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pdfCHAPTER 47
HOME HEALTH AGENCY COST REPORT
FORM CMS-1728-20
Section
General ................................................................................................................................ 4700
Rounding Standards for Fractional Computations .............................................................. 4701
Acronyms and Abbreviations ............................................................................................. 4702
Recommended Sequence for Completing Form CMS-1728-20 ......................................... 4703
Worksheet S - Home Health Agency Cost Report Certification and Settlement
Summary ........................................................................................................................ 4704
Part I - Cost Report Status ......................................................................................... 4704.1
Part II - Certification .................................................................................................. 4704.2
Part III - Settlement Summary ................................................................................... 4704.3
Worksheet S-2, Part I - Identification Data ........................................................................ 4705
Worksheet S-2, Part II - Reimbursement Data ................................................................... 4706
Worksheet S-3 - Statistical Data ......................................................................................... 4707
Part I - Visits Data ...................................................................................................... 4707.1
Part II - Employment Data (Full Time Equivalent) ................................................... 4707.2
Part III - Core Based Statistical Area (CBSA) Data .................................................. 4707.3
Part IV - PPS Activity Data ....................................................................................... 4707.4
Part V - Direct Care Expenditures ............................................................................. 4707.5
Worksheet S-4 - HHA-Based Hospice Statistical Data ...................................................... 4708
Part I - Enrollment Days ............................................................................................ 4708.1
Part II - Contracted Statistical Data ........................................................................... 4708.2
Worksheet A - Reclassification and Adjustment of Trial Balance of Expenses ................. 4709
Worksheet A-6 - Reclassifications ...................................................................................... 4710
Worksheet A-8 - Adjustments to Expenses ........................................................................ 4711
Worksheet A-8-1 - Costs of Services from Related Organizations and/or Home
Office/Chain Organizations ............................................................................................ 4712
Part I - Adjustments Required as a Result of Transactions with Related
Organizations and/or Home Office/Chain Organizations ....................................... 4712.1
Part II - Interrelationship Between Related Organizations and/or Home
Office/Chain Organizations .................................................................................... 4712.2
Worksheet B - Cost Allocation - Allocation of General Service Costs and
Worksheet B-1 - Cost Allocation - Statistical Bases ...................................................... 4713
Worksheet C - Apportionment of Patient Service Costs .................................................... 4714
Part I - Aggregate HHA Cost Per Visit and Aggregate Medicare Cost
Computation ............................................................................................................ 4714.1
Part II - Supplies, Drugs, and Disposable Devices Cost Computation ...................... 4714.2
Worksheet D - Calculation of Reimbursement Settlement ................................................. 4715
Part I - Computation of the Lesser of Reasonable Cost or Customary
Charges for Vaccines .............................................................................................. 4715.1
Part II - Computation of Reimbursement Settlement ................................................ 4715.2
Worksheet D-1 - Analysis of Payments to HHA for Services Rendered to
Program Beneficiaries .................................................................................................... 4716
Worksheet F- Balance Sheet ............................................................................................... 4717
Worksheet F-1 Statement of Revenues and Expenses ........................................................ 4718
Rev. 1
47-1
CHAPTER 47
Section
Worksheet O - Analysis of HHA-Based Hospice Costs ..................................................... 4719
Worksheet O-1, O-2, O-3, O-4 Analysis of HHA-Based Hospice Costs ........................... 4720
Worksheet O-1 - Analysis of HHA-Based Hospice Costs - Continuous Home Care
Worksheet O-2 - Analysis of HHA-Based Hospice Costs - Routine Home Care
Worksheet O-3 - Analysis of HHA-Based Hospice Costs - Inpatient Respite Care
Worksheet O-4 - Analysis of HHA-Based Hospice Costs - General Inpatient Care
Worksheet O-5 - Determination of HHA-Based Hospice Total Expenses for
Allocation ....................................................................................................................... 4721
Worksheet O-6, Part I - Cost Allocation - HHA-Based Hospice - Allocation of
HHA-Based Hospice General Service Costs
Worksheet O-6, Part II - Cost Allocation - HHA-Based Hospice - Statistical
Bases ............................................................................................................................... 4722
Worksheet O-7 - Apportionment of HHA-Based Hospice Shared Service Costs
by Level of Care ............................................................................................................. 4723
Worksheet O-8 - Calculation of HHA-Based Hospice Per Diem Cost .............................. 4724
Electronic Reporting Specifications for Form CMS-1728-20 ............................................ 4790
Form CMS-1728-20 Worksheets ........................................................................................ 4795
47-2
Rev. 1
DRAFT
4700.
FORM CMS-1728-20
4700
GENERAL
The Paperwork Reduction Act of 1995 requires that the private sector be informed why
information is collected and how it will be used by the government. Under the authority of
§§1815(a) and 1833(e) of the Social Security Act (the Act), a home health agency (HHA) as
defined under §1861(o), participating in the Medicare program is required to submit annual
information to determine costs for health care services rendered to Medicare beneficiaries. HHAs
are required to follow reasonable cost principles under §1861(v)(1)(A) when completing the
Medicare cost report. The regulations at 42 CFR 413.20 and 413.24 require adequate cost data
and cost reports from HHAs on an annual basis. The information reported on Form CMS-1728-20,
must conform to the requirements and principles set forth in the Provider Reimbursement Manual,
(CMS Pub. 15-1), as well as those set forth in the Medicare Benefit Policy Manual,
(CMS Pub. 100-02, chapter 7),
and
the
Medicare
Claim
Processing
Manual,
(CMS Pub. 100-04, chapter 10). These instructions are effective for cost reporting periods
beginning on or after January 1, 2020, and ending on or after December 31, 2020.
The HHA cost report must be submitted to the Medicare administrative contractor (hereafter
referred to as contractor) in an electronic format in accordance with 42 CFR 413.24(f)(4). Cost
reports are due on or before the last day of the fifth month following the close of the period covered
by the report. For cost reports ending on a day other than the last day of the month, cost reports
are due 150 days after the last day of the cost reporting period, in accordance with
42 CFR 413.24(f)(2).
Form CMS-1728-20 must be used by all freestanding HHAs. HHAs that are considered part of a
hospital healthcare complex must use Form CMS-2552 and HHAs that are considered part of a
skilled nursing facility (SNF) healthcare complex must use Form CMS-2540.
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 0938-0022. The expiration date of this information
collection instrument is [XXXX XX, 202X]. The time required to complete this information
collection is estimated to average 195 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:
Centers for Medicare and Medicaid Services,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850. Please do not send applications, claims, payments, medical records or any
documentation 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.
Rev.
47-3
4701
FORM CMS-1728-20
4701.
DRAFT
ROUNDING STANDARDS FOR FRACTIONAL COMPUTATIONS
Throughout the Medicare cost report, where computations result in the use of fractions, use the
following rounding standards:
1. Round to 2 decimal places
a. Percentages
b. Averages
c. Full time equivalent employees
d. Per diems, hourly rates
2. Round to 5 decimal places
a. Sequestration (e.g., 2.092 percent is expressed as .02092)
3. Round to 6 decimal places
a. Ratios (e.g., unit cost multipliers, cost/charge ratios, days to days)
If a residual exists as a result of computing costs using a fraction, adjust the residual in the largest
amount resulting from the computation. For example, in cost finding, a unit cost multiplier is
applied to the statistics in determining costs. After rounding each computation, the sum of the
allocation may be more or less than the total cost allocated. This residual is adjusted to the largest
amount resulting from the allocation so that the sum of the allocated amounts equals the amount
allocated.
4702.
ACRONYMS AND ABBREVIATIONS
Throughout the Medicare cost report and instructions, a number of acronyms and abbreviations
are used. Commonly used acronyms and abbreviations are listed below.
A&G
CAP REL
CBSA
CCN
CFR
CMS
COL
DME
ECR
FR
FTE
HCHC
HCRIS
HFS
HGIP
HHA
HIRC
HO/CO
HRHC
IRS
LCC
LOC
LUPA
MBI
47-4
-
Administrative and General
Capital-Related
Core Based Statistical Area
CMS Certification Number
Code of Federal Regulations
Centers for Medicare & Medicaid Services
Column
Durable Medical Equipment
Electronic Cost Report
Federal Register
Full Time Equivalent
Hospice Continuous Home Care
Healthcare Cost Report Information System
Health Financial Systems
Hospice General Inpatient Care
Home Health Agency
Hospice Inpatient Respite Care
Home Office/Chain Organization
Hospice Routine Home Care
Internal Revenue Service
Lesser of Reasonable Cost or Customary Charges
Level of Care
Low Utilization Payment Adjustment
Medicare Beneficiary Identifier
Rev.
08-22
FORM CMS-1728-20
NPR
NPWT
OPPS
PEP
PHE
PRF
PPS
PS&R
SNF
WKST
4703.
-
4703
Notice of Program Reimbursement
Negative Pressure Wound Therapy
Outpatient Prospective Payment System
Partial Episode Payment
Public Health Emergency
Provider Relief Fund
Prospective Payment System
Provider Statistical and Reimbursement Report (or System)
Skilled Nursing Facility
Worksheet
RECOMMENDED SEQUENCE FOR COMPLETING FORM CMS-1728-20
All providers using Form CMS-1728-20 must adhere to the following sequence of completion. If
worksheets are not completed because they are not applicable, do not include blank worksheets in
the assembly of the cost report.
Step
Worksheet
Instructions
1
S-2
Read §§4705 through 4706. Complete entire worksheet.
2
S-3
Read §§4707 through 4707.5. Complete entire worksheet.
3
S-4
Read §§4708 through 4708.2. Complete entire worksheet.
4
A
Read §4709.
through 100.
5
A-6
Read §4710. Complete entire worksheet.
6
A
Read §4709. Complete columns 7 and 8, lines 1 through
100.
7
A-8-1
Read §4712. Complete entire worksheet.
8
A-8
Read §4711. Complete entire worksheet.
9
A
Read §4709. Complete columns 9 and 10, lines 1 through
100.
Rev. 3
Complete columns 1 through 6, lines 1
47-5
4703 (Cont.)
FORM CMS-1728-20
08-22
Step
Worksheet
Instructions
10
B and B-1
Read §4713. Complete all worksheets.
11
C
Read §§4714 through 4714.2. Complete entire worksheet.
12
D
Read §§4715 through 4715.2.
through 35.
13
D-1
Read §4716. Complete lines 1 through 4.
14
D
Read §4715.2. Complete lines 36 through 39.
15
F
Read §4717. Complete entire worksheet.
16
F-1
Read §4718. Complete entire worksheet.
17
O-1, O-2, O-3, O-4
Read §4720. Complete all worksheets, if applicable.
18
O
Read §4719. Complete entire worksheet, if applicable.
19
O-5
Read §4721. Complete entire worksheet, if applicable.
20
O-6
Read §4722. Complete both worksheets in entirety, if
applicable.
21
O-7
Read §4723. Complete entire worksheet, if applicable.
22
O-8
Read §4724. Complete entire worksheet, if applicable.
23
S
Read §§4704 through 4704.3. Complete Part III, then
complete Parts I and II.
47-6
Complete lines 1
Rev. 3
09-20
4704.
FORM CMS-1728-20
4704.1
WORKSHEET S - HOME HEALTH AGENCY COST REPORT CERTIFICATION
AND SETTLEMENT SUMMARY
Worksheet S consists of the following three parts:
Part I - Cost Report Status
Part II - Certification
Part III - Settlement Summary
4704.1 Part I - Cost Report Status.--This section is to be completed by the HHA and contractor
as indicated on the worksheet.
Provider use only.--The provider completes lines 1 through 4.
Line 1.--Indicate if the cost report is electronically prepared by entering “Y” for yes or “N” for no
in column 1. If yes, enter the electronic file creation date and time in columns 2 and 3, respectively.
If no, line 2 must be completed.
Line 2.--HHA cost reports are required to be prepared in an electronic format. If line 1 is no,
indicate this cost report is a manual submission by entering “Y” for yes. This line is only
completed by HHAs filing low utilization cost reports in accordance with
CMS Pub. 15-2, chapter 1, §110, or HHAs demonstrating financial hardship in accordance with
CMS Pub. 15-2, chapter 1, §133. If line 1 is yes, enter “N” for no on this line.
Line 3.--If this is an amended cost report, enter the number of times the cost report has been
amended.
Line 4.--Enter an “F” if this is full cost report, an “L” if this is a low Medicare utilization cost
report (“L” requires prior contractor approval, see CMS Pub. 15-2, chapter 1, §110), or an “N” if
this is a no Medicare utilization cost report.
Contractor use only.--The contractor completes lines 5 through 12.
Line 5.--Enter the Healthcare Cost Report Information System (HCRIS) cost report status code
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.--Enter the date (mm/dd/yyyy) the accepted cost report was received from the HHA.
Line 7.--Enter the 5-position contractor number.
Lines 8 and 9.--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 HHA CMS certification number (CCN). A final cost
report is a terminating cost report for a particular HHA CCN.
Line 10.--Enter the Notice of Program Reimbursement (NPR) date (mm/dd/yyyy). The NPR date
must be present if the cost report status code is 2, 3, or 4.
Rev. 1
47-7
4704.2
FORM CMS-1728-20
09-20
Line 11.--Enter the software vendor code of the cost report software used by the contractor to
process this HCRIS cost report file; use “3” for HFS CompuMax or “4” for HFS MCRIF32.
Line 12.--Complete this line only if the cost report status code on line 5 is “4”. If this is a reopened
cost report (response to line 5 cost report status, is “4”), enter the number of times the cost report
has been reopened.
4704.2 Part II - Certification.--This certification is read, prepared, and signed by a Chief
Financial Officer or administrator of the HHA after the cost report has been completed in its
entirety.
LINE DESCRIPTIONS
Line 1.--The signatory (administrator or Chief Financial Officer) must:
• sign in column 1 as provided in 42 CFR 413.24(f)(4)(iv)(C)(1); and enter Y in column 2
to check the electronic signature checkbox to transmit the HHA cost report electronically
with an electronic signature; or
• sign in column 1 as provided in 42 CFR 413.24(f)(4)(iv)(C)(1); and enter Y in column 2
to check the electronic signature checkbox to submit the HHA 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 HHA cost report with an original signature.
Lines 2, 3, and 4.--Enter the signatory name, the signatory title, and the date signed, respectively.
4704.3 Part III - Settlement Summary.--Enter the balance due to or due from the Medicare
program. Transfer the amount from Worksheet D, line 38, to line 1, column 1.
47-8
Rev. 1
09-20
FORM CMS-1728-20
4705
4705. WORKSHEET S-2, PART I - IDENTIFICATION DATA
The information required on this worksheet is needed to properly identify the provider.
Lines 1 and 2.--Enter the street address, post office box (if applicable), the city, state, and ZIP code
of the HHA.
Line 3.--Enter the HHA component name, CCN, and certification date in the appropriate columns.
Line 4.--Enter the component name, CCN, and certification date for the distinct part hospice, an
HHA-based and separately certified component of the HHA, that meets the requirements
of §1861(dd) of the Act. If you have more than one HHA-based hospice, subscript this line and
report the required information for each hospice.
Line 5.--Enter the inclusive dates covered by this cost report. Enter in column 1, the cost report
beginning date and enter in column 2, the cost report ending date.
Line 6.--Indicate the type of control under which the HHA operates by entering a number from the
list below.
1
2
3
4
5
6
7
= Voluntary Nonprofit, Church
= Voluntary Nonprofit, Other
= Proprietary, Individual
= Proprietary, Partnership
= Proprietary, Corporation
= Private Non-Profit
= Governmental and Private Combined
8
9
10
11
12
13
= Governmental, Federal
= Governmental, State
= Governmental, City
= Governmental, City-County
= Governmental, County
= Governmental, Health District
•
Combined Governmental and Private.--This is an HHA administered jointly by a private
organization and a governmental agency, supported by tax funds, public funds, earnings,
and contributions, which provides nursing and therapeutic services.
•
Governmental Agency.--This is an HHA administered by a state, county, city, or other
local unit of government and having as a major responsibility prevention of disease and
community education. It must offer nursing care of the sick in their homes.
•
Voluntary Non-Profit.--This is an HHA governed by a community-based board of directors
and is usually financed by earnings and contributions. The primary function is the care of
the sick in their homes. Some voluntary agencies are operated under church auspices.
•
Private Not-for-Profit.--This is a privately developed HHA governed as a non-profit
organization that provides care of the sick in the home. This agency must qualify as a taxexempt organization under title 26 USC 501 of the Internal Revenue Code.
•
Proprietary Organization.--This is an HHA that is owned and operated by nongovernmental interests and is not a non-profit organization.
Rev. 1
47-9
4705 (Cont.)
FORM CMS-1728-20
09-20
Line 7.--Did the HHA qualify as a nominal charge provider (as explained in 42 CFR 409.3)? Enter
“Y” for yes or "N" for no.
Line 8.--Did the HHA contract with outside suppliers for physical therapy services? Enter “Y” for
yes or “N” for no.
Line 9.--Did the HHA contract with outside suppliers for occupational therapy services? Enter
“Y” for yes or “N” for no.
Line 10.--Did the HHA contract with outside suppliers for speech-language pathology services?
Enter “Y” for yes or “N” for no.
Line 11.--Are there any costs included on Worksheet A that resulted from transactions with a
related organization as defined in CMS Pub. 15-1, chapter 10, or home office and/or chain
organization (HO/CO) as defined in CMS Pub. 15-1, chapter 21? Enter “Y” for yes or “N” for no.
If yes, complete Worksheet A-8-1.
Line 12.--Is the HHA legally required to carry malpractice insurance? Enter “Y” for yes and “N”
for no.
Line 13.--If line 12 is yes, is the malpractice insurance a claims-made or occurrence policy?
Enter “1” for claims made or “2” for 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.
Line 14.--Enter the amount of malpractice insurance premiums paid in column 1, the total amount
of paid losses in column 2, and the total amount of self-insurance in column 3.
Malpractice insurance premiums are money paid by the provider to a commercial insurer to protect
the HHA against potential negligence claims made by their patients/clients. Malpractice paid
losses is money paid by the HHA to compensate a patient/client for professional negligence.
Malpractice self-insurance is money paid by the HHA where the HHA acts as its own insurance
company (either as a sole or part-owner) to financially protect itself against professional
negligence. Often HHAs will manage their own funds or purchase a policy referred to as captive
insurance, which provides insurance coverage they need but could not obtain economically
through the mainstream insurance market.
47-10
Rev. 1
09-20
FORM CMS-1728-20
4705 (Cont.)
Line 15.--Are malpractice premiums and/or paid losses reported in a cost center other than the
A&G cost center? Enter “Y” for yes or “N” for no. If yes, submit a supporting schedule listing
the cost centers and amounts contained therein.
Line 16.--If this HHA was part of a HO/CO as defined in CMS Pub. 15-1, chapter 21, §2150, and
received allocations of cost from the HO/CO (or from multiple HO/COs, such as from a corporate
home office and one or more regional or district offices), enter “Y” for yes in column 1; otherwise,
enter “N” for no. If column 1 is “Y”, in column 2 enter the number of HO/COs from which the
HHA received allocations of cost.
Line 17.--If line 16, column 1, is “Y” and line 16, column 2, is “1”, enter the name of the HO/CO
that allocated HO/CO costs to the HHA (column 1); the HO/CO CCN (column 2); the HO/CO
contractor number (column 3); and the HO/CO street address, city, state, and ZIP code (columns 4,
5, 6, and 7, respectively). If line 16, column 1, is “Y” and line 16, column 2, is greater than 1 (the
HHA received allocations of cost from multiple HO/COs), enter the HO/CO name (column 1);
HO/CO CCN (column 2); HO/CO contractor number (column 3); and the street address, city, state,
and ZIP code (columns 4, 5, 6, and 7, respectively); for each HO/CO that allocated HO/CO costs
to the HHA, beginning on line 17 and subscripting as necessary.
Rev. 1
47-11
4706
4706.
FORM CMS-1728-20
09-20
WORKSHEET S-2, PART II - REIMBURSEMENT DATA
This worksheet collects organizational, financial and statistical information previously reported on
Form CMS-339.
Where instructions for this worksheet direct the HHA to submit
documentation/information, mail or otherwise transmit the requested documentation to the
contractor with submission of the electronic cost report (ECR), the contractor has the right under
§§1815(a) and 1833(e) of the Act to request any missing documentation.
For questions that require a yes or no response, enter a “Y” or “N,” respectively. When the
instructions require documentation, indicate on the documentation the Worksheet S-2, Part II, line
number that the documentation supports. Lines 1 through 17 are required to be completed by all
HHAs reported on Worksheet S-2, Part I, line 3.
Line 1.--Did the HHA change ownership prior to the beginning of this cost reporting period? Enter
“Y” or “N” 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.--Did the HHA terminate participation in the Medicare program? Entering “Y” or “N” 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.--Was the HHA involved in business transactions, including management contracts, with
individuals or entities (e.g., HO/COs, drug or medical supply companies) that are related to the
HHA 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” or “N” in
column 1. If column 1 is “Y,” submit a list of the individuals, the organizations involved, and a
description of the transactions with the cost report.
NOTE for line 3: 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.)
Line 4.--Were the HHA’s financial statements prepared by a certified public accountant? Enter
“Y” or “N.” If column 1 is “Y,” enter in column 2 “A” for audited, “C” for compiled, or “R” for
reviewed. 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 column 1 is “N,” submit a copy of the internally prepared financial statements, and written
statements of significant accounting policy and procedure changes affecting Medicare
reimbursement that occurred during the cost reporting period. You may submit the changed
accounting or administrative procedures manual in lieu of written statements.
Line 5.--Do the total expenses and total revenues reported on the cost report differ from those on
the filed financial statements? Enter “Y” or “N.” If “Y,” a reconciliation must be submitted with
the cost report.
Line 6.--Are you are seeking reimbursement for bad debts resulting from Medicare deductible
and/or coinsurance amounts that are uncollectible from Medicare beneficiaries? (See
42 CFR 413.89(e) and CMS Pub. 15-1, chapter 3, §§306-324, for the criteria for an allowable bad
debt.) Enter “Y” or “N”. If “Y,” submit a completed Exhibit 1 to support the bad debt amount
claimed.
47-12
Rev. 1
09-20
FORM CMS-1728-20
4706 (Cont.)
Exhibit 1, Listing of Medicare Bad Debts and Appropriate Supporting Data, displayed at the end
of this section requires the following documentation:
Columns 1, 2, 3, 4, and 5 - Patient Last Name, Patient First Name, Medicare Beneficiary Identifier
(MBI) 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, MBI number, and dates of
service that correlate to the claimed bad debt. (See CMS Pub. 15-1, chapter 3, §314, and
42 CFR 413.89.)
Columns 6 and 7 - Eligible Medicaid Beneficiary or Beneficiary Deemed Indigent.--If the
beneficiary included in column 1 is eligible for Medicaid, enter the Medicaid beneficiary
identification number in column 6. If the beneficiary is not eligible for Medicaid but has been
deemed indigent, enter “yes” in column 7.
See the criteria in CMS Pub. 15-1,
chapter 3, §§312 and 322, and 42 CFR 413.89 for guidance on the billing requirements for
indigent and Medicaid beneficiaries.
Column 8 - Medicare Remittance Advice Dates.--Enter the Medicare remittance advice date that
correlates with the beneficiary name, MBI number, and dates of service shown in columns 1, 2, 3,
4, and 5, of this exhibit.
Column 9 - Medicaid Remittance Advice Dates (if applicable).--Enter the crossover Medicaid
remittance advice date that correlates with the Medicare beneficiary name, MBI number, and dates
of service shown in columns 1, 2, 3, 4, and 5, of this exhibit.
Column 10 - Beneficiary Responsibility.--Enter the amount the beneficiary is liable to pay. If the
beneficiary is Medicaid eligible or deemed indigent by the provider, enter the dollar amount the
beneficiary is deemed responsible to pay. For beneficiaries deemed indigent the application and
documentation to support the indigent determination will be required to support the bad debts. For
Medicaid eligible crossover claims, if there is a state cost sharing responsibility enter the amount.
If the Medicaid eligible crossover claim is for a QMB, they are exempt from any Medicare cost
sharing requirement; therefore, do not enter an amount but enter “QMB.”
Column 11 - Date First Bill Sent to Beneficiary.--Enter the date that the first bill was sent to the
beneficiary.
Column 12 - Accounts Receivable Write-Off Date.--Enter the date the beneficiary’s liability was
written off of the accounts receivable in the provider's financial accounting system. This should
be evidenced by corresponding journal entries, as well as entries in the beneficiary's account
history. However, this may not be the date the account was recorded as a Medicare bad debt. A
bad debt cannot be claimed for Medicare purposes until it has been written off in the provider's
financial accounting system and all collection efforts have ceased. If an account was sent to a
collection agency, complete column 13.
Column 13 - Account Sent to Collection Agency.--Enter a response of “Y” for yes or “N” for no
to indicate whether an account was sent to a collection agency.
Column 14 - Date Account Returned from Collection Agency.--Enter the date the account was
returned to the provider from the collection agency. This is the date that the collection agency
ceased collection effort on an account that had been referred to them. A bad debt must not be
written off prior to the cessation of all collection efforts, internal and external.
Rev. 1
47-13
4706 (Cont.)
FORM CMS-1728-20
09-20
Column 15 - Date Collection Effort Ceased.--Enter the date all collection effort ceased, both
internal and external, including Medicaid.
Column 16 - Medicare Write-Off Date.--Enter the date the deductible and coinsurance amounts
were written off as a Medicare bad debt. In order to be considered "written off" for Medicare
purposes, the amount must be written off as a bad debt in the provider's own accounting system,
all collection effort against the patient or other third parties (internal and external) must have
ceased, and a valid Medicaid RA must have been received from the State for Medicaid
beneficiaries.
Column 17 - Recoveries.--Enter the amount of recoveries for amounts previously written off as an
allowable Medicare bad debt (see CMS Pub. 15-1, chapter 3, §316).
Columns 18 and 19 - Deductibles and Coinsurance.--Enter the beneficiary’s deductible and
coinsurance amounts, reflected on the Medicare remittance advice, that relate to covered services.
Column 20 - Current Year Payments.--Enter any payments received from the beneficiary, the
beneficiary’s estate, third party insurance, etc. that were applied towards the beneficiary’s
deductible and coinsurance liability.
Column 21 - Payment Type.--If column 20 contains an amount, identify the source of the payment
in this column. Enter a general description of beneficiary, estate, third party, etc.
