new program for which the period of years is less than or more than three years. For urban
hospitals that began participating in training residents in a new program for the first time on or
after October 1, 2012, under 42 CFR 413.79(e)(1), include FTE residents in a new program on this
line if this cost reporting period is prior to the cost reporting period that coincides with or follows
the start of the sixth program year of the first new program started (see 79 FR 50110
(August 22, 2014)). For rural hospitals participating in a new program(s) on or after
October 1, 2012, under 42 CFR 413.79(e)(3), include FTE residents in a particular new program
on this line if this cost reporting period is prior to the cost reporting period that coincides with or
follows the start of the sixth program year of that new program (see 79 FR 50110
(August 22, 2014)).

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Line 17--Enter the additional FTEs for residents that were displaced by program or hospital
closure, which you would not be able to count without a temporary cap adjustment (see
42 CFR 412.105(f)(1)(v)).
Line 18--Enter the sum of lines 15, 16 and 17.
Line 19--Enter the current year resident to bed ratio by dividing line 18 by line 4.
Line 20--In general, enter from the prior year cost report the intern and resident to bed ratio by
dividing line 12 by line 4 (divide line 3.14 by line 3 if the prior year cost report was the
Form CMS-2552-96). However, if the provider is participating in training residents in a new
medical residency training program(s) under 42 CFR 413.79(e) for a new program started prior to
October 1, 2012, add to the numerator of the prior year intern and resident to bed ratio (i.e., line 12
of the prior cost report, which might be zero, if applicable), the number of FTE residents in the
current cost reporting period that are in the initial period of years of a new program (line 16) (i.e.,
the period of years is the minimum accredited length of the program). For a new program started
prior to October 1, 2012, contact your contractor for instructions on how to complete this line if
you have a new program for which the period of years is less than or more than three years. For
urban hospitals that began participating in training residents in a new program for the first time on
or after October 1, 2012, under 42 CFR 413.79(e)(1), if this cost reporting period is prior to the
cost reporting period that coincides with or follows the start of the sixth program year of the first
new program started, then divide line 16 of this cost report by line 4 of the prior year cost report
(see 79 FR 50110 (August 22, 2014)). For rural hospitals participating in a new program on or
after October 1, 2012, under 42 CFR 413.79(e)(3), for each new program started, if this cost
reporting period is prior to the cost reporting period that coincides with or follows the start of the
sixth program year of each particular new program, then add the amount from line 12 of the prior
year (if greater than zero) and line 16 of this cost report, and divide the sum by line 4 of the prior
year cost report (see 79 FR 50110 (August 22, 2014)). If the provider is participating in a
Medicare GME affiliation agreement under 42 CFR 413.79(f), and the provider increased its
current year FTE cap and current year FTE count due to this affiliation agreement, identify the
lower of: a) the difference between the current year numerator and the prior year numerator, and
b) the number by which the FTE cap increased per the affiliation agreement, and add the lower of
these two numbers to the prior year’s numerator (see 42 CFR 412.105(a)(1)(i)). If the hospital is
participating in a valid emergency Medicare GME affiliation agreement under a §1135 waiver,
and a portion of this cost report falls within the time frame covered by that emergency affiliation
agreement, then, effective on and after October 1, 2008, enter the current year resident-to-bed ratio
from line 19 (see 73 FR 48649 (August 19, 2008) and 42 CFR 412.105(f)(1)(vi)). Effective for
cost reporting periods beginning on or after October 1, 2002, if the hospital is training FTE
residents in the current year that were displaced by the closure of another hospital or program, also
adjust the numerator of the prior year ratio for the number of current year FTE residents that were
displaced by hospital or program closure (see 42 CFR 412.105(a)(1)(iii)). The amount added to
the prior year’s numerator is the displaced resident FTE amount that you would not be able to
count without a temporary cap adjustment. This is the same amount of displaced resident FTEs
entered on line 17.

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04-20

Line 21--Enter the lesser of line 19 or 20.
IME Add-on Payment For SCHs--Effective for cost reporting periods beginning on or after
October 1, 2014, all SCHs that are subsection (d) teaching hospitals will receive an IME add-on
payment for discharges of Medicare Part C (managed care) patients in accordance with the
79 FR 50004 (August 22, 2014), regardless of whether the SCH is paid based on the federal rate
or the hospital specific rate. For purposes of the comparison of payments based on the federal rate
and the hospital specific rate, Medicare Part C patients will no longer be included as part of the
federal rate payment.
Line 22--For cost reporting periods beginning before October 1, 2014, calculate the IME payment
adjustment as follows: Multiply the appropriate multiplier of the adjustment factor (currently 1.35)
times {((1 + line 21) to the .405 power) - 1} times {the sum of lines 1, 1.01, 1.02, 1.03, 1.04, and
3}.
Effective for cost reporting periods beginning on or after October 1, 2014, calculate the IME
payment adjustment as follows: Multiply the appropriate multiplier of the adjustment factor
(currently 1.35) times {((1 + line 21) to the .405 power) - 1} times {the sum of lines 1.01, 1.02,
1.03, and 1.04}.
Line 22.01--Effective for cost reporting periods beginning on or after October 1, 2014, calculate
the IME payment adjustment for managed care, as follows: Multiply the appropriate multiplier of
the adjustment factor (currently 1.35) times {((1 + line 21) to the .405 power) - 1} times line 3.
IME Adjustment Calculation for the Add-on--Computation of IME payments for additional
allopathic and osteopathic resident cap slots received under 42 CFR 412.105(f)(1)(iv)(C)(1)-Complete lines 23 through 28 only where the amount on line 23 is greater than zero (0).
Line 23--Section 422 IME FTE Cap--Enter the number of allopathic and osteopathic IME FTE
residents cap slots the hospital received under 42 CFR 412.105(f)(1)(iv)(C)(1), section 422, of the
Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA).

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Line 24--IME FTE Resident Count Over the Cap--Subtract line 9 from line 10, and enter the result.
If the result is zero or negative, the hospital does not need to use the 422 IME cap. Therefore, do
not complete lines 25 through 28.
Line 25--Section 422 Allowable IME FTE Resident Count--If the count on line 24 is greater than
zero, enter the lesser of line 23 or line 24.
Line 26--Resident to Bed Ratio for Section 422--Divide line 25 by line 4.
Line 27--IME Adjustment Factor for Section 422 IME Residents--Enter the result of the following:
.66 times [({1 + line 26} to the .405 power) - 1].
Line 28--IME Add On Adjustment--For cost reporting periods beginning before October 1, 2014,
enter the sum of lines 1, 1.01, 1.02, 1.03, 1.04, and 3, multiplied by the factor on line 27. For cost
reporting periods beginning on or after October 1, 2014, calculate the IME add-on adjustment as
follows: Enter the sum of lines 1.01, 1.02, 1.03, and 1.04, multiplied by the factor on line 27.
Line 28.01--IME Add On Adjustment - Managed Care--Effective for cost reporting periods
beginning on or after October 1, 2014, enter the result of line 3, multiplied by the factor on line 27.
Line 29--Total IME Payment--Enter the sum of lines 22 and 28.
Line 29.01--Total IME Payment - Managed Care--Effective for cost reporting periods beginning
on or after October 1, 2014, enter the sum of lines 22.01 and 28.01.
Disproportionate Share Adjustment--Section 1886(d)(5)(F) of the Act, as implemented by
42 CFR 412.106, requires additional Medicare payments to hospitals with a disproportionate share
of low income patients. Calculate the amount of the Medicare disproportionate share adjustment
on lines 30 through 34. Complete line 34 only if you are an IPPS hospital and answered yes to
line 22, column 1, of Worksheet S-2, Part I.
Line 30--Enter the percentage of SSI recipient patient days to Medicare Part A patient days.
(Obtain the percentage from your contractor.)
Line 31--Enter the percentage resulting from the calculation of Medicaid patient days
(Worksheet S-2, Part I, columns 1 through 6, line 24) to total days reported on Worksheet S-3,
Part I, column 8, line 14, plus line 32, minus the sum of lines 5 and 6, plus employee discount days
reported on line 30.
Line 32--Add lines 30 and 31, to equal the hospital’s DSH patient percentage.
Line 33--Compare the percentage on line 32 with the criteria described in 42 CFR 412.106(c) and
(d). Enter the payment adjustment factor calculated in accordance with 42 CFR 412.106(d).
Hospitals qualifying for DSH in accordance with 42 CFR 412.106(c)(2) (Pickle Amendment
hospitals), if Worksheet S-2, Part I, line 22, column 2, is “Y” for yes, enter 35.00 percent on
line 33.
NOTE: For cost reporting periods ending on or after October 1, 2014, and before
October 1, 2016, 42 CFR 412.102 provides for a 2-year transition to a rural DSH
payment amount from an urban DSH payment amount, for hospitals that received a
geographic redesignation from urban to rural under the OMB standards for delineating
statistical areas adopted by CMS in FY 2015. Impacted hospitals whose DSH payment
adjustment exceeds 12 percent will receive 2/3 of the difference between the urban and
rural operating DSH for FY 2015 and 1/3 of the difference between the urban and rural
operating DSH for FY 2016. This affects providers that responded yes in column 1 or
column 2, and yes in column 3 of Worksheet S-2, Part I, line 22.03. See 79 FR 49963
(August 22, 2014).
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01-22

NOTE: For cost reporting periods ending on or after October 1, 2020, and before
October 1, 2022, 42 CFR 412.102 provides for a 2-year transition to a rural DSH
payment amount from an urban DSH payment amount, for hospitals that received an
geographic redesignation from urban to rural under the OMB standards for delineating
statistical areas adopted by CMS in FY 2021. Impacted hospitals whose DSH payment
adjustment exceeds 12 percent will receive 2/3 of the difference between the urban and
rural operating DSH for FY 2021 and 1/3 of the difference between the urban and rural
operating DSH for FY 2022. This affects providers that responded “Y” for yes in
column 1 or column 2, and “Y” yes in column 3 of Worksheet S-2, Part I, line 22.04. See
85 FR 58746 (September 18, 2020).
Line 34--Multiply line 33 by line 1 for cost reporting periods ending on or before
September 30, 2013. Effective for cost reporting periods that overlap October 1, 2013, enter the
sum of {(line 33 times line 1.01), plus ((line 33 times the sum of lines 1.02 and 1.03) times
25 percent)}. For cost reporting periods beginning on or after October 1, 2013, multiply (line 33
times the sum of lines 1.01 through 1.03) times 25 percent. For cost reporting periods that overlap
or begin on or after October 1, 2014, enter the sum of {((line 33 times the sum of lines 1.01 and
1.03) times 25 percent), plus ((line 33 times the sum of lines 1.02 and 1.04) times 25 percent)}.
Section 3133 of the ACA provides that, for services occurring on or after October 1, 2013, a
subsection (d) (i.e., IPPS hospital) hospital which is entitled to receive a DSH payment will receive
two separately calculated payments. The “empirically justified Medicare DSH payment,” which
represents 25 percent of the amount the hospital would have received under 42 CFR 412.106(d),
is calculated on line 34. The “additional payment for uncompensated care” payment is calculated
on lines 35 through 36.
Uncompensated Care Adjustment--Section 3133 of the ACA: (1) provides that for discharges
occurring on or after October 1, 2013, subsection (d) hospitals’ Medicare DSH payments are
reduced by 75 percent (to the empirically justified Medicare DSH payment); and (2) established
an uncompensated care payment amount, which represents the remaining 75 percent of the DSH
payments, and distributes a portion of this amount to each qualifying DSH hospital based on its
share of uncompensated care. Effective for cost reporting periods overlapping or beginning on or
after October 1, 2013, complete lines 35 through 36, columns 1 and 2, as applicable, only if you
are a subsection (d) hospital and answered yes to Worksheet S-2, Part I, line 22, column 1.
If Worksheet S-2, Part I, line 22, column 1, is “Y” and Worksheet S-2, Part I, line 22.01,
columns 1 and 2, are “Y”, do not complete lines 35 and 35.01. If Worksheet S-2, Part I, line 22.01,
either column 1 or 2, is “N”, complete only the column with the “N” response for lines 35
and 35.01. A response of “Y” for both questions indicates that a hospital uncompensated care
payment has been pre-determined for your hospital for the applicable FFY. For SCHs, if
Worksheet S-2, Part I, line 22, column 1, is “Y” and Worksheet S-2, Part I, line 35, column 1, is
greater than or equal to 1, complete lines 35 through 35.03, columns 1 and 2, as applicable.
NOTE: For cost reporting periods that overlap October 1, 2013, leave column 1 blank and
complete only column 2. For cost reporting periods that begin on October 1, complete
only column 2; however, when the cost reporting period begins on October 1, and
overlaps October 1, of the subsequent year, complete column 1 for the first period
(October 1, through September 30) and complete column 2 for the remainder of the cost
reporting period.

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Line 35--If Worksheet S-2, Part I, line 22, column 1, is “Y” and Worksheet S-2, Part I, line 22.01,
column 1 or 2, is “N”, or Worksheet S-2, Part I, line 22, column 1, is “Y” and this is a newly
merged DSH eligible hospital (Worksheet S-2, Part I, line 22.02, column 1 or 2, is “Y”), enter in
the corresponding column the full amount (for all eligible IPPS hospitals) available for
uncompensated care payments for the appropriate FFY. For example, for a cost reporting period
ending December 31, 2013, enter zero in column 1 for the portion of the cost reporting period that
began prior to October 1, 2013, and enter the FFY14 uncompensated care payment amount in
column 2. The total uncompensated care payment amount for FFY 14 is $9,046,380,143 and for
FFY 15 is $7,647,644,885. Subsequent total uncompensated care amounts should be obtained
from the corresponding federal year IPPS final rule or correction notice, as applicable. If this is a
SCH and Worksheet S-2, Part I, line 22, column 1, is “Y”, but an amount for line 35.02 was not
determined by CMS for a FFY, complete this line accordingly.
Line 35.01--If Worksheet S-2, Part I, line 22.01, column 1 or 2, is “N”, enter the applicable
Factor 3 value determined by CMS for uncompensated care payments for the appropriate FFY in
columns 1 and 2. If this is a SCH and Worksheet S-2, Part I, line 22, column 1, is “Y”, but an
amount for line 35.02 was not determined by CMS for a FFY, enter the applicable Factor 3 value
determined by CMS for the appropriate FFY in column 1 and/or 2. If you are a new hospital
(Worksheet S-2, Part I, line 47, column 2, is “Y”), or a newly merged DSH eligible hospital
(Worksheet S-2, Part I, line 22.02, column 1 or 2, is “Y”), Factor 3 must be calculated. Refer to
the applicable FFY IPPS final rule for further information. In determining Factor 3, the numerator
is the applicable year cost report Medicaid days (Worksheet S-2, Part I, line 24, sum of columns 1
through 6) plus the SSI days published for the applicable FFY, divided by the denominator which
is a fixed amount obtained from the applicable FFY IPPS rule. For FFY 14 the denominator is
36,429,747, for FFY 15 the denominator is 36,484,622, and for FFY 16 the denominator is
36,755,805 (the denominator represents the total IPPS hospitals’ Medicaid days and SSI days for
the applicable FFY).
For FFY 2017, a hospital’s Factor 3 is the average of three individual Factor 3s calculated based
on cost reporting periods beginning in FY 2011, FY 2012, and FY 2013. The denominator for
FY 2011 Factor 3 is 36,930,764; FY 2012 Factor 3 is 37,123,932, and FY 2013 Factor 3 is
37,302,359. If the hospital does not have data for one or more of the three cost reporting periods,
compute Factor 3 for the periods available and average those by dividing the sum of the individual
Factor 3s by the number of cost reporting periods for which there are data. Round Factor 3 to
9 decimal places.
For FFY 2018, a hospital’s Factor 3 is the average of three individual Factor 3s calculated based
on cost reporting periods beginning in FY 2012, FY 2013, and FY 2014. The denominator for
FY 2012 Factor 3 is 37,065,316; FY 2013 Factor 3 is 37,311,194; and FY 2014 Factor 3 is based
on uncompensated care costs of $25,199,302,174. If the hospital does not have data for one or
more of the three cost reporting periods, compute Factor 3 for the periods available and average
those by dividing the sum of the individual Factor 3s by the number of cost reporting periods for
which there are data. Round Factor 3 to 9 decimal places. For FFY 2018, the Medicaid days and
uncompensated care costs are annualized.
For FFY 2019, a hospital’s Factor 3 is the average of three individual Factor 3s calculated based on
cost reporting periods beginning in FY 2013, FY 2014, and FY 2015. The denominator for FY 2013
Factor 3 is 37,539,919; FY 2014 Factor 3 is $31,598,052,056; and FY 2015 Factor 3 is
$30,210,112,106. FY 2014 and FY 2015 are based on uncompensated care cost. If the hospital does
not have data for one or more of the three cost reporting periods, compute Factor 3 for the periods
available and average those by dividing the sum of the individual Factor 3s by the number of cost
reporting periods for which there are data. Round Factor 3 to 9 decimal places. For FFY 2019, the
Medicaid days and uncompensated care costs are annualized.

For FFY 2020, a hospital’s Factor 3, is calculated based on data from cost reporting periods
beginning in FY 2015. If you are a new hospital eligible for DSH and the date certified
(Worksheet S-2, Part I, line 3, column 5) is on or after October 1, 2015, (see 84 FR 42371,
August 19, 2019)), in determining Factor 3, the numerator is the uncompensated care costs
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reported on Worksheet S-10, line 30, of the hospital’s FY 2020 cost report, and the denominator
is $29,616,638,717. For new hospitals located in Puerto Rico (that is, no Factor 3 calculated),
refer to the FY 2020 IPPS final rule for calculating a Factor 3, from Worksheet S-10, data from
the hospital’s FY 2020 cost report (84 FR 42370-42371 (August 16, 2019)).
For FFY 2021, a hospital’s Factor 3, is calculated based on data from cost reporting periods
beginning in FY 2017. If you are a new hospital eligible for DSH and the date certified
(Worksheet S-2, Part I, line 3, column 5) is on or after October 1, 2017, (see 85 FR 58829,
September 18, 2020)), in determining Factor 3, the numerator is the uncompensated care costs
reported on Worksheet S-10, line 30, of the hospital’s FY 2021 cost report, and the denominator
is $31,966,377,083. For new hospitals located in Puerto Rico (that is, no Factor 3 calculated),
refer to the FY 2021 IPPS final rule for calculating a Factor 3 from Worksheet S-10, data from the
hospital’s FY 2021 cost report.
For FFY 2022, a hospital’s Factor 3, is calculated based on data from cost reporting periods
beginning in FY 2018. If you are a new hospital eligible for DSH and the date certified
(Worksheet S-2, Part I, line 3, column 5) is on or after October 1, 2018, (see 86 FR 45244,
August 13, 2021)), in determining Factor 3, the numerator is the uncompensated care costs
reported on Worksheet S-10, line 30, of the hospital’s FY 2022 cost report, and the denominator
is $ 33,208,266,108. For new hospitals located in Puerto Rico (that is, no prospective Factor 3),
refer to the FY 2022 IPPS final rule for calculating a Factor 3 from Worksheet S-10, data from the
hospital’s FY 2022 cost report.
Line 35.02--If Worksheet S-2, Part I, line 22, column 1, is “Y” and Worksheet S-2, Part I,
line 22.01, column 1 or 2, is “Y”, enter the hospital uncompensated care payment amount
determined by CMS for the appropriate FFY in columns 1 and 2. If Worksheet S-2, Part I, line 22,
column 1, is “Y” and Worksheet S-2, Part I, line 22.01, column 1 or 2, is “N”, or Worksheet S-2,
Part I, line 22, column 1, is “Y” and Worksheet S-2, Part I, line 22.01, column 1 or 2, is “N”, and
Worksheet S-2, Part I, line 22.02, column 1 or 2, is “Y”, then CMS did not determine the hospital
uncompensated care payment amount for that FFY. Compute this amount by multiplying line 35
times line 35.01, for column 1 and column 2. If this is a SCH and Worksheet S-2, Part I, line 22,
column 1, is “Y” but an amount for line 35.02 was not determined by CMS for a FFY, compute
the amount by multiplying line 35 times line 35.01, for column 1 and column 2. If Worksheet S-2,
Part I, line 22, column 1, is “N” and/or line 34 above is zero, enter zero on this line.
Line 35.03--Enter the pro rata share of the hospital’s uncompensated care payment in columns 1
and 2. Enter in column 1, line 35.02, times the number of days in the cost reporting period prior
to October 1, divided by the total days in the FFY. Enter in column 2, line 35.02, times the number
of days in the cost reporting period on or after October 1, divided by the total days in the FFY.
For example, for a calendar year cost reporting period January 1, 2013, through
December 31, 2013, enter zero in column 1, for the period of January 1, 2013, through
September 30, 2013, because this period is prior to FFY 14 (the UCC payment is effective
beginning FFY 14); enter in column 2, for the period of October 1, 2013, through
December 31, 2013 (FFY 14), the result of 92 days divided by 365 days in FFY 14, multiplied by
line 35.02, column 2.
As another example, for a calendar year cost reporting period of January 1, 2014, through
December 31, 2014, enter in column 1, for the period of January 1, 2014, through
September 30, 2014 (FFY 14), the result of 273 days divided by 365 days in FFY 14, multiplied
by line 35.02, column 1; enter in column 2, for the period of October 1, 2014, through
December 31, 2014 (FFY 15), the result of 92 days divided by 365 days in FFY 15, multiplied by
line 35.02, column 2.
For SCH/MDH status changes, use subscripted lines 35.04 and 35.05. For SCH or MDH status
changes, subscript column 1, for any portion of the cost reporting period under IPPS status.

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Lines 35.04--For portions of the cost reporting period under MDH status, enter in columns 1 and 2,
the pro rata share of the hospital’s uncompensated care payment amounts reported on line 35.03,
columns 1 and 2. For any portion of the cost reporting period under IPPS, enter the pro rata share
of the hospital’s uncompensated care payment amounts reported on line 35.03, columns 1 and 2,
in subscripted column 1.01.
Lines 35.05--For portions of the cost reporting period under SCH status, enter in columns 1 and 2,
the pro rata share of the hospital’s uncompensated care payment amounts reported on line 35.03,
columns 1 and 2. For any portion of the cost reporting period under IPPS, enter the pro rata share
of the hospital’s uncompensated care payment amounts reported on line 35.03, columns 1 and 2,
in subscripted column 1.01.
For example, a hospital with a 2015 calendar year cost reporting period loses its MDH status on
October 15, 2015. Enter on line 35.04, column 1, for the period of January 1, 2015, through
September 30, 2015, the uncompensated care payment amount from line 35.03, column 1. Enter
on line 35.04, column 1.01, the pro rata share of the uncompensated care payment amount from
line 35.03, column 2 (IPPS status for the period of October 15, 2015, through
December 31, 2015), ((78 days/365 days) times line 35.03, column 2). Enter on line 35.04,
column 2, the pro rata share of the uncompensated care payment amount from line 35.03,
column 2, (MDH status for the period of October 1, 2015, through October 14, 2015),
((14 days/365 days) times line 35.03, column 2).
Line 36--Enter the hospital’s uncompensated care adjustment amount (the sum of columns 1 and 2,
line 35.03).
Lines 37 through 39--Reserved for future use.
Additional Payment for High Percentage of ESRD Beneficiary Discharges--Calculate the
additional payment amount allowable for a high percentage of ESRD beneficiary discharges
pursuant to 42 CFR 412.104. When the average weekly cost per dialysis treatment changes within
a cost reporting period, create an additional column (column 1.01) for lines 41 and 45.
Line 40--Enter total Medicare discharges excluding discharges for MS-DRGs 652, 682, 683, 684,
and 685 (see 73 FR 48447 and 48520 (August 19, 2008)). Effective for cost reporting periods
beginning on or after October 1, 2011, enter total Medicare discharges (see 76 FR 51693
(August 18, 2011)) for all Medicare beneficiaries entitled to Medicare Part A. Individuals entitled
to Medicare Part A include individuals receiving benefits under original Medicare, individuals
whose inpatient benefits are exhausted or whose stay was not covered by Medicare, and individuals
enrolled in Medicare Advantage Plans, cost contracts under §1876 of the Act (HMOs), and
competitive medical plans (CMPs). These discharges, excluding discharges for MS-DRGs 652,
682, 683, 684, and 685, must be included in the denominator of the calculation for the purpose of
determining eligibility for the ESRD additional payment to hospitals. Effective for discharges
occurring on or after October 1, 2020, exclude discharges for MS-DRGs 019, 650, 651, 682, 683,
and 684, from the denominator (see 85 FR 58844 (September 18, 2020)).
Line 41--Enter total Medicare discharges for ESRD beneficiaries who received dialysis treatment
during an inpatient stay (see 69 FR 49087 (August 11, 2004)) excluding MS-DRGs 652, 682, 683,
684, and 685 (see 73 FR 48520 and 48447 (August 19, 2008)). Effective for cost reporting periods
beginning on or after October 1, 2011, enter total Medicare discharges (see 76 FR 51693
(August 18, 2011)) for all ESRD Medicare beneficiaries entitled to Medicare Part A who receive
inpatient dialysis. Individuals entitled to Medicare Part A include individuals receiving benefits
under original Medicare, individuals whose inpatient benefits are exhausted or whose stay was not
covered by Medicare, and individuals enrolled in Medicare Advantage Plans, cost contracts under
§1876 of the Act (HMOs), and CMPs. These discharges, excluding discharges for MS-DRGs 652,
682, 683, 684, and 685, must be included in the numerator of the calculation for the purpose of
determining eligibility for the ESRD additional payment to hospitals. Effective for discharges
occurring on or after October 1, 2020, exclude discharges for MS-DRGs 019, 650, 651, 682, 683,
and 684, from the numerator (see 85 FR 58844 (September 18, 2020)).
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Line 41.01--Enter total Medicare discharges for ESRD beneficiaries who received dialysis
treatment during an inpatient stay (see 69 FR 49087 (August 11, 2004)) excluding MS-DRGs 652,
682, 683, 684, and 685 (see 73 FR 48520 and 48447 (August 19, 2008)). The discharges on this
line are associated with Medicare covered and paid hospital stays, and are included in the
discharges in Worksheet S-3, Part I, column 13, line 14. These discharges are a subset of the
discharges on line 41. The discharges on this line are only used to determine the ESRD add-on
payment, not eligibility for the add-on payment. Effective for discharges occurring on or after
October 1, 2020, exclude discharges for MS-DRGs 019, 650, 651, 682, 683, and 684, from this
line (see 85 FR 58844 (September 18, 2020)).
Line 42--Divide line 41, sum of columns 1 and 1.01 by line 40. If the result is less than 10 percent,
you do not qualify for the ESRD adjustment.
Line 43--Enter the total Medicare ESRD inpatient days excluding MS-DRGs 652, 682, 683, 684,
and 685, as applicable. The Medicare ESRD inpatient days must be included in the Medicare
inpatient days reported in Worksheet S-3, Part I, column 6, line 14, and are part of a Medicare
covered stay. Effective for discharges occurring on or after October 1, 2020, exclude days for
discharges for MS-DRGs 019, 650, 651, 682, 683, and 684, from this line (see 85 FR 58844
(September 18, 2020)).
Line 44--Enter the average length of stay expressed as a ratio to 7 days. For cost reporting periods
ending before June 30, 2014, divide line 43 by line 41, sum of columns 1 and 1.01, and divide that
result by 7 days. For cost reporting periods ending on or after June 30, 2014, divide line 43 by
line 41.01, sum of columns 1 and 1.01, and divide that result by 7 days.
Line 45--Enter the average weekly cost per dialysis treatment calculated by multiplying the
unadjusted composite rate per treatment by 3. For example, the average weekly cost per dialysis
treatment for CY 2013 is $435.60 ($145.20 times the average weekly number of treatments of 3).
This amount is subject to change on an annual basis. Consult the appropriate CMS change request
for future rates.
Line 46--For cost reporting periods ending before June 30, 2014, enter the ESRD payment
adjustment (line 44, column 1, times line 45, column 1, times line 41, column 1, plus, if
applicable, line 44, column 1, times line 45, column 1.01, times line 41, column 1.01). For cost
reporting periods ending on or after June 30, 2014, enter the ESRD payment adjustment (line 44,
column 1, times line 45, column 1, times line 41.01, column 1, plus, if applicable, line 44,
column 1, times line 45, column 1.01, times line 41.01, column 1.01).
Line 47--Enter the sum of lines 1, 1.01, 1.02, 2, 2.01, 2.02, 2.03, 2.04, 29, 34, 36, and 46.
Line 48--SCHs are paid the highest of the federal payment rate, the hospital-specific rate (HSR)
determined based on a FFY 1982 base period (see 42 CFR 412.73), the hospital-specific rate
determined based on a FFY 1987 base period (see 42 CFR 412.75), for cost reporting periods
beginning on or after October 1, 2000, the hospital-specific rate determined based on a FFY 1996
base period (see 42 CFR 412.77), or for cost reporting periods beginning on or after
January 1, 2009, the hospital-specific rate determined based on a FFY 2006 base period
(see 42 CFR 412.78). MDHs are paid the highest of the federal payment rate, or the federal rate
plus 75 percent of the amount of the excess over the federal rate of the highest rate for the 1982,
1987, or 2002 (see 42 CFR 412.79), base period hospital specific rate. Effective January 1, 2016,
former MDHs that lost their MDH status because they are no longer in a rural area due to the new
OMB delineations in FY 2015 (Worksheet S-2, Part I, line 37.01, is yes) will transition from
payments based, in part, on the hospital-specific rate to payments based entirely on the Federal
rate. For discharges occurring on or after January 1, 2016, and before October 1, 2016, these
former MDHs will receive the Federal rate plus two-thirds of 75 percent of the amount by which
the Federal rate payment is exceeded by the hospital’s hospital-specific rate payment. For
FY 2017, that is, for discharges occurring on or after October 1, 2016, and before October 1, 2017,
these former MDHs will receive the Federal rate plus one-third of 75 percent of the amount by
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which the Federal rate payment is exceeded by the hospital’s hospital-specific rate. For FY 2018,
that is, for discharges occurring on or after October 1, 2017, these former MDHs will be paid based
solely on the Federal rate. For SCHs, MDHs and former MDHs, enter the applicable hospitalspecific payments.
For SCHs only, the hospital-specific payment amount entered on this line is supplied by your
contractor. Calculate it by multiplying the sum of the DRG weights for the period (per the PS&R)
by the final per discharge hospital-specific rate for the period. Use the hospital specific rate based
on the higher of the cost reporting periods beginning in FFY 1982, 1987, or 1996.
Additionally, for SCHs only (effective for cost reporting periods beginning on or after
January 1, 2009), use the highest of the determined hospital specific rate based on FFY 1982,
1987, 1996, or 2006.
For MDH discharges occurring on or after October 1, 2006, and before October 1, 2022, an MDH
can use a FFY 2002 hospital specific rate. The MDH program ends on September 30, 2022.
Line 49--For SCHs, enter the greater of line 47 or 48, plus the amount from line 29.01. For MDH
discharges occurring on or after October 1, 2006, and before October 1, 2022, if line 47 is greater
than line 48, enter the amount on line 47, plus the amount from line 29.01. For MDHs, if line 48
is greater than line 47, enter the amount on line 47, plus 75 percent of the amount that line 48
exceeds line 47, plus the amount from line 29.01. Hospitals not qualifying as SCH or MDH
providers will enter the amount from line 47, plus the amount from line 29.01.
For former MDHs (Worksheet S-2, Part I, line 37.01, is yes), effective for cost reporting periods
that begin or overlap January 1, 2016, if line 48 is greater than line 47, enter the amount on line 47,
plus two-thirds of (75 percent of the amount that line 48 exceeds line 47, times (the number of
days in the cost reporting period between January 1, 2016, and September 30, 2016, divided by
the total number of days in the cost reporting period)), plus the amount from line 29.01. For cost
reporting periods that begin or overlap October 1, 2016, if line 48 is greater than line 47, enter the
amount on line 47, plus two-thirds of (75 percent of the amount that line 48 exceeds line 47, times
(the number of days in the cost reporting period prior to October 1, 2016, divided by the total
number of days in the cost reporting period)), plus one-third of (75 percent of the amount that
line 48 exceeds line 47, times (the number of days in the cost reporting period beginning on or
after October 1, 2016, and before October 1, 2017, divided by the total number of days in the cost
reporting period)), plus the amount from line 29.01.
For hospitals subscripting column 1 of line 47 due to a change in geographic location, this
computation will be computed separately for each column, and the sum of the calculations will be
entered in column 1 of this line.
Line 50--Enter the payment for inpatient program capital costs from Worksheet L, Part I, line 12,
or Part II, line 5, as applicable.
Line 51--Enter the special exceptions payment for inpatient program capital, if applicable pursuant
to 42 CFR 412.348(f) by entering the result of Worksheet L, Part III, line 13, less Worksheet L,
Part III, line 17. If this amount is negative, enter zero on this line.
Line 52--Enter the amount from Worksheet E-4, line 49. Complete this line only for the hospital
component.

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Obtain the payment amounts for lines 53 and 54 from your contractor.
Line 53-- Enter the amount of NAHE managed care payments, if applicable. When a healthcare
complex includes an IPF and/or IRF subprovider (excluded unit), enter the NAHE managed care
payments for the entire healthcare complex (i.e., the NAHE managed care payments for the
hospital plus NAHE managed care payments for any subproviders) on this line.
Line 54--Enter the special add-on payment for new technologies (see 42 CFR 412.87 and 412.88).
Include in the add-on payment for new technologies payments associated with Model 4 BPCI.
Line 54.01--Enter the special add-on payment for islet isolation cell transplantation (see CR 9570).
Line 55--Enter the net organ acquisition cost from Worksheet(s) D-4, Part III, column 1, line 69.
Line 55.01--Transfer the Medicare inpatient cellular therapy acquisition cost from
Worksheet D-6, Part III, line 10, column 1.
Line 56--Teaching hospitals or sub-providers electing to be reimbursed for services of physicians
on the basis of reasonable cost (see 42 CFR 415.160 and CMS Pub. 15-1, chapter 21, §2148), enter
the cost of physicians. For cost reporting periods ending before June 30, 2014, transfer the amount
from Worksheet D-5, Part II, column 3, line 20. For cost reporting periods ending on or after
June 30, 2014, transfer the amount from Worksheet D-5, Part IV, line 20.
Line 57--Enter the routine service other pass-through costs from Worksheet D, Part III, column 9,
lines 30 through 35 for the hospital.
Line 58--Enter the ancillary service other pass-through costs from Worksheet D, Part IV,
column 11, line 200.

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Line 59--Enter the sum of lines 49 through 58.
Line 60--Enter the amounts paid or payable by primary payers (when program liability is
secondary to that of a primary payer) such as:
•
•
•
•
•
•

Workers' compensation,
No fault coverage,
General liability coverage,
Working aged provisions,
Disability provisions, and
Working ESRD provisions.

Generally, when payment by the primary payer satisfies the total liability of the program
beneficiary, for cost reporting purposes only, treat the services as if they were non-program
services. (The primary payment satisfies the beneficiary's liability when you accept that payment
as payment in full. This is noted on no-pay bills submitted by you in these situations.) Include the
patient days and charges in total patient days and charges but do not include them in program
patient days and charges. In this situation, enter no primary payer payment on line 60. In addition,
exclude amounts paid by other primary payers for outpatient dialysis services reimbursed under
the composite rate system.
However, when the payment by the primary payer does not satisfy the beneficiary's obligation, the
program pays the lesser of (a) the amount it otherwise pays (without regard to the primary payer
payment or deductible and coinsurance) less the primary payer payment, or (b) the amount it
otherwise pays (without regard to the primary payer payment or deductible and coinsurance) less
applicable deductible and coinsurance. Credit primary payer payment toward the beneficiary's
deductible and coinsurance obligation.
When the primary payment does not satisfy the beneficiary's liability, include the covered days
and charges in program days and charges and include the total days and charges in total days and
charges for cost apportionment purposes. Enter the primary payer payment on line 60 to the extent
that primary payer payment is not credited toward the beneficiary's deductible and coinsurance.
Do not enter primary payer payments credited toward the beneficiary's deductible and coinsurance
on line 60.
Enter the primary payer amounts applicable to organ transplants. However, do not enter the
primary payer amounts applicable to organ acquisitions. Report these amounts on Worksheet D-4,
Part III, line 66.
If you are subject to PPS, include the covered days and charges in the program days and charges,
and include the total days and charges in the total days and charges for inpatient and pass-through
cost apportionment. Furthermore, include the DRG amounts applicable to the patient stay on
line 1. Enter the primary payer payment on line 60 to the extent that the primary payer payment
is not credited toward the beneficiary's deductible and coinsurance. Do not enter primary payer
payments credited toward the beneficiary's deductibles.
Line 61--Enter the result of line 59 minus line 60.
Line 62--Enter, from the PS&R or your records, the deductibles billed to program patients
excluding deductibles and coinsurance associated with Model 4 BPCI payments.
Line 63--Enter, from the PS&R or your records, the coinsurance billed to program patients
excluding deductibles and coinsurance associated with Model 4 BPCI payments.

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Line 64--Enter the program allowable bad debts, reduced by the bad debt recoveries. If recoveries
exceed the current year’s bad debts, line 64 and 65 will be negative. (See 42 CFR 413.89).
Line 65--Enter the result of line 64 (including negative amounts) times 70 percent for cost
reporting periods that begin prior to October 1, 2012. For cost reporting periods that begin on or
after October 1, 2012, enter the result of line 64 times 65 percent.
Line 66--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. These amounts must also be reported on line 64.
Line 67--Enter the sum of lines 61 and 65, minus the sum of lines 62 and 63.
Line 68--Enter, from the PS&R, the partial or full credits received from manufacturers for replaced
devices applicable to MS-DRGs listed in the IPPS final rule for the applicable cost reporting
period. (See CMS Pub. 100-04, chapter 3, §100.8.)
Line 69--Enter the time value of money for operating expenses, the capital outlier reconciliation
amount and time value of money for capital related expenses by entering the sum of lines 93, 95,
and 96.
For SCHs, if the hospital specific payment amount on line 48, is greater than the federal specific
payment amount on line 47, do not complete this line.
Line 70--Enter any other adjustments. Specify the adjustment in the space provided. Hardcoded
subscripts of this line are identified as such.
Line 70.50--Enter the §410A rural community hospital demonstration project payment adjustment
amount from line 218, column 1.
Line 70.87--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are subject to the
sequestration adjustment. Obtain this amount from the PS&R. Do not include demonstration
payment adjustment amounts reported on lines 70.50 and 70.89.
Line 70.88--Contractor use only: Enter the volume decrease adjustment for SCH or MDH
hospitals in accordance with 42 CFR 412.92(e) or 412.108(d), respectively.
Line 70.89--Enter the Pioneer Accountable Care Organization (ACO) demonstration payment
adjustment amount. Obtain this amount from the PS&R. Do not use this line for services rendered
on or after January 1, 2017. Report any ACO demonstration payment adjustments for services on
or after January 1, 2017, on line 70.87 or line 71.02, accordingly.
Line 70.90--For MDH use only. Enter the hospital value-based purchasing (HVBP) adjustment
amount relative to the HSP bonus payment from line 102, sum of columns 1 and 2.
Line 70.91--For MDH use only. Enter the hospital readmission reduction (HRR) adjustment
amount relative to the HSP bonus payment from line 104, columns 1 and 2.
Line 70.92--Enter the discount amount for the bundled payments for care improvement initiative
(also referred to as Model 1) in accordance with ACA 2010, §3023, effective for discharges
occurring on or after October 1, 2013. This demonstration actually began April 1, 2013; however,
the discounted payments begin October 1, 2013. Obtain this amount from the PS&R. Do not
change the sign of the amount displayed on the PS&R.

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Line 70.93--Enter the payment adjustment amount for the HVBP program in accordance with
ACA 2010, §3001, effective for discharges occurring on or after October 1, 2012. Obtain this
amount from the PS&R.
Line 70.94--Enter the adjustment amount resulting from the HRR program in accordance with
ACA 2010, §3025, effective for discharges occurring on or after October 1, 2012. Obtain this
amount from the PS&R.
Line 70.95--Enter the program share of any recovery of accelerated depreciation applicable to
prior periods resulting from your termination or a decrease in Medicare utilization. (See
CMS Pub. 15-1, chapter 1, §§136-136.16, and 42 CFR 413.134(d)(3)(i).)
Line 70.96 through 70.98 (lines 70.96 and 70.97 are hardcoded)--Effective
for
discharges
occurring during FFYs 2011 through 2018, the low volume payment adjustment is determined in
accordance with 42 CFR 412.101(c)(2). Effective for discharges occurring during FFYs 2019
through 2022, the low volume payment adjustment is determined in accordance with
42 CFR 412.101(c)(3). Effective for discharges occurring during FFY 2023 and subsequent years
the low volume payment adjustment is determined in accordance with 42 CFR 412.101(c)(1).
For cost reporting periods that are concurrent with the FFY (October 1, through September 30),
use line 70.97 only. For cost reporting periods that overlap October 1, enter on lines 70.96
(low- volume adjustment (enter the corresponding federal year for the period prior to October 1))
and line 70.97 (low-volume adjustment (enter the corresponding federal year for the period ending
on or after October 1)), and, if necessary, line 70.98 (low-volume adjustments for additional
portions of the cost reporting period, if necessary), the Medicare inpatient payment adjustment for
low-volume hospitals as applicable in accordance with Exhibit 4 (low-volume adjustment
calculation schedule and corresponding instructions).
Line 70.99--Enter the HAC program payment reduction adjustment amount effective for
discharges occurring on or after October 1, 2014. Use Exhibit 5 or similar worksheet to reconcile
the HAC payment adjustment amount.
Line 71--Enter the result of line 67 plus the sum of lines 69, 70 through 70.86, 70.88, 70.90, 70.91,
70.92, 70.93, 70.94, and 70.96 through 70.98; minus the sum of lines 68, 70.87, 70.89, 70.95, and
70.99.
Line 71.01--For cost reporting periods that overlap or begin on or after April 1, 2013, 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 six decimal places), rounded to four decimal places) times line 71]. Do not
apply the sequestration calculation when gross reimbursement is less than zero. (Note: In
accordance with §3709 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, as
amended by §102 of the Consolidated Appropriations Act of 2021, and §1 of Public Law 117-7,
do not apply the sequestration adjustment to the period of May 1, 2020, through
December 31, 2021.)
Line 71.02--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are not subject to the
sequestration adjustment. Obtain this amount from the PS&R.
Line 71.03--This line is a subset of line 71.01. Enter the sequestration adjustment amount for the
portion of the cost reporting period that the hospital participated in the PARHM demonstration.
Enter the sequestration adjustment amount as [(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 six decimal places), rounded to four decimal places) times the sum of lines 52,
53, 55, 57, 58, and 65]. (Note: In accordance with §3709 of the CARES Act, as amended by
§102 of the Consolidated Appropriations Act of 2021, and §1 of Public Law 117-7, do not apply
the sequestration adjustment to the period of May 1, 2020, through December 31, 2021.)
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Line 72--Enter the total interim payments (received or receivable) from Worksheet E-1, column 2,
line 4. For contractor final settlements, enter the amount reported on Worksheet E-1, column 2,
line 5.99, on line 73. Included in the interim payments are the amounts received as the estimated
nursing and allied health managed care payments and capital, IME, DSH, and outlier payments
associated with Model 4 BPCI.
Line 72.01--This line is a subset of line 72. Enter the interim pass-through payments received (or
receivable) for the portion of the cost reporting period that the hospital participated in the PARHM
demonstration. These payments should include bi-weekly pass through payments as well as any
lump sum adjustments received for bad debts, organ acquisition costs, and medical education
(DGME and NAHE).
Line 73--Tentative settlement amount (transfer this amount from Worksheet E-1, Part I, column 2,
line 5.99).
Line 73.01--Tentative settlement amount PARHM demonstration (enter the tentative settlement
amount from the PARHM demonstration Worksheet E-1, Part I, column 2, line 5.99)
Line 74--Enter line 71 minus the sum of lines 71.01, 71.02, 72, and 73. Transfer to Worksheet S,
Part III, column 2, line, 1. For providers participating in the PARHM demonstration, do not
transfer amounts from this line. See line 74.01 for instruction.
Line 74.01--For providers participating in the PARHM demonstration complete this line for the
settlement of pass-through payments paid outside of the PARHM demonstration. The amount
reported on this line is a subset of the amount reported on line 74. Enter the sum of lines 52, 53,
55, 57, 58, and 65, minus lines 71.03, 72.01 and 73.01. Transfer to Worksheet S, Part III,
column 2, line 1.01.
Line 75--Enter the program reimbursement effect of protested items. Estimate the reimbursement
effect of the non-allowable items by applying a reasonable methodology which closely
approximates the actual effect of the item as if it had been determined through the normal cost
finding process. (See CMS Pub. 15-2, chapter 1, §115.2.) Attach a schedule showing the details
and computations for this line.
Lines 76 through 89 were intentionally skipped to accommodate future revisions to this worksheet.
NOTE FOR LINES 90 THROUGH 96: CONTRACTOR USE ONLY. Complete lines 90
through 96 at cost report final settlement if the hospital meets the criteria at
CMS Pub. 100-04, chapter 3, §20.1.2.5.
Line 90--For cost reporting periods beginning prior to October 1, 2018, enter the operating outlier
amount from the provider’s submitted Worksheet E, Part A, line 2, sum of all columns. For cost
reporting periods beginning on or after October 1, 2018, enter the operating outlier amounts from
the provider’s submitted Worksheet E, Part A, sum of lines 2.03 and 2.04, sum of all columns.
Line 91--Enter the capital outlier amount from the provider’s submitted Worksheet L, Part I,
line 2.
Line 92--Enter the operating outlier reconciliation adjustment amount in accordance with
CMS Pub. 100-4, chapter 3, §§20.1.2.5 - 20.1.2.7.
Line 93--Enter the capital outlier reconciliation adjustment amount in accordance with
CMS Pub. 100-4, chapter 3, §§20.1.2.5 - 20.1.2.7.
Line 94--Enter the interest rate used to calculate the time value of money. (See CMS Pub. 100-04,
chapter 3, §§20.1.2.5 - 20.1.2.7.)
Line 95--Enter the operating time value of money for operating related expenses.
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Line 96--Enter the capital time value of money for capital related expenses.
Hospital Specific Payment (HSP) Bonus Payment HVBP Adjustment and HRR Adjustment--The
ACA 2010 §§3001 and 3025 implemented HVBP and HRR and applied special rules for MDHs
through FFY 13. Effective for discharges occurring on or after October 1, 2013, MDHs that
receive a HSP bonus payment on the cost report are subject to a HVBP and HRR adjustment for
that bonus payment amount. The HSP bonus payment amount is 75 percent of the amount that
line 48 exceeds line 47. Complete lines 100 through 104 only when line 48 exceeds line 47.
For a former MDH (Worksheet S-2, Part I, line 37.01, is yes), for FY 2016 the HSP bonus payment
amount determined for the period of January1, 2016, through September 30, 2016, is two-thirds of
75 percent of the amount by which line 48 exceeds line 47. For FY 2017, the HSP bonus payment
amount determined for the period of October 1, 2016, through September 30, 2017, is one-third of
75 percent of the amount by which line 48 is exceeds line 47.
NOTE: For cost reporting periods that overlap October 1, 2013, leave column 1 blank and
complete only column 2. For cost reporting periods that begin on October 1, complete
only column 2.
Line 100--If line 48 is greater than line 47, enter the pro rata share of the HSP bonus payment
amount in columns 1 and 2. Enter in column 1, {((line 48 minus line 47) times 75 percent) times
(the number of days in the cost reporting period prior to October 1, divided by the total days in the
cost reporting period)}. Enter in column 2, {((line 48 minus line 47) times 75 percent) times (the
number of days in the cost reporting period on or after October 1, divided by the total days in the
cost reporting period)}. If the hospital does not have MDH status for the entire cost reporting
period, prorate accordingly.
For former MDHs for FY 2016, for cost reporting periods that begin on or after January 1, 2016,
enter in column 1, two-thirds of {((line 48 minus line 47) times 75 percent) times (the number of
days in the cost reporting period on or after January 1, 2016, through September 30, 2016, divided
by the total days in the cost reporting period)}. Enter in column 2, one-third of {((line 48 minus
line 47) times 75 percent) times (the number of days in the cost reporting period on or after
October 1, 2016, through September 30, 2017, divided by the total days in the cost reporting
period)}. For cost reporting periods that overlap January 1, 2016, and end on or before
September 30, 2016, enter zero in column 1, and enter in column 2, two-thirds of {((line 48 minus
line 47) times 75 percent) times (the number of days in the cost reporting period on or after
January 1, 2016, through September 30, 2016, divided by the total days in the cost reporting
period)}. For cost reporting periods that overlap January 1, 2016, and October 1, 2016, enter in
column 1, two-thirds of {((line 48 minus line 47) times 75 percent) times (the number of days in
the cost reporting period on or after January 1, 2016, through September 30, 2016, divided by the
total days in the cost reporting period)}. Enter in column 2, one-third of {((line 48 minus line 47)
times 75 percent) times (the number of days in the cost reporting period on or after
October 1, 2016, through September 30, 2017, divided by the total days in the cost reporting
period)}.
For former MDHs for FY 2017, for cost reporting periods that begin October 1, 2016, enter in
column 2, one-third of {((line 48 minus line 47) times 75 percent) times (the number of days in
the cost reporting period on or after October 1, 2016, through September 30, 2017, divided by the
total days in the cost reporting period)}. For cost reporting periods that overlap October 1, 2016,
enter in column 1, two-thirds of {((line 48 minus line 47) times 75 percent) times (the number of
days in the cost reporting period prior to October 1, 2016, divided by the total days in the cost
reporting period)}. Enter in column 2, one-third of {((line 48 minus line 47) times 75 percent)
times (the number of days in the cost reporting period on or after October 1, 2016, through
September 30, 2017, divided by the total days in the cost reporting period)}. For cost reporting
periods that overlap September 30, 2017, enter in column 1, one-third of {((line 48 minus line 47)
times 75 percent) times (the number of days in the cost reporting period between October 1, 2016,
through September 30, 2017, divided by the total days in the cost reporting period)} and zero in
column 2.
Rev.

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DRAFT

Line 101--Enter the HVBP adjustment factor that corresponds to the portion of the cost reporting
period prior to October 1, in column 1 and the HVBP adjustment factor that corresponds to the
portion of the cost reporting period on or after October 1, in column 2. The HVBP adjustment
factors are published annually in the IPPS final rule and posted on the CMS website. Enter “1” if
the provider is not subject to the HVBP adjustment.
Line 102--The HVBP adjustment amount is computed as ((HSP Bonus x HVBP adjustment
factor)-HSP Bonus). Enter in column 1, the HVBP adjustment amount for the portion of the cost
reporting period prior to October 1, by multiplying (column 1, line 100, times column 1, line 101),
minus column 1, line 100. Enter in column 2, the HVBP adjustment amount for the portion of the
cost reporting period on or after October 1, by multiplying (column 2, line 100, times column 2,
line 101) minus column 2, line 100.
Line 103--Enter the HRR adjustment factor that corresponds to the portion of the cost reporting
period prior to October 1, in column 1, and HRR adjustment factor that corresponds to the portion
of the cost reporting period on or after October 1, in column 2. The HRR adjustment factors are
published annually in the IPPS final rule and posted on the CMS website. Enter “1” if the provider
is not subject to the HRR adjustment.
Line 104--The HRR adjustment amount is computed as ((HSP Bonus x HRR adjustment factor)HSP Bonus). Enter in column 1, the HRR adjustment amount for the portion of the cost reporting
period prior to October 1, by multiplying (column 1, line 100, times column 1, line 103) minus
column 1, line 100. Enter in column 2, the HRR adjustment amount for the portion of the cost
reporting period on or after October 1, by multiplying (column 2, line 100, times column 2,
line 103) minus column 2, line 100.
Rural Community Health Demonstration Project (§410A Demonstration) Adjustment--For cost
reporting periods ending on or after September 30, 2017, lines 200 through 218 provide for the
calculation of the §410 Demonstration project adjustment in accordance with the MMA of 2003,
§410A, and extended under §§3123 and 10313 of the ACA 2010, and §15003 of the 21st Century
Cures Act of 2016. Complete the applicable lines if Worksheet S-2, Part I, line 110, is “Y,” and
calculate line 201 based on reasonable cost at 100% (not 101%).
A hospital participating in the §410A Demonstration receives payment for inpatient hospital
services furnished to Medicare beneficiaries, with the exclusion of services furnished in a
psychiatric or rehabilitation unit that is a distinct part of the hospital, using the following rules: a)
For discharges occurring in the first cost reporting period on or after the implementation of the
extension, their reasonable costs of providing covered inpatient hospital services; b) For discharges
occurring during the second and subsequent cost reporting periods, the lesser of their reasonable
costs or a target amount. The target amount for the second cost reporting period is defined as the
reasonable costs of providing covered inpatient hospital services in the first cost reporting period,
increased by the IPPS update factor (as defined in section 1886(b)(3)(B)) for that particular cost
reporting period. The target amount for each subsequent cost reporting period is defined as the
preceding cost reporting period’s target amount increased by the IPPS update factor for that
particular cost reporting period.
Line 200--Is this the first year of the current 5-year demonstration period under the 21st Century
Cures Act? Enter “Y” for yes or “N” for no.
Line 201--Enter the Medicare inpatient service costs from Worksheet D-1, Part II, line 49.
Line 202--Enter the Medicare discharges from Worksheet S-3, column 13, line 1.

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Line 203--Enter the case-mix adjustment factor (four-decimal places) used to update the target
amount for years 2 through 5. Obtain the update factor from the contractor.
Line 204--Enter the Medicare target amount per discharge. Obtain the target amount per discharge
from the contractor.
Line 205--Enter the case-mix adjusted target amount for years 2 through 5, determined by
multiplying line 203 times line 204.
Line 206--Enter the Medicare inpatient routine cost cap determined by multiplying line 202 times
line 205.
Line 207--Enter the Program reimbursement as determined under the §410A Demonstration as
follows: For the first year of the current 5-year demonstration period, enter the amount from
line 201. For the subsequent years of the current 5-year demonstration period, enter the lesser of
line 201 or line 206.
Line 208--Enter the Medicare Part A inpatient service costs for Medicare beneficiaries from
Worksheet E, Part A, line 59.
Line 209--Enter the adjustment to Medicare IPPS payments (the difference between
reimbursement under IPPS and cost reimbursement under the §410A Demonstration). Enter the
result of line 207 minus line 208.
Line 210--This line is reserved for future use.
Line 211--Enter the total adjustment to the Medicare IPPS payment. Enter the total amount from
line 209.
Line 212--Enter the total adjustment to the Medicare Part A IPPS payment from line 211.
Line 213--Enter the low volume adjustment payments from Worksheet E, Part A, lines 70.96,
70.97, and 70.98, as applicable.
Lines 214 through 217--Reserved for future use.
Line 218--Enter the net adjustment to the Medicare Part A IPPS payment, the difference between
the IPPS payment and the cost reimbursement under the rural community hospital demonstration
project, by subtracting the amount on line 213 from the amount on line 212. Transfer the amount
in column 1 to line 70.50.

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DRAFT

Instructions for Completing Exhibit 4-Low-Volume Adjustment Calculation Schedule:
42 CFR 412.101 provides for a low-volume adjustment for Medicare discharges in qualifying
hospitals. The amount of any adjustment depends on the FFY in which the discharges occur.
42 CFR 412.101(c)(1) provides for the low-volume adjustment for Medicare discharges in
FFYs 2005 through 2010 (discharges on and after October 1, 2004, and before October 1, 2010),
and FFY 2023, and subsequent FFYs (discharges on and after October 1, 2022). Qualifying
hospitals, those hospitals more than 25 road miles from the nearest subsection (d) hospital and
with fewer than 200 discharges, receive a payment adjustment of an additional 25 percent for each
Medicare discharge.
42 CFR 412.101(c)(2) provides for a temporary change in the low-volume adjustment for
qualifying hospitals for FFYs 2011 through 2018 (discharges on and after October 1, 2010, and
before October 1, 2018). Qualifying hospitals, those hospitals more than 15 road miles from the
nearest subsection (d) hospital and with fewer than 1,600 Medicare discharges based on the latest
available Medicare Provider Analysis and Review (MedPAR) data, receive a payment adjustment
as follows:
•
•

Those hospitals with 200 or fewer Medicare discharges will receive an adjustment of
an additional 25 percent for each discharge; and
Those with more than 200 and fewer than 1,600 Medicare discharges will receive an
adjustment of an additional percentage for each discharge. This adjustment is
calculated using the formula [(4/14) - (Medicare discharges/5,600)].

42 CFR 412.101(c)(3) provides for a temporary change in the low-volume adjustment for
qualifying hospitals for FFYs 2019 through 2022 (discharges on and after October 1, 2018, and
before October 1, 2022). Qualifying hospitals, those hospitals more than 15 road miles from the
nearest subsection (d) hospital and with fewer than 3,800 total discharges based on the hospital’s
most recently submitted cost report, receive a payment adjustment as follows:
•

Those hospitals with 500 or fewer total discharges will receive an adjustment of an
additional 25 percent for each Medicare discharge; and,
Those with more than 500 and fewer than 3,800 total discharges will receive an
adjustment of an additional percentage for each Medicare discharge. This adjustment
is calculated using the formula [(95/330) - (total discharges/13,200)].

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•

04-20

FORM CMS-2552-10

4030.1 (Cont.)

CMS provided a table listing the IPPS hospitals with fewer than 1,600 Medicare discharges and
their low-volume percentage add-on, if applicable, for FFYs 2011 through 2018 (discharges before
October 1, 2018). However, this list is not a list of all hospitals that qualify for the low-volume
adjustment since it does not reflect whether or not the hospital meets the mileage criteria. Hospitals
were required to request low-volume status in writing to their contractor and provide
documentation that they met the mileage criteria.
The low-volume payment adjustment for eligible hospitals is based on their total per discharge
payments made under §1886 of the Act, including the capital IPPS payments, DSH payments, IME
payments, and outlier payments. For SCHs and MDHs, the low-volume payment adjustment for
eligible hospitals is based on either the federal rate or the hospital-specific payment (HSP) rate,
whichever results in a greater operating IPPS payment. The low-volume payment amount
calculated by the IPPS Pricer is an interim payment amount and is subject to adjustment during
year end cost report settlement if any of the payment amounts upon which the low-volume payment
amount is based are also recalculated at cost report settlement (for example, payments for DSH
and IME or federal rate versus HSP rate payments for SCHs and MDHs).
NOTE: Because a hospital’s eligibility for the low-volume payment adjustment and/or a
hospital’s applicable low-volume adjustment percentage can change during its cost
reporting period (for example, a hospital with a cost report that spans the start of the
FFY), it is necessary to determine the low-volume payment amount using the applicable
low-volume adjustment percentage for the FFY and payment amounts listed above for a
hospital’s discharges that occur during the FFY for each FFY included by the hospital’s
cost reporting period.
After the cost report is calculated for settlement, the low-volume payment adjustment must be
calculated. The low-volume payment amount must be calculated by FFY. Therefore, if the cost
report overlaps a FFY, the information computed on Worksheet E, Part A, must be recomputed by
FFY accordingly. The amounts may not be prorated, but must be calculated using the appropriate
information. The following payment amounts are multiplied by the low-volume payment
adjustment percentage by FFY:
−
−
−
−
−
−
−
−
−
−
−
−

Operating Federal IPPS payments;
Operating HSR payments;
Operating outlier payments including any Operating Outlier Reconciliation amounts;
Operating IME payments;
Operating IME payments for Medicare Advantage patients;
Operating DSH payments;
Uncompensated care payments;
ESRD adjustment payments;
Total Capital IPPS payment;
New technology payments;
Credits for replaced devices; and
Capital outlier reconciliation amounts (if applicable, see instructions)

Complete Exhibit 4 to compute the low-volume adjustment payment applicable to this cost
reporting period. The Exhibit 4 is designed to simulate the Medicare cost report and must be
completed after the cost report is calculated.
If the provider participated in the PARHM demonstration (Worksheet S-2, Part I, line 112,
column 1, is “Y”) for only a portion of the cost reporting period, complete Exhibit 4 only for the
non-participation portion of the cost reporting period.
Column 0--Line references are comparable to the actual line references on Worksheet E, Part A,
and Worksheet L, Part I.
Column 1--Enter from Worksheet E, Part A, and Worksheet L, Part I, the amounts reported on the
corresponding lines of the Medicare cost report.
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04-20

Column 2--Enter amounts related to discharges occurring in the cost reporting period either
pre-entitlement (discharges occurring in the cost reporting period prior to October 1) or
post-entitlement (discharges occurring in the cost reporting period on or after October 1).
Discharges occurring in these periods are not eligible for the low-volume adjustment.
In addition, if there are discharges occurring during this cost reporting period and the provider was
not eligible for the low-volume adjustment for the entire eligibility period, report the information
relative to those discharges in this column, for example, where a provider has a cost reporting
period ending June 30, 2011, which began prior to the October 1, 2010, effective date of the
provision. Or where the low-volume adjustment for discharges occurring in this cost reporting
period is effective for discharges on or after October, 1, 2010; however, the provider did not
request the low-volume adjustment until November 15, 2010, and the low-volume adjustment was
implemented within 30 days of the request. The period of time from October 1, 2010, until the
contractor notified the provider of eligibility, which should be no later than December 15, 2010,
is considered a period of ineligibility.
Column 3--Enter amounts related to discharges occurring during the provider’s low-volume
eligibility period and prior to October 1. If the cost reporting period is not concurrent with a federal
year of October 1, through September 30, do not include discharges occurring on or after
October 1, in this column.
If the provider goes in and out of eligibility for discharges occurring prior to October 1, add all
discharges for the eligibility periods prior to October 1, and include in this column. If the
provider’s classification (i.e. SCH to small rural) changes during the eligibility period, use
subscripted column 3.01 to accommodate the change for discharges occurring prior to October 1.
Column 4--Enter amounts related to discharges occurring during the provider’s low-volume
eligibility period and on or after October 1. If the cost reporting period is concurrent with a federal
year of October 1, through September 30, report all discharges occurring on or after October 1, in
this column. If the provider goes in and out of eligibility for discharges occurring on or after
October 1, add all discharges for the eligibility periods on or after October 1, and include in this
column. If the provider’s classification (i.e. SCH to small rural) changes during the eligibility
period, use subscripted column 4.01 to accommodate the change for discharges occurring on or
after October 1.
Columns 3, 3.01, 4, and 4.01--Use the beginning and ending dates of the applicable portion of the
cost reporting period as the respective column headings.
Column 5--Subtotal columns 2 through 4, and applicable subscripts. Column 5 must equal
column 1, and any resulting rounding difference must be applied to the highest value in columns 2
through 4, and applicable subscripts.
Line Descriptions
Line 1--The amount entered on this line is computed as the sum of the federal operating portion
(DRG payment) paid for PPS discharges during the cost reporting period and the DRG payments
made for PPS transfers during the cost reporting period. The PS&R information must be split and
reported in columns 2 through 4, and must concur with the PS&R paid-through date used to
calculate the cost report.
Line 1.01 (Corresponds to Worksheet E, Part A, line 1.01)--Enter the DRG amounts other than
outlier payments for discharges occurring prior to October 1, in column 3.
Line 1.02 (Corresponds to Worksheet E, Part A, line 1.02)--Enter the DRG amounts other than
outlier payments for discharges occurring on or after October 1, in column 4.
Line 1.03 (Corresponds to Worksheet E, Part A, line 1.03)--Enter the DRG for federal specific
operating payments for Model 4 BPCI on this line. The PS&R information must be split and
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FORM CMS-2552-10

4030.1 (Cont.)

reported in columns 2 through 4, and must concur with the PS&R paid-through date used to
calculate the cost report. Effective for cost reporting periods that overlap October 1, 2014, and
subsequent years, enter the amount of the federal specific operating portion (DRG payments) paid
for Model 4 BPCI discharges and transfers occurring prior to October 1, in columns 2 and 3
accordingly.
Line 1.04 (Corresponds to Worksheet E, Part A, line 1.04)--Enter the DRG for federal specific
operating payments for Model 4 BPCI occurring on or after October 1, on this line. The PS&R
information must be split and reported in columns 2 and 4 accordingly, and must concur with the
PS&R paid-through date used to calculate the cost report.
Line 2--Enter the amount of outlier payments made for PPS discharges occurring during the cost
reporting period. The PS&R information must be split and reported in columns 2 through 4, and
must concur with the PS&R paid-through date used to calculate the cost report. For cost reporting
periods beginning on or after October 1, 2018, do not complete this line, but complete lines 2.02
and 2.03.
Line 2.01 (Corresponds to Worksheet E, Part A, line 2.02)--Enter the outlier payment for
discharges for Model 4 BPCI on this line. The PS&R information must be split and reported in
columns 2 through 4, and must concur with the PS&R paid-through date used to calculate the cost
report.
Line 2.02 (Corresponds to Worksheet E, Part A, line 2.03)--For cost reporting periods beginning
on or after October 1, 2018, enter the amount of the outlier payments made for PPS discharges
occurring prior to October 1, in column 3.
Line 2.03 (Corresponds to Worksheet E, Part A, line 2.04)--For cost reporting periods beginning
on or after October 1, 2018, enter the amount of the outlier payments made for PPS discharges
occurring on or after October 1, in column 4.
Line 3 (Corresponds to Worksheet E, Part A, line 2.01)--For inpatient PPS services rendered
during the cost reporting period, enter the operating outlier reconciliation amount for operating
expenses from line Worksheet E, Part A, line 92, for each respective period. The lump sum utility
produces a claim-by-claim output. If the provider has two different low-volume hospital
adjustment percentages during its cost reporting period, the contractor must report the operating
and capital outlier reconciliation adjustment amounts for the discharges occurring in each of the
FFYs spanned by the cost report separately. The sum of columns 2 through 4 must equal the
amount reported on Worksheet E, Part A, line 2.01.
Line 4 (Corresponds to Worksheet E, Part A, line 3)--Enter the IME for managed care patients
based on the DRG payment that would have been made if the service had not been a managed care
service. The PS&R will capture, in conjunction with the PPS PRICER, the simulated payments.
Enter the total managed care “simulated payments” from the PS&R. The PS&R information must
be split and reported in columns 2 through 4, and must concur with the PS&R paid-through date
used to calculate the cost report.
Line 5 (Corresponds to Worksheet E, Part A, line 21)--Enter the ratio calculated from
Worksheet E, Part A, line 21, in columns 2 through 4.
Line 6 (Corresponds to Worksheet E, Part A, line 22)--For cost reporting periods beginning before
October 1, 2014, calculate the IME payment adjustment as follows: Multiply the appropriate
multiplier of the adjustment factor (currently 1.35) times {((1 + line 5) to the .405 power) - 1}
times {the sum of lines 1, 1.01, 1.02, 1.03, 1.04, and line 4}. The sum of columns 2 through 4
must equal the amount reported on Worksheet E, Part A, line 22.
Effective for cost reporting periods beginning on or after October 1, 2014, calculate the IME
payment adjustment as follows: Multiply the appropriate multiplier of the adjustment factor
(currently 1.35) times {((1 + line 5) to the .405 power) - 1} times {the sum of lines 1.01, 1.02, 1.03
and 1.04}.
Rev. 15

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10-18

Line 6.01 (Corresponds to Worksheet E, Part A, line 22.01)--Effective for cost reporting periods
beginning on or after October 1, 2014, calculate the IME payment adjustment for managed care,
as follows: Multiply the appropriate multiplier of the adjustment factor (currently 1.35) times
{((1 + line 5) to the .405 power) - 1} times line 4.
Line 7 (Corresponds to Worksheet E, Part A, line 27)--Enter the ratio calculated from
Worksheet E, Part A, line 27, in columns 2 through 4.
Line 8 (Corresponds to Worksheet E, Part A, line 28)--IME Add On Adjustment--For cost
reporting periods beginning before October 1, 2014, enter the sum of lines 1, 1.01, 1.02, 1.03, 1.04,
and 4, multiplied by the factor on line 7.
Effective for cost reporting periods beginning on or after October 1, 2014, calculate the IME addon adjustment as follows: Enter the sum of lines 1.01, 1.02, 1.03 and 1.04, multiplied by the factor
on line 7.
Line 8.01 (Corresponds to Worksheet E, Part A, line 28.01)--IME Add On Adjustment - Managed
Care--Effective for cost reporting periods beginning on or after October 1, 2014, enter the result
of line 4, multiplied by the factor on line 7.
Line 9 (Corresponds to Worksheet E, Part A, line 29)--Total IME Payment--Enter the sum of
lines 6 and 8. The sum of columns 2 through 4 must equal the amount reported on Worksheet E,
Part A, line 29.
Line 9.01 (Corresponds to Worksheet E, Part A, line 29.01)--Total IME Payment - Managed
Care--Effective for cost reporting periods beginning on or after October 1, 2014, enter the sum of
lines 6.01 and 8.01. The sum of columns 2 through 4 must equal the amount reported on
Worksheet E, Part A, line 29.01.
Line 10 (Corresponds to Worksheet E, Part A, line 33)--Enter the DSH percentage calculated from
Worksheet E, Part A, line 33, in columns 2 through 4.
Line 11 (Corresponds to Worksheet E, Part A, line 34)--Multiply line 10 by line 1 for cost
reporting periods ending on or before September 30, 2013. Effective for cost reporting periods
that overlap October 1, 2013, enter the sum of {(line 10 times line 1.01), plus ((line 10 times the
sum of lines 1.02 and 1.03) times 25 percent)}. For cost reporting periods beginning on or after
October 1, 2013, multiply (line 10 times the sum of lines 1.01, 1.02, and 1.03) times 25 percent.
For cost reporting periods overlapping or beginning on or after October 1, 2014, multiply (line 10
times the sum of lines 1.01, 1.02, 1.03, and 1.04) times 25 percent. The sum of columns 2 through
4 must equal the amount reported on Worksheet E, Part A, line 34.
Line 11.01 (Corresponds to Worksheet E, Part A, line 36)--Enter the uncompensated care
payments. For cost reporting periods that overlap or begin on or after October 1, 2013, when you
are eligible for the low-volume payment adjustment for the entire cost reporting period, enter in
column 3, the uncompensated care payments from Worksheet E, Part A, column 1, line 35.03, and
enter in column 4, the uncompensated care payments from Worksheet E, Part A, column 2,
line 35.03.
For cost reporting periods that overlap or begin on or after October 1, 2013, when you are not
eligible for the low-volume payment adjustment for any portion of the cost reporting period, enter
the uncompensated care payments as follows:
•

Enter in column 3, the uncompensated care payment eligible for the low-volume
payment adjustment for the portion of the cost reporting period prior to October 1
(calculated as the amount from Worksheet E, Part A, column 1, line 35.03, times the
ratio of the number of days prior to October 1, in the cost reporting period eligible for
the low-volume payment adjustment divided by the total days in the cost reporting
period prior to October 1).

