CMS-10821. Supplemental to Form CMS-2552-10-i (instructions)

SUPPLEMENTAL TO FORM CMS-2552-10
PAYMENT ADJUSTMENT FOR DOMESTIC
NIOSH-APPROVED SURGICAL N95 RESPIRATORS
This supplemental form calculates the inpatient and outpatient payment adjustments for
domestically-made National Institute for Occupational Safety and Health (NIOSH)-approved
surgical N95 respirators purchased by an 1886(d) hospital (IPPS hospital) and/or a hospital paid
for outpatient services under the hospital outpatient prospective payment system (OPPS hospital)
for cost reporting periods beginning on or after January 1, 2023. Only an 1886(d) hospital and/or
a hospital paid for outpatient services under the hospital OPPS completes this supplemental form;
the hospital must complete and submit this supplemental form with its Medicare cost report,
Form CMS-2552-10.
Definitions.-Domestic NIOSH-approved surgical N95 respirator (domestic respirator)--For purposes of this
policy, a domestic NIOSH-approved surgical N95 respirator is domestic if all of its components
are grown, reprocessed, reused, or produced in the United States.
Non-domestic NIOSH-approved surgical N95 respirator (non-domestic respirator)--For purposes
of this policy, any other NIOSH-approved surgical N95 respirator is non-domestic.
Part I - Domestic NIOSH-Approved Surgical N-95 Respirators Payment Adjustment Eligibility
and Data.--On this part, the hospital identifies its eligibility to receive a payment adjustment for
the purchase of domestic respirators. The hospital reports the cost and quantity of domenstic
respirators and non-domestic respirators, and, if eligible, uses this data to compute a payment
adjustment amount.
Line 1--If the hospital purchased domestic respirators, enter “Y” for yes in column 1; otherwise,
enter “N” for no. If the hospital purchased non-domestic respirators, enter “Y” for yes in column 2;
otherwise enter “N” for no. If either column 1 or 2 is “Y”, complete line 2.
Line 2--If line 1, column 1 or column 2, is “Y”, complete columns 1 through 4, from the hospital’s
books and records, by entering:
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

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in column 1, the total cost of domestic respirators purchased by the hospital or hospital
healthcare complex; if none purchased, enter zero.
in column 2, the number of domestic respirators purchased by the hospital or hospital
healthcare complex; if none purchased, enter zero.
in column 3, the total cost of non-domestic respirators purchased by the hospital or hospital
healthcare complex; if none purchased, enter zero.
in column 4, the number of non-domestic respirators purchased by the hospital or hospital
healthcare complex; if none purchased, enter zero.

SUPPLEMENTAL TO FORM CMS-2552-10
Part II - Calculation of Cost Differential for Domestic NIOSH-Approved Surgical N-95
Respirators.--This part calculates the additional cost incurred by the hospital for purchasing
domestic respirators.
Line 1--Transfer the cost of domestic respirators purchased from Part I, line 2, column 1, to
column 1; and, transfer the cost of non-domestic respirators purchased from Part I, line 2,
column 3, to column 2.
Line 2--Transfer the number of domestic respirators purchased from Part I, line 2, column 2, to
column 1; and, transfer the number of non-domestic respirators purchased from Part I, line 2,
column 4, to column 2.
Line 3--For columns 1 and 2, calculate the average cost per respirator by dividing line 1 (the total
cost of respirators purchased) by line 2 (the number of respirators purchased), rounding the result
to two decimal places. If the hospital purchased no domestic or non-domestic respirators, enter
zero in the respective column.
Line 4--Calculate the hospital-specific unit cost differential for domestic respirators as line 3,
column 1, (the average cost per domestic respirator), minus line 3, column 2, (the average cost per
non-domestic respirator). If the result is less than zero, enter zero.
Line 5--Calculate the total cost differential for the purchase of domestic respirators by multiplying
line 2, column 1, (the number of domestic respirators purchased) by line 4, column 3, (the
hospital-specific unit cost differential).
Part III - Calculation of Domestic NIOSH-Approved Surgical N95 Respirators Payment
Adjustment.--This part calculates the domestic N95 respirator payment adjustment.
Line 1--Enter Medicare costs of the hospital and hospital healthcare complex from Medicare cost
report, Form CMS-2552-10, as follows:
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
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In column 1, enter Medicare inpatient costs from the IPPS hospital Worksheet D-1, Part II,
line 49.
In column 2, enter Medicare outpatient costs from the OPPS hospital Worksheet D, Part V,
line 202, sum of columns 5, 6, and 7.
In column 3, enter Medicare outpatient costs from the IPF subprovider Worksheet D,
Part V, line 202, sum of columns 5, 6, and 7.
In column 4, enter Medicare outpatient costs from the IRF subprovider Worksheet D,
Part V, line 202, sum of columns 5, 6, and 7.

Line 2--In column 5, enter the total facility costs from Worksheet C, Part I, line 202, column 5.
Line 3--For each column 1 through 4, calculate the percentage of Medicare costs to total facility
costs as line 1 divided by line 2, column 5, rounding the result to six decimal places.

SUPPLEMENTAL TO FORM CMS-2552-10
Line 4--Calculate the domestic NIOSH-approved surgical N95 respirators payment adjustment for
columns 1, 2, 3, and 4, by multiplying the domestic respirators cost differential from Part II, line 5,
column 3, by the Medicare percentage from Part III, line 3, of each column, rounding the result to
zero decimal places. In column 5, enter the sum of columns 1, 2, 3, and 4. To transfer the payment
adjustments to the Medicare cost report:








For a hospital Part A, payment adjustment in column 1, subscript the Medicare cost report
Worksheet E, Part A, line 70, to create line 70.75 with the line label “N95 respirator
payment adjustment,” and transfer the hospital Part A payment adjustment to the
Worksheeet E, Part A, line 70.75.
For a hospital Part B, payment adjustment in column 2, subscript the Medicare cost report
hospital Worksheet E, Part B, line 39, to create line 39.75 with the line label “N95
respirator payment adjustment,” and transfer the hospital Part B payment adjustment to the
hospital Worksheeet E, Part B, line 39.75.
For an IPF subprovider Part B, payment adjustment in column 3, subscript the Medicare
cost report IPF subprovider Worksheet E, Part B, line 39, to create line 39.75 with the line
label “N95 respirator payment adjustment,” and transfer the IPF subprovider Part B
payment adjustment to the IPF subprovider Worksheeet E, Part B, line 39.75.
For an IRF subprovider Part B, payment adjustment in column 4, subscript the Medicare
cost report IRF subprovider Worksheet E, Part B, line 39, to create line 39.75 with the line
label “N95 respirator payment adjustment,” and transfer the IRF subprovider Part B
payment adjustment to the IPF subprovider Worksheeet E, Part B, line 39.75.

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