Column 22 - Allowable Medicare Bad Debts.--Enter the bad debt amount for each claim. This
amount must be less than or equal to the amounts report in columns 18 and 19, less any payments
received from the beneficiary. This total amount reported in this column must agree with the bad
debts claimed on Worksheet D, line 27.
Column 23 - Comments.--This column is for informational purposes. Enter any comments or
additional information as needed.
Line 7.--If line 6 is “Y”, did the bad debt collection policy change during the cost reporting period?
Enter “Y” or “N”. If “Y”, submit a copy of the revised bad debt policy.
Line 8.--If line 6 is “Y”, were patient coinsurance amounts waived? Enter “Y” or “N” in column 1.
If column 1 is “Y”, ensure the coinsurance amounts are not included on the bad debt listing
(Exhibit 1) submitted with the cost report.
Line 9.--Was this cost report prepared using the Provider Statistical & Reimbursement (PS&R)
Report only. Enter “Y” or “N” in column 1. If column 1 is “Y”, enter the paid through date of the
PS&R in column 2. 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 10.--Was this cost report prepared using the PS&R for totals and HHA records for allocation?
Enter “Y” or “N” in column 1. If column 1 is “Y” enter the paid-through date of the PS&R used
to prepare this cost report in column 2. 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 the revenue codes 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 work papers 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.
47-14
Rev. 1
09-20
FORM CMS-1728-20
4706 (Cont.)
Line 11.--If you entered “Y” on either line 9 or 10, 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” or “N” in column 1. If column 1 is “Y”, include a schedule supporting
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 12.--If you entered “Y” on either line 9 or 10, column 1, indicate whether adjustments were
made to the PS&R data for corrections of other PS&R information. Enter “Y” or “N” in column 1.
If column 1 is “Y”, submit a detailed explanation and documentation to provide an audit trail from
the PS&R to the cost report.
Line 13.--If you entered “Y” on either line 9 or 10, column 1, indicate whether other adjustments
were made to the PS&R data. Enter “Y” or “N” in column 1. If column 1 is “Y”, include a
description of the other adjustments and documentation to provide an audit trail from the PS&R to
the cost report.
Line 14.--Indicate whether the cost report was prepared using HHA records only. Enter “Y” or
“N” in column 1. If column 1 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.
The minimum requirements for detailed documentation of the system used to submit the data
reported are:
•
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 report.
•
A reconciliation of remittance totals to the provider’s internal records.
•
The name of the system used and system maintainer (vendor or HHA). If the HHA
maintained the system, include date of last software update.
NOTE for line 14: Additional information may be submitted, such as narrative documentation,
internal flow charts, or outside vendor informational material, to further describe and
validate the reliability of the system.
Line 15.--Enter the cost report preparer’s first name, last name, and title/position, in columns 1, 2,
and 3, respectively.
Line 16.--Enter the employer/company name of the cost report preparer.
Line 17.--Enter the telephone number and email address of the cost report preparer in columns 1
and 2, respectively.
Rev. 1
47-15
4706 (Cont.)
FORM CMS-1728-20
09-20
EXHIBIT 1
LISTING OF MEDICARE BAD DEBTS AND APPROPRIATE SUPPORTING DATA
HHA Name:
HHA CCN:
FYE:
Patient
Last Name
1
Prepared By:
Date Prepared:
Patient
First Name
2
Date Account
Returned from
Collection
Agency (If
Applicable)
14
MBI No.
3
Date Collection
Efforts Ceased
(Internal and
External,
Including
Medicaid RA)
15
Dates of
Service
From
To
4
5
Medicare
“Write-Off
Date”
16
Eligible
Medicaid
Beneficiary
Medicaid #
6
Recoveries
Only
17
Beneficiary
Deemed
Indigent (Not
Medicaid
Eligible)
Yes or No
7
Medicare
Deductible*
18
Medicare
Remittance
Advice
Dates
8
Medicaid
Remittance
Advice
Dates (If
Applicable)
9
Beneficiary
Responsibility $
(Enter QMB if
Medicaid QMB
Beneficiary)
10
Date First
Bill Sent to
Beneficiary
11
Medicare
Coinsurance*
19
Current
Year
Payments
(Prior to
Account
Write-Off)
20
Payment Type
(Patient, Third
Party
Insurance,
etc.)
21
Allowable Bad
Debts (As
Reported on
Cost Report)
22
Internal
Accounts
Receivable
(A/R)
Write-Off
Date)
12
Account
Sent to
Collection
Agency
13
Comments
23
*These amounts must not be claimed unless the HHA or HHA-based entity bills for these services with the intention of payment.
See instructions for columns 6 and 7 - Medicaid or Indigent Beneficiary, for possible exception.
47-16
Rev. 1
09-20
4707.
FORM CMS-1728-20
4707
WORKSHEET S-3 - STATISTICAL DATA
Worksheet S-3 consists of the following five parts:
Part I Part II Part III Part IV Part V -
Visits Data
Employment Data (Full Time Equivalent)
Core Based Statistical Area (CBSA) Data
PPS Activity Data
Direct Care Expenditures
In accordance with 42 CFR 413.20 and 42 CFR 413.24, you are required to maintain statistical
records for proper determination of costs payable under titles XVIII and XIX. The statistics
required on Part I of this worksheet pertain to an HHA. The data to be maintained, depending on
the services provided by the HHA, includes the number of program visits, total number of HHA
visits, number of program home health aide hours, total HHA home health aide hours, program
patient census count, total patient census count, program patient unduplicated census count, and
total patient unduplicated census count. Part II of this worksheet collects required FTE data by
employee staff, contracted staff, and total staff. Part III of this worksheet identifies the total
number of CBSAs where Medicare services were provided.
HHA Visits.--A visit is an episode of personal contact with the patient by staff of the HHA, or
others under arrangements with the HHA, for the purpose of providing a covered home health
service as described in 42 CFR 409.45(b) through (g). Medicare type visits generally fall under
the definition of Medicare visits as described in 42 CFR 409.48. In counting Medicare type visits,
it is critical that non-Medicare visits are of the same type as those that would be covered by
Medicare. This ensures that costs of services are comparable across insurers and that costs are
apportioned appropriately between Medicare and non-Medicare. A visit is initiated with the
delivery of covered home health services and ends at the conclusion of delivery of covered home
health services. In those circumstances in which all reasonable and necessary home health services
cannot be provided in the course of a single visit, HHA staff or others providing services under
arrangements with the HHA may remain at the patient's home between visits (e.g., to provide noncovered services). However, if all covered services could be provided in the course of one visit,
only one visit may be covered. (See 42 CFR 409.48(c)(4)).
Patient Census.--Each patient is counted once for each type of service. For example, if a patient
receives multiple Medicare covered skilled nursing visits from a registered nurse and multiple
Medicare covered medical social service visits, he or she is counted only once in column 2 for the
corresponding service. Another example is if a patient receives both covered services and noncovered services, he or she is counted once as title XVIII (for covered services), once as other (for
non-covered services), and only once as total.
Unduplicated Census Count.--Each patient is counted only once, no matter how many HHA
services they receive during the cost reporting period. A patient who receives HHA services
throughout the year should be counted and reported no more than one time. The unduplicated
census count answers the question: How many patients did the HHA serve during this cost
reporting period?
Rev. 1
47-17
4707.1
FORM CMS-1728-20
09-20
On lines 1 through 10, report the number of visits and corresponding patient census count. The
patient census count in columns 2, 4, 6, and 8, includes each individual who received each type of
service. Include each individual patient only once for each type of service. For example, a patient
who received multiple Medicare covered skilled nursing visits from a registered nurse and multiple
Medicare covered medical social service visits is counted only once in column 2 for the
corresponding service. The total of lines 1 through 9 for columns 2 and 4, and the total of lines 1
through 10, for columns 6 and 8, may not equal line 13, unduplicated census count, since many
patients receive more than one type of service. Beneficiaries who experience multiple spells of
illnesses (multiple visits, multiple episodes, and/or multiple discharges and admissions) within a
cost reporting period must be counted only once in the unduplicated census count.
4707.1
Part I - Visits Data.--
Columns 1 and 2.--Enter data pertaining to title XVIII-Medicare patients only. Enter in column 1
all Medicare visits rendered during the entire cost reporting period. See CMS Pub. 100-02,
chapter 7, §70.2, for visit count determination. For each line, enter in column 2 the patient census
count applicable to the Medicare visits reported in column 1.
Columns 3 and 4.--Enter data pertaining to title XIX-Medicaid patients only. Enter in column 3
all Medicaid visits rendered during the entire cost reporting period. For each line, enter in
column 4 the patient census count applicable to the Medicaid visits reported in column 3.
Columns 5 and 6.--Enter data pertaining to Medicare Managed Care, Medicaid Managed Care, and
all other patients. Do not include data reported in columns 1 through 4. Enter in column 5 all
visits from patients not covered by Medicare (reported in column 1) or Medicaid (reported in
column 3). For each line, enter in column 6 the patient census count applicable to all other patient
visits reported in column 5.
Columns 7 and 8.--Enter total HHA visits and patient census count. Enter in column 7, all visits
rendered for all patients during the cost reporting period for each discipline. For each line, enter
in column 8, the patient census count for all patients during the cost reporting period. The sum of
columns 1, 3, and 5, must equal column 7. The sum of columns 2, 4, and 6, may not equal
column 8. For example, if a patient receives both Medicare covered services (columns 1 and 2)
and Medicare non-covered services (columns 5 and 6), count the patient once in column 2 (for
covered services), once in column 6 (for non-covered services), and once in column 8, total.
Lines 1 through 9.--These lines identify the type of home health services rendered to patients. The
entries reflect the number of visits furnished and the number of patients receiving a particular type
of service.
Line 10.--This line may not be used for columns 1 through 4. Enter in columns 5 and 7 the total
of all other visits provided by the HHA. Enter in columns 6 and 8 the patient census count
applicable to the other visits furnished by the HHA.
Line 11.--Enter the sum of lines 1 through 9 for each of columns 1 and 3. Enter the sum of lines 1
through 10 for each of columns 5 and 7.
Line 12.--Enter the number of hours applicable to home health aide services.
47-18
Rev. 1
09-20
FORM CMS-1728-20
4707.3
Line 13.--Enter the unduplicated count of all patients receiving home visits or other care provided
by employees of the HHA or under contractual arrangement in the appropriate column for the
entire cost 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 may not equal
the sum of the title XVIII and all other patient census counts. For purposes of calculating the
unduplicated census count, if a beneficiary has received health care by more than one HHA, you
must prorate the unduplicated census count based on the ratio of visits provided by this HHA to
the total visits furnished to the beneficiary by all HHAs so as to not exceed a total of one (1). For
example, if an HHA furnishes 100 visits to an individual beneficiary in Maryland during the cost
reporting period and the same individual received a total of 400 visits (the other 300 visits were
furnished in Florida during the cost reporting period), the reporting HHA would count the
beneficiary as a .25 (100 divided by 400) in the unduplicated census count for Medicare patients
for the cost reporting period. Round the result to two decimal places, e.g., .2543 is rounded to .25.
An HHA must query the beneficiary to determine if he or she has received health care from another
provider during the year, i.e., Maryland versus Florida for beneficiaries with seasonal residence.
4707.2
Part II - Employment Data (Full Time Equivalent).--
Line 14.--Enter the number of hours in a normal work week (i.e., 40 hours per week or 35 hours
per week).
Lines 15 through 33.--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 15
through 32. Enter any additional categories needed on line 33 and its subscripts.
Report in column 1 the full time equivalent (FTE) employees on the HHA’s payroll. These are
staff for which an Internal Revenue Service (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: For each category listed on lines 15 through 33, add
all hours that 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. For each category
listed on lines 15 through 33, add all hours that 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.
4707.3
Part III - Core Based Statistical Area (CBSA) Data.--
Line 34.--Enter the total number of CBSAs where Medicare covered services were provided
during this cost reporting period. Each five-character CBSA code identifies the geographic area
where Medicare covered services are furnished. Obtain these codes from your contractor.
Line 35.--List all CBSA codes where Medicare covered home health services were provided
during the cost reporting period. Line 35 contains the first code. Enter one CBSA code on each
line. If additional lines are needed, subscript line 35 beginning with lines 35.01, 35.02, etc., as
necessary, entering one CBSA code on each subscripted line. Obtain these codes from your
contractor.
Rev. 1
47-19
4707.4
4707.4
FORM CMS-1728-20
09-20
Part IV - PPS Activity Data.--
The statistics required on this worksheet pertain to home health services reimbursed under the
HHA PPS in accordance with §1895 of the Act. Depending on the services provided by the HHA
the data to be maintained for each episode/period of care payment category for each covered
discipline include aggregate program visits, corresponding aggregate program charges, total visits,
total charges, total episodes/period and total outlier episodes/periods, and total non-routine medical
supply charges.
All data captured in Part IV of this worksheet is associated with episodes/periods of care that end
during the current cost reporting period for payment purposes. Similarly, when an episode/period
of care begins in one cost reporting period and ends in the subsequent cost reporting period, all
data required in Part IV of this worksheet associated with that episode/period will appear in the
cost reporting period on the PS&R in which the episode/period of care ended.
HHA Visits. See the second paragraph of §4707 for the definition of an HHA visit.
Episode/Period of Care. Home health services under a plan of care are paid based on a 60-day
episode of care (beginning on or before December 31, 2019) or a 30-day period of care (beginning
on or after January 1, 2020) as required by section 1895(b)(2)(B) of the Act, as amended by
section 51001(a)(1) of the Bipartisan Budget Act (BBA) of 2018.
Episode of Care: Effective prior to January 1, 2020, under home health PPS, the 60-day episode
is the basic unit of payment where the episode payment is specific to one individual beneficiary.
The duration of a full-length episode will be 60 days. An episode begins with the start of care date
on or prior to December 31, 2019, and must end by the 60th day from the start of care date.
Beneficiaries are covered for an unlimited number of non-overlapping episodes provided that the
start of care date is prior to January 1, 2020. Note: The latest a full 60-day episode that spans the
crossover date effectuating the change to period of care on January 1, 2020, will end on
February 28, 2020.
Period of Care: Effective beginning on or after January 1, 2020, under home health PPS, the
30-day period of care is the basic unit of payment where the period payment is specific to one
individual beneficiary. A period begins with the start of care date on or after January 1, 2020 and
must end by the 30th day from the start of care. Beneficiaries are covered for an unlimited number
of non-overlapping periods.
47-20
Rev. 1
09-20
FORM CMS-1728-20
4707.4 (Cont.)
Less than a full Episode/Period of Care.
For episodes of care beginning before January 1, 2020, if an HHA provides four or fewer
visits in a 60-day episode, the result is a low utilization payment adjustment (LUPA). In
this instance the HHA will be reimbursed based on a standardized per visit payment.
Additionally, 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.
For periods of care beginning on or after January 1, 2020, if an HHA provides fewer than
the threshold of visits specified for the period’s home health resources group, they will be
paid a standardized per visit payment called a LUPA.
Additionally, a period may end before the 30th 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.
On lines 1 through 12, report the number of visits and the corresponding visit charges for each
discipline for each episode/period payment category. Lines 13 and 15 identify the total number of
visits and the total corresponding charges, respectively, for each episode/period payment category.
Line 16 identifies the total number of episodes/periods completed for each episode/period payment
category. Line 17 identifies the total number of outlier episodes/periods completed for each
episode/period payment category.
Outlier episodes/periods do not apply to: 1) Full
Episodes/Periods without Outliers, and 2) LUPA Episodes/Periods. Line 18 identifies the total
non-routine medical supply charges incurred for each episode/period payment category. The
statistics and data required on this worksheet are obtained from the PS&R report.
Columns 1 through 4.--Enter in the appropriate columns 1 through 4, lines 1 through 12, the
number of aggregate program visits furnished in each episode/period of care payment category for
each covered discipline and the corresponding aggregate program visit charges imposed for each
covered discipline for each episode/period of care payment category. The visit counts and
corresponding charge data are mutually exclusive for all episode/period of care payment
categories.
Line 13.--Enter in columns 1 through 4 for each episode/period of care payment category,
respectively, the sum total of visit from lines 1, 3, 5, 7, 9, and 11.
Line 14.--Enter in columns 1 through 4 for each episode/period of care payment category,
respectively, the sum total of other charges for all other unspecified services reimbursed under
PPS.
Line 15.--Enter in columns 1 through 4 for each episode/period of care payment category,
respectively, the sum total of charges for services from lines 2, 4, 6, 8, 10, 12, and 14.
NOTE for lines 16 and 17: The standard episodes/periods entered on line 16 and outlier
episodes/periods entered on line 17 are mutually exclusive.
Line 16.--Enter in columns 1, 3, and 4, for each episode/period of care payment category
identified, respectively, the total number of standard episodes/periods of care rendered and
concluded in the HHA’s fiscal year.
Rev. 1
47-21
4707.5
FORM CMS-1728-20
09-20
Line 17.--Enter in columns 2 and 4 for each episode/period of care payment category identified,
respectively, the total number of outlier episodes/periods of care rendered and concluded in the
HHA’s fiscal year. Outlier episodes/periods do not apply to columns 1 and 3 (Full
Episodes/Periods without Outliers and LUPA Episodes/Periods, respectively).
Line 18.--Enter in columns 1 through 4 for each episode/period of care payment category,
respectively, the total non-routine medical supply charges for services rendered and concluded in
the provider’s fiscal year.
Column 5.--Enter on lines 1 through 18, respectively, the sum total of amounts from columns 1
through 4.
4707.5 Part V - Direct Care Expenditures.--This part provides for the collection of HHA direct
care expenditures. Report only the costs associated with Medicare and Medicare like visits in
reimbursable cost centers. Complete this form for employees who are full-time and part-time,
directly hired, and acquired under contract.
Column 1.--Enter the total of paid wages and salaries for the specified category of HHA employees
including overtime, vacation, holiday, sick, lunch, and other paid-time-off, severance, and bonuses
on lines 1 through 3, and lines 5 through 12. Enter on line 13, any HHA direct care expenditures
for clinicians not identified on lines 1 through 12.
Enter the amount paid (include only those costs attributable to services rendered in the HHA),
rounded to the nearest dollar, for contracted direct patient care services on lines 14 through 16,
and lines 18 through 25. Enter on line 26, any HHA contracted direct care expenditures for
clinicians not identified on lines 14 through 25.
Column 2.--Enter on lines 1 through 3, and lines 5 through 13, the amount of fringe benefits.
Column 3.--Enter on each line the result of column 1 plus column 2.
Column 4.--Enter on each line the number of paid hours corresponding to the amount reported in
column 3.
Column 5.--Enter on each line the average hourly wage resulting from dividing column 3 by
column 4.
47-22
Rev. 1
09-20
4708.
FORM CMS-1728-20
4708.1
WORKSHEET S-4 - HHA-BASED HOSPICE STATISTICAL 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 an HHA-based hospice. Complete a separate Worksheet S-4
for each HHA-based hospice.
4708.1
Part I - Enrollment Days.--
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.--An HCHC day is a day when 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.--An HRHC day is a day when the hospice patient is
at home and not receiving HRHC.
Hospice Inpatient Respite Care (HIRC) Day.--An HIRC day is a day when 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.--An HGIP day is a day when the hospice patient
receives care in a Medicare certified hospice facility, hospital or SNF for pain control or acute or
chronic symptom management that cannot be managed in other settings.
Lines 1 through 4.--Enter the enrollment days applicable to each level of care (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 3 only when the hospice provided or arranged to
provide the inpatient respite care.
Line 5.--Enter the total of lines 1 through 4 for columns 1 through 4.
Rev. 1
47-23
4708.2
4708.2
FORM CMS-1728-20
09-20
Part II - Contracted Statistical Data.--
This section collects unduplicated day’s data for inpatient services at a contracted facility. The
days reported in Part II are a subset of the days reported in Part I.
Lines 6 and 7.--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.
47-24
Rev. 1
09-20
4709.
FORM CMS-1728-20
WORKSHEET A - RECLASSIFICATION
BALANCE OF EXPENSES
AND
4709
ADJUSTMENT
OF
TRIAL
Worksheet A provides for recording the trial balance of expense accounts from the HHA
accounting books and records. The worksheet also provides for the necessary reclassifications and
adjustments to certain accounts prior to the cost finding calculations. Also include on
Worksheet A all expenses incurred for only those visits completed in the current cost reporting
period when the episode of care overlaps the cost report year end. Enter directly on Worksheet A
the total expenses for Salaries (column 1), Employee Benefits (column 2), Transportation
(column 3), Contracted/Purchased Services (column 4), and Other Costs (column 5) in the
appropriate cost center.
This worksheet lists cost centers in a manner that facilitates the transfer of the cost center expenses
to the cost finding worksheets. Each of the cost centers listed does not apply to all providers using
these forms. Therefore, use those cost centers applicable to your type of HHA.
Under certain conditions, a provider may elect to use different cost centers for allocation purposes.
These conditions are stated in CMS Pub. 15-1, chapter 23, §2313.
Standard (i.e., preprinted) CMS line numbers and cost center descriptions cannot be changed. If a
provider needs to use additional or different cost center descriptions, it may do so by adding
additional lines to the cost report. Added cost centers must be appropriately coded. Identify the
added line as a numeric subscript of the immediately preceding line, e.g., if two lines are added
between lines 2 and 3, identify them as lines 2.01 and 2.02. If additional lines are added for general
services cost centers, corresponding columns must be added to Worksheets B and B-1 for cost
finding.
NOTE: Cost centers appearing on Worksheet A, lines 16 through 24, may not be subscripted
beyond those which are preprinted. (See CMS Pub. 15-1, chapter 23, §2313.2c.)
Submit the working trial balance of the HHA 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.
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. The Form CMS-1728-20 provides for
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. An additional cost center with general meaning has been identified in the following
sections: General Service Cost Centers, HHA Reimbursable Services, HHA Nonreimbursable
Services and Special Purpose Cost Centers. These additional cost centers must contain a
description if used, and will hereafter be referred to as nonstandard label cost centers to provide
for situations where no match in meaning to the standard cost centers can be found. Refer to
Worksheet A, lines 9, 30, 50, and 58.
Rev. 1
47-25
4709 (Cont.)
FORM CMS-1728-20
09-20
The use of this coding methodology allows providers to continue to use labels for cost centers that
have meaning within the individual institution. The four-digit cost center codes that are associated
with each provider label in their electronic file provide standardized meaning for data analysis.
The preparer is 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 §4790, Table 5, of the electronic reporting specifications.
If the cost elements of a cost center are separately maintained on the HHA books, maintain a
reconciliation of the costs per the accounting books and records to those on this worksheet. The
reconciliation is subject to review by the contractor.
Column 1.--Salaries are the gross salaries paid to employees before taxes and other items are
withheld. Salaries include deferred compensation, overtime, incentive pay, and bonuses. Enter
salaries from the HHA accounting books and records.
Column 2.--Enter the costs of employee benefits from the HHA accounting books and records.
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
identifiable to a particular cost center, enter them on line 4.
Column 4.--Enter the cost of contracted purchased services.
Column 5.--Enter on the applicable lines in column 5 all HHA costs that have not been reported
in columns 1 through 4.
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 in column 6 that are needed
to effect proper cost allocation.
Worksheet A-6 reflects the reclassifications affecting the cost center expenses. This worksheet
need not be completed by all providers, but is completed only to the extent reclassifications are
needed and appropriate in the particular provider’s circumstances. Show reductions to expenses
in parentheses ( ).
The net total of the entries in column 7 must equal zero on line 100.
Column 8.--Adjust the amounts entered in column 6 by the amounts entered in column 7 (increase
or decrease) and extend the net balances to column 8. The total of column 8 must equal the total
of column 6 on line 100.
Column 9.--Enter on the appropriate lines the amounts of any adjustments to expenses. Enter on
the appropriate lines the amounts of any adjustments to expenses indicated on Worksheet A-8,
column 2. The amount on Worksheet A, column 9, line 100, must equal the amount on
Worksheet A-8, column 2, line 50.
Column 10.--Adjust the amounts in column 8 by the amounts in column 9 (increase or decrease)
and extend the net balances to column 10.
47-26
Rev. 1
09-20
FORM CMS-1728-20
4709 (Cont.)
Transfer the amounts in column 10, lines 1 through 58, to the corresponding lines on Worksheet B,
column 0.
Line Descriptions
General Service Cost Centers
Lines 1 and 2 - Capital Related - Buildings & Fixtures and Capital Related - Movable
Equipment.--Capital related buildings and fixtures and capital related moveable equipment costs
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 - Plant Operation & Maintenance.--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 HHA property.
Line 4 - 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 5 - Telecommunication Technology.--Enter allowable administrative costs related to
telecommunication technology, referred to as remote patient monitoring as described in
42 CFR 409.46(e). Remote patient monitoring is defined as the collection of physiologic data (for
example, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the
patient or caregiver or both to the home health agency. If remote patient monitoring is used by the
home health agency to augment the care planning process, the costs of the equipment, set-up, and
service related to this system are allowable only as administrative costs. Visits to a beneficiary's
home for the sole purpose of supplying, connecting, or training the patient on the remote patient
monitoring equipment, without the provision of a skilled service are not separately billable. Do
not report telehealth services on this line.
Line 6 - Administrative and General.--Enter all A&G costs, including services that are allowable
as administrative costs as described in 42 CFR 409.46(a) through (d). A&G costs are general
service costs that benefit the entire HHA that are not included on lines 1 through 5. Examples
include fiscal services, legal services, accounting, data processing, taxes, and malpractice costs. If
the option to componentize 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
(e.g., 6.01 A&G shared costs). See §4713 for additional information on componentized A&G
costs.
Line 7 - Nursing Administration.--Enter the cost of overall management and direction of the
nursing services. Do not include the cost of direct nursing services including nursing supervisor
services assigned on lines 16 through 30, 39 through 50, or 57 and 58.
Line 8 - Medical Records.--Enter the direct cost of medical records including the medical record
library. Costs associated with a general library and/or medical library are reported in
administrative and general and must not be included in this cost center.
Line 9.--Use this line to identify expenses for other general service costs not identified on lines 1
through 8. Provide a description for the amount reported on this line. See Table 5 in §4790 for
proper cost center coding for this line.
Lines 10 through 15.--Reserved for future use.
Rev. 1
47-27
4709 (Cont.)