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FORM CMS-2552-10

4030.1 (Cont.)

•

Enter in column 4, the uncompensated care payment eligible for the low-volume
payment adjustment for the portion of the cost reporting period on and after October 1
(calculated as the amount from Worksheet E, Part A, column 2, line 35.03, times the
ratio of the number of days on and after October 1, in the cost reporting period eligible
for the low-volume payment adjustment divided by the total days in the cost reporting
period on and after October 1).

•

Enter in column 2, the uncompensated care payments not eligible for the low-volume
payment adjustment (calculated as the total uncompensated care payment, from
Worksheet E, Part A, line 35.03, sum of columns 1 and 2, minus the sum of the
uncompensated care payments reported in columns 3 and 4 of this exhibit). The sum
of columns 2 through 4, must equal Worksheet E, Part A, line 36.

Line 12 (Corresponds to Worksheet E, Part A, line 46)--Prorate in columns 2 through 4, the
amount reported on Worksheet E, Part A, line 46, based on the ratio of days in each applicable
period to total days in the cost reporting period. The sum of columns 2 through 4 must equal the
amount reported on Worksheet E, Part A, line 46.
Line 13 (Corresponds to Worksheet E, Part A, line 47)--Enter the sum of lines 1, 1.01, 1.02, 2,
2.01, 2.02, 2.03, 3, 9, 11, 11.01, and 12. The sum of columns 2 through 4 must equal the amount
reported on Worksheet E, Part A, line 47.
Line 14 (Corresponds to Worksheet E, Part A, line 48)--For SCHs and MDHs, enter the applicable
hospital-specific payments. The sum of columns 2 through 4 must equal the amount reported on
Worksheet E, Part A, line 48. If Worksheet E, Part A, line 47, is greater than Worksheet E, Part A,
line 48, do not complete this line.
Line 15 (Corresponds to Worksheet E, Part A, line 49)--Enter in column 1, the amount from
Worksheet E, Part A, line 49. For SCHs, if line 13, column 1, is greater than line 14, column 1,
enter in columns 2 through 4, the amount reported on line 13, plus the amount from line 9.01, for
each applicable column. If line 14, column 1, is greater than line 13, column 1, enter in columns 2
through 4, the amount reported on line 14, plus the amount from line 9.01, for each applicable
column. For MDH discharges occurring on or after October 1, 2006, and before October 1, 2022,
if line 13, column 1, is greater than line 14, column 1, enter in columns 2 through 4, the amount
reported on line 13, plus the amount from line 9.01, for each applicable column. If line 14,
column 1, is greater than line 13, column 1, enter in columns 2 through 4, the amount on line 13,
for each applicable column, plus 75 percent of the difference between line 14 minus line 13, plus
the amount from line 9.01. Hospitals not qualifying as SCH or MDH providers will enter in
columns 2 through 4, the amount from line 13, plus the amount from line 9.01, for each applicable
column. The sum of columns 2 through 4 must equal the amount reported on Worksheet E, Part A,
line 49.
For former MDHs, line 15 is calculated based on the amounts in column 1. For former MDHs
(Worksheet S-2, Part I, line 37.01, is yes) for FY 2016, for cost reporting periods that begin on or
after January 1, 2016, if line 14, column 1, is greater than line 13, column 1, enter in column 3, the
amount on line 13, column 1, times (the number of days in the cost reporting period prior to
October 1, divided by the total days in the cost reporting period), plus Worksheet E, Part A,
line 100, column 1, plus the amount from line 9.01, column 3. Enter in column 4, the amount on
line 13, column 1, times (the number of days in the cost reporting period on or after
October 1, divided by the total days in the cost reporting period), plus Worksheet E, Part A,
line 100, column 2, plus the amount from line 9.01, column 4. For cost reporting periods that
overlap January 1, 2016, and end on or before September 30, 2016, enter in column 3, the amount
on line 13, column 1, times (the number of days in the cost reporting period prior to
October 1, divided by the total days in the cost reporting period), plus Worksheet E, Part A,
line 100, column 1, plus the amount from line 9.01, column 3. Enter in column 4, the amount on
line 13, column 1, times (the number of days in the cost reporting period on or after October 1,
divided by the total days in the cost reporting period), plus Worksheet E, Part A, line 100,
column 2, plus the amount from line 9.01, column 4. For cost reporting periods that overlap
Rev. 15

40-176.7

4030.1 (Cont.)

FORM CMS-2552-10

10-18

January 1, 2016, and October 1, 2016, enter in column 3, the amount on line 13, column 1, times
(the number of days in the cost reporting period prior to October 1, divided by the total days in the
cost reporting period), plus Worksheet E, Part A, line 100, column 1, plus the amount from
line 9.01, column 3. Enter in column 4, the amount on line 13, column 1, times (the number of
days in the cost reporting period on or after October 1, divided by the total days in the cost
reporting period), plus Worksheet E, Part A, line 100, column 2, plus the amount from line 9.01,
column 4.
For former MDHs for FY 2017, for cost reporting periods that begin October 1, 2016, enter in
column 4, the amount on line 13, column 1, times (the number of days in the cost reporting period
on or after October 1, divided by the total days in the cost reporting period), plus Worksheet E,
Part A, line 100, column 2, plus the amount from line 9.01, column 4. For cost reporting periods
that overlap October 1, 2016, enter in column 3, the amount on line 13, column 1, times (the
number of days in the cost reporting period prior to October 1, divided by the total days in the cost
reporting period), plus Worksheet E, Part A, line 100, column 1, plus the amount from line 9.01,
column 3. Enter in column 4, the amount on line 13, column 1, times (the number of days in the
cost reporting period on or after October 1, divided by the total days in the cost reporting period),
plus Worksheet E, Part A, line 100, column 2, plus the amount from line 9.01, column 4. For cost
reporting periods that overlap September 30, 2017, enter in column 3, the amount on line 13,
column 1, times (the number of days in the cost reporting period prior to October 1, divided by the
total days in the cost reporting period), plus Worksheet E, Part A, line 100, column 1, plus the
amount from line 9.01, column 3. Enter in column 4, the amount on line 13, column 1, times (the
number of days in the cost reporting period on or after October 1, divided by the total days in the
cost reporting period), plus Worksheet E, Part A, line 100, column 2, plus the amount from
line 9.01, column 4.
Line 16 (Corresponds to Worksheet E, Part A, line 50)--Enter in columns 2 through 4, the amounts
computed from line 26, columns 2 through 4. The sum of columns 2 through 4 must equal the
amount reported on Worksheet E, Part A, line 50. If Worksheet S-2, Part I, line 47, column 2, is
yes, and Worksheet S-2, Part I, line 48, column 2, is no, do not transfer the amount from
Worksheet E, Part A, line 50.
Line 17 (Corresponds to Worksheet E, Part A, line 54)--Enter the add-on payment for new
technologies. The PS&R information must be split and reported in columns 2 through 4 and must
concur with the PS&R paid-through date used to calculate the cost report.
Line 17.01 (Corresponds to Worksheet E, Part A, line 55)--Do not complete this line. Organ
acquisition costs are not included in the low volume adjustment calculation.
Line 17.02 (Corresponds to Worksheet E, Part A, line 68)--For discharges on or after
October 1, 2014, enter the credits for replaced devices. The PS&R information must be split and
reported in columns 2 through 4 and must concur with the PS&R paid-through date used to
calculate the cost report.
Line 18 (Corresponds to Worksheet E, Part A, line 93)--Enter the capital outlier reconciliation
adjustment amount in columns 2 through 4 accordingly. The sum of columns 2 through 4 must
equal the amount reported on Worksheet E, Part A, line 93.
Line 19 (Subtotal)--Enter in columns 2 through 4, the sum of amounts on lines 15, 16, 17, and 18.
For SCH, if the hospital specific payment amount on line 14, column 1, is greater than the federal
specific payment amount on line 13, column 1, enter in columns 2 through 4, the sum of the
amounts on lines 15, 16, 17, and 17.02.

40-176.8

Rev. 15

10-18

FORM CMS-2552-10

4030.1 (Cont.)

Line 20 (Corresponds to Worksheet L, Part I, line 1)--Enter the amount of the federal rate portion
of the capital DRG payments for other than outlier during this cost reporting period. The PS&R
information must be split and reported in columns 2 through 4 and must concur with the PS&R
paid-through date used to calculate the cost report for settlement. The sum of columns 2 through
4 must equal the amount reported on Worksheet L, Part I, line 1, column 1, and, if applicable,
column 1.01.
Line 20.01 (Corresponds to Worksheet L, Part I, line 1.01)--Enter the Model 4 BPCI Capital DRG
other than outlier payments. The PS&R information must be split and reported in columns 2
through 4 and must concur with the PS&R paid-through date used to calculate the cost report for
settlement. The sum of columns 2 through 4 must equal the amount reported on Worksheet L,
Part I, line 1.01, column 1, and, if applicable, column 1.01.
Line 21 (Corresponds to Worksheet L, Part I, line 2)--Enter the amount of the federal rate portion
of the capital outlier payments made for PPS discharges during this cost reporting period. The
PS&R information must be split and reported in columns 2 through 4 and must concur with the
PS&R paid-through date used to calculate the cost report. The sum of columns 2 through 4 must
equal the amount reported on Worksheet L, Part I, line 2.
Line 21.01 (Corresponds to Worksheet L, Part I, line 2.01)--Enter the Model 4 BPCI Capital DRG
outlier payments. The PS&R information must be split and reported in columns 2 through 4 and
must concur with the PS&R paid-through date used to calculate the cost report. The sum of
columns 2 through 4 must equal the amount reported on Worksheet L, Part I, line 2.01.
Line 22 (Corresponds to Worksheet L, Part I, line 5)--Enter the ratio calculated from Worksheet L,
Part I, line 5, in all applicable columns.
Line 23 (Corresponds to Worksheet L, Part I, line 6)--Multiply line 22 by the sum of lines 20 and
20.01. The sum of columns 2 through 4 must equal the amount reported on Worksheet L, Part I,
line 6.
Line 24 (Corresponds to Worksheet L, Part I, line 10)--Enter the percentage calculated from
Worksheet L, Part I, line 10, in all applicable columns.
Line 25 (Corresponds to Worksheet L, Part I, line 11)--Multiply line 24 by the sum of lines 20 and
20.01, and enter the result. The sum of columns 2 through 4 must equal the amount reported on
Worksheet L, Part I, line 11.
Line 26 (Corresponds to Worksheet L, Part I, line 12)--Enter the sum of lines 20, 20.01, 21, 21.01,
23, and 25. If the amounts on lines 20 and/or 20.01, columns 3 and/or 4, or applicable subscripts
of either column, pertain to rural status, enter zero. Transfer this amount to line 16. The sum of
columns 2 through 4 must equal the amount reported on Worksheet L, Part I, line 12.
Low-volume payment adjustment--Effective for discharges occurring during FFYs 2011 and
subsequent, compute the amount of the low-volume adjustment as follows:
Line 27--Low-volume adjustment factor--Enter the appropriate adjustment factor in columns 3
and 4. For FFYs 2011 through 2018, obtain the adjustment factor from the appropriate IPPS final
rule. For FFYs 2019 through 2022, calculate the adjustment factor in accordance with
42 CFR412.101(c)(3), using the most recently submitted cost report. For FFYs 2023 forward
(discharges on or after October 1, 2022), use an adjustment factor of 25 percent.
Line 28 (Corresponds to Worksheet E, Part A, line 70.96 discharges prior to October 1)--Multiply
line 19 by line 27. Transfer this amount to the cost report, Worksheet E, Part A, line 70.96.
Line 29 (Corresponds to Worksheet E, Part A, line 70.97 discharges on or after October 1)-Multiply line 19 by line 27. Transfer this amount to the cost report, Worksheet E, Part A,
line 70.97.
Rev. 15

40-176.9

4030.1 (Cont.)

FORM CMS-2552-10

10-18

EXHIBIT 4
LOW-VOLUME ADJUSTMENT CALCULATION SCHEDULE
LOW-VOLUME CALCULATION

PROVIDER CCN:

EXHIBIT 4

_______________

1
1.01
1.02
1.03
1.04
2
2.01
2.02
2.03
3
4

12
13
14
15
16
17
17.01
17.02
18
19

DRG Amounts Other than Outlier Payments
DRG amounts other than outlier payments for discharges occurring prior to October 1
DRG amounts other than outlier payments for discharges occurring on or after October 1
DRG for Federal specific operating payment for Model 4 BPCI occurring prior to October 1
DRG for Federal specific operating payment for Model 4 BPCI occurring on or after October 1
Outlier payments for discharges (see instructions)
Outlier payment for discharges for Model 4 BPCI
Outlier payments for discharges occurring prior to October 1 (see instructions)
Outlier payments for discharges occurring on or after October 1 (see instructions)
Operating outlier reconciliation
Managed Care Simulated Payments
Indirect Medical Education Adjustment
Amount from Worksheet E, Part A, line 21 (see instructions)
IME payment adjustment (see instructions)
IME payment adjustment for managed care (see instructions)
Indirect Medical Education Adjustment for the Add-on for Section 422 of the MMA
IME payment adjustment factor (see instructions)
IME add-on adjustment amount (see instructions)
IME payment adjustment add on for managed care (see instructions)
Total IME payment (sum of lines 6 and 8)
Total IME payment for managed care (sum of lines 6.01 and 8.01)
Disproportionate Share Adjustment
Allowable disproportionate share percentage (see instructions)
Disproportionate share adjustment (see instructions)
Uncompensated care payments
Additional payment for high percentage of ESRD beneficiary discharges
Total ESRD additional payment (see instructions)
Subtotal (see instructions)
Hospital specific payments (completed by SCH and MDH, small rural hospitals only) (see instructions)
Total payment for inpatient operating costs (see instructions)
Payment for inpatient program capital (from Wkst. L, Pt. I, if applicable)
Special add-on payments for new technologies
Net organ acquisition cost
Credits received from manufacturers for replaced devices for applicable MS-DRGs
Capital outlier reconciliation adjustment amount (see instructions)
SUBTOTAL

20
20.01
21
21.01
22
23
24
25
26

Capital DRG other than outlier
Model 4 BPCI Capital DRG other than outlier
Capital DRG outlier payments
Model 4 BPCI Capital DRG outlier payments
Indirect medical education percentage (see instructions)
Indirect medical education adjustment (see instructions)
Allowable disproportionate share percentage (see instructions)
Disproportionate share adjustment (see instructions)
Total prospective capital payments (see instructions)

5
6
6.01
7
8
8.01
9
9.01
10
11
11.01

27
28
29

Low-volume adjustment factor
Low-volume adjustment (transfer amount to Wkst. E, Pt. A, line 70.96) (prior to 10/1)
Low-volume adjustment (transfer amount to Wkst. E, Pt. A, line 70.97) (on and after 10/1)

40-176.10

Wkst. E, Pt. A,
line
(0)
1
1.01
1.02
1.03
1.04
2
2.02
2.03
2.04
2.01
3

(Amt. from
Wkst. E, Pt. A)
(1)

Pre/Post Entitlement
(2)

Prior to 10/1
(3)

On and after 10/1
(4)

PERIOD:
FROM: ____________
TO: ____________
Total
(cols. 2 through 4)
(5)

1
1.01
1.02
1.03
1.04
2
2.01
2.02
2.03
3
4

21
22
22.01

5
6
6.01

27
28
28.01
29
29.01

7
8
8.01
9
9.01

33
34
36

10
11
11.01

46
47
48
49
50
54
55
68
93

12
13
14
15
16
17
17.01
17.02
18
19

Wkst. L, line
(0)
1
1.01
2
2.01
5
6
10
11
12
Wkst. E, Pt. A, line
(0)

(Amt. from Wkst. L)
(1)

(2)

(3)

(4)

(5)

(Amt. to Wkst. E, Pt. A)
(1)

(2)

(3)

(4)

(5)

20
20.01
21
21.01
22
23
24
25
26
27
28
29

Rev. 15

04-20

FORM CMS-2552-10

4030.1 (Cont.)

Instructions for Completing Exhibit 5-Adjustment to Hospital Payments for Hospital Acquired Conditions (HAC) Calculation Schedule:
Section 3008 of ACA 2010 establishes the HAC Reduction Program, beginning in FFY 2015
(discharges occurring on or after October 1, 2014), for IPPS hospitals to improve patient safety.
HACs are medical errors or serious infections that patients contract while in the hospital. Under
the HAC Reduction Program, a 1 percent payment reduction applies to a hospital whose ranking
is in the top quartile (25 percent) of all applicable hospitals, relative to the national average, of
HACs acquired during the applicable period, and applies to all of the hospital’s discharges for the
specific fiscal year. For SCHs and MDHs, the HAC reduction percentage applies to either the
federal payment rate or the HSP rate, whichever results in a greater operating IPPS payment. See
2015 IPPS final rule (79 FR 50087-50104 (August 22, 2014)).
Applicable IPPS hospitals subject to the HAC reduction adjustment for discharges occurring
during FFY 2015 (i.e., discharges occurring on or after October 1, 2014, through
September 30, 2015) are listed in Table 17 of the FY 2015 IPPS final rule. Consult the appropriate
CMS final rule for the table listing IPPS hospitals subject to the HAC reduction adjustment. The
HAC reduction adjustment amount is calculated after all IPPS per discharge payments, which
includes adjustment for DSH (including the uncompensated care payment (UCP)), IME payments,
outliers, new technology, net organ acquisition costs, credits for replace devices, readmissions,
HVBP, and capital payments. The HAC reduction adjustment calculated by the IPPS Pricer is an
interim payment amount and is subject to adjustment during cost report settlement if any of the
payment amounts upon which the HAC reduction adjustment is based are also recalculated at cost
report settlement (for example, payments for DSH, IME, Low volume adjustment, or federal rate
versus HSP rate payments for SCHs and MDHs).
After the cost report is calculated for settlement, the HAC reduction adjustment must be calculated
by FFY. If the cost report overlaps a FFY, the information computed on Worksheet E, Part A,
must be recomputed by FFY accordingly. The amounts are not prorated (except where noted), but
must be calculated using the appropriate information. The following payment amounts are
required to calculate the HAC reduction adjustment by FFY:
−
−
−
−
−
−
−
−
−
−
−
−
−
−
−

Operating Federal IPPS payments;
Operating HSR payments;
Operating Outlier payments including any Operating Outlier Reconciliation amounts;
Operating IME payments;
Operating IME payments for Medicare Advantage patients;
Operating DSH payments;
Uncompensated care payments;
ESRD adjustment payments;
Total capital IPPS payment;
New technology payments;
Credits for replaced devices;
Low volume adjustment;
HVBP payment adjustment;
HRR adjustment; and
Capital outlier reconciliation amounts (if applicable, see instructions)

Complete Exhibit 5 to compute the HAC reduction adjustment applicable to this cost reporting
period. The following Exhibit 5 is designed to simulate the Medicare cost report and must be
completed after the cost report is calculated.

Rev. 16

40-176.11

4030.1 (Cont.)

FORM CMS-2552-10

0-20

If the provider participated in the PARHM demonstration (Worksheet S-2, Part I, line 112,
column 1, is “Y”) for only a portion of the cost reporting period, complete Exhibit 5 only for the
non-participation portion of the cost reporting period.
Column 0--Line references are comparable to the actual line references on Worksheet E, Part A,
and Worksheet L, Part I.
Column 1--Enter from Worksheet E, Part A, and Worksheet L, Part I, the amounts reported on the
corresponding lines of the Medicare cost report.
Column 2--Enter amounts related to discharges occurring during the applicable provider’s HAC
reduction period prior to October 1. If the cost reporting period is not concurrent with a federal
year (October 1, through September 30), do not include discharges occurring on or after October 1,
in this column. If the provider’s classification (i.e. SCH to small rural) changes during the HAC
reduction period, use subscripted column 2.01 to accommodate the change for discharges
occurring prior to October 1st.
Column 3--Enter amounts related to discharges occurring during the applicable provider’s HAC
reduction period on or after October 1. If the cost reporting period is concurrent with a federal
year (October 1, through September 30), report all discharges occurring on or after October 1, in
this column. If the provider’s classification (i.e. SCH to small rural) changes during the HAC
reduction period, use subscripted column 3.01 to accommodate the change for discharges
occurring prior to October 1.
When a hospital with a cost reporting period that is not concurrent with a FFY is subject to the
HAC reduction adjustment for only part of the cost reporting period, complete both columns 2 and
3. If Worksheet S-2, Part I, line 40, column 1, is “N” do not complete the HAC reduction program
adjustment amount in column 2, line 32. If Worksheet S-2, Part I, line 40, column 2, is “N” do
not complete the HAC reduction program adjustment amount in column 3, line 32.
Columns 2 and 3--Use the beginning and ending dates of the applicable portion of the cost
reporting period as the respective column headings.
Column 4--Sum of columns 2 and 3. Column 4 must equal column 1 and any resulting rounding
difference must be applied to the highest value in column 2 or column 3.
Line Descriptions
Line 1--Do not use this line.
Line 1.01 (Corresponds to Worksheet E, Part A, line 1.01)--Enter the DRG amounts other than
outlier payments for discharges occurring prior to October 1, in column 2.
Line 1.02 (Corresponds to Worksheet E, Part A, line 1.02)--Enter the DRG amounts other than
outlier payments for discharges occurring on or after October 1 in column 3.
Line 1.03 (Corresponds to Worksheet E, Part A, line 1.03)--Enter the DRG for federal specific
operating payments for Model 4 BPCI on this line. The PS&R information must be split and
reported in columns 2 and 3, and must concur with the PS&R paid-through date used to calculate
the cost report. Effective for cost reporting periods that overlap October 1, 2014, and subsequent
years, enter the amount of the federal specific operating portion (DRG payments) paid for Model 4
BPCI discharges and transfers occurring prior to October 1, in column 2.
Line 1.04 (Corresponds to Worksheet E, Part A, line 1.04)--Enter the DRG for federal specific
operating payments for Model 4 BPCI on this line. The PS&R information must be split and
reported in columns 2 and 3, and must concur with the PS&R paid-through date used to calculate
the cost report.
40-176.12

Rev. 16

10-18

FORM CMS-2552-10

4030.1 (Cont.)

Line 2--Enter the amount of outlier payments made for PPS discharges occurring during the cost
reporting period. The PS&R information must be split and reported in columns 2 and 3, and must
concur with the PS&R paid-through date used to calculate the cost report. For cost reporting
periods beginning on or after October 1, 2018, do not complete this line, but complete lines 2.02
and 2.03.
Line 2.01 (Corresponds to Worksheet E, Part A, line 2.02)--Enter the outlier payment for
discharges for Model 4 BPCI on this line. The PS&R information must be split and reported in
columns 2 and 3, and must concur with the PS&R paid-through date used to calculate the cost
report.
Line 2.02 (Corresponds to Worksheet E, Part A, line 2.03)--For cost reporting periods beginning
on or after October 1, 2018, enter the amount of the outlier payments made for PPS discharges
occurring prior to October 1, in column 2.
Line 2.03 (Corresponds to Worksheet E, Part A, line 2.04)--For cost reporting periods beginning
on or after October 1, 2018, enter the amount of the outlier payments made for PPS discharges
occurring on or after October 1, in column 3.
Line 3 (Corresponds to Worksheet E, Part A, line 2.01)--For inpatient PPS services rendered
during the cost reporting period, enter the operating outlier reconciliation amount for operating
expenses from line Worksheet E, Part A, line 92, for each respective period. The lump sum utility
produces a claim-by-claim output. If the provider has two different low-volume hospital
adjustment percentages during its cost reporting period, the contractor must report the operating
and capital outlier reconciliation adjustment amounts for the discharges occurring in each of the
FFYs spanned by the cost report separately. The sum of columns 2 and 3 must equal the amount
reported on Worksheet E, Part A, line 2.01.
Line 4 (Corresponds to Worksheet E, Part A, line 3)--Enter the IME for managed care patients
based on the DRG payment that would have been made if the service had not been a managed care
service. The PS&R will capture, in conjunction with the PPS PRICER, the simulated payments.
Enter the total managed care simulated payments from the PS&R. The PS&R information must
be split and reported in columns 2 and 3, and must concur with the PS&R paid-through date used
to calculate the cost report.
Line 5 (Corresponds to Worksheet E, Part A, line 21)--Enter
Worksheet E, Part A, line 21, in columns 2 and 3.

the

ratio

calculated

from

Line 6 (Corresponds to Worksheet E, Part A, line 22)--For cost reporting periods that overlap
October 1, 2014, calculate the IME payment adjustment as follows: Multiply the appropriate
multiplier of the adjustment factor (currently 1.35) times {((1 + line 5) to the .405 power) - 1}
times {the sum of lines 1.01, 1.02, 1.03, 1.04 and line 4}. The sum of columns 2 and 3 must equal
the amount reported on Worksheet E, Part A, line 22.
Effective for cost reporting periods beginning on or after October 1, 2014, calculate the IME
payment adjustment as follows: Multiply the appropriate multiplier of the adjustment factor
(currently 1.35) times {((1 + line 5) to the .405 power) - 1} times {the sum of lines 1.01, 1.02, 1.03
and 1.04}. The sum of columns 2 and 3 must equal the amount reported on Worksheet E, Part A,
line 22.
Line 6.01 (Corresponding to Worksheet E, Part A, line 22.01)--Effective for cost reporting
periods beginning on or after October 1, 2014, calculate the IME payment adjustment for managed
care, as follows: Multiply the appropriate multiplier of the adjustment factor (currently 1.35) times
{((1 + line ) to the .405 power) - 1} times line 4.
Line 7 (Corresponds to Worksheet E, Part A, line 27)--Enter
Worksheet E, Part A, line 27, in columns 2 and 3.
Rev. 15

the

ratio

calculated

from

40-176.13

4030.1 (Cont.)

FORM CMS-2552-10

10-18

Line 8 (Corresponds to Worksheet E, Part A, line 28)--IME Add On Adjustment--For cost
reporting periods that overlap October 1, 2014, enter the sum of lines 1.01, 1.02, 1.03, 1.04, and
4, multiplied by the factor on line 7.
Effective for cost reporting periods beginning on or after October 1, 2014, calculate the IME addon adjustment as follows: Enter the sum of lines 1.01, 1.02, 1.03, and 1.04, multiplied by the factor
on line 7.
Line 8.01 (Corresponding to Worksheet E, Part A, line 28.01)--Total IME Add On Adjustment
for Managed Care--Effective for cost reporting periods beginning on or after October 1, 2014,
enter the result of line 4, multiplied by the factor on line 7.
Line 9 (Corresponds to Worksheet E, Part A, line 29)--Total IME Payment--Enter the sum of
lines 6 and 8. The sum of columns 2 and3 must equal the amount reported on Worksheet E, Part A,
line 29.
Line 9.01 (Corresponding to Worksheet E, Part A, line 29.01)--Total IME Payment - Managed
Care--Effective for cost reporting periods beginning on or after October 1, 2014, enter the sum of
lines 6.01 and 8.01. The sum of columns 2 and 3 must equal the amount reported on Worksheet E,
Part A, line 29.01.
Line 10 (Corresponds to Worksheet E, Part A, line 33)--Enter the DSH percentage calculated from
Worksheet E, Part A, line 33, in columns 2 and 3.
Line 11 (Corresponds to Worksheet E, Part A, line 34)--Multiply (line 10 times the sum of
lines 1.01, 1.02 1.03, and 1.04) times 25 percent. The sum of columns 2 and 3 must equal the
amount reported on Worksheet E, Part A, line 34.
Line 11.01 (Corresponds to Worksheet E, Part A, line 36)--Enter the uncompensated care
payments. For cost reporting periods that overlap October 1, enter in column 2, the
uncompensated care payments from Worksheet E, Part A, column 1, line 35.03, and enter in
column 3, the uncompensated care payments from Worksheet E, Part A, column 2, line 35.03.
Line 12 (Corresponds to Worksheet E, Part A, line 46)--Prorate, in columns 2 and 3, the amount
reported on Worksheet E, Part A, line 46, based on the ratio of days in each applicable period to
total days in the cost reporting period. The sum of columns 2 and 3 must equal the amount reported
on Worksheet E, Part A, line 46.
Line 13 (Corresponds to Worksheet E, Part A, line 47)--Enter the sum of lines 1.01, 1.02, 2, 2.01,
2.02, 2.03, 3, 9, 11, 11.01, and 12. The sum of columns 2 and 3 must equal the amount reported
on Worksheet E, Part A, line 47.
Line 14 (Corresponds to Worksheet E, Part A, line 48)--For SCHs and MDHs, enter the applicable
hospital-specific payments. The sum of columns 2 and 3 must equal the amount reported on
Worksheet E, Part A, line 48. If Worksheet E, Part A, line 47, is greater than Worksheet E, Part A,
line 48, do not complete this line.

40-176.14

Rev. 15

03-18

FORM CMS-2552-10

4030.1 (Cont.)

Line 15 (Corresponds to Worksheet E, Part A, line 49)--Enter in column 1, the amount from
Worksheet E, Part A, line 49. For SCHs, if line 13, column 1 is greater than line 14, column 1,
enter in columns 2 and 3, the amount reported on line 13, plus the amount from line 9.01, for each
applicable column. If line 14, column 1, is greater than line 13, column 1, enter in columns 2 and
3, the amount reported on line 14, plus the amount from line 9.01, for each applicable column. For
MDH discharges occurring on or before October 1, 2022, if line 13, column 1, is greater than
line 14, column 1, enter in columns 2 and 3, the amount reported on line 13, plus the amount from
line 9.01, for each applicable column. If line 14, column 1, is greater than line 13, column 1, enter
in columns 2 and 3, the amount on line 13, for each column, plus 75 percent of the difference
between line 14 minus line 13, plus the amount from line 9.01. Hospitals not qualifying as SCH
or MDH providers will enter in columns 2 and 3, the amount from line 13, plus the amount from
line 9.01, for each column. The sum of columns 2 and 3 must equal the amount reported on
Worksheet E, Part A, line 49.
For former MDH’s, line 15 is calculated based on the amounts in column 1. For former MDHs
(Worksheet S-2, Part I, line 37.01 is yes) for FY 2016, for cost reporting periods that begin on or
after January 1, 2016, if line 14, column 1 is greater than line 13, column 1, enter in column 2, the
amount on line 13, column 1, times (the number of days in the cost reporting prior to
October 1, divided by the total days in the cost reporting period), plus Worksheet E, Part A,
line 100, column 1, plus the amount from line 9.01, column 2. Enter in column 3, the amount on
line 13, column 1, times (the number of days in the cost reporting period on or after
October 1, divided by the total days in the cost reporting period), plus Worksheet E, Part A,
line 100, column 2, plus the amount from line 9.01, column 3. For cost reporting periods that
overlap January 1, 2016, and end on or before September 30, 2016, enter in column 2, the amount
on line 13, column 1, times (the number of days in the cost reporting period prior to
October 1, divided by the total days in the cost reporting period), plus Worksheet E, Part A,
line 100, column 1, plus the amount from line 9.01, column 2. Enter in column 3, the amount on
line 13, column 1, times (the number of days in the cost reporting period on or after
October 1, divided by the total days in the cost reporting period), plus Worksheet E, Part A,
line 100, column 2, plus the amount from line 9.01, column 3. For cost reporting periods that
overlap January 1, 2016, and October 1, 2016, enter in column 2, the amount on line 13, column 1,
times (the number of days in the cost reporting period prior to October 1, divided by the total days
in the cost reporting period), plus Worksheet E, Part A, line 100, column 1, plus the amount from
line 9.01, column 2. Enter in column 3, the amount on line 13, column 1, times (the number of
days in the cost reporting period on or after October 1, divided by the total days in the cost
reporting period), plus Worksheet E, Part A, line 100, column 2, plus the amount from line 9.01,
column 3.
For former MDHs for FY 2017, for cost reporting periods that begin October 1, 2016, enter in
column 3, the amount on line 13, column 1, times (the number of days in the cost reporting period
on or after October 1, divided by the total days in the cost reporting period), plus Worksheet E,
Part A, line 100, column 2, plus the amount from line 9.01, column 3. For cost reporting periods
that overlap October 1, 2016, enter in column 2, the amount on line 13, column 1, times (the
number of days in the cost reporting period prior to October 1, divided by the total days in the cost
reporting period), plus Worksheet E, Part A, line 100, column 1, plus the amount from line 9.01,
column 2. Enter in column 3, the amount on line 13, column 1, times (the number of days in the
cost reporting period on or after October 1, divided by the total days in the cost reporting period),
plus Worksheet E, Part A, line 100, column 2, plus the amount from line 9.01, column 3. For cost
reporting periods that overlap September 30, 2017, enter in column 2, the amount on line 13,
column 1, times (the number of days in the cost reporting period prior to October 1, divided by the
total days in the cost reporting period), plus Worksheet E, Part A, line 100, column 1, plus the
amount from line 9.01, column 2. Enter in column 3, the amount on line 13, column 1, times (the
number of days in the cost reporting period on or after October 1, divided by the total days in the
cost reporting period), plus Worksheet E, Part A, line 100, column 2, plus the amount from
line 9.01, column 3.

Rev. 14

40-176.15

4030.1 (Cont.)

FORM CMS-2552-10

03-18

Line 16 (Corresponds to Worksheet E, Part A, line 50)--Enter in columns 2 and 3, the amounts
computed from line 26, columns 2 and 3. The sum of columns 2 and 3 must equal the amount
reported on Worksheet E, Part A, line 50. If Worksheet S-2, Part I, line 47, column 2, is yes, and
Worksheet S-2, Part I, line 48, column 2 is no, do not transfer the amount from Worksheet E,
Part A, line 50.
Line 17 (Corresponds to Worksheet E, Part A, line 54)--Enter the add-on payment for new
technologies. The PS&R information must be split and reported in columns 2 and 3 and must
concur with the PS&R paid-through date used to calculate the cost report.
Line 17.01 (Corresponds to Worksheet E, Part A, line 55)--Do not complete this line. Organ
acquisition costs are not included in the HAC reduction calculation.
Line 17.02 (Corresponds to Worksheet E, Part A, line 68)--Enter the credits for replaced devices.
The PS&R information must be split and reported in columns 2 and 3 and must concur with the
PS&R paid-through date used to calculate the cost report.
Line 18 (Corresponds to Worksheet E, Part A, line 93)--Enter the capital outlier reconciliation
adjustment amount in columns 2 and 3. The sum of columns 2 and 3 must equal the amount
reported on Worksheet E, Part A, line 93.
Line 19 Subtotal--Enter in columns 2 and 3, the sum of amounts on lines 15, 16, 17, 17.02, and
18. For SCH, if the hospital specific payment amount on line 14, column 1, is greater than the
federal specific payment amount on line 13, column 1, enter in columns 2 and 3, the sum of the
amounts on lines 15, 16, 17, and 17.02.
Line 20 (Corresponds to Worksheet L, Part I, line 1)--Enter the amount of the federal rate portion
of the capital DRG payments other than outlier during this cost reporting period. The PS&R
information must be split and reported in columns 2 and 3, and must concur with the PS&R
paid-through date used to calculate the cost report. The sum of columns 2 and 3 must equal the
amount reported on Worksheet L, Part I, line 1, column 1, and, if applicable, column 1.01.
Line 20.01 (Corresponds to Worksheet L, Part I, line 1.01)--Enter the Model 4 BPCI Capital DRG
other than outlier payments. The PS&R information must be split and reported in columns 2 and 3,
and must concur with the PS&R paid-through date used to calculate the cost report. The sum of
columns 2 and 3 must equal the amount reported on Worksheet L, Part I, line 1.01, column 1, and,
if applicable, column 1.01.
Line 21 (Corresponds to Worksheet L, Part I, line 2)--Enter the amount of the federal rate portion
of the capital outlier payments made for PPS discharges during this cost reporting period. The
PS&R information must be split and reported in columns 2 and 3, and must concur with the PS&R
paid-through date used to calculate the cost report. The sum of columns 2 and 3 must equal the
amount reported on Worksheet L, Part I, line 2.
Line 21.01 (Corresponds to Worksheet L, Part I, line 2.01)--Enter the Model 4 BPCI Capital DRG
outlier payments. The PS&R information must be split and reported in columns 2 and 3, and must
concur with the PS&R paid-through date used to calculate the cost report. The sum of columns 2
and 3 must equal the amount reported on Worksheet L, Part I, line 2.01.
Line 22 (Corresponds to Worksheet L, Part I, line 5)--Enter the ratio calculated from Worksheet L,
Part I, line 5, in all applicable columns.
Line 23 (Corresponds to Worksheet L, Part I, line 6)--Multiply line 22 by the sum of lines 20 and
20.01. The sum of columns 2 and 3 must equal the amount reported on Worksheet L, Part I, line 6.
Line 24 (Corresponds to Worksheet L, Part I, line 10)--Enter the percentage calculated from
Worksheet L, Part I, line 10, in applicable columns.
40-176.16

Rev. 14

10-18

FORM CMS-2552-10

4030.1 (Cont.)

Line 25 (Corresponds to Worksheet L, Part I, line 11)--Multiply line 24 by the sum of lines 20 and
20.01, and enter the result. The sum of columns 2 and 3 must equal the amount reported on
Worksheet L, Part I, line 11.
Line 26 (Corresponds to Worksheet L, Part I, line 12)--Enter the sum of lines 20, 20.01, 21, 21.01,
23, and 25. If the amounts on lines 20 and/or 20.01, columns 2 and/or 3, or applicable subscripts
of either column, pertain to rural status, enter zero. Transfer this amount to line 16 of this exhibit.
The sum of columns 2 and 3 must equal the amount reported on Worksheet L, Part I, line 12.
Line 27--Do not use. This line was left blank to maintain line number consistency between the
low-volume and HAC adjustment worksheets.
Line 28 (Corresponds to Worksheet E, Part A, line 70.96 discharges prior to October 1)--Enter the
amount from Worksheet E, Part A, line 70.96, in column 2.
Line 29 (Corresponds to Worksheet E, Part A, line 70.97 discharges on or after October 1)-- Enter
the amount from Worksheet E, Part A, line 70.97, in column 3.
Line 30 (Corresponds to Worksheet E, Part A, line 70.93)--Enter the HVBP payment adjustment
amount. The PS&R information for Worksheet E, Part A, line 70.93, must be split and reported
in columns 2 and 3, and must concur with the PS&R paid-through date used to calculate the cost
report. The sum of columns 2 and 3 must equal the amount reported on Worksheet E, Part A,
line 70.93.
Line 30.01 (Corresponds to Worksheet E, Part A, line 70.90)--Enter in columns 2 and 3, the
HVBP payment adjustment amounts from Worksheet E, Part A, line 102, columns 1 and 2,
respectively. The sum of columns 2 and 3 must equal the amount reported on Worksheet E, Part A,
line 70.90.
Line 31 (Corresponds to Worksheet E, Part A, line 70.94)--Enter the HRR adjustment amount.
The PS&R information for Worksheet E, Part A, line 70.94, must be split and reported in
columns 2 and 3, and must concur with the PS&R paid-through date used to calculate the cost
report. The sum of columns 2 and 3 must equal the amount reported on Worksheet E, Part A,
line 70.94.
Line 31.01 (Corresponds to Worksheet E, Part A, line 70.91)--Enter in columns 2 and 3, the HRR
adjustment amounts from Worksheet E, Part A, line 104, columns 1 and 2, respectively. The sum
of columns 2 and 3 must equal the amount reported on Worksheet E, Part A, line 70.91.
Line 32 (Corresponds to Worksheet E, Part A, line 70.99)--Enter the HAC reduction adjustment
amount. If you responded “N” on Worksheet S-2, Part I, line 40, column 1, do not complete the
HAC reduction adjustment in column 2. If you responded “N” on Worksheet S-2, Part I, line 40,
column 2, do not complete the HAC reduction adjustment in column 3. Enter in column 2, the
sum of lines 19, 28, 30, 30.01, 31, and 31.01, times 1 percent. For cost reporting periods that
overlap October 1, 2014, enter zero in column 2. Enter in column 3, the sum of lines 19, 29, 30,
30.01, 31, and 31.01, times 1 percent. Enter in column 4, the sum of columns 2 and 3. Transfer
the amount in column 4 to the cost report calculated settlement, Worksheet E, Part A, line 70.99.

Rev. 15

40-176.17

4030.1 (Cont.)

FORM CMS-2552-10

10-18

EXHIBIT 5
HOSPITAL ACQUIRED CONDITION (HAC) REDUCTION CALCULATION SCHEDULE
HOSPITAL ACQUIRED CONDITION (HAC) REDUCTION
CALCULATION
EXHIBIT 5

1
1.01
1.02
1.03
1.04
2
2.01
2.02
2.03
3
4

12
13
14
15
16
17
17.01
17.02
18
19

DRG Amounts Other than Outlier Payments
DRG amounts other than outlier payments for discharges occurring prior to October 1
DRG amounts other than outlier payments for discharges occurring on or after October 1
DRG for Federal specific operating payment for Model 4 BPCI occurring prior to October 1
DRG for Federal specific operating payment for Model 4 BPCI occurring on or after October 1
Outlier payments for discharges (see instructions)
Outlier payment for discharges for Model 4 BPCI
Outlier payments for discharges occurring prior to October 1 (see instructions)
Outlier payments for discharges occurring on or after October 1 (see instructions)
Operating outlier reconciliation
Managed Care Simulated Payments
Indirect Medical Education Adjustment
Amount from Worksheet E, Part A, line 21 (see instructions)
IME payment adjustment (see instructions)
IME payment adjustment for managed care (see instructions)
Indirect Medical Education Adjustment for the Add-on for Section 422 of the MMA
IME payments adjustment factor (see instructions)
IME add-on adjustment amount (see instructions)
IME payment adjustment add-on for managed care (see instructions)
Total IME payment (sum of lines 6 and 8)
Total IME payment for managed care (sum of lines 6.01 and 8.01)
Disproportionate Share Adjustment
Allowable disproportionate share percentage (see instructions)
Disproportionate share adjustment (see instructions)
Uncompensated care payments
Additional payment for high percentage of ESRD beneficiary discharges
Total ESRD additional payment (see instructions)
Subtotal (see instructions)
Hospital specific payments (completed by SCH and MDH, small rural hospitals only) (see instructions)
Total payment for inpatient operating costs (see instructions)
Payment for inpatient program capital (from Wkst. L, Pt. I, if applicable)
Special add-on payments for new technologies
Net organ acquisition cost
Credits received from manufacturers for replaced devices for applicable MS-DRGs
Capital outlier reconciliation adjustment amount (see instructions)
SUBTOTAL

20
20.01
21
21.01
22
23
24
25
26

5
6
6.01
7
8
8.01
9
9.01
10
11
11.01

27
28
29
30
30.01
31
31.01
32

PROVIDER CCN:
Wkst. E, Pt. A, line
(0)
1
1.01
1.02
1.03
1.04
2
2.02
2.03
2.04
2.01
3

40-176.18

Prior to 10/1
(2)

On or after 10/1
(3)

PERIOD:
FROM:___________
TO:___________
Total (cols. 2 and 3)
(4)

1
1.01
1.02
1.03
1.04
2
2.01
2.02
2.03
3
4

21
22
22.01

5
6
6.01

27
28
28.01
29
29.01

7
8
8.01
9
9.01

33
34
36

10
11
11.01

46
47
48
49
50
54
55
68
93

12
13
14
15
16
17

Wkst. L, line
(0)
1
1.01
2
2.01
5
6
10
11
12
Wkst. E, Pt. A, line
(0)

Low-volume adjustment prior to October 1
Low-volume adjustment on or after October 1
HVBP payment adjustment (see instructions)
HVBP payment adjustment for HSP bonus payment (see instructions)
HRR adjustment (see instructions)
HRR adjustment for HSP bonus payment (see instructions)
HAC Reduction Program adjustment (see instructions) (amount in col. 4 to Wkst. E, Pt. A)

(Amt. from Wkst. E, Pt.
A)
(1)

_______________

70.96
70.97
70.93
70.90
70.94
70.91
70.99

17.01
17.02
(Amt. from Wkst. L)
(1)

(2)

(3)

(4)

(Amt. from Wkst. E, Pt.
A)
(1)

(2)

(3)

(4)

18
19

20
20.01
21
21.01
22
23
24
25
26

27
28
29
30
30.01
31
31.01
32

Rev. 15

DRAFT

FORM CMS-2552-10

4030.2

4030.2 Part B - Medical and Other Health Services.--Use Worksheet E, Part B, to calculate
reimbursement settlement for hospitals, sub-providers, and SNFs and providers participating in the
PARHM demonstration.
For IPPS hospitals participating in the PARHM demonstration during this cost reporting period
and (1) the hospital participated in the PARHM demonstration for the entire cost reporting period,
select the “PARHM Demonstration” box only and complete this worksheet; or (2) the hospital
participated in the PARHM demonstration for a portion of the cost reporting period, select the
“PARHM Demonstration” box and complete Worksheet E, Part B, for the portion of the cost
reporting period, included in the demonstration. Select the “Hospital” box and complete a separate
Worksheet E, Part B, for the portion of the cost reporting period not included in the demonstration.
For hospitals participating in the PARHM demonstration for a portion of this cost reporting period,
enter the applicable data on Worksheet E, Part B, for the PARHM demonstration. The data input
for line 5 must be the same for the PARHM participation portion and non-participation portion of
the cost reporting period.
Use a separate copy of Worksheet E, Part B, for each of these reporting situations. If you have
more than one hospital-based sub-provider or are a hospital participating in the PARHM
demonstration, complete a separate worksheet for each facility and PARHM demonstration. Enter
check marks in the appropriate spaces at the top of each page of Worksheet E to indicate the
component program for which it is used. When the worksheet is completed for a component, show
both the hospital and component numbers. For purposes of prospective payment for outpatient
services when the PCR transition date (applicable to cancer hospitals) (see the following
paragraph), transitional outpatient payment calculation date, or geographic reclassification date
(urban to rural only) (42 CFR 412.103 and 412.230), occurs at other than the cost report period
beginning date, complete subscripted column 1.01 in addition to column 1, for lines 2 through 8
only. Order the subscripted columns chronologically as the transition dates or geographic
reclassification dates correspond to your fiscal year. The dates should also agree with the format
on Worksheet D, Part V, columns 2, 2.01, 2.02, 2.03, etc., if applicable.
In accordance with ACA 2010, §3138, cancer hospitals (as defined in 42 CFR 412.23(f)) must
utilize a predetermined target PCR to calculate the corresponding transitional outpatient payment
effective for services rendered beginning January 1, 2012. Where the cost reporting period
overlaps a target PCR revision date, subscript column 1 as indicated in the preceding paragraph to
correspond to each target PCR period.
NOTE: If you are not a cancer or children’s hospital or covered by ACA §3121, do not complete
lines 2 and 5 through 8.
Line Descriptions
Line 1--Enter the cost of medical and other health services for title XVIII, Part B. This amount
also includes the cost of ancillary services furnished to inpatients under the medical and other
health services benefit of Medicare Part B. These services are covered in this manner for Medicare
beneficiaries with Part B coverage only when Part A benefits are not available. Obtain this amount
from Worksheet D, Part V, line 202, columns 6 and 7, for hospitals and enter in column 1. For
SNFs transfer the amount from Worksheet D, Part V, columns 6 and 7.
The following providers are temporarily eligible for hold harmless payments and must use
columns 1 and 1.01 to correspond to the respective portion of the cost reporting period for lines 2
through 8. Rural hospitals with 100 or fewer beds whose reporting period overlaps
December 31, 2012, are eligible through December 31, 2012; SCHs and EACHs regardless of bed
size whose reporting period overlaps February 29, 2012, are eligible through February 29, 2012;
and SCHs and EACHs with 100 or fewer beds whose reporting period overlaps
December 31, 2012, are eligible through December 31, 2012, (Worksheet S-2, Part I, line 120,
column 1 or 2 is “Y” for yes).
Rev.

40-177

4030.2 (Cont.)

FORM CMS-2552-10

DRAFT

CAHs are not subject to transitional corridor payments, therefore, lines 2 through 9 do not apply
to CAHs. Transfer Worksheet D, Part V, columns 6 and 7, line 202.
Line 2--Enter the cost of medical and other health services reimbursed under OPPS from
Worksheet D, Part V, column 5, and applicable subscripts, line 202; plus allogeneic hematopoietic
stem cell acquisition cost from Worksheet D-6, Part III, line 9, column 2. Subtract from this
amount outpatient pass through costs reported on Worksheet D, Part IV, line 200, column 13.
Line 3--Enter the gross OPPS payments received including payment for drugs and device pass
through payments.
Line 4--Enter the amount of outlier payments made for OPPS services rendered during the cost
reporting period.
Contractors only, add or subtract, as applicable, to the gross OPPS payments the total outlier
reconciliation amount from line 94. Effective for cost reporting periods ending on or after
September 30, 2017, do not include the outlier reconciliation amount on this line, but rather enter
the amount on line 4.01.
Line 4.01--Contractor use only: Effective for cost reporting periods ending on or after
September 30, 2017, for OPPS services rendered during the cost reporting period, enter the
operating outlier reconciliation amount for operating expenses from line 94.
Line 5--Enter the hospital specific payment to cost ratio provided by your contractor. If a new
provider does not file a full cost report for a cost reporting period that ends prior to January 1, 2001,
the provider is not eligible for transitional corridor payments and should enter zero (0) on this line.
(See PM A-01-51.)
For a cancer hospital, enter the target PCR as published in the applicable OPPS final rule (or
correction notice), and subscript column 1 for each PCR period when the cost reporting period
overlaps a PCR revision date. Following is a table of the PCRs beginning with CY 2012.
CY
PCR

2012
0.91

2013
0.91

2014
0.90

2015
0.90

2016
0.92

2017
0.91

2018
0.88

2019
0.88

2020
0.89

2021
0.89

Line 6--Enter the result of line 2 times line 5.
If the sum of lines 3, 4, and 4.01, is less than line 6, complete lines 7 and 8; otherwise, do not
complete lines 7 and 8.
Line 7--Enter the result of the sum of lines 3, 4, and 4.01, divided by line 6.
Line 8--Enter the transitional corridor payment amount calculated based on the following:
a. If the sum of lines 3, 4, and 4.01, is less than the amount on line 6, and Worksheet S-2,
Part I, line 3, column 4, response is 3 or 7 (cancer or children’s hospital, respectively),
enter the result of line 6 minus the sum of lines 3, 4, and 4.01.
In accordance with ACA 2010, section 3121, and MMEA of 2010, section 108, as amended by the
Temporary Payroll Tax Cut Continuation Act of 2011, section 308, and the Middle Class Tax
Relief and Job Creation Act of 2012, section 3002, the outpatient hold harmless provision is
effective for services rendered from January 1, 2010, through February 29, 2012, to all SCHs and
EACHs regardless of bed size; and from March 1, 2012, through December 31, 2012, to all SCHs
and EACHs with 100 or fewer beds; and from January 1, 2010, through December 31, 2012, for
rural hospitals with 100 or fewer beds.
a. For services rendered January 1, 2010, through December 31, 2012, if Worksheet S-2,
Part I, line 120, column 1 or 2, is “Y”, enter 85 percent of the result of line 6 minus the
sum of lines 3 and 4.
40-178

Rev.

DRAFT

FORM CMS-2552-10

4030.2 (Cont.)

Line 9--Enter the outpatient ancillary pass through amount from Worksheet D, Part IV, column13,
line 200.
Line 10--If you are a CTC with an approved transplant program, enter the cost of organ
acquisition from Worksheet D-4, Part III, column 2, line 69, when this worksheet is completed for
the hospital. Do not complete this line for a hospital distinct part unit or sub-provider. The
Medicare program only reimburses CTCs for organ acquisition costs.
Line 11--Enter the sum of lines 1 and 10.
Computation of Lesser of Reasonable Cost or Customary Charges--You are paid the lesser of the
reasonable cost of services furnished to beneficiaries or the customary charges made by you for
the same services. This part provides for the computation of the lesser of reasonable cost or
customary charges as defined in 42 CFR 413.13(a).
NOTE: CAHs are not subject to the computation of the lesser of reasonable costs or customary
charges. If the component is a CAH, do not complete lines 12 through 20. Instead, enter
on line 21 the amount computed on line 11.
Line Descriptions
NOTE: If the medical and other health services reported here qualify for exemption from the
application of LCC (see 42 CFR 413.13(c)), also enter the total reasonable cost from
line 11 directly on line 21. Still complete lines 6 through 16 to ensure that you meet one
of the criteria for this exemption.
Lines 12 through 20--These lines provide for the accumulation of charges which relate to the
reasonable cost on line 11.
Do not include on these lines: (1) the portion of charges applicable to the excess cost of luxury
items or services (see CMS Pub. 15-1, chapter 21, §2104.3) and (2) charges to beneficiaries for
excess costs. (See CMS Pub. 15-1, chapter 25, §§2570-2577.)
Line 12--For total charges for medical and other services, enter the sum of Worksheet D, Part V,
columns 3 and 4, line 202.
Line 13--If you are an approved CTC, enter the organ acquisition charges from Worksheet D-4,
Part III, column 4, line 69, for the hospital.
Line 14--Enter the sum of lines 12 and 13.
Lines 15 through 18--These lines provide for the reduction of program charges when you do not
actually impose such charges on most of the patients liable for payment for services on a charge
basis or fail to make reasonable efforts to collect such charges from those patients. If line 17 is
greater than zero, multiply line 14 by line 17, and enter the result on line 18. If you impose these
charges and make reasonable efforts to collect the charges from patients liable for payment for
services on a charge basis, you are not required to complete lines 15 through 17. Enter on line 18
the amount from line 14. In no instance may the customary charges on line 18 exceed the actual
charges on line 14. (See 42 CFR 413.13(e).)
Line 19--Enter the excess of the customary charges over the reasonable cost. If line 18 exceeds
line 11, enter the difference.
Line 20--Enter the excess of reasonable cost over the customary charges. If line 11 exceeds
line 18, enter the difference.
Line 21--Enter the amount from line 11, less any amount reported on line 20 for hospital/services
subject to LCC.
Rev.

40-178.1

4030.2 (Cont.)

FORM CMS-2552-10

DRAFT

For hospital/services that are not subject to LCC in accordance with 42 CFR 413.13 (e.g., nominal
charge public or private hospitals identified on Worksheet S-2, Part I, lines 155 through 161), enter
the reasonable costs from line 11.
For CAHs enter on this line 101 percent of line 11.
Line 22--Enter the cost of services rendered by interns and residents as follows from
Worksheet D-2.
Provider/Component
Hospital

Title XVIII
Hospital

Title XVIII
Sub-provider

Title XVIII
SNF

Part I, col. 9,
line 9, plus
line 27; or Part II,
col. 7, line 37; or
Part III, col. 6,
line 45

Part I, col. 9,
lines 10, 11, or 12;
or Part II, col. 7,
lines 38, 39, or 40;
or Part III, col. 6,
line 46, 47, or 48

Part I, col. 9,
line 13; or Part II,
col. 7, line 41; or
Part III, col. 6,
line 49

Line 23--Teaching hospitals or sub-providers participating in an approved GME program, electing
to be reimbursed for services of physicians on the basis of reasonable cost (see 42 CFR 415.160
and CMS Pub. 15-1, chapter 21, §2148), enter the cost of physicians. For cost reporting periods
ending before June 30, 2014, transfer the amount from Worksheet D-5, Part II, line 21, column 3.
For cost reporting periods ending on or after June 30, 2014, transfer the amount from
Worksheet D-5, Part IV, line 21.
Line 24--Enter the sum of lines 3, 4, 4.01, 8, and 9, all columns.
Computation of reimbursement Settlement
Line 25--Enter the Part B deductible and the Part B coinsurance amounts billed to Medicare
beneficiaries. DO NOT INCLUDE deductible or coinsurance amounts billed to program patients
for physicians' professional services. If a hospital bills beneficiaries a discounted amount for
coinsurance, enter on this line the full coinsurance amount, not the discounted amount. For
provider Part B services exempt from LCC, enter only the Part B deductible amounts billed to the
program beneficiaries, as reimbursement for those services is based on 80 percent of reasonable
cost net of the Part B deductible amounts. Do not enter any Part B coinsurance amounts for those
provider Part B services exempt from LCC.
Line 26--Enter the deductible and coinsurance amounts relating to the amounts reported on line 24.
NOTE: If these services are exempt from LCC as a result of charges being equal to or less than
60 percent of cost (refer to Worksheet S-2, Part I, lines 155 through 161, columns 1
through 5, as applicable), enter the Part B deductible amounts billed to program
beneficiaries only. Do not enter any Part B coinsurance. For CAHs, enter the deductible
amounts on line 25, and the coinsurance amounts on line 26.
Line 27--Subtract lines 25 and 26 from lines 21 and 24, respectively. Add to that result the sum
of lines 22 and 23.
NOTE: If these services are exempt from LCC, (line 21 minus line 25 minus Worksheet D,
Part V, line 202, column 7) times 80 percent, then add back Worksheet D, Part V,
line 202, column 7, plus lines 22 and 23. Add to that result line 24 minus line 26.
CAHs enter the lesser of (line 21 minus the sum of lines 25 and 26) or 80 percent times the result
of (line 21 minus line 25 minus 101% of lab cost (Worksheet D, Part V, column 6, lines 60, 61,
and subscripts) minus 101% of costs not subject to deductible and coinsurance (Worksheet D,
Part V, column 7, line 202). Add back the aforementioned 101% of lab cost and 101% of cost not
subject to deductibles and coinsurance. Add to that result the sum of lines 22 and 23.
40-178.2

Rev.

DRAFT

FORM CMS-2552-10

4030.2 (Cont.)

Line 28--Enter in column 1, the amount from Worksheet E-4, line 50. Complete this line for the
hospital component only.
Line 29--Enter in column 1, the amount from Worksheet E-4, line 36. Complete this line for the
hospital component only.
Line 30--Enter in column 1, the sum of columns 1 and 1.01, lines 27 through 29.
Line 31--Enter the amounts paid or payable by workers’ compensation and other primary payers
when program liability is secondary to that of the primary payer. There are six situations under
which Medicare payment is secondary to a primary payer:
•
•
•
•
•
•

Workers’ compensation,
No fault coverage,
General liability coverage,
Working aged provisions,
Disability provisions, and
Working ESRD provisions.

Generally, when payment by the primary payer satisfies the total liability of the program
beneficiary, the services are treated as if they were non-program services for cost reporting
purposes only. (The primary payment satisfies the beneficiary's liability when you accept that
payment as payment in full. This is noted on no-pay bills submitted in these situations.) Include
the patient charges in total charges but not in program charges. In this situation, enter no primary
payer payment on line 31. In addition, exclude amounts paid by other primary payers for
outpatient dialysis services reimbursed under the composite rate system.
However, when the payment by the primary payer does not satisfy the beneficiary's obligation, the
program pays the lesser of (a) the amount it otherwise pays (without regard to the primary payer
payment or deductible and coinsurance) less the primary payer payment, or (b) the amount it
otherwise pays (without regard to the primary payer payment or deductible and coinsurance) less
applicable deductible and coinsurance. Credit primary payer payment toward the beneficiary's
deductible and coinsurance obligation.
When the primary payment does not satisfy the beneficiary's liability, include the covered charges
in program charges, and include the charges in charges for cost apportionment purposes. Enter
the primary payer payment on line 31 to the extent that primary payer payment is not credited
toward the beneficiary's deductible and coinsurance. Primary payer payments credited toward the
beneficiary's deductible and coinsurance are not entered on line 31.
Line 32--Enter line 30 minus line 31.
Line 33--Enter the amount of allowable bad debts for deductibles and coinsurance for ESRD
services reimbursed under the composite rate system from Worksheet I-5, line 11.

Rev.

40-179

4030.2 (Cont.)

FORM CMS-2552-10

DRAFT

Allowable bad debts (Exclude bad debts for professional services)
Line 34--Enter from your records allowable bad debts for deductibles and coinsurance net of
recoveries for other services, excluding professional services. Do not include ESRD bad debts.
These are reported on line 33. Bad debts associated with ambulance services rendered (since these
costs are reimbursed on a fee basis) are not allowable. If recoveries exceed the current year’s bad
debts, lines 34 and 35 will be negative. (See 42 CFR 413.89.)
Line 35--Multiply the amount (including negative amounts) on line 34 times 70 percent (hospitals
and sub-providers only). The reduction does not apply to CAHs.
For cost reporting periods that begin on or after October 1, 2012, multiply the amount (including
negative amounts) on line 34 times 65 percent (hospitals and sub-providers only).
For CAHs with cost reporting periods beginning on or after October 1, 2012, multiply the amount
on line 34 (including negative amounts) times 88 percent. For cost reporting periods beginning on
or after October 1, 2013, multiply the amount on line 34 times 76 percent. For cost reporting
periods beginning on or after October 1, 2014, multiply the amount on line 34 times 65 percent.
For SNFs with cost reporting periods beginning prior to October 1, 2012, enter the amount on
line 34. For cost reporting periods beginning on or after October 1, 2012, calculate this line as
follows: [((line 34 - line 36) * 65 percent) + (line 36 * 88 percent)]. For cost reporting periods
beginning on or after October 1, 2013, calculate this line as follows: [((line 34 - line 36) *
65 percent) + (line 36 * 76 percent)]. For cost reporting periods beginning on or after
October 1, 2014, multiply the amount on line 34 times 65 percent.
Line 36--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only except for the calculation of dual eligible bad debts for SNFs
cost reporting periods beginning on or after October 1, 2012. This amount must also be reported
on line 34.
Line 37--Enter the sum of lines 32, 33 and 34 or 35 (hospitals and sub-providers only). For cost
reporting periods beginning on or after October 1, 2012, enter the sum of lines 32, 33, and 35
(hospital, CAH, sub-providers and SNFs).
Line 38--Enter the MSP-LCC reconciliation amount. Obtain this amount from the PS&R.
Line 39--Enter any other adjustments. Specify the adjustment in the space provided.
Line 39.50--Enter the Pioneer ACO demonstration payment adjustment amount. Obtain this
amount from the PS&R. Do not use this line for services rendered on or after January 1, 2017.
Report any ACO demonstration payment adjustments for services on or after January 1, 2017, on
line 39.97 or line 40.02, accordingly.
Line 39.97--Enter any demonstration payment adjustment amounts for all demonstration projects
in which the provider participated where the demonstration adjustment amounts are subject to the
sequestration adjustment. Obtain this amount from the PS&R. Do not include payment
demonstration adjustment amounts included on line 39.50.
Line 39.98--Enter from the PS&R, the partial or full credits received from manufacturers for
replaced devices. See CMS Pub. 100-04, chapter 4, §61.3. This is captured for informational
purposes only.

40-180

Rev.

01-22

FORM CMS-2552-10

4030.2 (Cont.)

Line 39.99--Enter the program share of any recovery of accelerated depreciation applicable to
prior periods resulting from your termination or a decrease in Medicare utilization. (See
CMS Pub. 15-1, chapter 1, §§136-136.16, and 42 CFR 413.134(d)(3)(i).)
Line 40--Enter the result of line 37, plus or minus line 39 and its subscripts not previously
identified (excluding line 39.98 that is for informational purposes only), minus lines 38, 39.50,
39.97, and 39.99.
Line 40.01--For cost reporting periods that overlap or begin on or after April 1, 2013, 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 six decimal places), rounded to four decimal places) times line 40]. Do not
apply the sequestration calculation when gross reimbursement (line 40) is less than zero. (Note:
In accordance with §3709 of the CARES Act, as amended by §102 of the Consolidated
Appropriations Act of 2021, and §1 of Public Law 117-7, do not apply the sequestration
adjustment to the period of May 1, 2020, through December 31, 2021.) Do not apply
Line 40.02--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are not subject to the
sequestration adjustment. Obtain this amount from the PS&R.
Line 40.03-- This line is a subset of line 40.01. Enter the sequestration adjustment amount for the
portion of the cost reporting period that the hospital participated in the PARHM demonstration.
Enter the sequestration adjustment amount as [(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 six decimal places), rounded to four decimal places) times the sum of lines 9,
10, 22, 28, 29, and 35]. (Note: In accordance with §3709 of the CARES Act, as amended by
§102 of the Consolidated Appropriations Act of 2021, and §1 of Public Law 117-7, do not apply
the sequestration adjustment to the period of May 1, 2020, through December 31, 2021.)
Line 41--Enter interim payments from Worksheet E-1, column 4, line 4. For contractor final
settlements, enter the amount reported on line 5.99 on line 42. For contractor purposes, it will be
necessary to make a reclassification of the bi-weekly pass through payments from Part A to Part B,
and report that Part B portion on line 42. Maintain the necessary documentation to support the
amount of the reclassification.

