Form CMS-10821 Supplement to Form CMS-2552-10

SUPPLEMENTAL TO FORM CMS-2552-10
This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim payments made since the beginning of the cost reporting
period being deemed overpayments (42 USC 1395g).
PAYMENT ADJUSTMENTS FOR DOMESTIC NIOSH-APPROVED
SURGICAL N95 RESPIRATORS

PROVIDER CCN:
_______________

FORM APPROVED
OMB NO. 0938-XXXX
EXPIRES XX-XX-XXXX
PERIOD:
FROM __________
TO _____________

PART I - DOMESTIC NIOSH-APPROVED SURGICAL N95 RESPIRATORS PAYMENT ADJUSTMENT ELIGIBILITY AND DATA
DOMESTIC
RESPIRATORS
RESPIRATORS
1

NON-DOMESTIC
RESPIRATORS
RESPIRATORS
2

1 Did the hospital or hospital healthcare complex purchase domestic (column 1) or non-domestic (column 2) respirators? Enter "Y" for yes or
"N" for no in each column. If "Y" for either column, complete line 2.
DOMESTIC RESPIRATORS
TOTAL
NUMBER
COST
PURCHASED
1
2

1

NON-DOMESTIC RESPIRATORS
TOTAL
NUMBER
COST
PURCHASED
3
4

2 Enter the total cost of domestic respirators purchased in column 1 and the number of domestic
respirators purchased in column 2.
Enter the total cost of non-domestic respirators purchased in column 3 and the number of
non-domestic respirators purchased in column 4.

2

PART II - CALCULATION OF COST DIFFERENTIAL FOR DOMESTIC NIOSH-APPROVED SURGICAL N95 RESPIRATORS
DOMESTIC
RESPIRATORS
1
1
2
3
4
5

NON-DOMESTIC
RESPIRATORS
2

COST
DIFFERENTIAL
3

Total cost of NIOSH-approved surgical N95 respirators purchased
Number of NIOSH-approvied surgical N95 respirators purchased
Average cost per respirator
Hospital-specific unit cost differential for domestic respirators
Total cost differential for domestic respirators

PART III - CALCULATION OF PAYMENT ADJUSTMENT FOR DOMESTIC NIOSH-APPROVED SURGICAL N95 RESPIRATORS
CCN ____________
CCN ____________
IPF
HOSPITAL
HOSPITAL
SUBPROVIDER
PART A
PART B
PART B
1
2
3
1 Medicare costs
2 Total facility costs
3 Medicare percentage
4 Domestic NIOSH-approved surgical N95 respirators payment adjustment

1
2
3
4
5

CCN ____________
IRF
SUBPROVIDER
PART B
4

TOTAL
5

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-XXXX. The time required to complete this information collection is estimated to be .50 hours per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s), or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Report Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 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.

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