FORM CMS-1728-20
09-20
HHA Reimbursable Services
Line 16 - Skilled Nursing Care - Registered Nurse.--This cost center includes skilled nursing care
which is a service that must be provided by or under the supervision of a registered nurse for the
purpose of assessing a beneficiary’s health needs, determining if the HHA can meet those health
needs, and formulating a plan of care for the beneficiary are allowable administrative costs.
Line 17 - Skilled Nursing Care - Licensed Practical Nurse.--This cost center includes the costs of
nursing care furnished by licensed practical nurses. Do not include costs for certified nursing
assistant (CNA) services on this line; report the costs for CNA services on line 24.
Line 18 - Physical Therapy.--This cost center includes the costs of physical therapy services
provided by a qualified physical therapist as prescribed by a physician. These services meet the
individual’s medical needs, promote recovery, and ensure medical safety for the purpose of
rehabilitation.
Line 19 - Physical Therapy Assistant.--This cost center includes the costs of physical therapy
assistant services performed under the direct supervision of a qualified physical therapist as
prescribed by a physician. These services are planned, delegated, and supervised by the physical
therapist. The physical therapy assistant also provides support to the physical therapist as they
assist in preparing clinical notes and progress reports, and participate in educating the patient and
family.
Line 20 - Occupational Therapy.--This cost center includes the costs of occupational therapy
services provided by a qualified occupational therapist as prescribed by a physician. These
services meet the individual’s medical needs, promote recovery, and ensure medical safety for the
purpose of rehabilitation.
Line 21 - Certified Occupational Therapy Assistant.--This cost center includes the costs of
certified occupational therapy assistant services performed under the direct supervision of a
qualified occupational therapist as prescribed by a physician. These services are planned,
delegated, and supervised by the occupational therapist. The certified occupational therapy
assistant also provides support to the occupational therapist as they assist in preparing clinical
notes and progress reports, and participate in educating the patient and family.
Line 22 - Speech-Language Pathology.--This cost center includes the costs of physicianprescribed 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 23 - Medical Social Services.--Enter the cost of medical social services. 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 HHA; (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 HHA care.
47-28
Rev. 1
04-21
FORM CMS-1728-20
4709 (Cont.)
Line 24 - Home Health Aide.--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
therapist, speech-language pathologist, 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, indicating 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. Include the cost of CNAs that meet the criteria for an aide
in this cost center.
Line 25 - Medical Supplies Charged to Patients.--The cost of medical supplies reported in this cost
center are those costs that 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 not reported on this line are those minor medical and surgical supplies not
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 26 - Drugs.--Enter the cost incurred for pneumococcal, influenza, hepatitis B vaccines and
osteoporosis drugs. 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 public health
emergency (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,
providers may only report the cost for the vaccine administration on line 27. 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. Do not include the cost of administering vaccines, drugs or monoclonal
antibodies on this line. 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(s)(10).
If the vaccine is administered in the course of an otherwise covered home health visit, the visit
would be covered as usual, but the cost and charges for the vaccine and its administration
(excluding administration of osteoporosis drugs which are covered in the PPS rate) must be
excluded from the cost and charges of the visit. The HHA would be entitled to separate payment
for the vaccine and its administration under the Part B vaccine benefit.
Line 27 - Cost of Administering Vaccines.--Enter the cost of administering pneumococcal,
influenza, and hepatitis B vaccines. Enter the cost incurred to administer the COVID-19 vaccine,
and monoclonal antibody products to treat COVID-19, authorized for use during the COVID-19
PHE. All vaccine administration costs reported on this line are reimbursed under OPPS.
Rev. 2
47-29
4709 (Cont.)
FORM CMS-1728-20
04-21
Attach a schedule detailing the methodology employed to develop the administration of these
vaccines. These vaccines are reimbursable under Part B only. 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 nonreimbursable.
Line 28 - Durable Medical Equipment/Oxygen.--Enter the direct expenses incurred in renting or
selling durable medical equipment (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.
Line 29 - Disposable Devices.--Enter the cost of disposable devices, i.e., negative pressure wound
therapy (NPWT) devices.
Line 30.--Use this line and subscripts of this line to identify expenses for other reimbursable
services not identified on lines 16 through 29. Provide a description for each amount reported on
this line and its subscripts. See Table 5 in §4790 for proper cost center coding for this line.
Lines 31 through 38.--Reserved for future use.
HHA Nonreimbursable Services
Line 39.--Enter the cost of home dialysis aide services furnished in connection with a home
dialysis program.
Line 40.--For respiratory therapy services enter the cost incurred for the assessment, diagnostic
evaluation, treatment, management, and monitoring of patients with deficiencies or abnormalities
of cardiopulmonary function.
Lines 41 through 49.--Identify additional nonreimbursable services commonly provided by
HHAs.
Line 41 - Private Duty Nursing.--Enter the costs of private duty nurses, who may be licensed as
RNs, LPNs/LVNs (Licensed Practical Nurses), or CNAs that provide private duty care work oneon-one with individual beneficiaries.
Line 42 - Clinic.--Enter the nonreimbursable clinic costs. A clinic is a facility that is primarily
focused on the care of outpatients.
Line 43 - Health Promotion Activities.--Enter the costs of health promotion and disease
prevention programs focus on keeping people healthy.
Line 44 - Day Care Program.--Adult day care programs provide frail seniors and persons with
Alzheimer's with supervision and care in a structured setting during daytime hours allowing their
primary caregivers to work or take a break from their caregiving responsibilities. Medicare does
not cover adult day care programs.
47-30
Rev. 2
04-21
FORM CMS-1728-20
4709 (Cont.)
Line 45 - Home Delivered Meals Program.--Home health coverage does not include home
delivered meals or personal care as part of its coverage. Enter the costs of the HHA’s home
delivered meals program on this line.
Line 46 - Homemaker Service.--Services such as shopping, cleaning, laundry, etc. are considered
homemaker services and they are not reimbursed by Medicare. Enter the costs of homemaker
services on this line.
Line 47 - Telehealth.--Enter the direct costs associated with telehealth. Telecommunication
technology is considered remote patient monitoring and not a telehealth service. Telehealth
services are subject to limitations under §1834(m) of the Act, namely that the beneficiary must be
located in a health professional shortage area (HPSA) or rural area, and that the beneficiary must
be physically present at a specific site of service. Telehealth services performed by a
physician/practitioner under §1834(m) of the Act are outside the scope of the Medicare home
health benefit and home health PPS.
Line 48 - Advertising.--Enter the costs associated with nonallowable community education,
business development, marketing and advertising. (See CMS Pub. 15-1, chapter 21, §2136.)
Line 49 - Fundraising.--Enter the costs associated with nonallowable fundraising. (See
CMS Pub. 15-1, chapter 21, §2136.)
Line 50.--Use this line and subscripts of this line to identify expenses for other nonreimbursable
services not identified on lines 39 through 49. Provide a description for each amount reported on
this line and its subscripts. See Table 5 in §4790 for proper cost center coding for this line.
Lines 51 through 56.--Reserved for future use.
Special Purpose Cost Centers
Line 57 - Hospice.--Enter the direct costs associated with the HHA-based hospice. Do not include
shared service costs on this line. Likewise, if there are general service costs unique to the hospice
and not related to the HHA, report those direct costs on this line and separately identify them on
Worksheet O.
Line 58.--Use this line and subscripts of this line to identify expenses for all other special purpose
cost centers not identified on line 57. Provide a description for each amount reported on this line
and its subscripts. See Table 5 in §4790 for the proper cost center coding for this line.
Lines 59 through 99.--Reserved for future use.
Line 100.--Enter the total of lines 1 through 58.
Rev. 2
47-31
4710
4710.
FORM CMS-1728-20
04-21
WORKSHEET A-6 - RECLASSIFICATIONS
This worksheet provides for the reclassification of expense accounts to effect proper cost allocation
under cost finding. Submit copies of any workpapers used to compute reclassification affected on
this worksheet.
COMPLETE WORKSHEET A-6 ONLY TO THE EXTENT THAT EXPENSES HAVE BEEN
INCLUDED IN COST CENTERS THAT DIFFER FROM THE RESULT THAT IS OBTAINED
USING THE INSTRUCTIONS FOR THIS SECTION.
Examples of reclassifications that may be needed are:
A. Licenses and Taxes (Other Than Income Taxes).--This expense consists of the
business license expense and tax expense incidental to the operation of the HHA. Such expenses
are normally included in the A&G cost centers.
Licenses and taxes applicable to buildings and fixtures must be reclassified to the capital related buildings and fixtures account (Worksheet A, line 1). Any licenses and taxes that cannot be
identified to a specific cost center and are incidental to the general overall operation of the HHA
must be included in the A&G account (Worksheet A, line 6).
B. Interest.--Interest expense related to loans for HHA working capital is includable in
A&G (Worksheet A, line 6). Interest expense attributable to mortgages on buildings is includable
in Capital Related - Buildings and Fixtures (Worksheet A, line 1). Interest related to loans for
movable equipment is includable in Capital Related - Movable Equipment (Worksheet A, line 2).
C. Insurance.--Malpractice insurance may be reclassified to cost centers, other than A&G,
only if the insurance policy specifically identifies the premium for each cost center involved.
D. Services Under Arrangements.--Where a provider purchases services (e.g., physical
therapy) under arrangements for Medicare patients, but does not purchase such services under
arrangements for non-Medicare patients, the providers’ books reflect only the cost of the Medicare
services. However, if the provider does not use the grossing up technique for purposes of
allocating overhead, and if the provider incurs related direct costs applicable to all patients,
Medicare and non-Medicare (e.g., paramedics or aides who assist a physical therapist in
performing physical therapy services), reclassify such related costs from the HHA reimbursable
service cost center and allocate them as part of administrative and general expense.
E. Leases.--This expense consists of all rental costs of buildings and equipment incidental
to the operation of the HHA. Leases applicable to buildings or movable equipment must be
reclassified to the capital related account. Any lease which cannot be identified to a special cost
center and is incidental to the general overall operation of the HHA must be included in the A&G
account (Worksheet A, line 6).
47-32
Rev. 2
09-20
4711.
FORM CMS-1728-20
4711
WORKSHEET A-8 - ADJUSTMENTS TO EXPENSES
In accordance with 42 CFR 413.9(c)(3), if the HHA operating costs include amounts not related
to patient care, these amounts are not reimbursable under the program. If 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.
This worksheet provides for the adjustments to the expenses listed on Worksheet A, column 8.
These adjustments, which are required under the Medicare principles of reimbursement, are to be
made on the basis of cost or amount received (revenue) only if the costs (including direct costs 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, “B” for amount received. Line descriptions indicate the more common activities affecting
allowable costs or result in costs incurred for reasons other than patient care and, thus, require
adjustments.
Types of items entered on Worksheet A-8 are: (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 this worksheet.
Line Descriptions
Columns 2, 3, and 4.--For each adjustment, enter the amount in column 2, enter the Worksheet A
cost center line number reference in column 4, and enter the corresponding cost center description
in column 3.
Line 1.--Enter funds received from miscellaneous sources not specifically listed on this schedule.
Line 4.--Enter the amount from Worksheet A-8-1, Part I, column 8, line 50. The amount from
Worksheet A-8-1, Part I, lines 1 through 49, represent the detail of the various cost centers for
related party and HO/CO costs that were allocated to the HHA and may or may not already be
included on Worksheet A.
Line 5.--Enter the amount received from the sale of medical records and abstracts and offset the
amount against the A&G cost centers.
Line 6.--Enter the cash received from imposition of interest, finance, or penalty charges on overdue
receivables. This income must be used to offset the allowable A&G costs.
Rev. 1
47-33
4711 (Cont.)
FORM CMS-1728-20
09-20
Line 9.--Enter interest expense imposed by the contractor on Medicare overpayments to the
provider. Also, enter the interest expense on loans incurred to repay Medicare overpayments to
the provider.
Line 10.--Enter the expense incurred for political and lobbying activities be identified and
disallowed. (See CMS Pub. 15-1, chapter 21, §§2139-2139.3.)
Line 11.--Enter the expense incurred for advertising costs be identified and disallowed. (See
CMS Pub. 15-1, chapter 21, §§2136-2136.2.)
Line 12 through 49.--Use these lines and any subscripts thereof to enter any additional adjustments
required under the Medicare principals of reimbursement. Provide a description for each amount
reported on these lines that indicates the nature of the required adjustment and the amount.
Line 50.--Enter the sum of lines 1 through 49. Transfer the amounts in column 2 to the appropriate
lines on Worksheet A, column 9.
47-34
Rev. 1
09-20
4712.
FORM CMS-1728-20
4712.1
WORKSHEET A-8-1 - COSTS OF SERVICES FROM RELATED ORGANIZATIONS
AND/OR HOME OFFICE/CHAIN ORGANIZATIONS
Worksheet A-8-1 consists of the following two parts:
Part I - Adjustments Required as a Result of Transactions with Related Organizations or
Home Office/Chain Organizations Costs
Part II - Interrelationship Between Related Organizations and/or Home Office/Chain
Organizations
In accordance with 42 CFR 413.17, costs applicable to services, facilities, and supplies furnished
to the HHA by organizations related to the HHA by common ownership or control are includable
in the HHA allowable cost at the cost to the related organization, see 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 HHA by related organizations
or costs associated with the HO/CO.
Complete this worksheet if you answered yes to question 11 on Worksheet S-2, Part I, and there
are costs included on Worksheet A resulting from transactions with related organizations as
defined in CMS Pub. 15-1, chapter 10, or HO/CO cost as described in CMS Pub. 15-1, chapter 21.
If there are no costs incurred as a result of transactions with related organizations or HO/CO cost
allocations, DO NOT complete Worksheet A-8-1.
4712.1 Part I - Adjustments Required as a Result of Transactions with Related Organizations
and/or Home Office/Chain Organizations. This part of this worksheet provides for the
computation of adjustments needed to properly report costs of services, facilities, and supplies
furnished to the HHA by related organizations or costs associated with the HO/CO. However,
such costs must not exceed the amount a prudent and cost-conscious buyer would pay for the
comparable services, facilities, or supplies that are purchased elsewhere.
Columns 1 and 2.--Enter in column 1 the Worksheet A cost center line number to be adjusted.
Enter the corresponding cost center description in column 2.
Column 3.--Enter the description of the related organization or HO/CO expenses.
Column 4.--Enter the Worksheet A-8-1, Part II, line number on which the related organization is
reported. For example, Brothers HHA leases office space from Brothers Property Management, a
related party. Brothers HHA reports the lease expense on line 1 and identifies Brothers Property
Management as a related organization in Part II, line 1. On Part I, line 1, column 4, Brothers HHA
enters a 1 (the line number from Part II) to identify the interrelationship.
Column 5.--Enter the Worksheet S-2, Part I, line number (line 17 or subscript) of the HO/CO that
allocated the cost reported in column 6. For example, Brothers HHA receives a cost allocation
from Brothers Home Office. Brothers Home Office is identified on Worksheet S-2, Part I,
line 17.01. Brothers HHA reports the A&G HO/CO costs on line 2 and enters 17.01 (the line
number from Worksheet S-2, Part I) to identify the HO/CO.
Rev. 1
47-35
4712.2
FORM CMS-1728-20
09-20
Column 6.--Enter the allowable costs from the books and/or records of the related organization or
HO/CO. Allowable costs are the actual costs incurred by the related organization or HO/CO for
services, facilities, and/or supplies and exclude any markup, profit or amounts that otherwise
exceed the acquisition cost of such items.
Column 7.--Enter the amount included on Worksheet A for services, facilities, and/or supplies
acquired from related organizations and/or HO/CO.
Column 8.--Enter the result of column 6 minus column 7. Transfer this amount to Worksheet A-8,
line 4, column 2.
4712.2 Part II - Interrelationship between Related Organizations and/or Home Office/Chain
Organizations. This part of the worksheet identifies the interrelationship between the HHA and
individuals, partnerships, corporations, or other organizations having either a related interest to, a
common ownership with, or control over the HHA as defined in CMS Pub. 15-1, chapter 10.
Complete columns 1 through 6, as applicable, for each interrelationship. For additional
information on HO/CO, see CMS Pub. 15-1, chapter 21.
Complete only those columns that are pertinent to the type of relationship that exists.
Column 1.--Enter the symbol that represents the interrelationship between the HHA and the related
organization or HO/CO. Select from the following choices:
Symbol
A
B
C
D
E
F
G
Relationship
Individual has financial interest (stockholder, partner, etc.) in both
related organization and in provider
Corporation, partnership or other organization has financial interest in
provider
Provider has financial interest in corporation, partnership, or other
organization
Director, officer, administrator or key person of provider or
organization
Individual is director, officer, administrator or key person of provider
and related organization
Director, officer, administrator or key person of related organization
or relative of such person has financial interest in provider
Other (financial or non-financial) -- specify
Column 2.--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 reported in column 2, or the organization reported in column 4, has a
financial interest in the HHA, enter the percent of ownership.
Column 4.--Enter the name of each related corporation, partnership, or other organization.
Column 5.--If the HHA, or an individual reported in column 2, has a financial interest in the
organization reported in column 4, enter the percent of ownership.
Column 6.--Enter the type of business applicable to the related organization (e.g., medical drugs
and/or supplies, janitorial services).
47-36
Rev. 1
09-20
4713.
FORM CMS-1728-20
4713
WORKSHEET B - COST ALLOCATION - ALLOCATION OF GENERAL SERVICE
COSTS AND WORKSHEET B-1 - COST ALLOCATION - STATISTICAL BASIS
Worksheet B 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, and special purpose cost centers.
Obtain the total direct expenses from Worksheet A, column 10. To facilitate transferring amounts
from Worksheet A to Worksheet B, the same cost centers with corresponding line numbers (lines 1
through 58) are listed on both worksheets.
Worksheet B-1 provides for the proration of the statistical data needed to equitably allocate the
expenses of the general service cost centers on Worksheet B.
To facilitate the allocation process, the general format of Worksheets B and B-1 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 Worksheet A.
NOTE: General services, columns 1 through 9, must be consistent on Worksheets B and B-1.
The statistical bases shown at the top of each column on Worksheet B-1 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
further clarified in CMS Pub. 15-1, chapter 23, §2306.1, which also clarifies the order of allocation
for step-down 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 HHA 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 it is accurate, 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 will revert 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.)
Rev. 1
47-37
4713 (Cont.)
FORM CMS-1728-20
09-20
If the amount of any cost center on Worksheet A, column 10, has a credit balance, show this
amount as a credit balance on Worksheet B, 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 on the first line of the column and on line 100. This enables column 10,
line 100, to cross foot to columns 0 and 5A, line 100. After receiving costs from the applicable
overhead cost centers, if a revenue producing cost center has a credit balance on Worksheet B,
column 10, 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 the total statistics
applicable to the cost center being 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).
Use accumulated cost for allocating administrative and general 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 the HHA 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 B-1, line 100, the total expenses of the cost center to be allocated. Obtain this
amount from Worksheet B 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 B, column 1,
line 1.
Divide the amount entered on line 100 by the total statistical base entered in the same column on
the first line. Enter the resulting unit cost multiplier on line 101. Round the unit cost multiplier to
at least the nearest 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 B 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 100) of all of the cost centers receiving the allocation on Worksheet B 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 Worksheets B and B-1 before proceeding to the next cost center.
47-38
Rev. 1
09-20
FORM CMS-1728-20
4713 (Cont.)
After all the costs of the general service cost centers have been allocated on Worksheet B, enter in
column 10 the sum of the expenses on lines 16 through 58. The total expenses entered in
column 10, line 100, should equal the total expenses entered in column 0, line 100.
Transfer the amounts in column 10 to Worksheet C, column 2, as follows:
From Worksheet B
Column 10, Line:
To Worksheet C
Column 2, Line:
16
17
18
19
20
21
22
23
24
1
2
3
4
5
6
7
8
9
Column Descriptions
Worksheet B, 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 feet of area 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.
If an HHA occupies more than one building (e.g., several branch offices), it may allocate the
depreciation and related expenses by building, using a supportive worksheet showing the detailed
allocation and transferring the accumulated costs by cost center to Worksheet B, column 1.
Worksheet B, 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 or if approved, the alternative
basis of square feet.
Worksheet B, column 3.--Allocate all expenses for plant operation and maintenance to the
appropriate cost centers on the basis of square feet.
Rev. 1
47-39
4713 (Cont.)
FORM CMS-1728-20
09-20
Worksheet B, column 4.--The cost of vehicles owned or rented by the HHA and all other
transportation costs that were not directly assigned to another cost center on Worksheet A,
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. The HHA may use weighted trips
rather than actual miles as a basis of allocation for transportation costs that are not directly
assigned. However, the 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.
Worksheet B, column 4A.--For each line enter the sum of columns 0 through 4.
Worksheet B, column 5.--Allocate all expenses for telecommunication technology to the
appropriate cost centers on the basis of accumulated costs. Transfer the amounts from
Worksheet B, column 4A, lines 16 through 24, and 57, to Worksheet B-1, column 5, lines 16
through 24, and 57.
Worksheet B-1, column 5A.--Enter on line 5, the costs attributable to the difference between the
total accumulated cost reported on Worksheet B, column 4A, lines 5, 16 through 24, and 57, and
the accumulated costs reported on Worksheet B-1, column 5, line 5. For lines 16 through 24,
and 57, enter a negative one (-1) in this column to identify the cost center that should be excluded
from receiving an allocation. If only a portion of the costs from a cost center are to receive an
allocation, use the reconciliation column to reduce the allocation statistic by that amount to ensure
proper allocation.
Worksheet B, column 5A.--For each line enter the sum of columns 4A and 5.
Worksheet B, 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 B-1,
column 6, from Worksheet B, columns 5A.
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.
47-40
Rev. 1
04-21
FORM CMS-1728-20
4713 (Cont.)
When contract service costs include A&G the contracted services must be excluded from the total
cost statistic on Worksheet B-1, column 6. For purposes of determining the basis of allocation,
use Worksheet B-1, column 6A to adjust the allocation statistic on Worksheet B-1, column 6. This
procedure may be followed when the HHA contracts for services to be performed for the HHA or
HHA-based hospice and the contract identifies the A&G costs applicable to those purchased
services.
Worksheet B-1, column 6A.--Enter the costs attributable to the difference between the total
accumulated cost reported on Worksheet B, column 5A, line 100, and the accumulated cost
reported on Worksheet B-1, column 6, line 6. Enter any amounts reported on Worksheet B,
column 5A, for (1) any service provided under arrangements to program patients that 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. Including these costs in the statistics for allocating administrative and
general expenses causes an improper distribution of overhead. In addition, report on line 6 the
administrative and general costs reported on Worksheet B, column 6, line 6, since these costs are
not included on Worksheet B-1, column 6, as an accumulated cost statistic.
For fragmented or 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 6 (A&G), the reconciliation column
designation must be 6A.
Worksheet B-1, column 6.--The administrative and general expenses are allocated on the basis of
accumulated costs. Therefore, the amount entered on Worksheet B-l, column 6, line 6, is the
difference between the amounts entered on Worksheet B, column 5A, and Worksheet B-1,
column 6A. A negative cost center balance in the statistics for allocating administrative and
general expenses causes an improper distribution of this overhead cost center. Exclude negative
balances from the allocation statistics.
Rev. 2
47-41
4713 (Cont.)
FORM CMS-1728-20
04-21
An HHA may establish multiple A&G cost centers (referred to as componentized or fragmented)
by using one of two possible methodologies. The rationale for allocating the shared A&G service
cost center first is that shared A&G cost centers service all other cost centers, while 100 percent
of HHA A&G reimbursable and 100 percent of HHA A&G nonreimbursable only service their
respective cost centers. That is consistent 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.” Under the first
methodology (also referred to as option 1), the HHA must classify all A&G costs as either A&G
shared costs, A&G reimbursable costs, or A&G nonreimbursable costs. That is, 100 percent of
the componentized A&G costs relate exclusively to either the HHA reimbursable or HHA
nonreimbursable cost centers. The remaining costs are classified as A&G shared costs. The
componentized A&G costs are allocated through cost finding to their respective cost centers in
aggregate.
First, allocate A&G shared costs to all applicable cost centers, including to the A&G reimbursable
and A&G nonreimbursable cost centers on the basis of accumulated costs. Then allocate HHA
A&G reimbursable costs to all applicable HHA reimbursable cost centers (not including special
purpose cost centers) on the basis of accumulated costs and allocate HHA A&G nonreimbursable
costs to all applicable HHA nonreimbursable cost centers on the basis of accumulated costs. Only
A&G shared costs will be allocated to the special purpose cost centers. Accordingly, the total
A&G costs in the Hospice worksheets must equal the corresponding A&G shared costs on
Worksheet B. The following three A&G cost center categories will be created: (1) A&G shared
costs, (2) 100 percent HHA reimbursable costs, and (3) 100 percent HHA nonreimbursable costs,
in this order only. Do not allocate A&G reimbursable costs to the A&G nonreimbursable cost
center. Calculate the accumulated cost statistics as follows:
A&G Cost Center
Sum of Worksheet B
Transfer to Worksheet B-1
A&G Shared Costs
Col. 5A, lines 6.02 through 58
Col. 6.01, lines 6.02 through 58
A&G Reimb. Costs
Col. 5A plus 6.01, lines 16 through 30 Col. 6.02, lines 16 through 30
A&G Nonreimb. Costs Col. 5A plus 6.01, lines 39 through 50 Col. 6.03, lines 39 through 50
47-42
Rev. 2
04-21
FORM CMS-1728-20
4713 (Cont.)
Under the second methodology (also referred to as option 2), unique A&G cost centers may be
created (see CMS Pub. 15-1, chapter 23, §2313.1) to further refine the allocation process. The
statistical basis used to allocate fragmented A&G costs must represent, as accurately as possible,
the consumption or usage of A&G services by the benefiting cost centers. An HHA wishing to
use an alternative allocation methodology (i.e., a change in allocation basis or the sequence of cost
center allocation) must do so in accordance with CMS Pub. 15-1, chapter 23, §2313. The
fragmentation of A&G costs may constitute a direct assignment of A&G costs and, as such, must
follow the policy established under CMS Pub. 15-1, chapter 23, §2307.
Worksheet B, column 7.--Allocate all expenses for nursing administration to the appropriate cost
centers on the basis of direct nursing hours.
Worksheet B, column 7A.--For each line enter the sum of columns 5A through 7.