Rev. 17

40-180.1

4030.2 (Cont.)

FORM CMS-2552-10

01-22

Line 41.01-- This line is a subset of line 41. Enter the interim pass-through payments received (or
receivable) for the portion of the cost reporting period that the hospital participated in the PARHM
demonstration. These payments should include bi-weekly pass through payments as well as any
lump sum adjustments received for bad debts, organ acquisition costs, and medical education
(DGME and NAHE).
Line 42--Tentative settlement amount (transfer this amount from Worksheet E-1, Part I, column
4, line 5.99).
Line 42.01--Tentative settlement amount PARHM demonstration (enter the tentative settlement
amount from the PARHM demonstration Worksheet E-1, Part I, column 4, line 5.99).
Line 43--Enter line 40 minus the sum of lines 40.01, 40.02, 41 and 42. Transfer this amount to
Worksheet S, Part III, column 3, line as appropriate. For providers participating in the PARHM
demonstration, do not transfer amounts from this line. See line 43.01 for instruction.
Line 43.01--For providers participating in the PARHM demonstration complete this line for the
settlement of pass-through payments paid outside of the PARHM demonstration. The amount
reported on this line is a subset of the amount reported on line 43. Enter the sum of lines 9, 10, 22,
28, 29, and 35, minus lines 40.03, 41.01 and 42.01. Transfer to Worksheet S, Part III, column 3,
line, 1.01.
Line 44--Enter the program reimbursement effect of protested items. Estimate the reimbursement
effect of the nonallowable items by applying a reasonable methodology which closely
approximates the actual effect of the item as if it had been determined through the normal cost
finding process. (See CMS Pub. 15-2, chapter 1, §115.2.) Attach a schedule showing the details
and computations for this line.
Lines 45 through 89 were intentionally skipped to accommodate future revisions to this worksheet.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET E, PART B. LINES 90
THROUGH 94 ARE FOR CONTRACTOR USE ONLY.
Line 90--Enter the original outlier amount from line 4 (sum of all columns) prior to the inclusion
of line 94 of Worksheet E, Part B.
Line 91--Enter the outlier reconciliation adjustment amount in accordance with CMS Pub. 100-04,
chapter 4, §§10.7.2.2-10.7.2.4.
Line 92--Enter the rate used to calculate the time value of money. (See CMS Pub. 100-04,
chapter 4, §§10.7.2.2-10.7.2.4.)
Line 93--Enter the time value of money.
Line 94--Enter sum of lines 91 and 93.

40-180.2

Rev. 17

04-20

FORM CMS-2552-10

4031.1

4031.

WORKSHEET E-1 - ANALYSIS OF PAYMENTS TO PROVIDERS FOR SERVICES
RENDERED

4031.1

Part I - Analysis of Payments to Providers for Services Rendered.--

Complete this worksheet for each component of the health care complex which has a separate
provider or sub-provider number as shown on Worksheet S-2, Part I. Hospitals that participated
in the PARHM demonstration must complete a separate Worksheet E-1 for each PARHM
demonstration E series worksheet (i.e. Worksheets E Part A; E Part B; E-2; and E-3, Part V). If
you have more than one hospital-based sub-provider, complete a separate worksheet for each
facility. When the worksheet is completed for a component, show both the hospital provider
number and the component number. Complete this worksheet only for Medicare interim payments
paid by the contractor. Do not complete it for purposes of reporting interim payments for titles V
or XIX or for reporting payments made under the composite rate for ESRD services. Providers
paid on an interim basis on periodic interim payment (PIP) adjust the interim payments for
MSP/LCC claims.
For IPPS hospitals participating in the PARHM demonstration during this cost reporting period
and (1) the hospital participated in the PARHM demonstration for the entire cost reporting period,
select the “PARHM Demonstration” box only and complete this worksheet; or (2) the hospital
participated in the PARHM demonstration for a portion of the cost reporting period, select the
“PARHM Demonstration” box and complete Worksheet E-1, for the portion of the cost reporting
period, included in the demonstration. Select the “Hospital” box and complete a separate
Worksheet E-1, for the portion of the cost reporting period not included in the demonstration.
The following components use the indicated worksheet instead of Worksheet E-1:
•
•
•
•

Hospital-based HHAs use Worksheet H-5.
Hospital-based outpatient rehabilitation facilities use Worksheet J-4.
Hospital-based RHCs/FQHCs use Worksheet M-5.
Hospital-based FQHCs under FQHC PPS use Worksheet N-5.

The column headings designate two categories of payments:
Columns 1 and 2 - Inpatient Part A
Columns 3 and 4 - Part B
Complete lines 1 through 4. The remainder of the worksheet is completed by your contractor. All
amounts reported on this worksheet must be for services, the costs of which are included in this
cost report.
NOTE: When completing the heading, enter the provider number and the component number
which corresponds to the provider, sub-provider, SNF, or swing-bed SNF which you
indicated.
DO NOT reduce any interim payments by recoveries as a result of medical review
adjustments where the recoveries were based on a sample percentage applied to the
universe of claims reviewed and the PS&R was not also adjusted.
DO NOT include fee-schedule payments for ambulance services rendered.

Rev. 16

40-181

4031.1 (Cont.)

FORM CMS-2552-10

04-20

* For the PARHM demonstration Worksheet E-1, only complete information related to non-claims
based payments (pass through payments for DGME, organ acquisition costs, bad debt and NAHE
costs)
Line Descriptions
Line 1--Enter the total Medicare interim payments paid to you (excluding payments made under
the composite rate for ESRD services), including amounts paid under PPS, pass through payments,
payments from the supplemental PS&R associated with the Model 4 BPCI, and volume decrease
adjustment payments received for SCHs and MDHs as reported on Worksheet E, Part A,
line 70.88. The amount entered must reflect 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 also include amounts withheld from your interim payments due to an offset against
overpayments applicable to the prior cost reporting periods. Do not include (1) any retroactive
lump sum adjustment amounts based on a subsequent revision of the interim rate, (2) tentative or
net settlement amounts, or (3) interim payments payable. If you are reimbursed under the periodic
interim payment method of reimbursement, enter the periodic interim payments received for this
cost reporting period. For the PARHM demonstration worksheet do not include PPS payment
amounts. Include pass through payments for DGME, organ acquisition, bad debt, and NAHE only.
Line 2--Enter the total Medicare interim payments (excluding payments made under the ESRD
composite rate) 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. Also, include in column 4 the total Medicare payments
payable for servicing home program renal dialysis equipment when the provider elected 100
percent cost reimbursement. For the PARHM demonstration worksheet do not complete this line.
Line 3--Enter the amount of each retroactive lump sum adjustment and the applicable date. For
the PARHM demonstration worksheet only include lump sum payment adjustments to pass
through payments for the applicable period.
Line 4--Enter the total amount of the interim payments (sum of lines 1, 2, and 3.99). Transfer as
follows: (* Use these lines on the applicable PARHM worksheet)
Reimbursement
Method

From
Column

Transfer
To

Part B Payments

Wkst. E, Part B, line 41 (*41.01)

Part A Payments
IPPS
TEFRA
IPF PPS
IRF PPS
LTC PPS
Cost
SNF PPS Title XVIII

2
2
2
2
2
2
2

Wkst. E, Part A, line 72 (*72.01)
Wkst. E-3, Part I, line 19
Wkst. E-3, Part II, line 32
Wkst. E-3, Part III, line 33
Wkst. E-3, Part IV, line 23
Wkst. E-3, Part V, line 31 (*31.01)
Wkst. E-3, Part VI, line 16

NOTE: For a swing-bed SNF, transfer the column 2, line 4, and column 4, line 4, amounts to
Worksheet E-2, columns 1 and 2, line 20 (*20.01), respectively.

40-182

Rev. 16

DRAFT

FORM CMS-2552-10

4031.1 (Cont.)

PROVIDERS DO NOT COMPLETE THE REMAINDER OF WORKSHEET E-1.
LINES 5 THROUGH 8 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 settlement payment after the cost report is received together with the
date of payment. If the cost report is reopened after the NPR has been issued, continue to report
all settlement payments after the cost report is received separately on this line. For the PARHM
demonstration worksheet only include tentative settlement payment amounts applicable to the
PARHM demonstration payment (global payment adjustments, pass through payment amounts
and bad debts for the applicable period).
Line 6--Enter the net settlement amount (balance due the provider or balance due the program).
Obtain the amounts as follows:
Worksheet E-1,
Column as Indicated
2
4
2
2
2
2
2
2

From
Settlement Worksheet
Wkst. E, Part A, line 74 (*74.01)
Wkst. E, Part B, line 43 (*43.01)
Wkst. E-3, Part I, line 21
Wkst. E-3, Part II, line 34
Wkst. E-3, Part III, line 35
Wkst. E-3, Part IV, line 25
Wkst. E-3, Part V, line 33 (*33.01)
Wkst. E-3, Part VI, line 18

For swing-bed SNF services, column 2 must equal Worksheet E-2, column 1, line 22. Column 4
must equal Worksheet E-2, column 2, line 22 (*22.01).
* Line references for PARHM demonstration worksheet.
NOTE: On lines 3, 5, and 6, when a provider to program amount is due, 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 in columns 2 and 4, the sum of lines 4 through 6. Enter amounts due the program
as a negative number. These amounts must agree with amount due provider reported on
Worksheet E, Part A, line 71, less the amount on lines 71.01 and 71.02 (for PARHM
demonstration Worksheet E Part A, sum of lines 52, 53, 55, 57, 58 and 65 minus line 71.03);
Worksheet E, Part B, line 40, less the amount on lines 40.01 and 40.02 (for PARHM
demonstration Worksheet E Part B, sum of lines 11, 22, 23, 28, 29, and 35 minus line 40.03);
Worksheet E-2, line 19, less the amount on line 19.01 and 19.02 (for PARHM demonstration
Worksheet E -2, sum of lines 3.01 and 17.01 minus line 19.03); Worksheet E-3, Part I, line 18,
less the amount on line 18.01 and 18.02; Worksheet E-3, Part II, line 31, less the amount on
line 31.01 and 31.02; Worksheet E-3, Part III, line 32, less the amount on line 32.01and 32.02;
Worksheet E-3, Part IV, line 22, less the amount on line 22.01 and 22.02; Worksheet E-3, Part V,
line 30, less the amount on line 30.01 and 30.02 (for PARHM demonstration Worksheet E-3,
Part V, sum of lines 2, 3, 18 and 26 minus line 30.03); and Worksheet E-3, Part VI, line 15, less
the amount on line 15.01 and 15.02.
Line 8--Enter the contractor name, the contractor number and NPR date in columns 0, 1, and 2,
respectively.

Rev.

40-183

4031.2
4031.2

FORM CMS-2552-10

DRAFT

Part II - Calculation of Reimbursement Settlement for Health Information Technology.--

THIS PART IS COMPLETED BY THE CONTRACTOR FOR STANDARD COST
REPORTING PERIODS AND BY THE CONTRACTOR FOR NONSTANDARD COST
REPORTING PERIODS. Hospitals that qualify for the HIT incentive payment under
ARRA 2009, §4120, complete this worksheet for cost reporting periods ending on or before
September 30, 2016; do not complete this worksheet for cost reporting periods beginning on
or after October 1, 2016. Hospitals that qualify for the HIT incentive payment under
CAA 2016, §602, complete this worksheet for cost reporting periods ending on or before
September 30, 2021; do not complete this worksheet for cost reporting periods beginning on
or after October 1, 2021.
In accordance with the ARRA of 2009, §4102, inpatient acute care services under IPPS for
providers subject to §1886(d) of the Act, and CAHs are eligible for HIT payments. The
CAA 2016, §602, added subsection (d) hospitals in Puerto Rico as hospitals eligible for HIT
payments. Puerto Rico hospitals may begin participation for EHR reporting periods in 2016.
This part captures relevant data used to compute the HIT payment and records the single HIT
initial payment paid by the contractor to the provider and any corresponding adjustments to this
initial payment.
Data Collection Required for the Health Information Technology Calculation-NOTE: Lines 1 through 7 must transfer data as indicated below for reporting periods which
cover exactly 12 months (referred to as standard cost reporting periods and covers
a range of 360 through 371 days). For cost reporting periods which cover other
than exactly 12 months (less than or greater than 12 months) (referred to as nonstandard cost reporting periods and covers a range of less than 360 days or greater
than 371 days), lines 1 through 8 must be directly input by the contractor.
NOTE: For standard cost reporting periods, the provider will complete lines 30 and 31 in
the “as filed” cost report, and the amount computed on line 32 will be transferred
to Worksheet S, Part III, column 4. For non-standard cost reporting periods, the
“as filed” cost report will display zeroes on all lines, and a zero will be transferred
from line 32 to Worksheet S, Part III, column 4. The contractor must complete this
worksheet for non-standard cost reporting periods at cost report settlement.
Line 1--As defined in ARRA, §4102, transfer the total hospital discharges from Worksheet S-3,
Part I, column 15, line 14.
Line 2--Transfer the Medicare days from Worksheet S-3, Part I, column 6, sum of lines 1,
8 through 12, and, for cost reporting periods beginning on or after October 1, 2013, line 32.
Line 3--Transfer the Medicare HMO days from Worksheet S-3, Part I, column 6, line 2.
Line 4--Transfer the total inpatient days from Worksheet S-3, Part I, column 8, sum of lines 1,
8 through 12, and, for cost reporting periods beginning on or after October 1, 2013, line 32.
Line 5--Transfer the hospital charges from Worksheet C, Part I, column 8, line 200.
Line 6--Transfer the hospital charity care charges from Worksheet S-10, column 3, line 20.
Effective for cost reporting periods beginning on or after October 1, 2022, transfer the hospital
charity care charges from Worksheet S-10, Part I, column 3, line 20.
Line 7--CAHs only, transfer the reasonable costs to purchase certified HIT technology from
Worksheet S-2, Part I, line 168.

40-184

Rev.

01-22

FORM CMS-2552-10

4031.2 (Cont.)

Line 8--Calculate and enter the HIT payment in accordance with ARRA, §4102, as indicated
below. This line can be overridden by the contractor in instances where the provider’s
circumstances require a customized HIT calculation. The HIT payment calculation uses a
Medicare share calculation defined as follows:
EHR Medicare share: (Part A days + Part C days) ÷ [(total inpatient days) × ((total
hospital charges - charity care charges) ÷ total hospital charges)].
The EHR Medicare share is expressed as {(H1/(line 4 × H2)} in the CAH HIT calculation (see
following paragraphs), and as {(H2/(line 4 × H3)} for the IPPS hospital HIT calculation (see
following paragraphs). The EHR Medicare share calculation is rounded to 4 decimal places, with
no rounding of the imbedded calculations.
For CAHs, if Worksheet S-2, lines 105 and 167, are both “Y” for yes, enter the result of
{(H1)/(line 4 x H2)} rounded to 4 decimal places + .20 times the amount on Worksheet S-2, Part I,
line 168. (Note: the result of {(H1)/(line 4 x H2)} + .20 cannot exceed 100 percent.) The resulting
amount must be fully expensed in the current reporting period. H1 = line 2 plus line 3. H2 = total
charges from Worksheet C, Part I, column 8, line 200, minus charity care charges from
Worksheet S-10 (effective for cost reporting periods beginning on or after October 1, 2022,
Worksheet S-10, Part I), column 3, line 20, divided by Worksheet C, Part I, column 8, line 200.
OR
For an acute care IPPS hospital (§1886(d) of the Act), or a subsection (d) hospital in Puerto Rico
(eligible for the HIT payment under §602 of the CAA), if Worksheet S-2, line 105, is “N” for no
and line 167 is “Y” for yes, enter the result of {($2,000,000.00 + H1) x {(H2)/(line 4 x H3)}
rounded to 4 decimal places x H4}. If line 1 is less than 1,150 discharges, then H1 equals 0 (zero).
If line 1 equals 1,150 through 23,000 discharges, then H1 equals the result of line 1 minus 1,149
times $200. If line 1 is greater than or equal to 23,000 discharges, then H1 = $4,370,200 [that is:
23,000 minus 1,149 times $200]. H2 = line 2 plus line 3. H3 = total charges from Worksheet C,
Part I, column 8, line 200, minus charity care charges from Worksheet S-10 (effective for cost
reporting periods beginning on or after October 1, 2022, Worksheet S-10, Part I), column 3,
line 20, divided by Worksheet C, Part I, column 8, line 200. H4 = the transition factor from
Worksheet S-2, Part I, line 169.
Line 9--If the EHR reporting period ending date on Worksheet S-2, line 170, column 2, is on or
after April 1, 2013, enter the sequestration adjustment amount as follows: [2 percent times line 8].
If the EHR reporting period ending date on Worksheet S-2, line 170, column 2, is on or after
April 1, 2013, and the cost reporting period overlaps any portion of the period from May 1, 2020,
through March 31, 2021, 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 six decimal places), rounded to four decimal
places) times line 8]. (Note: In accordance with §3709 of the CARES Act, as amended by §102 of
the Consolidated Appropriations Act of 2021, and §1 of Public Law 117-7, do not apply the
sequestration adjustment to the period of May 1, 2020, through December 31, 2021.)
Line 10--Calculate and enter the HIT payment after application of the sequestration adjustment by
entering the result of line 8 minus line 9.
Lines 11 through 29--Reserved for future use.
Inpatient Hospital Services Under the IPPS & CAH-Line 30--Enter the initial (first) payment received for HIT assets for this cost reporting period.
This initial payment is a single payment for the cost reporting period rather than a series of periodic
interim payments during the period. This line must be completed by the providers for standard
cost reporting periods and by the contractors for nonstandard cost reporting periods.
Line 31--Enter the sum of all additional initial payment adjustments, as applicable for this cost
reporting period. Enter a positive amount on this line if the sum of the initial payment adjustments

Rev. 17
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represents an increase to the initial payment. Enter a negative amount on this line if the sum of
the initial payment adjustments represents a decrease to the initial payment.
Line 32--Balance Due Provider/(Program)--Calculate and enter the result of line 8 minus the sum
of lines 30 and 31. Effective for cost reporting periods that overlap or begin on or after
April 1, 2013, calculate and enter the result of line 10 minus the sum of lines 30 and 31. Transfer
this amount to Worksheet S, Part III, column 4, line 1.
4032.

WORKSHEET E-2 - CALCULATION OF REIMBURSEMENT SETTLEMENT SWING-BEDS

This worksheet provides for the reimbursement calculation for swing-bed services rendered to
program patients under titles V, XVIII, and XIX. It provides for an accumulation of reimbursable
costs determined on various worksheets within the cost report package. It also provides (under
Part B) for the computation of the lesser of 80 percent of reasonable cost after deductibles or
reasonable cost minus coinsurance and deductibles. These worksheets have been designed so that
components must prepare a separate worksheet for swing-bed SNF title XVIII, Parts A and B, and
separate worksheets for swing-bed NF for title V and title XIX. Use column 1 only on the
worksheets for title V and title XIX. Indicate the use of each worksheet by checking the
appropriate boxes.
For IPPS hospitals participating in the PARHM demonstration during this cost reporting period
and (1) the hospital participated in the PARHM demonstration for the entire cost reporting period,
select the “PARHM Demonstration” box only and complete this worksheet; or (2) the hospital
participated in the PARHM demonstration for a portion of the cost reporting period, select the
“PARHM Demonstration” box and complete Worksheet E-2, for the portion of the cost reporting
period, included in the demonstration. Select the “Swing-Bed SNF” box and complete a separate
Worksheet E-2, for the portion of the cost reporting period not included in the demonstration.
Lines 1 through 9--Enter in the appropriate column on lines 1 through 7, the indicated costs for
each component of the health care complex.
Line 1--Post-hospital swing-beds in rural hospitals (other than CAHs) are paid in accordance with
SNF PPS. Enter the total SNF PPS payments in column 1 or 2, as applicable, from the provider’s
books and records or the PS&R. (See 42 CFR 413.114(a)(2).) For CAHs, transfer 101 percent of
the cost of swing-bed SNF inpatient routine services from Worksheet D-1, Part II, line 66.
Do not use lines 2 and 3, column 1, for swing-bed SNF PPS providers.
Line 2--Enter the cost of swing-bed NF inpatient routine services from Worksheet D-1, Part II,
line 69 (titles V and XIX only). Make no entry on line 2 when Worksheet E-2 is used for swingbed SNF.
Line 3--Enter the amount of ancillary services provided by swing-bed-SNFs for vaccines
(pneumococcal, influenza, COVID-19, and monoclonal antibody products for treatment of
COVID-19) that are cost reimbursed in column 2. For CAH title XVIII services, transfer 101
percent of the amounts from the applicable worksheets and, for swing-bed SNF services that are
cost reimbursed, transfer 100 percent of the amount from the applicable worksheet:
Title V
Title XVIII, Part A
Title XVIII, Part B
Title XIX

from
from
from
from

Worksheet D-3, col. 3, line 200
Worksheet D-3, col. 3, line 200
The sum of Worksheet D, Part V, columns 6 and 7, line 202
Worksheet D-3, col. 3, line 200

Enter title XVIII, Part B amounts only in column 2. Enter all other amounts in column 1.
For swing-bed pass through costs, transfer the title XVIII, Part A amounts from Worksheet D,
Part IV, column 11, line, 200.

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FORM CMS-2552-10

Line 3.01-- This line is a subset of line 3. Amounts included are from Worksheet D, Part IV,
column 11, line, 200. Only those participating in the PARHM demonstration complete this line.
k
Line 4--Enter (in column 1 for titles V and XIX and in column 2 for title XVIII) the per diem cost
for interns and residents not in an approved teaching program transferred from Worksheet D-2,
Part I, column 4, line 2.
Line 5--For title XVIII, enter in column 1 the total number of days in which program swing-bed
SNF patients were inpatients. Transfer these days from Worksheet D-1, Part I, sum of lines 10
and 11. For titles V or XIX, enter in column 1 the total number of days in which program swingbed NF patients were inpatients. Transfer these days from Worksheet D-1, Part I, sum of lines 12
and 13. For title XVIII, enter in column 2, the total number of days in which Medicare swing-bed
beneficiaries were inpatients and had Medicare Part B coverage. Determine such days without
regard to whether Part A benefits were available. Submit a reconciliation with the cost report
demonstrating the computation of Medicare Part B inpatient days.
The following reconciliation format is recommended:
Part A
Inpatient
Days

Plus

Part B
Only
Days

NOTE: See §4026.1.

Minus

Part A Coverage
But No
Part B
Days Coverage

Equals

Medicare
Part B
Days

Line 6--Enter the amount on line 4 multiplied by the number of days recorded on line 5. Also, if
the hospital qualifies for the exception for GME payments in 42 CFR 413.77(d)(1), enter the
amount transferred from Worksheet D-2, Part II, column 7, line 30.
Line 7--If Worksheet E-2 is completed for a certified SNF, enter the applicable program's share of
the reasonable compensation paid to physicians for services on utilization review committees
applicable to the SNF.
Line 8--Enter the sum of lines 1 through 3, plus lines 6 and 7, for each column.
Line 9--Enter any amounts paid and/or payable by workers’ compensation and other primary
payers. (See instructions for Worksheet E, Part A, line 60, in §4030.1 for further clarification.)
Line 10--Line 8 minus line 9.
Line 11--Enter the deductible billed to program patients. DO NOT INCLUDE deductible
applicable to physician professional services. Obtain this amount from your records.
Line 12--Enter line 10 minus line 11.
Line 13--Enter from your records the amounts billed to program patients for coinsurance. DO
NOT INCLUDE coinsurance billed to program patients for physician professional services.
Line 14--For cost reporting periods beginning before September 30, 2019, in column 2, enter
80 percent of the amount on line 12. For cost reporting periods ending on or after
September 30, 2019, do not complete this line.
Line 15--For cost reporting periods beginning before September 30, 2019, enter the lesser of
line 12 less line 13, or line 14. For cost reporting periods ending on or after September 30, 2019,
enter the amount of line 12 less line 13.
Line 16--Enter any other adjustments.

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Line 16.50--Enter the Pioneer ACO demonstration payment adjustment amount. Obtain this
amount from the PS&R. Do not use this line for services rendered on or after January 1, 2017.
Report any ACO demonstration payment adjustments for services on or after January 1, 2017, on
line 16.99 or line 19.02, accordingly.
Line 16.55--Enter the §410A rural community hospital demonstration project payment adjustment
amount.
Line 16.99--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are subject to the
sequestration adjustment. Obtain this amount from the PS&R. Do not include demonstration
payment adjustment amounts reported on lines 16.50 and 16.55.
Line 17--When Worksheet E-2 is completed for Medicare, enter the amount of bad debts (net of
bad debt recoveries) for billed deductibles and coinsurance (excluding bad debts for physician
professional services and bad debts arising from covered services paid under a reasonable chargebased methodology or a fee-schedule) for Part A services in column 1, and for Part B services in
column 2. If recoveries exceed the current year’s bad debts, line 17 will be negative.
(See 42 CFR 413.89).
Line 17.01--For cost reporting periods that begin prior to October 1, 2012, enter the amount on
line 17. For cost reporting periods that begin on or after October 1, 2012, calculate this line as
follows: [((line 17 - line 18) * 65 percent) + (line 18 * 88 percent)]. For cost reporting periods
that begin on or after October 1, 2013, calculate this line as follows: [((line 17 - line 18) *
65 percent) + (line 18 * 76 percent)]. For cost reporting periods that begin on or after
October 1, 2014, multiply the amount on line 17 by 65 percent.
Line 18--Enter the gross allowable bad debts for dual eligible beneficiaries. For cost reporting
periods that begin prior to October 1, 2012, this amount is reported for statistical purposes only.
This amount must also be reported on line 17.
Line 19--For title XVIII, Part A, enter in column 1, the sum of lines 15, 16.55, and 17.01, plus or
minus line 16, and minus lines 16.50, and 16.99. For title XVIII, Part B, enter in column 2, the
sum of lines 15 and 17.01, plus or minus line 16, and minus lines 16.50, and 16.99. For titles V
and XIX, enter in column 1, the sum of line 15, plus or minus line 16.
Line 19.01--For cost reporting periods that overlap or begin on or after April 1, 2013, enter the
sequestration adjustment amount as follows: [(2 percent times (total days in the cost reporting
period that occur during the sequestration sequestration period, divided by total days in the entire
cost reporting period, rounded to six decimal places), rounded to four decimal places) times
line 19]. Do not apply the sequestration calculation when gross reimbursement (line 19) is less
than zero. (Note: In accordance with §3709 of the CARES Act, as amended by §102 of the
Consolidated Appropriations Act of 2021, and §1 of Public Law 117-7, do not apply the
sequestration adjustment to the period of May 1, 2020, through December 31, 2021.)
For non-CAHs’ for cost reporting periods that overlap or begin on or after May 1, 2020, enter the
sequestration adjustment amount from the PS&R (claims based amounts). (Note: In accordance
with §3709 of the CARES Act, as amended by §102 of the Consolidated Appropriations Act
of 2021, and §1 of Public Law 117-7, do not apply the sequestration adjustment to the period of
May 1, 2020, through December 31, 2021.)
Line 19.02--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are not subject to the
sequestration adjustment. Obtain this amount from the PS&R.
Line 19.03--This line is a subset of line 19.01. Enter the sequestration adjustment amount for the
portion of the cost reporting period that the hospital participated in the PARHM demonstration.
Enter the sequestration adjustment amount as [(2 percent times the sum of lines 3.01and 17.01]

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For cost reporting periods that overlap or begin on or after May 1, 2020, this line is a subset of
line 19.25. Enter the sequestration adjustment amount for the portion of the cost reporting period
that the hospital participated in the PARHM demonstration. Enter the sequestration adjustment
amount as [(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 six
decimal places), rounded to four decimal places) times the sum of lines 3.01 and 17.01]. (Note:
In accordance with §3709 of the CARES Act, as amended by §102 of the Consolidated
Appropriations Act of 2021, and §1 of Public Law 117-7, do not apply the sequestration
adjustment to the period of May 1, 2020, through December 31, 2021.)
Line 19.25--For non-CAHs’ for cost reporting periods that overlap or begin on or after
May 1, 2020, enter the sequestration adjustment for non-claims based amounts as [(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 six decimal places), rounded to four decimal
places) times the sum of (lines 3, 6, 7, 16 and its subscripts, 16.55 (do not use lines 16.50 or 16.99
in this calculation), and line 17.01)]. If the sum is less than zero, do not calculate the sequestration
adjustment. (Note: In accordance with §3709 of the CARES Act, as amended by §102 of the
Consolidated Appropriations Act of 2021, and §1 of Public Law 117-7, do not apply the
sequestration adjustment to the period of May 1, 2020, through December 31, 2021.)
Line 20--For title XVIII, enter in column 1, the amount from the appropriate Worksheet E-1,
column 2, line 4, and enter in column 2, the amount from the appropriate Worksheet E-1,
column 4, line 4. For contractor final settlement, report on line 21 the amount from line 5.99 for
columns 2 and 4. For titles V and XIX, enter interim payments from your records.
Line 20.01-- This line is a subset of line 20. Enter the interim pass-through payments received (or
receivable) for the portion of the cost reporting period that the hospital participated in the PARHM
demonstration. These payments should include bi-weekly pass through payments as well as any
lump sum adjustments received for bad debts and NAHE.
Line 21--Tentative settlement amount (transfer this amount from Worksheet E-1, Part I, columns 2
and 4, as applicable, line 5.99).
Line 21.01--Tentative settlement amount PARHM demonstration (enter the tentative settlement
amount from the PARHM demonstration Worksheet E-1, Part I, columns 2 and 4, as applicable,
line 5.99).
Line 22--Enter line 19 minus the sum of lines 19.01, 19.02, 19.25, 20, and 21. Transfer this
amount to Worksheet S, Part III, columns as appropriate, lines 5 or 6, for the swing-bed SNF or
the swing-bed NF, respectively. For providers participating in the PARHM demonstration, do not
transfer amounts from this line. See line 22.01 for instruction.
Line 22.01--For providers participating in the PARHM demonstration complete this line for the
settlement of pass-through payments paid outside of the PARHM demonstration. The amount
reported on this line is a subset of the amount reported on line 22. Enter the sum of lines 3.01
and 17.01, minus lines 19.03, 20.01 and 21.01. Transfer to Worksheet S, Part III, columns as
appropriate, line 5.01 for the swing-bed PARHM-CAH only.
Line 23--Enter the Medicare reimbursement effect of protested items. Estimate the reimbursement
effect of the non-allowable items by applying reasonable methodology which closely approximates
the actual effect of the item as if it had been determined through the normal cost finding process.
(See CMS Pub. 15-2, chapter 1, §115.2.) Attach a schedule showing the supporting details and
computations for this line.
Rural Community Health Demonstration Project (§410A Demonstration) Adjustment--For cost
reporting periods ending on or after September 30, 2017, lines 200 through 215 provide for the
calculation of the §410A Demonstration project adjustment in accordance with the MMA of 2003,
§410A, and extended under §§3123 and 10313 of the ACA 2010, and §15003 of the 21st Century

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40-188.1
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Cures Act of 2016. Complete the applicable lines if Worksheet S-2, Part I, line 110, is “Y,” and
calculate lines 201 and 202 based on reimbursement cost at 100% (not 101%).
A hospital participating in the §410A Demonstration receives payment for inpatient swing-bed
SNF services, furnished to Medicare beneficiaries, with the exclusion of services furnished in a
psychiatric or rehabilitation unit that is a distinct part of the hospital, using the following rules:
a) For discharges occurring in the first cost reporting period on or after the implementation
of the extension, their reasonable costs of providing covered inpatient swing-bed services;
b) For discharges occurring during the second and subsequent cost reporting periods, the
lesser of their reasonable costs or a target amount.
c) The target amount for each of the remaining cost reporting periods of the 5-year
extension period is defined as the reasonable costs of providing covered inpatient swingbed services in the first cost reporting period, increased by the applicable percentage
increase (under clause (i) of §1886(b)(3)(B) of the Act) in the market basket percentage
increase for each particular cost reporting period.
Line 200--Is this the first year of the current 5-year demonstration period under the 21st Century
Cures Act? Enter “Y” for yes or “N” for no.
Line 201--Enter in column 1, the Medicare swing-bed SNF inpatient routine service costs from the
hospital Worksheet D-1, Part II, line 66.
Line 202--Enter in column 1, the Medicare swing-bed SNF inpatient ancillary service costs from
the Swing-bed SNF Worksheet D-3, column 3, line 200.
Line 203--Enter in column 1, the sum of lines 201 and 202.
Line 204--Enter in column 1, the Medicare swing-bed SNF discharges. Obtain this amount from
the PS&R.
Line 205--Enter in column 1, the Medicare swing-bed target amount per discharge. Obtain the
target amount from the contractor.
Line 206--Enter in column 1, the Medicare swing-bed inpatient routine cost cap determined by
multiplying line 205 times line 204.
Line 207--Enter in column 1, the Program reimbursement as determined under the §410A
Demonstration as follows: For the first year of the current 5-year demonstration period, enter the
amount from line 203. For the subsequent years of the current 5-year demonstration period, enter
the lesser of line 203 or line 206.
Line 208--Enter in column 1, the Medicare swing-bed SNF inpatient service costs for Medicare
beneficiaries from Worksheet E-2, column 1, line 1 (inpatient routine service costs), and line 3
(inpatient ancillary service costs).
Line 209--Enter in column 1, the adjustment to the Medicare swing-bed PPS payments by
subtracting line 208 (reimbursement under IPPS) from line 207 (cost reimbursement under the
§410A Demonstration).
Line 210--This line is reserved for future use.
Line 215--Enter in column 1, the total adjustment to the Medicare swing-bed PPS payment, the
amount from line 209. Transfer the amount to column 1, line 16.55.

40-188.2
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4033.

FORM CMS-2552-10

Rev. 17
4033.1

WORKSHEET E-3 - CALCULATION OF REIMBURSEMENT SETTLEMENT

The five parts of Worksheet E-3 are used to calculate reimbursement settlement:
Part I
Part II
Part III
Part IV
Part V

Calculation of Medicare Reimbursement Settlement Under TEFRA
Calculation of Medicare Reimbursement Settlement Under IPF PPS
Calculation of Medicare Reimbursement Settlement Under IRF PPS
Calculation of Medicare Reimbursement Settlement Under LTCH PPS
Calculation of Reimbursement Settlement for Medicare Part A Services - Cost
Reimbursement
Part VI - Calculation of Reimbursement Settlement - Title XVIII Part A PPS SNF
Services
Part VII - Calculation of Reimbursement Settlement - All Other Health Services for
Titles V or XIX Services

4033.1 Part I - Calculation of Medicare Reimbursement Settlement Under TEFRA.--Use
Worksheet E-3, Part I, to calculate Medicare reimbursement settlement under TEFRA for cancer
hospitals, children’s hospitals, and extended neoplastic disease care hospitals.
The “TEFRA” payment system includes long term care hospitals (LTCH) classified as extended
neoplastic disease care hospitals (previously referred to as “subclause (II)” LTCHs), children’s
hospitals, cancer hospitals, Religious Non-Medical Health Care Institutions (RNHCIs), and
hospitals located outside the 50 States, the District of Columbia, and Puerto Rico (i.e., hospitals
located in the U.S. Virgin Islands, Guam, the Northern Mariana Island, and American Samoa).
Line Descriptions
Line 1--Enter the amount from Worksheet D-1, Part II, line 63.
Line 1.01--Enter the amount of Nursing and Allied Health Managed Care payments if applicable.
Only complete this line if your facility is a freestanding/ independent non-PPS provider that does
not complete Worksheet E, Part A.
Line 2--If you are an approved CTC, enter the cost of organ acquisition from Worksheet(s) D-4,
Part III, column 1, line 69. If you are not an approved CTC do not complete line 2.
Line 3--Teaching hospitals participating in an approved GME program, electing to be reimbursed
for services of physicians on the basis of reasonable cost (see 42 CFR 415.160 and
CMS Pub. 15-1, chapter 21, §2148), enter the cost of physicians. For cost reporting periods ending
before June 30, 2014, transfer the amount from Worksheet D-5, Part II, column 3, line 20. For
cost reporting periods ending on or after June 30, 2014, transfer the amount from Worksheet D-5,
Part IV, line 20.
Line 4--Enter the sum of lines 1 through 3.
Line 5--Enter the amounts paid or payable by workers’ compensation and other primary payers
when program liability is secondary to that of the primary payer. There are six situations under
which Medicare payment is secondary to a primary payer:
•
•
•
•
•
•

Workers' compensation,
No fault coverage,
General liability coverage,
Working aged provisions,
Disability provisions, and
Working ESRD provisions.

Generally, when payment by the primary payer satisfies the total liability of the program
beneficiary, for cost reporting purposes only, the services are treated as if they were non-program

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services. (The primary payment satisfies the beneficiary's liability when you accept that payment
as payment in full. This is noted on no-pay bills submitted in these situations.)
Include the patient days and charges in total patient days and charges but do not include them in
program patient days and charges. In this situation, enter no primary payer payment on line 5. In
addition, exclude amounts paid by other primary payers for outpatient dialysis services reimbursed
under the composite rate system.
However, when the payment by the primary payer does not satisfy the beneficiary's obligation, the
program pays the lesser of (a) the amount it otherwise pays (without regard to the primary payer
payment or deductible and coinsurance) less the primary payer payment, or (b) the amount it
otherwise pays (without regard to primary payer payment or deductibles and coinsurance) less
applicable deductible and coinsurance. Primary payer payment is credited toward the beneficiary's
deductible and coinsurance obligation.
When the primary payment does not satisfy the beneficiary's liability, include the covered days
and charges in program days and charges, and include the total days and charges in total days and
charges for cost apportionment purposes. Enter the primary payer payment on line 5 to the extent
that primary payer payment is not credited toward the beneficiary's deductible and coinsurance.
Do not enter on line 5 primary payer payments credited toward the beneficiary's deductible and
coinsurance.
Line 6--Enter line 4 minus line 5.
Line 7--Enter the Part A deductibles.
Line 8--Enter line 6 less line 7.
Line 9--Enter the Part A coinsurance.
Line 10--Enter the result of subtracting line 9 from line 8.
Line 11--Enter program allowable bad debts reduced by recoveries. If recoveries exceed the
current year’s bad debts, lines 11 and 12 will be negative. (See 42 CFR 413.89.)
Line 12--Multiply the amount (including negative amounts) from line 11 by 70 percent for cost
reporting periods beginning prior to October 1, 2012, and 65 percent for cost reporting periods that
begin on or after October 1, 2012.
Line 13--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. This amount must also be reported on line 11.
Line 14--Enter the sum of lines 10 and 12.
Line 15--Enter the amount from Worksheet E-4, line 49, for the hospital component only.
Line 16--DO NOT USE THIS LINE.
Line 17--Enter any other adjustments. Specify the adjustment in the space provided. See
line 17.98 to report the recovery of accelerated depreciation. Do not report adjustments resulting
from permanent or other adjustments to the TEFRA target amount per discharge on this line.
Line 17.50--Enter the Pioneer ACO demonstration payment adjustment amount. Obtain this
amount from the PS&R. Do not use this line for services rendered on or after January 1, 2017.
Report any ACO demonstration payment adjustments for services on or after January 1, 2017, on
line 17.99 or line 18.02, accordingly.

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4033.2

Line 17.98--Enter the program share of any recovery of accelerated depreciation applicable to
prior periods resulting from your termination or a decrease in Medicare utilization. (See
CMS Pub. 15-1, chapter 1, §§136-136.16 and 42 CFR 413.134(d)(3)(i).) This line is identified as
“Recovery of accelerated depreciation.”
Line 17.99--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are subject to the
sequestration adjustment. Obtain this amount from the PS&R.
Line 18--Enter the sum of lines 14, 15, and 16, plus or minus line 17, and minus lines 17.50, 17.98,
and 17.99.
Line 18.01--For cost reporting periods that overlap or begin on or after April 1, 2013, 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 six decimal places), rounded to four decimal places) times line 18]. Do not
apply the sequestration calculation when gross reimbursement (line 18) is less than zero. (Note: In
accordance with §3709 of the CARES Act, as amended by §102 of the Consolidated
Appropriations Act of 2021, and §1 of Public Law 117-7, do not apply the sequestration
adjustment to the period of May 1, 2020, through December 31, 2021.)
Line 18.02--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are not subject to the
sequestration adjustment. Obtain this amount from the PS&R.
Line 19--Enter the amount of interim payments from Worksheet E-1, column 2, line 4. For
contractor final settlements, report on line 20 the amount on line 5.99.
Line 20--Contractor use only: Report the amount from Worksheet E-1, column 2, line 5.99.
Line 21--Enter line 18 minus the sum of lines 18.01, 18.02, 19, and 20. Transfer this amount to
Worksheet S, Part III, line 1.
Line 22--Enter the program reimbursement effect of protested items. Estimate the reimbursement
effect of the nonallowable items by applying a reasonable methodology which closely
approximates the actual effect of the item as if it had been determined through the normal cost
finding process. (See CMS Pub. 15-2, chapter 1, §115.2.) Attach a schedule showing the details
and computations.
4033.2 Part II - Calculation of Medicare Reimbursement Settlement Under IPF PPS.--Use
Worksheet E-3, Part II, to calculate Medicare reimbursement settlement under IPF PPS for
hospitals and sub-providers. (See 42 CFR 412, Subpart N.)
Use a separate copy of Worksheet E-3, Part II, for each of these reporting situations. Enter check
marks in the appropriate spaces at the top of each page of Worksheet E-3, Part II, to indicate the
component for which it is used. When the worksheet is completed for a component, show both
the hospital and component numbers.
Line Descriptions
Line 1--Enter the net Federal IPF PPS payment. This amount excludes payments for outliers,
electroconvulsive therapy (ECT), and the teaching adjustment. Obtain this information from the
PS&R and/or your records.
Line 2--Enter the net IPF outlier payment. Obtain this from the PS&R and/or your accounting
books records.

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Line 3--Enter the net IPF payments for ECT. Obtain this from the PS&R and/or your accounting
books and records.
NOTE: Complete only line 4 or line 5, but not both.
Line 4--For providers that trained residents in the most recent cost reporting period filed on or
before November 15, 2004 (response on Worksheet S-2, Part I, line 71, column 1, is “Y” for yes),
enter the unweighted FTE resident count for the most recent cost reporting period filed on or before
November 15, 2004. See 69 FR 66922 (November 4, 2004) for a detailed explanation.
Line 4.01--For IPFs that qualify to receive a temporary adjustment to the FTE cap, enter the
additional unweighted FTE count for residents that were displaced by program or hospital closure,
which you would not be able to count without a temporary cap adjustment under
42 CFR 412.424(d)(1)(iii)(F)(1) or (2).
Line 5--If the response to Worksheet S-2, Part I, line 71, column 2, is “Y” and your facility did not
train residents in the most recent cost report filed before November 15, 2004, but qualifies to
receive a cap adjustment under 42 CFR 412.424(d)(1)(iii)(D), enter the new program cap
adjustment on this line. Do not complete this line until the new program growth period has ended
using the method described in 42 CFR 413.79(e)(1)(i) and (ii). For new programs started prior to
October 1, 2012, if your fiscal year end does not correspond to the program year end, and this cost
reporting period includes the beginning of the fourth program year following the new program
growth period of the first new program, then prorate the cap adjustment accordingly. For facilities
that participate in training residents in a new program for the first time on or after October 1, 2012,
consistent with the regulations at 42 CFR 413.79(e)(1), complete this line effective beginning with
the facility’s cost reporting period that coincides with or follows the start of the sixth program year
of the first new program started (see 79 FR 50110 (August 22, 2014)).
Line 6--Enter the current year unweighted FTE resident count excluding FTEs in the new program
growth period as determined using the method described in 42 CFR 413.79(e)(1)(i) and (ii). FTEs
in the new program growth period are reported on line 7. For new programs started prior to
October 1, 2012, if your fiscal year end does not correspond to the program year end, and this cost
reporting period includes the beginning of the fourth program year following the new program
growth period of the first new program, then prorate the FTE count accordingly. For facilities that
began participating in training residents in a new program for the first time on or after
October 1, 2012, consistent with the regulations at 42 CFR 413.79(e)(1), include FTE residents in
a new program on this line if this cost reporting period is the cost reporting period that coincides
with or follows the start of the sixth program year of the first new program started (i.e., the initial
years, see 79 FR 50110 (August 22, 2014)). Continue to report FTE residents on this line in
subsequent cost reporting periods.
Line 7--Enter the current year unweighted FTE count for residents in the new program growth
period. Complete this line only during the new program growth period of the first new program’s
existence. For new programs started prior to October 1, 2012, if your fiscal year end does not
correspond to the program year end, and this cost reporting period includes the beginning of the
fourth program year following the new program growth period of the first new program, then
prorate the FTE count accordingly. For facilities that began participating in training residents in a
new program for the first time on or after October 1, 2012, if your fiscal year end does not
correspond to the program year end, and this cost reporting period includes the beginning of the
sixth program year following the new program growth period of the first new program, then prorate
the FTE count accordingly. (See 42 CFR 413.79(e)(1).)
Line 8--For providers that completed line 4, enter the lower of the FTE count on line 6 or the sum
of the cap amounts on lines 4 and 4.01.
For providers that qualify to receive a cap adjustment under 42 CFR 412.424(d)(1)(iii)(D) during
the new program growth period of the first new program’s existence, enter the FTE count from
line 7.

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For new programs started prior to October 1, 2012, beginning with the program year following the
new program growth period of the first new program’s existence, enter the lower of the FTE count
on line 6 or the FTE count on line 5. Add to this count the FTEs on line 7 if your fiscal year end
does not correspond with the program year end, and this cost reporting period includes the
beginning of the fourth program year following the new program growth period of the first new
program. For new programs started on or after October 1, 2012, effective beginning with the
facility’s cost reporting period that coincides with or follows the start of the sixth program year of
the first new program started, enter the lower of the FTE count on line 6 or the FTE count on line 5.
Add to this count the FTEs on line 7 if your fiscal year end does not correspond with the program
year end, and this cost reporting period includes the beginning of the sixth program year following
the new program growth period of the first new program.
Beginning with the program year that does not coincide with but follows the new program growth
period of the first new program’s existence, enter the lower of the FTE count on line 6 or the FTE
count on line 5.
Line 9--Enter the total IPF patient days divided by the number of days in the cost reporting period
(Worksheet S-3, Part I, column 8, line 1 (independent/freestanding), or 16, and applicable
subscripts (sub-provider/provider based), divided by the total number of days in cost reporting
period). This is the average daily census.
Line 10--Enter the teaching adjustment factor by adding 1 to the ratio of line 8 to line 9. Raise
that result to the power of .5150. Subtract 1 from this amount to calculate the teaching adjustment
factor. This is expressed mathematically as {(1 + (line 8 / line 9)) to the .5150 power - 1}.
Line 11--Enter the teaching adjustment by multiplying line 1 by line 10.
Line 12--Enter the adjusted net IPF PPS payments by entering the sum of lines 1, 2, 3, and 11.
Line 13-- Enter the amount of NAHE managed care payments, if applicable. Only complete this
line if your facility is a freestanding/independent IPF PPS hospital or a freestanding/independent
IPF PPS hospital with an IRF PPS subprovider (i.e., enter the NAHE managed care payment for
the IPF PPS hospital plus the NAHE managed care payments for the IRF PPS subprovider).
Line 14--DO NOT USE THIS LINE.
Line 15--Teaching IPFs or IPF sub-providers participating in an approved GME program, electing
to be reimbursed for services of physicians on the basis of reasonable cost (see 42 CFR 415.160
and CMS Pub. 15-1, chapter 21, §2148), enter the cost of physicians. For cost reporting periods
ending before June 30, 2014, transfer the amount from Worksheet D-5, Part II, column 3, line 20.
For cost reporting periods ending on or after June 30, 2014, transfer the amount from
Worksheet D-5, Part IV, line 20.
Line 16--Enter the sum of lines 12, 13, 14, and 15.
Line 17--Enter the amounts paid or payable by primary payers (when program liability is
secondary to that of a primary payer) such as:
•
•
•
•
•
•

Rev.

Workers’ compensation,
No fault coverage,
General liability coverage,
Working aged provisions,
Disability provisions, and
Working ESRD provisions.

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Generally, when payment by the primary payer satisfies the total liability of the program
beneficiary, for cost reporting purposes only, the services are treated as if they were non-program
services. (The primary payment satisfies the beneficiary’s liability when you accept that payment
as payment in full. This is noted on no-pay bills submitted in these situations.) Include the patient
days and charges in total patient days and charges but do not include them in program patient days
and charges. In this situation, enter no primary payer payment on line 17. In addition, exclude
amounts paid by other primary payers for outpatient dialysis services reimbursed under the
composite rate system.
However, when the payment by the primary payer does not satisfy the beneficiary’s obligation,
the program pays the lesser of (a) the amount it otherwise pays (without regard to the primary
payer payment or deductible and coinsurance) less the primary payer payment, or (b) the amount
it otherwise pays (without regard to primary payer payment or deductibles and coinsurance) less
applicable deductible and coinsurance. Primary payer payment is credited toward the beneficiary’s
deductible and coinsurance obligation.
When the primary payment does not satisfy the beneficiary’s liability, include the covered days
and charges in program days and charges, and include the total days and charges in total days and
charges for cost apportionment purposes. Enter the primary payer payment on line 17 to the extent
that primary payer payment is not credited toward the beneficiary’s deductible and coinsurance.
Do not enter on line 17 primary payer payments credited toward the beneficiary’s deductible and
coinsurance.
Line 18--Enter line 16 minus line 17.
Line 19--Enter the Part A deductibles.
Line 20--Enter line 18 minus line 19.
Line 21--Enter the Part A coinsurance.
Line 22--Enter the result of subtracting line 21 from line 20.
Line 23--Enter program allowable bad debts reduced by recoveries. If recoveries exceed the
current year’s bad debts, lines 23 and 24 will be negative. (See 42 CFR 413.89.)
Line 24--Multiply the amount (including negative amounts) from line 23 by 70 percent for cost
reporting periods beginning prior to October 1, 2012, and 65 percent for cost reporting periods that
begin on or after October 1, 2012.
Line 25--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. This amount must also be reported on line 23.
Line 26--Enter the sum of lines 22 and 24.
Line 27--Enter the amount from the applicable Worksheet E-4, line 49, for the freestanding IPF
hospital or the CAH-based IPF excluded unit. Do not complete this line for a hospital-based IPF
excluded unit.
Line 28--Enter the routine service other pass through costs from Worksheet D, Part III, column 9,
line 30, for a freestanding facility or line 40 for the IPF sub-provider. Add to this amount the
ancillary service other pass through costs from Worksheet D, Part IV, column 11, line 200.
Line 29--Enter the outlier reconciliation amount by entering the sum of lines 51 and 53.

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Line 30--Enter any other adjustments. For example, if you change the recording of vacation pay
from the cash basis to accrual basis, etc., enter the adjustment. (See CMS Pub. 15-1, chapter 21,
§2146.4.) Specify the adjustment in the space provided. See line 30.98 to report the recovery of
accelerated depreciation.
Line 30.50--Enter the Pioneer ACO demonstration payment adjustment amount. Obtain this
amount from the PS&R. Do not use this line for services rendered on or after January 1, 2017.
Report any ACO demonstration payment adjustments for services on or after January 1, 2017, on
line 30.99 or line 31.02, accordingly.
Line 30.98--Enter the program share of any recovery of accelerated depreciation applicable to
prior periods resulting from your termination or a decrease in Medicare utilization. (See
CMS Pub. 15-1, chapter 1, §§136 through 136.16 and 42 CFR 413.134(d)(3)(i).) This line is
identified as “Recovery of accelerated depreciation.”
Line 30.99--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are subject to the
sequestration adjustment. Obtain this amount from the PS&R.
Line 31--Enter the sum of lines 26 through 28 plus or minus lines 29 and 30, and minus
lines 30.50, 30.98, and 30.99.
Line 31.01--For cost reporting periods that overlap or begin on or after April 1, 2013, 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 six decimal places), rounded to four decimal places) times line 31]. Do not
apply the sequestration calculation when gross reimbursement (line 31) is less than zero. (Note:
In accordance with §3709 of the CARES Act, as amended by §102 of the Consolidated
Appropriations Act of 2021, and §1 of Public Law 117-7, do not apply the sequestration adjustment
to the period of May 1, 2020, through December 31, 2021.)
Line 31.02--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are not subject to the
sequestration adjustment. Obtain this amount from the PS&R.
Line 32--Enter the amount of interim payments from Worksheet E-1, column 2, line 4. For
contractor final settlements, report on line 33 the amount on line 5.99.
Line 34--Enter line 31 minus the sum of lines 31.01, 31.02, 32 and 33. Transfer this amount to
Worksheet S, Part III, line 1, or line 2, as appropriate.
Line 35--Enter the program reimbursement effect of protested items. Estimate the reimbursement
effect of the nonallowable items by applying a reasonable methodology which closely
approximates the actual effect of the item as if it had been determined through the normal cost
finding process. (See CMS Pub. 15-1, chapter 1, §115.2.) Attach a schedule showing the details
and computations.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET E-3, PART II. LINES 50
THROUGH 53 ARE FOR CONTRACTOR USE ONLY.
Line 50--Enter the original outlier amount from Worksheet E-3, Part II, line 2.
Line 51--Enter the outlier reconciliation adjustment amount in accordance with CMS Pub. 100-04,
chapter 3, §§190.7.2.3-190.7.2.5.
Line 52--Enter the interest rate used to calculate the time value of money. (See CMS Pub. 100-04,
chapter 3, §§190.7.2.3-190.7.2.5.)
Line 53--Enter the time value of money.
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01-22

4033.3 Part III - Calculation of Medicare Reimbursement Settlement Under IRF PPS.--Use
Worksheet E-3, Part III, to calculate Medicare reimbursement settlement under IRF PPS for
hospitals and sub-providers. (See 42 CFR 412, Subpart P.)
Use a separate copy of Worksheet E-3, Part III, for each of these reporting situations. Enter check
marks in the appropriate spaces at the top of each page of Worksheet E-3, Part III, to indicate the
component for which it is used. When the worksheet is completed for a component, show both
the hospital and component numbers.
Line Descriptions
Line 1--Enter the net federal IRF PPS payment. The federal payment includes short stay outlier
amounts. Exclude low income patient (LIP) and outlier payments. Obtain this information from
the PS&R and/or your records.
In accordance with the 78 FR 47869 (August 6, 2013), effective for IRF discharges rendered on
or after October 1, 2013, the IRF LIP adjustment factor is updated. Subscript column 1 for lines 1
and 3 for cost reporting periods that overlap October 1, 2013. Enter the net federal IRF PPS
payments associated with IRF PPS discharges prior to October 1, 2013, in column 1 and the net
federal IRF PPS payments associated with IRF PPS discharges on or after October 1, 2013, in
column 1.01 to facilitate the calculation of the LIP adjustment on line 3, columns 1 and 1.01,
respectively. Do not subscript column 1 for cost reporting periods beginning on or after
October 1, 2013.
Line 2--Enter the Medicare SSI ratio from your contractor as applicable for a freestanding IRF
(IRF hospital or facility) or a hospital based IRF (sub-provider or subunit).
Line 3--Effective for cost reporting periods ending prior to October 1, 2013, enter the IRF LIP
payment as the result of {(1 + (line 2) + (L1/L2)) to the .4613 power - 1} times (line 1). L1 = IRF
Medicaid Days from Worksheet S-2, Part I, columns 1 through 6, line 25. L2 = IRF total days
from Worksheet S-3, Part I, column 8, lines 1 or 17 as applicable plus employee discount days
(Worksheet S-3, Part I, column 8, line 30 (line 31 for IRF sub-providers)).
For cost reporting periods that overlap October 1, 2013, subscript column 1. To calculate the IRF
LIP payment for discharges prior to October 1, 2013, enter in column 1 the result of {(1 + (line 2)
+ (L1/L2)) to the .4613 power - 1} times (line 1, column 1). To calculate the IRF LIP payment
for discharges on or after October 1, 2013, enter in column 1.01 the result of {(1 + (line 2) +
(L1/L2)) to the .3177 power - 1} times (line 1, column 1.01). Do not subscript column 1 for cost
reporting periods beginning on or after October 1, 2013. To calculate the IRF LIP payment for
cost reporting periods beginning on or after October 1, 2013, enter in column 1 the result of {(1 +
(line 2) +(L1/L2)) to the .3177 power - 1} times line 1.
Line 4--Enter the IRF outlier payment. Obtain this from the PS&R and/or your records.
NOTE: Complete only line 5 or line 6, but not both.
Line 5--For providers that trained residents in the most recent cost reporting period ending on
or before November 15, 2004 (response to Worksheet S-2, Part I, line 76, column 1 is “Y” for
yes), enter the unweighted FTE resident count for the most recent cost reporting period ending on
or before November 15, 2004.
Line 5.01--For IRFs that qualify to receive a temporary adjustment to the FTE cap, enter the
additional unweighted FTE count for residents that were displaced by program or hospital closure,
which you would not be able to count without a temporary cap adjustment in accordance with
76 FR 47846 (August 5, 2011).

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Line 6--If the response to Worksheet S-2, Part I, line 76, column 2, is “Y” and your facility did not
train residents in the most recent cost reporting period ending on or before November 15, 2004,
and qualifies to receive a cap adjustment (see 70 FR 47929 (August 15, 2005) enter the new cap
adjustment on this line. Do not complete this line until the new program growth period has ended
using the method described in 42 CFR 413.79(e)(1)(i) and (ii). For new programs started prior to
October 1, 2012, if your fiscal year end does not correspond to the program year end, and this cost
reporting period includes the beginning of the fourth program year following the new program
growth period of the first new program, then prorate the cap adjustment accordingly. For facilities
that participate in training residents in a new program for the first time on or after October 1, 2012,
consistent with the regulations at 42 CFR 413.79(e)(1), complete this line effective beginning with
the facility’s cost reporting period that coincides with or follows the start of the sixth program year
of the first new program started (see 79 FR 50110 (August 22, 2014)).
Line 7--Enter the current year unweighted FTE resident count excluding FTEs in the new program
growth period as determined using the method described in 42 CFR 413.79(e)(1)(i) and (ii). FTEs
in the new program growth period are reported on line 8. If your fiscal year end does not
correspond to the program year end and this cost reporting period includes the beginning of the
fourth program year following the new program growth period of the first new program, then
prorate the FTE count accordingly. For facilities that began participating in training residents in a
new program for the first time on or after October 1, 2012, consistent with the regulations at
42 CFR 413.79(e)(1), include FTE residents in a new program on this line if this cost reporting
period is the cost reporting period that coincides with or follows the start of the sixth program year
of the first new program started (i.e., the initial years, see 79 FR 50110 (August 22, 2014)).
Continue to report FTE residents on this line in subsequent cost reporting periods.
Line 8--Enter the current year unweighted FTE count for residents in the new program growth
period. Complete this line only during the new program growth period of the first new program’s
existence. For new programs started prior to October 1, 2012, if your fiscal year end does not
correspond with the program year end, and this cost reporting period includes the beginning of the
fourth program year following the new program growth period of the first new program, then
prorate the FTE count accordingly. For facilities that began participating in training residents in a
new program for the first time on or after October 1, 2012, if your fiscal year end does not
correspond to the program year end, and this cost reporting period includes the beginning of the
sixth program year following the new program growth period of the first new program, then prorate
the FTE count accordingly.
Line 9--For providers that completed line 5, enter the lower of the FTE count on line 7 or the sum
of the cap amounts on lines 5 and 5.01.
For providers that qualify to receive a cap adjustment (see 70 FR 47929 (August 15, 2005)), during
the new program growth period of the first new program’s existence enter the FTE count from
line 8.
For new programs started prior to October 1, 2012, beginning with the program year following the
new program growth period of the first new program’s existence, enter the lower of the FTE count
on line 7 or the FTE count on line 6. Add to this count the FTEs on line 8 if your fiscal year end
does not correspond with the program year end, and this cost reporting period includes the
beginning of the fourth program year following the new program growth period of the first new
program. For new programs started on or after October 1, 2012, effective beginning with the
facility’s cost reporting period that coincides with or follows the start of the sixth program year of
the first new program started, enter the lower of the FTE count on line 7 or the FTE count on line 6.
Add to this count the FTEs on line 8 if your fiscal year end does not correspond with the program
year end, and this cost reporting period includes the beginning of the sixth program year following
the new program growth period of the first new program.
Beginning with the program year that does not coincide with but follows the new program growth
period of the first new program’s existence, enter the lower of the FTE count on line 7 or the FTE
count on line 6.
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04-20

Line 10--Enter the total IRF patient days divided by the number of days in the cost reporting period
(Worksheet S-3, column 8, line 1 (independent/freestanding), or 17, and applicable subscripts
(sub-provider/provider based), divided by the total number of days in cost reporting period). This
is the average daily census.
NOTE: For cost reporting periods overlapping October 1, 2013, subscript column 1 (add
column 1.01) for lines 11 and 12. For cost reporting periods beginning on or after
October 1, 2013, do not script column 1.
Line 11--For cost reporting periods ending prior to October 1, 2013, calculate in column 1, the
teaching adjustment factor by adding 1 to the ratio of line 9 divided by line 10. Raise that result
to the power of .6876. Subtract 1 from this amount to calculate the teaching adjustment factor.
This is expressed mathematically as {(1 + (line 9 / line 10)) to the .6876 power - 1}.
In accordance with the 78 FR 47869 (August 6, 2013), effective for IRF discharges rendered on
or after October 1, 2013, the teaching adjustment factor is updated. For cost reporting periods that
overlap October 1, 2013, subscript column 1.
To calculate the teaching adjustment factor for discharges prior to October 1, 2013, enter in
column 1 the result of adding 1 to the ratio of line 9 divided by line 10. Raise that result to the
power of .6876 and then subtract 1 from this amount. This is expressed mathematically as {(1 +
(line 9 / line 10)) to the .6876 power - 1}. To calculate the teaching adjustment factor for
discharges on or after October 1, 2013, enter in column 1.01, the result of adding 1 to the ratio of
line 9 divided by line 10. Raise that result to the power of 1.0163 and then subtract 1 from this
amount. This is expressed mathematically as {(1 + (line 9 / line 10)) to the 1.0163 power - 1}. Do
not subscript column 1 for cost reporting periods beginning on or after October 1, 2013.
To calculate the teaching adjustment factor for cost reporting periods beginning on or after
October 1, 2013, enter in column 1, the result of adding 1 to the ratio of line 9 divided by line 10.
Raise that result to the power of 1.0163 and then subtract 1 from this amount. This is expressed
mathematically as {(1 + (line 9 / line 10)) to the 1.0163 power - 1}.
Line 12--For cost reporting periods ending prior to October 1, 2013, calculate the teaching
adjustment by multiplying line 1, by line 11. For cost reporting periods that overlap
October 1, 2013, subscript column 1. Calculate the teaching adjustment for discharges prior to
October 1, 2013 in column 1 by multiplying line 1, column 1 by line 11, column 1. Calculate the
teaching adjustment for discharges on or after October 1, 2013, in column 1.01 by multiplying
line 1, column 1.01 by line 11, column 1.01. Do not subscript column 1 for cost reporting periods
beginning on or after October 1, 2013. For cost reporting periods beginning on or after
October 1, 2013, calculate the teaching adjustment by multiplying line 1, by line 11.
Line 13--Enter the sum of line 1, columns 1 and 1.01; line 3, columns 1 and 1.01; line 4 and
line 12, columns 1 and 1.01.
Line 14-- Enter the amount of NAHE managed care payments, if applicable. Only complete this
line if your facility is a freestanding/independent IRF PPS hospital or a freestanding/independent
IRF PPS hospital with an IPF PPS subprovider (i.e., enter the NAHE managed care payment for
the IRF PPS hospital plus the NAHE managed care payments for the IPF PPS subprovider).
Line 15--DO NOT USE THIS LINE.
Line 16--Teaching IRFs or IRF sub-providers participating in an approved GME program, electing
to be reimbursed for services of physicians on the basis of reasonable cost (see 42 CFR 415.160
and CMS Pub. 15-1, chapter 21, §2148), enter the cost of physicians. For cost reporting periods
ending before June 30, 2014, transfer the amount from Worksheet D-5, Part II, column 3, line 20.
For cost reporting periods ending on or after June 30, 2014, transfer the amount from
Worksheet D-5, Part IV, line 20.
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Line 17--Enter the sum of lines 13, 14, 15, and 16.
Line 18--Enter the amounts paid or payable by workers' compensation and other primary payers
when program liability is secondary to that of the primary payer. There are six situations under
which Medicare payment is secondary to a primary payer:
•
•
•
•
•
•

Workers' compensation,
No fault coverage,
General liability coverage,
Working aged provisions,
Disability provisions, and
Working ESRD provisions.

Generally, when payment by the primary payer satisfies the total liability of the program
beneficiary, for cost reporting purposes only, the services are treated as if they were non-program
services. (The primary payment satisfies the beneficiary's liability when you accept that payment
as payment in full. This is noted on no-pay bills submitted in these situations.) Include the patient
days and charges in total patient days and charges but do not include them in program patient days
and charges. In this situation, enter no primary payer payment on line 18. In addition, exclude
amounts paid by other primary payers for outpatient dialysis services reimbursed under the
composite rate system.
However, when the payment by the primary payer does not satisfy the beneficiary's obligation, the
program pays the lesser of (a) the amount it otherwise pays (without regard to the primary payer
payment or deductible and coinsurance) less the primary payer payment, or (b) the amount it
otherwise pays (without regard to primary payer payment or deductibles and coinsurance) less
applicable deductible and coinsurance. Primary payer payment is credited toward the beneficiary's
deductible and coinsurance obligation.
When the primary payment does not satisfy the beneficiary's liability, include the covered days
and charges in program days and charges, and include the total days and charges in total days and
charges for cost apportionment purposes. Enter the primary payer payment on line 18 to the extent
that primary payer payment is not credited toward the beneficiary's deductible and coinsurance.
Do not enter on line 18 primary payer payments credited toward the beneficiary's deductible and
coinsurance.
Line 19--Enter line 17 minus line 18.
Line 20--Enter the Part A deductibles.
Line 21--Enter line 19 less line 20.
Line 22--Enter the Part A coinsurance.
Line 23--Enter the result of subtracting line 22 from line 21.
Line 24--Enter program allowable bad debts reduced by recoveries. If recoveries exceed the
current year’s bad debts, lines 24 and 25 will be negative. (See 42 CFR 413.89.)
Line 25--Multiply the amount (including negative amounts) from line 24 by 70 percent for cost
reporting periods beginning prior to October 1, 2012, and 65 percent for cost reporting periods that
begin on or after October 1, 2012.
Line 26--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. This amount must also be reported on line 24.