Worksheet B, column 8.--Allocate all expenses for medical records to the appropriate cost centers
on the basis of accumulated costs. Transfer the amounts from Worksheet B, column 7A, lines 16
through 24, 39 through 42, 44, 47 and 57, to Worksheet B-1, column 8, lines 16 through 24, 39
through 42, 44, 47 and 57.
Worksheet B-1, column 8A.--Enter the costs attributable to the difference between the total
accumulated cost reported on Worksheet B, column 7A, lines 8, 16 through 24, 39 through 42, 44,
47 and 57, and the accumulated costs reported on Worksheet B-1, column 8, line 8. For lines 16
through 24, 39 through 42, 44, 47 and 57, enter a negative one (-1) in this column to identify the
cost center which should be excluded from receiving an allocation. If only a portion of the costs
from a cost center are to receive an allocation, use the reconciliation column to reduce the
allocation statistic by that amount to ensure proper allocation.
Worksheet B, column 9.--Allocate all expenses for other general service costs not identified in
columns 1 through 8 using a statistical basis that will equitably allocate costs.
Rev. 2
47-43
4714
4714.
FORM CMS-1728-20
04-21
WORKSHEET C - APPORTIONMENT OF PATIENT SERVICE COSTS
Worksheet C consists of the following two parts:
Part I - Aggregate HHA Cost per Visit and Aggregate Medicare Cost Computation
Part II - Supplies, Drugs, and Disposable Devices Cost Computation
Certain services may be rendered by an HHA that are not covered under the home health provision
of §1832(a)(2)(A) of the Act. These services are covered under a different provision, i.e.,
§1832(a)(2)(B) of the Act. Under §1832(a)(2)(B) of the Act, any provider may render the services
authorized under that section. An HHA is a provider. Therefore, an HHA may render medical
and other health services and are reimbursed in accordance with §1833(a)(2)(B) of the Act under
OPPS. If a beneficiary receives any of these services, the beneficiary is liable for coinsurance
(i.e., 20 percent of reasonable charges) and/or deductibles. The reimbursement for these services
is subject to the lesser of reasonable cost or customary charges (LCC), and such reimbursement
cannot exceed 80 percent of the reasonable cost of these services. These services are considered
as Medicare services reimbursable under title XVIII of the Act and are includable as Medicare
visits for statistical purposes. The HHA must maintain auditable records of the number of visits,
charges, deductibles, and coinsurance applicable to those visits. A separate reimbursement
computation and a separate LCC computation is required.
4714.1 Part I - Aggregate HHA Cost per Visit and Aggregate Medicare Cost Computation.--This
part provides for the computation of the average HHA cost per visit used to derive the total
allowable cost attributable to Medicare patient care visits. This part also provides for the
computation of the reasonable cost for Medicare services provided by the HHA. Complete this
part once for the entire HHA. This computation is required by 42 CFR 413.30 and 42 CFR 413.53.
Column Descriptions for Cost per Visit and Aggregate Medicare Cost Computation
Column 2.--Enter in column 2 the amount for each discipline from Worksheet B, column 10, lines
as indicated on the worksheet.
Column 3.--Transfer the total HHA visits from Worksheet S-3, Part I, column 7, lines 1 through 9,
for each discipline listed on lines 1 through 9.
Column 4.--Compute the average cost per visit for each type of discipline. Divide the cost in
column 2 by the number of visits in column 3 for each discipline.
Column 5.--Enter in column 5 the Medicare HHA visits by practitioner from your records or the
PS&R data on lines 1 through 9. The total visits on line 10, column 5 must equal the total visits
on Worksheet S-3, part IV, line 13, column 5.
Column 6.--To determine the Medicare cost of services, multiply the average cost per visit amount
in column 4 by the number of Medicare covered visits in column 5, lines 1 through 9, for each
discipline. Enter the product in column 6.
Line 10.--For each column 2, 3, 5, and 6, respectively, enter the sum total of lines 1 through 9.
47-44
Rev. 2
04-21
FORM CMS-1728-20
4714.2
4714.2 Part II - Supplies, Drugs, and Disposable Devices Cost Computation.--Certain items
covered by Medicare and furnished by an HHA are not included in the visit for apportionment
purposes. Since an average cost per visit does not apply to these items, the ratio of total cost to
total charges is developed and applied to Medicare charges to arrive at the Medicare cost for these
items.
Lines 11 through 14.--Enter in column 1 the total applicable costs for the entire cost reporting
period for each line item from Worksheet B, column 10, lines 25, 26, 27, and 29. Enter in
column 2 the corresponding total charges for the entire cost reporting period. Enter in column 3
the ratio of costs in column 1 to charges in column 2 for each line.
Line 11.--Enter in columns 5 (not subject to deductibles and coinsurance) and 6 (subject to
deductibles and coinsurance) charges for medical supplies from the HHA records or the PS&R.
These charges are captured for statistical purposes only (has no reimbursement impact) as all
medical supplies are covered under the HHA PPS.
Line 12.--Enter in column 5 the charges for pneumococcal vaccine, influenza vaccine, hepatitis B
vaccine, COVID-19 vaccine, and monoclonal antibody products for treatment of COVID-19.
These vaccines are not subject to deductibles and coinsurance. Enter in column 6 the charge for
covered osteoporosis drugs. Osteoporosis drugs are subject to deductibles and coinsurance. Do
not include the charges for administering vaccines or drugs.
Line 13.--Enter in column 4 the charges for administering pneumococcal, influenza, hepatitis B,
and COVID-19 vaccines; and administration of monoclonal antibody products from the HHA
records or the PS&R.
Line 14.--Enter in column 4 the charges for covered disposable devices from the HHA records or
the PS&R. Disposable devices are subject to deductibles and coinsurance.
Column 7.--To determine the Medicare cost of disposable devices reimbursed under OPPS,
multiply the cost to charge ratio column 3 by the Medicare charges in column 4. Enter the product
in column 7.
Column 8.--To determine the Medicare cost not subject to deductibles and coinsurance, multiply
the cost to charge ratio in column 3 by the Medicare charges in column 5 for each line item as
applicable. Enter the product in column 8.
Column 9.--To determine the Medicare cost subject to deductibles and coinsurance, multiply the
cost to charge ratio in column 3 by the Medicare charges in column 6 for each line item, as
applicable. Enter the product in column 9.
Rev. 2
47-45
4715
4715.
FORM CMS-1728-20
04-21
WORKSHEET D - CALCULATION OF REIMBURSEMENT SETTLEMENT
Worksheet D consists of the following two parts:
Part I - Computation of the Lesser of Reasonable Cost or Customary Charges for
Vaccines
Part II - Computation of Reimbursement Settlement
This worksheet applies to title XVIII only. This computation is required by 42 CFR 413.9,
42 CFR 413.13, and 42 CFR 413.30.
4715.1 Part I - Computation of the Lesser of Reasonable Cost or Customary Charges for
Vaccines.--Providers are paid the lesser of the reasonable cost of services furnished to beneficiaries
or the customary charges for the same services. This part provides for the computation of the
lesser of reasonable cost as defined in 42 CFR 413.13(b) or customary charges as defined in the
42 CFR 413.13(e).
NOTE: Nominal charge providers (42 CFR 413.13(a) and (f)) are not subject to the LCC.
Therefore, a nominal charge HHA (Worksheet S-2, Part I, line 7, is “Y” for yes) only
completes Part I, lines 1 and 9.
Line Descriptions
Line 1.--Transfer the cost from Worksheet C, Part II, column 8, line 12, to column 1, and the cost
from Worksheet C, Part II, column 9, line 12, to column 2 of this worksheet.
Line 2.--Transfer the charges from Worksheet C, Part II, column 5, line 12, to column 1, and the
charges from Worksheet C, Part II, column 6, line 12.
Lines 3 through 6.--These lines provide for the accumulation of charges which relate to the
reasonable cost on line 1.
47-46
Rev. 2
08-22
FORM CMS-1728-20
4715.1 (Cont.)
Lines 3, 4, 5, and 6.--These lines provide for the reduction of Medicare charges where 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.
Enter on line 6 the product of multiplying the ratio on line 5 by line 2 for each column. Providers
that 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 columns 1 and 2 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 applicable column on this line 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 (0) on line 7.
Line 8.--Enter in each applicable column on this line 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 (0) on line 8. A
nominal charge provider (response of “Y” to Worksheet S-2, Part I, line 7) enters zero (0) on this
line.
Line 9.--Enter the sum of the amounts on line 1, columns 1 and 2, minus the sum of the amounts
on line 8, columns 1 and 2.
Rev. 3
47-47
4715.2
4715.2
FORM CMS-1728-20
08-22
Part II - Computation of Reimbursement Settlement.--
Lines 10 through 13.--Under PPS, enter only payment amounts associated with episodes/periods
completed in the current cost reporting period (see §4707.4 for additional information on episodes
and periods). Payments for episodes/periods of care that overlap fiscal years must be recorded in
the fiscal year in which the episode was completed. Enter on lines 10 through 13, as applicable,
the appropriate PPS payment for each episode of care payment category indicated on the
worksheet.
Lines 14 and 15.--Enter as applicable, the appropriate PPS outlier payment for each episode/period
of care payment category indicated on the worksheet.
Line 16.--Enter the total of other payments, excluding NPWT. Also, include on this line the value
of Other Adjustments as found on the PS&R.
Line 17.--Enter OPPS payment amounts for services rendered. This includes OPPS payments for
the administration of pneumococcal, influenza, hepatitis B, and COVID-19 vaccines,
administration of monoclonal antibody products for treatment of COVID-19, and disposable
devices such as NPWT devices.
Lines 18 through 20.--Enter the gross payments for DME, oxygen, and prosthetics and orthotics
payments, respectively, associated with home health PPS services (bill type 32x only). Obtain
these amounts from the HHA records or PS&R report.
Line 21.--Enter the amounts paid or payable by the primary payer and reported on the PS&R. The
primary payer rules are more fully explained in 42 CFR 411.
Line 22.--Enter the applicable Part B deductibles billed to Medicare patients. Exclude coinsurance
amounts. Include any amounts of deductibles satisfied by primary payer payments. Do not enter
deductibles for DME, oxygen, and prosthetics and orthotics.
Line 23.--Enter the sum of lines 9 through 15, plus lines 17 through 20, minus lines16, 21, and 22.
Line 24.--Enter all coinsurance billable to Medicare beneficiaries, including amounts satisfied by
primary payer payments. Coinsurance is applicable for services reimbursable under §1832(a)(2)
of the Act. Do not enter coinsurance for DME, oxygen, and prosthetics and orthotics.
NOTE for line 24: If the component qualifies as a nominal charge provider, enter 20 percent of
costs subject to coinsurance on this line. Compute this amount by subtracting deductibles
on line 22 and primary payment amount on line 21, from the costs subject to coinsurance
in column 2, line 1. Multiply the resulting amount by 20 percent and enter it on line 24.
Line 25.--Enter Medicare allowable bad debts, reduced by bad debt recoveries. If recoveries
exceed the current year’s bad debts, lines 25 and 26 will be negative.
Line 26.--Multiply the amount (including negative amounts) from line 25 by 65 percent.
Line 27.--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 25.
Line 28.--Enter the result of line 23 minus line 24, plus line 26.
47-48
Rev. 3
08-22
FORM CMS-1728-20
4715.2 (Cont.)
Line 29.--Use this line to enter any other adjustments not identified on lines 10 through 27.
Provide a description for the amount reported on this line in the space provided.
Line 30.--Enter all demonstration payment adjustment amounts before sequestration.
Line 31.--Enter the result of line 28 plus or minus line 29, minus line 30.
Line 32.--Enter the sequestration adjustment amount from the PS&R report (claims based
amounts). 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, §1 of
Public Law 117-7, and §2 of the Protecting Medicare and American Farmers from Sequester Cuts
Act of 2021 (PAMA), the sequestration adjustment for the period of May 1, 2020, through March
31, 2022, is not applicable. In accordance with §2 of the PAMA 2021, the sequestration adjustment
is 1 percent for the portion of the cost reporting period from April 1, 2022, through June 30, 2022;
and 2 percent for the portion of the cost reporting period on or after July 1, 2022.
Line 32.75.--For cost reporting periods that overlap or begin on or after May 1, 2020, calculate 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 (line 9, columns 1 and 2, plus line 26, plus or minus line 29 and its subscripts)]. If the sum of
line 9, columns 1 and 2, plus line 26, plus or minus line 29 and its subscripts is less than zero, do
not calculate the sequestration adjustment. In accordance with §3709 of the CARES Act, as
amended by §102 of the Consolidated Appropriations Act of 2021, §1 of Public Law 117-7, and
§2 of the PAMA, do not apply the sequestration adjustment to the period of May 1, 2020, through
March 31, 2022. In accordance with §2 of the PAMA 2021, for cost reporting periods that overlap
or begin on or after April 1, 2022, calculate the sequestration adjustment amount for the period of
April 1, 2022, through June 30, 2022, as follows: [(1 percent times (total days in the cost reporting
period that occur from April 1, 2022, through June 30, 2022, divided by total days in the entire
cost reporting period, rounded to six decimal places), rounded to four decimal places), times the
sum of (line 9, columns 1 and 2, plus line 26, plus or minus line 29 and its subscripts)]; and for
cost reporting periods that overlap or begin on or after July 1, 2022, calculate the sequestration
adjustment amount as follows: [(2 percent times (total days in the cost reporting period that occur
on or after July 1, 2022, through the end of the cost reporting 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 (line 9, columns 1 and 2, plus line 26, plus or minus line 29 and its subscripts)].
Line 33.--Enter the result of line 31 minus lines 32 and 32.75 due after sequestration adjustment.
Line 34.--Enter all demonstration payment adjustment amounts after sequestration.
Line 35.--Enter the result of line 33 minus line 34.
Line 36.--Enter the amount of interim payments from Worksheet D-1, column 2, line 4.
Line 37.--FOR CONTRACTOR USE ONLY.--Enter the tentative settlement amount from
Worksheet D-1, column 2, line 5.99.
Line 38.--Enter the total amount from line 35 minus the amounts on lines 36 and 37. This
represents the amount due to or from the provider. Indicate overpayments by parentheses ( ).
Transfer this amount to Worksheet S, Part III, column 1, line 1.
Rev. 3
47-49
4716
FORM CMS-1728-20
08-22
Line 39.--Enter the Medicare 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.
4716.
WORKSHEET D-1 - ANALYSIS OF PAYMENTS TO HHA FOR SERVICES
RENDERED TO PROGRAM BENEFICIARIES
Complete lines 1 through 4 for Medicare interim payments only. (See 42 CFR 413.64.) Do not
report interim payments for title XIX.
The remainder of the worksheet is completed by the Medicare contractor. All amounts reported
on this worksheet must be for services rendered during the cost reporting period for which the
costs are included in this cost report.
NOTE: DO NOT reduce any interim payments by recoveries as a result of medical review
adjustments where the recoveries were based on a sample percent applied to the universe
of claims reviewed and the PS&R was not also adjusted.
Line Descriptions
Line 1.--Enter the total Medicare interim payments paid to the HHA for all covered services.
Additionally, enter the total Medicare interim payments paid to the HHA for covered
osteoporosis drugs and any other vaccines (pneumococcal, influenza, hepatitis B, COVID-19 and
monoclonal antibody products for treatment of COVID-19) paid on a cost reimbursement basis.
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 and includes amounts
withheld from the HHA’s interim payments due to an offset against overpayments to the HHA
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 amounts; nor does it include interim payments
payable. If the HHA is reimbursed under the periodic interim payment method of reimbursement,
enter the periodic interim payments received for this cost reporting period. Do not include
payments received for services reimbursed on a fee schedule basis.
47-50
Rev. 3
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FORM CMS-1728-20
4716 (Cont.)
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 Worksheet D, line 36.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET D-1.
LINES 5
THROUGH 7 ARE FOR CONTRACTOR USE ONLY.
(EXCEPTION: IF
WORKSHEET S, PART I, LINE 3, IS GREATER THAN ZERO (AMENDED COST
REPORT), THE HHA MAY COMPLETE LINES 5 THROUGH 7.)
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 Notice of Program Reimbursement (NPR) has
been issued, all settlement payments prior to the current reopening settlement are reported on
line 5.
Line 6.--Enter the net settlement amount from Worksheet D, line 38, transferring the amount to
column 2.
NOTE: On lines 3, 5, and 6, when an amount is due HHA to program, show the amount and date
on which the HHA 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 6.01 or 6.02, in column 2, as
appropriate. Enter amounts due the program in parentheses ( ). The amount in column 2 must
equal the amount on Worksheet D, line 35.
Line 8.--Enter the contractor’s name, contractor number, and NPR date, in columns 0, 1, and 2,
respectively.
Rev. 1
47-51
4717
4717.
FORM CMS-1728-20
09-20
WORKSHEET F - BALANCE SHEET
Prepare this worksheet from the HHA’s accounting books and records. Where applicable, the
worksheets must be consistent with the HHA financial statements.
Line 1 - Cash on hand and in banks.--Enter 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, impress cash
funds, saving accounts, certificates of deposit, treasury bills and treasury notes and other cash
accounts.
Line 2 - Temporary investments.--Enter current securities evidenced by certificates of ownership
or indebtedness. Typical accounts would be marketable securities and other current investments.
Line 3 - Notes receivable.--Enter current unpaid amounts evidenced by certificates of
indebtedness.
Line 4 - Accounts receivable.--Enter unpaid inpatient and outpatient billings. Include direct
billings to patients for deductibles, co-insurance and other patient chargeable items not included
elsewhere.
Line 5 - Other receivable.--Enter other unpaid amounts due to the HHA.
Line 6 - Less: Allowances for uncollectible notes and accounts receivable.--Enter the estimated
amount of the HHA accounts receivable not expected to be paid.
Line 7 - Inventory.--Enter the costs of unused HHA 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 hospice.
The 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 that are properly chargeable to a future
accounting period.
Line 9 - Other current assets.--Enter the balances of all other current assets not identified and
reported on lines 1 through 8.
Line 10 - Total current assets.--Enter the sum of lines 1 through 9.
Line 11 - Land.--Enter the cost of land as defined in CMS Pub. 15-1, chapter 1, §104.6.
Lines 12 and 13 - Land improvements.--Enter on line 12 the costs of land improvements as
defined in CMS Pub. 15-1, chapter 1, §104.7. Enter accumulated depreciation on line 13.
Lines 14 and 15 - Buildings.--Enter on line 14 the costs of the HHA buildings as defined in
CMS Pub. 15-1, chapter 1, §104.2. Enter accumulated depreciation on line 15.
47-52
Rev. 1
04-21
FORM CMS-1728-20
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Lines 16 and 17 - Leasehold improvements.--Enter on line 16 the costs of leasehold improvements
as defined in CMS Pub. 15-1, chapter 1, §104.8. Enter accumulated depreciation on line 17.
Lines 18 and 19 - Fixed equipment.--Enter on line 18 the costs of building equipment as defined
in CMS Pub. 15-1, chapter 1, §104.3. Enter accumulated depreciation on line 19.
Lines 20 and 21 - Automobiles and trucks.--Enter on line 20 the costs of automobiles and trucks
used in HHA operations. Enter accumulated depreciation on line 21.
Lines 22 and 23 - Major movable equipment.--Enter on line 22 the costs of equipment as defined
in CMS Pub. 15-1, chapter 1, §104.4. Enter accumulated depreciation on line 23.
Lines 24 and 25 - Minor equipment depreciable.--Enter on line 24 the costs of minor equipment
as defined in CMS Pub. 15-1, chapter 1, §106(c). Enter accumulated depreciation on line 25.
Line 26 - Minor equipment (non-depreciable).--Enter the costs of minor equipment nondepreciable as defined in CMS Pub. 15-1, chapter 1, §106(c).
Line 26.50 - Other fixed assets.--Enter the costs of other fixed assets not identified on lines 11
through 26.
Line 27 - Total fixed assets.--Enter the sum of lines 11 through 26 and 26.50.
Line 28 - Investments.--Enter the cost of investments purchased with HHA funds and the fair
market value (at date of donation) of securities donated to the HHA.
Line 29 - Deposits on leases.--Enter the amount of deposits on leases including security deposits.
Line 30 - Due from owners/officers.--Enter the amount loaned to the owner’s and/or officers by
the HHA.
Line 30.50 - Other assets.--Enter the balances of all other assets not identified and reported on
lines 28 through 30. This could include intangible assets such as goodwill, unamortized loan costs
and other organization costs.
Line 31 - Total other assets.--Sum of lines 28 through 30 and 30.50.
Line 32 - Total assets.--Sum of lines 10, 27, and 31.
Line 33 - Accounts payable.--Enter amounts due trade creditors and others for supplies and
services purchased.
Line 34 - Salaries, wages and fees payable.--Enter the actual or estimated liabilities of salaries and
wages/fees payable.
Line 35 - Payroll taxes payable.-- Enter the actual or estimated liabilities of amounts payable for
payroll taxes withheld from salaries and wages, payroll taxes to be paid and other payroll
deductions, such as hospitalization insurance premiums.
Line 36 - Notes and loans payable (short term).--Enter amounts payable on notes and loans as
evidenced by certificates of indebtedness due in the next 12 months.
Rev. 2
47-53
4717 (Cont.)
FORM CMS-1728-20
04-21
Line 37 - Deferred income.--Enter the amount of deferred income received or accrued 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.
Line 38 - Accelerated payments.--Enter the amounts payable for accelerated payments in
accordance with CMS Pub 15-1, chapter 24, §2412.
Line 39 - Other current liabilities.--Enter the balances of all other current liabilities not identified
and reported on lines 33 through 38.
Line 40 - Total current liabilities.--Enter the sum of lines 33 through 39.
Line 41 - Mortgage payable.--Enter the long-term financing obligation as evidenced by
certificates of indebtedness used to purchase real estate/property.
Line 42 - Notes payable.--Enter amounts payable on notes and loans as evidenced by certificates
of indebtedness due after the next 12 months.
Line 43 - Unsecured loans.--Enter amounts payable for unsecured liabilities due after the next
12 months.
Line 44 - Other long-term liabilities.--Enter the balances of all other long-term liabilities not
identified and reported on lines 41 through 43.
Line 45 - Total long-term liabilities.--Enter the sum of lines 41 through 44.
Line 46 - Total liabilities.--Enter the sum of lines 40 and 45.
Line 47 - Fund balance.--Enter the end of period fund balance.
Line 48 - Total liabilities and fund balance.--Enter the sum of lines 46 and 47.
47-54
Rev. 2
09-20
4718.
FORM CMS-1728-20
4718
WORKSHEET F-1 - STATEMENT OF REVENUES AND EXPENSES
This worksheet is prepared from the HHA’s accounting books and records. It requires the
reporting of total patient revenues (specifically including Medicare, Medicaid and other revenues)
for the entire HHA and operating expenses for the entire HHA. Additional worksheets may be
submitted if necessary.
Line 1.--Enter total patient revenue from the HHA accounting books and/or records in columns 1
through 3, by program as indicated. Note: revenue from a managed care program must be entered
in column 3, “Other”. Enter the sum of columns 1 through 3 in column 4.
Line 2.--Enter allowances and discounts in columns 1 through 3, by program as indicated. These
allowances and discounts are total patient revenues not received including:
Provision for Bad Debts,
Contractual Adjustments,
Charity Discounts,
Teaching Allowances,
Policy Discounts,
Administrative Adjustments, and
Other Deductions from Revenue
Line 3.--Enter in each column the sum of line 1 minus line 2.
Line 4.--Enter in column 2, total operating expenses from Worksheet A, column 6, line 100.
Lines 5 through 10.--Use these lines to enter any additions to operating expenses in column 1.
Provide a description for each amount reported on these lines and any subscripts thereof.
Lines 11 through 16.--Use these lines to enter any subtractions to operating expenses in column 1.
Provide a description for each amount reported on these lines and any subscripts thereof.
Line 17.--Enter in column 2, the sum of line 4, column 2, and lines 5 through 16, column 1.
Line 18.--Enter in column 2, the sum of line 3, column 4, minus line 17, column 2.
Lines 19 through 27.--Enter all other income as specified in column 1.
Lines 28 through 31.--Use these lines to enter any other revenues in column 1.
description for each amount reported on these lines and any subscripts thereof.
Provide a
Line 31.50.--Enter the aggregate revenue received for COVID-19 Public Health Emergency (PHE)
funding including both PRF and Small Business Association (SBA) Loan Forgiveness amounts.
Line 32.--Enter in column 2, the sum of the amounts on lines 19 through 31, column 1.
Line 33.--Enter in column 2, the sum of line 18 plus line 32, column 2.
Rev. 1
47-55
4719
4719.
FORM CMS-1728-20
09-20
WORKSHEET O - ANALYSIS OF HHA-BASED HOSPICE COSTS
The O series of worksheets must be completed by all HHA-based hospices. This worksheet is to
record the trial balance of expense accounts from the provider’s 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 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 Worksheet 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 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 57.
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 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, the sums of columns 2
through 5, line 57.
Column 3.--For each cost center, enter the total of columns 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
to the extent reclassifications are needed or reported on Worksheet A, line 57. 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 Worksheet 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 7, line 57.
Column 5.--For each cost center, enter the total of the amount in column 3 plus or minus the
amount in column 4.
47-56
Rev. 1
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FORM CMS-1728-20
4719 (Cont.)
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 §4711).
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 9, line 57. 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 Worksheet 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 Worksheet 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 9, line 57.
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
Rev. 1
From Worksheet O, Column 7,
Line Number and
Cost Center Description
Cap Rel Costs-Bldg & Fixt
Cap Rel Costs-Mvble Equip
Employee Benefits Department
Administrative & General
Plant Operation & 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 & 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
47-57
4719 (Cont.)
FORM CMS-1728-20
09-20
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. For
example, the general service cost centers appear on Worksheet O-5, and Worksheets O-6, Parts I
and 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.
General service cost centers (lines 1 through 17) include expenses incurred in operating the
hospice 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. 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 & 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.--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, and
CMS Pub. 15-1, chapter 23, §2307.) Enter the employee benefits.
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 & Maintenance.--This cost center includes expenses incurred in the
operation and maintenance of the plant and equipment (see §4709). Enter in columns 1 and 2, the
costs of plant operation and maintenance.
Line 6 - Laundry & Linen Service.--This cost center includes the cost of routine laundry and linen
services whether performed in-house or by outside contractors.