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DRAFT

Line 27--Enter the sum of lines 23 and 25.
Line 28--Enter the amount from the applicable Worksheet E-4, line 49, for the freestanding IRF
hospital or the CAH-based IRF excluded unit. Do not complete this line for a hospital-based IRF
excluded unit.
Line 29--Enter the routine service other pass through costs from Worksheet D, Part III, column 9,
line 30 for a freestanding facility or line 41 for IRF the sub-providers. Add to this amount the
ancillary service other pass through costs from Worksheet D, Part IV, column 11, line 200.
Line 30--Enter the outlier reconciliation amount by entering the sum of lines 51 and 53.
Line 31--Enter any other adjustments. For example, if you change the recording of vacation pay
from the cash basis to accrual basis, etc., enter the adjustment. (See CMS Pub. 15-1, chapter 21,
§2146.4.) Specify the adjustment in the space provided. See line 31.98 to report the recovery of
accelerated depreciation.
Line 31.50--Enter the Pioneer ACO demonstration payment adjustment amount. Obtain this
amount from the PS&R. Do not use this line for services rendered on or after January 1, 2017.
Report any ACO demonstration payment adjustments for services on or after January 1, 2017, on
line 31.99 or line 32.02, accordingly.
Line 31.98--Enter the program share of any recovery of accelerated depreciation applicable to
prior periods resulting from your termination or a decrease in Medicare utilization. (See
CMS Pub. 15-1, chapter 1, §§136 - 136.16, and 42 CFR 413.134(d)(3)(i).) This line is identified
as “Recovery of accelerated depreciation.”
Line 31.99--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are is subject to the
sequestration adjustment. Obtain this amount from the PS&R.
Line 32--Enter the sum of lines 27, 28, and 29 plus or minus lines 30, and 31, and minus
lines 31.50, 31.98, and 31.99.
Line 32.01--For cost reporting periods that overlap or begin on or after April 1, 2013, 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 six decimal places), rounded to four decimal places) times line 32]. Do not
apply the sequestration calculation when gross reimbursement (line 32) is less than zero. (Note: In
accordance with §3709 of the CARES Act, as amended by §102 of the Consolidated
Appropriations Act of 2021 and §1 of Public Law 117-7, do not apply the sequestration adjustment
to the period of May 1, 2020, through December 31, 2021.)
Line 32.02--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are not subject to the
sequestration adjustment. Obtain this amount from the PS&R.
Line 33--Enter the amount of interim payments from Worksheet E-1, column 2, line 4. For
contractor final settlement, report on line 34 the amount on line 5.99.
Line 35--Enter line 32 minus the sum of lines 32.01, 32.02, 33 and 34. Transfer this amount to
Worksheet S, Part III, line 1 or 3, as appropriate.
Line 36--Enter the program reimbursement effect of protested items. Estimate the reimbursement
effect of the nonallowable items by applying a reasonable methodology which closely
approximates the actual effect of the item as if it had been determined through the normal cost
finding process. (See CMS Pub. 15-2, chapter 1, §115.2.) Attach a schedule showing the details
and computations.
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DO NOT COMPLETE THE REMAINDER OF WORKSHEET E-3, PART III. LINES 50
THROUGH 53 ARE FOR CONTRACTOR USE ONLY.
Line 50--Enter the original outlier amount from Worksheet E-3, Part III, line 4.
Line 51--Enter the outlier reconciliation adjustment amount in accordance with CMS Pub. 100-04,
chapter 3, §140.2.8 - §140.2.10.
Line 52--Enter the interest rate used to calculate the time value of money. (See CMS Pub. 100-04,
chapter 3, §140.2.8 - §140.2.10)
Line 53--Enter the time value of money.
4033.4 Part IV - Calculation of Medicare Reimbursement Settlement Under LTCH PPS.--Use
Worksheet E-3, Part IV, to calculate Medicare reimbursement settlement under LTCH PPS for
hospitals. (See 42 CFR 412, Subpart O.) Providers that qualify as an extended neoplastic disease
care hospital do not complete this worksheet, but rather complete Worksheet E-3, Part I.
Line Descriptions
Line 1--Enter the net federal LTCH PPS payment including short stay outlier payments. Obtain
this information from the PS&R and/or your records. Effective for cost reporting periods ending
on or after September 30, 2017, enter the sum of the amounts on lines 1.01 through 1.04.
Complete lines 1.01 through 1.04 for discharges occurring in cost reporting periods beginning on
or after October 1, 2015. See 42 CFR 412.522. These amounts may be obtained from the PS&R
and/or your records.
NOTE: The amounts on lines 1.01 through 1.04 are for informational purposes only. The amount
on line 1 above includes the amounts on lines 1.01 through 1.04, and must reconcile to
line 1.
Line 1.01--Enter the full standard LTCH PPS payment.
Line 1.02--Enter the short stay outlier standard payment amount.
Line 1.03--Enter the cost-based site neutral payment amount.
Line 1.04--Enter the LTCH PPS comparable site neutral payment amount, which may include high
cost outlier payments.
Line 2--Enter the high cost outlier payments. Obtain this from the PS&R and/or your records.
Line 3--Enter the sum of lines 1 and 2.

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Line 4--Enter the amount of nursing and allied health managed care payments, if applicable.
Line 5--DO NOT USE THIS LINE.
Line 6--Teaching hospitals participating in an approved GME program, electing to be reimbursed
for services of physicians on the basis of reasonable cost (see 42 CFR 415.160 and
CMS Pub. 15-1, chapter 21, §2148), enter the cost of physicians. For cost reporting periods ending
before June 30, 2014, transfer the amount from Worksheet D-5, Part II, column 3, line 20. For
cost reporting periods ending on or after June 30, 2014, transfer the amount from Worksheet D-5,
Part IV, line 20.
Line 7--Enter the sum of lines 3, 4, 5, and 6.
Line 8--Enter the amounts paid or payable by workers' compensation and other primary payers
when program liability is secondary to that of the primary payer. There are six situations under
which Medicare payment is secondary to a primary payer:
•
•
•
•
•
•

Workers' compensation,
No fault coverage,
General liability coverage,
Working aged provisions,
Disability provisions, and
Working ESRD provisions.

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Line 10--Enter the Part A deductibles.
Line 11--Enter line 9 less line 10.
Line 12--Enter the Part A coinsurance.
Line 13--Enter the result of subtracting line 12 from line 11.
Line 14--Enter program allowable bad debts reduced by recoveries. If recoveries exceed the
current year’s bad debts, lines 14 and 15 will be negative. (See CMS Pub. 15-1, chapter 3.)
Line 15--Multiply the amount (including negative amounts) from line 14 by 70 percent for cost
reporting periods beginning prior to October 1, 2012, and 65 percent for cost reporting periods that
begin on or after October 1, 2012.
Line 16--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. This amount must also be reported on line 14.
Line 17--Enter the sum of lines 13 and 15.
Line 18--Enter the amount from Worksheet E-4, line 49, for the hospital.
Line 19--Enter the routine service other pass through costs from Worksheet D, Part III, column 9,
sum of lines 30 and 31, for a freestanding facility. Add to this amount the ancillary service other
pass through costs from Worksheet D, Part IV, column 11, line 200.
Line 20--Enter the outlier reconciliation amount by entering the sum of lines 51 and 53.
Line 21--Enter any other adjustments. For example, if you change the recording of vacation pay
from the cash basis to accrual basis, enter the adjustment. (See CMS Pub. 15-1, chapter 21,
§2146.4.) Specify the adjustment in the space provided. See line 21.98 to report the recovery of
accelerated depreciation.
Line 21.50--Enter the Pioneer ACO demonstration payment adjustment amount. Obtain this
amount from the PS&R. Do not use this line for services rendered on or after January 1, 2017.
Report any ACO demonstration payment adjustments for services on or after January 1, 2017, on
line 21.99 or line 22.02, accordingly.
Line 21.98--Enter the program share of any recovery of accelerated depreciation applicable to
prior periods resulting from your termination or a decrease in Medicare utilization. (See
CMS Pub. 15-1, chapter 1, §§136 - 136.16, and 42 CFR 413.134(d)(3)(i).) This line is identified
as “Recovery of accelerated depreciation.”
Line 21.99--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are subject to the
sequestration adjustment. Obtain this amount from the PS&R.
Line 22--Enter the sum of lines 17, 18, and 19, plus or minus lines 20, and 21, and minus
lines 21.50 and 21.99.
Line 22.01--For cost reporting periods that overlap or begin on or after April 1, 2013, 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 six decimal places), rounded to four decimal places) times line 22]. Do not
apply the sequestration calculation when gross reimbursement (line 22) is less than zero. (Note:
In accordance with §3709 of the CARES Act, as amended by §102 of the Consolidated
Appropriations Act of 2021, and §1 of Public Law 117-7, do not apply the sequestration adjustment
to the period of May 1, 2020, through December 31, 2021.)
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Line 22.02--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are not subject to the
sequestration adjustment. Obtain this amount from the PS&R.
Line 23--Enter the amount of interim payments from Worksheet E-1, column 2, line 4. For
contractor final settlements, report on line 24 the amount on line 5.99.
Line 25--Enter line 22 minus the sum of lines 22.01, 22.02, 23, and 24. Transfer this amount to
Worksheet S, Part III, line 1.
Line 26--Enter the program reimbursement effect of protested items. Estimate the reimbursement
effect of the nonallowable items by applying a reasonable methodology which closely
approximates the actual effect of the item as if it had been determined through the normal cost
finding process. (See CMS Pub. 15-2, chapter 1, §115.2.) Attach a schedule showing the details
and computations.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET E-3, PART IV. LINES 50
THROUGH 53 ARE FOR CONTRACTOR USE ONLY.
Line 50--Enter the original outlier amount from line 2. For cost reporting periods beginning on or
after October 1, 2015, and ending before October 1, 2018, enter the sum of the amounts reported
on lines 1.02 and 2.
Line 51--Enter the outlier reconciliation adjustment amount in accordance with CMS Pub. 100-04,
chapter 3, §150.26 - §150.28.
Line 52--Enter the interest rate used to calculate the time value of money. (See CMS Pub. 100-04,
chapter 3, §150.26 - §150.28.)
Line 53--Enter the time value of money.
4033.5 Part V - Calculation of Reimbursement Settlement for Medicare Part A Services - Cost
Reimbursement.--Use Worksheet E-3, Part V, to calculate reimbursement settlement for Medicare
Part A services furnished under cost reimbursement for (1) CAHs, including those participating in
the PARHM demonstration; and (2) new children’s or new cancer hospitals exempt from the rate
of increase limits in accordance with 42 CFR 413.40(f).
For hospitals participating in the PARHM demonstration during this cost reporting period and
(1) the hospital participated in the PARHM demonstration for the entire cost reporting period,
select the “PARHM Demonstration” box only and complete this worksheet; or (2) the hospital
participated in the PARHM demonstration for a portion of the cost reporting period, select the
“PARHM Demonstration” box and complete Worksheet E-3, Part V, for the portion of the cost
reporting period, included in the demonstration. Select the “Hospital” box and complete a separate
Worksheet E-3, Part V, for the portion of the cost reporting period not included in the
demonstration.

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Line Descriptions
Line 1--Enter the inpatient operating costs for the hospital (CAH, new children’s hospital, or new
cancer hospital) from Worksheet D-1, Part II, line 49.
Line 2--Enter the amount of nursing and allied health managed care payments, if applicable. Only
complete this line if your facility is a CAH.
Line 3--If you are approved as a CTC, enter the cost of organ acquisition from Worksheet D-4,
Part III, column 1, line 69, when this worksheet is completed for the hospital (or the hospital
component of a health care complex). Make no entry on line 3 in other situations because the
Medicare program reimburses only CTCs for organ acquisition costs.
Line 3.01-- Transfer the Medicare inpatient cellular therapy acquisition cost from Worksheet D-6,
Part III, line 10, column 1.
Line 4--Enter the sum of lines 1 through 3.01.
Line 5--Enter the amounts paid or payable by workers' compensation and other primary payers
when program liability is secondary to that of the primary payer. There are six situations under
which Medicare payment is secondary to a primary payer:
•
•
•
•
•
•

Workers' compensation,
No fault coverage,
General liability coverage,
Working aged provisions,
Disability provisions, and
Working ESRD provisions.

Generally, when payment by the primary payer satisfies the total liability of the program
beneficiary, for cost reporting purposes only, the services are treated as if they were non-program
services. (The primary payment satisfies the beneficiary's liability when you accept that payment
as payment in full. This is noted on no-pay bills submitted in these situations.) Include the patient
days and charges in total patient days and charges but not in program patient days and charges. In
this situation, enter no primary payer payment on line 5. In addition, exclude amounts paid by
other primary payers for outpatient dialysis services reimbursed under the composite rate system.
However, when the payment by the primary payer does not satisfy the beneficiary's obligation, the
program pays the lesser of (a) the amount it otherwise pays (without regard to the primary payer
payment or deductible and coinsurance) less the primary payer payment, or (b) the amount it
otherwise pays (without regard to primary payer payment or deductibles and coinsurance) less
applicable deductible and coinsurance. Primary payer payment is credited toward the beneficiary's
deductible and coinsurance obligation.
When the primary payment does not satisfy the beneficiary's liability, include the covered days
and charges in program days and charges and include the total days and charges in total days and
charges for cost apportionment purposes. Enter the primary payer payment on line 5 to the extent
that primary payer payment is not credited toward the beneficiary's deductible and coinsurance.
Do not enter on line 5 primary payer payments credited toward the beneficiary's deductible and
coinsurance.
Line 6--For a new children’s or new cancer hospital that is cost reimbursed, enter the result of
line 4 minus line 5.
For CAHs: For cost reporting periods beginning before October 1, 2014, if Worksheet S-2,
line 167, is “Y”, then multiply the amount on line 4 by 101 percent minus the amount on line 5.
For cost reporting periods beginning in FFY 2015 and subsequent years, if the CAH is a
meaningful user (Worksheet S-2, line 167, is “Y”), then multiply the amount on line 4 by
101 percent minus the amount on line 5.
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If the CAH is not a meaningful user of EHR for cost reporting periods beginning in FFY 2015 and
subsequent years, (Worksheet S-2, line 167, is “N”) and it does not qualify for a hardship exception
(Worksheet S-2, line 168.01, is “N”), calculate line 6 as follows:
For cost reporting periods beginning in FFY 2015 (October 1, 2014, through
September 30, 2015), (multiply the amount on line 4 by 100.66 percent) minus the amount
on line 5.
For cost reporting periods beginning in FFY 2016 (October 1, 2015, through
September 30, 2016), (multiply the amount on line 4 by 100.33 percent) minus the amount
on line 5.
For cost reporting periods beginning in FFY 2017 and each subsequent fiscal year (cost
reporting periods beginning on or after October 1, 2016), (multiply the amount on line 4
by 100 percent) minus the amount on line 5.
Computation of Lesser of Reasonable Cost or Customary Charges--This part provides for the
computation of the lesser of reasonable cost of services furnished to beneficiaries or customary
charges made by you for the same services, as defined in 42 CFR 413.13(a). A new children’s or
new cancer hospital exempt from the rate of increase limits must complete lines 7 through 16.
CAHs do not complete lines 7 through 16 as they are exempt from the application of the LCC
principle.
Line Descriptions
Lines 7 through 16--These lines provide for the accumulation of charges which relate to the
reasonable cost on line 6.
Do not include on these lines (1) the portion of charges applicable to the excess cost of luxury
items or services (see CMS Pub. 15-1, chapter 21, §2104.3) and (2) your charges to beneficiaries
for excess costs as described in CMS Pub. 15-1, chapter 25, §§2570-2577.
Line 7--Enter the program inpatient routine service charges from your records for the applicable
component. Include charges for both routine and special care units. The amounts entered include
covered late charges billed to the program when the patient's medical condition is the cause of the
stay past the checkout time. Also, these amounts include charges relating to a stay in an intensive
care type hospital unit for a few hours when your normal practice is to bill for the partial stay.
Line 8--Enter the total charges for inpatient ancillary services from Worksheet D-3, column 2, sum
of lines 50 through 98.
Line 9--If you are an approved CTC, enter the organ acquisition charges from Worksheet D-4,
Part III, column 3, line 69, when Worksheet E-3, Part V, is completed for the hospital or the
hospital component of a health care complex.
Line 10--Enter the sum of lines 7 through 9.
Lines 11 through 14--These lines provide for the reduction of program charges when you do not
actually impose such charges on most of the patients liable for payment for services on a charge
basis or when you fail to make reasonable efforts to collect such charges from those patients. If
line 13 is greater than zero, multiply line 10 by line 13, and enter the result on line 14. If you
impose these charges and make reasonable efforts to collect the charges from patients liable for
payment for services on a charge basis, you are not required to complete lines 11 through 13. Enter
on line 14 the amount from line 10. In no instance may the customary charges on line 14 exceed
the actual charges on line 10. (See 42 CFR 413.13(e).)

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Line 15--Enter the excess of the customary charges on line 14 over the reasonable cost on line 6.
Line 16--Enter the excess of reasonable cost on line 6 over the customary charges on line 14.
Transfer line 16 to line 21.
Line 17--Teaching hospitals participating in an approved GME program, electing to be reimbursed
for services of physicians on the basis of reasonable cost (see 42 CFR 415.160 and
CMS Pub. 15-1, chapter 21, §2148), enter the cost of physicians. For cost reporting periods ending
before June 30, 2014, transfer the amount from Worksheet D-5, Part II, column 3, line 20. For
cost reporting periods ending on or after June 30, 2014, transfer the amount from Worksheet D-5,
Part IV, line 20. CAHs do not complete this line.
Computation of Reimbursement Settlement
Line 18--New children’s or new cancer hospitals enter the amount from Worksheet E-4, line 49.
CAHs do not complete this line.
Line 19--Enter the sum of lines 6 and 17.
Line 20--Enter the Part A deductibles billed to Medicare beneficiaries.
Line 21-- Enter the amount from line 16. If you are a nominal charge provider, enter zero.
Line 22--Enter line 19 minus lines 20 and 21.
Line 23--Enter from PS&R or your records the coinsurance billed to Medicare beneficiaries.
Line 24--Enter line 22 minus line 23.
Line 25--Enter from your records program allowable bad debts net of recoveries. If recoveries
exceed the current year’s bad debts, lines 25 and 26 will be negative. (See 42 CFR 413.89.)
Line 26--No reduction is required for CAHs for cost reporting periods beginning prior to
October 1, 2012, enter the amount from line 25.
Multiply the amount from line 25 (including negative amounts) by 88 percent for cost reporting
periods beginning on or after October 1, 2012, 76 percent for cost reporting periods beginning on
or after October 1, 2013, and 65 percent for cost reporting periods beginning on or after
October 1, 2014.
Line 27--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. This amount must also be reported on line 25.
Line 28--Enter the sum of lines 24 and 26.
Line 29--Enter any other adjustments. See line 29.98 to report the recovery of accelerated
depreciation.
Line 29.50--Enter the Pioneer ACO demonstration payment adjustment amount. Obtain this
amount from the PS&R. Do not use this line for services rendered on or after January 1, 2017.
Report any ACO demonstration payment adjustments for services on or after January 1, 2017, on
line 29.99 or line 30.02, accordingly.
Line 29.98--Enter the program share of any recovery of accelerated depreciation applicable to
prior periods resulting from your termination or a decrease in Medicare utilization. (See
CMS Pub. 15-1, chapter 1, §§136 through 136.16 and 42 CFR 413.134(d)(3)(i).) This line is
identified as “Recovery of accelerated depreciation.”
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Line 29.99--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are subject to the
sequestration adjustment. Obtain this amount from the PS&R.
Line 30--Enter line 28, plus or minus line 29, and minus lines 29.50, 29.98, and 29.99.
Line 30.01--For cost reporting periods that overlap or begin on or after April 1, 2013, 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 six decimal places), rounded to four decimal places) times line 30]. Do not
apply the sequestration calculation when gross reimbursement (line 30) is less than zero. (Note:
In accordance with §3709 of the CARES Act, as amended by §102 of the Consolidated
Appropriations Act of 2021, and §1 of Public Law 117-7, do not apply the sequestration adjustment
to the period of May 1, 2020, through December 31, 2021.)
Line 30.02--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are not subject to the
sequestration adjustment. Obtain this amount from the PS&R.
Line 30.03--This line is a subset of line 30.01. Enter the sequestration adjustment amount for the
portion of the cost reporting period that the hospital participated in the PARHM demonstration.
Enter the sequestration adjustment amount as [(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 six decimal places), rounded to four decimal places) times the sum of lines 2,
3, 18, and 26]. (Note: In accordance with §3709 of the CARES Act, as amended by §102 of the
Consolidated Appropriations Act of 2021, and §1 of Public Law 117-7, do not apply the
sequestration adjustment to the period of May 1, 2020, through December 31, 2021.)
Line 31--Enter interim payments from Worksheet E-1, column 2, line 4. For contractor final
settlement, report on line 32 the amount from line 5.99.
Line 31.01-- This line is a subset of line 31. Enter the interim pass-through payments received (or
receivable) for the portion of the cost reporting period that the hospital participated in the PARHM
demonstration. These payments should include bi-weekly pass through payments as well as any
lump sum adjustments received for bad debts, organ acquisition costs, and medical education
(DGME and NAHE).
Line 33--Enter line 30 minus the sum of lines 30.01, 30.02, 31, and 32. Transfer this amount to
Worksheet S, Part III, columns as appropriate, line 1. For providers participating in the PARHM
demonstration, do not transfer amounts from this line. See line 33.01 for instruction.
Line 33.01-- For providers participating in the PARHM demonstration complete this line for the
settlement of pass-through payments paid outside of the PARHM demonstration. The amount
reported on this line is a subset of the amount reported on line 33. Enter the sum of lines 2, 3, 18,
and 26, minus lines 30.03, 31.01 and 32.01. Transfer this amount to Worksheet S, Part III, columns
as appropriate, line 1.01.
Line 34--Enter the program reimbursement effect of protested items. Estimate the reimbursement
effect of the nonallowable items by applying a reasonable methodology which closely
approximates the actual effect of the item as if it had been determined through the normal cost
finding process. (See CMS Pub. 15-2, chapter 1, §115.2.) Attach a schedule showing the details
and computations for this line.

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This page is reserved for future use

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4033.6 Part VI - Calculation of Reimbursement Settlement - Title XVIII Part A PPS SNF
Services.--For title XVIII SNFs reimbursed under PPS, complete this part for settlement of Part A
services. For Part B services, all SNFs complete Worksheet E, Part B.
When this part is completed for a component, show both the hospital and component numbers.
Computation of Net Costs of Covered Services
Line Descriptions
Prospective Payment Amount
Line 1--Compute the sum of the following amounts obtained your books and records or from the
PS&R:
•

The Resource Utilization Group (RUG) payments made for PPS discharges during the
cost reporting period, and

•

The RUG payments made for PPS transfers during the cost reporting period.

Line 2--Enter the amount from Worksheet D, Part III, column 9, line 44.
Line 3--Enter the amount from Worksheet D, Part IV, column 11, line 200.
Line 4--Enter the sum of lines 1 through 3.
Line 5--Do not use this line as vaccine costs are included on line 1 of Worksheet E, Part B. Line 5
is shaded on Worksheet E-3, Part VI.
Line 6--Enter any deductible amounts imposed.
Line 7--Enter any coinsurance amounts.
Line 8--Enter from your records program allowable bad debts for deductibles and coinsurance net
of bad debt recoveries. If recoveries exceed the current year’s bad debts, line 8 will be negative.
(See 42 CFR 413.89.)
Line 9--Enter the allowable bad debts for deductibles and coinsurance for dual eligible
beneficiaries, net of recoveries of bad debts for dual eligible beneficiaries. This amount is included
in the amount reported on line 8. If recoveries of bad debts for dual eligible beneficiaries exceed
the current year’s bad debts for dual eligible beneficiaries, line 9 will be negative.
Line 10--SNF Bad Debt--Calculate this line as follows for cost reporting periods beginning prior
to October 1, 2012: [((line 8 - line 9) * 70 percent) + line 9]. This is the adjusted SNF
reimbursable bad debt in accordance with the Deficit Reduction Act (DRA) 2005, section 5004.
In accordance with DRA 2005 SNF Bad Debt as amended by section 3201(b) of the Middle Class
Tax Relief and Job Creation Act of 2012, calculate this line as follows: for cost reporting periods
beginning on or after October 1, 2012, calculate this line as follows: [((line 8 - line 9) * 65 percent)
+ (line 9 * 88 percent)]. For cost reporting periods beginning on or after October 1, 2013, calculate
this line as follows: [((line 8 - line 9) * 65 percent) + (line 9 * 76 percent)]. For cost reporting
periods beginning on or after October 1, 2014, multiply the amount on line 8 by 65 percent.

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Line 11--Enter the title XVIII reasonable compensation paid to physicians for services on
utilization review committees to an SNF. Include on this line the amount eliminated from total
costs on Worksheet A-8. Transfer this amount from Worksheet D-1, Part III, line 85.
Line 12--Enter the result of line 4 plus line 5, minus the sum of lines 6 and 7, plus lines 10 and 11.
Line 13--Enter the amounts paid or payable by workers’ compensation and other primary payers
where program liability is secondary to that of the primary payer for inpatient services. Enter only
the primary payer amounts applicable to Part A routine and ancillary services.
Line 14--Enter any other adjustments. For example, if you change the recording of vacation pay
from the cash basis to accrual basis, enter the adjustment. (See CMS Pub. 15-1, chapter 21,
§2146.4.) Specify the adjustment in the space provided. See line 14.98 to report the recovery of
accelerated depreciation.
Line 14.50--Enter the Pioneer ACO demonstration payment adjustment amount. Obtain this
amount from the PS&R. Do not use this line for services rendered on or after January 1, 2017.
Report any ACO demonstration payment adjustments for services on or after January 1, 2017, on
line 14.99 or line 15.02, accordingly.
Line 14.98--Enter the program share of any recovery of accelerated depreciation applicable to
prior periods resulting from your termination or a decrease in Medicare utilization. (See
CMS Pub. 15-1, chapter 1, §§136 through 136.16, and 42 CFR 413.134(d)(3)(i).) This line is
identified as “Recovery of accelerated depreciation.”
Line 14.99--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are subject to the
sequestration adjustment. Obtain this amount from the PS&R.
Line 15--Enter the result of line 12, plus or minus line 14, minus lines 13, 14.50, 14.98, and 14.99.
Line 15.01--For cost reporting periods that overlap or begin on or after April 1, 2013, 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 six decimal places), rounded to four decimal places) times line 15]. Do not
apply the sequestration calculation when gross reimbursement (line 15) is less than zero.
For cost reporting periods that overlap or begin on or after May 1, 2020, enter the sequestration
adjustment amount from the PS&R (claims based amounts). (Note: In accordance with §3709 of
the CARES Act, as amended by §102 of the Consolidated Appropriations Act of 2021, and §1 of
Public Law 117-7, do not apply the sequestration adjustment to the period of May 1, 2020, through
December 31, 2021.)
Line 15.02--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are not subject to the
sequestration adjustment. Obtain this amount from the PS&R.
Line 15.75.--For cost reporting periods that overlap or begin on or after May 1, 2020, enter the
sequestration adjustment for non-claims based amounts as [(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 six decimal places), rounded to four decimal places) times the sum of
(lines 10 and 11, plus or minus line 14 and its subscripts not previously identified (do not use lines
14.50 or 14.99 in this calculation))]. If the sum of lines 10 and 11, plus or minus line 14 and its
subscripts not previously identified is less than zero, do not calculate the sequestration adjustment.
(Note: In accordance with §3709 of the CARES Act, as amended by §102 of the Consolidated
Appropriations Act of 2021, and §1 of Public Law 117-7, do not apply the sequestration adjustment
to the period of May 1, 2020, through December 31, 2021.)
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Line 16--For title XVIII, enter the total interim payments from Worksheet E-1, column 2, line 4.
Line 17--For contractor final settlement, report the amount from Worksheet E-1, column 2,
line 5.99.
Line 18--Enter line 15 minus the sum of the amounts on lines 15.01, 15.02, 15.75, 16, and 17.
Transfer this amount to Worksheet S, Part III, line 5 or 7, as appropriate.
Line 19--Enter the program reimbursement effect of protested items. Estimate the reimbursement
effect of the nonallowable items by applying a reasonable methodology which closely
approximates the actual effect of the item as if it had been determined through the normal cost
finding process. (See CMS Pub. 15-2, chapter 1, §115.2.) Attach a schedule showing the details
and computations.
4033.7 Part VII - Calculation of Reimbursement Settlement - All Other Health Services for
Titles V or XIX Services.--This worksheet calculates reimbursement for titles V or XIX services
for hospitals, sub-providers, other nursing facilities and ICF/IIDs.
Use a separate copy of this part for each of these reporting situations. Enter check marks in the
appropriate spaces at the top of each page of this part to indicate the component and program for
which it is used. When this part is completed for a component, show both the hospital and
component numbers. Enter check marks in the appropriate spaces to indicate the applicable
reimbursement method for inpatient services (e.g., TEFRA, OTHER).
Computation of Net Costs of Covered Services
Line Descriptions
Line 1--Enter the appropriate inpatient operating costs.
Cost Reimbursement
Hospital/CAH or Sub-provider - Worksheet D-1, Part II, line 49
Skilled Nursing Facility, Other Nursing Facility, ICF/IID - Worksheet D-1, Part III,
line 86. If Worksheet S-2, line 92, is answered “yes”, and multiple Worksheets D-1 are
prepared, add the multiple Worksheets D-1, and enter the result.
TEFRA
Hospital or Sub-provider - Worksheet D-1, Part II, line 63
NOTE: If you are a new provider reimbursed under TEFRA, use Worksheet D-1, Part II, line 49.
Line 2--Enter the cost of outpatient services for titles V or XIX, which is the sum of Worksheet D,
Part V, columns 6 and 7, and subscripts, where applicable.
Line 3--For titles V and XIX, enter in column 1 the amount paid or payable by the State program
for organ acquisition.
Line 4--Enter the sum of lines 1 through 3.

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Line 5--Enter in column 1 the amounts paid or payable by workers’ compensation and other
primary payers where program liability is secondary to that of the primary payer for inpatient
services for titles V and XIX.
Line 6--Enter in column 2 the primary payer amounts applicable to outpatient services for titles V
and XIX.
Line 7--Enter line 4 minus the sum of lines 5 and 6.
Computation of Lesser of Reasonable Cost or Customary Charges--You are paid the lesser of the
reasonable cost of services furnished to beneficiaries or your customary charges for the same
services. This part provides for the computation of the lesser of reasonable cost or customary
charges as defined in 42 CFR 413.13(a).
Line Descriptions
Lines 8 through 11--These lines provide for the accumulation of charges which relate to the
reasonable cost on line 4.
Do not include on these lines (1) the portion of charges applicable to the excess cost of luxury
items or services (see CMS Pub. 15-1, chapter 21, §2104.3), and, (2) your charges to beneficiaries
for excess costs as described in CMS Pub. 15-1, chapter 25, §§2570-2577.
Line 8--Enter in column 1 the program inpatient routine service charges from your records for the
applicable component for title V or XIX. This includes charges for both routine and special care
units.
The amounts entered on line 8 include covered late charges billed to the program when the
patient’s medical condition is the cause of the stay past the checkout time. Also, these amounts
include charges relating to a stay in an intensive care type hospital unit for a few hours when your
normal practice is to bill for the partial stay.
Line 9--Enter in column 1, the charges from Worksheet D-3, column 2, line 202. Enter in
column 2, the sum of the appropriate program ancillary charges from Worksheet D, Part V,
columns 3 and/or 4, plus subscripts as applicable, line 202.
Line 10--Enter in column 1, for title V or XIX, the organ acquisition charges from line 3.
Line 11--Enter in column 1, for title V or XIX, the amount of the incentive resulting from the target
amount computation on Worksheet D-1, Part II, line 58, if applicable.
Line 12--Enter the sum of the amounts recorded on lines 8 through 11.
Lines 13 through 16--These lines provide for the reduction of program charges when you do not
actually impose such charges on most of the patients liable for payment for services on a charge
basis or fail to make reasonable efforts to collect such charges from those patients. If line 15 is
greater than zero, multiply line 12 by line 15, and enter the result on line 16. If you do impose
these charges and make reasonable efforts to collect the charges from patients liable for payment
for services on a charge basis, you are not required to complete lines 13 through 15. Enter on
line 16, the amount from line 12. In no instance may the customary charges on line 16 exceed the
actual charges on line 12.
Line 17--Enter the excess of the customary charges over the reasonable cost. If the amount on
line 16 is greater than the amount on line 4, enter the excess.
Line 18--Enter the excess of total reasonable cost over the total customary charges. If the amount
on line 4 exceeds the amount on line 16, enter the excess.
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Line 19--Enter for title V or XIX, columns 1 and 2, the cost of services rendered by interns and
residents as follows from Worksheet D-2:
Col. 1
Title V

Col. 2
Title V

Col. 1
Title XIX

Col. 2
Title XIX

Hospital

Part I,
col. 8,
line 9

Part I,
col. 8,
line 27

Part I,
col. 10,
line 9

Part I,
col. 10,
line 27

Sub-provider

Part I,
col. 8,
lines 10-12
as applicable

Part I,
col. 10,
lines 10-12
as applicable

Nursing Facility, ICF/IID

Part I,
col. 8,
line 14

Part I,
col. 10,
line 14

Line 20--Teaching hospitals or sub-providers participating in an approved GME program, electing
to be reimbursed for services of physicians on the basis of reasonable cost (see 42 CFR 415.160
and CMS Pub. 15-1, chapter 21, §2148), enter the cost of physicians. For cost reporting periods
ending before June 30, 2014, transfer the amounts from Worksheet D-5, Part II, column 3, as
follows:
From Worksheet D-5,
Part II, column 3
Line 18
Line 19
Line 22
Line 23

Title
V
V
XIX
XIX

To Worksheet E-3,
Part VII, line 20:
Column 1
Column 2
Column 1
Column 2

For cost reporting periods ending on or after June 30, 2014, transfer the amounts from
Worksheet D-5, Part IV, as follows:
Title
V
V
XIX
XIX

From
Worksheet D-5, Part IV
Line 18
Line 19
Line 22
Line 23

To Worksheet E-3,
Part VII, line 20:
Column 1
Column 2
Column 1
Column 2

Line 21--Enter the lesser of line 4 or line 16. If this is a CAH, or otherwise exempt from lower of
cost or charges, transfer the amount from line 4.
Prospective Payment Amount
NOTE: Lines 22 through 26 must only be completed for PPS providers.
Line 22--Enter the total IPPS payments for titles V and/or XIX, as applicable, in column 1. Enter
the total OPPS payments for title V or XIX, as applicable, in column 2. Obtain this from your
books and records.
Line 23--Enter the amount of outlier payments made for the IPPS discharges during the period, in
column 1. Enter the outlier payment for the OPPS in column 2.

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Line 24--Enter in column 1 the payment for inpatient program capital costs from Worksheet L,
Part I, line 12; or Part II, line 5, as applicable.
Line 25--Enter in column 1 the result of Worksheet L, Part III, line 13 less Worksheet L, Part III,
line 17. If this amount is negative, enter zero on this line.
Line 26--Enter in column 1, the routine and ancillary service other pass through costs from
Worksheet D, Part III, column 9, line 200, and from Worksheet D, Part IV, column 11, line 200,
respectively. Enter in column 2, the amount from Worksheet D, Part IV, column 13, line 200.
Line 27--For each column, enter the sum of lines 22 through 26.
Line 28--For title V or XIX only, enter the customary charges for the IPPS in column 1, and the
OPPS in column 2.
Line 29--For each column, enter the sum of lines 21 and 27.
Computation of Reimbursement Settlement
Line 30--For each column, enter the amount, if any, from line 18.
Line 31--For each column, enter the sum of lines 19 and 20 plus line 29 minus lines 5 and 6.
Line 32--For each column, enter any deductible amounts imposed.
Line 33--For each column, enter any coinsurance amounts imposed.
Line 34--For each column, enter from your records reimbursable bad debts for deductibles and
coinsurance net of bad debt recoveries.
Line 35--Enter in column 1, the reasonable compensation paid to physicians for services on
utilization review committees to an SNF. Include the amount on this line in the amount eliminated
from total costs on Worksheet A-8. Transfer this amount from Worksheet D-1, Part III, line 85.
Line 36--For each column, enter the sum of lines 31, 34, and 35, minus the sum of lines 32 and 33.
Line 37--For each column, enter any other adjustments. For example, if you change the recording
of vacation pay from the cash basis to the accrual basis, enter the adjustment. (See CMS Pub. 15-1,
chapter 21, §2146.4.) Specify the adjustment in the space provided.
Line 38--For each column, enter the result of line 36 plus or minus line 37.
Line 39--Enter the amount from Worksheet E-4, line 31, in column 1.
Line 40--For each column, enter the sum of lines 38 and 39.
Line 41--For each column, enter the interim payments obtained from your records.
Line 42--For each column, enter the result of line 40 minus line 41. Transfer the sum of columns 1
and 2 to Worksheet S, Part III, column 1 (title V) or column 5 (title XIX), line as appropriate.
Line 43--Enter the program reimbursement effect of protested items. Estimate the reimbursement
effect of the nonallowable items by applying a reasonable methodology which closely
approximates the actual effect of the item as if it had been determined through the normal cost
finding process. (See CMS Pub. 15-2, chapter 1, §115.2.) Attach a schedule showing the details
and computations.

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4034
4034.

FORM CMS-2552-10

01-22

WORKSHEET E-4 - DIRECT GRADUATE MEDICAL EDUCATION (GME) AND
ESRD OUTPATIENT DIRECT MEDICAL EDUCATION COSTS

Use this worksheet to calculate each program’s payment (i.e., titles XVIII, V, and XIX) for direct
GME costs as determined under 42 CFR 413.75 through 413.83. This worksheet applies to the
direct GME cost applicable to interns and residents in approved teaching programs in hospitals,
hospitals with excluded units, and CAH-based excluded units. Do not complete this worksheet for
interns and residents training in the general acute care part of a CAH; those CAH costs are
reimbursed on a reasonable cost basis on Worksheet E-3, Part V. The direct medical education
costs of the nursing programs and paramedical education programs continue to be paid on a
reasonable cost basis as determined under 42 CFR 413.85. However, the nursing program and
paramedical education costs, formerly paid through the ESRD composite rate as an exception, are
paid on this worksheet on the basis of reasonable cost under 42 CFR 413.85. Effective for cost
reporting periods beginning on or after October 1, 1997, the unweighted direct GME FTE is
limited to the hospital’s FTE count for the most recent cost reporting period ending on or before
December 31, 1996. This limit applies to allopathic and osteopathic residents but excludes
dentistry and podiatry. The GME payment is also based on the inclusion of Medicare HMO
patients treated in the hospital. This worksheet will also calculate payment for direct GME as
determined under 42 CFR 413.79(c)(3) and (4) and IME as determined under
42 CFR 412.105(f)(1)(iv)(B) and (C) for hospitals that received an adjustment (reduction or
increase) to their FTE resident caps for direct GME and/or IME under section 422 of
Public Law 108-173.
NOTE: Do not complete this worksheet for a cost reporting period prior to the base period used
for calculating the per resident amount (PRA) in situations where the hospital did not
train residents in approved residency training programs or did not participate in the
Medicare program during the base period but either condition changed in a cost reporting
period beginning on or after July 1, 1985. 42 CFR 413.77(e)(1) specified that in this
situation, any GME costs for the cost reporting period prior to the base period are
reimbursed on a reasonable cost basis.
Complete this worksheet if this is the first month in which residents were on duty during the first
month of the cost reporting period or if residents were on duty during the entire prior cost reporting
period. (See 42 CFR 413.77(e)(1).)
This worksheet consists of five sections:
1.
2.
3.
4.
5.

Computation of Total Direct GME Amount
Computation of Program Patient Load
Direct Medical Education Costs for ESRD Composite Rate - Title XVIII only
Apportionment of Medicare Reasonable Cost (title XVIII only)
Allocation of Medicare Direct GME Costs Between Part A and Part B

Computation of Total Direct GME Amount--This section computes the total approved amount.
For IPPS hospitals participating in the PARHM demonstration during this cost reporting period
and (1) the hospital participated in the PARHM demonstration for the entire cost reporting period,
select the “PARHM Demonstration” box only and complete this worksheet; or (2) the hospital
participated in the PARHM demonstration for a portion of the cost reporting period, select the
“PARHM Demonstration” box and complete Worksheet E-4, for the portion of the cost reporting
period, included in the demonstration. Select the “Hospital” box and complete a separate
Worksheet E-4, for the portion of the cost reporting period not included in the demonstration.

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Line Descriptions
Line 1--Enter the unweighted resident FTE count for allopathic and osteopathic programs for the
most recent cost reporting period ending on or before December 31, 1996. If this cost report is
less than a full 12 months, contact your contractor. (42 CFR 413.79(c)(2)) Also include here the
30 percent increase to the count for qualified rural hospitals (42 CFR 413.79(c)(2)(i)), and the
increase due to primary care residents that were on approved leaves of absence (42 CFR 413.79(i)).
Temporarily reduce the cap of a hospital that closed a program(s), if the regulations at
42 CFR 413.79(h)(3)(ii) are applicable. (Effective October 1, 2001.)
Line 2--Enter the unweighted resident FTE count for allopathic and osteopathic programs that
meet the criteria for an adjustment to the cap for new programs in accordance with
42 CFR 413.79(e). For hospitals qualifying for a cap adjustment under 42 CFR 413.79(e)(1) or
(e)(3), the cap is effective beginning with the fourth program year of the first new program
accredited or begun on or after January 1, 1995, but before October 1, 2012. For urban hospitals
that participate in training residents in a new program for the first time on or after October 1, 2012,
under 42 CFR 413.79(e)(1), the cap is effective beginning with the cost reporting period that
coincides with or follows the start of the sixth program year of the first new program started (see
(79 FR 50110 (August 22, 2014)). For rural hospitals that participate in training residents in a new
program on or after October 1, 2012 under 42 CFR 413.79(e)(3), each new program in which the
rural hospital participates has its own initial years before the rural hospital’s FTE resident cap is
adjusted based on each new program. Therefore, the rural hospital’s FTE resident cap is adjusted
for each new program effective with the hospital’s cost reporting period that coincides with or
follows the start of the sixth program year of each new program started (see 79 FR 50110
(August 22, 2014)). For hospitals qualifying for a cap adjustment under 42 CFR 413.79(e)(2), the
cap for each new program accredited or begun on or after January 1, 1995, and before
August 6, 1997, is reported on this line and is effective in the fourth program year of each of those
new programs (see 66 FR August 1, 2001, 39881). The cap adjustment reported on this line should
not include any resident FTEs that were already included in the cap on line 1. Do not report new
program FTEs during the time frame prior to the effective date of the hospital’s FTE cap on this
line. New program FTEs during the time frame prior to the effective date of the hospital’s FTE
cap are reported on line 15. For urban hospitals that already have an FTE cap on line 1 but start a
rural track program in accordance with 42 CFR 413.75(k), enter the unweighted allopathic or
osteopathic FTE count for residents in all years of the rural track program that meet the criteria for
an add-on to the cap under 42 CFR 413.79(k). (If the rural track program is a new program under
42 CFR 413.79(l) and the hospital qualifies for a cap adjustment under 42 CFR 413.79(e)(1) or
(e)(3), do not report FTE residents in the rural track program on this line during the time frame
prior to the effective date of the hospital’s FTE cap).
Line 3--Enter the section 422 reduction amount to the direct GME cap as specified under
42 CFR 13.79(c)(3).
Line 3.01--Enter the section 5503 reduction amount to the direct GME cap as specified under
42 CFR 413.79(m). If this cost report straddles July 1, 2011, then calculate the prorated
section 5503 reduction amount off the cost report and enter the result on this line. (Prorate the cap
reduction amount by multiplying it by the ratio of the number of days from July 1, 2011, to the
end of the cost reporting period to the total number of days in the cost reporting period). Otherwise
enter the full cap reduction amount.
Line 4--Enter the adjustment (increase or decrease) for the unweighted resident FTE count for
allopathic or osteopathic programs for affiliated programs in accordance with 42 CFR 413.75(b),
413.79(f), and (63 FR 26336 (May 12, 1998), and 67 FR 50069 (August 1, 2002).
Line 4.01--Enter, as applicable, all or a portion of the amount of the FTE cap slots the hospital was
awarded under section 5503 of ACA. The amount of the section 5503 award that is reported on
this line is the amount of the section 5503 award that is being “used” in this cost reporting period.
In the 5-year evaluation period following implementation of section 5503 (that is, July 1, 2011
through June 30, 2016), at least 75 percent of the slots are to be “used” for additional primary care
and/or general surgery residents, while 25 percent of the amount that is reported may be (but need
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04-20

not be) “used” for other purposes. During the 5-year evaluation period, failure to meet the
requirements at 42 CFR 413.79(n)(2) of the regulations means loss of a hospital’s section 5503
slots. Therefore, for portions of cost reporting periods occurring during the 5-year evaluation
period (July 1, 2011, and before July 1, 2016), do not automatically report the full amount of the
section 5503 slots; only enter the amount of the section 5503 award that equates to at least
75 percent of the FTEs being “used” for additional primary care and/or general surgery FTEs, and
no more than 25 percent being used for other FTEs. If, during the 5-year evaluation period, your
hospital has not added any primary care or general surgery residents in accordance with receipt of
the section 5503 award, leave this line blank and do not report any of the section 5503 award on
this line in this cost reporting period. For portions of cost reporting periods occurring during the
5-year evaluation period (July 1, 2011, and before July 1, 2016), if the amount reported on
Worksheet S-2, Part I, line 61.02, column 3, is less than the amount on line 61.01, column 3, then
report zero on this line.
Line 4.02--Enter the amount of increase if the hospital was awarded FTE cap slots from a closed
teaching hospital under section 5506 of ACA. Further subscript this line (lines 4.03 through 4.20)
as necessary if the hospital receives FTE cap slot awards on more than one occasion under
section 5506. Refer to the letter from CMS awarding this hospital the slots under section 5506 to
determine the effective date of the cap increase. If the section 5506 award is phased in over more
than one effective date, only report the portions of the section 5506 award as they become effective.
If the effective date of the cap increase is not the same as your fiscal year beginning date, then
prorate the cap increase accordingly. (Prorate the cap increase amount by multiplying it by the
ratio of the number of days from the effective date of the cap increase to the end of the cost
reporting period to the total number of days in the cost reporting period.)
Line 5--Enter the result of line 1 plus line 2 minus line 3 minus line 3.01 plus or minus line 4 plus
line 4.01 plus line 4.02 plus subscripts as applicable. However, if the resulting cap is less than
zero, enter zero on this line.
Line 6--Enter the unweighted resident FTE count for allopathic or osteopathic programs for the
current year from your records, other than those in the initial years of the program, i.e., the program
has not yet completed one cycle of the program (the “period of years” or the minimum accredited
length of the program. The residents in programs within the “period of years” are exempt from
the rolling average rules. (42 CFR 413.79(d)(5) and (e).) Contact your contractor for instructions
on how to complete this line if you have a new program for which the period of years is less than
or greater than 3 years. Exclude FTE residents displaced by hospital or program closures that are
in excess of the cap for which a temporary cap adjustment is needed (42 CFR 413.79(h)).
Line 7--Enter the lesser of lines 5 or 6.
Line 8--Enter in column 1, the weighted FTE count for primary care physicians and OB/GYN
residents in an allopathic or osteopathic program for the current year. Enter in column 2, the
weighted FTE count for all other physicians in an allopathic or osteopathic program for the current
year. Exclude FTE residents in the initial period of years of the new program, which for urban or
rural hospitals that began training residents in a new program under 42 CFR 413.79(e)(1) or (e)(3),
prior to October 1, 2012, means that the program has not yet completed one cycle of the program
(i.e., “period of years,” or minimum accredited length of the program. (42 CFR 413.79(d)(5) and
(e)). For new programs started prior to October 1, 2012, contact your contractor for instructions
on how to complete this line if you have a new program for which the period of years is less than
or more than three years. For urban hospitals that began participating in training residents in a
new program for the first time on or after October 1, 2012, under 42 CFR 413.79(e)(1), do not
include FTE residents in a new program on this line if this cost reporting period is prior to the cost
reporting period that coincides with or follows the start of the sixth program year of the first new
program started (i.e., the initial years, see 79 FR 50110 (August 22, 2014)). For rural hospitals
participating in a new program on or after October 1, 2012, under 42 CFR 413.79(e)(3), each new
program in which the rural hospital participates has its own initial years before the rural hospital’s
FTE resident cap is adjusted based on each new program. Therefore, for rural hospitals, do not
include FTE residents in a new program on this line if this cost reporting period is prior to the cost
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4034 (Cont.)

reporting period that coincides with or follows the start of the sixth program year of each individual
new program started (see 79 FR 50110 (August 22, 2014)). For both urban and rural hospitals,
report FTE residents in the initial years of the new program on line 15. Exclude FTE residents
displaced by hospital or program closures that are in excess of the cap for which a temporary cap
adjustment is needed (42 CFR 413.79(h)). Enter in column 3, the sum of columns 1 and 2.
Line 9--If line 6 is less than or equal to line 5, enter the amounts from line 8, columns 1 and 2, in
columns 1 and 2, of this line. Otherwise, multiply the amount in each column of line 8 by
(line 5/line 6). Enter in column 3, the sum of columns 1 and 2. (42 CFR 413.79(c)(2)(iii).)
Line 10--Enter in column 2, the weighted dental and podiatric resident FTE count for the current
year.
Line 10.01--Enter in column 2, the unweighted dental and podiatric resident FTE count for the
current year. This amount is used for informational purposes only and does not impact the
calculations on this worksheet.
Line 11--Enter in column 1, the amount from column 1, line 9. Enter in column 2, the sum of the
amounts in column 2, lines 9 and 10.
Line 12--Enter in column 1, the weighted FTE count for primary care residents for the prior year,
other than those in the initial years of the program that meet the criteria for an exception to the
averaging rules (42 CFR 413.79(d)(5)). However, if the period of years during which the FTE
residents in any of your new training programs were exempted from the rolling average has expired
(see 42 CFR 413.79(d)(5)), also enter on this line the count of FTE residents in that specific
primary care (or OB/GYN) program included in Form CMS-2552-96, Worksheet E-3, Part IV,
line 3.22, or Form CMS-2552-10, Worksheet E-4, from line 15 of the prior year’s cost report. If
subject to the cap in the prior year Form CMS-2552-96 cost report, report the result of
Worksheet E-3, Part IV, line 3.07, times (line 3.04/line 3.05). If subject to the cap in the prior year
Form CMS-2552-10 cost report, report the result of Worksheet E-4, column 1, line 8, times
(line 5/line 6).
Enter in column 2, the weighted FTE count for nonprimary care residents for the prior year, other
than those in the initial years of the program that meet the criteria for an exception to the averaging
rules (42 CFR 413.79(d)(5)). However, if the period of years during which the FTE residents in
any of your new training programs were exempted from the rolling average has expired (see
42 CFR 413.79(d)(5)), also enter on this line the count of FTE residents in that specific nonprimary
care program included in Form CMS-2552-96, Worksheet E-3, Part IV, line 3.16, or
Form CMS-2552-10, Worksheet E-4, from line 15 of the prior year’s cost report. If subject to the
cap in the prior year Form CMS-2552-96 cost report, report the result of Worksheet E-3, Part IV,
line 3.08, times (line 3.04/line 3.05), plus line 3.11. If subject to the cap in the prior year
Form CMS-2552-10 cost report, report the result of Worksheet E-4, column 2, line 8, times
(line 5/line 6) plus line 10.
Line 13--Enter in column 1, the weighted FTE count for primary care (or OB/GYN) residents for
the cost reporting year before last, other than those in the initial years of the program that meet the
criteria for an exception to the averaging rules (42 CFR 413.79(d)(5)). However, if the period of
years during which the FTE residents in any of your new training programs were exempted from
the rolling average has expired (see 42 CFR 413.79(d)(5)), also enter on this line the count of FTE
residents in that specific primary care (or OB/GYN) program included on Form CMS-2552-96,
line 3.22, or Form CMS-2552-10, from line 15 of that year’s cost report. If subject to the cap in
the year before last Form CMS-2552-96 cost report, report the result of line 3.07, times
(line 3.04/line 3.05). If subject to the cap in that year Form CMS-2552-10 cost report, report the
result of column 1, line 8, times (line 5/line 6).
Enter in column 2, the weighted FTE count for nonprimary care residents for the cost reporting
year before last, other than those in the initial years of the program that meet the criteria for an
exception to the averaging rules (42 CFR 413.79(d)(5)). However, if the period of years during
which the FTE residents in any of your new training programs were exempted from the rolling
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average has expired (see 42 CFR 413.79(d)(5)), also enter on this line the count of FTE residents
in that specific nonprimary care program included in Form CMS-2552-96, line 3.16, or
Form CMS-2552-10, from line 15 of that year’s cost report. If subject to the cap in the cost
reporting year before last, Form CMS-2552-96 cost report, report the result of line 3.08, times
(line 3.04/line 3.05), plus line 3.11. If subject to the cap in that year Form CMS-2552-10 cost
report, report the result of column 2, line 8, times (line 5/line 6), plus line 10.
Line 14--Enter the rolling average FTE count in each column, by adding lines 11 through 13, and
dividing by 3.
Line 15--Enter the weighted number of FTE residents in the initial years of a program in column 1
for primary care and OB/GYN, and in column 2 for nonprimary care FTEs. For a new program
started prior to October 1, 2012, contact your contractor for instructions on how to complete this
line if you have a new program for which the period of years is less than or more than three years.
For urban hospitals that began participating in training residents in a new program for the first time
on or after October 1, 2012 under 42 CFR 413.79(e)(1), include FTE residents in a new program
on this line if this cost reporting period is prior to the cost reporting period that coincides with or
follows the start of the sixth program year of the first new program started (see 79 FR 50110
(August 22, 2014)). For rural hospitals participating in a new program(s) on or after
October 1, 2012 under 42 CFR 413.79(e)(3), include FTE residents in a particular new program
on this line if this cost reporting period is prior to the cost reporting period that coincides with or
follows the start of the sixth program year of that new program (see 79 FR 50110
(August 22, 2014)).
Line 15.01--Enter the unweighted number of FTE residents in the initial years of a program in
column 1 for primary care and OB/GYN, and in column 2 for nonprimary care. Use line 15
instructions to determine the unweighted FTE resident counts for this line. This amount is used
for informational purposes only and does not impact the calculations on this worksheet.
Line 16--Enter the temporary weighted FTE residents that were displaced by program or a hospital
closure in column 1 for primary care, and in column 2 for nonprimary care, which you would not
be able to count without a temporary cap adjustment. (42 CFR 413.79(h).)
Line 16.01--Enter the temporary unweighted FTE residents that were displaced by program or a
hospital closure in column 1 for primary care, and in column 2 for nonprimary care, which you
would not be able to count without a temporary cap adjustment. (42 CFR 413.79(h).) This amount
is used for informational purposes only and does not impact the calculations on this worksheet.
Line 17--Enter the sum of lines 14 through 16.
Line 18-- Enter in column 1, the primary care and OB/GYN per resident amount. Enter in
column 2, the nonprimary care per resident amount.
Line 19--Enter the result of multiplying lines 17 times line 18. Enter in column 3, the sum of
columns 1 and 2.
Line 20--Section 422 Direct GME FTE Cap--Enter the number of unweighted allopathic and
osteopathic direct GME FTE resident cap slots the hospital received under 42 CFR §413.79(c)(4).
Line 21--Direct GME FTE Resident Unweighted Count Over/Under the Cap--Subtract line 7 from
line 6 and enter the result here. If the result is zero or negative, the hospital does not need to use
the direct GME section 422 additional cap and lines 22 through 24 will not be completed.
Line 22--Section 422 Allowable Direct GME FTE Resident Count--If the count on line 21 is less
than or equal to the count on line 20, then divide line 8 by line 6, and multiply the resulting ratio
by the amount on line 21. If the count on line 21 is greater than the count on line 20, then divide
line 8 by line 6, and multiply the resulting ratio by the amount on line 20.
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Line 23--Enter the locality adjusted national average per resident amount as specified at
42 CFR section 413.77(g), inflated to the hospital’s cost reporting period.
Line 24--Enter the product of lines 22 and 23. This is the allowable section 422 GME cost.
Line 25--Enter the sum of lines 19 and 24. This is the total Part A direct GME cost.
Computation of Program Patient Load--This section computes the ratio of program inpatient days
to the total inpatient days. For this calculation, total inpatient days include inpatient days of the
hospital along with its sub-providers, including distinct part units excluded from the PPS. Record
hospital inpatient days of Medicare beneficiaries whose stays are paid by risk basis HMOs and
organ acquisition days as non-Medicare days. Do not count inpatient days applicable to nursery,
hospital-based SNFs and other nursing facilities, and other non-hospital level of care units for the
purpose of determining the Medicare patient load.
The BBRA provided that payments that are made to teaching hospitals for costs of direct GME
associated with services to MA enrollees will be reduced by an estimated percentage in each CY.
Specifically, the law provides that the estimated reductions in MA direct GME payments must
equal the estimated total additional MA nursing and allied health education payments.
Accordingly, for portions of cost reporting periods occurring in a calendar year, all hospitals that
receive MA direct GME payments (including those that do not receive additional nursing and
allied health payments under the BIPA provision) will have these payments reduced by the percent
reduction in accordance with CR 11642 or subsequent applicable CRs.
Complete lines 26 through 30, columns 2 and 2.01, as applicable. Calendar year providers
complete only column 2.
Line Descriptions
Line 26--Effective for cost reporting periods beginning prior to October 1, 2013, enter in
column 1, for title XVIII, the sum of the days reported on Worksheet S-3, Part I, column 6, lines 1,
8 through 12, 16 and 17, and subscripts as applicable.
Effective for cost reporting periods beginning on or after October 1, 2013, enter in column 1, for
title XVIII, the sum of the days reported on Worksheet S-3, Part I, column 6, or column 6.01, (for
the PARHM demonstration worksheet) lines 1, 8 through 12, 16, and 17, and subscripts as
applicable, and line 32. For titles V or XIX, enter the amounts from columns 5 or 7, respectively,
sum of lines 1, 8 through 12, 16 and 17, and subscripts, as applicable, plus column 7, line 32, for
title XIX.
For title XVIII, if you are a calendar year provider or not impacted by CR 11642, enter in column 2,
the Medicare managed care days from Worksheet S-3, Part I, column 6, or column 6.01, (for the
PARHM demonstration worksheet) lines 2, 3, and 4. For title XIX, enter in column 2, Medicaid
managed care days from Worksheet S-3, Part I, column 7, lines, 2, 3, and 4.
If you are impacted by CR 11642 or subsequent CRs, the response to Worksheet S-2, Part I, line 56,
column 2, is “Y”, for title XVIII, and you are not a calendar year end provider enter in column 2,
the portion of the Medicare managed care days reported on Worksheet S-3, Part I, columns 6, or
column 6.01, (for the PARHM demonstration worksheet), lines 2, 3, and 4 occurring prior to
January 1; and enter in column 2.01, the portion of the Medicare managed care days reported on
Worksheet S-3, Part I, columns 6, or column 6.01, (for the PARHM demonstration worksheet),
lines 2, 3, and 4, occurring on or after January 1.

Rev. 17

40-216.1

4034 (Cont.)

FORM CMS-2552-10

01-22

Line 27--Effective for cost reporting periods beginning prior to October 1, 2013, transfer to
columns 1, 2, and 2.01, respectively, the sum of the days reported on Worksheet S-3, Part I,
column 8, lines 1, 8 through 12, 16 and 17, and subscripts as applicable.
Effective for cost reporting periods beginning on or after October 1, 2013, transfer to columns 1,
2 and 2.01, the sum of the days reported on Worksheet S-3, Part I, column 8, lines 1, 8 through 12,
16, 17, and subscripts as applicable, and line 32.
Line 28--In each column, divide line 26 by line 27 and enter the result (expressed as a decimal).
Column 1 is the title XVIII Part A inpatient utilization and columns 2 and 2.01 is the Medicare
managed care inpatient utilization.
Line 29--Multiply the amount on line 25, column 1, by the amount reported in each column of
line 28. Enter in column 3, the sum of columns 1, 2, and 2.01.
Line 29.01--If the response to Worksheet S-2, Part I, line 56, column 2, is “Y”, enter in columns
2 and 2.01, the applicable reduction percentage to MA direct GME payments. Enter in column 2,
the MA reduction percentage for the portion of the cost reporting period prior to January 1; and
enter in column 2.01, the MA reduction percentage for the portion of the cost reporting period on
or after January 1. Calendar year providers complete only column 2.
CY
2010
Percent reduction to 9.77
MA DGME

2011 2012
7.85 7.16

2013
6.41

2014
5.86

2015
5.32

2016
4.99

2017
4.44

2018
4.12

2019
4.07

Line 30--In column 2, enter the amount on line 29, column 2, multiplied by the reduction factor
reported in the 65 FR 47038 and 47039 (August 1, 2000). This is the reduction for direct GME
payments for Medicare Advantage. If the response to Worksheet S-2, Part I, line 56, column 2, is
“Y”, enter in column 2 the result of line 29, column 2, multiplied by the reduction factor on
line 29.01, column 2, and enter in column 2.01 the result of line 29, column 2.01, multiplied by
the reduction factor on line 29.01, column 2.01. Enter in column 3, the sum of columns 2 and 2.01.
Line 31--Enter the sum of columns 1, 2 and 2.01, line 29, less the amount in columns 2 and 2.01,
line 30.
Direct Medical Education Costs for ESRD Composite Rate Title XVIII Only--This section
computes the title XVIII nursing program and paramedical education costs applicable to the ESRD
composite rate. These costs are reimbursable based on the reasonable cost principles under
42 CFR 413.85 separate from the ESRD composite rate.
Line Descriptions
Line 32--Enter the amount from Worksheet B, Part I, sum of columns 20 and 23, lines 74 and 94.
Line 33--Enter the amount from Worksheet C, Part I, column 8, sum of lines 74 and 94. This
amount represents the total charges for renal and home dialysis.
Line 34--Divide line 32 by line 33, and enter the result. This amount represents the ratio of ESRD
direct medical education costs to total ESRD charges.
Line 35--Enter from your records the Medicare outpatient ESRD charges.
Line 36--Enter the result of multiplying line 34 by line 35. This represents the Medicare outpatient
ESRD costs. Transfer this amount to Worksheet E, Part B, line 29.

40-216.2

Rev. 17

DRAFT

FORM CMS-2552-10

4034 (Cont.)

Apportionment of Medicare Reasonable Cost of GME--This section determines the ratio of
Medicare reasonable costs applicable to Part A and Part B. The allowable costs of GME that per
resident amounts are established include GME costs attributable to the entire hospital complex
(including non-hospital portions of a health care complex). Therefore, the reasonable costs used
in the apportionment between Part A and Part B include the hospital, hospital-based providers, and
distinct part units. Do not complete this section for titles V and XIX.
Line Descriptions
Line 37--Include the Part A reasonable cost for the entire hospital complex computed by adding
the following amounts:
•

Hospital and Sub-provider(s) - Sum of each Worksheet D-1, Part II, line 49;

•

Hospital-Based HHAs - Worksheet H-4, Part I, column 1, line 1;

•

Swing-Bed SNF - Worksheet E-2, line 1, column 1;

•

Hospital-Based PPS SNF - Sum of Worksheet D-1, Part III, line 74, and
Worksheet E-3, Part VI, column 1, line 4.

Line 38--Enter the organ acquisition costs from Worksheet(s) D-4, Part III, column 1, line 69.
Line 39--Enter the cost of teaching physicians from Worksheet(s) D-5, Part II, column 3, line 20,
or D-5, Part IV, column 1, line 20, as applicable.
Line 40--Enter the total Medicare Part A primary payer amounts for the hospital complex from the
applicable worksheets.
•

PPS hospital and/or sub-providers - Worksheet E, Part A, line 60;

•

TEFRA hospital and/or sub-providers - Worksheet E-3, Part I, line 5;

•

IPF PPS hospital and/or sub-providers - Worksheet E-3, Part II, line 17;

•

IRF PPS hospital and/or sub-providers - Worksheet E-3, Part III, line 18;

•

LTCH PPS hospital - Worksheet E-3, Part IV, line 8;

•

Cost reimbursed hospital and/or sub-providers - Worksheet E-3, Part V, line 5;

•

Hospital-based HHAs - Each Worksheet H-4, Part I, column 1, line 9;

•

Swing-Bed SNF and/or NF - Worksheet E-2, column 1, line 9; and

•

Hospital-based PPS SNF - Worksheet E-3, Part VI, column 1, line 13.

Line 41--Enter the sum of lines 37 through 39 minus line 40.
Line 42--Enter the Part B Medicare reasonable cost. Enter the sum of the amounts on each
title XVIII Worksheet E, Part B, columns 1 and 1.01, sum of lines 1, 2, 9, 10, 22, and 23;
Worksheet E-2, column 2, line 8; Worksheet H-4, Part I, sum of columns 2 and 3, line 1;
Worksheet J-3, column 1, line 1; Worksheet M-3, line 16; and Worksheet N-2, sum of columns 11
and 12, line 11.

Rev.

40-216.3

4034 (Cont.)

FORM CMS-2552-10

DRAFT

Line 43--Enter the Part B primary payer amounts. Enter the sum of the amounts on each
Worksheet E, Part B, line 31; Worksheet E-2, column 2, line 9; Worksheet H-4, Part I, sum of
columns 2 and 3, line 9; Worksheet J-3, line 4; Worksheet M-3, sum of columns 1 and 2, line 17;
and Worksheet N-4, line 5.
Line 44--Enter line 42 minus line 43
Line 45--Enter the sum of lines 41 and 44.
Line 46--Divide line 41 by line 45, and enter the result.
Line 47--Divide line 44 by line 45, and enter the result.
Allocation of Medicare Direct GME Costs Between Part A and Part B--Use this section to compute
the GME payments for title XVIII, Part A and Part B, and to compute the total GME payments
applicable to titles V and XIX.
Line Descriptions
Line 48--Enter the amount from line 31.
Line 49--Complete for title XVIII only. Multiply line 46 by line 48, and enter the result. If you
are a hospital subject to IPPS, transfer this amount to Worksheet E, Part A, line 52. Although this
amount includes the Part A GME payments for sub-providers, for ease of computation, transfer
this amount to the primary hospital component worksheet only. If you are freestanding facility
subject to TEFRA, transfer this amount to Worksheet E-3, Part I, line 15. If you are a freestanding
IPF PPS, transfer this amount to Worksheet E-3, Part II, line 27. If you are a freestanding IRF
PPS, transfer this amount to Worksheet E-3, Part III, line 28. If you are a freestanding LTCH PPS,
transfer this amount to Worksheet E-3, Part IV, line 18.
Line 50--Complete for title XVIII only. Multiply line 47 by line 48, and enter the result. Transfer
this amount to Worksheet E, Part B, line 28. Although this amount includes the Part B GME
payments for sub-providers, for ease of computation, transfer this amount to the hospital
component only.