Line 7 - Housekeeping.--This cost center includes the cost of routine housekeeping activities such
as mopping, vacuuming, cleaning restrooms, lobbies, waiting areas and otherwise maintaining
patient and non-patient care areas.
Line 8 - Dietary.--This cost center includes 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.--This cost center includes 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 the hospice 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.
47-58
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FORM CMS-1728-20
4719 (Cont.)
Line 10 - Routine Medical Supplies.--This cost center includes 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-routine medical supplies on line 42.
Line 11 - Medical Records.--This cost center includes 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.
Line 12 - Staff 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 hospice business. Staff transportation costs do not include
patient transportation costs; report patient transportation costs on line 39.
Line 13 - Volunteer Service Coordination.--This cost center includes the cost of the overall
coordination of service volunteers including their recruitment and training costs of volunteers.
Line 14 - Pharmacy.--This cost center includes 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 46.
For additional information, please refer to the instructions for line 43 - Drugs Charged to Patients
prior to completing this line.
Line 15 - Physician Administrative Services.--This cost center includes the costs for physicians’
administrative and general 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 16.--Use this line to identify expenses for other general service costs not identified on lines 1
through 15. Provide a description for the amount reported on this line. See Table 5 in §4790 for
proper cost center coding for this line.
Line 17 - Patient/Residential Care Services.--Do not use this line on this worksheet. This cost
center is used on Worksheet O-5 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-5 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.
Rev. 1
47-59
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FORM CMS-1728-20
09-20
Direct patient care service costs 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.
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.
47-60
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FORM CMS-1728-20
4719 (Cont.)
Line 32 - Speech-Language Pathology.--This cost center includes the costs of physicianprescribed 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 includes 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.
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.
Rev. 1
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FORM CMS-1728-20
09-20
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 43 - 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 44 - 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 45 and 46 - 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.
Line 47.--Use this line and subscripts of this line to identify expenses for other direct patient care
service costs not identified on lines 25 through 46. Provide a description for each amount reported
on this line and its subscripts. See Table 5 in §4790 for proper cost center coding for this line.
Lines 48 and 49.--Reserved for future use.
Lines 50 through 53.--Reserved for use on Worksheet O-6, Parts I and II.
Lines 54 through 59.--Reserved for future use.
Nonreimbursable cost centers 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 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.--This cost center includes the cost 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.--This cost center includes costs of volunteer programs.
42 CFR 418.78 and CMS Pub. 15-1, chapter 7.)
(See
Line 62 - Fundraising.--This cost center includes costs of fundraising. (See CMS Pub. 15-1,
chapter 21, §2136.2.)
47-62
Rev. 1
09-20
FORM CMS-1728-20
4719 (Cont.)
Line 63 - Hospice/Palliative Medicine Fellows.--This cost center includes 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.
Line 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).
Line 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)).
Line 69 - Thrift Store.--Enter in columns 1 and 2, the salary and other costs of thrift stores.
Line 70 - Nursing Facility Room & 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.
Line 71.--Use this line and subscripts of this line to identify expenses for other nonreimbursable
costs not identified on lines 60 through 70. Provide a description for each amount reported on this
line and its subscripts. See Table 5 in §4790 for proper cost center coding for this line.
Lines 72 through 99.--Reserved for future use.
Rev. 1
47-63
4720
4720.
FORM CMS-1728-20
09-20
WORKSHEETS O-1, O-2, O-3, AND O-4 - ANALYSIS OF HHA-BASED HOSPICE
COSTS
Worksheet O-1 - Analysis of HHA-Based Hospice Costs - Continuous Home Care
Worksheet O-2 - Analysis of HHA-Based Hospice Costs - Routine Home Care
Worksheet O-3 - Analysis of HHA-Based Hospice Costs - Inpatient Respite Care
Worksheet O-4 - Analysis of HHA-Based Hospice Costs - 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
records.
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
Worksheet O-1, O-2, O-3, and O-4, column 4, must equal the amount on the corresponding line
on 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 §4711.) 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
47-64
To Worksheet O-5, column 1, line:
50
51
52
53
Rev. 1
09-20
4721.
FORM CMS-1728-20
4721
WORKSHEET O-5 - DETERMINATION OF HHA-BASED HOSPICE TOTAL
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 services costs reported on Worksheet O, lines 1 through 17, with the
overhead allocation of the HHA general services costs reported on Worksheet B, line 57,
columns 1 through 7.
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, column 1, must equal the amount on Worksheet A, column 10, line 57.
Column 2.--For each general service cost center, transfer the amount from the corresponding
column on Worksheet B, line 57 as follows:
Line:
1
2
3
4
5
6
7
8
From Worksheet B,
line 57, column(s):
1
2
N/A
5 and 6
3
N/A
N/A
N/A
Line:
9
10
11
12
13
14
15
16
From Worksheet B,
line 57, column(s):
7
N/A
8
4
N/A
N/A
N/A
9
Column 3.--For each line, enter the sum of columns 1 and 2. The total on line 100, column 3, must
equal the amount on Worksheet B, column 10, line 57. Transfer the amount from each cost center
to the corresponding line on Worksheet O-6, Part I, column 0.
Rev. 1
47-65
4722
4722.
FORM CMS 1728-20
09-20
WORKSHEET O-6 - COST ALLOCATION - HHA-BASED HOSPICE
Worksheet O-6 consists of the following two parts:
Part I - Allocation of HHA-Based Hospice General Service Costs
Part II - Statistical Bases
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 services 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 order of allocation and/or allocation statistics, as appropriate, 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 in the normal manner, including to those cost centers with a negative
balance. Close a general service cost center with a negative balance by entering the negative
balance in parentheses on the first line and on lines 99 and 100 of the column, and do not allocate.
This enables Worksheet O-6, Part I, line 100, column 18, to cross foot to Worksheet O-6, Part I,
line 100, column 0. 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.
47-66
Rev. 1
09-20
FORM CMS 1728-20
4722 (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 accounting books and 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 101, 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 101, 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 102.
For each column on Worksheet O-6, Part II, multiply the unit cost multiplier on line 102 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 50 through 71, column 18, the sum of the costs in columns 3A through
column 17. The total costs entered on Worksheet O-6, Part I, column 18, line 100, must equal the
total costs entered in column 0, line 100.
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 or HGIP
services and the contractual costs include A&G costs, the contractual costs reported on
Worksheet O-3, column 7, line 25, or Worksheet O-4, column 7, line 25, may be used to reduce
the accumulated cost statistic on Worksheet O-6, Part II, column 4A, line 52 or line 53,
respectively.
Rev. 1
47-67
4722 (Cont.)
FORM CMS 1728-20
09-20
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,
column 3A, line 4, to Worksheet O-6, Part II, column 4A, line 4.
The total accumulated cost statistic for Worksheet O-6, Part II, column 4, line 4, is the difference
between the total on Worksheet O-6, Part I, column 3A, line 101, 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
47-68
To Worksheet O-8,
column 3:
Line 1
Line 6
Line 11
Line 16
Rev. 1
04-21
4723.
FORM CMS 1728-20
47-
WORKSHEET O-7 - APPORTIONMENT OF HHA-BASED HOSPICE SHARED
SERVICE COSTS BY LEVEL OF CARE
This worksheet calculates the cost of ancillary services provided by HHA departments to
HHA-based hospice patients.
Column Descriptions
Column 1.--For each cost center, enter in column 1, the cost for each discipline from Worksheet B,
column 10, lines as indicated.
Column 2.--For each cost center, enter on the appropriate lines the total HHA charges from the
provider’s records, applicable to the HHA-based hospice.
Column 3.--For each cost center, enter in column 3, the cost-to-charge ratio by dividing the HHA
cost in column 1 by the HHA charges in column 2.
Columns 4 through 7.--For each cost center, enter the charges, from the provider’s records, for
ancillary services provided by HHA ancillary departments to HHA-based hospice patients. Enter
the charges by LOC in the appropriate LOC column.
Columns 8 through 11.--For each column, calculate cost of ancillary services provided by HHA
ancillary departments to HHA-based hospice patients as follows:
Column:
8
9
10
11
Calculation:
col. 3 x col. 4
col. 3 x col. 5
col. 3 x col. 6
col. 3 x col. 7
For each column 8 through 11, enter the sum of lines 1 through 9, on line 10.
Rev. 2
47-69
4724
4724.
FORM CMS 1728-20
04-21
WORKSHEET O-8 - CALCULATION OF HHA-BASED HOSPICE PER DIEM COST
Worksheet O-8 calculates the average cost per diem by level of care and in total.
Line 1.--Enter in column 3, the total HCHC cost from Worksheet O-6, Part I, column 18, line 50,
plus Worksheet O-7, column 8, line 10.
Line 2.--Enter in column 3, the total HCHC days from Worksheet S-4, column 4, line 1.
Line 3.--Enter in column 3, the average HCHC cost per diem by dividing column 3, line 1, by
column 3, line 2.
Line 4.--Enter in column 1, the title XVIII - Medicare HCHC days from Worksheet S-4, Part I,
column 1, line 1. Enter in column 2, the title XIX - Medicaid HCHC days from Worksheet S-4,
Part I, column 2, line 1.
Line 5.--Enter in column 1, the title XVIII - Medicare program cost calculated by multiplying
column 3, line 3, by column 1, line 4. Enter in column 2, the title XIX - Medicaid program cost
calculated by multiplying column 3, line 3, by column 2, line 4.
Line 6.--Enter in column 3, the total HRHC cost from Worksheet O-6, Part I, column 18, line 51,
plus Worksheet O-7, column 9, line 10.
Line 7.--Enter in column 3, the total HRHC days from Worksheet S-4, column 4, line 2.
Line 8.--Enter in column 3, the average HRHC cost per diem by dividing column 3, line 6, by
column 3, line 9.
Line 9.--Enter in column 1, the title XVIII - Medicare HRHC days from Worksheet S-4, column 1,
line 2. Enter in column 2, the title XIX - Medicaid HRHC days from Worksheet S-4, column 2,
line 2.
Line 10.--Enter in column 1, the title XVIII - Medicare program cost calculated by multiplying
column 3, line 8, by column 1, line 9. Enter in column 2, the title XIX - Medicaid program cost
calculated by multiplying column 3, line 8, by column 2, line 9.
Line 11.--Enter in column 3, the total HIRC cost from Worksheet O-6, Part I, column 18, line 52,
plus Worksheet O-7, column 10, line 10.
Line 12.--Enter in column 3, the total HIRC days from Worksheet S-4, column 4, line 3.
Line 13.--Enter in column 3, the average HIRC cost per diem by dividing column 3, line 11, by
column 3, line 12.
Line 14.--Enter in column 1, the title XVIII - Medicare HIRC days from Worksheet S-4, column 1,
line 3. Enter in column 2, the title XIX - Medicaid HIRC days from Worksheet S-4, column 2,
line 3.
47-70
Rev. 2
04-21
FORM CMS 1728-20
4724 (Cont.)
Line 15.--Enter in column 1, the title XVIII - Medicare program cost calculated by multiplying
column 3, line 13, by column 1, line 14. Enter in column 2, the title XIX - Medicaid program cost
calculated by multiplying column 3, line 13, by column 2, line 14.
Line 16.--Enter in column 3, the total HGIP cost from Worksheet O-6, Part I, column 18, line 53,
plus Worksheet O-7, column 11, line 10.
Line 17.--Enter in column 3, the total HGIP days from Worksheet S-4, column 4, line 4.
Line 18.--Enter in column 3, the average HGIP cost per diem by dividing column 3, line 16, by
column 3, line 17.
Line 19.--Enter in column 1, the title XVIII - Medicare HGIP days from Worksheet S-4, column 1,
line 4. Enter in column 2, the title XIX - Medicaid HGIP days from Worksheet S-4, column 2,
line 4.
Line 20.--Enter in column 1, the title XVIII - Medicare program cost calculated by multiplying
column 3, line 18, by column 1, line 19. Enter in column 2, the title XIX - Medicaid program cost
calculated by multiplying column 3, line 18, by column 2, line 19.
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-4, column 4, line 5.
Line 23.--Enter the average cost per diem by dividing column 3, line 21, by column 3, line 22.
Rev. 2
47-71
4724 (Cont.)
FORM CMS 1728-20
04-21
This page intentionally left blank.
47-72
Rev. 2
09-20
FORM CMS-1728-20
4790
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE OF CONTENTS
Topic
Page(s)
Table 1:
Record Specifications
47-303 - 47-311
Table 2:
Worksheet Indicators
47-312 - 47-314
Table 3:
List of Data Elements With Worksheet, Line, and Column
Designations
47-315 - 47-337
Table 3A:
Worksheets Requiring No Input
47-338
Table 3B:
Tables to Worksheet S-2, Part I
47-338
Table 3C:
Lines That Cannot Be Subscripted
Table 4:
Reserved for future use
Table 5:
Cost Center Coding
Table 6:
Edits:
Rev. 1
47-338 - 47-339
47-340
47-341 - 47-344
Level 1 Edits
47-345 - 47-354
Level 2 Edits
47-355 - 47-357
47-301
4790 (Cont.)
FORM CMS-1728-20
09-20
This page is reserved for future use.
47-302
Rev. 1
08-22
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 1 - RECORD SPECIFICATIONS
Table 1 specifies the standard record format to be used for electronic cost reporting (ECR) file.
Each electronic cost report submission (file) has four types of records. The first group (type 1
records) contains information for identifying, processing, and resolving problems. The text used
throughout the cost report for variable line labels (e.g., Worksheet A) and variable column headers
(Worksheet B-1) is included in the type 2 records. Refer to Table 5 for cost center coding. The
data detailed in Table 3 are identified as type three records. The encryption coding at the end of
the file, records 1, 1.01, and 1.02, are type 4 records.
The medium for transferring ECR files to contractors is CD, flash drive, or the CMS-approved
Medicare Cost Report E-filing (MCREF) portal, [URL: https://mcref.cms.gov]. ECR files must
comply with the CMS specifications. Providers should seek approval from their contractors
regarding the method of submission to ensure that the method of transmission is acceptable.
The following are requirements for all records:
1.
2.
3.
All alpha characters must be in upper case.
For micro systems, the end of record indicator must be a carriage return and line feed, in that
sequence.
No record may exceed 60 characters.
Below is an example of a set of type 1 records with a narrative description of their meaning.
1
2
3
4
5
123456789012345678901234567890123456789012345678901234567890
1
1
1
1
2
4
6
147100202000120203668A99P00120210902020366
1728-20
14:30
Record #1: This is a cost report file submitted by Provider 147100 for the period from
January 1, 2020 (2020001) through December 31, 2020 (2020366). It is filed on
Form CMS-1728-20. It is prepared with vendor number A99’s PC based system,
version number 1. Position 38 changes with each new test case and/or approval and
is alpha. Positions 39 and 40 remain constant for approvals issued after the first test
case. This file is prepared by the home health agency on March 31, 2021 (2021090).
The electronic cost report specification dated December 31, 2020 (2020366) is used
to prepare this file.
FILE NAMING CONVENTION
Name each cost report ECR file in the following manner:
HHNNNNNN.YYLC, where
1. HH (Home Health Agency Cost Report) is constant;
2. NNNNNN is the 6-digit CMS Certification Number;
3. YY is the year in which the provider's cost reporting period ends;
4. L is a character variable (A-Z) to enable separate identification of files from HHAs with
two or more cost reporting periods ending in the same calendar year; and
5. C is the number of times this original cost report is being filed.
Name each cost report PI file in the following manner:
PINNNNNN.YYLC, where
1. PI (Print Image) is constant;
2. NNNNNN is the 6-digit CMS Certification Number;
3. YY is the year in which the provider's cost reporting period ends;
4. L is a character variable (A-Z) to enable separate identification of files from HHAs with
two or more cost reporting periods ending in the same calendar year; and
5. C is the number of times this original cost report is being filed.
Rev. 3
47-303
4790 (Cont.)
FORM CMS-1728-20
08-22
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 1 - RECORD SPECIFICATIONS
RECORD NAME: Type 1 Records - Record Number 1
Size
Usage
Loc.
Remarks
1.
Record Type
1
X
1
Constant “1”
2.
NPI
10
9
2-11
Numeric only
3.
Space
1
X
12
4.
Record Number
1
X
13
5.
Spaces
3
X
14-16
6.
HHA CCN
6
9
17-22
Field must have 6 numeric characters.
7.
Fiscal Year
Beginning Date
7
9
23-29
YYYYDDD - Julian date; first day
covered by this cost report
8.
Fiscal Year
Ending Date
7
9
30-36
YYYYDDD - Julian date; last day
covered by this cost report
9.
MCR Version
1
9
37
Constant “8” (for FORM
CMS-1728-20)
10.
Vendor Code
3
X
38-40
To be supplied upon approval. Refer
to page 47-503.
11.
Vendor Equipment
1
X
41
P = PC; M = Main Frame
12.
Version Number
3
X
42-44
Version of extract software, e.g.,
001=1st, 002=2nd, etc. or 101=1st,
102=2nd. The version number must
be incremented by 1 with each
recompile and release to client(s).
13.
Creation Date
7
9
45-51
YYYYDDD - Julian date; date on
which the file was created (extracted
from the cost report)
14.
ECR Spec. Date
7
9
52-58
YYYYDDD - Julian date; date of
electronic cost report specifications
used in producing each file. Valid for
cost reporting periods ending on or
after 2022243 (08/31/2022). Prior
approvals: 2020366.
47-304
Constant “1”
Rev. 3
09-20
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 1 - RECORD SPECIFICATIONS
RECORD NAME: Type 1 Records - Record Numbers 2 - 99
Size
Usage
Loc.
Remarks
1.
Record Type
1
9
1
Constant "1"
2.
Spaces
10
X
2-11
3.
Record Number
2
9
12-13
#2 - Cost report iteration identifier is
1728-20 in positions 21 through 27.
#3 - Vendor information; optional
record for use by vendors. Left
justified in positions 21 through 60.
#4 - The time that the ECR file is
created. This is represented in military
time as alpha numeric. Use positions
21 through 25. Example 2:30PM is
expressed as 14:30.
#5 through 99 - Reserved for future
use.
4.
Spaces
7
X
14-20
Spaces (optional)
5.
ID Information
40
X
21-60
Left justified to position 21.
RECORD NAME: Type 2 Records for Labels
Size
Usage
Loc.
Remarks
1.
Record Type
1
9
1
Constant “2”
2.
Worksheet Indicator
7
X
2-8
Alphanumeric. Refer to Table 2.
3.
Spaces
2
X
9-10
4.
Line Number
3
9
11-13
Numeric
5.
Subline Number
2
9
14-15
Numeric
6.
Column Number
3
X
16-18
Alphanumeric
7.
Sub column Number
2
9
19-20
Numeric
8.
Cost Center Code
4
9
21-24
Numeric. Refer to Table 5 for
appropriate cost center codes.
9.
Labels/Headings
a. Line Labels
36
X
25-60
Alphanumeric, left justified
b. Column Headings
Statistical Basis
& Code
10
X
21-30
Alphanumeric, left justified
Rev. 1
47-305
4790 (Cont.)
FORM CMS-1728-20
09-20
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 1 - RECORD SPECIFICATIONS
RECORD NAME: Type 2 Records for Labels (Cont.)
The type 2 records contain text that appears on the printed cost report. Of these, there are three
groups: (1) Worksheet A cost center names (labels); (2) column headings for step down entries;
and (3) other text appearing in various places throughout the cost report.
A Worksheet A cost center label must be furnished for every cost center with cost or charge data
anywhere in the cost report. The line and subline numbers for each label must be the same as the
line and subline numbers of the corresponding cost center on Worksheet A. The columns and subcolumn numbers are always set to zero.
Column headings for the General Service cost centers on Worksheets B, B-1, and O-6, Parts I
and II, are supplied once, consisting of one to three records (lines 1 through 3). The statistical
basis shown on Worksheets B-1 and O-6, Part II, are also reported. The statistical basis consists
of one or two records (lines 4 and 5). Statistical basis code is supplied only to Worksheet B-1
columns and is recorded as line 6. The statistical code must agree with the statistical bases
indicated on lines 4 and 5, i.e., code 1 = square footage, code 2 = dollar value, code 3 = mileage
(for transportation costs), and code 4 = all others. Refer to Table 2 for the special worksheet
identifier to be used with column headings and statistical basis and to Table 3 for line and column
references.
47-306
Rev. 1
04-21
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 1 - RECORD SPECIFICATIONS
RECORD NAME: Type 2 Records for Labels (Cont.)
Use the following type 2 cost center descriptions for Worksheet A standard cost center lines.
Line
Description
1
2
3
4
5
6
6.01
6.02
6.03
7
8
16
17
18
19
20
21
22
23
24
25
26
27
28
29
39
40
41
42
43
44
45
46
47
48
49
57
CAPITAL RELATED-BUILDINGS & FIXTURES
CAPITAL RELATED-MOVABLE EQUIPMENT
PLANT OPERATION & MAINTENANCE
TRANSPORTATION
TELECOMMUNICATIONS TECHNOLOGY
ADMINISTRATIVE & GENERAL
A&G SHARED COSTS ▲
A&G REIMBURSABLE COSTS ▲
A&G NONREIMBURSABLE COSTS ▲
NURSING ADMINISTRATION
MEDICAL RECORDS
SKILLED NURSING CARE-RN
SKILLED NURSING CARE-LPN
PHYSICAL THERAPY
PHYSICAL THERAPY ASSISTANT
OCCUPATIONAL THERAPY
CERTIFIED OCCUPATIONAL THERAPY ASST
SPEECH-LANGUAGE PATHOLOGY
MEDICAL SOCIAL SERVICES
HOME HEALTH AIDE
MEDICAL SUPPLIES CHARGED TO PATIENTS
DRUGS
COST OF ADMINISTERING VACCINES
DURABLE MEDICAL EQUIPMENT/OXYGEN
DISPOSABLE DEVICES
HOME DIALYSIS AIDE SERVICES
RESPIRATORY THERAPY
PRIVATE DUTY NURSING
CLINIC
HEALTH PROMOTION ACTIVITIES
DAY CARE PROGRAM
HOME DELIVERED MEALS PROGRAM
HOMEMAKER SERVICES
TELEHEALTH
ADVERTISING
FUNDRAISING
HOSPICE
▲ Use these standard cost center descriptions when administrative and general fragmentation
option 1 is elected.
Rev. 2
47-307
4790 (Cont.)
FORM CMS-1728-20
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 1 - RECORD SPECIFICATIONS
Type 2 records for Worksheet B-1, columns 1 through 8, for lines 1 through 5, and line 6, for
columns 1, 2, and 4 only (capital cost centers and transportation columns), are listed below. The
numbers running vertical to line 1 description are the general service cost center line designations.
LINE
1
2
3
4
5
6
6.01
6.02
6.03
7
8
1
CAP REL
CAP REL
PLANT
TRANSTELEADMINISA&G
A&G
A&G
NURSING
MEDICAL
2
BLDGS &
MOVABLE
OPERATION
PORTATION
COMMUN.
TRATIVE &
SHARED
REIMBURS
NONREIMBUR
ADMINISRECORDS
3
FIXTURES
EQUIPMENT
& MAINT
4
SQUARE
DOLLAR
SQUARE
MILEAGE
TECHNOLOGY ACCUM.
GENERAL
ACCUM.
COSTS
ACCUM.
COSTS
ACCUM.
COSTS
ACCUM.
TRATION
DIRECT
ACCUM.
5
FEET
VALUE
FEET
COST
COST
COST
COST
COST
NURS. HRS.
COST
6
1
2
3
Examples of type 2 records are below. Either zeros or spaces may be used in the line, subline,
column, and sub column number fields (positions 11 through 20). Spaces are preferred. (See first
two lines of the example.)* Refer to Table 5 and 6 for additional cost center code requirements.
Examples:
Worksheet A line labels with embedded cost center codes:
*
*
2A000000
1
0100CAP REL COSTS-BLDGS & FIXT
2A0000000000200000000200CAP REL COSTS-MVBLE EQUIP
2A000000
6
0600ADMINISTRATIVE & GENERAL
2A000000
18
1800PHYSICAL THERAPY
2A000000
41
4100PRIVATE DUTY NURSING
2A000000
47
4700TELEHEALTH
Examples of column headings for Worksheets B-1 and B, O-6 (Part II) and O-6 (Part I); statistical
bases used in cost allocation on Worksheets B-1, O-6 (Part II), and statistical codes used for
Worksheet B-1 (line 6) are displayed below. Also, below is an example of Worksheets O-6, Part
II (4th character indicates the 1st Hospice).
2B10000*
2B10000*
2B10000*
2B10000*
2B10000*
2B10000*
2B10000*
2B10000*
2B10000*
2B10000*
2B10000*
2B10000*
47-308
1
2
3
4
5
6
1
2
3
4
5
6
1
1
1
1
1
1
2
2
2
2
2
2
CAP REL
BLDGS &
FIXTURES
SQUARE
FEET
1
CAP REL
MOVABLE
EQUIPMENT
DOLLAR
VALUE
2
2O61002*
2O61002*
2O61002*
2O61002*
2O61002*
2O61002*
2O61002*
2O61002*
2O61002*
1
2
3
4
5
1
2
4
5
1
1
1
1
1
6
6
6
6
CAP REL
BLDG
FIX
SQUARE
FEET
LAUNDRY
& LINEN
IN-FACILITY DAYS
Rev. 2
09-20
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 1 - RECORD SPECIFICATIONS
Type 2 records for Worksheet O-6, Part II, columns 1 through 17, lines 1 through 5 are listed
below. The numbers running vertical to line 1 description, are the general service cost center line
designations.
LINE
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
CAP REL
CAP REL
EMPLOYEE
ADMINISPLANT
LAUNDRY
HOUSEDIETARY
NURSING
ROUTINE
MEDICAL
STAFF
VOLUNTEER
PHARMACY
PHYSICIAN
OTHER
PATIENT/
2
3
BLDG
MVBLE
BENEFITS
TRATIVE &
OP &
& LINEN
KEEPING
& FIX
EQUIP
DEPARTMENT
GENERAL
MAINT
ADMINISMEDICAL
RECORDS
TRANSSVC COOR-
TRATION
SUPPLIES
ADMIN
GENERAL
RESIDENT
SERVICES
SERVICE
CARE SVCS
PORTATION
DINATION
4
SQUARE
DOLLAR
GROSS
ACCUM.
SQUARE
IN-FACILSQUARE
IN-FACILDIRECT
PATIENT
PATIENT
HOURS OF
PATIENT
SPECIFY
IN-FACIL-
5
FEET
VALUE
SALARIES
COST
FEET
ITY DAYS
FEET
ITY DAYS
NURS. HRS.
DAYS
DAYS
MILEAGE
SERVICE
CHARGES
DAYS
BASIS
ITY DAYS
Worksheet O-6, Part II, records share the same size constraints as the Worksheet B-1 records.
Rev. 1
47-309
4790 (Cont.)
FORM CMS-1728-20
09-20
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 1 - RECORD SPECIFICATIONS
RECORD NAME: Type 3 Records for Non Label Data
Size
Usage
Loc.
Remarks
1.
Record Type
1
9
1
Constant “3”
2.
Wkst. Indicator
7
X
2-8
Alphanumeric. Refer to Table 2.
3.
Spaces
2
X
9-10
4.
Line Number
3
9
11-13
Numeric
5.
Subline Number
2
9
14-15
Numeric
6.
Column Number
3
X
16-18
Alphanumeric
7.
Sub
Number
2
9
19-20
Numeric
8.
Field Data
36
X
21-56
Left justified. (Y or N for yes/no
answers;
dates
must
use
MM/DD/YYYY format - slashes, no
hyphens.)
Refer to Table 6 for
additional requirements for alpha data.
4
X
57-60
Spaces (optional).
16
9
21-36
Right justified. May contain embedded
decimal point. Leading zeros are
suppressed; trailing zeros to the right of
the decimal point are not. Positive
values are presumed; no “+” signs are
allowed. Use leading minus to specify
negative values unless the field is
defined as negative on the form.
Express percentages as decimal
equivalents, i.e., 8.75% is expressed as
.087500. All records with zero values
are dropped. Refer to Table 6 for
additional requirements regarding
numeric data.
column
a. Alpha Data
b. Numeric Data
A sample of type 3 records and a number line for reference are below.
1
2
3
4
5
6
123456789012345678901234567890123456789012345678901234567890
3A000000
5
1
20502
3A000000
8
1
6347
3A000000
17
2
98469
47-310
Rev. 1
09-20
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 1 - RECORD SPECIFICATIONS
The line numbers are numeric. In several places throughout the cost report (see list below), the
line numbers themselves are data. The placement of the line and subline numbers as data must be
uniform.
Worksheet A-6, columns 3 and 7
Worksheet A-8, column 4
Worksheet A-8-1, Part I, column 1
Examples of records (*) with a Worksheet A line number as data and a number line for reference
are listed below. Example of grand total record for Worksheet A-6 (**) is also listed below.
1
2
3
4
5
6
123456789012345678901234567890123456789012345678901234567890
** 3A600000 100
4
225321
** 3A600000 100
8
225321
3A6000G0
13
0 RENTAL EXPENSE
3A6000G0
13
1 G
* 3A6000G0
13
3
1.00
3A6000G0
13
5
221409
* 3A6000G0
13
7
42.00
3A6000G0
13
9
225321
3A6000G0
14
0 RENTAL EXPENSE
3A6000G0
14
1 G
* 3A6000G0
14
3
4.00
3A6000G0
14
5
3912
3A800000
3A800000
3A800000
* 3A800000
3A800000
3A800000
3A800000
* 3A800000
12
12
12
12
13
13
13
13
0
1
2
4
0
1
2
4
* 3A810001
3
3
3
3
3
3
1
3
4
5
6
7
3A810001
3A810001
3A810001
3A810001
3A810001
IRS PENALTY
B
-935
4.00
ADVERTISING
A
-14525
4.00
CAT SCANS
6.00
1.00
17.00
3352
1122
RECORD NAME: TYPE 4 RECORDS
File Encryption and Date and Tape Stamp
This type 4 record consists of 3 records: 1, 1.01, and 1.02. These records are created at the point
in which the ECR file has been completed and saved to disk, CD, or flash drive to ensure the
integrity of the file.
Rev. 1
47-311
4790 (Cont.)
FORM CMS-1728-20
09-20
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 2 - WORKSHEET INDICATORS
This table contains the worksheet indicators that are used for electronic cost reporting. A
worksheet indicator is provided for only those worksheets for which data are to be provided.
The worksheet indicator consists of seven digits in positions 2 through 8 of the record identifier.
The first two digits of the worksheet indicator (positions 2 and 3 of the record identifier) always
show the worksheet. The third digit of the worksheet indicator (position 4 of the record identifier)
is used in several ways. First, it may be used to identify worksheets for multiple HHA-based
hospices (e.g., S-4 and O series). Alternatively, it may be used as part of the worksheet, e.g.,
worksheet A-8-1. The fourth digit of the worksheet indicator (position 5 of the record identifier)
is not used. For Worksheet A-6, the fifth and sixth digits of the worksheet indicator (positions 6
and 7 of the record identifier) identify the reclassification code. The seventh digit of the worksheet
indicator (position 8 of the record identifier) represents the worksheet or worksheet part.
Worksheets That Apply to the Home Health Agency Cost Report
Worksheet
S, Part I
S, Part II
S, Part III
S-2, Part I
S-2, Part II
S-3, Parts I, II, & III
S-3, Part IV
S-3, Part V
S-4, Parts I and II
A
A-6
A-8
A-8-1, Part I
A-8-1, Part II
B-1 (For use in
column headings)
B
B-1
C, Parts I and II
D, Parts I and II
D-1
F
F-1
47-312
Worksheet Indicator
S000001
S000002
S000003
S200001
S200002
S300000
(a)
S300004
S300005
S410000
(a) (b)
A000000
A600??0
(c)
A800000
A810001
A810002
B10000*
(d)
B000000
B100000
C000000
D000000
D100000
F000000
F100000
(a)
(a)
Rev. 1
09-20
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 2 - WORKSHEET INDICATORS
Worksheets That Apply to the Home Health Agency Cost Report (Continued)
Worksheet
O
O-1
O-2
O-3
O-4
O-5
O-6, Part I
O-6, Part II (For use in
column headings)
O-6, Part II
O-7
O-8
Rev. 1
Worksheet Indicator
O010000
(b)
O110000
(b)
O210000
(b)
O310000
(b)
O410000
(b)
O510000
(b)
O610001
(b)
O61002*
(b) (d)
O610002
O710000
O810000
(b)
(b)
(b)
47-313
4790 (Cont.)
FORM CMS-1728-20
09-20
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 2 - WORKSHEET INDICATORS
FOOTNOTES:
(a) Worksheets with Multiple Parts Using Identical Worksheet Indicator
Although some worksheets have multiple parts, the lines are numbered sequentially. In these
instances, the same worksheet identifier is used with all lines from this worksheet regardless
of the worksheet part. This differs from the Table 3 presentation, which still identifies each
worksheet and part as they appear on the printed cost report. This affects Worksheets S-3, S-4,
C, and D.
(b) Multiple HHA-Based Hospices
The third digit of the worksheet indicator (position 4th of the record) is numeric from 1 to 0 to
accommodate multiple HHA-based hospices. If there is only one HHA-based hospice, the
default is 1. This affects Worksheets S-4; O; O-1; O-2; O-3; O-4; O-5; O-6, Parts I and II;
O-7; and O-8.
(c) Worksheet A-6
For Worksheet A-6, include in the worksheet identifier the reclassification code as the 5th and
6th digits (positions 6th and 7th of the record). For example, 3A6000A0 or 3A6000B0,
3A6000C0, 3A600AA0, 3A600AB0, or 3A600ZZ0. Additionally, for Worksheet A-6 include
in the worksheet identifier “00” in the 5th and 6th digits (6th and 7th of the record) (3A600000)
to identify grand total reclassification increases and grand total reclassification decreases.
(d) Type 2 Records for Use in Column Headings
The asterisk (*) as the 7th digit of the worksheet indicator (position 8th of the record) indicates
the data is a type 2 record identifying the column heading and statistical basis. This affects
Worksheets B-1 and O-6, Part II.
47-314
Rev. 1
04-21
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
This table identifies the collection of all data elements from all worksheets in a home health agency
cost report. This includes data elements necessary to calculate a home health agency cost report,
informational data, and calculated data. Calculated fields (e.g., Worksheet A, column 10) are used
to verify the mathematical accuracy of the raw data elements and to isolate differences between
the file submitted by the home health agency complex and the report produced by the Medicare
contractor. Where an adjustment is made, that record must be present in the electronic data file.
For explanations of the adjustments required, refer to the cost report instructions.
Table 3 “Usage” column is used to specify the format of each data item as follows:
9
Numeric, greater than or equal to zero.
-9
Numeric, may be either greater than, less than, or equal to zero.
9(x).9(y) Numeric, greater than zero, with x or fewer significant digits to the left of the
decimal point, a decimal point, and exactly y digits to the right of the decimal point.
X
Character.
Consistency in line numbering (and column numbering for general service cost centers) for each
cost center is essential. The sequence of some cost centers does change among worksheets.
Table 3 refers to the data elements needed from a standard cost report. When a standard line is
subscripted, the subscripted lines must be numbered sequentially with the first subline number
displayed as “01” or “1” (with a space preceding the 1) in field locations 14 and 15. It is
unacceptable to format in a series of 10, 20, or skip subline numbers (i.e., 01, 03), except for
skipping subline numbers for prior year cost center(s) deleted in the current period or initially
created cost center(s) no longer in existence after cost finding. Exceptions are specified in this
manual. For “Other (specify)” lines, i.e., Worksheet settlement series and any other nonstandard
cost center lines, all subscripted lines should be in sequence and consecutively numbered
beginning with subscripted line number 01. Subscripts of lines and columns are based on the
format (line or column (as applicable), field size, and usage) of the primary/parent line or column
where the specifications in Table 3 do not specifically identify line or column designations.
Automated systems should reorder these numbers where providers skip or delete a line in the
series.
Drop all records with zero values from the file. Any record absent from a file is treated as if it
were zero.
All numeric values are presumed positive. Leading minus signs may only appear in data with
values less than zero that are specified in Table 3 with a usage of “-9”. Amounts that are within
preprinted parentheses on the worksheets, indicating the reduction of another number, are reported
as positive values.
Rev. 2
47-315
4790 (Cont.)
FORM CMS-1728-20
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE,
AND COLUMN DESIGNATIONS
Description
Column
Field
Size
Usage
1
2
3
1
1
1
1
1
1
X
X
X
4
1
1
X
5
1
1
X
6
7
8
9
10
2
2
2
2
3
10
5
1
1
10
X
X
X
X
X
11
12
3
3
1
1
X
X
1
1
36
X
1
2
1
X
2
3
4
1
1
1
36
36
10
X
X
X
1
1
11
-9
Line
WORKSHEET S
Part I - Cost Report Status
Provider Use Only
Electronically filed cost report
Manually submitted cost report
If this is an amended report enter the
number of times the provider
resubmitted this cost report
Medicare Utilization - Enter “F” for full,
“L” for low, or “N” for no utilization.
Contractor Use Only
Cost Report Status
Enter the cost report status code: 1 for as
submitted, 2 for settled without audit, 3
settled with audit, 4 reopened, or 5
amended.
Date received (mm/dd/yyyy)
Contractor Number
Initial report for this Provider CCN
Final report for this Provider CCN
Notice of Program Reimbursement (NPR)
date (mm/dd/yyyy)
Enter contractor’s vendor code (ADR)
If line 5, column 1 is 4: enter the number
of times reopened = 0-9
Part II - Certification
Signature of Chief Financial Officer or
Administrator
Checkbox (enter “Y” if electronic
signature; otherwise, leave blank)
Printed Name
Title
Signature date (mm/dd/yyyy)
Part III - Settlement Summary
Balances due provider or program:
Title XVIII
47-316
Rev. 2
09-20
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE,
AND COLUMN DESIGNATIONS
Description
Column
Field
Size
Usage
1
2
1
2
3
36
9
36
2
10
X
X
X
X
X
3, 4
3, 4
3, 4
5
1
2
3
1
36
6
10
10
X
X
X
X
5
2
10
X
6
7
1
1
2
1
X
X
8
1
1
X
9
1
1
X
10
1
1
X
11
1
1
X
Line
WORKSHEET S-2, PART I
Home Health Agency Complex Address
Street
1
P. O. Box
1
City
2
State
2
ZIP Code
2
Home Health Agency Component
Identification
Component Name
Provider CCN
Date Certified (mm/dd/yyyy)
Cost reporting period beginning date
(MM/DD/YYYY)
Cost reporting period ending date
(MM/DD/YYYY)
Type of Control (See Table 3B)
Does the HHA qualify as a nominal
charge provider?
Does the HHA contract with outside
suppliers for physical therapy services?
(Y/N)
Does the HHA contract with outside
suppliers for occupational therapy
services? (Y/N)
Does the HHA contract with outside
suppliers for speech therapy services?
(Y/N)
Are there any costs included in
Worksheet A that resulted from
transactions with related organizations
or HO/CO costs as defined in CMS
Pub. 15-1, chapter 10? (Y/N) If yes,
complete Worksheet A-8-1.
Rev. 1
47-317
4790 (Cont.)
FORM CMS-1728-20
09-20
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE,
AND COLUMN DESIGNATIONS
Description
Line
Column
WORKSHEET S-2, PART I (Cont.)
Malpractice Insurance Information
Is this HHA legally required to carry
12
1
malpractice insurance? (Y/N)
If line 12 is yes, is the malpractice
13
1
insurance a claims-made or occurrence
policy? Enter “1” for claims-made or
“2” for occurrence policy.
List amounts of malpractice premiums in
14
1, 2, 3
column 1, paid losses in column 2, or
self-insurance in column 3.
Are malpractice premiums and paid losses
15
1
reported in a cost center other than
A&G? (Y/N) If yes, submit supporting
schedule listing cost centers and
amounts contained therein.
Home Office/Chain Organization
Information
Receive allocation (Y/N)
Number of allocations
Name
CCN
Contractor Number
Street
City
State
ZIP Code
47-318
16
16
17-17.99
17-17.99
17-17.99
17-17.99
17-17.99
17-17.99
17-17.99
1
2
1
2
3
4
5
6
7
Field
Size
Usage
1
X
1
X
11
9
1
X
1
2
36
6
6
36
36
2
10
X
X
X
X
X
X
X
X
X
Rev. 1
09-20
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE,
AND COLUMN DESIGNATIONS
Description
Field
Size
Usage
1
1
X
2
10
X
1
1
X
2
10
X
3
1
X
1
1
X
4
1
1
X
4
2
1
X
4
3
10
X
5
1
1
X
6
1
1
X
7
1
1
X
8
1
1
X
Line
Column
WORKSHEET S-2, PART II
Provider Organization and Operation
Has the HHA changed ownership prior to
1
the beginning of this cost reporting
period? (Y/N)
If yes, enter the date of the change in
1
column 2. (mm/dd/yyyy)
Has the HHA terminated participation in
2
the Medicare program? (Y/N)
If column 1 is yes, enter in column 2 the
2
date of termination. (mm/dd/yyyy)
If column 1 is yes, enter in column 3, “V”
2
for voluntary or “I” for involuntary.
Is the HHA involved in business
3
transactions, including management
contracts, with individuals or entities
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?
(Y/N)
Financial Data and Reports
Were the financial statements prepared by
a certified public accountant? (Y/N)
If column 1 is yes, enter in column 2 “A”
for audited, “C” for compiled or “R” for
reviewed.
Submit a complete copy of financial
statements or enter date available in
column 3. (mm/dd/yyyy)
Are the cost report total expenses and total
revenues different from those on the
filed financial statements? (Y/N)
Bad Debts
Is the HHA or HHA-based entities
seeking reimbursement for bad debts?
(Y/N)
If line 6 is yes, did the HHA's bad debt
collection policy change during this cost
reporting period? (Y/N)
If line 6 is yes, were patient coinsurance
amounts waived? (Y/N)
Rev. 1
47-319
4790 (Cont.)
FORM CMS-1728-20
09-20
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE,
AND COLUMN DESIGNATIONS
Description
Line
WORKSHEET S-2, PART II
PS&R Report Data
Was the cost report prepared using the
9
PS&R Report only? (Y/N)
If yes, enter in column 2 the paid-through
9
date of the PS&R Report used to
prepare the cost report. (mm/dd/yyyy)
Was the cost report prepared using the
10
PS&R Report for totals and the HHA’s
records for allocation? (Y/N)
If yes, enter in column 2 the paid-through
10
date of the PS&R Report.
(mm/dd/yyyy)
If line 9 or 10 is yes, were adjustments
11
made to the PS&R Report data for
additional claims that have been billed
but are not included on the PS&R
Report used to file the cost report?
(Y/N)
If line 9 or 10 is yes, were adjustments
12
made to the PS&R Report data for
corrections of other PS&R Report
information? (Y/N)
If line 9 or 10 is yes, describe the other
13
adjustments.
If line 9 or 10 is yes, were adjustments
13
made to the PS&R Report data for
Other? (Y/N)
Was the cost report prepared only using
14
the HHA’s records? (Y/N)
Cost Report Preparer Contact Information
Enter the preparer’s information:
First Name
Last Name
Title
Employer
Phone Number
Email Address
47-320
15
15
15
16
17
17
Field
Size
Usage
1
1
X
2
10
X
1
1
X
2
10
X
1
1
X
1
1
X
0
36
X
1
1
X
1
1
X
1
2
3
1
1
2
36
36
36
36
36
36
X
X
X
X
X
X
Column
Rev. 1
09-20
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE,
AND COLUMN DESIGNATIONS
Description
Line
Column
Field
Size
Usage
WORKSHEET S-3, PART I, II, & III
Part I - Visits Data
Number of HHA Visits by Discipline:
Title XVIII - Medicare
Title XIX - Medicaid
Other
Total All Visits
Patient Census by Discipline:
Title XVIII - Medicare
Title XIX - Medicaid
Other
Total All Patients
Total Visits:
Title XVIII - Medicare
Title XIX - Medicaid
Other
Total All Visits
Home Health Aide Hours:
Title XVIII - Medicare
Title XIX - Medicaid
Other
Total Home Health Aide Hours
Unduplicated Census Count:
Title XVIII - Medicare
Title XIX - Medicaid
Other
Total
Part II - Employment Data (Full-Time
Equivalent)
Number of hours in a normal work week
Other (specify)
Number of full-time equivalent employees:
Staff, Contract staff, Total
Part III - Core Based Statistical Area Data
Total number of CBSAs where Medicare
covered services were provided during the
cost reporting period
List all CBSA codes for areas where
Medicare covered home health services
were provided
Rev. 1
1-9
1-9
1-10
1-10
1
3
5
7
11
11
11
11
9
9
9
9
1-9
1-9
1-10
1-10
2
4
6
8
11
11
11
11
9
9
9
9
11
11
11
11
1
3
5
7
11
11
11
11
9
9
9
9
12
12
12
12
1
3
5
7
11
11
11
11
9
9
9
9
13
13
13
13
2
4
6
8
9
9
9
9
9(6).99
9(6).99
9(6).99
9(6).99
14
33
0
0
6
36
9(3).99
X
15-33
1-3
6
9(3).99
34
1
2
9
35
1
5
X
47-321
4790 (Cont.)
FORM CMS-1728-20
09-20
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE,
AND COLUMN DESIGNATIONS
Description
Column
Field
Size
Usage
1, 3, 5, 7, 9,
11
2, 4, 6, 8, 10,
12
13
14
15
16
17
18
1, 2, 3, 4
11
9
1, 2, 3, 4
11
9
1, 2, 3, 4
1, 2, 3, 4
1, 2, 3, 4
1, 3, 4
2, 4
1, 2, 3, 4
11
11
11
11
11
11
9
9
9
9
9
9
1, 3, 5, 7, 9,
11
2, 4, 6, 8, 10,
12
13
14
15
16
17
18
5
11
9
5
11
9
5
5
5
5
5
5
11
11
11
11
11
11
9
9
9
9
9
9
Line
Worksheet S-3, Part IV
Part IV - PPS Activity Data
For each payment category:
Covered home health visits by cost center
Home health charges by cost center
Total Visits
Other Charges
Total Charges
Total Number of Episodes/Periods
Total Number of Outlier Episodes/Periods
Total Non-Routine Medical Supply
Charges
Totals:
Total home health visits by cost center
Total home health charges by cost center
Total Visits
Other Charges
Total Charges
Total Number of Episodes/Periods
Total Number of Outlier Episodes/Periods
Total Non-Routine Medical Supply
Charges
47-322
Rev. 1
09-20
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE,
AND COLUMN DESIGNATIONS
Description
Line
Column
Field
Size
Usage
WORKSHEET S-3, PART V
Part V - Occupational Category
Direct Salaries - Nursing Occupations and
Total Nursing:
Reported salaries
Fringe benefits
Adjusted salaries
Paid hours related to salary in column 3
Average hourly wage
1-13
1-13
1-13
1-13
1-13
1
2
3
4
5
11
11
11
11
6
9
9
9
9(8).99
9(3).99
Contract Labor - Nursing Occupations and
Total Nursing:
Reported salaries
Adjusted salaries
Paid hours related to salary in column 3
Average hourly wage
14-26
14-26
14-26
14-26
1
3
4
5
11
11
11
6
9
9
9(8).99
9(3).99
1
2
3
4
5
1, 2, 3, 4
1, 2, 3, 4
1, 2, 3, 4
1, 2, 3, 4
1, 2, 3, 4
11
11
11
11
11
9
9
9
9
9
6
7
1, 2, 3, 4
1, 2, 3, 4
11
11
9
9
Part I - Enrollment Days
Hospice Continuous Home Care
Hospice Routine Home Care
Hospice Inpatient Respite Care
Hospice General Inpatient Care
Total Hospice Days
WORKSHEET S-4, PARTS I & II
Part II - Contracted Statistical Data
Hospice Inpatient Respite Care
Hospice General Inpatient Care
Rev. 1
47-323
4790 (Cont.)
FORM CMS-1728-20
09-20
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE,
AND COLUMN DESIGNATIONS
Description
Line
Column
Field
Size
Usage
1
11
-9
2
11
-9
3
11
-9
4
11
-9
5
11
-9
6
11
-9
7
11
-9
8
11
-9
9
11
-9
10
11
-9
1-10
11
9
WORKSHEET A
Salaries
Employee Benefits
Transportation Costs
Contracted Purchased Services
Other Costs
Total
Reclassifications
Reclassified Trial Balance
Adjustments
Expenses for Cost Allocation
Total Costs
47-324
3-9, 16-30,
39-50, 57-58
3-9, 16-30,
39-50, 57-58
1-9, 16-30,
39-50, 57-58
3-9, 16-30,
39-50, 57-58
1-9, 16-30,
39-50, 57-58
1-9, 16-30,
39-50, 57-58
1-9, 16-30,
39-50, 57-58
1-9, 16-30,
39-50, 57-58
1-9, 16-30,
39-50, 57-58
1-9, 16-30,
39-50, 57-58
100
Rev. 1
09-20
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE,
AND COLUMN DESIGNATIONS
Description
Column
Field
Size
Usage
1-99
1-99
0
1
36
2
X
X
1-99
1-99
1-99
1-99
2
3
4
5
36
5
11
11
X
99.99
9
9
1-99
1-99
1-99
1-99
100#
100#
100#
6
7
8
9
4, 5, 8, 9
4, 5
8, 9
36
5
11
11
11
11
11
X
99.99
9
9
9
9
9
Line
WORKSHEET A-6
For each expense reclassification:
Explanation
Reclassification identification code
Increases:
Worksheet A cost center
Worksheet A line number
Reclassification salary amount
Reclassification other amount
Decreases:
Worksheet A cost center
Worksheet A line number
Reclassification salary amount
Reclassification other amount
Total
Total Reclassification Increases
Total Reclassification Decreases
#
See footnote “c” in “Table 2 - Worksheet Indicators” for appropriate worksheet indicators.
Rev. 1
47-325
4790 (Cont.)
FORM CMS-1728-20
09-20
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE,
AND COLUMN DESIGNATIONS
Description
Description of adjustment
Basis (A or B) *
Amount *
Cost Center
Worksheet A line number +
Total
Line
WORKSHEET A-8
12-49
1, 2, 3, 5-49
1-49
1, 2, 3, 5-49
1, 2, 3, 5-49
50
Column
Field
Size
Usage
0
1
2
3
4
2
36
1
11
36
5
11
X
X
-9
X
99.99
-9
* These include subscripts of lines 12 through 49, requiring records for columns 1 and 2.
+ Include only subscripts of those lines, if activated by an entry in either of columns 1 or 2.
WORKSHEET A-8-1
Part I
Worksheet A line number
Cost center
Expense item(s)
Worksheet A-8-2, Part II, line number
Worksheet S-2, Part I, line number
Amount of allowable cost
Amount included in Worksheet A
Net Adjustments
Total
Part II
Type of interrelationship (A through G)
If type is G, description of relationship
must be included
Name of individual or partnership with
interest in provider and related
organization
Percentage of ownership in provider
Name of related individual or organization
Percentage of ownership of provider
Type of business
47-326
1-49
1-49
1-49
1-49
1-49
1-49
1-49
1-49
50
1
2
3
4
5
6
7
8
6-8
5
36
36
5
5
11
11
11
11
99.99
X
X
99.99
99.99
-9
-9
-9
-9
1-50
1-50
1
0
1
36
X
X
1-50
2
36
X
1-50
1-50
1-50
1-50
3
4
5
6
6
36
6
36
9(3).99
X
9(3).99
X
Rev. 1
04-21
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE,
AND COLUMN DESIGNATIONS
Description
Line
Column
Field
Size
WORKSHEETS B AND B-1 - COLUMN HEADINGS *
Cost center name
1, 2, 3 *
1-9
10
Statistical basis
4, 5 *
1-9
10
Usage
X
X
* Refer to Table 1 for specifications and Table 2 for the worksheet identifier for column headings.
There may be up to five type 2 records (3 for cost center name and 2 for the statistical basis) for
each column. However, for any column that has less than five type 2 record entries, blank
records or the word “blank” is not required to maximize each column record count.
WORKSHEET B
Net expenses for cost allocation
Total expenses for cost allocation
Costs after cost finding by department
Subtotal
Subtotal
Subtotal
Costs after cost finding and post stepdown adjustments by department
Total costs after cost finding and post
step-down adjustments
Rev. 2
1-9, 16-30,
39-50, 57-58
100
0
11
9
0
11
9
1-9, 16-30,
39-50, 57-58
5-9, 16-30
39-50, 57-58
6-9, 16-30
39-50, 57-58
8-9, 16-30
39-50, 57-58
16-30, 39-50,
57-58
100
1-4, 5, 6-7,
8-9
4A
11
-9
11
-9
5A
11
-9
7A
11
-9
10
11
-9
1-10
11
9
47-327
4790 (Cont.)