40-216.4

Rev.

DRAFT
4035.

FORM CMS-2552-10

4035

WORKSHEET E-5 - OUTLIER RECONCILIATION AT TENTATIVE SETTLEMENT

This worksheet is for contractor use only for cost reporting periods beginning on or after
October 1, 2020. The contractor completes this worksheet to report outlier reconciliation
amounts during the cost report tentative settlement if the hospital meets the criteria based on
information available at tentative settlement. Do not adjust or revise this worksheet after tentative
settlement; calculate the outlier reconciliation amount for final settlement on Worksheet E, Part A,
lines 90 through 96.
Line 1--Enter the sum of the operating outlier amounts from the provider’s submitted Worksheet E,
Part A, lines 2.03 and 2.04, sum of all columns.
Line 2--Enter the capital outlier amount from the provider’s submitted Worksheet L, Part I, line 2.
Line 3--Enter the operating outlier reconciliation adjustment amount.
Line 4--Enter the capital outlier reconciliation adjustment amount.
Line 5--Enter the interest rate used to calculate the time value of money. (See CMS Pub. 100-04,
chapter 3, §§20.1.2.6.)
Line 6--Enter the operating time value of money for operating related expenses.
Line 7--Enter the capital time value of money for capital related expenses.
SECTIONS 4036 THROUGH 4039 ARE RESERVED FOR FUTURE USE.

Rev.

40-216.5

4035 (Cont.)

FORM CMS-2552-10

DRAFT

This page is reserved for future use

40-216.6

Rev.

11-17
4040.

FORM CMS-2552-10

4040.1

FINANCIAL STATEMENT WORKSHEETS

Prepare these worksheets from your accounting books and records.
Complete all worksheets in the “G” series. Complete Worksheets G and G-1 if you maintain fundtype accounting records, complete separate amounts for General, Specific Purpose, Endowment
and Plant funds on Worksheets G and G-1. If you do not maintain fund-type accounting records,
complete the general fund column only. Cost reports received with incomplete G worksheets are
returned to you for completion. If you do not follow this procedure, you are considered as having
failed to file a cost report. Where applicable, Worksheets G, G-1, G-2 and G-3 must be consistent
with financial statements prepared by Certified Public Accountants.
4040.1 Worksheet G - Balance Sheet. --If the lines on the Worksheet G are not sufficient, use
lines 5 (Other receivables), 9 (Other current assets), 44 (Other current liabilities), and 49 (Other
long term liabilities), as appropriate, to report the sum of account balances and adjustments.
Maintain supporting documentation or subscript the appropriate lines.
Enter accumulated depreciation as a negative amount.
Column 1--General Fund--Use only this fund column when you do not maintain fund-type
accounting records. This fund is similar to a general ledger account and records all assets and
liabilities of the entity
Column 2--Specific Purpose Fund--These accounts are used for funds held for specific purposes
such as research and education.
Column 3--Endowment Fund--These accounts are for amounts restricted for endowment purposes.
Column 4--Plant Fund--These accounts are for amounts restricted for the replacement and
expansion of the plant.
Line 1--Cash on Hand and in Banks--The amounts on this line represent the amount of cash on
deposit in banks and immediately available for use in financing activities, amounts on hand for
minor disbursements and amounts invested in savings accounts and certificates of deposit. Typical
accounts would be cash, general checking accounts, payroll checking accounts, other checking
accounts, imprest cash funds, saving accounts, certificates of deposit, treasury bills and treasury
notes, and other cash accounts.
Line 2--Temporary Investments--The amounts on this line represent current securities evidenced
by certificates of ownership or indebtedness. Typical accounts would be marketable securities and
other current investments.
Line 3--Notes Receivable--The amounts on this line represent current unpaid amounts evidenced
by certificates of indebtedness.
Line 4--Accounts Receivable--Include on this line all unpaid inpatient and outpatient billings.
Include direct billings to patients for deductibles, co-insurance and other patient chargeable items
if they are not included elsewhere.
Line 6--Less: Allowance for Uncollectable Notes and Accounts--These are valuation (or contraasset) accounts whose credit balances represent the estimated amount of uncollectible receivables
from patients and third-party payers. Enter this amount as a negative.

Rev. 12

40-217

4040.1 (Cont.)

FORM CMS-2552-10

11-17

Line 7--Inventory--Enter the costs of unused hospital supplies. Perpetual inventory records may
be maintained and adjusted periodically to physical count. The extent of inventory control and
detailed record-keeping will depend upon the size and organizational complexity of the hospital.
Hospital inventories may be valued by any generally accepted method, but the method must be
consistently applied from year to year.
Line 8--Prepaid Expenses--Enter the costs incurred which are properly chargeable to a future
accounting period.
Line 9--Other Current Assets --These balances include other current assets not included in other
asset categories.
Line 10--Due from Other Funds--There are four funds: General Fund, Specific Purpose Fund,
Endowment Fund and Plant Fund. These are represented in columns 1 through 4, respectively.
Amounts reported in each column should be the amount due from other funds in another column
on Worksheet G, line 43 (Due to Other Funds).
The sum of the amounts on line 10, columns 1 through 4 must equal the sum of the amounts on
line 43, columns 1 through 4.
Line 12--Land--This balance reflects the cost of land used in hospital operations. Included here is
the cost of off-site sewer and water lines, public utility, charges for servicing the land,
governmental assessments for street paving and sewers, the cost of permanent roadways and of
grading of a non-depreciable nature. Unlike building and equipment, land does not deteriorate
with use or with the passage of time; therefore, no depreciation is accumulated.
The cost of land includes (1) the cash purchase price, (2) closing costs such as title and attorney’s
fees, (3) real estate broker’s commission, and (4) accrued property taxes and other liens on the
land assumed by the purchaser.
Land 13--Land Improvements--Amounts on this line include structural additions made to land,
such as driveways, parking lots, sidewalks; as well as the cost of shrubbery, fences and walls,
landscaping, on-site sewer and water lines, and underground sprinklers. The cost of land
improvements includes all expenditures necessary to make the improvements ready for their
intended use.
Line 15--Buildings--This line includes the cost of all buildings and subsequent additions used in
hospital operations (including purchase price, closing costs, (attorney fees, title insurance, etc.,)
and real estate broker commission). Included are all architectural, consulting and legal fees related
to the acquisition or construction of buildings, and interest paid for construction financing.
Line 17--Leasehold Improvements--All expenditures for the improvement of a leasehold used in
hospital operations are included on this line.
Line 19--Fixed Equipment--Include the cost of building equipment that has the following general
characteristics:
1. Affixed to the building, not subject to transfer or removal.
2. A life of more than one year, but less than that of the building to which it is affixed.
3. Used in hospital operations.
Fixed equipment includes such items as boilers, generators, engines, pumps, and refrigeration
machinery, wiring, electrical fixtures, plumbing, elevators, heating system, air conditioning
system, etc.

40-218

Rev. 12

01-22

FORM CMS-2552-10

4040.1 (Cont.)

Line 21--Automobiles and Trucks--Enter the cost of automobiles and trucks used in hospital
operations.
Line 23--Major movable Equipment--Costs of equipment included on this line has the following
general characteristics:
1. Ability to be moved, as distinguished from fixed equipment (but not automobiles or
trucks).
2. A more or less fixed location in the building.
3. A unit cost large enough to justify the expense incident to control by means of an
equipment ledger and greater than or equal to $5,000.
4. Sufficient individuality and size to make control feasible by means of identification
tags.
5. A minimum life of usually three years or more.
6. Used in hospital operations.
Line 25--Minor Equipment-Depreciable--Costs of equipment included on this line has the
following general characteristics:
1. Ability to be moved, as distinguished from fixed equipment.
2. A more or less fixed location in the building
3. A unit cost large enough to justify the expense incident to control by means of an
equipment ledger but less than $5,000.
4. Sufficient individuality and size to make control feasible by means of identification
tags.
5. A minimum life of usually three years or more.
6. Used in hospital operations.
Line 27--Health Information Technology (HIT) Designated Assets--The amounts included here
are the acquisition costs of HIT acquired assets in accordance with ARRA 2009, section 4102.
Acute care hospitals are required to depreciate such assets in accordance with their applicable
depreciation schedules. CAHs are required to identify such assets on this line, but do not
depreciate such assets as they will be fully expensed during the year of acquisition.
Line 29--Minor Equipment-Nondepreciable--Costs of equipment included on this line has the
following general characteristics:
1. Location generally not fixed; subject to requisition or use by various departments of
the hospital.
2. Relatively small size.
3. Subject to storeroom control.
4. Fairly large number in use.
5. Generally a useful life of usually approximately three years or less.
6. Used in hospital operations.
Minor equipment includes such items as, but is not limited to wastebaskets, bed pans, syringes,
catheters, basins, glassware, silverware, pots and pans, sheets, blankets, ladders, and surgical
instruments.
Lines 14, 16, 18, 20, 22, 24, 26 and 28--Less Accumulated Depreciation--These balances,
respectively, include the depreciation accumulated on the related assets used in hospital operations.
Enter this amount as a negative.
Line 31--Investments--This field contains the cost of investments purchased with hospital funds
and the fair market value (at date of donation) of securities donated to the hospital.
Line 32--Deposits on Leases--Report the amount of deposits on leases. This includes security
deposits.
Rev. 17

40-219

4040.1 (Cont.)

FORM CMS-2552-10

01-22

Line 33--Due from Owners/Officers--Report the unpaid amount of the amount loaned to the
owners and/or officers by the hospital.
Line 34--Other Assets--This is the amount of assets not reported on line 9 (other current assets) or
any other line 1 through 33. This could include intangible assets such as goodwill, unamortized
loan costs and other organization costs.
Line 35--Total Other Assets--Sum of lines 31 through 34.
Line 36--Total Assets--Sum of lines 11, 30 and 35.
Line 37--Accounts Payable--This amount reflects the amounts due trade creditors and others for
supplies and services purchased.
Line 38--Salaries, Wages and Fees Payable--This amount reflects the actual or estimated liabilities
of the hospital for salaries and wages/fees payable.
Line 39--Payroll Taxes Payable--This amount reflects the actual or estimated liabilities of the
hospital for amounts payable for payroll taxes withheld from salaries and wages, payroll taxes to
be paid by the hospital and other payroll deductions, such as hospitalization insurance premiums.
Line 40--Notes and Loans Payable (Short-Term)--The amounts on this line represent current
amounts owing as evidenced by certificates of indebtedness coming due in the next 12 months.
Line 41--Deferred Income--Deferred income is received or accrued income which is applicable to
services to be rendered within the next accounting period. Deferred income applicable to
accounting periods extending beyond the next accounting period is included as other current
liabilities. These amounts also reflect the effects of any timing differences between book and tax
or third-party reimbursement accounting.
Line 42--Accelerated Payments--Accelerated payments are payments not yet due to be repaid to
the contractor.
Line 43--Due to Other Funds--There are four funds: General Fund, Specific Purpose Fund,
Endowment Fund and Plant Fund. These are in columns 1 through 4 respectively. Amounts are
reported in the fund owing the amount. Each amount recorded as “due to” must also be reported
on Worksheet G, line 10 (Due From Other Funds).
The sum of the amounts on line 10, columns 1 through 4 must equal the sum of the amounts on
line 41, columns 1 through 4.
Line 44--Other Current Liabilities--This line is used to record any current liabilities not reported
on lines 37 through 43.
Line 45--Total Current Liabilities--Enter the sum of lines 37 through 44.
Line 46--Mortgage Payable--This amounts reflects the long-term financing obligation used to
purchase real estate/property.
Line 47--Notes Payable--These amounts reflect liabilities of the hospital to vendors, banks and
other, evidenced by promissory notes due and payable longer than one year.

40-220

Rev. 17

12-10

FORM CMS-2552-10

4040.1 (Cont.)

Line 48--Unsecured Loans--These amounts are not loaned on the basis of collateral.
Line 49--Other Long-Term Liabilities--This line is used to record any long-term liabilities not
reported on lines 46 through 48.
Line 50--Total Long-Term Liabilities--Enter the sum of lines 46 through 49.
Line 51--Total Liabilities--Enter the sum of lines 45 and 50.
Line 52--General Fund Balance--This represents the difference between the total of General Fund
assets and General Fund Liabilities in column 1. This amount usually equals the end of period
fund balance on Worksheet G-1, column 2, line 19.
Line 53--Specific Purpose Fund--This represents the difference between the total of Specific
Purpose Fund assets and Specific Purpose Fund Liabilities in column 2.
Line 54--Donor Created - Endowment Fund Balance - Restricted--The sum of the amounts on
lines 54, 55 and 56, represent the difference between the total of Endowment Fund assets and
Endowment Fund Liabilities in column 3.
Line 55--Donor Created - Endowment Fund Balance - Unrestricted.
Line 56--Governing Body Created - Endowment Fund Balance.
Line 57--Plant Fund Balance - Invested in Plant--The sum of the amounts on lines 57 and 58,
represent the difference between the total of Plant Fund assets and Plant Fund Liabilities in
column 4.
Line 58--Plant Fund Balance - Reserves for Plant Improvement, Replacement and Expansion--The
credit balances of the restricted funds reported on lines 54 through 56, represent the net amount of
each restricted fund’s assets available for its designated purpose. The accounts should be credited
for all income earned on restricted fund assets, as well as gains on the disposal of such assets. If,
however, such items are treated as General Fund income (considering legal requirements and
donor intent), the restricted Fund Balance account is charged, and the Due to General Fund account
credited, for such income.
For Investor-Owned Corporations, the accounts on lines 53 through 58 include stock, paid in
capital and retained earnings. For Investor-Owned Partnerships, the amounts on lines 53 through
58 include capital and partner’s draw. For Investor-Owned - Division of a Corporation, the
amounts on lines 53 through 58 include the division’s or subsidiary’s stock, paid in capital and
divisional equity.
Line 59--Total Fund Balances--Enter the sum of lines 52 through 58.
Line 60--Total Liabilities and Fund Balances--Enter the sum of lines 51 and 59.
For each Fund, the amount on line 36 equals the amount on line 60.

Rev. 1

40-221

4040.2
4040.2

FORM CMS-2552-10

12-10

Worksheet G-1 - Statement of Changes in Fund Balances.--

Columns 1 and 2--General Fund.
Columns 3 and 4--Specific Purpose Fund--These accounts are used for funds held for specific
purposes such as research and education.
Columns 5 and 6--Endowment Fund--These accounts are for amounts restricted for endowment
purposes.
Columns 7 and 8--Plant Fund--These accounts are for amounts restricted for the replacement and
expansion of the plant.
Line 1--Fund Balance at Beginning of Period--The fund balance at the beginning of the period
comes from the prior year cost report Worksheet G-1, line 19, columns 2, 4, 6 and 8, respectively.
Line 2--Net Income--Transfer to column 2, the amount from Worksheet G-3, line 29. Columns 1,
3, 4, 5, 6, 7 and 8 are not completed.
Line 3--Total--For column 2, enter the sum of lines 1 and 2. Leave columns 1, 3, 5, and 7 blank.
For columns 4, 6 and 8, bring down the amount on line 1.
Lines 4 through 9--Additions--Most income is included in the net income reported on line 2. Any
increases affecting the fund balance not included in net income are reported on these lines. A
description (not exceeding 36 characters) is entered for each entry on lines 4 through 9.
Line 10--Total Additions--In columns 2, 4, 6 and 8, enter the sum of lines 4 through 9 columns 1,
3, 5 and 7, respectively.
Line 11--Subtotals--Enter the sum of lines 3 and 10 for columns 2, 4, 6 and 8. Leave columns 1,
3, 5 and 7 blank.
Lines 12 through 17--Deductions--Most expenses are included in the net income reported on line 2.
Any decreases affecting the fund balance not included in net income are reported on these lines.
A description (not exceeding 36 characters) is entered for each entry on lines 12 through 17.
Line 18--Total Deductions--In columns 2, 4, 6 and 8, enter the sum of lines 12 through 17,
columns 1, 3, 5 and 7, respectively.
Line 19--Fund Balance at the end of Period per Balance Sheet--Enter the result of line 11 minus
line 18 for columns 2, 4, 6 and 8. Leave columns 1, 3, 5 and 7 blank. The amount in line 19,
column 2 must agree with Worksheet G, line 52, column 1. The amount on line 19, column 4,
must agree with Worksheet G, line 53, column 2. The amount on line 19, column 6 must agree
with the sum of Worksheet G, column 3, lines 54 through 56. The amount on line 19, column 8
must agree with the sum of Worksheet G, column 4, lines 57 and 58.
These amounts will also be used to start next year’s Worksheet G-1.

40-222

Rev. 1

04-20

FORM CMS-2552-10

4040.3

4040.3 Worksheet G-2, Parts I and II - Statement of Patient Revenues and Operating Expenses.-This worksheet requires the reporting of total patient revenues for the entire facility and 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.
If you have more than one hospital-based HHA and/or more than one outpatient rehabilitation
provider, subscript the appropriate lines on Worksheet G-2, Part I, to report the revenue for each
multiple based facility separately.
Part I - Patient Revenues--Enter total patient revenues associated with the appropriate cost centers
on lines 1 through 9, 11 through 15, and 18 through 25.
Line 1--Hospital--Enter revenues generated by the hospital component of the complex. Obtain
these amounts from your accounting books and/or records.
Line 2—Sub-provider - IPF--Enter revenues generated by the IPF (also referred to as the IPF
excluded unit) of the complex. Obtain this amount from your accounting books and/or records.
Line 3—Sub-provider - IRF--Enter revenues generated by the IRF (also referred to as the IRF
excluded unit) of the complex. Obtain this amount from your accounting books and/or records.
Line 4—Sub-provider - Other--Enter revenues generated by components identified as
sub-providers of the complex that were not identified on lines 2 or 3. Subscript this line as
necessary. Obtain these amounts from your accounting books and/or records.
Line 5--Swing-Bed SNF--Enter the swing-bed SNF revenue from your accounting books and/or
records.
Line 6--Swing-Bed NF--Enter the swing-bed NF revenue from your accounting books and/or
records.
Line 7--Skilled Nursing Facility--Enter the skilled nursing facility revenue from your accounting
books and/or records.
Line 8--Nursing Facility--Enter the nursing facility revenue from your accounting books and/or
records.
Line 9--Other Long Term Care-- Enter the revenue generated from other long term care subproviders from your accounting books and/or records. Subscript this line as necessary.
Line 10--Total General Inpatient Routine Care--Sum of lines 1 through 9.
Line 11--Intensive Care Unit--Enter the intensive care unit revenue from your accounting books
and/or records.
Line 12--Coronary Care Unit--Enter the coronary care unit revenue from your accounting books
and/or records.
Line 13--Burn Intensive Care Unit--Enter the burn intensive care unit revenue from your
accounting books and/or records.
Line 14--Surgical Intensive Care Unit--Enter the surgical intensive care unit revenue from your
accounting books and/or records.

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04-20

Line 15--Other Special Care-- Enter all other intensive care unit revenue not identified on lines 11
through 14 from your accounting books and/or records. Subscript this line as necessary.
Line 16--Total Intensive Care Type Inpatient Hospital--Sum of lines 11 through 15.
Line 17--Total Inpatient Routine Care Services--Sum of lines 10 and 16.
Line 18--Ancillary Services--Enter in the appropriate column revenue from inpatient ancillary
services and outpatient ancillary services from your accounting books and/or records.
Line 19--Outpatient Services--Enter in the appropriate column revenue from outpatient ancillary
services from your accounting books and/or records.
Line 20--Rural Health Clinic (RHC)--Enter RHC revenue from your accounting books and/or
records. Subscript this line to identify each rural health clinic separately.
Line 21--Federally Qualified Health Center (FQHC)--Enter FQHC revenue from your accounting
books and/or records. Subscript this line to identify each FQHC separately.
Line 22--Home Health Agency--Enter HHA revenue from your accounting books and/or records.
If there is more than one HHA, include the revenues for all HHAs on this line.
Line 23--Ambulance Services--Enter from your accounting books and/or records the revenue
relative to the ambulance service cost reported on Worksheet A, line 95.
Line 24--Outpatient Rehabilitation Providers--Enter in column 2 only, the revenue generated from
CMHC, CORF, outpatient therapy providers (OPTs, OOTs and OSPs), and any other outpatient
rehabilitation providers. Subscript this line to identify each outpatient rehabilitation provider
separately. Obtain this information from your accounting books and/or records.
Line 25--Ambulatory Surgical Center(s)--Enter from your accounting books and/or records the
revenue relative to the ASC costs report on Worksheet A, lines 75, and 115.
Line 26--Hospice--Enter from your accounting books and/or records in the appropriate column,
the revenue generated from hospice services rendered. If there is more than one hospice, include
the revenues for all hospices on this line.
Line 27--Enter in the appropriate column all other revenues not identified on lines 18 through 26.
Line 28--Total Patient Revenues--Enter the sum of lines 17 through 27.
Column 3--For lines 1 through 28, enter the sum of columns 1 and 2, as applicable, in column 3.
Part II - Operating Expenses--Enter the expenses incurred that arise during the ordinary course of
operating the hospital complex.
Line 29--Operating Expenses--This amount is transferred from Worksheet A, line 200, column 3.
Lines 30 through 35--Add (Specify)--Identify on these lines additional operating expenses not
included in line 29.
Line 36--Total Additions--Enter on line 36, column 2, the sum of lines 30 through 35, column 1.

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FORM CMS-2552-10

4040.4

Lines 37 through 41--Deduct (specify)--Identify on these lines deductions from operating expenses
not accounted for included in line 29.
Line 42--Total Deductions--Enter on line 42, column 2, the sum of lines 37 to 41, column 1.
Line 43--Total Operating Expenses--Enter on line 43, column 2, the result of line 29, column 2,
plus line 36, column 2, less line 42, column 2.
4040.4 Worksheet G-3 - 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--Transfer from Worksheet G-2, Part I, line 28, column 3.
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,
Implicit Price Concessions, and
Other Deductions from Revenue.
Line 3--Net Patient Revenues--Subtract line 2 from line 1.
Line 4--Less: Total Operating Expenses--Transfer from Worksheet G-2, Part II, line 43.
Line 5--Net Income from Service to Patients--Subtract line 4 from line 3.
Lines 6 through 23--Enter on the appropriate line 6 through 23 all other revenue not reported on
line 1. Obtain these amounts from your accounting books and/or records.
Line 24--Other (Specify)--Enter from hospital books. Enter all other revenue not reported on
lines 6 through 23. Obtain this from your accounting books and/or records. Subscript this line as
necessary.
Line 24.50--COVID-19 PHE Funding--Enter the aggregate revenue received for COVID-19 PHE
funding including both PRF and Small Business Association Loan Forgiveness amounts.
Line 25--Total Other Income--Enter the sum of lines 6 through 24.
Line 26--Total--Enter the sum of lines 5 and 25.
Line 27--Other Expenses (Specify)--Enter all other expenses not reported on lines 6 through 24.
Subscript this line as necessary.
Line 28--Total Other Expenses--Enter the sum of line 27 and subscripts.
Line 29--Net Income (or Loss) for the Period--Enter the result of line 26 minus line 28.

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4041
4041.

FORM CMS-2552-10

01-22

WORKSHEET H - ANALYSIS OF HOSPITAL-BASED HOME HEALTH AGENCY
COSTS

This worksheet provides for the recording of direct HHA costs such as salaries, fringe benefits,
transportation, and contracted services as well as other costs from your accounting books and
records to arrive at the identifiable agency cost. This data is required by 42 CFR 413.20. It also
provides for the necessary reclassifications and adjustments to certain accounts prior to the cost
finding calculations. The direct costs reported in columns 1, 2, and 4 are obtained from your
accounting books and records. All of the cost centers listed do not apply to all agencies.
The HHA must maintain the records necessary to determine the split in salary (and employeerelated benefits) between two or more cost centers and must adequately substantiate the method
used to split the salary and employee-related benefits. These records must be available for audit
by your contractor. Your contractor can accept or reject the method used to determine the split in
salary. Any deviation or change in methodology to determine splits in salary and employee
benefits must be requested in writing and approved by your contractor before any change is
effectuated. Where approval of a method has been requested in writing and this approval has been
received (prior to the beginning of the cost reporting period), the approved method remains in
effect for the requested period and all subsequent periods until you request in writing to change to
another method or until your contractor determines that the method is no longer valid due to
changes in your operations.
Column 1--Enter all salaries and wages (a salary is the gross amount paid to the employee before
taxes and other items are withheld, including deferred compensation, overtime, incentive pay, and
bonuses) for the HHA in this column for the actual work performed within the specific area or cost
center. For example, if the administrator spends 100 percent of his/her time in the HHA and
performs skilled nursing care which accounts for 25 percent of that person’s time, then 75 percent
of the administrator’s salary is entered on line 5 (A&G - HHA), and 25 percent of the
administrator’s salary is entered on line 6 (skilled nursing care). Enter the sum of column 1, lines 1
through 23, on line 24.
Column 2--Enter all payroll-related employee benefits for the HHA in the appropriate cost center
in this column. See CMS Pub. 15-1, chapter 21, §§2144-2145 for a definition of fringe benefits.
Entries are made using the same basis as that used for reporting salaries and wages in column 1.
Therefore, using the same example as given for column 1, 75 percent of the administrator’s
payroll-related fringe benefits is entered on line 5 (A&G - HHA) and 25 percent of the
administrator’s payroll-related fringe benefits is entered on line 6 (skilled nursing care). Enter the
sum of column 2, lines 1 through 23, on line 24.
Report payroll-related employee benefits in the cost center where the applicable employee’s
compensation is reported. This assignment is performed on an actual basis or upon the following
basis:
• FICA based on actual expense by cost center;
• Pension and retirement and health insurance (non-union) based on gross salaries of
participating individuals by cost centers;
• Union health and welfare based on gross salaries of participating union members by
cost center; and
• All other payroll-related benefits based on gross salaries by cost center.

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Include nonpayroll-related employee benefits in the administrative and general-HHA cost center.
Costs for such items as personal education, recreation activities, and day care are included in the
administrative and general - HHA cost center.
Column 3--If the transportation costs, i.e., owning or renting vehicles, public transportation
expenses, or payments to employees for driving their private vehicles can be directly assigned to
a particular cost center, enter those costs in the appropriate cost center. If these costs are not
identifiable to a particular cost center, enter them on line 4. Enter the sum of column 3, lines 1
through 23 on line 24.
Column 4--Enter the contracted and purchased services amounts in the appropriate cost center in
this column. If a contracted/purchased service covers more than one cost center, then include the
amount applicable to each cost center on each affected cost center line. Enter the sum of column 4,
lines 1 through 23 on line 24.
Column 5--From your books and records, enter on the applicable lines all other identifiable costs
which have not been reported in columns 1 through 4. Enter the sum of column 5, lines 1 through
23, on line 24.
Column 6--Add the amounts in columns 1 through 5 for each cost center, and enter the totals in
column 6.
Column 7--Enter any reclassifications among the cost center expenses listed in column 6 which
are needed to effect proper cost allocation. This column need not be completed by all providers,
but is completed only to the extent reclassifications are needed and appropriate in the particular
circumstances. Show reductions to expenses as negative amounts.
Column 8--Add column 7 to column 6, and extend the net balances to column 8.
Column 9--In accordance with 42 CFR 413ff, enter on the appropriate lines the amounts of any
adjustments to expenses required under the Medicare principles of reimbursement. (See §4016.)
Column 10--Adjust the amounts in column 8 by the amounts in column 9, and extend the net
balance to column 10.
Transfer the amounts in column 10, lines 1 through 24, to the corresponding lines on
Worksheet H-1, Part I, column 0.
Line Descriptions
Lines 1 and 2--These cost centers include depreciation, leases and rentals for the use of facilities
and/or equipment, interest incurred in acquiring land or 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.
Line 3--Enter the direct expenses incurred in the operation and maintenance of the plant and
equipment, maintaining general cleanliness and sanitation of the plant, and protecting employees,
visitors, and agency property.
Line 4--Enter all of the cost of transportation except those costs previously directly assigned in
column 3. This cost is allocated during the cost finding process.

Rev. 10

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11-16

Line 5--Use this cost center to record the expenses of several costs which benefit the entire facility.
Examples include fiscal services, legal services, accounting, data processing, taxes, and
malpractice costs.
Line 6--Skilled nursing care is a service that must be provided by or under the supervision of a
registered nurse. The complexity of the service, as well as the condition of the patient, are factors
to be considered when determining whether skilled nursing services are required. Additionally,
the skilled nursing services must be required under the plan of treatment.
Line 7--Enter the direct costs of physical therapy services by or under the direction of a registered
physical therapist as prescribed by a physician. The therapist provides evaluation, treatment
planning, instruction, and consultation.
Line 8--These services include (1) teaching of compensatory techniques to permit an individual
with a physical impairment or limitation to engage in daily activities; (2) evaluation of an
individual's level of independent functioning; (3) selection and teaching of task-oriented
therapeutic activities to restore sensory-integrative function; and (4) assessment of an individual's
vocational potential, except when the assessment is related solely to vocational rehabilitation.
Line 9--These are services for the diagnosis and treatment of speech and language disorders that
create difficulties in communication.
Line 10--These services include (1) assessment of the social and emotional factors related to the
individual's illness, need for care, response to treatment, and adjustment to care furnished by the
facility; (2) casework services to assist in resolving social or emotional problems that may have an
adverse effect on the beneficiary's ability to respond to treatment; and (3) assessment of the
relationship of the individual's medical and nursing requirements to his or her home situation,
financial resources, and the community resources available upon discharge from facility care.
Line 11--Enter the cost of home health aide services. The primary function of a home health aide
is the personal care of a patient. The services of a home health aide are given under the supervision
of a registered professional nurse and, if appropriate, a physical, speech, or occupational therapist.
The assignment of a home health aide to a case must be made in accordance with a written plan of
treatment established by a physician which indicates the patient's need for personal care services.
The specific personal care services to be provided by the home health aide must be determined by
a registered professional nurse and not by the home health aide.
Line 12--The cost of medical supplies reported in this cost center are those costs which are directly
identifiable supplies furnished to individual patients and for which a separate charge is made.
These supplies are generally specified in the patient’s plan of treatment and furnished under the
specific direction of the patient’s physician.
Medical supplies which are not reported on this line are those minor medical and surgical supplies
which would not be expected to be specifically identified in the plan of treatment or for which a
separate charge is not made. These supplies (e.g., cotton balls, alcohol prep) are items that are
frequently furnished to patients in small quantities (even though in certain situations, these items
may be used in greater quantity) and are reported in the (A&G) cost center.
Line 13--Enter the costs of vaccines exclusive of the cost of administering the vaccines. A visit
by an HHA nurse for the sole purpose of administering a vaccine is not covered as an HHA visit
under the home health benefit, even though the patient may be an eligible home health beneficiary
receiving services under a home health plan of treatment. Section 1862(a)(1)(B) of the Act
excludes Medicare coverage of vaccines and their administration other than the Part B coverage
contained in §1861 of the Act.

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FORM CMS-2552-10

4041 (Cont.)

If the vaccine is administered in the course of an otherwise covered home health visit, the visit is
covered as usual, but the cost and charges for the vaccine and its administration must be excluded
from the cost and charges of the visit. The HHA is entitled to separate payment for the vaccine
and its administration under the Part B vaccine benefit.
The cost of administering pneumococcal, influenza, COVID19, and hepatitis B vaccines, and
monoclonal antibody products for treatment of COVID-19 is reimbursed under the OPPS, but the
actual cost of the pneumococcal, influenza, COVID-19, and hepatitis B vaccines, and monoclonal
antibody products for treatment of COVID-19 are cost reimbursed. Additionally, the cost of
administering the osteoporosis drugs are included in the skilled nursing visit while the actual cost
of the osteoporosis drug is reimbursed at reasonable cost.
Enter the cost for the COVID-19 vaccine and monoclonal antibody products to treat COVID-19,
authorized and furnished for use during the COVID-19 PHE. The COVID-19 vaccine and
monoclonal antibody product costs and its administration will be reimbursed in the same way
influenza vaccine cost and its administration is reimbursed. When COVID-19 vaccine doses are
provided by the government without charge, do not report the cost for such vaccines on this line.
In addition, Medicare will not provide payment for the monoclonal antibody products to treat
COVID-19 that health care providers receive for free, as will be the case upon the product’s initial
availability in response to the COVID-19 PHE.
Enter on this line the vaccine and drug cost (exclusive of the cost to administer these vaccines)
incurred for pneumococcal, influenza (includes COVID-19), and hepatitis B vaccines, and
monoclonal antibody products for treatment of COVID-19, as well as osteoporosis drugs.
Some of the expenses includable in this cost center are the costs of syringes, cotton balls, bandages,
etc., but the cost of travel is not permissible as a cost of administering vaccines, nor is the travel
cost includable in the A&G cost center. The travel cost is non-reimbursable. Attach a schedule
detailing the methodology employed to develop the administration of these vaccines. These
vaccines are reimbursable under Part B only.
Line 14--Enter the direct expenses incurred in renting or selling DME items to the patient for the
purpose of carrying out the plan of treatment. Also, include all the direct expenses incurred by
you in requisitioning and issuing the DME to patients.
Lines 15 through 23--Lines 15 through 23 identify nonreimbursable services commonly provided
by HHAs. These include home dialysis aide services (line 15), respiratory therapy (line 16),
private duty nursing (line 17), clinic (line 18), health promotion activities (line 19), day care
program (line 20), home delivered meals program (line 21), and homemaker service (line 22). The
cost of all other nonreimbursable services are aggregated on line 23. If you are reporting costs for
telemedicine, these costs are to be reported on line 23.50. Use this line throughout all applicable
worksheets.

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40-229

4042
4042.

FORM CMS-2552-10

01-22

WORKSHEET H-1 - COST ALLOCATION - HHA GENERAL SERVICE COST

Worksheet H-1, Part I, provides for the allocation of the expenses of each HHA general service
cost center to those cost centers which receive the services. The cost centers serviced by the
general service cost centers include all cost centers within the HHA, i.e., other general service cost
centers, reimbursable cost centers, and nonreimbursable cost centers. Obtain the total direct
expenses from Worksheet H, column 10. To facilitate transferring amounts from Worksheet H to
Worksheet H-1, Part I, the same cost centers with corresponding line numbers (lines 1 through 24)
are listed on both worksheets.
Worksheet H-1, Part II, provides for the proration of the statistical data needed to equitably
allocate the expenses of the HHA general service cost centers on Worksheet H-1, Part I. If there
is a difference between the total accumulated costs reported on the Part II statistics and the total
accumulated costs calculated on Part I, use the reconciliation column on Part II for reporting any
adjustments. See §4020 for the appropriate usage of the reconciliation columns. For
componentized A&G cost centers, the accumulated cost center line number must match the
reconciliation column number.
To facilitate the allocation process, the general format of Parts I and II are identical. The column
and line numbers for each general service cost center are identical on both parts. In addition, the
line numbers for each general, reimbursable, and nonreimbursable cost centers are identical on the
two parts of the worksheet. The cost centers and line numbers are also consistent with
Worksheet H.
The statistical bases shown at the top of each column on Worksheet H-1, Part II, are the
recommended bases of allocation of the cost centers indicated. If a different basis of allocation is
used, the provider must indicate the basis of allocation actually used at the top of the column.
Most cost centers are allocated on different statistical bases. However, for those cost centers where
the basis is the same (e.g., square feet), the total statistical base over which the costs are to be
allocated will differ because of the prior elimination of cost centers that have been closed.
When closing the general service cost center, first close those cost centers that render the most
services to and receive the least services from other cost centers. The cost centers are listed in this
sequence from left to right on the worksheet. However, the circumstances of an agency may be
such that a more accurate result is obtained by allocating to certain cost centers in a sequence
different from that followed on these worksheets.
NOTE: The HHA can elect to change the order of allocation and/or allocation statistics, as
appropriate, for the current cost reporting period if a request is received by the contractor,
in writing, 90 days prior to the end of that reporting period. The contractor has 60 days
to make a decision and notify the provider of that decision or the change is automatically
accepted. The change must be shown to more accurately allocate the overhead or
demonstrate simplification in maintaining the changed statistics. If a change in statistics
is requested, the provider must maintain both sets of statistics until an approval is made.
If both sets are not maintained and the request is denied, the provider reverts back to the
previously approved methodology. The provider must include with the request all
supporting documentation and a thorough explanation of why the alternative approach
should be used. (See CMS Pub. 15-1, chapter 23, §2313.)
EXCEPTION: A small freestanding HHA, as defined in 42 CFR 413.24(d), does not have to
request written permission to use the procedures outlined for small HHAs below.

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FORM CMS-2552-10

4042 (Cont.)

On Worksheet H-1, Part II, enter on the first line in the column of the cost center being allocated
the total statistical base over which the expenses are allocated (e.g., in column 1, capital-related buildings and fixtures, enter on line 1 the total square feet of the building on which depreciation
was taken). For all cost centers to which the capital-related cost is allocated, enter that portion of
the total statistical base applicable to each. The sum of the statistical base applied to each cost
center receiving the services must equal the total base entered on the first line. Use accumulated
cost for allocating A&G expenses.
Do not include any statistics related to services furnished under arrangements unless:
•

Both Medicare and non-Medicare costs of arranged for services are recorded in your
records; or

• Your contractor determines that you are able to (and do) gross up the costs and charges
for services to non-Medicare patients so that both cost and charges are recorded as if
you had furnished such services directly to all patients. (See CMS Pub. 15-1,
chapter 23, §2314.)
Enter on Worksheet H-1, Part II, line 25, the total expenses of the cost center to be allocated.
Obtain this amount from Worksheet H-1, Part I, from the same column and line number used to
enter the statistical base on Worksheet H-1, Part II. In the case of capital-related costs - buildings
and fixtures, this amount is on Worksheet H-1, Part I, column 1, line 1.
NOTE: On Worksheet H-1, Parts I and II, the first line of each column must equal line 24 of the
column. Therefore, when totaling a column exclude from line 24 the amount on the first
line of that column.
Divide the amount entered on Worksheet H-1, Part II, line 25, by the total statistical base entered
in the same column on the first line. Enter the resulting unit cost multiplier on line 26. Round the
unit cost multiplier to six decimal places.
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 H-1,
Part I, in the corresponding column and line.
After the unit cost multiplier has been applied to all the cost centers receiving costs, the total
expenses (line 24) of all of the cost centers receiving the allocation on Worksheet H-1, Part I, must
equal the amount entered on the first line of the cost center being allocated.
The preceding procedures must be performed for each general service cost center. Each cost center
must be completed on both Part I and Part II before proceeding to the next cost center.
After all the costs of the general service cost centers have been allocated on Worksheet H-1, Part I,
enter in column 6, line 24 the sum of the expenses on lines 6 through 23. The total expenses
entered in column 6, line 24, equals the total expenses entered in column 0, line 24.
Column Descriptions
Column 1--Depreciation on buildings and fixtures and expenses pertaining to buildings and
fixtures such as 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 footage
of the occupied area. The square footage may be weighted if the person who occupies a certain
area of space spends their time in more than one function. For example, if a person spends
10 percent of time in one function, 20 percent in another function, and 70 percent in still another
function, the square footage may be weighted according to the percentages of 10 percent,
20 percent, and 70 percent to the applicable functions.

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11-16

Column 2--Allocate all expenses (e.g., interest, personal property tax) for movable equipment to
the appropriate cost centers on the basis of dollar value.
Column 3--Allocate all expenses for plant operation and maintenance based on square feet.
Column 4--The cost of vehicles owned or rented by the agency and all other transportation costs
which were not directly assigned to another cost center on Worksheet H, column 3, is included in
this cost center. Allocate this expense to the cost centers to which it applies on the basis of miles
applicable to each cost center.
This basis of allocation is not mandatory and a provider may use weighted trips rather than actual
miles as a basis of allocation for transportation costs which are not directly assigned. However,
an HHA must request the use of the alternative method in accordance with CMS Pub. 15-1,
chapter 23, §2313. The HHA must maintain adequate records to substantiate the use of this
allocation.
Column 5--The A&G expenses are allocated on the basis of accumulated costs after
reclassifications and adjustments. Therefore, obtain the amounts to be entered on Worksheet H-1,
Part II, column 5, from Worksheet H-1, Part I, columns 0 through 4.
A negative cost center balance in the statistics for allocating A&G expenses causes an improper
distribution of this overhead cost center. Negative balances are excluded from the allocation
statistics when A&G expenses are allocated on the basis of accumulated cost.
A&G costs applicable to contracted services may be excluded from the total cost (Worksheet H-1,
Part I, column 0) for purposes of determining the basis of allocation (Worksheet H-1, Part II,
column 5) of the A&G costs. This procedure may be followed when the HHA contracts for
services to be performed for the HHA and the contract identifies the A&G costs applicable to the
purchased services. The contracted A&G costs must be added back to the applicable cost center
after allocation of the HHA A&G cost before the reimbursable costs are transferred to
Worksheet H-2. A separate worksheet must be included to display the breakout of the contracted
A&G costs from the applicable cost centers before allocation and the adding back of these costs
after allocation. Contractor approval does not have to be secured in order to use the above
described method of cost finding for A&G.
Column 6--For lines 6 through 23, add the amounts on each line in columns 4A and 5, and enter
the result for each line in this column.
Transfer the amounts in column 6 to Worksheet H-2, Part I, column 0, as follows:

40-232

From Worksheet H-1,
Part I, Column 6

To Worksheet H-2,
Part I, Column 0

Line 6
7

Line 2
3

Rev. 10

09-15

Rev. 8

FORM CMS-2552-10
From Worksheet H-1,
Part I, Column 6

To Worksheet H-2,
Part I, Column 0

Line 8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

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

4042 (Cont.)

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4043
4043.

FORM CMS-2552-10

09-15

WORKSHEET H-2 - ALLOCATION OF GENERAL SERVICE COSTS TO HHA
COST CENTERS

Use this worksheet only if you operate a certified hospital-based HHA as part of your complex. If
you have more than one hospital-based HHA, complete a separate worksheet for each facility.
4043.1 Part I - Allocation of General Service Costs to HHA Cost Centers.--Worksheet H-2,
Part I, provides for the allocation of the expenses of each general service cost center of the hospital
to those cost centers which receive the services. Worksheet H-2, Part II, provides for the proration
of the statistical data needed to equitably allocate the expenses of the general service cost centers
on Worksheet H-2, Part I.
Obtain the total direct expenses (column 0, line 20) from Worksheet A, column 7, line 101. Obtain
the cost center allocations (column 0, lines 1 through 19) from Worksheet H-1, Part I, lines as
indicated, the sum of which agrees with the amount entered on column 0, line 20. The amounts
on line 20, columns 0 through 23 and column 25 must agree with the corresponding amounts on
Worksheet B, Part I, columns 0 through 23, and column 25, line 101. Complete the amounts
entered on lines 1 through 19, columns 1 through 23, and column 25, in accordance with the
instructions in §4043.2.
NOTE: Worksheet B, Part I, established the method used to reimburse direct GME cost (i.e.,
reasonable cost or the per-resident amount). Therefore, this worksheet must follow that
method. If Worksheet B, Part I, column 25, excluded the costs of interns and residents,
column 25, on this worksheet must also exclude these costs.
In column 24, Part I, enter the total of columns 4A through 23.
In column 27, Part I, enter on line 21, the unit cost multiplier (column 26, line 1, divided by the
sum of column 26, line 20 minus column 26, line 1). Round the unit cost multiplier to 6 decimal
places. Multiply each amount in column 26, lines 2 through 19, by the unit cost multiplier on
line 21, and enter the result on the corresponding line of column 27. On line 20, enter the total of
the amounts on lines 2 through 19. The total on line 20 must equal the amount in column 26,
line 1.
In column 28, Part I, enter on lines 2 through 19, the sum of columns 26 and 27. The total on
line 20 must equal the total in column 27, line 20.
4043.2 Part II - Allocation of General Service Costs to HHA Cost Centers -Statistical Basis.--To
facilitate the allocation process, the general format of Worksheet H-2, Parts I and II, is identical.
Worksheet H-2, Part II, provides for the proration of the statistical data needed to equitably
allocate the expenses of the hospital’s general service cost centers on Worksheet H-2, Part I.
The statistical basis shown at the top of each column on Worksheet H-2, Part II, is the
recommended basis of allocation of the cost center indicated.
Lines 1 through 19--On Worksheet H-2, Part II, for all cost centers to which the general service
cost center is being allocated, enter that portion of the total statistical base applicable to each.

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Line 20--Enter the total of lines 1 through 19, for each column. The total in each column must be
the same as shown for the corresponding column on Worksheet B-1, line 101.
Line 21--Enter the total expenses for the cost center allocated. Obtain this amount from
Worksheet B, Part I, line 101, from the same column used to enter the statistical base on
Worksheet H-2, Part II (e.g., in the case of capital-related cost buildings and fixtures, this amount
is on Worksheet B, Part I, column 1, line 101).
Line 22--Enter the unit cost multiplier which is obtained by dividing the cost entered on line 21 by
the total statistic entered in the same column on line 20. Round the unit cost multiplier to six
decimal places.
Multiply the unit cost multiplier by that portion of the total statistic applicable to each cost center
receiving the services. Enter the result of each computation on Worksheet H-2, Part I, in the
corresponding column and line.
After the unit cost multiplier has been applied to all the cost centers receiving the services, the
total cost (Part I, line 20) must equal the total cost on Part II, line 21.
Perform the preceding procedures for each general service cost center.

Rev. 8

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4044

FORM CMS-2552-10

4044.

WORKSHEET H-3 - APPORTIONMENT OF PATIENT SERVICE COSTS

09-15

This worksheet provides for the apportionment of home health patient service costs to titles V,
XVIII, and XIX. Titles V and XIX use the columns identified as Part A for each program.
4044.1 Part I - Computation of the Aggregate Program Cost.--This part provides for the
computation of the total cost and reasonable program cost by discipline based on program patient
care visits as required by 42 CFR 413.20, 42 CFR 413.24, and 42 CFR 484.200. For HHA
services rendered on or after October 1, 2000, §1895 of the Social Security Act requires an HHA
to be paid based on a PPS subject to periodic updates.
Cost Per Visit Computation
Column Descriptions
Column 1--Enter the cost for each discipline from Worksheet H-2, Part I, column 28, lines as
indicated. Enter the total on line 7.
Column 2--Where the hospital complex maintains separate Physical Therapy, Occupational
Therapy and/or Speech Pathology departments, and these departments provide services to patients
of the hospital’s HHA, transfer the amounts from Worksheet H-3 Part II, column 3, lines 1 through
3, to lines 2 through 4, as appropriate. Enter the total on line 7.
Column 3--Enter the sum of columns 1 and 2.
Column 4--Enter the total agency visits from your records for each type of discipline on lines 1
through 6. Total visits reported in column 4 reflect visits rendered for the entire fiscal year and
equal the visits reported on S-3, Part I, regardless of when the episode was completed.
Column 5--Compute the average cost per visit for each type of discipline. Divide the number of
visits (column 4) into the cost (column 3) for each discipline.
Columns 6 and 9--To determine title XVIII, Part A; V; and XIX; cost of service, multiply the
number of Medicare covered visits in completed episodes made to beneficiaries (column 6) (from
your records) by the average cost per visit amount in column 5, for each discipline. Enter the
product in column 9.
NOTE: Statistics in column 7, lines 1 through 7, reflect statistics for services that are part of a
home health plan, and thus not subject to deductibles and coinsurance. OBRA 1990
provides for the limited coverage of injectable drugs for osteoporosis. While covered as
a home health benefit under Part B, these services are subject to deductibles and
coinsurance. Report charges for osteoporosis injections in column 8, line 16, in addition
to statistics for services that are not part of a home health plan.
Columns 7 and 10--To determine the Medicare Part B cost of service, not subject to deductibles
and coinsurance, multiply the number of Medicare covered visits made in completed episodes to
Part B beneficiaries (column 7) (from your records) by the average cost per visit amount in
column 5 for each discipline. Enter the product in column 10. Note if the PS&R reports Part B
services separately as "subject to and not subject to” deductibles and coinsurance, add the two
reports together for each discipline.
Columns 6, 7, 9, 10 and 12--Enter visits and costs as applicable in columns 6, 7, 9, 10, and 12.

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4044.1 (Cont.)

NOTE: The sum of visits reported in columns 6 and 7 must equal the corresponding amounts on
Worksheet S-4, column 5, lines 21, 23, 25, 27, 29, and 31. These visits are reported for
episodes completed during the fiscal year.
Columns 8 and 11--Do not use these columns.
Column 12--Enter the total program cost for each discipline (sum of columns 9 and 10). Add the
amounts on lines 1 through 6, and enter this total on line 7.
Visits by CBSA--Lines 8 through 14--HHAs are paid for home health services under title XVIII
on the basis of the geographic location at which the service is furnished. Enter for each discipline
the CBSA code of the location where the home health service was furnished. Subscript each
discipline line to accommodate multiple CBSAs serviced by your HHA.
Column Descriptions
Column 1--Enter the CBSA code in which the corresponding HHA visits were rendered for each
discipline on lines 8 through 13.
Columns 2 and 3--Enter the visit count for each of the corresponding disciplines for each CBSA.
Column 4, lines 8 through 14--These lines are shaded to prevent data input.
Line 14--Enter the total program visits for each discipline by adding lines 8 through 13, and
subscripts, and enter this total on line 14.
Supplies and Drugs Cost Computation.--Certain services covered by the program and furnished
by an HHA are not included in the cost per visit for apportionment purposes. Since an average
cost per visit and HHA PPS do not apply to these items, develop and apply the ratio of total cost
to total charges to program charges to arrive at the program cost for these services.
Column 1--Enter the facility costs in column 1, lines 15 and 16, from Worksheet H-2, Part I,
column 28, lines 8 and 9, respectively.
Column 2--Enter the shared ancillary costs from Worksheet H-3, Part II, column 3, lines 4 and 5.
Columns 3 through 5--In column 3, enter the sum total of columns 1 and 2, on lines 15 and 16,
respectively. Enter in column 4, lines 15 and 16, respectively, the total charges for such services
in accordance with the instructions in §4041, lines 12 and 13. Develop a ratio of total cost
(column 3) to total charges (column 4) (from your records), and enter this ratio in column 5.
Columns 6 through 8--Enter in the appropriate column the program charges for drugs and medical
supplies charged to patients subject to cost reimbursement. The actual vaccine/drug cost for
pneumococcal, influenza, COVID-19, hepatitis B, osteoporosis, and monoclonal antibody
products for treatment of COVID-19 are cost reimbursed.
Do not enter charges for drugs and medical supplies subject to reimbursement on the basis of a fee
schedule.

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Line Descriptions for Columns 6 through 8
Line 15--Columns 6 through 11 are shaded to prevent the input of medical supplies charged to
patients as all medical supplies are covered under the HHA PPS benefit. Effective for cost
reporting periods ending on or after October 1, 2014, enter in columns 6 through 11, medical
supplies covered under the HHA PPS benefit. This information is captured for statistical purposes
only.
Line 16--This line represents pneumococcal, influenza, COVID-19, and hepatitis B vaccine costs
and injectable osteoporosis drugs, and monoclonal antibody products for treatment of COVID-19,
but not the administration of these medications. Enter the program covered charges for drugs
charged to patients for items not reimbursed on the basis of a fee schedule or the OPPS. Enter in
column 7 the program charges for pneumococcal, influenza, and COVID-19 vaccines, and
monoclonal antibody products for treatment of COVID-19, all exclusive of their respective
administration costs. Enter in column 8, the program charges for hepatitis B vaccine and injectable
osteoporosis drugs exclusive of their respective administration costs.
Columns 6 and 9--To determine the Medicare cost, multiply the program charges (column 6) by
the ratio (column 5) for each line. Enter the product in column 9.
Columns 7 and 10--To determine the Medicare Part B cost, multiply the Medicare charges
(column 7) by the ratio (column 5) for each line. Enter the product in column 10.
Columns 8 and 11--To determine the Medicare Part B cost, multiply the Medicare charges
(column 8) by the ratio (column 5) for each line. Enter the result in column 11.
4044.2 Part II - Apportionment of Cost of HHA Services Furnished by Shared Hospital
Departments.--Use this part only where the hospital complex maintains a separate department for
any of the cost centers listed on lines 1 through 5 of this part of the worksheet, and these
departments provide services to patients of the hospital's HHA. Subscript lines 1 through 5, as
applicable, if subscripted on Worksheet C, Part I.
Column 1--Where applicable, enter in column 1 the cost-to-charge ratio from Worksheet C, Part I,
column 9, lines as indicated.
Column 2--Where hospital departments provide services to the HHA, enter on the appropriate lines
the charges applicable to the hospital-based HHA.
Column 3--Multiply the amounts in column 2 by the ratios in column 1, and enter the result in
column 3. Transfer the amounts in column 3 to Worksheet H-3, Part I, as indicated. If lines 1
through 5 are subscripted, transfer the aggregate of each line.

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FORM CMS-2552-10

4045.

4045.1

WORKSHEET H-4 - CALCULATION OF HHA REIMBURSEMENT SETTLEMENT

This worksheet provides for the reimbursement calculation of titles V; XVIII, Parts A and B; and
XIX. This computation is required by 42 CFR 413.9, 42 CFR 413.13, and 42 CFR 413.30.
Worksheet H-4 consists of the following two parts:
Part I - Computation of the Lesser of Reasonable Cost or Customary Charges
Part II - Computation of HHA Reimbursement Settlement
4045.1 Part I - Computation of Lesser of Reasonable Cost or Customary Charges.--Services not
paid based on a fee schedule or the OPPS are paid the lesser of the reasonable cost of services
furnished to beneficiaries or the customary charges made by the providers for the same services.
This part provides for the computation of the lesser of reasonable cost or customary charges as
defined in 42 CFR 413.13(a).
NOTE: Nominal charge providers are not subject to the lesser of cost or charges (LCC).
Therefore, a nominal charge provider only completes lines 1, 2, and 9, of Part I. Transfer
the resulting cost to Part II, line 10.
Line Descriptions
Line 1--This line provides for the computation of reasonable cost reimbursed program services.
Enter the cost of services from Worksheet H-3, Part I, as follows:
To Worksheet H-4, Line 1

From Worksheet H-3,

Col. 1, Part A

Part I, col. 9, line 16

Col. 2, Part B - Not subject to
deductibles and coinsurance

Part I, col. 10, line 16

Col. 3, Part B - Subject to
deductibles and coinsurance

Part I, col. 11, line 16

The above table reflects the transfer of the cost of pneumococcal and influenza, and COVID-19
vaccines and monoclonal antibody products for treatment of COVID-19, from Worksheet H-3,
Part I, column 10, line 16, to column 2 of this worksheet, and the cost of hepatitis B vaccines and
injectable osteoporosis drugs from worksheet H-3, Part I, column 11, line 9, to column 3 of this
worksheet.
Lines 2 through 6--These lines provide for the accumulation of charges which relate to the
reasonable cost on line 1. Do not include on these lines (1) the portion of charges applicable to
the excess costs of luxury items or services (see CMS Pub. 15-1, chapter 21, §2104.3) and
(2) provider charges to beneficiaries for excess costs as described in CMS Pub. 15-1, chapter 25,
§2570. When provider operating costs include amounts that flow from the provision of luxury
items or services, such amounts are not allowable in computing reimbursable costs.
Enter only the charges for applicable Medicare covered pneumococcal, influenza, COVID-19, and
hepatitis B vaccines and injectable osteoporosis drugs and monoclonal antibody products for
treatment of COVID-19, which are all cost reimbursed.
Line 2--Enter from your records in the applicable column the program charges for Part A, Part B
not subject to deductibles and coinsurance, and Part B subject to deductibles and coinsurance.

Rev. 17

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FORM CMS-2552-10

01-22

Enter in column 2, the charges for Medicare covered pneumococcal and influenza, COVID-19
vaccines and monoclonal antibody products for treatment of COVID-19 (from Worksheet H-3,
line 16, column 7). In column 3, enter the charges for Medicare covered hepatitis B vaccines and
osteoporosis drugs (from Worksheet H-3, line 16, column 8).
Lines 3 through 6--These lines provide for the reduction of program charges when the provider
does not actually impose such charges (in the case of most patients liable for payment for services
on a charge basis) or fails to make reasonable efforts to collect such charges from those patients.
If line 5 is greater than zero, multiply line 2 by line 5, and enter the result on line 6. Providers
which do impose these charges and make reasonable efforts to collect the charges from patients
liable for payment for services on a charge basis are not required to complete lines 3, 4, and 5, but
enter on line 6 the amount from line 2. (See 42 CFR 413.13(b).) In no instance may the customary
charges on line 6 exceed the actual charges on line 2.
Line 7--Enter in each column the excess of total customary charges (line 6) over the total
reasonable cost (line 1). In situations when, in any column, the total charges on line 6 are less than
the total cost on line 1 of the applicable column, enter zero on line 7.
Line 8--Enter in each column the excess of total reasonable cost (line 1) over total customary
charges (line 6). In situations when, in any column, the total cost on line 1 is less than the
customary charges on line 6 of the applicable column, enter zero on line 8.
Line 9--Enter the amounts paid or payable by workers’ compensation and other primary payers
where program liability is secondary to that of the primary payer. There are several situations
under which program payment is secondary to a primary payer. Some of the most frequent
situations in which the Medicare program is a secondary payer include:
•
•
•
•
•
•

Workers’ compensation,
No fault coverage,
General liability coverage,
Working aged provisions,
Disability provisions, and
Working ESRD beneficiary provisions.

Generally, when payment by the primary payer satisfies the total liability of the program
beneficiary, for cost reporting purposes only, the services are considered to be nonprogram
services. (The primary payment satisfies the beneficiary's liability when the provider accepts that
payment as payment in full. The provider notes this on no-pay bills submitted in these situations.)
The patient visits and charges are included in total patient visits and charges, but are not included
in program patient visits and charges. In this situation, no primary payer payment is entered on
line 9.
However, when the payment by the primary payer does not satisfy the beneficiary's obligation, the
program pays the lesser of (a) the amount it otherwise pays (without regard to the primary payer
payment or deductible and coinsurance) less the primary payer payment, or (b) the amount it
otherwise pays (without regard to primary payer payment or deductibles and coinsurance) less
applicable deductible and coinsurance. Primary payer payment is credited toward the beneficiary's
deductible and coinsurance obligation.
When the primary payer payment does not satisfy the beneficiary's liability, include the covered
days and charges in both program visits and charges and total visits and charges for cost
apportionment purposes. Enter the primary payer payment on line 9, to the extent that primary
payer payment is not credited toward the beneficiary's deductible and coinsurance. Do not enter
on line 9 the primary payer payments that are credited toward the beneficiary's deductible and
coinsurance. The primary payer rules are more fully explained in 42 CFR 411.

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Rev. 17

01-22
4045.2

FORM CMS-2552-10

4045.2

Part II - Computation of HHA Reimbursement Settlement.--

Line 10--Enter in column 1 the amount in Part I, column 1, line 1, less the amount in column 1,
line 9. Enter in column 2, the sum of the amounts from Part I, columns 2 and 3, line 1, less the
sum of the amounts in columns 2 and 3, on line 9. This line will only include pneumococcal,
influenza, hepatitis B and injectable osteoporosis drugs reduced by primary payer amounts.
Lines 11 through 24--Enter in column 1 only, for lines 11 through 14, as applicable, the appropriate
PPS reimbursement amount for each episode of care payment category as indicated on the
worksheet. Enter in column 1 only, on lines 15 and 16, as applicable, the appropriate PPS outlier
reimbursement amount for each episode of care payment category as indicated on the worksheet.
Enter on lines 18 through 20, the total DME, oxygen, prosthetics and orthotics payments,
respectively, associated with home health PPS services (bill types 32 and 33). For lines 18 through
20, do not include any payments associated with services paid under bill type 34X. Obtain these
amounts from your PS&R report.
Line 21--Enter in column 2, the Part B deductibles billed to program patients. Include any amounts
of deductibles satisfied by primary payer payments.
Line 23--If there is an excess of reasonable cost over customary charges in any column on line 8,
enter the amount of the excess in the appropriate column.
Line 25--Enter in column 2, all coinsurance billable to program beneficiaries including amounts
satisfied by primary payer payments. Coinsurance is applicable for services reimbursable under
§1832(a)(2) of the Act.
NOTE: If the component qualifies as a nominal charge provider, enter 20 percent of the costs
subject to coinsurance on this line. Compute this amount by subtracting Part B
deductibles on line 21, and primary payment amounts in column 3, line 9, from Part B
costs subject to coinsurance in column 3, line 1. Multiply the resulting amount by 20
percent and enter it on this line.
Line 27--Enter the allowable bad debts in the appropriate columns. If recoveries exceed the current
year’s bad debts, line 27 will be negative. This line is shaded as HHAs cannot generate bad debts.
Line 28--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. This amount must also be reported on line 27. This line is
shaded as HHAs cannot generate bad debts.
Line 29--Enter the result of line 26 plus 27.
Line 30--Enter any other adjustments. For example, enter an adjustment from changing the
recording of vacation pay from the cash basis to accrual basis. (See CMS Pub. 15-1, chapter 21,
§2146.4.)
Line 30.50--Enter the Pioneer ACO demonstration payment adjustment amount. Obtain this
amount from the PS&R. Do not use this line for services rendered on or after January 1, 2017.
Report any ACO demonstration payment adjustments on or after January 1, 2017 on line 30.99 or
line 31.02, accordingly.
Line 30.99--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are subject to the
sequestration adjustment. Obtain this amount from the PS&R.

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01-22

Line 31--Enter the result of line 29, plus or minus line 30, and minus lines 30.50 and 30.99.
Line 31.01--Enter the sequestration adjustment amount from the PS&R report. (Note: In
accordance with §3709 of the CARES Act, as amended by §102 of the Consolidated
Appropriations Act of 2021, and §1 of Public Law 117-7, do not apply the sequestration adjustment
to the period of May 1, 2020, through December 31, 2021.)
Line 31.02--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are not subject to the
sequestration adjustment. Obtain this amount from the PS&R.
Line 32--Enter the interim payment amount from Worksheet H-5, line 4. For contractor final
settlement, report on line 33 the amount from Worksheet H-5, line 5.99. For titles V and XIX,
enter the interim payments from your records.
Line 34--The amounts show the balance due the provider or the program by entering the result of
line 31 minus the sum of lines 31.01, 31.02, 32, and 33. Transfer to Worksheet S, Part III, line 9,
as applicable.
Line 35--Enter the program reimbursement effect of protested items. The reimbursement effect of
the nonallowable items is estimated by applying a reasonable methodology which closely
approximates the actual effect of the item as if it had been determined through the normal cost
finding process. (See CMS Pub. 15-2, chapter 1, §115.2.) A schedule showing the supporting
details and computations for this line must be attached.
4046.

WORKSHEET H-5 - ANALYSIS OF PAYMENTS TO HOSPITAL-BASED HOME
HEALTH AGENCIES FOR SERVICES RENDERED TO PROGRAM
BENEFICIARIES

Complete this worksheet for Medicare interim payments only. (See 42 CFR 413.64.)
The column headings designate two categories of payments: Part A and Part B.
Complete the identifying information on lines 1 through 4. The remainder of the worksheet is
completed by your contractor. Do not include on this worksheet any payments made for DME or
medical supplies charged to patients that are paid on the basis of a fee schedule.
Line Descriptions
Line 1--Enter the total Medicare interim payments paid to the HHA for cost and HHA PPS
reimbursed services. The amount entered reflects payments for all episodes concluded in this
fiscal year. Do not include any payments received for fee scheduled services. 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 includes amounts withheld
from your interim payments due to an offset against overpayments 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 you are reimbursed under the periodic interim payment method of
reimbursement, enter the periodic interim payments received for this cost reporting period.

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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 the appropriate column on Worksheet H-4, Part II, line 32.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET H-5. THE REMAINDER
OF THE WORKSHEET IS COMPLETED BY YOUR CONTRACTOR. (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 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.
Enter in column 2 the amount on Worksheet H-4, Part II, column 1, line 34. Enter in column 4 the
amount on Worksheet H-4, Part II, column 2, line 34.
NOTE: On lines 3, 5, and 6, when an amount is due from the provider to the program, show the
amount and date on which you agree to the amount of repayment, even though total
repayment is not accomplished until a later date.
Line 7--Enter the total of the amounts on lines 4, 5.99, and 6. Enter in column 2, the amount on
Worksheet H-4, Part II, column 1, line 31 less the amount on lines 31.01 and 31.02. Enter in
column 4, the amount on Worksheet H-4, Part II, column 2, line 31, less the amount on lines 31.01
and 31.02.
Line 8--Enter the contractor name, the contractor number and NPR date in columns 0, 1 and 2,
respectively.

Rev. 16

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4047
4047.

FORM CMS-2552-10

04-20

ANALYSIS OF RENAL DIALYSIS DEPARTMENT COSTS

This worksheet provides for the analysis of the direct and indirect expenses related to the renal
dialysis cost centers, allocation of cost between inpatient and outpatient renal dialysis services
where separate cost centers are not maintained, and the allocation of the cost to the various modes
of outpatient dialysis treatment. The ancillary renal dialysis cost center is serviced by the general
cost centers and includes all reimbursable cost centers within the provider organization which
provide services to the renal dialysis department. The cost used in the analysis for the renal dialysis
department is obtained, in part, from Worksheets A; B, Part I; and C. Complete a separate
Worksheet I series for lines 74 and 94 of Worksheet A. In other words, complete one Worksheet I
series for line 74, and one for line 94, if appropriate.
4048.

WORKSHEET I-1 - ANALYSIS OF RENAL DIALYSIS DEPARTMENT COSTS

This part provides for recording the direct salaries and other direct expenses applicable to the total
inpatient and outpatient renal dialysis cost center or outpatient renal dialysis cost center where you
maintain a separate and distinct outpatient renal dialysis cost center. If you have more than one
renal dialysis department, and/or more than one home dialysis department, submit one Worksheet I
series combining the renal dialysis departments and a separate Worksheet I series combining the
home dialysis departments. You must also have on file, as supporting documentation, a
Worksheet I series for each renal dialysis department and for each home dialysis department along
with the appropriate workpapers. File this documentation with exception requests in accordance
with CMS Pub. 15-1, chapter 27, §2720. Do not combine the cost of the renal dialysis with home
program dialysis reported separately on Worksheet A, lines 74 and 94.
This worksheet also provides for recording the indirect expenses applicable to the total renal or
outpatient renal dialysis department obtained from Worksheet B, Part I, columns 1 through 23,
line 74 as adjusted for post stepdown adjustments, if any. When completing a separate
Worksheet I for home program dialysis, transfer the direct expenses from Worksheet B, Part I,
columns 1 through 23, line 94. Do not combine the cost of the renal department with home
program dialysis. These costs are listed separately on Worksheet A, lines 74 and 94, respectively.
Column Descriptions
Column 1--Enter on lines 1 through 8, the amounts included from Worksheet A, column 7, for
salaries only. Enter on lines 10 through 16, and 18 through 26, the amounts from Worksheet B,
Part I, all columns for lines 74 and 94. The subtotal on Worksheet I-1, line 27, agrees with the
sum of Worksheet B, Part I, column 26, line 74, or line 94 if a home dialysis cost center was
established and used on Worksheet A.
Column 2--This column lists the statistical bases for allocating costs on Worksheet I-3.
Column 3--Enter paid hours per type of staff listed on lines 1 through 6.
Column 4--Enter FTEs by dividing column 3 by 2080 hours.
Line Descriptions
Lines 1 through 6--Enter on these lines the direct patients care salaries after adjustments and
reclassification reported in column 7 of Worksheet A. Direct patient care salary includes only the
salary of staff providing direct patient care services. Also include fees paid to non-employees
providing direct patient care services. Time spent furnishing administrative or management
services by direct patient care personnel is reported on line 8, non-patient care salary.