FORM CMS-1728-20
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE,
AND COLUMN DESIGNATIONS
Description
For each cost allocation using
accumulated costs as the statistic,
include a record containing an X.
All cost allocation statistics
Reconciliation
Cost to be allocated
Unit cost multiplier
Line
WORKSHEET B-1
0
1-9, 16-30, 3950, 57-58
5-9, 16-30, 3950, 57-58▲
100
101
Column
Field
Size
Usage
1-9
1
X
1-9 *
11
9
5A-9A
11
-9
1-9 +
1-9
11
10
9
9(3).9(6)
* In any column using accumulated costs as the statistical basis for allocating costs, identify any
cost center that is not to receive an allocation either by entering a negative 1 (-1) on the
appropriate line in the accumulated cost column, or by entering the total accumulated cost as a
negative amount on the appropriate line in the reconciliation column. Cost centers that are not
to receive an allocation cannot have entries in both the reconciliation and accumulated costs
columns when the accumulated cost statistic is offset to zero.
▲ For those cost centers that are to receive partial allocation of costs, enter only the cost to be
excluded from the statistics as a negative amount on the appropriate line in the reconciliation
column. This will result in entries in both the reconciliation column and accumulated column
simultaneously on the same line where a partial accumulated cost statistic is offset.
If line 6 is fragmented, line 6 must be deleted and subscripts of line 6 must be used.
+ Include any column which uses accumulated cost as its basis for allocation.
47-328
Rev. 2
08-22
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE,
AND COLUMN DESIGNATIONS
Description
Line
Column
Field
Size
Usage
WORKSHEET C, PARTS I & II
Part I - Aggregate HHA Cost Per Visit
and Aggregate Medicare Cost
Computation
Total cost by discipline
Total visits by discipline
Average cost per visit by discipline
HHA Medicare program visits by
discipline
HHA Medicare program costs by
discipline
Total (sum of lines 1 through 9)
Part II - Supplies, Drugs, and Disposable
Devices Cost Computation
Total cost
Total charges
Ratio of costs to charges
Medicare covered charges for medical
supplies from HHA records or the
PS&R
Medicare covered charges for drugs from
HHA records or the PS&R
Medicare cost not subject to deductibles
and coinsurance
Medicare cost subject to deductibles and
coinsurance
Medicare covered charges for
administering vaccines and disposable
devices from HHA records or the PS&R
Medicare cost of administering vaccines
and disposable devices reimbursed
under OPPS
Rev. 3
1-9
1-9
1-9
1-9
2
3
4
5
11
11
6
11
9
9
9(3).99
9
1-9
6
11
9
10
2, 3, 5, 6
11
9
11, 12, 13, 14
11, 12, 13, 14
11, 12, 13, 14
11
1
2
3
5, 6
11
11
8
11
9
9
9.9(6)
9
12
5, 6
11
9
11, 12
8
11
9
11, 12
9
11
9
13, 14
4
11
9
13, 14
7
11
9
47-329
4790 (Cont.)
FORM CMS-1728-20
08-22
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE,
AND COLUMN DESIGNATIONS
Description
Column
Field
Size
Usage
1
2
3
1, 2
1, 2
1, 2
11
11
11
9
9
9
4
1, 2
11
9
5
6
7
1, 2
1, 2
1, 2
8
11
11
9.9(6)
9
9
8
1, 2
11
9
9
1, 2
11
9
10, 11, 12, 13
14, 15
16
17
1
1
1
1
11
11
11
11
9
9
-9
9
18, 19, 20
1
11
9
21
22
1
1
11
11
9
9
23
1
11
9
Line
WORKSHEET D
Part I - Computation of the Lesser of
Reasonable Cost or Customary Charges
for Vaccines
Reasonable cost of vaccines
Total vaccines charges
Aggregate amount actually collected from
patients liable for payment for services
on a charge basis
Amount that would have been realized
from patients liable for payment for
services on a charge basis had such
payment been made in accordance with
42 CFR 413.13(e)
Ratio of line 3 to line 4
Total customary charges
Excess of total customary charges over
total reasonable cost
Excess of reasonable cost over customary
charges
Subtotal of reasonable cost
Part II - Computation of Reimbursement
Settlement
Total PPS payments by episode type
Total PPS outlier payments
Total other payments (see instructions)
Payment for services reimbursed under
OPPS
Payments for DME, oxygen, and
prosthetics & orthotics
Primary payer payments
Part B deductibles billed to Medicare
patients
Subtotal
47-330
Rev. 3
04-21
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE,
AND COLUMN DESIGNATIONS
Description
Column
Field
Size
Usage
24
25
26
27
1
1
1
1
11
11
11
11
9
9
9
9
28
29
29
30
1
0
1
1
11
36
11
11
9
X
-9
-9
31
1
11
9
32
32.75
1
1
11
11
9
9
33
1
11
9
34
1
11
-9
35
36
37
38
39
1
1
1
1
1
11
11
11
11
11
-9
-9
-9
-9
-9
Line
WORKSHEET D (CONT.)
Part II - Computation of Reimbursement
Settlement (cont.)
Coinsurance billed to Medicare patents
Allowable bad debts
Adjusted reimbursable bad debts
Allowable bad debts for dual eligible
beneficiaries
Subtotal
Other adjustments (specify)
Other adjustments
Other demonstration payment adjustment
amount before sequestration
Amount due HHA prior sequestration
adjustment
Sequestration adjustment
Sequestration adjustment for non-claims
based
Amount due HHA after sequestration
adjustment
Other demonstration payment adjustment
amount after sequestration
Amount due HHA
Total interim payments
Tentative settlement
Balance due HHA/Medicare program
Protested amounts
Rev. 2
47-331
4790 (Cont.)
FORM CMS-1728-20
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE,
AND COLUMN DESIGNATIONS
Description
Column
Field
Size
Usage
1
2
3.01-3.98
2
2
1
11
11
10
9
9
X
3.01-3.49
3.50-3.98
3.99
4
5.01-5.98
2
2
2
2
1
11
11
11
11
10
9
9
-9
9
X
5.01-5.49
5.50-5.98
5.99
6.01-6.02
2
2
2
1
11
11
11
10
9
9
-9
X
6.01
2
11
9
6.02
2
11
9
7
8
8
8
2
1
2
3
11
36
5
10
9
X
X
X
Line
WORKSHEET D-1
Total interim payments paid to HHA
Interim payments payable
Date of each retroactive lump sum
adjustment (mm/dd/yyyy)
Amount of each retroactive lump sum
adjustment:
Program to Provider
Provider to Program
Subtotal
Total interim payments
Date of each tentative settlement payment
(mm/dd/yyyy)
Amount of each tentative settlement
payment:
Program to Provider
Provider to Program
Subtotal
Date of the net settlement amount
(mm/dd/yyyy)
Net settlement amount Program to
Provider
Net settlement amount Provider to
Program
Total Medicare program liability
Name of Contractor
Contractor Number
NPR date (mm/dd/yyyy)
47-332
Rev. 2
04-21
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Description
Line
Column
Field
Size
Usage
1
1
1
1
1
11
11
11
11
11
-9
-9
-9
-9
-9
1
1
1
1
1
1
1
1
1
11
11
11
11
11
11
11
11
11
-9
-9
-9
-9
-9
-9
-9
-9
-9
WORKSHEET F
Current Assets
Total Current Assets
Fixed Assets
Total Fixed Assets
Other Assets
1-9
10
11-26, 26.50
27
28, 29, 30,
30.50
31
32
33-39
40
41-44
45
46
47
48
Total Other Assets
Total Assets
Current Liabilities
Total Current Liabilities
Long Term Liabilities
Total Long Term Liabilities
Total Liabilities
Fund Balances
Total Liabilities and Fund Balances
NOTE: All amounts for lines 6, 13, 15, 17, 19, 21, 23, and 25 should be entered as positive
amounts (the usage is 9).
WORKSHEET F-1
Gross patient revenues
Allowances and discounts on patients’
accounts
Net patient revenues
Operating expenses
Additions to operating expenses (specify)
Additions to operating expenses
Subtractions from operating expenses
(specify)
Subtractions from operating expenses
Total operating expenses
Net income from service to patients
Other revenues
Other revenues (specify)
COVID-19 PHE funding
Total other income
Net income or loss for the period
Rev. 2
1
2
1-4
1-4
11
11
9
-9
3
4
5-10
5-10
11-16
1-4
2
0
1
0
11
11
36
11
36
9
9
X
9
X
11-16
17
18
19-31
28-31
31.50
32
33
1
2
2
1
0
1
2
2
11
11
11
11
36
11
11
11
9
9
-9
9
X
9
9
-9
47-333
4790 (Cont.)
FORM CMS-1728-20
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE,
AND COLUMN DESIGNATIONS
Description
Line
Column
Field
Size
Usage
1
11
-9
2
11
-9
3
11
-9
4
11
-9
5
11
-9
6
11
-9
7
11
-9
1-7
11
9
1-7
1-7
11
11
-9
9
1
2-7
1-7
11
11
11
-9
-9
9
WORKSHEET O
Salaries
3-16, 26-47,
60-71
1-16, 25-47,
60-71
1-16, 25-47,
60-71
1-16, 25-47,
60-71
1-16, 25-47,
60-71
1-16, 25-47,
60-71
1-16, 25-47,
60-71
100
Other Costs
Subtotal
Reclassifications
Subtotal
Adjustments
Net Expenses for Allocation
Total
WORKSHEETS O-1 & O-2
Direct Patient Care Service Cost Centers
Total
26-47
100
WORKSHEETS O-3 & O-4
Direct Patient Care Service Cost Centers
Direct Patient Care Service Cost Centers
Total
47-334
26-47
25-47
100
Rev. 2
09-20
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE,
AND COLUMN DESIGNATIONS
Description
Line
Column
Field
Size
Usage
1
11
-9
2
11
-9
3
11
-9
1, 2, 3
11
9
WORKSHEET O-5
Hospice Direct Expenses
1-16, 50-53,
60-71
1, 2, 4, 5, 9,
11, 12, 16
1-16, 50-53,
60-71
100
General Service Expenses
Total Expenses
Total
WORKSHEET O-6, PART II – COLUMN HEADINGS *
Cost center name
Statistical basis
1, 2, 3 *
4, 5 *
1-17
1-17
10
10
X
X
* Refer to Table 1 for specifications and Table 2 for the worksheet identifier for column headings.
There may be up to five type 2 records (3 for cost center name and 2 for the statistical basis) for
each column. However, for any column that has less than five type 2 record entries, blank
records or the word “blank’ is not required to maximize each column record count.
WORKSHEET O-6, PART I
Net expenses for cost allocation
Total expenses for cost allocation
Costs after cost finding by department
Subtotal
Costs after cost finding and post step-down
adjustments by department
Total costs after cost finding and post stepdown adjustments
Rev. 1
1-16, 50-53,
60-71
100
1-17, 50-53,
60-71, & 99
4-17, 50-53,
60-71
50-53, 60-71,
& 99
100
0
11
9
0
1-3, 4-17
11
11
9
-9
3A
11
-9
18
11
-9
1-18
11
9
47-335
4790 (Cont.)
FORM CMS-1728-20
09-20
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE,
AND COLUMN DESIGNATIONS
Description
Line
Column
Field
Size
Usage
1
X
11
9
11
-9
11
10
9
9(3).9(6)
WORKSHEET O-6, PART II
For each cost allocation using
0
1-17
accumulated costs as the statistic,
include a record containing an X.
All cost allocation statistics
1-17, 50-53,
1-17 *
60-71
Reconciliation
4-17, 50-53,
4A
60-71
Cost to be allocated
101
1-17 +
Unit cost multiplier
102
1-17
* In any column using accumulated costs as the statistical basis for allocating costs, identify any
cost center that is not to receive an allocation either by entering a negative 1 (-1) on the
appropriate line in the accumulated cost column, or by entering the total accumulated cost as a
negative amount on the appropriate line in the reconciliation column. Cost centers that are not
to receive an allocation cannot have entries in both the reconciliation and accumulated cost
columns when the accumulated cost statistic is offset to zero.
For those cost centers that are to receive partial allocation of costs, enter only the cost to be
excluded from the statistics as a negative amount on the appropriate line in the reconciliation
column. This will result in entries in both the reconciliation column and accumulated column
simultaneously on the same line where a partial accumulated cost statistic is offset.
+ Include any column which uses accumulated cost as its basis for allocation.
WORKSHEET O-7
Total HHA Costs
Total HHA Charges
Cost to Charge Ratio
Charges by Level Of Care:
HCHC
HRHC
HIRC
HGIP
Shared Service Costs by Level Of Care:
HCHC
HRHC
HIRC
HGIP
Total
47-336
1-9
1-9
1-9
1
2
3
11
11
8
9
9
9.9(6)
1-9
1-9
1-8
1-8
4
5
6
7
11
11
11
11
9
9
9
9
1-9
1-9
1-8
1-8
10
8
9
10
11
8-11
11
11
11
11
11
9
9
9
9
9
Rev. 1
04-21
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE,
AND COLUMN DESIGNATIONS
Description
Column
Field
Size
Usage
1, 6, 11, 16
2, 7, 12, 17
3, 8, 13, 18
4, 9, 14, 19
5, 10, 15, 20
3
3
3
1, 2
1, 2
11
11
9
11
11
9
9
9(6).99
9
9
21
22
23
3
3
3
11
11
9
9
9
9(6).99
Line
WORKSHEET O-8
Level Of Care:
Total cost
Total unduplicated days
Total average cost per diem
Unduplicated program days
Program cost
Total Hospice Care:
Total cost
Total unduplicated days
Total average cost per diem
Rev. 2
47-337
4790 (Cont.)
FORM CMS-1728-20
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3A - WORKSHEETS REQUIRING NO INPUT
All Worksheets require input
TABLE 3B - TABLE TO WORKSHEET S-2, PART I
Type of Control:
1
2
3
4
5
6
7
8
9
10
11
12
13
=
=
=
=
=
=
=
=
=
=
=
=
=
Voluntary Nonprofit, Church
Voluntary Nonprofit, Other
Proprietary, Individual
Proprietary, Partnership
Proprietary, Corporation
Private Non-Profit
Governmental and Private Combined
Governmental, Federal
Governmental, State
Governmental, City
Governmental, City-County
Governmental, County
Governmental, Health District
TABLE 3C - LINES THAT CANNOT BE SUBSCRIPTED
(BEYOND THOSE PREPRINTED)
Worksheet S, Parts I, II, & III: ALL
Worksheet S-2, Part I: lines 1, 2, 3, and 5 through 16
Worksheet S-2, Part II: ALL
Worksheet S-3, Parts I, II, & III: lines 1 through 32, and 34
Worksheet S-3, Part IV: ALL
Worksheet S-3, Part V: ALL
Worksheet S-4, Parts I & II: ALL
Worksheet A: lines 1 through 5, 7, 8, 16 through 29, 39 through 49, and 100
Worksheet A-6: ALL
Worksheet A-8: lines 1 through 11, and 50
Worksheet A-8-1, Part I: line 50
Worksheet A-8-1, Part II: line 50
Worksheet B: SAME AS WORKSHEET A
Worksheet B-1: SAME AS WORKSHEET A
Worksheet C, Parts I & II: ALL
Worksheet D: ALL, except line 29
Worksheet D-1: lines 1, 2, 4, and 6, 7, 8
47-338
Rev. 2
09-20
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 3C - LINES WHICH CANNOT BE SUBSCRIPTED
(BEYOND THOSE PREPRINTED) - (Cont.)
Worksheet F: ALL
Worksheet F-1: ALL, except lines 5 through 10, 11 through 16, and 28 through 31
Worksheet O, Part I: ALL
Worksheet O-1: ALL
Worksheet O-2: ALL
Worksheet O-3: ALL
Worksheet O-4: ALL
Worksheet O-5: ALL
Worksheet O-6, Part I: ALL
Worksheet O-6, Part II: ALL
Worksheet O-7: ALL
Worksheet O-8: ALL
Rev. 1
47-339
4790 (Cont.)
FORM CMS-1728-20
09-20
This page is reserved for future use.
47-340
Rev. 1
09-20
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
COST CENTER CODING
INSTRUCTIONS FOR PROGRAMMERS
Cost center coding is required because there are thousands of unique cost center names in use by
providers. Many of these names are unique to the reporting provider and give no hint as to the
actual function of the cost center. Cost center coding provides standardized meanings and
facilitates data analysis.
Worksheet A presents the cost center codes and descriptions for standard cost centers (see Table 5).
When the preparer subscripts a Worksheet A cost center, they must select from the list of allowed
non-standard cost center codes and associated descriptions (if applicable) for that subscripted line
(see Table 5). If the non-standard cost center code does not have an associated cost center label,
the cost report preparer must enter a unique cost center label in the description column.
Additional guidelines are:
•
•
•
•
•
•
•
•
Any pre-existing codes for the line must not be allowed to carry over.
All “Other . . .” lines must not be pre-coded.
The order of choice is standard first, followed by specific nonstandard, and lastly, the
nonstandard “Other . . .” cost centers.
When the nonstandard “Other . . .” is chosen, the preparer must be prompted with “Is this the
most appropriate choice?” and offered a chance to answer yes or to select another description.
The cost center coding process must be able to be edited for purposes of making corrections.
A separate list showing the preparer’s added cost center name on the left with the chosen
standard or nonstandard descriptions and code on the right must be printed for review.
The number of times a description can be selected on a given report must be displayed on the
screen next to the description and this number must decrease with each usage to show the
remaining number available. The number of times a description can be selected is shown on
the standard and nonstandard cost center tables.
Standard cost center lines, descriptions, and codes are not to be changed. The acceptable
format for these are displayed in the STANDARD COST CENTER DESCRIPTIONS AND
CODES listed on page 47-343. The proper line number is the first two digits of the cost center
code. All “Other” nonstandard lines must include an appropriate cost center name.
INSTRUCTIONS FOR PREPARERS
Coding of Cost Center Labels
Cost center coding is a methodology for standardizing the meaning of cost center labels as used
by the HHA on the Medicare cost report. The use of this coding methodology allows the HHA to
use their labels for cost centers that have meaning within the institution.
The four-digit codes are required and must be associated with each cost center label/description.
The codes provide standardized meaning for data analysis. The preparer must code all added cost
center labels/descriptions. Standard cost center labels/descriptions are automatically coded by
CMS approved cost report software.
Rev. 1
47-341
4790 (Cont.)
FORM CMS-1728-20
09-20
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
COST CENTER CODING
Coding of Cost Center Labels (cont.)
Additional cost center descriptions have been identified through analysis of provider labels. The
meanings of these additional descriptions were sufficiently different when compared to the
standard labels to warrant their use. These additional descriptions are hereafter referred to as the
nonstandard labels. Included with the nonstandard descriptions are “Other . . .” designations to
provide for situations where no match in meaning can be found. Refer to Worksheet A, lines 9,
30, 50, and 58. Both the standard and nonstandard cost center descriptions, along with their cost
center codes, are shown on Table 5. The “USE” column on that table indicates the number of
times that a given code can be used on one cost report. Compare your added cost center
labels/descriptions to the standard and nonstandard table and select the appropriate cost center
code. CMS approved software provides an automated process for selecting an appropriate code to
properly match with your added cost center label/description.
Additional Guidelines
Categories
You must make your selection from the proper category such as general service description for
general service cost center lines, nonreimbursable descriptions for nonreimbursable cost center
lines, etc.
Cost Center Coding and Line Restrictions
Cost center codes may only be used in designated lines in accordance with the classification of the
cost center(s), i.e., lines 1 through 9 may only contain cost center codes within the general service
cost centers category of both standard and nonstandard coding. For example, in the general service
cost centers category for “Other General Service (specify)” cost, line 9 and subscripts must contain
cost center codes of 0900 through 0919 which are identified as nonstandard cost center codes.
This logic must hold true for all other cost center categories, i.e., other health care costs, other than
HHA services, and nonreimbursable cost centers.
Administrative and General Cost Centers
A&G can either be shown as one cost center with a code of 0600 or fragmented by one of two
distinct methods. If A&G is fragmented, do not use line 6 or cost center code 0600. Elect one of
the following options to allocate fragmented A&G service costs, but do not use both.
Option 1: Fragment the A&G service cost center into HHA shared costs, HHA 100% reimbursable
costs, and HHA 100% nonreimbursable costs, in this order only:
Cost Center Description
Line Numbers
A&G Shared costs
A&G Reimbursable costs
A&G Nonreimbursable costs
6.01
6.02
6.03
Cost Center Codes
0623
0621
0622
Option 2: Standard A&G service cost center fragmentation:
Line Numbers
6.01 through 6.19
47-342
Cost Center Codes
0601 through 0619
Rev. 1
04-21
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 5 - STANDARD COST CENTER DESCRIPTIONS AND CODES
CODE
USE
0100
0200
0300
0400
0500
0600
0700
0800
(01)
(01)
(01)
(01)
(01)
(20)
(01)
(01)
HHA REIMBURSABLE SERVICES
Skilled Nursing Care-RN
Skilled Nursing Care-LPN
Physical Therapy
Physical Therapy Assistant
Occupational Therapy
Certified Occupational Therapy Asst
Speech-Language Pathology
Medical Social Services
Home Health Aide
Medical Supplies Charged to Patients
Drugs
Cost of Administering Vaccines
Durable Medical Equipment/Oxygen
Disposable Devices
1600
1700
1800
1900
2000
2100
2200
2300
2400
2500
2600
2700
2800
2900
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
HHA NONREIMBURSABLE SERVICES
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Services
Telehealth
Advertising
Fundraising
3900
4000
4100
4200
4300
4400
4500
4600
4700
4800
4900
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
SPECIAL PURPOSE COST CENTERS
Hospice
5700
(10)
GENERAL SERVICE COST CENTERS
Capital Related - Bldg & Fixt
Capital Related - Mvble Equip
Plant Operation & Maintenance
Transportation
Telecommunications Technology
Administrative & General
Nursing Administration
Medical Records
Rev. 2
47-343
4790 (Cont.)
FORM CMS-1728-20
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 5 - NONSTANDARD COST CENTER DESCRIPTIONS AND CODES
CODE
USE
0623
0621
0622
0900
(01)
(01)
(01)
(20)
HHA REIMBURSABLE SERVICES
Other HHA Reimbursable Service Costs (specify)
3000
(20)
HHA NONREIMBURSABLE SERVICES
Other HHA Nonreimbursable Service Costs (specify)
5000
(20)
SPECIAL PURPOSE COST CENTERS
Other Special Purpose Cost Centers (specify)
5800
(20)
GENERAL SERVICE COST CENTERS
A&G Shared Costs
A&G Reimbursable Costs
A&G Nonreimbursable Costs
Other General Service Costs (specify)
47-344
Rev. 2
09-20
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
EDITS
Medicare cost reports submitted electronically must meet a variety of edits. These include
mathematical accuracy edits, certain minimum file requirements, and other data edits. Any vendor
software which produces an electronic cost report file for Medicare HHAs must automate all of
these edits. Failure to properly implement these edits may result in the suspension of a vendor's
system certification until corrective action is taken. The vendor’s software should provide
meaningful error messages to notify the HHA of the cause of every exception. The edit message
generated by the vendor systems must contain the related 4 digit and 1 alpha character, where
indicated, reject/edit code specified below. Any file submitted by a provider containing a level 1
edit will be rejected by the contractors. Notification must be made to CMS for any exceptions.
The edits are applied at two levels. Level 1 edits (1000 series reject codes) test the format of the
data to identify error conditions that must be corrected or they will result in a cost report rejection.
These edits also test for critical data elements specified in Table 3. Vendor programs must prevent
HHAs from generating an electronic cost report (ECR) file when the cost report violates any level 1
edits. Level 2 edits (2000 series edit codes) identify potential inconsistencies and missing data
items. These items should be resolved at the HHA site and supporting documentation (such as
worksheets or data) should be submitted with the cost report.
The vendor requirements (above) and the edits (below) reduce both contractor processing time and
unnecessary rejections. Vendors must develop their programs to prevent their client HHAs from
generating an ECR file where Level 1 edit conditions exist. In addition, ample warnings should
be given to the HHA where level 2 edit conditions are violated.
Level 1 edit conditions are to be applied against title XVIII services only. However, any
inconsistencies or omissions that would cause a Level 1 condition for non-title XVIII services
must be resolved prior to acceptance of the cost report. [01/01/2020b and ending on or after
12/31/2020]
NOTE: The date in brackets [ ] at the end of each edit indicates the effective date of the edit. A
date without an alpha suffix, such as [12/31/2020], indicates the edit is effective for cost reporting
periods ending on or after the date in brackets. A date followed by a “b”, such as [01/01/2020b],
indicates the edit is effective for cost reporting periods beginning on or after the date in brackets.
A date followed by an “s”, such as [01/01/2020s], indicates the edit is effective for services
rendered on or after the date in brackets.
I.
Level 1 Edits (Minimum File Requirements)
Edit
Condition
1000
The first digit of every record must be either 1, 2, 3, or 4 (encryption code only).
[12/31/2020]
1005
No record may exceed 60 characters. [12/31/2020]
1010
All alpha characters must be in upper case. This is exclusive of the encryption code, type 4
record, record numbers 1, 1.01, and 1.02. [12/31/2020]
1015
For micro systems, the end of record indicator must be a carriage return and line feed, in
that sequence. [12/31/2020]
Rev. 1
47-345
4790 (Cont.)
FORM CMS-1728-20
09-20
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 6 - EDITS
Edit
Condition
1020
The HHA provider number (record #1, positions 17 through 22) must be valid and numeric
(issued by the applicable certifying agency and falls within the specified range).