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Line 7--Include on this line amounts paid to physicians for their administrative services of
managing the renal department. These payments are subject to the limitation contained in
CMS Pub. 15-1, chapter 8, §40.6. Also include payments to physicians for their medical services
if the box on line 21 of Worksheet S-5 is marked the initial method. No payment to physicians for
patient medical services should appear on this line if the monthly capitation payment (MCP) box
is marked on Worksheet S-5. Under the MCP, contractors pay physicians directly for their medical
services.
Line 8--Enter the amount of salaries paid non-patient care personnel after reclassifications and
adjustments that you report in column 7 of Worksheet A.
Lines 10 through 16--Include on the appropriate lines costs directly charged to the renal
department after reclassifications and adjustments. Report on line 16, other direct costs that cannot
be specifically identified on lines 11 through 15. Line 15 must include all ESA costs effective for
cost reporting periods beginning on or after October 1, 2015.
Lines 17--Add lines 9 through 16. The total in column 1 must agree with the total on Worksheet A,
column 7 for line 74 or line 94, as appropriate.
Lines 18 through 26--Enter the allocated general service costs from Worksheet B, Part I, lines 74
or 94, as listed in the chart below.
NOTE: Line 25 excludes the costs of all ESAs administered to ESRD patients in the renal
department and home program identified on Worksheet B-2, lines 1, 2, 3 or 4.
Worksheet I-1,
Part I, Column 1,
Line Number

Rev.

General Service Cost Centers

Worksheet B,
Part I, Lines 74
or 94, Columns

Capital-Related CostsBuildings and Fixtures

Capital-Related CostsMoveable Equipment

Employee Benefits

Administrative and General

Maintenance & Repairs, Operation
of Plant and Housekeeping

Sum of 6, 7,
and 9

Medical Education Programs

Sum of 20, 21, 22,
23, and 25 (medical
education only)

Central Services & Supplies

Pharmacy

Other Allocated Costs

Sum of 8, 10,
11, 12, 13, 16,
17, 18, and 19

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FORM CMS-2552-10

DRAFT

Line 27--For cost reporting periods beginning prior to October 1, 2015, add lines 17 through 26.
This total must agree with the total on Worksheet B, Part I, column 26, line 74 or line 94, if a home
dialysis cost center was established. Effective for cost reporting periods beginning on or after
October 1, 2015, add lines 17 through 26. This total must agree with the total on Worksheet B,
Part I, column 24, line 74, or line 94 if a home dialysis cost center was established, less the sum
of columns 21 and 22, as appropriate.
Lines 28, 29, and 30--These lines provide for the allocation of costs associated with routine dialysis
services furnished to renal patients from other ancillary departments. Enter the cost to charge ratio
from Worksheet C, Part I, column 9. Payment for routine laboratory services, as defined in
CM Pub. 100-02, chapter 11, §30.2, is paid for under the composite payment rate. No separate
payment is made for routine laboratory tests. The costs of these services are allocated to the renal
department based on the provider’s laboratory cost to charge ratio from Worksheet C, Part I,
column 9, line 60. Providers must maintain a log of routine laboratory charges for allocating
routine laboratory costs to the renal department. The lab charges reported on Worksheet C do not
include the lab charges for ESRD therefore those charges must be grossed up in accordance with
CMS Pub. 15-1, chapter 23, §2314. The cost to charge ratio must be recalculated and applied
against the charges reported in column 3 of this worksheet. Do not gross up ESRD charges.
Instead, the cost to charge ratio for lab charges reported on Worksheet C will be used.
Line 31--Enter the sum lines 27 through 30.

40-246

Rev.

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FORM CMS-2552-10

4049.

4049

WORKSHEET I-2 - ALLOCATION OF RENAL DEPARTMENT COSTS TO
TREATMENT MODALITIES

The purpose of this schedule is to allocate costs to the different services furnished in the renal
department. Line 1 combines the costs reported on Worksheet I-1 for allocating costs to the
different services furnished in the renal department.
Line 1--Add the costs from Worksheet I-1, column 1, and transfer these amounts to line 1 in the
following manner:
Worksheet I-2 Description

Worksheet I-2 Column

From Worksheet I-1, column 1:

Capital & Main Building Costs
Capital, Machine & Repair Costs
Registered Nurses Direct Patient
Care Salary
Other Direct Patient Care Salary
Employee Benefits
Drugs

1
2
3

Sum of lines 11, 18, and 22
Sum of lines 12, 13, and 19
Line 1

4
5
6

Medical Supplies
Routine Ancillary Services
Subtotal
Overhead

7
8
9
10

Sum of lines 2, 3, 4, 5, and 6
Sum of lines 10 and 20
Sum of lines 15 and 25, minus
Worksheet S-5, line 22 (and
subscripts), col. 2 (renal
dialysis department), or col. 3
(home program dialysis)
Sum of lines 14 and 24
Sum of lines 28, 29, and 30
Not applicable
Sum of lines 7, 8, 16, 21, and 26

Complete columns 1 through 8, and 10, in conjunction with Worksheet I-3, which contains the
statistical bases for allocating costs to the proper lines. For each line item in columns 1 through 8,
and 10, multiply the statistic entered in the corresponding line and column of Worksheet I-3 by
the unit cost multiplier on line 18.
Lines 2 through 11--These lines identify the type of dialysis treatments, including acute kidney
injury (AKI) renal dialysis services. Medicare began paying for AKI services furnished to
Medicare beneficiaries on January 1, 2017 (see 42 CFR 413, Subpart K); report AKI services for
cost reporting periods ending on or after September 30, 2018. The total costs (column 11) for
these individual dialysis services are transferred to Worksheet I-4.
Transfer the total on Worksheet I-2, column 11, to Worksheet I-4 per the following instructions.
From Worksheet I-2, column 11
Lines 2 and 2.01
Lines 3 and 3.01
Line 4
Line 5
Line 6
Line 7
Line 8
Line 9
Line 10
Line 11

To Worksheet I-4, column 2
Line 1
Line 2
Line 3
Line 4
Line 5
Line 6
Line 7
Line 8
Line 9
Line 10

If you complete a Worksheet I-2 for the renal department and the home program dialysis
department, complete a separate Worksheet I-4.

Rev. 15

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FORM CMS-2552-10

10-18

Lines 12 through 16--These services are not paid for under the composite payment rate system.
Therefore, the costs of these services are not transferred to Worksheet I-4. Exclude these costs in
the calculation of reimbursement composite payment rate bad debts. (See 42 CFR 413.89(i)(2).)
Line 12--Report inpatient costs. Inpatient dialysis services are paid under the DRG system for
Medicare patients.
Line 13--Report the costs of support services furnished to Method II home patients. Payment for
Method II home patient dialysis services are subject to the rules in 42 CFR 414.330. Under
Method II, a renal provider is only allowed to bill for support services and not dialysis equipment
or supplies. Payment for support services is limited to the lower of the provider’s reasonable cost
or the payment limit as defined in the regulation, which is $121.15 per patient per month. This
amount includes payment for support services and routine laboratory tests furnished to home
patients. Beginning January 1, 2011, Method II is no longer an option for home dialysis items and
services under Medicare. Therefore, beginning January 1, 2011, all home dialysis patients are
Method I.
Line 14--Report the direct costs of EPO net of discounts furnished in the renal department. Include
all costs for patients receiving outpatient, home, or training dialysis treatments. This amount
includes EPO cost furnished in the renal department or any other department if furnished to an end
stage renal dialysis patient. Enter EPO amount for informational purposes only. This amount is
not included in the total on line 17. For cost reporting periods beginning on or after
October 1, 2015, this line will be identified as “ESAs” and providers must enter the direct costs of
all ESAs net of discounts furnished in the renal department on this line.
Line 15--Report the direct costs of Aranesp net of discounts furnished in the renal department.
Include all costs for patients receiving outpatient, home, or training dialysis treatments. This
amount includes Aranesp cost furnished in the renal department or any other department if
furnished to an end stage renal dialysis patient. Enter Aranesp amount for informational purposes
only. This amount is not included in the total on line 17. For cost reporting periods beginning on
or after October 1, 2015, do not complete this line and enter all ESA amounts on line 14.
Line 16--Report the costs of other services furnished and billed in the renal department that are
paid for outside the composite payment rate.
Line 17--Add columns and enter totals. Since lines 14 and 15, column 9, are shaded, no costs for
EPO and Aranesp and all other ESA’s are included in the total for line 17, column 9; and, for
column 6, exclude lines 14 and 15 from the total.
Line 18--Enter the amount of medical educational program costs from Worksheet I-1, line 23.
Payment for medical educational program costs allocated to the renal department is not included
in the composite payment rate.
Line 19--Add lines 17 and 18. This total, plus the amounts in column 6, lines 14 and 15, agrees
with the sum of Worksheet I-1, column 1, line 31.
Column Description
Columns 1 through 8--For each line, multiply the unit cost multiplier on Worksheet I-3, line 18,
by the statistical base, and enter the result on the corresponding line and column on Worksheet I-2.
Column 9--Add columns 1 through 8 for each line, except lines 14 and 15, and enter the total.
Column 10--Multiply the unit cost multiplier on Worksheet I-3, column 10, line 18, by the line
amounts in column 9 of Worksheet I-2, and enter the amount in column 10.
Column 11--Add columns 9 and 10 for each line, and enter the result.
40-248

Rev. 15

10-18
4050.

FORM CMS-2552-10

4050

WORKSHEET I-3 - DIRECT AND INDIRECT RENAL DIALYSIS COST
ALLOCATION - STATISTICAL BASIS

To accomplish the allocation of your direct and indirect costs reported on Worksheet I-1 to the
different services provided in the department, you must maintain renal department statistics. To
facilitate the allocation process, the format of Worksheets I-2 and I-3 is identical.
Line 1--Transfer the amounts on Worksheet I-2, line 1, columns 1 through 10 to Worksheet I-3,
line 1, columns 1 through 10.
Lines 2 through 16--Enter on these lines and in the appropriate columns, the statistic for allocating
costs to the appropriate line item. The statistical basis used in each column is defined in the column
heading and on Worksheet I-1.
NOTE: If you wish to change your allocation basis for a particular general cost center, you must
receive written approval from your contractor before the start of your cost reporting
period for which the alternative method is used. (See §4017 for Worksheets B and B-1.)
Line 12--Enter, in the area provided, the number of inpatient dialysis treatments furnished during
the cost reporting period.
Line 17--Add the statistical basis for each column, except columns 9 and 10.
Line 18--Calculate the unit cost multiplier by dividing the amount on line 1 by the total statistical
basis on line 17 for each column. Multiply the unit cost multiplier by the statistical base, and enter
the cost on the appropriate line and column number on Worksheet I-2.
Column Descriptions
Column 1--Use the square footage of the renal department to allocate capital and maintenance
building costs.
Column 2--Use percentage of time to allocate capital and maintenance equipment costs.
Columns 3 and 4--Use paid hours to allocate registered nurses and direct patient care salary.
Column 5--Use total direct patient care salaries in columns 4 and 5 of Worksheet I-2 to allocate
employee benefits.
Columns 6 and 7--Use cost of requisitions to allocate drug and medical supply costs.
Column 8--Use routine laboratory charges to allocate laboratory costs.
Column 10--Use subtotal costs in column 9, Worksheet I-2 to allocate overhead cost. To compute
the unit cost multiplier, transfer the amount from Worksheet I-2, line 17, column 9, to
Worksheet I-3, line 17, column 10. Do not allocate overhead costs to lines 14 or 15.

Rev. 15

40-249

4051
4051.

FORM CMS-2552-10

10-18

WORKSHEET I-4 - COMPUTATION OF AVERAGE COST PER TREATMENT FOR
OUTPATIENT RENAL DIALYSIS

This worksheet records the apportionment of total outpatient cost to the types of dialysis treatment
furnished by you and shows the computation of expenses of dialysis items and services that you
furnished to Medicare dialysis patients. This information is used for overall program evaluation,
determining the appropriateness of program reimbursement rates, and meeting statutory
requirements for determining the cost of ESRD care.
Complete separate worksheets to report the costs of the renal dialysis department and the home
program dialysis department.
If you have more than one renal dialysis and/or home program dialysis department, submit one
Worksheet I-4 combining the renal dialysis departments and/or one Worksheet I-4 combining the
home dialysis departments as only one average payment composite rate will apply to each
modality. Enter on the combined Worksheet I-4 each provider’s satellite number if you are
separately certified as a satellite facility.
In accordance with section 1881(b)(12)(A) of the Act, as added by section 623(d)(1) of
MMA 2003, the ESRD payment is replaced by a calculated ESRD composite rate. Section 153(b)
of MIPPA amended section 1881(b) of the Act effective for services rendered on or after
January 1, 2011, the calculated ESRD composite rate is replaced by an ESRD bundled payment
system.
For cost reporting periods that straddle January 1, 2011, report the rates for each modality on
Worksheet I-4 as follows: For the portion of the cost reporting period prior to January 1, 2011,
enter the average composite rate for each modality in column 7. For the portion of the cost
reporting period on and after January 1, 2011, enter the average ESRD PPS payment rate for each
modality in column 7.02.
For cost reporting periods that straddle January 1, 2012,
January 1, 2013, and January 1, 2014, report the average ESRD PPS payment rate for each
modality on Worksheet I-4 as follows: For the portion of the cost reporting period prior to
January 1, enter the average ESRD PPS payment rate for each modality in column 7.01. For the
portion of the cost reporting period on and after January 1, enter the average ESRD PPS payment
rate for each modality in column 7.02.
Columns 1 through 3 refer to total outpatient statistics, i.e., to all outpatient dialysis services
furnished, whether reimbursed directly by the program or not.
Column 1--Enter on the appropriate lines the total number of outpatient treatments/patient weeks
by renal dialysis department or home program department. These statistics include all treatments
furnished to all patients in the outpatient renal department, both Medicare and non-Medicare.
Column 2--Enter on the appropriate lines the total cost transferred from Worksheet I-2, column 11,
lines as appropriate. Transfer from Worksheet I-2, the sum of lines 2 and 2.01, column 11, to
line 1, column 2. Transfer from Worksheet I-2, the sum of lines 3 and 3.01, column 11, to line 2,
column 2.
Column 3--Determine the amounts entered on the appropriate lines by dividing the cost entered on
each line in column 2 by the number of treatments entered on each line in column 1.

40-250

Rev. 15

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FORM CMS-2552-10

4051 (Cont.)

Line 9--Report continuous ambulatory peritoneal dialysis (CAPD) in terms of weeks. Compute
patient weeks by totaling the number of weeks each Method I patient was dialyzed at home using
CAPD.
Line 10--Report continuous cycling peritoneal dialysis (CCPD) in terms of weeks. Compute
patient weeks by totaling the number of weeks each Method I patient was dialyzed at home by
CCPD.
Medicare Treatments
Columns 4 through 7 refer only to treatments furnished to Medicare beneficiaries that were billed
to the facility and reimbursed by the program directly. (Amounts entered in these columns are
reconcilable to your records.)
Column 4--Enter on the appropriate lines the number of treatments billed to the Medicare program
directly. Obtain this information from your records and/or the PS&R. For cost reporting periods
that straddle January 1, 2011, enter on column 4 the total number of treatments or patient weeks
billed to Medicare for services rendered prior to January 1, 2011.
Column 4.01--For cost reporting periods that straddle January 1, 2012, January 1, 2013, or
January 1, 2014, enter the total number of treatments or patient weeks billed to Medicare for
services rendered prior to January 1.
Column 4.02--For cost reporting periods that straddle or begin January 1, 2011, January 1, 2012,
or January 1, 2013, enter the total number of treatments or patient weeks billed to Medicare for
services rendered on and after January 1. For cost reporting periods that straddle January 1, 2014,
enter the total number of treatments or patient weeks billed to Medicare for services rendered on
and after January 1.
For cost reporting periods beginning on or after January 1, 2014, enter the number of ESRD PPS
treatments billed to Medicare in column 4 and eliminate columns 4.01 and 4.02.
Column 5--Determine the amounts entered on the appropriate lines by multiplying the number of
treatments entered on each line in column 4 by the average cost per treatment entered on the
corresponding line in column 3. For cost reporting periods that straddle or begin on or after
January 1, 2011, enter total expenses determined by multiplying the sum of columns 4, 4.01, and
4.02, by the average cost per treatment entered on each corresponding line in column 3. Transfer
the total expenses from this column, line 11 to Worksheet I-5, line 1. If you complete a
Worksheet I-4 for renal dialysis and a Worksheet I-4 for home dialysis, add the sum of the cost
from this column, line 11, and transfer the total to Worksheet I-5, line 1.
Column 6--Total Program Payment--Enter the total program payment by the type of treatment for
the reporting period. Since this amount is calculated on a patient basis and is case mix adjusted,
the total program payment will be provider specific for each modality. For cost reporting periods
that straddle January 1, 2011, enter in column 6, the total program payment by the type of
treatment for services rendered prior to January 1, 2011. For cost reporting periods beginning on
or after January 1, 2014, enter the total program payment by the type of treatment. Obtain this
from the PS&R. Transfer the total from column 6, line 11, to Worksheet I-5, line 2, column 1.
Column 6.01--For cost reporting periods that straddle January 1, 2012, January 1, 2013, or
January 1, 2014, enter the total program payment by the type of treatment for Medicare for services
rendered prior to January 1. Obtain this from the PS&R. Transfer the total from column 6.01,
line 11, to Worksheet I-5, line 2.01, column 1.

Rev. 10

40-251

4051 (Cont.)

FORM CMS-2552-10

11-16

Column 6.02--For cost reporting periods that straddle or begin January 1, 2011, January 1, 2012,
or January 1, 2013, enter the total program payment by the type of treatment for Medicare for
services rendered on and after January 1. For cost reporting periods that straddle January 1, 2014,
enter the total program payment by the type of treatment for services rendered on and after
January 1. Obtain this from the PS&R. Transfer the total from column 6.02, line 11, to
Worksheet I-5, line 2.02, column 1.
For cost reporting periods beginning on or after January 1, 2014, enter the total program payment
by the type of treatment in column 6 and eliminate columns 6.01 and 6.02.
The ESRD Medicare payment rate is an average payment calculated based on the total Medicare
payments by type of treatment divided by the total ESRD Medicare treatments.
Column 7--Average Payment Rate--For cost reporting periods that straddle January 1, 2011, for
the portion of the cost reporting period prior to January 1, 2011, enter the total average payment
rate by the type of treatment for the reporting period. Determine the amounts entered on the
appropriate lines by dividing the total payments on each corresponding line in column 6 by the
number of treatments entered on each line in column 4.
Column 7.01--For cost reporting periods that straddle January 1, 2012, January 1, 2013, or
January 1, 2014, report the average ESRD PPS payment rate for each modality in column 7.01 for
the portion of the cost reporting period prior to January 1 by entering the result of column 6.01
divided by column 4.01.
Column 7.02--For cost reporting periods that straddle or begin January 1, 2011, January 1, 2012,
or January 1, 2013, report the average ESRD PPS payment rate for each modality in column 7.02
for the portion of the cost reporting period on and after January 1, by entering the result of
column 6.02 divided by column 4.02. For cost reporting periods that straddle January 1, 2014,
report the average ESRD PPS payment rate for each modality in column 7.02 for the portion of
the cost reporting period on and after January 1.
The ESRD composite payment rates and the ESRD PPS payment rates are average payments
calculated based on the total Medicare payments (by type of treatment) divided by the total
corresponding ESRD treatments per the facility’s PS&R data. For example, the total Medicare
payment for hemodialysis is divided by the total ESRD hemodialysis treatments.
For cost reporting periods beginning on or after January 1, 2014, enter all ESRD PPS payment
rates in column 7, and eliminate columns 7.01 and 7.02 and.
Line 11--Enter in columns 1 and 4 the sum total of lines 1 through 8. Enter in columns 2, 5, and
6 the sum total of lines 1 through 10.
Line 12--Report “total provider treatments” on this line. This line is informational only. This line
will be used for contractor verification. Continuous cycling peritoneal dialysis (CCPD) and
continuous ambulatory peritoneal dialysis (CAPD) are daily treatment modalities, and ESRD
facilities are paid the equivalent of three hemodialysis treatments for each week that CCPD and
CAPD treatments are provided.
Compute hemodialysis equivalent treatments for lines 9 and 10 by multiplying the number of
weeks reported in column 1 times 3 treatments for each week. Add to this amount the treatments
computed on line 11, column 1.

40-251.1

Rev. 10

11-16
4052.

FORM CMS-2552-10

4052

WORKSHEET I-5 - CALCULATION OF REIMBURSABLE BAD DEBTS TITLE XVIII - PART B

This worksheet provides for the calculation of reimbursable Part B bad debts relating to outpatient
renal dialysis treatments. If you have completed more than one Worksheet I-2 (i.e., one for renal
dialysis department and one for home program dialysis), make a consolidated bad debt
computation.
Part I - Calculation of Reimbursable Bad Debts Title XVIII – Part B--Under the composite rate
payment system for services prior to January 1, 2011, the contractor pays the facility its allowable
ESRD bad debts, up to the facility’s unreimbursed reasonable costs as determined under Medicare
principles. Under the ESRD PPS payment system, effective for dates of service on and after
January 1, 2011, the contractor pays the facility for allowable ESRD bad debts, up to the facility’s
unreimbursed reasonable costs for those items and services associated with the basic case-mix
adjusted composite rate portion of the ESRD PPS payment rate. Allowable bad debts must relate
to specific Medicare deductibles and coinsurance amounts.
Determination of bad debt amounts for the basic case-mix adjusted composite rate payment portion
of the ESRD PPS payment, is based on the percentage of basic composite rate payment costs to
total costs on a facility specific basis. The facility specific composite rate percentage is applied to
the facility’s total bad debt amounts associated with the ESRD PPS payment. The resulting bad
debt amount is used to determine the allowable Medicare bad debt payment in accordance with
42 CFR §§413.89 and 42 CFR 413.178 of the regulations. During the transition periods, apply the
facility specific composite cost percentage to the bad debt amounts associated with the transition
portion of the ESRD PPS payment.
The resulting bad debt amount will be added to the bad debt amount associated with the transition
portion of the facility’s ESRD reasonable costs to determine the total allowable Medicare bad debt
(For example, a facility that does not elect 100 percent PPS, will be in transition period 1 for
services rendered beginning January 1, 2011, through December 31, 2011. Under transition
period 1, services rendered during this period are paid based on 75 percent composite rate and
25 percent ESRD PPS payment rate. The facility specific composite cost percentage will be
applied to 25 percent of the bad debts and the resulting bad debt amount will be added to the
transitional 75 percent to determine the total allowable bad debt pertaining to services rendered
during this period).
EXCEPTION: The transition period payment method will not apply to ESRD services rendered
on and after January 1, 2011, by a facility that (1) elected 100 percent of the
payment amount to be based on the ESRD PPS Payment, or (2) was certified for
Medicare participation and began providing dialysis services on or after
January 1, 2011.
Column 1--Enter the total amounts by line description.
Column 2--This column is used to compute the appropriate reduction to each amount reported in
column 1, based on the facility’s transition period and application of their facility specific
composite cost ratio.
Line 1--Enter the amount from Worksheet I-4, column 5, line 11. The amount reported is reflective
of the provider’s calculated basic composite rate payment cost.
Line 2--Enter the amount from Worksheet I-4, column 6, line 11. For cost reporting periods that
overlap January 1, 2011, enter in column 1 the amount from Worksheet I-4, column 6, line 11.
Enter in column 2, the amount reported in column 1. For cost reporting periods beginning on or
after January 1, 2014, enter in column 1, the sum of the amount from Worksheet I-4, column 6,
line 11. Enter in column 2, the amount reported in column 1 times the facility specific composite
cost ratio from, line 14. For cost reporting periods beginning on or after January 1, 2014, do not
complete lines 2.01 and 2.02.
Rev. 10

40-251.2

4052 (Cont.)

FORM CMS-2552-10

11-16

Line 2.01--Enter in column 1, the sum of the amount from Worksheet I-4, column 6.01, line 11.
Enter in column 2, the portion of the amount reported in column 1 as it relates to the ESRD PPS
payment times the facility specific composite cost ratio from line 14. Add to this amount the
composite cost portion of the payment. For cost reporting periods beginning on or after
January 1, 2014, do not complete this line.
Line 2.02--Enter in column 1, the sum of the amount from Worksheet I-4, column 6.02, line 11.
Enter in column 2, the portion of the amount reported in column 1 as it relates to the ESRD PPS
payment times the facility specific composite cost ratio from line 14. Add to this amount the
composite cost portion of the payment. For cost reporting periods beginning on or after
January 1, 2014, do not complete this line.
Line 2.03--Enter the sum of lines 2, 2.01, and 2.02 in columns 1 and 2 accordingly.
Line 2.04--Enter the amount for outlier payments applicable to Medicare (Part B) patients from
your records. (Informational only)
Line 3--Enter the amount shown in your records for deductibles billed to Medicare (Part B) for
dialysis treatments. For cost reporting periods that overlap January 1, 2011, enter in column 1, the
amount shown in your records for deductibles billed to Medicare (Part B) patients for dialysis
treatments. Include only deductibles amounts that are related to the payments listed on line 2,
column 1, and apply to Medicare beneficiaries under the composite payment rate. Enter in
column 2, the amount reported in column 1. For cost reporting periods beginning on or after
January 1, 2014, enter in column 1, the amount shown in your records for deductibles billed to
Medicare (Part B) patients. Enter in column 2, the amount reported in column 1 times the facility
specific composite cost ratio from line 14.
For cost reporting periods beginning on or after January 1, 2014, do not complete lines 3.01 and
3.02.
Line 3.01--Enter in column 1, the amount shown in your records for deductibles billed to Medicare
(Part B) patients. Include only deductible amounts that are related to the payments listed on
line 2.01, column 1, and apply to Medicare beneficiaries under the ESRD PPS payment rate. Enter
in column 2, the portion of the amount reported in column 1, as it relates to the ESRD PPS payment
times the facility specific composite cost ratio from line 14. Add to this amount the composite
cost portion of the payment.
Line 3.02--Enter in column 1, the amount shown in your records for deductibles billed to Medicare
(Part B) patients. Include only deductible amounts that are related to the payments listed on
line 2.02, column 1, and apply to Medicare beneficiaries under the ESRD PPS payment rate. Enter
in column 2, the portion of the amount reported in column 1, as it relates to the ESRD PPS payment
times the facility specific composite cost ratio from line 14. Add to this amount the composite
cost portion of the payment.
Line 3.03--Enter the sum of lines 3, 3.01 and 3.02, columns 1 and 2, respectively.
Line 4--Enter the amount shown in your records for coinsurance billed to Medicare (Part B) for
dialysis treatments. For cost reporting periods that overlap January 1, 2011, enter in column 1, the
amount shown in your records for coinsurance billed to Medicare (Part B) patients for dialysis
treatments. Include only coinsurance amounts that are related to the payments listed on line 2,
column 1, and apply to Medicare beneficiaries under the composite payment rate. Enter in

40-251.3

Rev. 10

DRAFT

FORM CMS-2552-10

4052 (Cont.)

column 2, the amount reported in column 1. For cost reporting periods beginning on or after
January 1, 2014, enter in column 1 the amount shown in your records for coinsurance billed to
Medicare (Part B) patients. Enter in column 2, the amount reported in column 1 times the facility
specific composite cost ratio from line 14.
For cost reporting periods beginning on or after January 1, 2014, do not complete lines 4.01 and
4.02.
Line 4.01--Enter in column 1, the amount shown in your records for coinsurance billed to
Medicare (Part B) patients. Include only coinsurance amounts that are related to the payments
listed on line 2.01, column 1, and apply to Medicare beneficiaries under the ESRD PPS payment
rate. Enter in column 2, the portion of the amount reported in column 1, as it relates to the ESRD
PPS payment times the facility specific composite cost ratio from line 14. Add to this amount the
composite cost portion of the payment.
Line 4.02--Enter in column 1, the amount shown in your records for coinsurance billed to
Medicare (Part B) patients. Include only coinsurance amounts that are related to the payments
listed on line 2.02, column 1, and apply to Medicare beneficiaries under the ESRD PPS payment
rate. Enter in column 2, the portion of the amount reported in column 1, as it relates to the ESRD
PPS payment times the facility specific composite cost ratio from line 14. Add to this amount the
composite cost portion of the payment.
Line 4.03--Enter the sum of lines 4, 4.01 and 4.02, columns 1 and 2, respectively.
Line 5--Enter the uncollectible portion of the amounts entered on lines 3 and 4 reduced by any
amount recovered during the cost reporting period. For cost reporting periods that overlap or begin
on or after January 1, 2011, enter in column 1, the bad debt amount for deductible and coinsurance,
net of recoveries, for services rendered prior to January 1, 2011. Transfer this amount to column 2.
(See 42 CFR 413.89.)
Line 5.01--Enter in column 1, the bad debt amount for deductible and coinsurance, net of
recoveries, for services rendered on or after January 1, 2011, but before January 1, 2012. Enter in
column 2, 75 percent of the amount in column 1, plus 25 percent of the amount in column 1 times
the facility specific composite cost ratio on line 14. If the provider indicated “Y” on
Worksheet S-5, line 10.02, and elected 100 percent PPS, do not complete this line, but complete
line 5.04.
Line 5.02--Enter in column 1, the bad debt amount for deductible and coinsurance, net of
recoveries, for services rendered on or after January 1, 2012, but before January 1, 2013. Enter in
column 2, 50 percent of the amount in column 1, plus 50 percent of the amount in column 1 times
the facility specific composite cost ratio on line 14. If the provider indicated “Y” on
Worksheet S-5, line 10.02, and elected 100 percent PPS, do not complete this line, but complete
line 5.04.
Line 5.03--Enter in column 1, the bad debt amount for deductible and coinsurance, net of
recoveries, for services rendered on or after January 1, 2013, but before January 1, 2014. Enter in
column 2, 25 percent of the amount in column 1, plus 75 percent of the amount in column 1, times
the facility specific composite cost ratio on line 14. If the provider indicated “Y” on
Worksheet S-5, line 10.02, and elected 100 percent PPS, do not complete this line, but complete
line 5.04.

Rev.

40-251.4

4052 (Cont.)

FORM CMS-2552-10

DRAFT

Line 5.04--Enter in column 1, the bad debt amount for deductible and coinsurance, net of
recoveries, for services rendered on or after January 1, 2014. Enter in column 2, 100 percent of
the amount in column 1, times the facility specific composite cost ratio on line 14. If the provider
indicated “Y” on Worksheet S-5, line 10.02, and elected 100 percent PPS, DO NOT complete
lines 5.01, 5.02, or 5.03, but enter in column 1, the bad debt amount for deductible and
coinsurance, net of recoveries for all services rendered on or after January 1, 2011. Enter in
column 2, 100 percent of the amount in column 1, times the facility specific composite cost ratio
on line 14.
Line 5.05--Enter in column 1, the sum of lines 5 through 5.04, column 1. This amount must
reconcile to the provider’s bad debt listing(s). Enter in column 2, the sum of lines 5 through 5.04,
column 2.
Line 6--Enter the result of line 5.05, column 2 (including negative amounts), times 88 percent for
cost reporting periods beginning on or after October 1, 2012, 76 percent for cost reporting periods
beginning on or after October 1, 2013, and 65 percent for cost reporting periods beginning on or
after October 1, 2014.
Line 7--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is reported
for statistical purposes only. This amount must also be included in the amount on line 5.05,
column 1, i.e., line 7 is a subset of line 5.05, column 1.
Line 8--Enter the sum of lines 3 and 4, less line 5, in column 1. For cost reporting periods that
overlap or begin on or after January 1, 2011, enter in column 2, the sum of lines 3.03, column 2,
and line 4.03, column 2, less line 5.05, column 2.
Line 9--Subtract line 3 from line 2, and enter 80 percent of the difference in column 1. For cost
reporting periods that overlap or begin on or after January 1, 2011, subtract line 3.03, column 2,
from line 2.03, column 2, and enter 80 percent of the difference in column 2.
Line 10--Enter the result of line 1, minus the sum of lines 8 and 9, in column 1. If the result is
negative, enter zero and do not complete line 11. For cost reporting periods that overlap or begin
on or after January 1, 2011, enter in column 2, the result of line 1 minus the sum of lines 8 and 9,
column 2. For cost reporting periods beginning on or after January 1, 2013, do not complete this
line.
Line 11--Enter in column 1, the lesser of line 5 or line 10, column 1. For cost reporting periods
that overlap or begin on or after January 1, 2011, enter in column 1, the lesser of line 5.05,
column 2 or line 10, column 2. For cost reporting periods that begin on or after October 1, 2012,
enter in column 1, the lesser of line 6, column 1, or line 10, column 2. For cost reporting periods
beginning on or after January 1, 2013, enter in column 1, the result of line 6, column 1. Transfer
the amount on this line to Worksheet E, Part B, line 33.
Part II - Calculation of Facility Specific Composite Cost Percentage.--A facility specific composite
cost percentage is applied to the facility’s total bad debt amounts and associated cost data necessary
to compute the ESRD facility bad debt payments. This percentage is computed by dividing your
facility’s basic composite rate costs by your total allowable expenses.
Line 12--For cost reporting periods that overlap or begin on or after January 1, 2011, enter the total
allowable expenses from Worksheet I-4, column 2, line 11, plus Worksheet B-2, sum of the
absolute values of lines 1 through 6, column 4.
Line 13--Enter total base composite rate costs from Worksheet I-4, column 2, line 11.
Line 14--Compute the facility specific composite cost percentage (line 13 divided by line 12).

40-252

Rev.

09-15
4053.

FORM CMS-2552-10

4053.2

WORKSHEET J-1 - ALLOCATION OF GENERAL SERVICE COSTS TO
COMMUNITY MENTAL HEALTH CENTERS

Use this worksheet only if you operate as part of your complex a certified hospital-based
community mental health center (CMHC) furnishing services to Medicare titles XVIII, title XIX,
and V. Additionally, while comprehensive outpatient rehabilitation facilities (CORFs), outpatient
rehabilitation facilities (ORFs) which generally furnish outpatient physical therapy (OPT),
outpatient occupational therapy (OOT), or outpatient speech pathology (OSP) services, do not
complete the J series worksheets they must complete the applicable Worksheet A cost center for
the purpose of overhead allocation. Only those cost centers that represent services for which the
facility is certified are used. If you have more than one hospital-based CMHC, complete a separate
worksheet for each facility.
4053.1 Part I - Allocation of General Service Costs to Community Mental Health Center Cost
Centers.--Worksheet J-1, Part I, provides for the allocation of the expenses of each general service
cost center to those cost centers which receive the services. Obtain the total direct expenses
(column 0, line 22) from Worksheet A, column 7, lines as appropriate:
Component

From Worksheet A, Column 7

CMHC

line 99 and subscripts

Obtain the cost center allocations (column 0, lines 1 through 21) from your records, the sum of
which must equal the amount entered on column 0, line 22. The amounts on line 22, columns 0
through 23, and column 25, must equal the corresponding amounts on Worksheet B, Part I,
columns 0 through 23, and column 25, lines as appropriate:
Component

Worksheet B, Part I, Columns 0 through 23 and 25

CMHC

line 99 and subscripts

Complete the amounts entered on lines 1 through 21, columns 1 through 23, and column 25, in
accordance with the instructions contained in §4053.2.
NOTE: Worksheet B, Part I, established the method used to reimburse direct GME cost (i.e.,
reasonable cost or the per resident amount). Therefore, this worksheet must follow that
method. If Worksheet B, Part I, column 25, excluded the costs of interns and residents,
column 25, on this worksheet must also exclude these costs.
In column 24, Part I, enter the total of columns 4A through 23.
In column 27, Part I, enter the unit cost multiplier (column 26, line 1, divided by the sum of
column 26, line 22, minus column 26, line 1) on line 23. Round the unit cost multiplier to six
decimal places. Multiply each amount in column 26, lines 2 through 21, by the unit cost multiplier
on line 23, and enter the result on the corresponding line of column 27. On line 22, enter the total
of the amounts on lines 2 through 21. The total on line 22 equals the amount in column 26, line 1.
In column 28, Part I, enter on lines 2 through 21, the sum of columns 26 and 27. The total on
line 22 equals the total in column 26, line 22.
4053.2 Part II - Allocation of General Service Costs to Community Mental Health Center Cost
Centers - Statistical Basis.--Worksheet J-1, Part II, provides for the proration of the statistical data
needed to equitably allocate the expenses of the hospital’s general service cost centers on
Worksheet J-1, Part I. If there is a difference between the total accumulated costs reported on the
Part II statistics and the total accumulated costs calculated on Part I, use the reconciliation

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09-15

column on Part II for reporting any adjustments. See §4020 for the appropriate usage of the
reconciliation columns. For subscripted (componentized) A&G cost centers, the accumulated cost
center line must match the reconciliation column number.
To facilitate the allocation process, the general format of Worksheet J-1, Parts I and II, is identical.
The statistical basis shown at the top of each column on Worksheet J-1, Part II, is the
recommended basis of allocation of the cost center indicated and must be consistent with the
statistical basis utilized on Worksheet B, Part I.
Lines 1 through 21--On Worksheet J-1, Part II, for all cost centers to which the general service
cost center is being allocated, enter that portion of the total statistical base applicable to each.
Line 22--Enter the total of lines 1 through 21 for each column. The total in each column must be
the same as shown for the corresponding column on Worksheet B-1, lines as appropriate:
Component

Worksheet B-1, Corresponding Column

CMHC

line 99

Line 23--Enter the total expenses for the cost center allocated. Obtain this amount from
Worksheet B, Part I, lines as appropriate (see §4020), from the same column used to enter the
statistical base on Worksheet J-1, Part II (e.g., for a CMHC provider, in the case of capital-related
cost buildings and fixtures, this amount is on Worksheet B, Part I, column 1, line 99).
Line 24--Enter the unit cost multiplier which is obtained by dividing the cost entered on line 23 by
the total statistic entered in the same column on line 22. Round the unit cost multiplier to six
decimal places.
Multiply the unit cost multiplier by that portion of the total statistic applicable to each cost center
receiving the services. Enter the result of each computation on Worksheet J-1, Part I, in the
corresponding column and line.
After the unit cost multiplier has been applied to all the cost centers receiving the services, the
total cost (line 22, Part I) must equal the total cost on line 23, Part II.
Perform the preceding procedures for each general service cost center.

40-254

Rev. 8

DRAFT
4054.

FORM CMS-2552-10

4055

WORKSHEET J-2 - COMPUTATION OF COMMUNITY MENTAL HEALTH
CENTER PROVIDER COSTS

Use this worksheet only if you operate a hospital-based CMHC. If you have more than one
hospital-based CMHC, complete a separate worksheet for each facility.
4054.1

Part I - Apportionment of CMHC Cost Centers.--

Column 1--Enter on each line the total cost for the cost center as previously computed on
Worksheet J-1, Part I, column 28. To facilitate the apportionment process, the line numbers are
the same on both worksheets. Do not transfer lines 19 and 20 from Worksheet J-1.
Column 2--Enter the charges for each cost center. Obtain the charges from your records.
Column 3--For each cost center, enter the ratio derived by dividing the cost in column 1, by the
charges in column 2.
Columns 4, 6, and 8--For each cost center, enter the charges from your records for title V in
column 4 and title XIX in column 8. Enter 0 (zero) for each line in column 6 for title XVIII charges
as CMHCs are reimbursed under the OPPS. Not all facilities are eligible to participate in all
programs.
Columns 5, 7, and 9--For each cost center, enter the costs obtained by multiplying the charges in
columns 4, 6, and 8, by the ratio in column 3.
Line 20--Enter the totals of lines 1 through 19, in columns 1, 2, and 4 through 9.
4054.2 Part II - Apportionment of Cost of CMHC Services Furnished by Shared Hospital
Departments.--Use this part only when the hospital complex maintains a separate department for
any of the cost centers listed on this worksheet, and the department provides services to patients
of the hospital's CMHC.
Column 3--For each of the cost centers listed, enter the ratio of cost to charges that is shown on
Worksheet C, Part I, column 9, from the appropriate line for each cost center.
Columns 4, 6, and 8--For each cost center, enter the charges from your records for title V in
column 4, and title XIX in column 8. Enter 0 (zero) for each line in column 6 for title XVIII
charges as CMHCs are reimbursed under the OPPS.
Columns 5, 7, and 9--For each cost center, enter the costs obtained by multiplying the charges in
columns 4, 6, and 8, respectively, by the ratio in column 3.
Line 28--Enter the totals for columns 4 through 9.
Line 29--Enter the total costs from Part I, columns 5, 7, and 9, line 20, plus columns 5, 7, and 9,
line 28, respectively, and transfer to Worksheet J-3, line 1.
4055.

WORKSHEET J-3 - CALCULATION OF REIMBURSEMENT SETTLEMENT –
COMMUNITY MENTAL HEALTH CENTER PROVIDER SERVICES

Submit a separate Worksheet J-3 for each title (V, XVIII, or XIX) under which reimbursement is
claimed. If you have more than one hospital-based CMHC, complete a separate worksheet for
each facility.
Line 1--Enter the cost of the component's services from Worksheet J-2, Part II, line 29 from
columns 5, 7, or 9, as applicable (column 5 for title V, column 7 for title XVIII (enter 0 (zero)),
and column 9 for title XIX).
Rev.

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4055 (Cont.)

FORM CMS-2552-10

DRAFT

Line 2--Enter the gross PPS payments received for services rendered during the cost reporting
period excluding outliers. Obtain this amount from the PS&R and/or your records.
Line 3--Enter the total outliers payments received. Obtain this amount from the PS&R and/or your
records.
Line 4--Enter the amounts paid and payable by workers’ compensation and other primary payers
where program liability is secondary to that of the primary payer (from your records).
Line 5--Title XVIII CMHCs enter the result obtained by subtracting line 4 from the sum of lines 2
and 3. Titles V and XIX providers not reimbursed under PPS enter the total reasonable costs by
subtracting line 4 from line 1.
Line 6--Enter the charges for the applicable program services from Worksheet J-2, sum of Parts I
and II, columns 4, 6, and 8, as appropriate, lines 20 and 28.
Lines 7 through 10--These lines provide for the reduction of program charges where the provider
does not actually impose charges on most of the patients liable for payment for services on a charge
basis or fails to make reasonable efforts to collect such charges from those patients. If line 9 is
greater than zero (0), enter on line 10, the product of multiplying the ratio on line 9 by line 6.
Providers that do impose charges and make reasonable efforts to collect the charges from patients
liable for payment for services on a charge basis are not required to complete lines 7, 8, and 9, but
enter on line 10, the amount from line 6. (See 42 CFR 413.13(e).) In no instance may the
customary charges on line 10 exceed the actual charges on line 6.
Do not include on these lines (1) the portion of charges applicable to the excess costs of luxury
items or services (see CMS Pub. 15-1, chapter 21, §2104.3), and (2) provider charges to
beneficiaries for excess costs as described in CMS Pub. 15-1, chapter 25, §2570. When provider
operating costs include amounts that flow from the provision of luxury items or services, such
amounts are not allowable in computing reimbursable costs.
Lines 11 and 12--Lines 11 and 12 provide for the computation of the lesser of reasonable cost or
customary charges as defined in 42 CFR 413.13(a).
Enter on line 11, the excess of total customary charges (line 10) over the total reasonable cost
(line 5). In situations where the total charges on line 10 are less than the total cost on line 5, enter 0
(zero) on line 11.
Enter on line 12, the excess of total reasonable cost (line 5) over total customary charges (line 10).
In situations when in any column the total cost on line 5 is less than the customary charges on
line 10, enter zero (0) on line 12.
NOTE: CMHCs not subject to reasonable cost reimbursement do not complete lines 11 and 12.
Line 13--Enter the total reasonable costs from line 5.
Line 14--Enter the Part B deductibles billed to program patients (from your records) excluding
coinsurance amounts.
Line 16--If there is an excess of reasonable cost over customary charges, enter the amount from
line 12.
Line 18--CMHCs enter 0 (zero) as these services are reimbursed under the OPPS. For titles V and
XIX, enter 100 percent less the applicable coinsurance.
Line 19--Enter the actual coinsurance billed to program patients (from your records).
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FORM CMS-2552-10

4055 (Cont.)

Line 20--For title XVIII, enter the difference of line 17 minus line 19. For titles V and XIX, enter
the difference of line 18 minus line 19.
Line 21--Enter allowable bad debts, net of recoveries, applicable to any deductibles and
coinsurance (from your records). If recoveries exceed the current year’s bad debts, line 21 will be
negative. (See 42 CFR 413.89.)
Line 22--Enter the result of line 21 (including negative amounts) times 88 percent for cost
reporting periods beginning on or after October 1, 2012, 76 percent for cost reporting periods
beginning on or after October 1, 2013, and 65 percent for cost reporting periods beginning on or
after October 1, 2014.
Line 23--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. This amount must also be reported on line 21.
Line 24--Enter the result of line 20 plus line 21. For cost reporting periods beginning on or after
October 1, 2012, enter the result of line 20 plus line 22.
Line 25--Enter any other adjustment. For example, if you change the recording of vacation pay
from the cash basis to the accrual basis (see CMS Pub. 15-1 chapter 21, §2146.4), enter the
adjustment. Specify the adjustment in the space provided.
Line 25.50--Enter the Pioneer ACO demonstration payment adjustment amount. Obtain this
amount from the PS&R. Do not use this line for services rendered on or after January 1, 2017.
Report any ACO demonstration payment adjustments for services on or after January 1, 2017, on
line 25.99 or line 26.02, accordingly.
Line 25.99--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are subject to the
sequestration adjustment. Obtain this amount from the PS&R.
Line 26--Enter the result of line 24 plus or minus line 25, and minus lines 25.50 and 25.99.
Line 26.01--For cost reporting periods that overlap or begin on or after April 1, 2013, 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 six decimal places), rounded to four decimal places) times line 26]. Do not
apply the sequestration calculation when gross reimbursement (line 26) is less than zero. (Note:
In accordance with §3709 of the CARES Act, as amended by §102 of the Consolidated
Appropriations Act of 2021, and §1 of Public Law 117-7, do not apply the sequestration adjustment
to the period of May 1, 2020, through December 31, 2021.)
Line 26.02--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are not subject to the
sequestration adjustment. Obtain this amount from the PS&R.
Line 27--Enter the total interim payments applicable to this cost reporting period. For title XVIII,
transfer this amount from Worksheet J-4, column 2, line 4.
Line 28--For contractor final settlement, report on this line the amount from Worksheet J-4,
line 5.99.
Line 29--Enter the balance due provider/program (line 26 minus lines 26.01, 26.02, 27, and 28),
and transfer this amount to Worksheet S, Part III, columns as appropriate, lines as appropriate.
Line 30--Enter the program reimbursement effect of nonallowable cost report items which you are
disputing. Compute the reimbursement effect in accordance with CMS Pub. 15-2, chapter 1,
§115.2. Attach a schedule showing the supporting details and computation.
Rev.

40-257

4056
4056.

FORM CMS-2552-10

DRAFT

WORKSHEET J-4 - ANALYSIS OF PAYMENTS TO HOSPITAL-BASED
COMMUNITY MENTAL HEALTH CENTER FOR SERVICES RENDERED TO
PROGRAM BENEFICIARIES

Complete this worksheet for Medicare interim payments only. If you have more than one hospitalbased CMHC, complete a separate worksheet for each facility.
Complete the identifying information on lines 1 through 4. The remainder of the worksheet is
completed by your contractor.
Line Descriptions
Line 1--Enter the total program interim payments paid to the CMHC. 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 includes amounts withheld from the
component's interim payments due to an offset against overpayments to the component 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.
Line 2--Enter the total program 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. It 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--Transfer the total interim payments to the title XVIII Worksheet J-3, line 27.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET J-4. 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 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 from the provider to the 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, in column 2. The amount in column 2
must equal the amount on Worksheet J-3, line 26 less the amount on lines 26.01 and 26.02.
Line 8--Enter the contractor name, the contractor number, and NPR date, in columns 0, 1 and 2,
respectively.

40-258

Rev.

11-16

FORM CMS-2552-10

4057.

WORKSHEET K - ANALYSIS OF HOSPITAL-BASED HOSPICE COSTS

4057

In accordance with 42 CFR 413.20, the methods of determining costs payable under title XVIII
involve making use of data available from the institution's basic accounts, as usually maintained,
to arrive at equitable and proper payment for services. The K series worksheets must be completed
by all hospital-based hospices. This worksheet provides for recording the trial balance of expense
accounts from your 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, which
facilitates the transfer of the various cost center data to the cost finding worksheets (e.g., on
Worksheets K, K-4, Parts I and II, the line numbers are consistent, and the total line is set at 39).
Not all of the cost centers listed apply to all providers using these forms. Effective for cost
reporting periods beginning on or after October 1, 2015, do not complete these worksheets, but
complete the O series worksheets.
Column 1--Obtain salaries to be reported from Worksheet K-1, column 9, line 3 through 38.
Column 2--Obtain employee benefits to be reported from Worksheet K-2, column 9, lines 3
through 38.
Column 3--If the transportation costs, i.e., owning or renting vehicles, public transportation
expenses, or payments to employees for driving their private vehicles can be directly identified to
a particular cost center, enter those costs in the appropriate cost center. If these costs are not
identified to a particular cost center enter them on line 27.
Column 4--Obtain the contracted services to be reported from Worksheet K-3, col. 9, lines 3
through 38.
Column 5--Enter in the applicable lines all costs which have not been reported in columns 1
through 4.
Column 6--Enter the sum of columns 1 through 5 for each cost center.
Column 7--Enter any reclassifications among cost center expenses in column 6 which are needed
to effect proper cost allocation. This column need not be completed by all providers, but is
completed only to the extent reclassifications are needed and appropriate in the particular
circumstances. Show reductions to expenses as negative amounts.
Column 8--Adjust the amounts entered in column 6 by the amounts in column 7 (increases and
decreases) and extend the net balances to column 8. The total of column 8, line 39 must equal the
total of column 6, line 39.
Column 9--In accordance with 42 CFR 413.9(c)(3), enter on the appropriate lines the amounts of
any adjustments to expenses required under Medicare principles of reimbursements. (See §4016.)
Column 10--Adjust the amounts in column 8 by the amounts in column 9, (increases or decreases)
and extend the net balances to column 10.
Transfer the amount in column 10, line 1 through 38, to the corresponding lines on Worksheet K-4,
Part I, column 0, lines 1 through 38.
Line Descriptions
Lines 1 and 2--Capital Related Cost - Buildings and Fixtures and Capital Related Cost -Movable
Equipment--These cost centers should include 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.
Rev. 10

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11-16

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 or lease or lease payments
for repair and/or maintenance agreements; 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--Plant Operation and Maintenance--This cost center contains the direct expenses incurred
in the operation and maintenance of the plant and equipment, maintaining general cleanliness and
sanitation of plant, and protecting the employees, visitors, and agency property.
Plant Operation and Maintenance include the maintenance and service of utility systems such as
heat, light, water, air conditioning and air treatment. This cost center also includes the cost of
maintenance and repair of building, parking facilities and equipment, painting, elevator
maintenance, performance of minor renovation of buildings, and equipment. The maintenance of
grounds such as landscape and paved areas, streets on the property, sidewalk, fenced areas,
fencing, external recreation areas and parking facilities are part of this cost center. The care or
cleaning of the interior physical plant, including the care of floors, walls, ceilings, partitions,
windows (inside and outside), fixtures and furnishings, and emptying of trash containers, as well
as the costs of similar services purchased from an outside organization which maintains the safety
and well-being of personnel, visitors and the provider’s facilities, are all included in this cost
center.
Line 4--Transportation-Staff--Enter all of the cost of transportation except those costs previously
directly assigned in column 3. This cost is allocated during the cost finding process.
Line 5--Volunteer Service Coordination--Enter all of the cost associated with the coordination of
service volunteers. This includes recruitment and training costs.
Line 6--Administrative and General--Use this cost center to record expenses of several costs which
benefit the entire facility. If the option to componentize (also known as fragmentation or
subscripting) A&G costs into more than one cost center is elected, eliminate line 6.
Componentized A&G lines must begin with subscripted line 6.01 and continue in sequential order
(i.e., 6.01 A&G shared costs, 6.02 A&G reimbursable costs, etc.). Examples include fiscal
services, legal services, accounting, data processing, taxes, and malpractice costs.
Line 7--Inpatient - General Care--This cost center includes costs applicable to patients who receive
this level of care because their condition is such that they can no longer be maintained at home.
Generally, they require pain control or management of acute and severe clinical problems which
cannot be managed in other settings. The costs incurred on this line are those direct costs of
furnishing routine and ancillary services associated with inpatient general care for which other
provisions are not made on this worksheet.
Costs incurred by a hospice in furnishing direct patient care services to patients receiving general
inpatient care either directly from the hospice or under a contractual arrangement in an inpatient
facility is to be included in the visiting service costs section.
For a hospice that maintains its own inpatient beds, these costs include (but are not limited to) the
costs of furnishing 24 hours nursing care within the facility, patient meals, laundry and linen
services, and housekeeping. Plant operation and maintenance cost would be recorded on line 3.
For a hospice that does not maintain its own inpatient beds, but furnishes inpatient general care
through a contractual arrangement with another facility, record contracted/purchased costs on
Worksheet K-3. Do not include any costs associated with providing direct patient care. These
costs are recorded in the visiting services section.

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FORM CMS-2552-10

4057 (Cont.)

Line 8--Inpatient - Respite Care--This cost center includes costs applicable to patients who receive
this level of care on an intermittent, nonroutine and occasional basis. The costs included on this
line are those direct costs of furnishing routine and ancillary services associated with inpatient
respite care for which other provisions are not made on this worksheet. Costs incurred by the
hospice in furnishing direct patient care services to patients receiving inpatient respite care either
directly by the hospice or under a contractual arrangement in an inpatient facility are to be included
in visiting service costs section.
For a hospice that maintains its own inpatient beds, these costs include (but are not limited to) the
costs of furnishing 24 hours nursing care within the facility, patient meals, laundry and linen
services and housekeeping. Plant operation and maintenance costs would be recorded on line 3.
For A hospice that does not maintain its own inpatient beds, but furnishes inpatient respite care
through a contractual arrangement with another facility, record contracted/purchased costs on
Worksheet K-3. Do not include any costs associated with providing direct patient care. These
costs are recorded in the visiting service costs section.
Line 9--Physician Services--In addition to the palliation and management of terminal illness and
related conditions, hospice physician services also include meeting the general medical needs of
the patients to the extent that these needs are not met by the attending physician. The amount
entered on this line includes costs incurred by the hospice or amounts billed through the hospice
for physicians’ direct patient care services.
Line 10--Nursing Care--Generally, nursing services are provided as specified in the plan of care
by or under the supervision of a registered nurse at the patient’s residence.
Line 11--Nursing Care-Continuous Home Care--Enter the continuous home care portion of costs
for nursing services provided by a registered nurse, licensed practical nurse, or licensed vocational
nurse as specified in the plan of care by or under the supervision of a registered nurse at the
patient’s residence.
Line 12--Physical Therapy--Physical therapy is the provision of physical or corrective treatment
of bodily or mental conditions by the use of physical, chemical, and other properties of heat, light,
water, electricity, sound massage, and therapeutic exercise by or under the direction of a registered
physical therapist as prescribed by a physician. Therapy and speech-language pathology 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 13--Occupational Therapy--Occupational therapy is the application of purposeful goaloriented activity in the evaluation, diagnostic, for the persons whose function is impaired by
physical illness or injury, emotional disorder, congenial or developmental disability, and to
maintain health. Therapy and speech-language pathology 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 14--Speech/Language Pathology--These are physician-prescribed services provided by or
under the direction of a qualified speech-language pathologist to those with functionally impaired
communications skills. This includes the evaluation and management of any existing disorders of
the communication process centering entirely, or in part, on the reception and production of speech
and language related to organic and/or nonorganic factors. Therapy and speech-language
pathology 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 15--Medical Social Services--This cost center includes only direct expenses incurred in
providing Medical Social Services. Medical Social Services consist of counseling and assessment
activities, which contribute meaningfully to the treatment of a patient’s condition. These services
must be provided by a qualified social worker, under the direction of a physician.
Rev. 10

40-261

4057 (Cont.)

FORM CMS-2552-10

10-16

Lines 16 through 18--Counseling--Counseling Services must be available to the terminally ill
individual, their family members, and other persons caring for the individual at home. Counseling,
including dietary counseling, may be provided both for the purpose of training the individual’s
family or other care giver to provide care, and for the purpose of helping the individual and those
caring for him or her to adjust to the individual’s approaching death. This includes dietary,
spiritual, and other counseling services provided while the individual is enrolled in the hospice.
Costs associated with the provision of such counseling are accumulated in the appropriate
counseling cost center. Costs associated with bereavement counseling are recorded on line 35.
Line 19--Home Health Aide And Homemaker--Enter the cost of home health aide and homemaker
services. Home health aide services are provided under the general supervision of a registered
professional nurse and may be provided by only individuals who have successfully completed a
home health aide training and competency evaluation program or competency evaluation program
as required in 42 CFR 484.36.
Home health aides may provide personal care services. Aides may also perform household
services to maintain a safe and sanitary environment in areas of the home used by the patient, such
as changing the bed or light cleaning and laundering essential to the comfort and cleanliness of the
patient.
Homemaker services may include assistance in personal care, maintenance of a safe and healthy
environment and services to enable the individual to carry out the plan of care.
Line 20--Home Health Aide and Homemaker-Continuous Home Care--Enter the continuous care
portion of cost for home health aide and/or homemaker services provided as specified in the plan
of care and under the supervision of a registered nurse.
Line 21--Other-- Enter on this line any other visiting cost which cannot be appropriately identified
in the services already listed.
Line 22--Drugs, Biological and Infusion Therapy--Only drugs as defined in §1861(t) of the Act
and which are used primarily for the relief of pain and symptom control related to the individual’s
terminal illness are covered. The amount entered on this line includes costs incurred for drugs or
biologicals provided to the patients while at home. If a pharmacist dispenses prescriptions and
provides other services to patients while the patient is both at home and in an inpatient unit, a
reasonable allocation of the pharmacist cost must be made and reported respectively on line 22
(drugs and Biologicals) and line 7 (Inpatient General Care) or line 8 (Inpatient Respite Care) of
Worksheet K.
A hospice may, for example, use the number of prescriptions provided in each setting to make that
allocation, or may use any other method that results in a reasonable allocation of the pharmacist’s
cost in relation to the service rendered.
Infusion therapy may be used for palliative purposes if you determine that these services are
needed for palliation. For the purposes of a hospice, infusion therapy is considered to be the
therapeutic introduction of a fluid other than blood, such as saline solution, into a vein.
Line 23--Analgesics--Enter the cost of analgesics.
Line 24--Sedatives/Hypnotics--Enter the cost of sedatives/hypnotics.
Line 25--Other Specify--Specify the type and enter the cost of any other drugs which cannot be
appropriately identified in the drug cost center already listed.

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Line 26--Durable Medical Equipment/Oxygen--DME, as defined in 42 CFR 410.38, as well as
other self-help and personal comfort items related to the palliation or management of the patient’s
terminal illness, are covered. Equipment is provided by the hospice for use in the patient’s home
while he or she is under hospice care.
Line 27—Patient Transportation--Enter all of the cost of transportation except those costs
previously directly assigned in column 3. This cost is allocated during the cost finding process.
Line 28--Imaging Services--Enter the cost of imaging services including MRI.
Line 29--Labs and Diagnostics--Enter the cost of laboratory and diagnostic tests.
Line 30--Medical Supplies--The cost of medical supplies reported in this cost center are those costs
which are directly identifiable supplies furnished to individual patients.
These supplies are generally specified in the patient’s plan of treatment and furnished under the
specific direction of the patient’s physician.
Line 31--Outpatient Service--Use this line for any outpatient services costs not captured elsewhere.
This cost can include the cost of an emergency room department.
Lines 32 through 33--Radiation Therapy and Chemotherapy--Radiation, chemotherapy and other
modalities may be used for palliative purposes if you determine that these services are needed for
palliation. This determination is based on the patient’s condition and your care giving philosophy.
Line 34--Other--Enter any additional costs involved in providing visiting services which has not
been provided for in the previous lines.
Lines 35 through 38--Hospice Non Reimbursable Service--Enter in the appropriate lines the
applicable costs. Bereavement program costs consists of counseling services provided to the
individual’s family after the individual’s death. In accordance with §1814 (i)(1)(A) of the Social
Security Act, bereavement counseling is a required hospice service, but is not reimbursable.
Line 39--Total--Line 39, column 10, should agree with Worksheet A, line 116, column 7.
4058.

WORKSHEET K-1 - COMPENSATION ANALYSIS - SALARIES AND WAGES

Enter all salaries and wages for the hospice on this worksheet for the actual work performed within
the specific area or cost center in accordance with the column headings. For example, if the
administrator also performs visiting services which account for 25 percent of that person’s time,
then enter 75 percent of the administrator’s salary on line 6 (A&G), and 25 percent of the
administrator’s salary enter on line 10 (nursing care).
The records necessary to determine the split in salary between two or more cost centers must be
maintained by the hospice and must adequately substantiate the method used to split the salary.
These records must be available for audit by the contractor and the contractor can accept or reject
the method used to determine the split in salary. When approval of a method has been requested
in writing and this approval has been received prior to the beginning of a cost reporting period, the
approved method remains in effect for the requested period and all subsequent periods until you
request in writing to change to another method or until the contractor determines that the method
is no longer valid due to changes in your operations.

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Definitions
Salary--This is gross salary paid to the employee before taxes and other items are withheld,
includes deferred compensation, overtime, incentive pay, and bonuses. (See CMS Pub. 15-1,
chapter 21.)
Administrator (Column 1)-Possible Titles: President, Chief Executive Officer
Duties: This position is the highest occupational level in the agency. This individual is the chief
management official in the agency. The administrator develops and guides the organization by
taking responsibility for planning, organizing, implementing, and evaluating. The administrator
is responsible for the application and implementation of established policies. The administrator
may act as a liaison among the governing body, the medical staff, and any departments.
The administrator provides for personnel policies and practices that adequately support sound
patient care and maintains accurate and complete personnel records. The administrator
implements the control and effective utilization of the physical and financial resources of the
provider.
Director (Column 2)-Possible Titles: Medical Director, Director of Nursing, or Executive Director
Duties: The medical director is responsible for helping to establish and assure that the quality of
medical care is appraised and maintained. This individual advises the chief executive officer on
medical and administrative problems and investigates and studies new developments in medical
practices and techniques.
The nursing director is responsible for establishing the objectives for the department of nursing.
This individual administers the department of nursing and directs and delegates management of
professional and ancillary nursing personnel.
Medical Social Worker (Column 3)--This individual is a person who has at least a bachelor’s
degree from a school accredited or approved by the council of social work education. These
services must be under the direction of a physician and must be provided by a qualified social
worker.
Supervisors (Column 4)--Employees in this classification are primarily involved in the direction,
supervision, and coordination of the hospice activities.
When a supervisor performs two or more functions, e.g., supervision of nurses and home health
aides, the salaries and wages must be split in proportion with the percent of the supervisor’s time
spent in each cost center, provided the hospice maintains the proper records (continuous time
records) to support the split. If continuous time records are not maintained by the hospice, enter
the entire salary of the supervisor on line 6 (A&G), and allocate to all cost centers through
stepdown. However, if the supervisor’s salary is all lumped in one cost center, e.g., nursing care,
and the supervisor’s title coincides with this cost center, e.g., nursing supervisor, no adjustment is
required.
Total Therapists (Column 6)--Include in column 6, on the line indicated, the cost attributable to
the following services:
Physical therapy
Occupational therapy Speech pathology
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Therapy and speech-language pathology may be provided for purposes of symptom control or to
enable the individual to maintain activities of daily living and basic functional skill.
Physical therapy is the provision of physical or corrective treatment of bodily or mental conditions
by the use of physical, chemical, and other properties of heat, light, water, electricity, sound,
massage, and therapeutic exercise by or under the direction of a registered physical therapist as
prescribed by a physician.
Occupational therapy is the application of purposeful, goal-oriented activity in the evaluation,
diagnosis, and/or treatment of persons whose ability to work 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.
Speech-language pathology is the provision of services to persons with impaired functional
communications skills by or under the direction of a qualified speech-language pathologist as
prescribed by a physician. This includes the evaluation and management of any existing disorders
of the communication process centering entirely, or in part, on the reception and production of
speech and language related to organic and/or nonorganic factors.
Aides (Column 7)--Included in this classification are specially trained personnel employed for
providing personal care services to patients. These employees are subject to Federal wage and
hour laws. This function is performed by specially trained personnel who assist individuals in
carrying out physician instructions and established plans of care. The reason for the home health
aide services must be to provide hands-on, personal care services under the supervision of a
registered professional nurse.
Aides may provide personal care services and household services to maintain a safe and sanitary
environment in areas of the home used by the patient, such as changing the bed or light cleaning
and laundering essential to the comfort and cleanliness of the patient. Additional services include,
but are not limited to, assisting the patient with activities of daily living.
All Other (Column 8)--Employees in this classification are those not included in columns 1
through 7. Included in this classification are dietary, spiritual, and other counselors. Counseling
Services must be available to both the terminally ill individual and the family members or other
persons caring for the individual at home. Counseling, including dietary counseling, may be
provided both for the purpose of training the individual’s family or other care giver to provide
care, and for the purpose of helping the individual and those caring for him or her to adjust to the
individual’s approaching death. This includes dietary, spiritual and other counseling services
provided while the individual is enrolled in the hospice.
Total (Column 9)--Add the amounts of each cost center, columns 1 through 8, and enter the total
in column 9. Transfer these totals to Worksheet K, column 1, lines as applicable. To facilitate
transferring amounts from Worksheet K-1 to Worksheet K, the same cost centers with
corresponding line numbers are listed on both worksheets. Not all of the cost centers are applicable
to all agencies. Therefore, use only those cost centers applicable to your hospice.
4059.

WORKSHEET K-2 - COMPENSATION ANALYSIS - EMPLOYEE BENEFITS
(PAYROLL RELATED)

Enter all payroll-related employee benefits for the hospice on this worksheet. See CMS Pub. 15-1,
chapter 20, for a definition of fringe benefits. Use the same basis as that used for reporting salaries
and wages on Worksheet K-1. Therefore, using the same example as given for Worksheet K-1,

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enter 75 percent of the administrator’s payroll-related fringe benefits on line 6 (A&G) and enter
25 percent of the administrator’s payroll-related fringe benefits on line 10 (nursing care). Payrollrelated employee benefits must be reported in the cost center in which the applicable employee’s
compensation is reported.
This assignment can be performed on an actual basis or the following basis:
•

FICA - actual expense by cost center;

•

Pension and retirement and health insurance (nonunion) (gross salaries of participating
individuals by cost center);

•

Union health and welfare (gross salaries of participating union members by cost
center); and

•

All other payroll-related benefits (gross salaries by cost center). Include non-payrollrelated employee benefits in the A&G cost center, e.g., cost for personal education,
recreation activities, and day care.

Add the amounts of each cost center, columns 1 through 8, and enter the total in column 9.
Transfer these totals to Worksheet K, column 2, corresponding lines. To facilitate transferring
amounts from Worksheet K-2 to Worksheet K, the same cost centers with corresponding line
numbers are listed on both worksheets.
4060.

WORKSHEET K-3 - HOSPICE COMPENSATION ANALYSIS - CONTRACTED
SERVICES/PURCHASED SERVICES.

The hospice may contract with another entity for the provision of non-core hospice services.
However, nursing care, medical social services and counseling are core hospice services and must
routinely be provided directly by hospice employees. Supplemental services may be contracted in
order to meet unusual staffing needs that cannot be anticipated and that occur so infrequently it
would not be practical to hire additional staff to fill these needs. You may also contract to obtain
physician specialty services. If contracting is used for any services, maintain professional,
financial and administrative responsibility for the services and assure that all staff meet the
regulatory qualification requirements.
Enter on this worksheet all contracted and/or purchased services for the hospice. Enter the
contracted/purchased cost on the appropriate cost center line within the column heading which
best describes the type of services purchased. Costs associated with contracting for general
inpatient or respite care would be recorded on this worksheet. For example, where physical
therapy services are purchased, enter the contract cost of the therapist in column 6, line 12. If a
contracted/purchased service covers more than one cost center, then the amount applicable to each
cost center is included on each affected cost center line. Add the amounts of each cost center,
columns 1 through 8, and enter the total in column 9. Transfer these totals to Worksheet K,
column 4, corresponding lines. To facilitate transferring amounts from Worksheet K-3 to
Worksheet K, the same cost centers with corresponding line numbers are listed on both
worksheets.

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4061.

FORM CMS-2552-10

4061

WORKSHEET K-4, PART I - COST ALLOCATION - GENERAL SERVICE COSTS
AND, PART II - COST ALLOCATION - STATISTICAL BASIS

Worksheet K-4 provides for the allocation of the expenses of each general service cost center to
those cost centers, which receive the services. The cost centers serviced by the general service
cost centers include all cost centers within the provider organization, i.e., other general service
cost centers, reimbursable cost centers, nonreimbursable cost centers. Obtain the total direct
expenses from Worksheet K, column 10. To facilitate transferring amounts from Worksheet K to
Worksheet K-4, Part I, the same cost centers with corresponding line numbers (lines 3 through 39)
are listed on both worksheets.
Worksheet K-4, Part II, provides for the proration of the statistical data needed to equitably
allocate the expenses of the general service cost centers on Worksheet K-4, Part I.
To facilitate the allocation process, the general format of Worksheets K-4, Parts I and II, are
identical. The column and line numbers for each general service cost center are identical on the
two worksheets. In addition, the line numbers for each general, reimbursable, nonreimbursable,
and special purpose cost centers are identical on the two worksheets. The cost centers and line
numbers are also consistent with Worksheets K, K-1, K-2, and K-3.
The statistical bases shown at the top of each column on Worksheet K-4, Part II, are the
recommended bases of allocation of the cost centers indicated. If a different basis of allocation is
used, the provider must indicate the basis of allocation actually used at the top of the column.
Most cost centers are allocated on different statistical bases. However, for those cost centers where
the basis is the same (e.g., square feet), the total statistical base over which the costs are to be
allocated will differ because of the prior elimination of cost centers that have been closed.
Close the general service cost centers in accordance with 42 CFR 413.24(d)(1) which states, in
part, that the cost of nonrevenue-producing cost centers serving the greatest number of other
centers, while receiving benefits from the least number of centers, is apportioned first. This is
clarified in CMS Pub. 15-1, chapter 23, §2306.1, which further clarify the order of allocation for
stepdown purposes. Consequently, first close those cost centers that render the most services to
and receive the least services from other cost centers. The cost centers are listed in this sequence
from left to right on the worksheet. However, the circumstances of an agency may be such that a
more accurate result is obtained by allocating to certain cost centers in a sequence different from
that followed on these worksheets.
NOTE: A change in order of allocation and/or allocation statistics is appropriate for the current
fiscal year cost if received by the contractor, in writing, within 90 days prior to the end
of that fiscal year. The contractor has 60 days to make a decision or the change is
automatically accepted. The change must be shown to more accurately allocate the
overhead or, if the allocation is accurate, it should be changed due to simplification of
maintaining the statistics. If a change in statistics is made, the provider must maintain
both sets of statistics until an approval is made. If both sets are not maintained and the
request is denied, the provider reverts back to the previously approved methodology. The
provider must include with the request all supporting documentation and a thorough
explanation of why the alternative approach should be used. (See CMS Pub. 15-1,
chapter 23, §2313.)
If the amount of any cost center on Worksheet K, column 10, has a credit balance, show this
amount as a credit balance on Worksheet K-4, Part I, column 0. Allocate the costs from the
applicable overhead cost centers in the normal manner to the cost center showing a credit balance.

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After receiving costs from the applicable overhead cost centers, if a general service cost center has
a credit balance at the point it is allocated, do not allocate the general service cost center. Rather,
enter the credit balance on the first line of the column and on line 39. This enables column 6,
line 39, to crossfoot to columns 0 and 5A, line 39. After receiving costs from the applicable
overhead cost centers, if a revenue producing cost center has a credit balance on Worksheet K-4,
Part I, column 6, do not carry forward a credit balance to any worksheet.
On Worksheet K-4, Part II, enter on the first line in the column of the cost center the total statistics
applicable to the cost center being allocated (e.g., in column 1, capital-related cost - buildings and
fixtures, enter on line 1, the total square feet of the building on which depreciation was taken).
Use accumulated cost for allocating A&G expenses.
Such statistical base 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 your records.
For all cost centers (below the cost center being allocated) to which the service rendered is being
allocated, enter that portion of the total statistical base applicable to each.
The total sum of the statistical base applied to each cost center receiving the services rendered
must equal the total statistics entered on the first line.
Enter on Worksheet K-4, Part II, line 39, the total expenses of the cost center to be allocated.
Obtain this amount from Worksheet K-4, Part I from the same column and line number of the same
column. In the case of capital-related costs - buildings and fixtures, this amount is on
Worksheet K-4, Part I, column 1, line 1.
Divide the amount entered on line 39, by the total statistical base entered in the same column on
the first line. Enter the resulting unit cost multiplier on line 40. Round the unit cost multiplier to
six decimal places.
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 K-4,
Part I, in the corresponding column and line.
After the unit cost multiplier has been applied to all the cost centers receiving costs, the total
expenses (line 39) of all of the cost centers receiving the allocation on Worksheet K-4, Part I, must
equal the amount entered on the first line of the cost center being allocated.
The preceding procedures must be performed for each general service cost center. Each cost center
must be completed on Worksheets K-4, Parts I and II, before proceeding to the next cost center.
After all the costs of the general service cost centers have been allocated on Worksheet K-4, Part I,
enter in column 7, the sum of the expenses on lines 7 through 38. The total expenses entered in
column 7, line 39, must equal the total expenses entered in column 0, line 39.
Column Descriptions
Column 1--Depreciation on buildings and fixtures and expenses pertaining to buildings and
fixtures such as insurance, interest, rent, and real estate taxes are combined in this cost center to
facilitate cost allocation.

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FORM CMS-2552-10

4061 (Cont.)

Allocate all expenses to the cost centers on the basis of square footage of the space occupied. The
square footage may be weighted if the person who occupies a certain area of space spends their
time in more than one function. For example, if a person spends 10 percent of time in one function,
20 percent in another function, and 70 percent in still another function, the square footage may be
weighted according to the percentages of 10 percent, 20 percent, and 70 percent, to the applicable
functions.
Column 2--Allocate all expenses (e.g., interest, and personal property tax) for movable equipment
to the appropriate cost centers on the basis of dollar value.
Column 4--The cost of vehicles owned or rented by the agency and all other transportation costs
which were not directly assigned to another cost center on Worksheet K, column 3, is included in
this cost center. Allocate this expense to the cost centers to which it applies on the basis of miles
applicable to each cost center.
This basis of allocation is not mandatory and a provider may use weighted trips rather than actual
miles as a basis of allocation for transportation costs, which are not directly assigned. However, a
hospice must request the use of the alternative method in accordance with CMS Pub. 15-1,
chapter 23, §2313. The hospice must maintain adequate records to substantiate the use of this
allocation.
Column 6--The A&G expenses are allocated on the basis of accumulated costs after
reclassifications and adjustments.
Therefore, obtain the amounts to be entered on Worksheet K-4, Part II, column 6, from
Worksheet K-4, Part I, columns 0 through 5.
A negative cost center balance in the statistics for allocating A&G expenses causes an improper
distribution of this overhead cost center. Negative balances are excluded from the allocation
statistics when A&G expenses are allocated on the basis of accumulated cost.
A&G costs applicable to contracted services may be excluded from the total cost (Worksheet K-4,
Part I, column 0) for purposes of determining the basis of allocation (Worksheet K-4, Part II,
column 5) of the A&G costs. This procedure may be followed when the hospice contracts for
services to be performed for the hospice and the contract identifies the A&G costs applicable to
the purchased services
The contracted A&G costs must be added back to the applicable cost center after allocation of the
hospice A&G cost before the reimbursable costs are transferred to Worksheet K-5. A separate
worksheet must be included to display the breakout of the contracted A&G costs from the
applicable cost centers before allocation and the adding back of these costs after allocation.
Contractor approval does not have to be secured in order to use the above described method of
cost finding for A&G.
Worksheet K-4, Part II, Column 6A--Enter the costs attributable to the difference between the total
accumulated cost reported on Worksheet K-4, Part I, column 5A, line 39, and the accumulated cost
reported on Worksheet K-4, Part II, column 6, line 6. Enter any amounts reported on
Worksheet K-4, Part I, column 5A, for (1) any service provided under arrangements to program
patients only that is not grossed up and (2) negative balances. Including these costs in the statistics
for allocating A&G expenses causes an improper distribution of overhead.
In addition, report on line 6 the A&G costs reported on Worksheet K-4, Part I, column 6, line 6,
since these costs are not included on Worksheet K-4, Part II, column 6, as an accumulated cost
statistic.

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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 6 (A&G), the reconciliation column designation must be 6A.
Worksheet K-4, Part II, Column 6--The A&G expenses are allocated on the basis of accumulated
costs. Therefore, enter the amount from Worksheet K-4, Part I, column 5A.
4062.

WORKSHEET K-5 - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE
COST CENTERS

This worksheet distributes the hospital’s overhead to the specific cost centers of the hospice.
4062.1 Part I - Allocation of General Service Costs to Hospice Cost Centers.--Worksheet K-5,
Part I, provides for the allocation of the expenses of each general service cost center of the hospital
to those cost centers which receive the services.
Obtain the direct total expenses (column 0, lines 2 through 33) from Worksheet K-4 Part I, lines 7
through 38. The amounts on columns 0 through 23 and column 25, line 34, must agree with the
corresponding amounts on Worksheet B, Part I, columns 0 through 23, and column 25, line 116.
Complete the amounts entered on lines 1 through 33, columns 1 through 23, and column 25, in
accordance with the instructions in §4062.2.
NOTE: Worksheet B, Part I, established the method used to reimburse direct GME cost (i.e.,
reasonable cost or the per resident amount). Therefore, this worksheet must follow that
method. If Worksheet B, Part I, column 25, excluded the costs of interns and residents,
column 25 on this worksheet must also exclude these costs.
In column 24, enter the total of columns 4A through 23.
In column 27, for lines 2 through 33, multiply the amount in column 26, by the unit cost multiplier
on line 35, and enter the result in this column. The total of the amounts on lines 2 through 33 must
equal the amount in column 26, line 1.
In column 28, enter on lines 2 through 33, the sum of columns 26 and 27. The total on line 34
equals the total in column 26, line 34.
4062.2 Part II - Allocation of General Service Costs to Hospice Cost Centers - Statistical
Basis.--Worksheet K-5, Part II, provides for the proration of the statistical data needed to equitably
allocate the expenses of the hospital’s general service cost centers on Worksheet K-5, Part I. To
facilitate the allocation process, the general format of Worksheet K-5, Parts I and II, is identical.
The statistical basis shown at the top of each column on Worksheet K-5, Part II, is the
recommended basis of allocation of the cost center indicated and must be consistent with the
statistical basis utilized on Worksheet B, Part I.
Lines 1 through 33--On Worksheet K-5, Part II, for all cost centers to which the general service
cost center is being allocated, enter that portion of the total statistical base applicable to each.
Line 34--Enter the total of lines 1 through 33, for each column. The total in each column must be
the same as shown for the corresponding column on Worksheet B-1, line 116.

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FORM CMS-2552-10

Line 35--Enter the total expenses for the cost center allocated.
Worksheet B, Part I, columns as indicated, line 116.

4063
Obtain this amount from

Line 36--Enter the unit cost multiplier which is obtained by dividing the cost entered on line 35,
by the total statistic entered in the same column on line 34. Round the unit cost multiplier to six
decimal places.
Multiply the unit cost multiplier by that portion of the total statistic applicable to each cost center
receiving the services. Enter the result of each computation on Worksheet K-5, Part I, in the
corresponding column and line.
After the unit cost multiplier has been applied to all the cost centers receiving the services, the
total cost (Part I, line 34) must equal the total cost on Part II, line 34.
Perform the preceding procedures for each general service cost center.
4062.3 Part III - Computation of the Total Hospice Shared Costs.--This worksheet provides for
the shared therapy, drugs, or medical supplies from the hospital to the hospice.
Column Description
Column 1--Where applicable, enter in column 1 the cost to charge ratio from Worksheet C, Part I,
column 9, lines as indicated.
Column 2--Where hospital departments provide services to the hospice, enter on the appropriate
lines the charges, from the provider’s records, applicable to the hospital-based hospice.
Column 3--Multiply the amount in column 2 by the ratios in column 1, and enter the result in
column 3.
Line 11--Sum of column 3, lines 1 through 10.
4063.

WORKSHEET K-6 - CALCULATION OF HOSPICE PER DIEM COST

Worksheet K-6 calculates the average cost per day for a hospice patient. It is only an average and
should not be misconstrued as the absolute.
Line 1--Transfer the total cost from Worksheet K-5, Part I, column 28, line 34 less column 28,
line 33, plus Worksheet K-5, Part III, column 3, line 11. This line reflects the true cost including
shared cost and excluding any non-hospice related activity.
Line 2--Enter the total unduplicated days from Worksheet S-9, column 6, line 5.
Line 3--Calculate the aggregate cost per day by dividing the total cost from line 1 by the total
number of days from line 2.
Line 4--Enter the unduplicated Medicare days from Worksheet S-9, column 1, line 5.
Line 5--Calculate the aggregate Medicare cost by multiplying the average cost from column 4,
line 3, by the number of unduplicated Medicare days on column 1, line 4, to arrive at the average
Medicare cost.
Line 6--Enter the unduplicated Medicaid days from Worksheet S-9, column 2, line 5.

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Line 7--Calculate the aggregate Medicaid cost by multiplying the average cost from line 3 by the
number of unduplicated Medicaid days on line 6, to arrive at the average Medicaid cost.
Line 8--Enter the unduplicated SNF days from Worksheet S-9, column 3, line 5.
Line 9--Calculate the aggregate SNF cost by multiplying the average cost from line 3 by the
number of unduplicated SNF days on line 8, to arrive at the average SNF cost.
Line 10--Enter the unduplicated NF days from Worksheet S-9, column 4, line 5.
Line 11--Calculate the aggregate NF cost by multiplying the average cost from line 3 by the
number of unduplicated NF days on line 10, to arrive at the average NF cost.
Line 12--Enter the unduplicated Other days from Worksheet S-9, column 5, line 5.
Line 13--Enter the aggregate cost for other days by multiplying the average cost from line 3, by
the number of unduplicated Other days on line 12, to arrive at the average other cost.

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Rev. 8

04-20
4064.

FORM CMS-2552-10

4064.1

WORKSHEET L - CALCULATION OF CAPITAL PAYMENT

Worksheet L, Parts I through III, calculate program settlement for PPS inpatient hospital capitalrelated costs in accordance with 42 CFR 412, Subpart M. Only provider components paid under
the IPPS complete this worksheet.
Worksheet L consists of the following three parts:
Part I - Fully Prospective Method
Part II - Payment Under Reasonable Cost
Part III - Computation of Exception Payments
COMPLETE EITHER PART I OR PART II, OR PARTS I AND III.
At the top of the worksheet, indicate by checking the applicable boxes the health care program,
provider component, and the IPPS capital payment method for which the worksheet is prepared.
4064.1 Part I - Fully Prospective Method.--This part computes settlement under the fully
prospective method only, as defined in 42 CFR 412.340. Use the fully prospective method for the
IPPS capital settlement when the hospital’s base year hospital-specific rate is below the adjusted
federal rate and for IPPS hospitals with cost reporting periods beginning after the capital PPS
transition. If your facility experienced a geographic redesignation (see 42 CFR 412.102(a) and
(b), or 412.103) from urban to rural, or rural to urban (Worksheet S-2, lines 26 and 27, column 1,
are “1” and “2” or “2” and “1”, respectively, and the hospital contains at least 100 beds (as counted
in accordance with 42 CFR 412.105(b)), subscript column 1 (add column 1.01) for lines 1 and
1.01. Enter in co1umn 1, the capital DRG payments for the portion of the reporting period the
hospital is classified as urban, and enter in co1umn 1.01, the capital DRG payments for the portion
of the reporting period the hospital is classified as rural.
For IPPS hospitals participating in the PARHM demonstration during this cost reporting period
and (1) the hospital participated in the PARHM demonstration for the entire cost reporting period,
select the “PARHM Demonstration” box only and complete this worksheet; or (2) the hospital
participated in the PARHM demonstration for a portion of the cost reporting period, select the
“PARHM Demonstration” box and complete Worksheet L, for the portion of the cost reporting
period, included in the demonstration. Select the “Hospital” box and complete a separate
Worksheet L, for the portion of the cost reporting period not included in the demonstration.
Line Descriptions
Line 1--Enter the amount of the federal rate portion of the capital DRG payments for other than
outlier during the period. If your facility experienced a geographic redesignation (see
42 CFR 412.102(a) and (b), or 412.103), enter in column 1 the federal rate portion of the capital
DRG payments for other than outliers for discharges occurring during the urban classification
portion of the cost reporting period. Enter in column 1.01, the federal rate portion of the capital
DRG payments for other than outliers for discharges occurring during the rural classification
portion of the cost reporting period.
Line 1.01--Enter the amount of the federal rate portion of the capital DRG payments for other than
outlier during the period associated with Model 4 BPCI. If your facility experienced a geographic
redesignation (see 42 CFR 412.102(a) and (b), or 412.103), enter in column 1, the federal rate
portion of the capital DRG payments for other than outliers associated with Model 4 BPCI for
discharges occurring during the urban classification portion of the cost reporting period. Enter in
column 1.01, the federal rate portion of the capital DRG payments for other than outliers associated
with Model 4 BPCI for discharges occurring during the rural classification portion of the cost
reporting period.

Rev. 16

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FORM CMS-2552-10

04-20

Line 2--Enter the amount of the federal rate portion of the capital outlier payments made for PPS
discharges during the period. (See 42 CFR 412.312(c).)
Line 2.01--Enter the amount of the federal rate portion of the capital outlier payments made for
PPS discharges during the period associated with Model 4 BPCI. (See 42 CFR 412.312(c).)
Indirect Medical Education Adjustment
Lines 3 through 6
Line 3--Enter the result of dividing the sum of total patient days (Worksheet S-3, Part I, column 8,
lines 14 and 30) by the number of days in the cost reporting period (365, or 366 in case of leap
year). Effective for cost reporting periods beginning on or after October 1, 2013, also include in
total patient days, the labor and delivery days from Worksheet S-3, Part I, column 8, line 32. Do
not include statistics associated with an excluded unit (sub-provider).
NOTE: Reduce total patient days by nursery days (Worksheet S-3, Part I, column 8, line 13), and
swing-bed days (Worksheet S-3, Part I, column 8, lines 5 and 6).
Line 4--Obtain the intern and resident amount from Worksheet E, Part A, line 18, plus line 25.
Line 5--Enter the result of the following calculation: {e.2822 x line 4/line 3}-1 where e = 2.71828. See
42 CFR 412.322(a)(3) for limitation of the percentage of I&Rs to average daily census. Line 4
divided by line 3 cannot exceed 1.5.
Line 6--Multiply line 5 by the sum of lines 1 and 1.01, columns 1 and 1.01.
Capital Disproportionate Share Adjustment
Lines 7 through 11
Enter the amount of the federal rate portion of the additional capital payment amounts relating to
the DSH adjustment. Complete these lines if you answered yes to line 45 on Worksheet S-2, Part I.
(See 42 CFR 412.312(b)(3).) For hospitals qualifying for disproportionate share in accordance
with 42 CFR 412.106(c)(2) (Pickle Amendment hospitals), do not complete lines 7 through 9, and
enter 11.89 percent on line 10.
Line 7--Enter the percentage of SSI recipient patient days (from your contractor or your records)
to Medicare Part A patient days. Transfer this amount from Worksheet E, Part A, line 30.
Line 8--Enter the percentage resulting from the calculation of Medicaid patient days
(Worksheet S-2, Part I, columns 1 through 6, line 24) to total days reported on Worksheet S-3,
Part I, column 8, line 14, plus column 8, line 32, minus the sum of lines 5 and 6, plus employee
discount days reported on Worksheet S-3, Part I, column 8, line 30. This amount must agree with
the amount reported on Worksheet E, Part A, line 31.
Line 9--Add lines 7 and 8, and enter the result.
Line 10--Enter the percentage that results from the following calculation: (e.2025 x line 9)-1 where e
equals 2.71828. If Worksheet S-2, Part I, line 22, column 2, is “Y” (Pickle Amendment hospital),
enter 11.89 percent.
Line 11--Enter the result of line 10 multiplied by the sum of lines 1 and 1.01, column 1.
Line 12--Enter the sum of lines 1 and 1.01, columns 1 and 1.01, plus lines 2, 2.01, 6, and 11. For
title XVIII, transfer this amount to Worksheet E, Part A, line 50.

40-274

Rev. 16

09-15

FORM CMS-2552-10

4064.2

4064.2 Part II - Payment Under Reasonable Cost.--This part computes capital settlement under
reasonable cost principles subject to the reduction pursuant to 42 CFR 412.324(b). Use the
reasonable cost method for capital settlement determinations for new providers under
42 CFR 412.324(b) for the first two years or for titles V or XIX determinations, if applicable. This
part may also be completed for cost reporting periods beginning on or after October 1, 2002, for
the first two years for new providers under 42 CFR 412.304(c)(2)(i) (response to Worksheet S-2,
Part I, line 47, column 2 is “Y”, and line 48, column 2 is “N”).
Line Descriptions
Line 1--Enter the amount of program inpatient routine service capital costs. This amount is the
sum of the program inpatient routine capital costs from the appropriate Worksheet D, Part I,
column 7, sum of the amounts on lines 30 through 35, and 43 for the hospital (lines 40 through 42
as applicable, for the sub-provider).
Line 2--Enter the amount of program inpatient ancillary capital costs. This amount is the sum of
the amounts of program inpatient ancillary capital costs from the appropriate Worksheet D, Part II,
column 5, line 200.
Line 3--Enter the sum of lines 1 and 2.
Line 4--Enter a reduction factor of 85 percent.
Line 5--Multiply line 3 by line 4. For title XVIII, transfer the amount to Worksheet E, Part A,
line 50.

Rev. 8

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4064.2

FORM CMS-2552-10

09-15

This page is reserved for future use.

40-274.2

Rev. 8

09-15

FORM CMS-2552-10

4064.3

4064.3 Part III - Computation of Exception Payments.--This part computes minimum payment
levels by class of provider eligible for additional exception payment for extraordinary
circumstances pursuant to 42 CFR 412.312(e). Complete this part only if the provider component
completed Part I of this worksheet. Complete this part only if the provider qualifies for the
exception payment for extraordinary circumstances pursuant to 42 CFR 412.348(f) (the facility
indicates “Y” to question 46 on Worksheet S-2, Part I).
Line 1--Enter the amount of program inpatient routine service and ancillary service capital costs.
This amount is the sum of the program inpatient routine service capital costs from the appropriate
Worksheet D, Part I, column 7, sum of lines 30 through 35, and 43, for the hospital, lines 40
through 42, as applicable for the sub-provider, and program inpatient ancillary service capital costs
from Worksheet D, Part II, column 5, line 200.
Line 2--Enter program inpatient capital costs for extraordinary circumstances as provided by
42 CFR 412.348(f), if applicable, from Worksheet L-1, sum of Part II, column 7, sum of lines 30
through 35, and 43, for the hospital; lines 40 through 42, as applicable for the sub-providers; and
Part III, column 5, line 200.
Line 3--Enter line 1 less line 2.
Line 4--Enter the appropriate minimum payment level percentage: The minimum payment levels
for portions of cost reporting periods beginning on or after October 1, 2001, are:
• SCHs (located in either an urban or a rural area) - 90 percent;
• Urban hospitals with at least 100 beds and a disproportionate patient percentage of at
least 20.2 percent - 80 percent; and
• All other hospitals - 70 percent.
For providers that qualify for an exception payment for extraordinary circumstances pursuant to
42 CFR 412.348(f) in conjunction with 412.312(e) the appropriate minimum payment level is
70 percent.
The minimum payment levels will be revised, if necessary, to keep total payments under the
exceptions process at no more than 10 percent of capital prospective payments.
If you were an SCH during a portion of the cost reporting period, compute the minimum payment
level percentage by dividing the number of days in your cost reporting period for which you were
not an SCH (70 percent factor applicable) by the total number of days in the cost reporting period.
Multiply that ratio by 70 percent. Divide the number of days in your cost reporting period for
which you were an SCH (90 percent factor applicable) by the total number of days in the cost
reporting period. Multiply that ratio by 90 percent. Add the amounts from steps 1 and 2 to compute
the capital cost minimum payment level percentage. Display exception percentage in decimal
format, e.g., 70 percent is displayed as .70 or 0.70.
Line 5--Enter the product of line 3 multiplied by line 4.
Line 6--Hospitals that did not qualify as SCHs during the cost reporting period enter a reduction
factor of 85 percent. SCHs enter 100 percent. If you were a SCH during a portion of the cost
reporting period, compute the capital cost reduction percentage by dividing the number of days in
your cost reporting period for which you were not a SCH (reduction factor applicable) by the total
number of days in the cost reporting period. Multiply that ratio by 15 percent and subtract the
amount from 100. Enter the resulting extraordinary circumstance percentage adjustment in
decimal format, e.g., 85 percent is displayed as .85 or 0.85.

Rev. 8

40-275

4064.3 (Cont.)

FORM CMS-2552-10

09-15

Line 7--Enter the product of line 2 multiplied by line 6.
Line 8--Enter the sum of lines 5 and 7.
Line 9--Enter the amount from Part I, line 12, if applicable.
Line 10--Enter line 8 less line 9.
Lines 11 through 14--A hospital is entitled to an additional payment if its capital payments for the
cost reporting period is less than the applicable minimum payment level. The additional payment
equals the difference between the applicable minimum payment level and the capital payments
that the hospital would otherwise receive. This additional payment amount is reduced for any
amounts by which the hospital’s cumulative payments exceed its cumulative minimum payment
levels. The offsetting amounts will be determined based on the amounts by which the hospital’s
cumulative payments exceed its cumulative minimum payment levels in the lesser of the preceding
10-year period or the period of time under which the hospital is subject to the PPS for capital
related costs.
A positive amount on line 10 represents the amount of capital payments under the minimum
payment level in the current year. This amount must be offset for the amount by which the
hospital’s cumulative payments exceed its cumulative minimum payment levels in prior years, as
reported on line 11. If the net amount on line 12 remains a positive amount, this amount represents
the current year’s additional payment for capital payments under the minimum payment level.
Report this amount on line 13. If the net amount on line 12 is a negative amount, this amount
represents the reduced amount by which the accumulated capital payment amounts exceeded the
accumulated minimum payment levels. In this case, no additional payment is made in the current
year. Transfer the amount on line 12 to line 14, and carry it forward to the following cost reporting
period.
A negative amount on line 10 represents the amount of capital payments over the minimum
payment level in the current year. Add any carry forward of prior years’ amounts of the hospital’s
cumulative payments in excess of cumulative minimum payment levels, as reported on line 11, to
the current year excess on line 12. The net amount on line 12 represents the total amount by which
the accumulated capital payment amounts exceeded the accumulated minimum payment levels.
No additional payment is made in the current year. Transfer the amount on line 12 to line 14, and
carry it forward to the subsequent cost reporting period.
Line 11--The offsetting amounts will be determined based on the amounts by which the hospital’s
cumulative payments exceed its cumulative minimum payment levels in the lesser of the preceding
10-year period or the period of time under which the hospital is subject to the PPS for capital
related costs. Enter the appropriate offset amount as computed pursuant to 42 CFR 412.312(e)(3).
Line 12--Enter the sum of lines 10 and 11.
Line 13--If the amount on line 12 is positive, enter the amount on this line.
Line 14--If the amount on line 12 is negative, enter the amount on this line.
Complete lines 15 through 17 only when line 12 is a positive amount.
Line 15--Enter the current years allowable operating and capital payments calculated from
Worksheet E, Part A, line 47, plus the capital payments reported on line 9 above, minus 75 percent
of the current year’s operating disproportionate share payment amount reported on Worksheet E,
Part A, line 34.

40-276

Rev. 8

DRAFT

FORM CMS-2552-10

4065.1

Line 16--Current year operating and capital costs from Worksheet D-1, line 49 minus the sum of
Worksheet D, Part III, lines 30 through 35, column 9 (PPS sub-providers use lines 40 through 42,
as applicable, column 9), and Worksheet D, Part IV, column 11, line 200.
Line 17--Enter on this line the current year’s exception offset amount. This is computed as line 15
minus line 16. If this amount is negative, enter zero on this line. If the amount on line 13 is greater
than line 17, transfer the amount on line 13, less any reported amount on line 17, to Worksheet E,
Part A, line 51.
4065.

WORKSHEET L-1 - ALLOCATION OF ALLOWABLE CAPITAL COSTS FOR
EXTRAORDINARY CIRCUMSTANCES

This worksheet provides for the determination of direct and indirect capital-related costs associated
with capital expenditures for extraordinary circumstances, allocated to inpatient operating costs.
Only complete this worksheet for providers that qualify for an additional payment for
extraordinary circumstances under 42 CFR 412.348(f) (the facility indicates “Y” to question 46 on
Worksheet S-2, Part I).
4065.1 Part I - Allocation of Allowable Capital Costs for Extraordinary Circumstances.--Use
this part in conjunction with Worksheet B-l. The format and allocation process employed is
similar to that used on Worksheets B, Part I and B-1. Any cost center subscripted lines and/or
columns added to Worksheet B, Part I, are also added to this worksheet in the same sequence.
Column 0--Assign capital expenditures relating to extraordinary costs to specific cost centers on
this worksheet, column 0. Enter on the appropriate lines those capital-related expenditure amounts
relating to extraordinary costs which were directly assigned on Worksheet B, Part II. Enter on
lines 3 and 4, as applicable, the remaining capital expenditure amounts relating to extraordinary
costs which have not been directly assigned.
Columns 1 through 23--Transfer amounts on the top lines of columns 1 and 2, from column 0, line
as applicable. For example, transfer line 1, column 0 to line 1, column 1. For all other columns,
the top line represents the cross total amount.
For each column, enter on line 203 of this worksheet, Part I, the total statistics of the cost center
being allocated. Obtain the individual statistics from Worksheet B-1 from the same column and
line number used to allocate cost on this worksheet. (For example, obtain the amount of capitalrelated costs - buildings and fixtures from Worksheet B-1, column 1, line 1.)
Divide the amount entered on line 203, by the total capital expenses entered in the same column
on the first line. Enter the resulting unit cost multiplier on line 204. Round the unit cost multiplier
to six decimal places.
Multiply the unit cost multiplier by that portion of the total statistics applicable to each cost center
receiving the services. The applicable cost center statistics are reported on Worksheet B-1. Enter
the result of each computation on this worksheet in the corresponding column and line. (See
§4000.1 for rounding standards.)
After the unit cost multiplier has been applied to all the cost centers receiving the services rendered,
the total cost (line 197) of all the cost centers receiving the allocation on this worksheet must equal
the amount entered on the first line. Perform the preceding procedures for each general service
cost center. Complete the column for one cost center before proceeding to the column for the next
cost center.

Rev.

40-277

4065.2

FORM CMS-2552-10

DRAFT

After the capital-related costs of all the general service cost centers have been allocated, enter in
column 24 the sum of columns 2A through 23 for lines 30 through 196. (See §4020 for exception
regarding negative cost centers.)
When an adjustment is required to capital costs for extraordinary circumstances after cost
allocation, show the amount applicable to each cost center in column 25. Submit a supporting
schedule showing the computation of the adjustment.
Transfer from Worksheet L-1,
Part I, Column 26

To Worksheet L-1, Part II

Line 30 - Adults and Pediatrics

Column l, line 30 for the hospital

Lines 31 through 35 - Intensive
Care Type Inpatient Hospital
Units

Column 1, lines 31 through 35

Lines 40 through 42, as
applicable – Sub-provider

Column l, lines 40 through 42, as applicable

Line 43 - Nursery

Column 1, line 43 for titles V and XIX

Transfer from Worksheet L-1,
Part I, Column 26

To Worksheet L-1, Part III

Lines 50 through 78 - Ancillary
Services

Column l, lines 50 through 78

Lines 88 through 91 and 93 Outpatient Service Cost

Column l, lines 88 through 91 and 93

Subscripts of line 92 - Distinct
Part Observation Bed Units

Column 1, subscripts of line 92

Lines 88, 89, 94, 97, and 98

Column l, lines 88, 89, 94, 97, and 98

4065.2 Part II - Computation of Program Inpatient Routine Service Capital Costs for
Extraordinary Circumstances.--This part computes the amount of capital costs for extraordinary
circumstances applicable to hospital inpatient routine service costs. Complete only one
Worksheet L-1, Part II, for each title. Report hospital and sub-provider information on the same
worksheet, lines as appropriate.
Column 1--Enter on each line the capital costs for extraordinary circumstances as appropriate.
Obtain this amount from Worksheet L-1, Part I, column 26.
Column 2--Compute the amount of the swing-bed adjustment. If you have a swing-bed agreement
or have elected the swing-bed optional method of reimbursement, determine the amount for the
cost center in which the swing-beds are located by multiplying the amount in column 1 by the ratio
of the amount entered on Worksheet D-1, line 26, to the amount entered on Worksheet D-1,
line 21.
Column 3--Enter column 1 minus column 2.
Column 4--Enter on each line the total patient days, excluding swing-bed days, by cost center from
the corresponding lines of Worksheet D, Part I, column 4.

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Rev.

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FORM CMS-2552-10

4065.3

Column 5--Divide the cost of each cost center in column 3 by the total patient days in column 4
for each line to determine the per diem cost capital cost for extraordinary circumstances. Enter the
resultant per diem cost in column 5.
Column 6--Enter the program inpatient days for the corresponding cost centers from Worksheet D,
Part I, column 6.
Column 7--Multiply the per diem in column 5, by the inpatient program days in column 6, to
determine the program’s share of capital costs for extraordinary circumstances applicable to
inpatient routine services, as applicable, and enter the result.
4065.3 Part III - Computation of Program Inpatient Ancillary Service Capital Costs For
Extraordinary Circumstances.--This part computes the program inpatient ancillary capital costs for
extraordinary circumstances for titles V, XVIII, Part A, and XIX. Complete a separate copy of
this part for the hospital and each sub-provider for titles V; XVIII, Part A; and XIX; as applicable.
In this case, enter the sub-provider component number in addition to showing the provider number.
Make no entries on this worksheet for any costs centers with a negative balance on Worksheet B,
Part I, column 26.
Column 1--Enter on each line the capital-related costs for each cost center as appropriate. Obtain
this amount from Worksheet L-1, Part I, column 26.
NOTE: Compute capital costs for extraordinary circumstances relating to non-distinct
observation bed units. To compute extraordinary circumstances relating to non-distinct
observation bed units, develop a ratio of total observation bed costs to total general
routine costs. Compute this ratio, rounded to six decimal places, by dividing the amount
from Worksheet L-1, Part I, column 26, line 30, by the amount on Worksheet D-1,
line 37. Then multiply this ratio by the general routine capital costs for extraordinary
circumstances from Supplemental Worksheet L-1, Part I, column 26, line 30, to obtain
the capital costs for extraordinary circumstances relating to non-distinct observation bed
units for line 92, column 1. Transfer distinct part observation bed unit costs from
Worksheet L-1, Part I, the appropriate subscript of column 26, line 92.
Column 2--Enter on each line the charges applicable to each cost center as shown on Worksheet C,
Part I, column 6.
Column 3--Divide the cost of each cost center in column 1 by the charges in column 2, for each
line to determine the cost/charge ratio. Round the ratios to six decimal places, e.g., round .0321514
to 032151. Enter the resultant departmental ratios in column 3.
Column 4--Enter on each line the appropriate titles V; XVIII, Part A; or XIX; inpatient charges.
Transfer these charges from the corresponding lines of Worksheet D, Part II, column 4.
Column 5--Multiply the ratio in column 3, by the charges in column 4, to determine the program’s
share of capital costs for extraordinary circumstances applicable to titles V; XVIII, Part A; or XIX;
inpatient ancillary services, as appropriate.

Rev. 10

40-279

4066
4066.

FORM CMS-2552-10

11-16

WORKSHEET M-1 - ANALYSIS OF HOSPITAL-BASED RHC/FQHC COSTS

Use this worksheet only if you operate a certified hospital-based RHC/FQHC. Use only those cost
centers that represent services for which the clinic/center is certified. If you have more than one
hospital-based RHC/FQHC, complete separate worksheets for each hospital-based RHC/FQHC,
unless the clinic/center has received prior contractor approval to file a consolidated cost report (see
CMS Pub. 100-4, chapter 9, §30). Effective for cost reporting periods beginning on or after
October 1, 2014, hospital-based FQHCs do not complete the M series worksheets, but must
complete the N series worksheets.
This worksheet is for the recording of direct hospital-based RHC/FQHC costs from your
accounting books and records to arrive at the identifiable RHC/FQHC cost. This data is required
by 42 CFR 413.20. The worksheet also provides for the necessary reclassifications and
adjustments to certain accounts prior to the cost finding calculations.
Column Descriptions
Columns 1 through 3--The expenses listed in these columns must be in accordance with your
accounting books and records. If the cost elements of a cost center are maintained separately on
your books, a reconciliation of costs per the accounting books and records to those on this
worksheet must be maintained by you and are subject to review by your contractor.
Enter on the appropriate lines in columns 1 through 3, the total expenses incurred during the
reporting period. Detail the expenses as Salaries (column 1) and Other (column 2). The sum of
columns 1 and 2 must equal column 3.
Column 4--Enter any reclassifications among the cost center expenses listed in column 3 which
are needed to effect proper cost allocation. This column need not be completed by all hospitalbased RHCs/FQHCs, but is completed only to the extent reclassifications are needed and
appropriate in the particular circumstances. See §4014 for examples of reclassifications that may
be needed. Submit with the cost report copies of any work papers used to compute the
reclassifications reported in this column. The net total of the entries in column 4 must equal zero
on line 30 if no reclassifications were reported on Worksheet A, column 4, of the appropriate
line 88 and/or 89.
Column 5--Add column 4 to column 3, and extend the net balances to column 5. The total of
column 5 must equal the total of column 3 on line 30, if no reclassifications were reported on
Worksheet A, column 4, of the appropriate line 88 and/or 89.
Column 6--In accordance with 42 CFR 413.9(c)(3), enter on the appropriate lines the amounts of
any adjustments to expenses required under the Medicare principles of reimbursement. (See
§4016.) Submit with the cost report copies of any work papers used to compute the adjustments
reported in this column.
NOTE: The allowable cost of the services furnished by Public Health Service personnel may be
included in your hospital-based RHCs/FQHCs costs. Obtain this amount from your
contractor, and include this as an adjustment to the appropriate lines on column 6.
Column 7--Adjust the amounts in column 5 by the amounts in column 6, and extend the net
balance to column 7. The total facility costs on line 32 must equal the net expenses for cost
allocation on Worksheet A for the hospital-based cost center.
Line Descriptions
Lines 1 through 9--Enter the costs of your health care staff.
Line 10--Enter the sum of the amounts on lines 1 through 9.
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Rev. 10

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FORM CMS-2552-10

4066 (Cont.)

Line 11--Enter the cost of physician medical services furnished under agreement.
Line 12--Enter the expenses of physician supervisory services furnished under agreement.
Line 14--Enter the sum of the amounts on lines 11 through 13.
Lines 15 through 20--Enter the expenses of other health care costs.
Line 20--Do not complete this line. Per 42 CFR 413.78(a), the GME payment to the hospital
includes all residents working in the hospital healthcare complex; therefore, no separate payment
is made to the hospital-based RHC/FQHC for GME costs.
Line 21--Enter the sum of the amounts on lines 15 through 20. For cost reporting periods ending
on or after October 1, 2014, enter the sum of the amounts on lines 15 through 19.
Line 22--Enter the sum of the amounts on lines 10, 14, and 21. Reduce that result by the amount
reported on line 20 if you are entitled to claim GME costs on line 20. Transfer this amount to
Worksheet M-2, line 10.
Lines 23 through 27--Enter the expenses applicable to services that are not reimbursable under the
RHC/FQHC benefit.
Line 25.01 - Telehealth.--This cost center includes the cost of telehealth distant-site services as
described in CMS Pub. 100-02, chapter 13, §190.
Line 25.02 - Chronic Care Management (CCM).--This cost center includes the structured
recording of patient health information, an electronic health care plan addressing all health issues,
access to chronic care management services, managing care transitions, and coordinating and
sharing patient information with practitioners and providers outside the practice. CCM services
are reimbursed as an add-on payment based on the Medicare Physician Fee Schedule (MPFS). See
80 FR 71080 (November 16, 2015).
Line 27--Do not complete this line.
Line 28--Enter the sum of the amounts on lines 23 through 27. For cost reporting periods ending
on or after October 1, 2014, enter the sum of the amounts on lines 23 through 26. Transfer the
total amount in column 5 to Worksheet M-2, line 11.
Line 29--Enter the overhead expenses directly costed to the hospital-based RHC/FQHC. These
expenses may include rent, insurance, interest on mortgage or loans, utilities, depreciation of
buildings and fixtures, depreciation of equipment, housekeeping and maintenance expenses, and
property taxes. Submit with the cost report supporting documentation to detail and compute the
facility costs reported on this line.
Line 30--Enter the expenses related to the administration and management of the hospital-based
RHC/FQHC that are directly costed to the facility. These expenses may include office salaries,
depreciation of office equipment, office supplies, legal fees, accounting fees, insurance, telephone
service, fringe benefits, and payroll taxes. Submit with the cost report supporting documentation
to detail and compute the administrative costs reported on this line.
Line 31--Enter the sum of the amounts on lines 29 and 30. Transfer the total amount in column 5
to Worksheet M-2, line 14.
Line 32--Enter the sum of the amounts on lines 22, 28, and 31. This is the total hospital-based
RHC/FQHC cost. This amount should agree with the amount reported for the hospital-based
RHC/FQHC on Worksheet A, column 7, reduced by any amounts claimed on line 20 above.

Rev. 10

40-281

4067
4067.

FORM CMS-2552-10

11-16

WORKSHEET M-2 - ALLOCATION OF OVERHEAD TO HOSPITAL-BASED
RHC/FQHC SERVICES

Use this worksheet only if you operate a certified hospital-based RHC/FQHC as part of your
healthcare complex. If you have more than one hospital-based RHC/FQHC, complete a separate
worksheet for each hospital-based RHC/FQHC.
Visits and Productivity--Worksheet M-2 summarizes the number of hospital-based RHC/FQHC
visits furnished by the health care staff and calculates the number of visits to be used in the rate
determination. Lines 1 through 9 list the types of practitioners (positions) for whom hospital-based
RHC/FQHC visits must be counted and reported.
Column descriptions
Column 1--Record the number of all FTE personnel in each of the applicable staff positions in the
hospital-based RHCs/FQHCs practice. (See CMS Pub. 100-04, chapter 9, §40.3 for a definition
of FTEs).
Column 2--Record the total visits actually furnished to all patients by all personnel in each of the
applicable staff positions in the reporting period. Count visits in accordance with instructions in
42 CFR 405.2463(a) defining a visit.
Column 3--Productivity standards established by CMS are applied as a guideline that reflects the
total combined services of the staff. Apply a level of 4200 visits for each physician and a level of
2100 visits for each non-physician practitioner. You are not subject to the productivity standards
if you answered “Yes” to question 12 of Worksheet S-8. If so, then enter the revised standards
established by you and your contractor.
Column 4--For lines 1 through 3, enter the product of column 1 and column 3. This is the
minimum number of hospital-based RHC/FQHC visits the personnel in each staff position are
expected to furnish.
Column 5--On line 4, enter the greater of the subtotal of the actual visits in column 2 or the
minimum visits in column 4.
Contractors have the authority to waive the productivity guideline in cases where you have
demonstrated reasonable justification for not meeting the standard. In such cases, the contractor
will substitute your actual visits if an exception is granted.
On lines 5 through 7, and 9, enter the actual number of visits for each type of position.
Line descriptions
Line 1--Enter the number of FTEs and total visits furnished to hospital-based RHC/FQHC patients
by staff physicians working at the hospital-based RHC/FQHC on a regular ongoing basis. Also
include on this line, physician data (FTEs and visits) for services furnished to hospital-based
RHC/FQHC patients by staff physicians working under contractual agreement with you on a
regular ongoing basis in the hospital-based RHC/FQHC facility. These physicians are subject to
productivity standards. (See 42 CFR 405.2468(d)(2)(v).)
Line 4--Enter the total of lines 1 through 3, for columns 1, 2 and 4.
Line 5--Enter the number of FTEs and total visits furnished to hospital-based RHC/FQHC patients
by visiting nurses working at the hospital-based RHC/FQHC. Visiting nurses provide skilled
nursing services to the homebound for services which require the skills of a nurse based on the
complexity of the service, e.g., intravenous or intramuscular injections or insertions of catheters.
(See CMS Pub. 100-02, chapter 13, §180.)
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Line 6--Enter the number of FTEs and total visits furnished to hospital-based RHC/FQHC patients
by clinical psychologists working at the hospital-based RHC/FQHC. Clinical psychologist
services may include the diagnosis, treatment and consultation of a patient.
(See
CMS Pub. 100-02, chapter 13, §140.)
Line 7--Enter the number of FTEs and total visits furnished to hospital-based RHC/FQHC patients
by clinical social worker working at the hospital-based RHC/FQHC. Clinical social worker
services may include the diagnosis, treatment and consultation of a patient.
(See
CMS Pub. 100-02, chapter 13, §140.)
Line 7.01--Enter the number of FTEs for registered dieticians or nutritional professionals and total
visits furnished to hospital-based FQHC patients for medical nutrition therapy (MNT) services
provided in hospital-based FQHCs. MNT services apply to hospital-based FQHCs only. (See
CMS Pub. 100-02, chapter 13, §210.2.4).
Line 7.02--Enter the number of FTEs for registered dieticians or nutritional professionals and total
visits furnished to hospital-based FQHC patients for diabetes self-management training (DSMT)
services provided in hospital-based FQHCs. DSMT services apply to hospital-based FQHCs only.
(See CMS Pub. 100-02, chapter 13, §210.2.4.)
Line 8--Enter the total of lines 4 through 7 (and subscripts).
Line 9--Enter the number of visits furnished to hospital-based RHC/FQHC patients by physicians
under agreement with you who do not furnish services to patients on a regular ongoing basis in the
hospital-based RHC/FQHC. Physicians’ services under agreements with you are (1) all medical
services performed at your site by a non-staff physician who is not the owner or an employee of
the facility, and (2) medical services performed at a location other than your site by such a
physician for which the physician is compensated by you. While all physician services at your
site are included in RHC/FQHC services, physician services furnished in other locations by
physicians who are not on your full-time staff are paid to you only if your agreement with the
physician provides for compensation for such services.
Determination of Total Allowable Cost Applicable To Hospital-Based RHC/FQHC Services.--Use
lines 10 through 18 to determine the amount of overhead costs incurred by both the parent provider
and the hospital-based RHC/FQHC.
Line 10--Enter the cost of health care services from Worksheet M-1, column 7, line 22.
Line 11--Enter the total nonreimbursable costs from Worksheet M-1, column 7, line 28.
Line 12--Enter the sum of lines 10 and 11 for the cost of all services (excluding overhead).
Line 13--Enter the percentage of hospital-based RHC or FQHC services. This percentage is
determined by dividing the amount on line 10 (the cost of health care services) by the amount on
line 12 (the cost of all services, excluding overhead).
Line 14--Enter the total hospital-based RHC/FQHC overhead costs incurred from Worksheet M-1,
column 7, line 31.
Line 15--Enter the overhead costs incurred by the parent provider allocated to the hospital-based
RHC/FQHC. This amount is the difference between the total costs after cost allocation on
Worksheet B, Part I, column 26 and Worksheet B, Part I, column 0. If GME costs are claimed on
line 20 of Worksheet M-1, do not include the GME costs allocated to the RHC/FQHC in
columns 21 and 22 of Worksheet B, Part I.
Line 16--Enter the sum of lines 14 and 15 to determine the total overhead costs related to the
hospital-based RHC/FQHC.
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Line 17--Do not complete this line. Per 42 CFR 413.78(a), the GME payment to the hospital
includes all residents working in the hospital healthcare complex; therefore, no separate payment
is made to the hospital-based RHC/FQHC for GME costs.
Line 18--Enter the amount from line 16.
Line 19--Enter the overhead amount applicable to hospital-based RHC/FQHC services. It is
determined by multiplying the amount on line 13 (the ratio of hospital-based RHC/FQHC services
to total services) by the amount on line 18 (total overhead costs).
Line 20--Enter the total allowable cost of hospital-based RHC/FQHC services, the sum of line 10
(cost of hospital-based RHC/FQHC health care services) and line 19 (overhead costs applicable to
hospital-based RHC/FQHC services).
4068.

WORKSHEET M-3 - CALCULATION OF REIMBURSEMENT SETTLEMENT FOR
HOSPITAL-BASED RHC/FQHC SERVICES

This worksheet applies to title XVIII only and provides for the reimbursement calculation for
services rendered. Use this worksheet to determine the interim all inclusive rate of payment and
the total program payment for the cost reporting period for each hospital-based RHC/FQHC
reported.
Determination of Rate For Hospital-Based RHC/FQHC Services--Worksheet M-3 calculates the
cost per visit for hospital-based RHC/FQHC services and applies the screening guideline
established by CMS on your health care staff productivity.
Line descriptions
Line 1--Enter the total allowable cost from Worksheet M-2, line 20.
Line 2--Report injection/infusion costs on this line from Worksheet M-4, line 15.
Line 3--Subtract the amount on line 2 from the amount on line 1 and enter the result.
Line 4--Enter the greater of the minimum or actual visits by the health care staff from
Worksheet M-2, column 5, line 8.
Line 5--Enter the visits made by physicians under agreement from Worksheet M-2, column 5,
line 9.
Line 6--Enter the total adjusted visits (sum of lines 4 and 5).
Line 7--Enter the adjusted cost per visit. This is determined by dividing the amount on line 3 by
the visits on line 6.
For services rendered from January 1, 2010, through December 31, 2013, the maximum rate per
visit entered on line 8 and the outpatient mental health treatment service limitation applied on
line 14 both correspond to the same time period (partial calendar year). Consequently, both are
entered in the same column and no further subscripting of the columns is necessary.
Lines 8 and 9--The payment limits are updated every January 1; however, the possibility exists
that payment limits may also be updated other than on January 1. Complete columns 1, 2, and 3,
if applicable (add column 3 for lines 8 through 14 if the cost reporting period overlaps three
payment limit periods) for lines 8 and 9, to identify costs and visits affected by different payment
limits within a cost reporting period, as may be the case when implementing §130 Consolidated
Appropriates Act of 2021, effective for services rendered on or after April 1, 2021, where an RHC
may span three payment limit periods within a single cost reporting period (see CR 12185, dated
May 4, 2021, or subsequent applicable CRs). If only one payment limit is applicable during the
cost reporting period (calendar year reporting period), complete column 2 only.
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Line 8--Enter the per visit payment limit. Obtain this amount from your contractor.
NOTE: For services rendered prior to April 1, 2021, if you are based in a small hospital with less
than 50 beds (the bed count is based on the same calculation used on Worksheet E,
Part A, line 4), in accordance with 42 CFR 412.105(b), do not apply the per visit payment
limit. Transfer the adjusted cost per visit (line 7) to line 9, columns 1 and/or 2.
NOTE: In accordance with §1833(f)(3) of the Act, as amended by §130 of the Consolidated
Appropriations Act of 2021, effective for services on or after April 1, 2021,
hospital-based RHCs with less than 50 beds (as calculated above) will have their per visit
payment limit calculated in accordance with §1833(f)(3)(B) of the Act by their
contractor. See CR 12185, dated May 4, 2021, or subsequent applicable CRs.
For hospital-based RHCs based in small urban hospitals transfer the adjusted cost per visit (line 7)
to line 9, column 1 and/or 2.
Line 9--Enter the lesser of the amount on line 7 or line 8.
Calculation of Settlement.--Complete lines 10 through 29 to determine the total program payment
due you for covered hospital-based RHC/FQHC services furnished to program beneficiaries during
the reporting period. Complete columns 1 and 2 of lines 10 through 14 to identify costs and visits
affected by different payment limits during a cost reporting period.
Line descriptions
Line 10--Enter the number of program covered visits excluding visits subject to the outpatient
mental health services limitation from your contractor records.
Line 11--Enter the subtotal of program cost. This cost is determined by multiplying the rate per
visit on line 9 by the number of visits on line 10 (the total number of covered program beneficiary
visits for hospital-based RHC/FQHC services during the reporting period).
Line 12--Enter the number of program covered visits subject to the outpatient mental health
services limitation from your contractor records.
Line 13--Enter the program covered cost for outpatient mental health services by multiplying the
rate per visit on line 9 by the number of visits on line 12.
Line 14--Enter the limit adjustment. In accordance with MIPPA 2008, section 102, the outpatient
mental health treatment service limitation applies as follows: For services rendered through
December 31, 2009, the limitation is 62.50 percent; services from January 1, 2010, through
December 31, 2011, the limitation is 68.75 percent; services from January 1, 2012, through
December 31, 2012, the limitation is 75 percent; services from January 1, 2013 through
December 31, 2013, the limitation is 81.25 percent; and services on or after January 1, 2014, the
limitation is 100 percent. This is computed by multiplying the amount on line 13 by the
corresponding outpatient mental health treatment service limit percentage. This limit applies only
to therapeutic services, not initial diagnostic services.
NOTE: Section 4104 of ACA eliminates coinsurance and deductible for preventive services,
effective for dates of service on or after January 1, 2011. Hospital-based RHCs/FQHCs
must provide detailed HCPCS coding for preventive services to ensure coinsurance and
deductible are not applied. Hospital-based RHCs/FQHCs must maintain this
documentation to apply the appropriate reductions on lines 16.03 and 16.04.
Line 15--Do not complete this line. Per 42 CFR 413.78(a), the GME payment to the hospital
includes all residents working in the hospital healthcare complex; therefore, no separate payment
is made to the hospital-based RHC/FQHC for GME costs.
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Line 16--For cost reporting periods that overlap January 1, 2011, enter in column 1, the sum of
lines 11 and 14, column 1, and in column 2, the sum of lines 11 and 14, column 2. For cost
reporting periods beginning on or after January 1, 2011, do not use column 1, and enter the total
program cost in column 2. This is equal to the sum of the amounts in columns 1 and 2, respectively
(and 3, if applicable), lines 11 and 14.
Line 16.01--Enter the total program charges from the contractor’s records (PS&R). For cost
reporting periods that overlap January 1, 2011, do not complete column 1 and enter total program
charges for services rendered on or after January 1, 2011 in column 2. For cost reporting periods
beginning on or after January 1, 2011, enter total program charges in column 2.
Line 16.02--Enter the total program preventive charges from the provider’s records. For cost
reporting periods that overlap January 1, 2011, do not complete column 1 and enter total program
preventive charges for services rendered on or after January 1, 2011 in column 2. For cost
reporting periods beginning on or after January 1, 2011, enter total program preventive charges in
column 2.
Line 16.03--Enter the total program preventive costs. For cost reporting periods that overlap
January 1, 2011, do not complete column 1, and enter the total program preventive costs
((line 16.02 divided by line 16.01) times line 16) for services rendered on or after January 1, 2011,
in column 2. For cost reporting periods beginning on or after January 1, 2011, enter the total
program preventive costs ((line 16.02 divided by line 16.01) times line 16, column 2.
Line 16.04--Enter the total program non-preventive costs. For cost reporting periods that overlap
January 1, 2011, do not complete column 1 and enter the total program non-preventive costs
((line 16 minus lines 16.03 and 18) times .80) for services rendered on or after January 1, 2011, in
column 2. For cost reporting periods beginning on or after January 1, 2011, enter the total program
non-preventive costs ((line 16, column 2, minus lines 16.03 and 18, column 2) times .80) in
column 2.
Line 16.05--Enter the total program costs. For cost reporting periods that overlap January 1, 2011,
enter total program costs (line 16 times .80) for services rendered prior to January 1, 2011, in
column 1, and enter the sum of lines 16.03 and 16.04, in column 2. For cost reporting periods
beginning on or after January 1, 2011, enter the sum of lines 16.03 and 16.04, in column 2.
Line 17--Enter the primary payer amounts from your records.
Line 18--Enter the amount credited to the hospital-based RHC's program patients to satisfy their
deductible liabilities on the visits on lines 10 and 12 as recorded by the contractor from clinic bills
processed during the reporting period. Hospital-based RHCs determine this amount from the
interim payment lists provided by the contractor. Hospital-based FQHCs enter zero on this line as
deductibles do not apply.
Line 19--Enter the coinsurance amount applicable to the hospital-based RHC/FQHC for program
patient visits on lines 10 and 12 as recorded by the contractor from clinic/center bills processed
during the reporting period. This line captures data for informational and statistical purposes only.
This line does not impact the settlement calculation.
Line 20--Enter the net program costs, excluding injections/infusions. For cost reporting periods
that overlap January 1, 2011, enter the result of subtracting the amount on line 17 from the amount
on line 16.05, columns 1 and 2. For cost reporting beginning on or after January 1, 2011, enter the
result of subtracting the amount on line 17 from the amount on line 16.05, column 2.
Line 21--Enter the amount from Worksheet M-4, line 16.
Line 22--Enter the total allowable Medicare cost, sum of the amounts on lines 20 and 21.

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Line 23--Enter your total allowable bad debts, net of recoveries, from your records. If recoveries
exceed the current year’s bad debts, line 23 will be negative. (See 42 CFR 413.89.)
Line 23.01--Enter the result of line 23 (including negative amounts) times 88 percent for cost
reporting periods beginning on or after October 1, 2012, 76 percent for cost reporting periods
beginning on or after October 1, 2013, and 65 percent for cost reporting periods beginning on or
after October 1, 2014.
Line 24--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. This amount must also be reported on line 23.
Line 25--Enter any other adjustment. For example, if you change the recording of vacation pay
from the cash basis to the accrual basis (see CMS Pub. 15-1, chapter 21, §2146.4), enter the
adjustment. Specify the adjustment in the space provided.
Line 25.50--Enter the Pioneer ACO demonstration payment adjustment amount. Do not use this
line for services rendered on or after January 1, 2017. Report any ACO demonstration payment
adjustments for services on or after January 1, 2017, on line 25.99 or line 26.02, accordingly.
Line 25.99--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are subject to the
sequestration adjustment. Obtain this amount from the PS&R.
Line 26--Enter the sum of lines 22 and 23 plus or minus line 25, and minus lines 25.50 and 25.99.
For cost reporting periods beginning on or after October 1, 2012, enter the sum of lines 22 and
23.01 plus or minus line 25 and minus line 25.50.
Line 26.01--For cost reporting periods that overlap or begin on or after April 1, 2013, 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 six decimal places), rounded to four decimal places) times line 26]. Do not
apply the sequestration calculation when gross reimbursement (line 26) is less than zero. (Note: In
accordance with §3709 of the CARES Act, as amended by §102 of the Consolidated
Appropriations Act of 2021, and §1 of Public Law 117-7, do not apply the sequestration adjustment
to the period of May 1, 2020, through December 31, 2021.)
Line 26.02--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are not subject to the
sequestration adjustment. Obtain this amount from the PS&R.
Line 27--Enter the total interim payments from Worksheet M-5 made to you for covered services
furnished to program beneficiaries during the reporting period (from contractor records).
Line 28--For contractor use only, enter the on line 5.99 of Worksheet M-5.
Line 29--Enter the total amount due to/from the program (line 26 minus lines 26.01, 26.02, 27, and
28). Transfer this amount to Worksheet S, Part III, column 3, line 10 and/or 11 as applicable.
Line 30--Enter the program reimbursement effect of protested items. The reimbursement effect of
the nonallowable items is estimated by applying a reasonable methodology which closely
approximates the actual effect of the item as if it had been determined through the normal cost
finding process. (See CMS Pub. 15-1, chapter 1, §115.2.) A schedule showing the supporting
details and computations must be attached.

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WORKSHEET M-4 - COMPUTATION OF HOSPITAL-BASED RHC/FQHC
VACCINE COST

The cost and administration of pneumococcal and influenza vaccine to Medicare beneficiaries are
100 percent reimbursable by Medicare. This worksheet provides for the computation of the cost
of these vaccines. Additionally, only use this worksheet for vaccines rendered to patients who, at
the time of receiving the vaccine(s), were not inpatients or outpatients of the hospital. If a patient
simultaneously received vaccine(s) with any Medicare covered services as an inpatient or
outpatient of the hospital, those vaccine costs are reimbursed through the hospital and cannot be
claimed by the hospital-based RHC/FQHC. Additionally, in accordance with §3713 of the CARES
Act, during the COVID-19 PHE, this worksheet computes the cost of COVID-19 vaccines and
monoclonal antibody products for treatment of COVID-19 and their administration to Medicare
and MA enrollees for calendar years 2020 and 2021.
Report the applicable data in columns 1, 2, 2.01, and 2.02, for pneumococcal vaccines, influenza
vaccines, COVID-19 vaccines, and monoclonal antibody products for treatment of COVID-19,
authorized for use during the COVID-19 PHE. The data entered in all columns (1, 2, 2.01,
and 2.02) for lines 4, 11, 13, and 13.01, are mutually exclusive. That is, the injection/infusion
costs, the total number of injection/infusion administered, and the total number of Medicare/MA
covered injections/infusions must only be represented one time in the appropriate column.
Line 1--Enter the health care staff cost from Worksheet M-1, column 7, line 10.
Line 2--Enter the ratio of the estimated percentage of time involved in administering
injections/infusions, including the time involved in administering COVID-19 vaccines and
monoclonal antibodies for treatment of COVID-19, to the total health care staff time. Do not
include physician service under agreement time in this calculation.
Line 3--Multiply the amount on line 1 by the amount on line 2 and enter the result.
Line 4--Enter the cost of injections/infusions and related medical supplies from your records. Do
not include cost of monoclonal antibody products for COVID-19 provided by the government free
of charge, as was the case upon the product’s initial availability in response to the COVID-19 PHE.
Line 5--Enter the sum of lines 3 and 4.
Line 6--Enter the amount from Worksheet M-1, column 7, line 22. This is your total direct cost
of the facility.
Line 7--Enter the amount from Worksheet M-2, line 19.
Line 8--Divide the amount on line 5 by the amount on line 6 and enter the result.
Line 9--Multiply the amount on line 7 by the amount on line 8 and enter the result.
Line 10--Enter the sum of the amounts on lines 5 and 9.
Line 11--Enter the total number of injections/infusions from your records.

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Line 12--Enter the cost per injection/infusion by dividing the amount on line 10 by the number on
line 11.
Line 13--Enter the number of injections/infusions from your records or the PS&R.
Line 13.01.--For services rendered in calendar years 2020 and 2021, enter from your records the
number of COVID-19 injections/infusions administered to MA enrollees, in columns 2.01
and 2.02, respectively.
Line 14--Enter the program cost for vaccine injections by multiplying the amount on line 12 by
the sum of the amounts on lines 13 and 13.01, as applicable.
Line 15--Enter the total cost of injections/infusions and their administration by entering the sum
of the amounts in columns 1, 2, 2.01, and 2.02, line 10.
Transfer this amount to Worksheet M-3, line 2.
Line 16--Enter the Medicare cost of injections/infusions and their administration costs. This is
equal to the sum of the amounts in columns 1, 2, 2.01, and 2.02, line 14.
Transfer the result to Worksheet M-3, line 21.
4070.

WORKSHEET M-5 - ANALYSIS OF PAYMENTS TO HOSPITAL-BASED
RHC/FQHC FOR SERVICES RENDERED TO PROGRAM BENEFICIARIES

Complete this worksheet for Medicare interim payments only. If you have more than one hospitalbased RHC/FQHC, complete a separate worksheet for each facility.
Complete the identifying information on lines 1 through 4. The remainder of the worksheet is
completed by your contractor.
Line Descriptions
Line 1--Enter the total program interim payments paid to the hospital-based RHC/FQHC. 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 includes amounts
withheld from the component's interim payments due to an offset against overpayments to the
component 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.
Line 2--Enter the total program 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. It 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--Transfer the total interim payments to the title XVIII Worksheet M-3, line 27.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET M-5. LINES 5 THROUGH 7
ARE FOR CONTRACTOR USE ONLY. (EXCEPTION: IF WORKSHEET S, PART I,
LINE 5 IS “5” (AMENDED COST REPORT), THE HOSPITAL-BASED RHC/FQHC
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 NPR has been issued, report all settlement
payments prior to the current reopening settlement on line 5.
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Line 6--Enter the net settlement amount (balance due to the hospital-based RHC/FQHC 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 from the hospital-based RHC/FQHC to the
program, show the amount and date on which the hospital-based RHC/FQHC 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 in column 2. The amount in column 2
must equal the amount on Worksheet M-3, line 26 less the amount on lines 26.01 and 26.02.
Line 8--Enter the contractor name, the contractor number and NPR date in columns 0, 1 and 2,
respectively.
4071.

WORKSHEET N-1 - RECLASSIFICATION AND ADJUSTMENT OF TRIAL
BALANCE OF EXPENSES FOR HOSPITAL-BASED FQHC

Use the N worksheet series if you operate a certified hospital-based FQHC for cost reporting
periods beginning on or after October 1, 2014. Use only those cost centers that represent services
for which the hospital-based FQHC is certified. If you have more than one hospital-based FQHC,
complete a separate worksheet N series for each hospital-based FQHC, unless the hospital-based
FQHC has received prior contractor approval to file a consolidated cost report (see
CMS Pub. 100-04, chapter 9, §30).
This worksheet is for recording direct costs of the hospital-based FQHC from your accounting
books and records. It also provides for the necessary reclassifications and adjustments to certain
accounts. If the cost elements of a cost center are maintained separately on your accounting books,
a reconciliation of costs per the accounting books and records to those on this worksheet must be
maintained and are subject to review by your contractor. The cost centers listed may not apply to
every hospital-based FQHC using these forms. For example, a hospital-based FQHC that does not
have transportation costs will not complete line 11. Complete only those lines that are applicable.
Column Descriptions
Column 1--Enter direct salaries and wages plus related salary amounts for paid vacation, holiday,
sick, other paid-time-off (PTO), severance, and bonus pay.
Column 2--Enter all costs other than salaries.
Column 3--For each cost center, add the amounts in columns 1 and 2 and enter the total in
column 3.
Column 4--For each cost center, enter any reclassifications for expenses listed in column 3. The
net total of the entries in column 4, line 100, must equal zero if no reclassifications were reported
on Worksheet A, column 4, line 89. Show reductions to expenses as negative numbers. This
column is completed only to the extent reclassifications are needed and appropriate in the particular
circumstances. See §4014 for examples of reclassifications that may be needed. Submit with the
cost report copies of any work papers used to compute the reclassifications reported in this column.
Column 5--For each cost center, enter the total of the amount in column 3 plus or minus the amount
in column 4. The total on column 5, line 100 must equal the total on column 3, line 100, if no
reclassifications were reported on Worksheet A, column 4, line 89.
Column 6--For each cost center, enter on the appropriate lines the amounts of any adjustments to
expenses required under the Medicare principles of reimbursement. (See §4016.) Submit with the
cost report copies of any work papers used to compute the adjustments reported in this column.
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Column 7--For each cost center, enter the total of the amount in column 5, plus or minus the
amount in column 6. The amount on line 100 must equal the net expenses for cost allocation on
Worksheet A, column 7, line 89.
Line descriptions
This worksheet groups the trial balance of expenses into general service cost centers, direct patient
care cost centers, reimbursable pass through costs, other FQHC services, and nonreimbursable cost
centers to facilitate the transfer of costs to the various worksheets.
General Service Cost Centers-These cost centers include expenses incurred in operating the hospital-based FQHC 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 - Cap Rel Costs-Bldg & Fix and Cap Rel Costs-Mvble Equip--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 facilities and/or equipment,
including electronic health records systems, 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, and, software and hardware updates to electronic health
record systems. Do not include costs incurred for the repair or maintenance of equipment or
facilities; amounts specifically included in rentals or lease payments for repair and/or maintenance
agreements; 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 insurance or any
other form of insurance to provide protection other than the replacement of depreciable assets; or
taxes other than those assessed on the basis of some valuation of land or depreciable assets used
for patient care. However, if no amount of the lease payment is identified in the lease agreement
for maintenance, you are not required to carve out a portion of the lease payment to represent the
maintenance portion. Thus, the entire lease payment is considered a capital-related cost subject to
the provisions of 42 CFR 413.130(b).
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 and General--A&G includes a wide variety of administrative costs such as
but not limited to cost of fiscal services, legal and accounting services, facility administrative
services (not already included in other general service cost centers), etc.
Line 5 - Plant Operation and Maintenance--This cost center includes expenses incurred in the
plant operation and maintenance of the hospital-based FQHC. These costs include the
maintenance and service of utility systems such as heat, light, water, air conditioning and air
treatment. This cost center also includes costs incurred in maintaining the facility and grounds,
such as costs of routine painting, plumbing, mowing, and snow removal.
Line 6 - Janitorial--This cost center includes the cost of routine janitorial activities such as
mopping, vacuuming, cleaning restrooms, lobbies, waiting areas and otherwise maintaining patient
and non-patient care areas.
Line 7 - Medical Records--This cost center includes the cost of the medical records department
where patient medical records are maintained. The general library and the medical library are not
included in this cost center but are included in the A&G cost center. None of the costs associated
with electronic health records systems are reported in this cost center.
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Line 8 – Subtotal - Administrative Overhead--Enter the total of lines 1 through 7.
Line 9 - Pharmacy--This cost center includes only the routine costs of drugs (both prescription and
over the counter), pharmacy supplies, pharmacy personnel, and pharmacy services provided
incident to an FQHC visit. Drugs and pharmacy supplies that can be traced to individual patients
that are paid separately (outside the FQHC PPS national encounter rate) under Part B, C, or D, of
Medicare must be included on line 67 (Drugs Charged to Patients), of this worksheet. Drugs (both
prescription and over the counter), pharmacy supplies, pharmacy personnel and pharmacy services
provided by a retail pharmacy are reported on line 77. Do not include the cost of influenza and
pneumococcal, or COVID-19 vaccines, or monoclonal antibody products for treatment of
COVID-19, on this line as these costs are reported on lines 47 and 48 (and applicable subscripts),
respectively.
Line 10 - Medical Supplies--This cost center includes the cost of routine supplies used in the
normal course of caring for patients, such as gloves, masks, swabs, or glycerin sticks, and the nonroutine medical supplies that can be traced to individual patients. Do not include the cost of
medical supplies used in administering pneumococcal, influenza, or COVID-19 vaccines, or
monoclonal antibody products for treatment of COVID-19, on this line as these costs are reported
on lines 47 and 48 (and applicable subscripts), respectively.
Line 11 - Transportation--This cost center includes the cost of owning or renting vehicles, public
transportation expenses, parking, tolls, or payments to employees for driving their private vehicles
to see patients or for other hospital-based FQHC business.
Line 12 - Other General Service--Use this line to report the costs of other general service costs not
previously identified on lines 1 through 11.
Line 13 - Subtotal - Total Overhead--Enter the sum of lines 8 and 9 through 12.
Lines 14 through 22--Reserved for future use.
Direct Care Cost Centers-Line 23 - Physician--This cost center includes the costs incurred for physicians providing direct
patient care services and general supervisory services, participation in the establishment of plans
of care, supervision of care and services, periodic review and updating of plans of care, and
establishment of governing policies by the governing board. Reclassify the cost for the portion of
time physicians spent on general supervisory services or other hospital-based FQHC
administrative activities to A&G (line 4).
Line 24 - Physician Services Under Agreement--This cost center includes the costs incurred for
physicians who are providing services under agreement.
Line 25 - Physician Assistant--This cost center includes the costs incurred for PAs, including the
costs for PAs providing physician services.
Line 26 - Nurse Practitioner--This cost center includes the costs of nursing care provided by nurse
practitioners (NPs), including NPs providing physician services.
Line 27 - Visiting Registered Nurse--This cost center only includes the costs of nursing care
provided by registered nurses (RNs), who perform visiting nurse services in accordance with
CMS Pub. 100-02, chapter 13, §180. Costs associated with RNs who provide services incident to
a physician, PA, NP, certified nurse midwife (CNM), CP, or clinical social worker (CSW) (see
CMS Pub. 100-02, chapter 13, §§110, 120 and 140), are included in line 36.
Line 28 - Visiting Licensed Practical Nurses--This cost center includes the costs of nursing care
provided by licensed practical nurses (LPNs) who perform visiting nurse services in accordance
with CMS Pub. 100-02, chapter 13, §180. Costs associated with LPNs who provide services
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incident to a physician, PA, NP, CNM, CP or CSW (see CMS Pub. 100-02, chapter 13, §§110,
120 and 140), are included in line 36.
Line 29 - Certified Nurse Midwife--This cost center includes the costs of nursing care provided by
CNM’s.
Line 30 - Clinical Psychologist--This cost center includes the costs of a CP who holds a doctorate
in psychology and is licensed or certified by the State in which he or she practices, for diagnostic,
assessment, preventative and therapeutic services directed at individuals.
Line 31 - Clinical Social Worker--This cost center includes the costs of a CSW who possesses a
master’s degree or doctorate in social work and meets specified criteria established by regulation.
The CSW must directly examine the patient, or directly review the patient’s medical information,
to provide diagnosis, treatment and consultation.
Line 32 - Laboratory Technician--This cost center includes the costs of a person who, under the
supervision of a medical technologist or physician, performs microscopic and bacteriologic tests
of human blood, tissue, and fluid for diagnostic and research purposes.
Line 33 - Reg Dietician/Cert DSMT/MNT Educator--This cost center includes the costs of a
person who is either a registered dietician or nutritionist who meets specified criteria for providing
diabetes self-management training (DSMT) or medical nutrition therapy (MNT) services under the
Program.
Line 34 - Physical Therapist--This cost center includes the costs of physical or corrective
treatment of bodily or mental conditions by the use of physical, chemical, and other properties of
heat, light, water, electricity, sound massage, and therapeutic exercise by or under the direction of
a registered physical therapist as prescribed by a physician. Physical 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 35 - Occupational Therapist--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 36 - Other Allied Health Personnel--This cost center includes the cost of RNs and LPNs who
provide services incident to a physician, PA, NP, CNM, CP, or CSW in accordance with
CMS Pub. 100-02, chapter 13, §§110, 120 and 140 and the cost of other allied health personnel
that provide diagnostic, technical, therapeutic and direct patient care and support services to the
other health professionals they work with and the patients they serve. An example of other allied
health personnel is a medical assistant.
Line 37 - Subtotal Direct Patient Care Services--Enter the total of lines 23 through 36.
Lines 38 through 46--Reserved for future use.
Reimbursable Pass Through Costs-Line 47 - Pneumococcal Vaccines & Med Supplies--This cost center includes the cost of the
pneumococcal vaccines and the medical supplies attributable to pneumococcal vaccinations.
Line 48 - Influenza Vaccines & Med Supplies--This cost center includes the cost of the influenza
vaccines and the medical supplies attributable to influenza vaccinations.
Line 48.10 - COVID-19 Vaccines & Med Supplies.--Enter the cost of COVID-19 vaccines and the
medical supplies attributable to COVID-19 vaccinations, authorized and furnished for use during
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the COVID-19 PHE. Do not report the cost of COVID-19 vaccines provided by the government
free of charge.
Line 48.11 - Monoclonal Antibody Products.--Enter the cost of monoclonal antibody products for
treatment of COVID-19, authorized and furnished for use during the COVID-19 PHE. Do not
report the cost of monoclonal antibody products for treatment of COVID-19 provided by the
government free of charge.
Line 49 - Subtotal - Reimbursable Pass Through Costs--Enter the total of lines 47 through 48.
Lines 50 through 59--Reserved for future use.
Other FQHC Services-Line 60 - Medicare Excluded Services--This cost center includes the cost of routine dental care,
hearing tests, eye exams, etc., that are excluded from coverage under the Program.
Line 61 - Diagnostic & Screening Lab Tests--This cost center includes the technical component
cost of diagnostic and laboratory tests such as electrocardiograms and certain preventative services
authorized by the Medicare statute or the national coverage determination process. This cost center
does not include venipuncture, which is included in the pharmacy cost center when furnished by
the hospital-based FQHC.
Line 62 - Radiology - Diagnostic--This cost center includes the technical component of
radiological diagnostic tests such as x-rays and imaging services.
Line 63 - Prosthetic Devices--This cost center includes the costs of devices (other than dental)
which replace all or part of an internal body organ including colostomy bags and supplies directly
related to colostomy care, replacement of such devices, and one pair of conventional eyeglasses or
contact lenses furnished subsequent to each cataract surgery with the insertion of an intraocular
lens.
Line 64 - Durable Medical Equipment--This cost center includes the direct costs of DME rented
or sold (DME, as defined in 42 CFR 410.38) furnished to an individual patient and all direct
expenses incurred in requisitioning and issuing DME to patients.
Line 65 - Ambulance Services--Report all ambulance costs on this line for both owned and
operated services and services under arrangement.
Line 66 - Telehealth--This cost center includes the cost of telehealth distant-site services as
described in CMS Pub. 100-02, chapter 13, §190.
Line 67 - Drugs Charged to Patients--This cost center includes only those costs associated with
drugs (both prescription and over the counter), pharmacy supplies, pharmacy personnel and
pharmacy services that can be traced to individual patients that are paid separately (outside the
FQHC PPS national encounter rate) under Medicare Parts B, C, or D.
Line 68 - Chronic Care Management (CCM)--This cost center includes the structured recording of
patient health information, an electronic health care plan addressing all health issues, access to
chronic care management services, managing care transitions, and coordinating and sharing patient
information with practitioners and providers outside the practice. CCM services are reimbursed
as an add-on payment based on the Medicare Physician Fee Schedule (MPFS). See 80 FR 71080
(November 16, 2015).
Line 69 - Other--Use this line to report the costs of other FQHC services not previously identified
on lines 60 through 68.
Line 70 - Subtotal Other FQHC Services--Enter the total of lines 60 through 69.
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Lines 71 through 76--Reserved for future use.
Nonreimbursable Cost Centers-Line 77 - Retail Pharmacy--This cost center includes only those costs associated with drugs (both
prescription and over the counter), pharmacy supplies, pharmacy personnel and pharmacy services
that are sold through a retail pharmacy.
Line 78 - Other Nonreimbursable--Use this line to record the costs applicable to other
nonreimbursable cost centers not provided for on this worksheet.
Line 80 through 99--Reserved for future use.
Line 100 - Total--Enter the sum of lines 13, 37, 49, 70, and 79.
4071.1

WORKSHEET N-2 - CALCULATION OF HOSPITAL-BASED FQHC COST PER
VISIT

The purpose of Worksheet N-2 is to (1) summarize the hospital-based FQHC medical and mental
health visits furnished by practitioners, including health care staff and physicians under agreement,
and (2) apportion overhead costs to hospital-based FQHC services to determine the average cost
per visit for a medical visit and a mental health visit, by practitioner.
Column 1--Enter the total cost for each practitioner from Worksheet N-1, column 7, as indicated
on the worksheet.
Column 2--Enter the total medical and mental health visits actually furnished to all patients by
each practitioner during the cost reporting period. Each visit to the hospital-based FQHC by the
beneficiary counts as a single visit, even in the case where a beneficiary returns to the hospitalbased FQHC in the same day for a subsequent illness or injury. A beneficiary can have up to three
medical visits in a day to include the initial visit and two subsequent visits for illness or injury.
NOTE: Column 2, line 11 must equal Worksheet S-11, Part III, column 5, sum of lines 2 and 4.
For each line 1 through 10, column 2 must equal the sum of columns 7 and 8.
Column 3--Use this column to allocate costs associated with other direct care costs, sum of
Worksheet N-1, column 7, lines 9, 32, 34, 35, and 36. Calculate the UCM related to other direct
care costs by dividing the sum of Worksheet N-1, column 7, lines 9, 32, 34, 35, and 36, by
Worksheet N-2, column 2, line 11, total medical and mental health visits, and enter the result on
line 12. Calculate the costs for lines 1 through 10 by multiplying the visits on each corresponding
line, column 2 times the UCM on line 12.
Column 4--Use this column to allocate general service costs, sum of Worksheet N-1, column 7,
line 13, minus line 9, plus Worksheet B, Part I, line 89, column 26, minus Worksheet B, Part I,
line 89, column zero. Calculate the UCM by dividing Worksheet N-1, column 7, line 13, minus
line 9, plus Worksheet B, Part I, line 89, column 26, minus Worksheet B, Part I, line 89,
column zero, by Worksheet N-1, column 7, line 100, minus Worksheet N-1, column 7, line 13,
plus line 9, and enter the result on line 12. Allocate the general service cost attributable to each
practitioner on lines 1 through 10, by multiplying the UCM times the sum of the amounts in
columns 1 and 3, for each corresponding line.
Column 5--Enter the sum of columns 1, 3, and 4, for each practitioner.
Column 6--Calculate the average cost per visit by each practitioner by dividing the total cost in
column 5 by the total visits in column 2. Enter the result in column 6.
Column 7--Enter the total number of medical visits included in column 2, provided to all patients
by each practitioner during the cost reporting period.
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Column 8--Enter the total number of mental health visits included in column 2, provided to all
patients by each practitioner during the cost reporting period.
Column 9--Enter the total number of medical visits provided to Medicare beneficiaries by each
practitioner during the cost reporting period.
Column 10--Enter the total number of mental health visits provided to Medicare beneficiaries by
each practitioner during the cost reporting period.
NOTE: Worksheet S-11, Part III, column 2, line 2, must equal column 9, line 11; and
Worksheet S-11, Part III, column 2, line 4, must equal column 10, line 11.
Column 11--Calculate the Medicare cost per medical visit by practitioner by multiplying the
average cost per visit in column 6 by the Medicare visits in column 9.
Column 12--Calculate the Medicare cost per mental health visit by practitioner by multiplying the
average cost per visit in column 6 by the Medicare visits in column 10.
Line 11--Enter the sum of lines 1 through 10 for the applicable columns.
Line 13, column 6--Calculate the average cost per visit by dividing column 5, line 11 by column 2,
line 11.
Line 13, column 11--Calculate the Medicare average cost per medical visit by dividing column 11,
line 11 by column 9, line 11.
Line 13, column 12--Calculate the Medicare average cost per mental health visit by dividing
column 12, line 11 by column 10, line 11.

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4071.2

WORKSHEET N-3 - COMPUTATION OF HOSPITAL-BASED FQHC VACCINE
COST

The cost and administration of pneumococcal and influenza vaccine to Medicare beneficiaries are
100 percent reimbursable by Medicare. This worksheet provides for the computation of the cost
of the pneumococcal and influenza vaccines. Use this worksheet for vaccines rendered to hospitalbased FQHC patients who, at the time of receiving the vaccine(s), were not inpatients or
outpatients of the hospital. If a patient simultaneously received a vaccine(s) with any Medicare
covered services as an inpatient or outpatient of the hospital, those vaccine costs are reimbursed
through the hospital provider and cannot be claimed by the hospital-based FQHC. Additionally,
in accordance with §3713 of the CARES Act, during the COVID-19 PHE, this worksheet
computes the cost of COVID-19 vaccines and monoclonal antibody products for treatment of
COVID-19 and their administration furnished to Medicare and MA enrollees for calendar
years 2020 and 2021.
Report the applicable data in columns 1, 2, 2.01, and 2.02, for pneumococcal vaccines, influenza
vaccines, COVID-19 vaccines, and monoclonal antibody products for treatment of COVID-19,
authorized for use during the COVID-19 PHE. The data entered in all columns (1, 2, 2.01,
and 2.02) for lines 4, 11, 13, and 13.01 are mutually exclusive. That is, the injection/infusion costs,
the total number of injections/infusions administered, and the total number of Medicare covered
injections/infusions must only be represented one time in the appropriate column.
Line 1.--Enter the health care staff cost from Worksheet N-1, column 7, sum of lines 23, and 25
through 36, in columns 1 and 2, as applicable. Physician services under agreement are excluded
from this total.
Line 2.--Enter the ratio of the estimated percentage of time involved in
injections/infusions, including the time involved in administering COVID-19
monoclonal antibodies for treatment of COVID-19, to the total health care staff
include physician service under agreement time in this calculation. Obtain
percentage of time spent from your accounting books and records.

administering
vaccines and
time. Do not
the estimated

Line 3.--Multiply the amount on line 1 by the amount on line 2, and enter the result.
Line 4.--Enter the cost of injections/infusions and the cost of related medical supplies from
Worksheet N-1 column 7, lines 47, 48, 48.10, and 48.11, in columns 1, 2, 2.01, and 2.02,
respectively.
Line 5.--Enter the sum of lines 3 and 4.
Line 6.--Enter the total direct costs of the facility from Worksheet N-1, column 7, line 100, minus
Worksheet N-1, column 7, line 8.
Line 7.--Enter the administrative overhead of the facility from Worksheet N-1, column 7, line 8.
Line 8.--Divide the amount on line 5 by the amount on line 6 and enter the result.
Line 9.--Multiply the amount on line 7 by the ratio on line 8 and enter the result.
Line 10.--Enter the sum of the amounts on lines 5 and 9.
Line 11.--Enter in columns 1, 2, 2.01, and 2.02, respectively, the total number of
injections/infusions from your records.
Line 12.--Compute the cost per injection/infusion by dividing the costs on line 10 by the number
of injections on line 11 and entering the result.

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DRAFT

Line 13.--Enter from your records the number of injections/infusions administered to Medicare
beneficiaries, in columns 1, 2, 2.01, and 2.02, respectively.
Line 13.01.--For services rendered in calendar years 2020 and 2021, enter from your records the
number of COVID-19 injections/infusions administered to MA enrollees, in columns 2.01
and 2.02, respectively.
Line 14.--Enter the Medicare cost per injection/infusion by multiplying the cost per vaccine on
line 12 by the number of injections/infusions administered to Medicare beneficiaries and MA
enrollees on lines 13 and 13.01, as applicable.
Line 15.--Enter the total cost of injections/infusions and administration by entering the sum of the
amounts in columns 1, 2, 2.01, and 2.02, line 10.
Line 16.--Enter the Medicare cost of injections/infusions and administration by entering the sum
of the amount in columns 1, 2, 2.01, and 2.02, line 14. Transfer this amount to the Worksheet N-4,
line 2.
4071.3

WORKSHEET N-4 - CALCULATION
REIMBURSEMENT SETTLEMENT

HOSPITAL-BASED

FQHC

This worksheet provides for the reimbursement calculation for hospital-based FQHC services
rendered to program patients under the FQHC PPS. It also provides for an accumulation of
injection/infusion reimbursement and Medicare Advantage (MA) supplemental payments.
Line 1--FQHC services are paid in accordance with the FQHC PPS. Enter the total PPS payments
for hospital-based FQHC visits rendered during the cost reporting period. Obtain this from the
PS&R report.
Line 2--Enter the Medicare costs for injections/infusions and their administration from
Worksheet N-3, line 16.
Line 3--Medicare advantage supplemental payments are made to a FQHC when the amount paid
by the managed care organization is less than the amount paid under the FQHC PPS on a per visit
basis. Enter the total amount of Medicare advantage supplemental payments from the PS&R 778
report. This data is captured for informational purposes only and does not impact cost report
settlement.
Line 4--Enter the sum of lines 1 and 2.
Line 5--Enter the primary payer amounts from the PS&R.
Line 6--Enter the result of line 4 minus line 5.
Line 7--Enter the Part B coinsurance.
Line 8--Enter the result of line 6 minus line 7.
Line 9--Enter Medicare allowable bad debts, reduced by bad debt recoveries. If recoveries exceed
the current year’s bad debts, lines 9 and 10 will be negative. (See 42 CFR 413.89.)
Line 10--Multiply the amount (including negative amounts) from line 9 by 65 percent.
Line 11--Enter the gross reimbursable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. These amounts also are included on line 9.
Line 12--Enter the sum of lines 8 and 10.
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Line 13--This line is used to enter any other adjustments. Enter the amount in column 1 and
include a description of the adjustment in the space provided.
Line 13.99--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are subject to the
sequestration adjustment. Obtain this amount from the PS&R.
Line 14--Enter the result of line 12, plus or minus lines 13 and 13.99.
Line 15--Enter the sequestration adjustment amount as [(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 six decimal places), rounded to four decimal places) times line 14].
Do not apply the sequestration calculation when gross reimbursement (line 14) is less than zero.
For cost reporting periods that overlap or begin on or after May 1, 2020, enter the sequestration
adjustment amount from the PS&R (claims based amounts). (Note: In accordance with §3709 of
the CARES Act, as amended by §102 of the Consolidated Appropriations Act of 2021, and §1 of
Public Law 117-7, do not apply the sequestration adjustment to the period of May 1, 2020, through
December 31, 2021.)
Line 15.25--For cost reporting periods that overlap or begin on or after May 1, 2020, enter the
sequestration adjustment for non-claims based amounts as [(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 six decimal places), rounded to four decimal places) times the sum of
(lines 2, 10, and 13 and its subscripts not previously identified (do not use line 13.99 in this
calculation))]. If the sum is less than zero, do not calculate the sequestration adjustment. (Note:
In accordance with §3709 of the CARES Act, as amended by §102 of the Consolidated
Appropriations Act of 2021, and §1 of Public Law 117-7, do not apply the sequestration
adjustment to the period of May 1, 2020, through December 31, 2021.)
Line 16--Enter the result of line 14 minus lines 15 and 15.25.
Line 16.01--Enter any demonstration payment adjustment amounts for demonstration projects in
which the provider participated where the demonstration adjustment amounts are not subject to the
sequestration adjustment. Obtain this amount from the PS&R.
Line 17--Enter the amount of interim payments from Worksheet N-5, column 2, line 4.
Line 18--FOR CONTRACTOR USE ONLY.--Enter the tentative settlement amount from
Worksheet N-5, column 2, line 5.99.
Line 19--Enter the total amount due to/from the program (line 16 minus lines 16.01, 17, and 18).
Transfer this amount to Worksheet S, Part III, column 3, line 11.
Line 20--Enter the Medicare reimbursement effect of protested items. Estimate the reimbursement
effect of the non-allowable items by applying a reasonable methodology which closely
approximates the actual effect of the item as if it had been determined through the normal cost
finding process. (See CMS Pub. 15-2, chapter 1, §115.2.) Attach a schedule showing the
supporting details and computations for this line.

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WORKSHEET N-5 - ANALYSIS OF PAYMENTS TO HOSPITAL-BASED FQHC
FOR SERVICES RENDERED

Complete lines 1 through 4 of this worksheet for Medicare interim payments only. The remainder
of this worksheet is completed by your contractor.
Line descriptions
Line 1--Enter the total Medicare interim payments paid to the hospital-based FQHC. The amount
entered must reflect the sum of all interim payments paid on individual bills (net of adjustment
bills) for services rendered in this cost reporting period and amounts withheld from your interim
payments due to an offset against overpayments applicable to prior cost reporting periods. Do not
include MA supplemental payments on this worksheet. Do not include (1) any retroactive lump
sum adjustment amounts based on a subsequent revision of the interim rate, (2) tentative or net
settlement amounts, or (3) interim payments payable.
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. It 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 this
amount to Worksheet N-4, line 17.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET N-5.
LINES 5
THROUGH 8 ARE FOR CONTRACTOR USE ONLY.
(EXCEPTION:
IF
WORKSHEET S, PART I, LINE 5, IS “5” (AMENDED COST REPORT), THE
HOSPITAL-BASED FQHC MAY COMPLETE THIS SECTION.)
Line 5--List separately each tentative settlement payment after the cost report is accepted together
with the date of payment. If the cost report is reopened after the NPR has been issued, report all
settlement payments prior to the current reopening on this line.
Line 6--Enter the net settlement amount (balance due the hospital-based FQHC or balance due the
program) for the NPR, or, if this settlement is after a reopening of the NPR, for this reopening.
Enter in column 2, the amount from Worksheet N-4, line 19.
NOTE: On lines 3, 5, and 6, when a hospital-based FQHC to program amount is due, show the
amount and date the FQHC 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, in column 2. Enter amounts due the
program as a negative number. The amount in column 2 must equal the amount on Worksheet N-4,
line 16, less the amount on line 16.01.

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4072.

WORKSHEET O - ANALYSIS OF HOSPITAL-BASED HOSPICE COSTS

4072

The O series of worksheets must be completed by all hospital-based hospices effective for cost
reporting periods beginning on or after October 1, 2015. This worksheet is used to record the trial
balance of expense accounts from the provider’s accounting books and records. It also provides
for reclassifications 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.
Column Descriptions
For columns 1, 2, 4, and 6, direct patient care service costs (lines 25 through 46) are reported by
LOC on Worksheets O-1, O-2, O-3, and O-4. For each cost center on Worksheet O, enter the sum
of the amounts from Worksheets O-1, O-2, O-3, and O-4, for salaries, other costs, reclassifications,
and adjustments, in columns 1, 2, 4, and 6, respectively.
Column 1--Enter salaries from the provider’s accounting books and records. Salaries for the direct
patient care service cost centers (lines 25 through 46) must equal the sum of amounts reported on
the corresponding lines in column 1 of Worksheets O-1, O-2, O-3, and O-4. The total salaries for
column 1, line 100, must equal the salaries reported on Worksheet A, column 1, line 116.
Column 2--Enter all costs other than salaries from the provider’s accounting books and records.
Other costs for the direct patient care service cost centers (lines 25 through 46) must equal the sum
of amounts reported on the corresponding lines in column 2 of Worksheets O-1, O-2, O-3, and
O-4. The total other costs for column 2, line 100, must equal the other costs reported on
Worksheet A, column 2, line 116.
Column 3--For each cost center, enter the total of column 1 plus 2.
Column 4--Enter any reclassifications among cost center expenses in column 3 that are needed to
effect proper cost allocation. This column need not be completed by all providers, but is completed
only to the extent reclassifications are needed or reported on Worksheet A, line 116. Show
reductions to expenses as negative amounts.
If reclassifications are needed for direct patient care service cost centers (lines 25 through 46),
enter the reclassification amounts on the appropriate Worksheets O-1, O-2, O-3, and O-4,
column 4, for each level of care.
Reclassifications for the direct patient care service cost centers (lines 25 through 46) must equal
the sum of amounts reported on the corresponding lines in column 4 of Worksheets O-1, O-2, O-3,
and O-4. The total reclassifications for column 4, line 100, must equal the reclassifications
reported on Worksheet A, column 4, line 116.
Column 5--For each cost center, enter the total of the amount in column 3, plus or minus the
amount in column 4.

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Column 6--In accordance with 42 CFR 413.9(c)(3), enter on the appropriate lines, the amounts of
any adjustments to expenses required under Medicare principles of reimbursements. (See §4016.)
This column need not be completed by all providers, but is completed only to the extent
adjustments are needed or reported on Worksheet A, column 6, line 116. Show reductions to
expenses as negative amounts.
If adjustments are needed for direct patient care service cost centers (lines 25 through 46), enter
the adjustment amounts on the appropriate Worksheets O-1, O-2, O-3, and O-4, column 6, for each
level of care.
Adjustments for the direct patient care service cost centers (lines 25 through 46) must equal the
sum of amounts reported on the corresponding lines in column 6 of Worksheets O-1, O-2, O-3,
and O-4. The total adjustments for column 6, line 100, must equal the adjustments reported on
Worksheet A, column 6, line 116.
Column 7--For each cost center, enter the total of the amount in column 5 plus or minus the amount
in column 6. Transfer the amounts in column 7 for cost centers marked with an asterisk (*) to
Worksheet O-5, as follows:

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
60
61
62
63
64
65
66
67
68
69
70
71

From Worksheet O, Column 7,
Line Number and
Cost Center Description
Cap Rel Costs-Bldg & Fixt
Cap Rel Costs-Mvble Equip
Employee Benefits
Administrative & General
Plant Operation and Maintenance
Laundry & Linen
Housekeeping
Dietary
Nursing Administration
Routine Medical Supplies
Medical Records
Staff Transportation
Volunteer Service Coordination
Pharmacy
Physician Administrative Services
Other General Service
Bereavement Program
Volunteer Program
Fundraising
Hospice/Palliative Medicine Fellows
Palliative Care Program
Other Physician Services
Residential Care
Advertising
Telehealth/Telemonitoring
Thrift Store
Nursing Facility Room and Board
Other Nonreimbursable

To Worksheet O-5,
Column 1:
line 1
line 2
line 3
line 4
line 5
line 6
line 7
line 8
line 9
line 10
line 11
line 12
line 13
line 14
line 15
line 16
line 60
line 61
line 62
line 63
line 64
line 65
line 66
line 67
line 68
line 69
line 70
line 71

Line Descriptions
The Worksheet O cost centers are segregated into general service, direct patient care service, and
nonreimbursable categories to facilitate the transfer of costs to the various worksheets. The general
service cost centers appear on Worksheet O-5, and Worksheets O-6, Parts I and Part II, using the
same line numbers as Worksheet O. The direct patient care service cost centers appear on
Worksheets O-1, O-2, O-3, and O-4, using the same line numbers as Worksheet O.
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FORM CMS-2552-10

4072 (Cont.)

General service cost centers (lines 1 through 17) include expenses incurred in operating the facility
as a whole that are not directly associated with furnishing patient care such as mortgage, rent, plant
operations, administrative salaries, utilities, telephone, and computer hardware and software costs.
Except where descriptions are provided below, see §4013 for descriptions of general service cost
centers.
Lines 1 and 2 - Cap Rel Costs-Bldg & Fixt and Cap Rel Costs-Mvble Equip--Enter in column 2,
the capital-related costs for buildings and fixtures and the capital-related costs for moveable
equipment on lines 1 and 2, respectively.
Line 3 - Employee Benefits Department--Enter in columns 1 and 2, the salary and other costs of
the employee benefits department and fringe benefits paid (see CMS Pub. 15-1, chapter 21, §2144
and CMS Pub. 15-1, chapter 23, §2307).
Line 4 - Administrative & General--Enter in columns 1 and 2, the salary and other costs of A&G.
If the option to subscript A&G costs into more than one cost center is elected (in accordance with
CMS Pub. 15-1, chapter 23, §2313), eliminate line 4. Begin numbering the subscripted A&G cost
centers with line 4.01 and continue in sequential order.
Line 5 - Plant Operation and Maintenance--This cost center includes expenses incurred in the
operation and maintenance of the plant and equipment (see §4013, Maintenance and repairs, and
Operation of plant). Enter in columns 1 and 2, the costs of plant operation and maintenance.
Line 6 - Laundry & Linen Service--Enter in columns 1 and 2, the cost of routine laundry and linen
services.
Line 7 - Housekeeping--Enter in columns 1 and 2, the cost of routine housekeeping activities for
both patient related and non-patient related areas.
Line 8 - Dietary--Enter in columns 1 and 2, the cost of preparing meals for patients. Do not include
the cost of dietary counseling in this cost center; report dietary counseling on line 35.
Line 9 - Nursing Administration--Enter in columns 1 and 2, the cost of overall management and
direction of the nursing services. Do not include the cost of direct nursing services reported on
lines 27 through 29. The salary cost of direct nursing services, including the salary cost of nurses
who render direct service in more than one patient care area, is directly assigned to the various
patient care cost centers in which the services were rendered. However, if your accounting system
fails to specifically identify all direct nursing services to the applicable direct patient care cost
centers, then the salary cost of all direct nursing service is included in this cost center.
Line 10 - Routine Medical Supplies--Enter in columns 1 and 2, the cost of supplies used in the
normal course of caring for patients, such as gloves, masks, swabs, or glycerin sticks, that generally
are not traceable to individual patients. Do not include the costs of non-routine medical supplies
that can be traced to individual patients; report non-rou7tine medical supplies on line 42.
Line 11 - Medical Records--Enter in columns 1 and 2, the cost of the medical records department
where patient medical records are maintained. The general library and the medical library are not
included in this cost center but are included in the A&G cost center.

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03-18

Line 12 - Staff Transportation--Enter in columns 1 and 2, the cost of owning or renting vehicles,
public transportation expenses, parking, tolls, or payments to employees for driving their private
vehicles to see patients or for other hospice business. Staff transportation costs do not include
patient transportation costs; report patient transportation costs on line 39.
Line 13 - Volunteer Service Coordination--Enter in columns 1 and 2, the cost of the overall
coordination of service volunteers including their recruitment and training costs of volunteers.
Line 14 - Pharmacy--Enter in columns 1 and 2, the costs of drugs (both prescription and over-thecounter), pharmacy supplies, pharmacy personnel, and pharmacy services. Do not report the cost
of palliative chemotherapy drugs on this line; report the cost of palliative chemotherapy on line 45.
Line 15 - Physician Administrative Services--Enter in columns 1 and 2, the costs for physicians’
A&G supervisory activities that are included in the hospice payment rates. These activities include
participating in the establishment, review and updating of plans of care, supervising care and
services, conducting required face-to-face encounters for recertification, and establishing
governing policies. These activities are generally performed by the physician serving as the
medical director and the physician member of the interdisciplinary group. Nurse practitioners may
not serve as or replace the medical director or physician member of the interdisciplinary group.
Line 17 - Patient/Residential Care Services--Do not use this line on this worksheet. This cost
center is used on Worksheet O-6 to accumulate in-facility costs not separately identified as HIRC,
HGIP, or residential care services that are not part of a separate and distinct residential care unit
(e.g., depreciation related to in-facility areas that provide HIRC, HGIP or residential care). The
amounts allocated to this cost center on Worksheet O-6 are allocated to HIRC, HGIP and
residential care services that are not part of a separate and distinct residential care unit, based on
in-facility days. This cost center does not include any costs related to contracted inpatient services.
When a residential care unit is separate and distinct and only used for resident care services (such
as hospice home care provided in a residential unit), costs are reported directly on line 66.
Lines 18 through 24--Reserved for future use.
Direct patient care service costs (lines 25 through 46) are reported by LOC on Worksheets O-1,
O-2, O-3, and O-4. For each cost center on Worksheet O, enter the sum of the amounts from
Worksheets O-1, O-2, O-3, and O-4, for salaries, other costs, reclassifications, and adjustments in
columns 1, 2, 4, and 6, respectively.
Line 25 - Inpatient Care - Contracted--This cost center includes the contractual costs paid to
another facility for use by the hospice for hospice inpatient care (HIRC or HGIP) in accordance
with 42 CFR 418.108(c). This cost center does not include the cost of any direct patient care
services or nonreimbursable services provided by hospice staff in the contracted setting. Costs of
any services provided by hospice staff in the contracted setting are included in the appropriate
direct patient care service or nonreimbursable cost center. Costs in this cost center are excluded
from the allocation of A&G costs.
Line 26 - Physician Services--This cost center includes the costs incurred by the hospice for
physicians, or nurse practitioners providing physician services, for direct patient care services and
general supervisory services, participation in the establishment of plans of care, supervision of
care and services, periodic review and updating of plans of care, and establishment of governing
policies by the physician member of the interdisciplinary group. (See 42 CFR 418.304.)
Reclassify the cost for the portion of time physicians spent on general supervisory services or other
hospice administrative activities to Physician Administrative Services (line 15). This cost center
must not include costs associated with palliative care or other nonreimbursable physician services.
Those nonreimbursable physician services must be reported in the appropriate nonreimbursable
cost center.

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FORM CMS-2552-10

4072 (Cont.)

Line 27 - Nurse Practitioner--This cost center includes the costs of nursing care provided by nurse
practitioners. Do not include costs for nurse practitioners providing physician services on this line;
report the costs for nurse practitioners providing physician services on line 26.
Line 28 - Registered Nurse--This cost center includes the costs of nursing care provided by
registered nurses other than nurse practitioners.
Line 29 - LPN/LVN--This cost center includes the costs of nursing care provided by licensed
practical nurses (LPN) or licensed vocational nurses (LVN). Do not include costs for certified
nursing assistant (CNA) services on this line; report the costs for CNA services on line 37.
Line 30 - Physical Therapy--This cost center includes the costs of physical or corrective treatment
of bodily or mental conditions by the use of physical, chemical, and other properties of heat, light,
water, electricity, sound massage, and therapeutic exercise by or under the direction of a registered
physical therapist as prescribed by a physician. Physical 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 31 - 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 32 - Speech/Language Pathology--This cost center includes the costs of physician-prescribed
services provided by or under the direction of a qualified speech/language pathologist to those
with functionally impaired communications skills. This includes the evaluation and management
of any existing disorders of the communication process centering entirely, or in part, on the
reception and production of speech and language related to organic and/or nonorganic factors.
Speech/language pathology 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 33 - Medical Social Services--This cost center includes the cost of the medical social services
defined in CMS Pub. 100-02, chapter 9, §40.1.2. Costs for nonreimbursable activities included in
this cost center must be reclassified to the appropriate nonreimbursable cost center.
Line 34 - Spiritual Counseling--This cost centers includes the cost of spiritual counseling services.
Costs for nonreimbursable activities included in this cost center must be reclassified to the
appropriate nonreimbursable cost center.
Line 35 - Dietary Counseling--This cost center includes the costs of dietary counseling services.
Line 36 - Counseling - Other--This cost center include the cost of counseling services not already
identified as spiritual, dietary or bereavement counseling. Costs for nonreimbursable activities
included in this cost center must be reclassified to the appropriate nonreimbursable cost center.
Line 37 - Hospice Aide and Homemaker Services--This cost center includes the costs of:
•

Hospice aide services such as personal care services and household services to maintain
a safe and sanitary environment in areas of the home used by the patient; and,

•

Homemaker services such as assistance in the maintenance of a safe and healthy
environment and services to enable the individual to carry out the plan of care.

Include the cost of CNAs that meet the criteria for an aide in this cost center.

Rev. 14

40-303

4072 (Cont.)

FORM CMS-2552-10

03-18

Line 38 - Durable Medical Equipment/Oxygen--This cost center includes the costs of DME and
oxygen, as defined in 42 CFR 410.38 and 42 CFR 418.202(f), furnished to individual HRHC or
HCHC patients. Report DME costs by the LOC the patient was receiving at the time the
DME/oxygen was delivered. If the LOC of a patient changed after delivery of the DME/Oxygen,
the hospice may report the costs proportionally between HRHC and HCHC based on patient days.
Line 39 - Patient Transportation--This cost center includes the costs of ambulance transports of
hospice patients, related to the terminal prognosis and occurring after the effective date of the
hospice election, that are the responsibility of the hospice. (See CMS Pub. 100-02, chapter 9,
§40.1.9.) When a patient is transferred to a new LOC, report the transportation cost to that LOC.
For example, a patient in a HGIP LOC is transferred to HRHC LOC and transported to their home,
the transportation cost associated with the transfer must be included in the HRHC LOC.
Line 40 - Imaging Services--This cost center includes the costs of imaging services.
Line 41 - Labs and Diagnostics--This cost center includes the costs of laboratory and diagnostic
tests.
Line 42 - Medical Supplies - Non-routine--This cost center includes the costs of medical supplies
furnished to individual patients for which a separate charge would be applicable. These supplies
are specified in the patient's plan of treatment and furnished under the specific direction of the
patient's physician. Do not include the cost of routine medical supplies used in the normal course
of caring for patients, (such as gloves, masks, swabs, or glycerin sticks) on this line; report routine
medical supplies on line 10. When a provider does not track the use of non-routine medical
supplies by LOC, the provider may report the costs proportionally between LOCs based on patient
days.
Line 42.50 - Drugs Charged to Patients--This cost center includes the costs of drugs furnished to
individual patients for which a separate charge would be applicable. These drugs are specified in
the patient’s plan of treatment and furnished under the specific direction of the patient’s physician.
When a provider does not track the use of drugs by LOC, the provider must report the costs on
line 14.
Line 43 - Outpatient Services--This cost center includes the costs of outpatient services costs not
captured elsewhere. This cost can include the cost of an emergency room department visit when
related to the terminal condition.
Lines 44 and 45 - Palliative Radiation Therapy and Palliative Chemotherapy--These cost centers
include costs of radiation, chemotherapy and other modalities used for palliative purposes based
on the patient’s condition and the hospice’s caregiving philosophy.
Lines 47 through 49--Reserved for future use.
Lines 50 through 53--Reserved for use on Worksheets O-6, Parts I and II.
Lines 54 through 59--Reserved for future use.
Nonreimbursable cost centers (lines 60 through 71) 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

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FORM CMS-2552-10

4072 (Cont.)

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 60 - Bereavement Program--Enter in columns 1 and 2, the salary and other costs of
bereavement services, defined as emotional, psychosocial, and spiritual support and services
provided before and after the death of the patient to assist with grief, loss, and adjustment
(42 CFR 418.3). Bereavement counseling is a required hospice service, but it is not reimbursable
(see §1814(I)(1)(A) of the Act).
Line 61 - Volunteer Program--Enter in columns 1 and 2, the salary and other costs of volunteer
programs. (See CMS Pub. 15-1, chapter 7.)
Line 62 - Fundraising--Enter in columns 1 and 2, the salary and other costs of fundraising. (See
CMS Pub. 15-1, chapter 21, §2136.)
Line 63 - Hospice/Palliative Medicine Fellows--Enter in columns 1 and 2, the salary and other
costs of hospice and palliative medicine fellows.
Line 64 - Palliative Care Program--Enter in columns 1 and 2, the salary and other costs of
palliative care provided to non-hospice patients. This includes physician services.
Line 65 - Other Physician Services--Enter in columns 1 and 2, the salary and other costs of other
physician services that are provided outside of a palliative care program to non-hospice patients.
Line 66 - Residential Care--Enter in columns 1 and 2, the salary and other costs of residential care
for patients living in the hospice, but who are not receiving inpatient hospice services. Patients
living in the hospice are considered residents, where the hospice is their home. These patients are
liable for their room and board charges; however, the outpatient hospice care services provided
must be recorded in the direct patient care cost centers on the appropriate HRHC and/or HCHC
LOC worksheet.
Lines 67 - Advertising--Enter in columns 1 and 2, the salary and other costs of nonallowable
community education, business development, marketing and advertising (see CMS Pub. 15-1,
chapter 21, §2136).
Lines 68 - Telehealth/Telemonitoring--Enter in columns 1 and 2, the salary and other costs of
telehealth/ telemonitoring services. These costs are nonreimbursable since a hospice is not an
approved originating site (see 42 CFR 410.78(b)(3)).
Lines 69 - Thrift Store--Enter in columns 1 and 2, the salary and other costs of thrift stores.
Line 70 - Nursing Facility Room and Board--Enter the costs incurred by a hospice for dually
eligible beneficiaries residing in a nursing facility (NF) when room and board is paid by the State
to the hospice. The full amount paid to the NF by the hospice must be included on this line and
offset by the State payment via an adjustment on Worksheet A-8. The residual cost is the net cost
incurred.
For example, a dually eligible beneficiary is residing in a NF and has elected the Medicare hospice
benefit. The NF charges $100 per day for room and board. The State pays the hospice $95 for the
NF room and board. The hospice has a written agreement with the NF that requires full room and
board payment of $100 per day. The hospice receives $95 per day, but pays the NF $100 per day,
thereby incurring a net cost of $5 per day.
Lines 72 through 99--Reserved for future use.

Rev. 12

40-305

4072.1
4072.1

FORM CMS-2552-10

11-17

WORKSHEETS O-1, O-2, O-3, AND O-4 - ANALYSIS OF HOSPITAL-BASED
HOSPICE COSTS

Worksheet O-1 - Analysis of Hospital-Based Hospice Costs Hospice Continuous Home Care
Worksheet O-2 - Analysis of Hospital-Based Hospice Costs Hospice Routine Home Care
Worksheet O-3 - Analysis of Hospital-Based Hospice Costs Hospice Inpatient Respite Care
Worksheet O-4 - Analysis of Hospital-Based Hospice Costs Hospice General Inpatient Care
Worksheets O-1, O-2, O-3, and O-4 provide for recording the direct patient care costs by LOC,
including reclassifications and adjustments. The general format of these worksheets is identical
to Worksheet O in order to facilitate the transfer of direct patient care costs to Worksheet O. For
each cost center, the sums of the amounts reported in columns 1, 2, 4, and 6, of these worksheets
are transferred to the corresponding columns on Worksheet O.
Column 1--For each LOC worksheet, enter salaries from the provider’s accounting books and
record.
Column 2--For each LOC worksheet, enter all costs other than salaries from the provider’s
accounting books and records.
Column 3--For each cost center, add the amounts in columns 1 and 2 and enter the total in
column 3.
Column 4--For each LOC worksheet, enter any reclassification of direct patient care service costs
needed to effect proper cost allocation. For each line, the sum of the reclassification entries on
Worksheets O-1, O-2, O-3, and O-4, column 4, must equal the amount on the corresponding line
of Worksheet O, column 4.
Column 5--For each cost center, enter the total of the amount in column 3 plus or minus the amount
in column 4.
Column 6--For each LOC worksheet, enter any adjustments for direct patient care service costs
(lines 25 through 46) required under Medicare principles of reimbursements. (See §4016.) Show
reductions to expenses as negative amounts. For each line, the sum of the adjustment entries on
Worksheets O-1, O-2, O-3, and O-4, column 6, must equal the amount on the corresponding line
of Worksheet O, column 6.
Column 7--For each cost center, enter the total of the amount in column 5 plus or minus the amount
in column 6. For each LOC worksheet, transfer the amount on line 100 to the corresponding LOC
line on Worksheet O-5, column 1, as follows:
From line 100 of:
Worksheet O-1
Worksheet O-2
Worksheet O-3
Worksheet O-4

40-306

To Worksheet O-5, column 1, line:
50
51
52
53

Rev. 12

01-22
4072.2

FORM CMS-2552-10

4072.2

WORKSHEET O-5 - COST ALLOCATION - DETERMINATION OF HOSPITALBASED HOSPICE NET EXPENSES FOR ALLOCATION

Worksheet O-5 determines total expenses of each general service cost center for proper allocation
of general service costs to each LOC and to nonreimbursable cost centers. This worksheet
combines the direct general service costs reported on Worksheet O, lines 1 through 17, with the
overhead allocation of the hospital general service costs reported on Worksheet B, Part I, line 116,
columns 1 through 18.
Column Descriptions
Column 1--For each general service and nonreimbursable cost center, transfer the amount from
the corresponding cost center on Worksheet O, column 7. For each LOC line, transfer amounts as
follows:
Line:
50
51
52
53

From column 7,line 100 of:
Worksheet O-1
Worksheet O-2
Worksheet O-3
Worksheet O-4

The total on line 100 of column 1 must equal the amount on Worksheet A, column 7, line 116.
Column 2--For each general service cost center, transfer the amount from the corresponding
column on Worksheet B, Part I, line 116, as follows:
NOTE: If a general service cost center on Worksheet B, Part I, is subscripted, add the amounts
on the standard cost center line and its corresponding subscripted lines, and transfer the
sum total to column 2 of the applicable line on this worksheet.
Line:
1
2
3
4
5
6
7
8
9

From Worksheet B,
line 116, column(s):
1
2
4
5, 11, and 12*
6 and 7*
8
9
10
13

Line:
10
11
12
13
14
15
16
17

From Worksheet B,
line 116, column(s):
14
16
N/A
N/A
15
N/A
18, 20, and 23
17

* If Worksheet S-9, column 4, line 12, plus line 13, is zero (no in-facility days), then transfer the
amounts from Worksheet B, Part I, columns 5, 6, 7, 11, and 12, line 116, to column 2, line 4, of
this worksheet; and enter zero in column 2, line 5, of this worksheet.
Column 3--For each line, enter the sum of columns 1 and 2. The total on line 100 of column 3
must equal the amount on Worksheet B, Part I, column 26, line 116. Transfer the amount from
each cost center to the corresponding line on Worksheet O-6, Part I, column 0.

Rev. 17

40-307

4072.3
4072.3

FORM CMS-2552-10

01-22

WORKSHEET O-6 - PART I - COST ALLOCATION - HOSPITAL-BASED HOSPICE
GENERAL SERVICE COSTS AND WORKSHEET O-6 - PART II - COST
ALLOCATION - HOSPITAL-BASED HOSPICE GENERAL SERVICE COSTS
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.
Worksheet O-6, Parts I and II, facilitate the step-down method of cost finding. This method
recognizes that general services of the hospice are utilized by other general service, LOC, and
nonreimbursable cost centers. Worksheet O-6, Part I, provides for the equitable allocation of
general service costs based on statistical data reported on Worksheet O-6, Part II. To facilitate the
allocation process, the general format of Worksheet O-6, Part I, is identical to that of
Worksheet O-6, Part II. The column and line numbers for each general service cost center are
identical on the two worksheets. The direct patient care service cost centers (lines 25 through 46
of Worksheet O) are reported by LOC on lines 50 through 53 of Worksheets O-6, Parts I and II.
The line numbers for nonreimbursable cost centers are identical on Worksheet O and
Worksheet O-6, Parts I and II.
When certain general service costs are related to in-facility days and are not separately identifiable
by LOC or service, Worksheet O-6, Parts I and II, provide for the accumulation of these costs on
line 17, Patient/Residential Care Services. The amounts accumulated in this cost center are
allocated based on the in-facility days for HIRC, HGIP, and residential care services that are not
part of a separate and distinct residential care unit. This cost center does not include any costs
related to contracted inpatient services.
The statistical basis shown at the top of each column on Worksheet O-6, Part II, 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. A hospice can elect to change
the allocation statistics, as appropriate for column 2 only, for the current cost reporting period if a
request is submitted in accordance with CMS Pub. 15-1, chapter 23, §2313.
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 hospice must
request approval in accordance with CMS Pub. 15-1, chapter 23, §2313.
If the amount of any cost center on Worksheet O-5, column 3, has a negative balance, show this
amount as a negative balance on Worksheet O-6, Part I, column 0. Allocate the costs from the
overhead cost centers to applicable cost centers, including those with a negative balance. Close a
general service cost center with a negative balance by entering the negative balance in parentheses
on line 99, as well as on the first line of the column and on line 100 of the column, and do not
allocate. This enables Worksheet O-6, Part I, column 18, line 100, to cross foot to Worksheet O-6,
Part I, column 0, line 100. After receiving costs from overhead cost centers, LOC cost centers
with negative balances on Worksheet O-6, Part I, column 18, are not transferred to Worksheet O-7.

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Rev. 17

03-18

FORM CMS-2552-10

4072.3 (Cont.)

On Worksheet O-6, Part II, enter on the first available line of each column the total statistics
applicable to the cost center being allocated (e.g., in column 1, Capital-Related Cost - Buildings
& Fixtures, enter on line 1 the total square feet of the building on which depreciation was taken).
Use accumulated cost for allocating A&G expenses.
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
hospice’s books/records; or

•

The contractor determines that the hospice 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 hospice had furnished such services directly to all patients. (See
CMS Pub. 15-1, chapter 23, §2314.)

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.
For each column on Worksheet O-6, Part II, enter on line 100, the total expenses of the cost center
to be allocated. Obtain the total expenses from the first line of the corresponding column on
Worksheet O-6, Part I, which includes the direct expenses from Worksheet O-6, Part I, column 0,
plus the allocated costs from previously closed cost centers. Divide the amount entered on
Worksheet O-6, Part II, line 100, by the total statistical base entered in the same column on the
first line. Enter the resulting unit cost multiplier (rounded to six decimal places) on line 101.
For each column on Worksheet O-6, Part II, multiply the unit cost multiplier on line 101 by the
portion of the total statistical base applicable to each cost center receiving services and enter the
result in the corresponding column and line on Worksheet O-6, Part I. For each column on
Worksheet O-6, Part I, the sum of the costs allocated (line 100) must equal the total cost on the
first line.
After the costs of the general service cost centers have been allocated on Worksheet O-6, Part I,
enter on each line of column 18, the sum of the costs in columns 3A through column 17, for
lines 50 through 71. The total costs entered on Worksheet O-6, Part I, line 100, column 18, must
equal the total costs entered on line 100, column 0.
Column Descriptions
Column 0--For each line, enter the total direct costs from the corresponding line on
Worksheet O-5, column 3.
Column 3A--For each line, enter the sum of columns 0 through 3. The sum for each line is the
accumulated cost and, unless an adjustment is required, is the Worksheet O-6, Part II, column 4
statistic for allocating A&G costs.
If an adjustment to the accumulated cost statistic on Worksheet O-6, Part II, column 4, is required
to properly allocate A&G costs, enter the adjustment amount on Worksheet O-6, Part II,
column 4A, for the applicable line. For example, when the hospice contracts for HIRC services
and the contractual costs include A&G costs, reduce the HIRC accumulated cost statistic on
Worksheet O-6, Part II, line 52, column 4A, by the contractual costs reported on Worksheet O-3,
line 25, column 7. Similarly, when the hospice contracts for HGIP services and the contractual
costs include A&G costs, reduce the HGIP accumulated cost statistic on Worksheet O-6, Part II,
line 53, column 4A, by the contractual costs reported on Worksheet O-4, line 25, column 7.

Rev. 14

40-309

4072.4

FORM CMS-2552-10

03-18

For each line, the accumulated cost statistic on Worksheet O-6, Part II, column 4, is the difference
between the amount on Worksheet O-6, Part I, column 3A and the adjustment amount on
Worksheet O-6, Part II, column 4A. Accumulated cost for A&G is not included in the total
statistic for the A&G cost center; therefore, transfer the amount on Worksheet O-6, Part I, line 4,
column 3A, to Worksheet O-6, Part II, line 4, column 4A.
The total accumulated cost statistic for Worksheet O-6, Part II, line 4, column 4, is the difference
between the total on Worksheet O-6, Part I, line 100, column 3A, and the amounts in column 4A
of Worksheet O-6, Part II.
A negative cost center balance in the statistics for allocating A&G expenses causes an improper
distribution of this overhead cost center. Negative balances are excluded from the allocation
statistics when A&G expenses are allocated on the basis of accumulated cost.
Column 18--Transfer the amounts on lines 50 through 53 as follows:
From Worksheet O-6, Part I,
Column 18:
line 50
line 51
line 52
line 53
4072.4

To Worksheet O-8,
Column 3:
line 1
line 6
line 11
line 16

WORKSHEET O-7 - APPORTIONMENT OF HOSPITAL-BASED HOSPICE
SHARED SERVICE COSTS BY LEVEL OF CARE

This worksheet calculates the cost of ancillary services provided by hospital ancillary departments
to hospital-based hospice patients.
Column Description
Column 1--For each cost center, enter in column 1, the cost-to-charge ratio from Worksheet C,
Part I, column 9, line as indicated in column 0.
Columns 2 through 5--For each cost center, enter the charges, from the provider’s records, for
ancillary services provided by hospital ancillary departments to hospital-based hospice patients.
Enter the charges by LOC in the appropriate LOC column.
Columns 6 through 9--For each column, calculate cost of ancillary services provided by hospital
ancillary departments to hospital-based hospice patients as follows:
Column:
6
7
8
9

Calculation:
col. 1 x col. 2
col. 1 x col. 3
col. 1 x col. 4
col. 1 x col. 5

For each column 6 through 9, enter the sum of lines 1 through 10 on line 11.

40-310

Rev. 14

04-20
4072.5

FORM CMS-2552-10

4072.5

WORKSHEET O-8 - CALCULATION OF HOSPITAL-BASED HOSPICE PER DIEM
COST

Worksheet O-8 calculates the average cost per diem by level of care and in total.
Line1--Enter in column 3, the sum of the total HCHC cost from Worksheet O-6, Part I, line 50,
column 18, plus Worksheet O-7, line 11, column 6.
Line 2--Enter in column 3, the total HCHC days from Worksheet S-9, line 10, column 4.
Line 3--Enter in column 3, the average HCHC cost per diem by dividing line 1, column 3, by
line 2, column 3.
Line 4--Enter in column 1, the title XVIII - Medicare HCHC days from Worksheet S-9, line 10,
column 1. Enter in column 2 the title XIX - Medicaid HCHC days from Worksheet S-9, line 10,
column 2.
Line 5--Enter in column 1, the title XVIII - Medicare program cost calculated by multiplying
line 3, column 3, by line 4, column 1. Enter in column 2, the title XIX - Medicaid program cost
calculated by multiplying line 3, column 3, by line 4, column 2.
Line 6--Enter in column 3, the total HRHC cost from Worksheet O-6, Part I, line 51, column 18,
plus Worksheet O-7, line 11, column 7.
Line 7--Enter in column 3, the total HRHC days from Worksheet S-9, line 11, column 4.
Line 8--Enter in column 3, the average HRHC cost per diem by dividing line 6, column 3, by
line 7, column 3.
Line 9--Enter in column 1, the title XVIII - Medicare HRHC days from Worksheet S-9, line 11,
column 1. Enter in column 2, the title XIX - Medicaid HRHC days from Worksheet S-9, line 11,
column 2.
Line 10--Enter in column 1, the title XVIII - Medicare program cost calculated by multiplying
line 8, column 3, by line 9, column 1. Enter in column 2, the title XIX - Medicaid program cost
calculated by multiplying line 8, column 3, by line 9, column 2.
Line 11--Enter in column 3, the total HIRC cost from Worksheet O-6, Part I, line 52, column 18,
plus Worksheet O-7, line 11, column 8.
Line 12--Enter in column 3, the total HIRC days from Worksheet S-9, line 12, column 4.
Line 13--Enter in column 3, the average HIRC cost per diem by dividing line 11, column 3, by
line 12, column 3.
Line 14--Enter in column 1, the title XVIII - Medicare HIRC days from Worksheet S-9, line 12,
column 1. Enter in column 3, the title XIX - Medicaid HIRC days from Worksheet S-9, line 12,
column 2.
Line 15.--Enter in column 1, the title XVIII - Medicare program cost calculated by multiplying
line 13, column 3, by line 14, column 1. Enter in column 2, the title XIX - Medicaid program cost
calculated by multiplying line 13, column 3, by line 14, column 2.
Line 16--Enter in column 3, the total HGIP cost from Worksheet O-6, Part I, line 53, column 18,
plus Worksheet O-7, line 11, column 9.
Line 17--Enter in column 3, the total HGIP days from Worksheet S-9, line 13, column 4.
Rev. 16

40-311

4072.5 (Cont.)

FORM CMS-2552-10

04-20

Line 18--Enter in column 3, the average HGIP cost per diem by dividing line 16, column 3, by
line 17, column 3.
Line 19--Enter in column 1, the title XVIII - Medicare HGIP days from Worksheet S-9, line 13,
column 1. Enter in column 3, the title XIX - Medicaid HGIP days from Worksheet S-9, line 13,
column 2.
Line 20--Enter in column 1, the title XVIII - Medicare program cost calculated by multiplying
line 18, column 3, by line 19, column 1. Enter in column 2, the title XIX - Medicaid program cost
calculated by multiplying line 18, column 3, by line 19, column 2.
Line 21--Enter in column 3, the sum of lines 1, 6, 11, and 16.
Line 22--Enter in column 3, total days from Worksheet S-9, line 14, column 4.
Line 23--Enter the average cost per diem by dividing line 21, column 3, by line 22, column 3.

40-312

Rev. 16

DRAFT

FORM CMS-2552-10

4090

Form CMS-2552-10 Worksheets
The following is a listing of the Form CMS-2552-10 worksheets and page numbers.

Rev.

Worksheets

Page(s)

Wkst. S, Parts I, II & III
Wkst. S-2, Part I
Wkst. S-2, Part II
Wkst. S-3, Part I
Wkst. S-3, Parts II & III
Wkst. S-3, Part IV
Wkst. S-3, Part V
Wkst. S-4
Wkst. S-5
Wkst. S-6
Wkst. S-7
Wkst. S-8
Wkst. S-9
Wkst. S-10, Parts I & II
Wkst. S-11, Parts I - III
Wkst. A
Wkst. A-6
Wkst. A-7, Parts I - III
Wkst. A-8
Wkst. A-8-1
Wkst. A-8-2
Wkst. A-8-3, Parts I - VI
Wkst. B, Part I
Wkst. B, Part II
Wkst. B-1
Wkst. B-2
Wkst. C, Part I
Wkst. C, Part II
Wkst. D, Part I
Wkst. D, Part II
Wkst. D, Part III
Wkst. D, Part IV
Wkst. D, Parts V
Wkst. D-1, Part I
Wkst. D-1, Part II
Wkst. D-1, Parts III & IV
Wkst. D-2, Parts I - III
Wkst. D-3
Wkst. D-4, Part I
Wkst. D-4, Part II
Wkst. D-4, Part III
Wkst. D-5, Part I
Wkst. D-5, Part II
Wkst. D-5, Part III
Wkst. D-5, Part IV
Wkst. D-6, Parts I & II
Wkst. D-6, Part III
Wkst. E, Part A
Wkst. E, Part B
Wkst. E-1, Part I

40-503
40-504 - 40-507
40-508 - 40-509
40-510 - 40-511
40-512 - 40-513
40-514
40-515
40-516
40-517
40-518
40-519 - 40-520
40-521
40-522
40-523 - 40-523.1
40-523.2 - 40-523.4
40-524 - 40-526
40-527
40-528
40-529
40-530
40-531
40-532 - 40-534
40-535 - 40-543
40-544 - 40-552
40-553 - 40-561
40-562
40-563 - 40-564
40-565 - 40-566
40-567
40-568
40-569
40-570 - 40-571
40-572
40-573
40-574
40-575
40-576 - 40-577
40-578
40-579
40-580
40-581
40-582
40-583
40-583.1
40-583.2
40-583.3
40-583.4
40-584 - 40-585
40-586 - 40-587
40-588

40-501

4090 (Cont.)

FORM CMS-2552-10

DRAFT

Form CMS-2552-10 Worksheets (Cont.)

40-502

Worksheets

Page(s)

Wkst. E-1, Part II
Wkst. E-2
Wkst. E-3, Part I
Wkst. E-3, Part II
Wkst. E-3, Part III
Wkst. E-3, Part IV
Wkst. E-3, Part V
Wkst. E-3, Part VI
Wkst. E-3, Part VII
Wkst. E-4
Wkst. E-5
Wkst. G
Wkst. G-1
Wkst. G-2, Parts I & II
Wkst. G-3
Wkst. H
Wkst. H-1, Part I
Wkst. H-1, Part II
Wkst. H-2, Part I
Wkst. H-2, Part II
Wkst. H-3, Parts I - III
Wkst. H-4
Wkst. H-5
Wkst. I-1
Wkst. I-2
Wkst. I-3
Wkst. I-4
Wkst. I-5
Wkst. J-1, Part I
Wkst. J-1, Part II
Wkst. J-2, Part I
Wkst. J-2, Part II
Wkst. J-3
Wkst. J-4
Wkst. K
Wkst. K-1
Wkst. K-2
Wkst. K-3
Wkst. K-4, Part I
Wkst. K-4, Part II
Wkst. K-5, Part I
Wkst. K-5, Part II
Wkst. K-5, Part III
Wkst. K-6
Wkst. L
Wkst. L-1, Part I
Wkst. L-1, Part II
Wkst. L-1, Part III
Wkst. M-1
Wkst. M-2
Wkst. M-3
Wkst. M-4
Wkst. M-5

40-589
40-590
40-591
40-592
40-593
40-594
40-595
40-596
40-597
40-598 - 40-599
40-599.1
40-600 - 40-601
40-602
40-603
40-604
40-605
40-606
40-607
40-608 - 40-610
40-611 - 40-613
40-614
40-615
40-616
40-617
40-618
40-619
40-620
40-621
40-622 - 40-624
40-625 - 40-627
40-628
40-629
40-630
40-631
40-632
40-633
40-634
40-635
40-636
40-637
40-638 - 40-640
40-641 - 40-643
40-644
40-645
40-646
40-647 - 40-655
40-656
40-657 - 40-658
40-659
40-660
40-661
40-662
40-663
Rev.

11-16

FORM CMS-2552-10

4090 (Cont.)

Form CMS-2552-10 Worksheets

Rev. 10

Worksheets

Page(s)

Wkst. N-1
Wkst. N-2
Wkst. N-3
Wkst. N-4
Wkst. N-5
Wkst. O
Wkst. O-1
Wkst. O-2
Wkst. O-3
Wkst. O-4
Wkst. O-5
Wkst. O-6, Part I
Wkst. O-6, Part II
Wkst. O-7
Wkst. O-8

40-664 - 40-665
40-666
40-667
40-668
40-669
40-670 - 40-671
40-672
40-673
40-674
40-675
40-676
40-677 - 40-678
40-679 - 40-680
40-681
40-682

40-502.1

4090 (Cont.)

FORM CMS-2552-10

11-16

This page is reserved for future use.

40-502.2

Rev. 10

File Type	application/pdf
Author	GAIL DUNCAN
File Modified	2022-06-22
File Created	2022-06-10