[12/31/2020]
1025
All calendar format dates must be edited for 10-character format, e.g., 01/01/2020
(MM/DD/YYYY). [12/31/2020]
1030
All dates (record #1, positions 23 through 29, 30 through 36, 45 through 51, and 52
through 58) must be in Julian format and legitimate. [12/31/2020]
1035
The fiscal year beginning date (record #1, positions 23 through 29) must be less than the
fiscal year ending date (record #1, positions 30 through 36). [12/31/2020]
1036
The fiscal year ending date (record #1, positions 30 through 36) must be 30 days greater
than the fiscal year beginning date (record #1, positions 23 through 29) and the fiscal year
ending date (record #1, positions 30 through 36) must be less than 458 days greater than
the fiscal year beginning date (record #1, positions 23 through 29). [12/31/2020]
1040
The vendor code (record #1, positions 38 through 40) must be a valid code. [12/31/2020]
1045
The type 1 record #1 must be correct and the first record in the file. [12/31/2020]
1050
All record identifiers (positions 1 through 20) must be unique. [12/31/2020]
1055
Only a Y or N is valid for fields which require a Yes/No response. [12/31/2020]
1060
Variable columns (Worksheet B and Worksheet B-1) must have a corresponding type 2
record (Worksheet A label) with a matching line number. [12/31/2020]
1065
All line, sub line, column, and sub column numbers (positions 11 through 13, 14
through 15, 16 through 18, and 19 through 20, respectively) must be numeric, except that
each cost center using accumulated cost as the statistical basis must have a Worksheet B-1
reconciliation column numbered the same as the Worksheet A line number followed by an
“A” as part of the line number followed by the sub line number. [12/31/2020]
1067
The cost center code (positions 21 through 24) (type 2 records) must be a code from
Table 5, Cost Center Coding, and each cost center code must be unique. [12/31/2020]
47-346
Rev. 1
04-21
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 6 - EDITS
Edit
Condition
1070
The standard cost centers listed below must be reported on the lines as indicated and the
corresponding cost center codes may only appear on the lines as indicated. No other cost
center codes may be placed on these lines or subscripts of these lines, unless indicated
herein. [12/31/2020]
Cost Center
Line
Code
Capital Related-Bldg & Fixt
1
0100
Capital Related-Mvble Equip
2
0200
Plant Operation & Maintenance
3
0300
Transportation
4
0400
Telecommunications Technology
5
0500
Administrative and General
6
0600
Nursing Administration
7
0700
Medical Records
8
0800
Physical Therapy Assistant
19
1900
Occupational Therapy
20
2000
Certified Occupational Therapy Asst
21
2100
Speech-Language Pathology
22
2200
Medical Social Services
23
2300
Home Health Aide
24
2400
Medical Supplies Charged to Patients
25
2500
Drugs
26
2600
Cost of Administering Vaccines
27
2700
Durable Medical Equipment/Oxygen
28
2800
Disposable Devices
29
2900
Home Dialysis Aide Services
39
3900
Respiratory Therapy
40
4000
Private Duty Nursing
41
4100
Clinic
42
4200
Health Promotion Activities
43
4300
Day Care Program
44
4400
Home Delivered Meals Program
45
4500
Homemaker Services
46
4600
Telehealth
47
4700
Advertising
48
4800
Fundraising
49
4900
Hospice
57
5700
1075
Cost center integrity must be maintained throughout the cost report. For subscripted lines,
the relative position must be consistent throughout the cost report. [12/31/2020]
1080
Every line used on Worksheet A, B, B-1, and C, there must be a corresponding type 2
record. [12/31/2020]
Rev. 2
47-347
4790 (Cont.)
FORM CMS-1728-20
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 6 - EDITS
Edit
Condition
1085
Fields requiring numeric data (charges, visits, days, costs, FTEs, etc.) may not contain any
alpha character. [12/31/2020]
1090
A numeric field (except unit cost multipliers) cannot exceed more than 11 positions. Unit
cost multipliers cannot exceed 13 positions. [12/31/2020]
1095
In all cases where the file includes both a total and the parts that comprise that total, each
total must equal the sum of its parts. [12/31/2020]
1100
All dates must be possible, e.g., no “00”, no “30”, or “31” of February. [12/31/2020]
1000S The HHA provider name, address, provider CCN, and certification date (Worksheet S-2,
Part I, line 3, column 1 (provider name); line 1, column 1 (street address); line 2, column 1
(city), column 2 (state), column 3 (ZIP code); line 3, column 2 (CCN); and line 3, column 3
(certification date), respectively) must be present and valid. [12/31/2020]
1001S If Worksheet S, Part I, line 5, is “5” (amended cost report), then line 3 must be greater than
zero, and vice versa. [12/31/2020]
1005S The cost report beginning date (Worksheet S-2, Part I, column 1, line 5) must be on or after
January 1, 2020, and the cost report ending date (Worksheet S-2, Part I, column 2, line 5)
must be on or after December 31, 2020. [12/31/2020]
1010S The type of control (Worksheet S-2, Part I, column 1, line 6) must have a value of 1
through 13. (See Table 3B.) [12/31/2020]
1015S All provider CCN and component numbers displayed on Worksheet S-2, Part I, column 2,
lines 3 and 4, must contain six (6) alphanumeric characters. [12/31/2020]
1020S The cost report period beginning date (Worksheet S-2, Part I, column 1, line 5) must
precede the cost report ending date (Worksheet S-2, Part I, column 2, line 5). [12/31/2020]
1025S For each provider/component name reported (Worksheet S-2, Part I, column 1, lines 3
and 4), there must be corresponding entries made on Worksheet S-2, Part I, lines 3 and 4,
for the CCN (column 2) and the certification date (column 3). If there is no component
name entered in column 1, then columns 2 and 3 for that line must also be blank.
[12/31/2020]
47-348
Rev. 2
08-22
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 6 - EDITS
Edit
Condition
1030S Worksheet S-2, Part I, column 2, lines as indicated below must only contain those CCNs
as indicated for that line. The type of provider is also indicated. The first two characters
“XX” corresponds to the two-digit state code. [12/31/2020]
Line
3
4
Provider CCN
XX-3100 through 3199
XX-7000 through 8499
XX-9000 through 9799
XX-1500 through 1799
Type of Provider
Home Health Agency
Home Health Agency
Home Health Agency
HHA-Based Hospice
1035S On Worksheet S-2, Part I, there must be a “Y” or “N” response for:
Column 1: lines 7 through 11, 12, 15, and 16. [12/31/2020]
1040S If Worksheet S-2, Part I, line 8, 9, or 10, is “Y”, respectively, then the corresponding
line 18, 20, or 22, column 10, on Worksheet A must be greater than zero. If Worksheet S-2,
Part I, line 8, 9, or 10, is “N”, then Worksheet A, column 4, the corresponding line 18, 20,
or 22, must be zero. [12/31/2020]
1045S The CBSA count on Worksheet S-3, Part III, column 1, line 34, must be greater than zero.
[09/30/2021]
1050S If Worksheet S-2, Part I, line 12, is “Y”, then line 13 must contain a “1” or “2”, and line 14,
sum of columns 1 through 3, must be greater than zero. [12/31/2020]
1060S If Worksheet S-2, Part I, line 16, column 1, is “Y”, then Worksheet S-2, Part I, line 16,
column 2, must be greater than zero; and if Worksheet S-2, Part I, line 16, column 1, is
“N”, then Worksheet S-2, Part I, line 16, column 2, must be blank. [12/31/2020]
1065S If Worksheet S-2, Part I, line 16, column 2, is greater than 1 (one), then Worksheet S-2,
Part I, line 17, must be subscripted so that the total number of lines available (line 17 and
subscripts) equals the number entered on Worksheet S-2, Part I, line 16, column 2.
[12/31/2020]
1070S If Worksheet S-2, Part I, line 16, column 1, is “Y”, then Worksheet S-2, Part I, line 17 and
each subscripted line thereof, must have a HO/CO name; HO/CO CCN; HO/CO contractor
number; and the HO/CO street address, city, state, and ZIP code; entered in columns 1
through 7, respectively; and if Worksheet S-2, Part I, line 17, any of columns 1 through 7,
has an entry, then Worksheet S-2 Part I, line 16, column 1, must be “Y” and
Worksheet S-2, Part I, line 16, column 2, must be greater than zero.
Conversely, if
Worksheet S-2, Part I, line 16, column 1, “N”, then Worksheet S-2, Part I, line 17,
columns 1 through 7, must be blank. [12/31/2020]
1100S On Worksheet S-2, Part II, there must be a “Y” or “N” response for:
Column 1: lines 1 through 6, 9, 10, and 14.
If column 1, line 6, is “Y”, then column 1, lines 7 and 8, must be “Y” or “N”.
If column 1, lines 9 or 10, is “Y”, then column 1, lines 11, 12, and 13, must be “Y” or “N”.
[12/31/2020]
Rev. 3
47-349
4790 (Cont.)
FORM CMS-1728-20
08-22
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 6 - EDITS
Edit
Condition
1105S If Worksheet S-2, Part II, column 1, line 1, is “Y”, then column 2 must contain a valid date
(MM/DD/YYYY), and vice versa. [12/31/2020]
1110S If Worksheet S-2, Part II, column 1, line 2, is “Y”, then column 2 must contain a valid date
(MM/DD/YYYY) and column 3 must contain a “V” or an “I”, and vice versa. [12/31/2020]
1120S If Worksheet S-2, Part II, column 1, line 3, is “N”, then Worksheet A-8-1 must not be
present. [12/31/2020]
1130S If Worksheet S-2, Part II, column 1, line 3, is “Y”, then Worksheet A-8-1, Part I, columns 6
or 7, sum of lines 1 through 49, must not equal zero; and Worksheet A-8-1, Part II,
column 1, any one of lines 1 through 50 must contain one of the alpha characters A, B, C,
D, E, F, or G. [12/31/2020]
1140S If Worksheet S-2, Part II, column 1, line 4, is “Y”, then column 2 must be “A”, “C” or “R”
and column 3, if entered, must be a valid date (MM/DD/YYY). If Worksheet S-2, Part II,
column 1, line 4, is “N”, then columns 2 and 3 must be blank. [12/31/2020]
1170S If Worksheet S-2, Part II, column 1, line 9, is “Y”, then column 2 must contain a valid date
(MM/DD/YYYY), and vice versa. [12/31/2020]
1180S If Worksheet S-2, Part II, column 1, line 10, is “Y”, then column 2 must contain a valid
date (MM/DD/YYYY), and vice versa. [12/31/2020]
1190S The cost report preparer information (Worksheet S-2, Part II, lines 15 through 17, all
columns) must be valid and present. [12/31/2020]
1200S All amounts reported on Worksheet S-3, Part I, must not be less than zero. [12/31/2020]
1210S If the visits reported on Worksheet S-3, Part I, columns 1, 3, and 5, lines 1 through 9,
respectively, are greater than zero, then the patient counts reported in columns 2, 4, and 6
must also be greater than zero, and vice versa. Apply this edit on a line by line basis.
[12/31/2020]
1215S If Worksheet S, Part I, line 4 is “N”, then Worksheet S-3, Part I, column 1, line 11, must
be zero, and vice versa. [12/31/2020]
1220S The patient count on Worksheet S-3, Part I, column 2, must be less than or equal to the
visit count in column 1, on a line by line basis for lines 1 through 9. [12/31/2020]
1225S Total visits for the HHA in Worksheet S-3, Part I, column 7, line 11 and unduplicated
census count for the HHA in Worksheet S-3, Part I, column 8, line 13, should be greater
than zero. [12/31/2020] This edit was previously 2100S.
1230S Total visits on Worksheet S-3, Part I, column 7, line 11, must be greater than or equal to
the unduplicated census count on Worksheet S-3, Part I, column 8, line 13. [12/31/2020]
47-350
Rev. 3
08-22
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 6 - EDITS
Edit
Condition
1235S Total FTEs on Worksheet S-3, Part II, column 3, sum of line 15 through 33, must be greater
than zero. [12/31/2020]
1240S If Worksheet S-3, Part III, line 34, has one or more CBSA codes, then line 35 and
applicable subscripts, must be completed with a valid five-position alphanumeric CBSA
code or more. [12/31/2020]
1260S For each column 1 through 4 on Worksheet S-3, Part IV, if either line 13 or 15 is greater
than zero, then both lines 13 and 15 must be greater than zero. Additionally, if lines 13
and 15 are greater than zero, then the sum of lines 16 and 17 must also be greater than zero.
[12/31/2020]
1270S Medical supply charges on Worksheet S-3, Part IV, column 5, line 18, must equal
Worksheet C, Part II, column 5, line 11. [12/31/2020]
1275S For each line on Worksheet S-3, Part IV, column 5, if the visits are greater than zero, then
the amount on Worksheet A, column 10, for the applicable lines 16 through 24, must be
greater than zero. Apply this edit as follows: [12/31/2020]
Worksheet S-3, Part IV
Worksheet A, Column 10,
Column 5 is greater than zero must be greater than zero
Line 1
Sum of lines 16 and 17
Line 3
Sum of lines 18 and 19
Line 5
Sum of lines 20 and 21
Line 7
Line 22
Line 9
Line 23
Line 11
Line 24
1280S Worksheet S-3, Part V, column 3, sum of lines 4 through 13, and 17 through 26, must be
greater than zero. [08/31/2022]
1300S If Worksheet S-4, Part I, column 4, line 1, is greater than zero, then Worksheet O-1,
column 7, line 100, must be greater than zero, and vice versa. [12/31/2020]
1310S If Worksheet S-4, Part I, column 4, line 2, is greater than zero, then Worksheet O-2,
column 7, line 100, must be greater than zero, and vice versa. [12/31/2020]
1320S If Worksheet S-4, Part I, column 4, line 3, is greater than zero, then Worksheet O-3,
column 7, line 100, must be greater than zero, and vice versa. [12/31/2020]
1330S If Worksheet S-4, Part I, column 4, line 4, is greater than zero, then Worksheet O-4,
column 7, line 100, must be greater than zero, and vice versa. [12/31/2020]
1340S Worksheet S-4, Part II, columns 1, 2, or 3, line 6, cannot be greater than Worksheet S-4,
Part I, columns 1, 2, or 3, line 3, respectively. [12/31/2020]
Rev. 3
47-351
4790 (Cont.)
FORM CMS-1728-20
08-22
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 6 - EDITS
Edit
Condition
1350S Worksheet S-4, Part II, columns 1, 2, or 3, line 7, cannot be greater than Worksheet S-4,
Part I, columns 1, 2, or 3, line 4, respectively. [12/31/2020]
1360S If Worksheet S-4, Part II, column 4, line 6, is greater than zero, then Worksheet O-3,
column 7, line 25, must be greater than zero, and if Worksheet S-4, Part II, column 4, line 7,
is greater than zero, then Worksheet O-4, column 7, line 25, must be greater than zero.
[12/31/2020]
1000A All amounts reported on Worksheet A, columns 1 through 5, and 10, line 100, must be
greater than or equal to zero. [12/31/2020]
1010A For each amount on Worksheet A, column 10, lines 16 through 24, that are greater than
zero, the corresponding total visits on Worksheet S-3, Part I, column 7, lines 1 through 9,
must also be greater than zero, and vice versa. [12/31/2020]
1020A For reclassifications reported on Worksheet A-6, the sum of all increases (column 4 plus
column 5) must equal the sum of all decreases (column 8 plus column 9). [12/31/2020]
1025A For each line on Worksheet A-6, when an entry is present in column 4 or 5, there must be
an entry in columns 1 and 3, and if an entry is present in column 8 or 9, there must be an
entry in columns 1 and 7. All entries in column 1 must be upper case alpha characters.
[12/31/2020]
1032A Worksheet A-6, column 0, must have an explanation present on the first line for each
reclassification code. [12/31/2020]
1040A For Worksheet A-8 adjustments on lines 1 through 3 and 5 through 11, if column 2 has an
amount, then column 1 must be either “A” or “B”, and column 4 for that line must have an
entry, and if lines 12 through 49, column 2 have entries, then columns 0, 1, and 4, for the
corresponding line must have entries. [12/31/2020]
1045A Worksheet A-8-1, Part I, columns 1 and 3, must have an entry when there is an amount in
column 6 or 7 for each of lines 1 through 49. [12/31/2020]
1000B On Worksheet B-1, all statistical amounts must be greater than or equal to zero, except for
reconciliation columns. [12/31/2020]
1005B Worksheet B, column 10, line 100, must be greater than zero. [12/31/2020]
47-352
Rev. 3
08-22
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 6 - EDITS
Edit
Condition
1010B For each general service cost center with a net expense for cost allocation greater than zero
(Worksheet B-1, columns 1 through 9, line 100), the corresponding total cost allocation
statistics (Worksheet B-1, column 1, line 1; column 2, line 2; etc.) must also be greater than
zero. Exclude from this edit any column that uses accumulated cost as its basis for
allocation and any reconciliation column. [12/31/2020]
1015B For any column that uses accumulated cost as its basis of allocation (on Worksheet B-1),
if there is a “-1” in the accumulated cost column, then there may not be an amount in the
reconciliation column for the same cost center line. [12/31/2020]
1010C Total Medicare program (Title XVIII) visits reported on Worksheet C, Part I, column 5,
must equal the visits reported on Worksheet S-3, Part IV, column 5, as follows:
Worksheet C, Part I, column 5:
Sum of lines 1 and 2
Sum of lines 3 and 4
Sum of lines 5 and 6
Line 7
Line 8
Line 9
[12/31/2020]
Must equal
Worksheet S-3, Part IV, column 5:
Line 1
Line 3
Line 5
Line 7
Line 9
Line 11
1015C For Worksheet C, Part II, lines 11 and 12, on a line by line basis, column 2, (total charges),
must be greater than or equal to Worksheet C, Part II, sum of columns 5 and 6 (Medicare
charges); and Worksheet C, Part II, lines 13 and 14, on a line by line basis, column 2, (total
charges), must be greater than or equal to Worksheet C, Part II, column 4 (Medicare
charges). [12/31/2020]
1020C For Worksheet C, Part II, lines 11 and 12, on a line by line basis, column 1, (total costs),
must be greater than or equal to Worksheet C, Part II, sum of columns 8 and 9 (Medicare
costs); and Worksheet C, Part II, lines 13 and 14, on a line by line basis, column 1 (total
costs), must be greater than or equal to Worksheet C, Part II, column 7 (Medicare costs).
[12/31/2020]
1010D If Medicare HHA visits (Worksheet S-3, Part I, column 1, line 11) are greater than zero,
then Medicare HHA costs (Worksheet D, Part II, column 1, line 28) must also be greater
than zero, and vice versa. [12/31/2020]
1020D If Worksheet D, Part II, column 1, line 35, is greater than zero, then Worksheet D-1,
column 2, line 4, must also be greater than zero, and vice versa. [12/31/2020]
1030D Worksheet D-1, column 2, line 4, and the sum of Worksheet D, Part II, column 1, lines 10
through 15 and lines 17 through 21, minus line 16, must both be greater than zero.
[12/31/2020]
Rev. 3
47-353
4790 (Cont.)
FORM CMS-1728-20
08-22
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 6 - EDITS
Edit
Condition
1000O For each HHA-based hospice, Worksheet O, column 7, line 100, must equal Worksheet A,
column 10, line 57 (or the applicable subscript), when Worksheet S-2, columns 2 and 3,
line 4 (or applicable subscripts), must have entries. [12/31/2020]
1050O Worksheet O-5, column 3, line 100, must equal Worksheet B, column 10, line 57.
[12/31/2020]
1110O For each general service cost center with a net expense for cost allocation greater than zero
(Worksheet O-6, Part II, columns 1 through 17, line 101), the corresponding total allocation
statistic (Worksheet O-6, Part II, column 1, line 1; column 2, line 2, etc.) must also be
greater than zero. Exclude from this edit any reconciliation column. [12/31/2020]
1120O Worksheet O-6, Part II, columns 6, 8, and 17, line 52, the statistic in each column must
equal Worksheet S-4, column 4, line 3, minus Worksheet S-4, column 4, line 6. For
Worksheet O-6, Part II, for each column 6, 8, and 17, if there is no cost on line 101, do not
apply this edit. [12/31/2020]
1130O Worksheet O-6, Part II, columns 6, 8, and 17, line 53, the statistic in each column must
equal Worksheet S-4, column 4, line 4, minus Worksheet S-4, column 4, line 7. For
Worksheet O-6, Part II, for each column 6, 8, and 17, if there is no cost on line 101, do not
apply this edit. [12/31/2020]
1140O Worksheet O-6, Part II, columns 10, 11, and 15, line 50, the statistic in each column must
equal Worksheet S-4, column 4, line 1. For Worksheet O-6, Part II, for each column 10,
11, and 15, if there is no cost on line 101, do not apply this edit. [12/31/2020]
1150O Worksheet O-6, Part II, columns 10, 11, and 15, line 51, the statistic in each column must
equal Worksheet S-4, column 4, line 2. For Worksheet O-6, Part II, for each column 10,
11, and 15, if there is no cost on line 101, do not apply this edit. [12/31/2020]
1160O Worksheet O-6, Part II, columns 10, 11, and 15, line 52, the statistic in each column must
equal Worksheet S-4, column 4, line 3. For Worksheet O-6, Part II, for each column 10,
11, and 15, if there is no cost on line 101, do not apply this edit. [12/31/2020]
1170O Worksheet O-6, Part II, columns 10, 11, and 15, line 53, the statistic in each column must
equal Worksheet S-4, column 4, line 4. For Worksheet O-6, Part II, for each column 10,
11, and 15, if there is no cost on line 101, do not apply this edit. [12/31/2020]
47-354
Rev. 3
08-22
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 6 - EDITS
II. Level 2 Edits (Potential Rejection Errors)
These conditions are usually, but not always, incorrect. These edit errors should be cleared when
possible through the cost report. When corrections on the cost report are not feasible, provide
additional information in schedules, note form, or any other manner as may be required by your
contractor. Failure to clear these errors in a timely fashion, as determined by your contractor, may
be grounds for withholding payments.
Edit
Condition
2000
All type 3 records with numeric fields and a positive usage must have values greater than
zero (supporting documentation may be required for negative amounts). [12/31/2020]
2005
All elements set forth in Table 3, with subscripts as appropriate, are required in the file.
[12/31/2020]
2015
Standard cost center lines, descriptions, and codes should not be changed. (See Table 5.)
This edit applies to the standard line only and not subscripts of that code. [12/31/2020]
2020
All standard cost center codes must be entered on the designated standard cost center line
and subscripts thereof as indicated in Table 5. [12/31/2020]
2025
Only nonstandard cost center codes within a cost center category may be placed on lines 9,
30, 50, and 58, and subscripts. [12/31/2020]
2035
Administrative and general cost center codes 00600, 00621, 00622, and 00623 (standard
and nonstandard) may only appear on line 6 and subscripts of line 6. Other nonstandard
descriptions and codes may also appear on subscripts of line 6, but must be within the
general services cost center category. [12/31/2020]
2010S The HHA certification date (Worksheet S-2, Part I, column 3, line 3) should be on or before
the cost report beginning date (Worksheet S-2, Part I, column 1, line 5). [12/31/2020]
2100S This edit has been redesignated as 1225S.
2105S If Medicare HHA unduplicated census count (Worksheet S-3, Part I, column 2, line 13) is
greater than zero, then Worksheet S-3, Part I, sum of columns 1 and 5, line 11, and
column 8, line 13, should be greater than zero. [12/31/2020]
Rev. 3
47-355
4790 (Cont.)
FORM CMS-1728-20
08-22
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 6 - EDITS
Edit
Condition
2110S Worksheet S-3, Part I, column 1, line 11 (total Medicare visits), must not equal
Worksheet S-3, Part IV, column 5, line 13 (PPS Medicare visits). [12/31/2020]
2010A Worksheet A, column 1, line 6 (A&G salaries), must be greater than zero. [12/31/2020]
Column headings (Worksheets B and B-1) are required as indicated for codes 2000B and 2005B:
2000B At least one cost center description (lines 1 through 3), at least one statistical basis label
(lines 4 through 5), and one statistical basis code (line 6) (capital cost center lines only)
must be present for each general service cost center with cost greater than zero
(Worksheet B-1, columns 1 through 9, line 100). Exclude any reconciliation columns from
this edit. [12/31/2020]
2005B The column numbering among these worksheets must be consistent. For example, data in
capital-related costs - buildings and fixtures is identified as coming from column 1 on all
applicable worksheets. [12/31/2020]
2010B If the sum of Medicare visits on Worksheet S-3, Part I, column 1, lines 1 through 9, are
greater than zero, then the corresponding cost on Worksheet B, column 10, lines 16
through 24, respectively (for each discipline), must also be greater than zero. [12/31/2020]
47-356
Rev. 3
04-21
FORM CMS-1728-20
4790 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-1728-20
TABLE 6 - EDITS
Edit
Condition
2000F Total assets on Worksheet F, line 32, must equal total liabilities and fund balances, line 48.
[12/31/2020]
2005F Gross patient revenues (Worksheet F-1, column 4, line 1) should be equal to or greater than
Medicare covered vaccines and drugs (Worksheet D, sum of columns 1 and 2, line 2).
[12/31/2020]
2010F Net income or loss (Worksheet F-1, column 2, line 33) should not equal zero. [12/31/2020]
2015F Gross patient revenues (Worksheet F-1, column 4, line 1) must be greater than or equal to
net patient revenues (Worksheet F-1, column 4, line 3). [12/31/2020]
2020F Worksheet F, line 48, must be greater than zero. [12/31/2020]
NOTE:
Rev. 2
CMS reserves the right to require additional edits to correct deficiencies that
become evident after processing the data commences and, as needed, to meet user
requirements.
47-357
4790 (Cont.)
FORM CMS-1728-20
04-21
This page is reserved for future use.
47-358
Rev. 2
09-20
FORM CMS 1728-20
4795
FORM CMS-1728-20 Worksheets
The following is a listing of the FORM CMS-1728-20 worksheets and the page number location.
Rev. 1
Worksheets
Page(s)
S, Parts I, II, & III
S-2, Part I
S-2, Part II
S-3, Parts I, II, & III
S-3, Part IV
S-3, Part V
S-4, Parts I & II
A
A-6
A-8
A-8-1
B
B-1
C, Parts I & II
D
D-1
F
F-1
O
O-1
O-2
O-3
O-4
O-5
O-6, Part I
O-6, Part II
O-7
O-8
47-503
47-504
47-505
47-506
47-507
47-508
47-509
47-510
47-511
47-512
47-513
47-514 - 47-515
47-516 - 47-517
47-518
47-519
47-520
47-521
47-522
47-523 - 47-524
47-525
47-526
47-527
47-528
47-529
47-530 - 47-531
47-532 - 47-533
47-534
47-535 - 47-536
47-501
4795
FORM CMS 1728-20
09-20
This page intentionally left blank.
47-502
Rev. 1
| File Type | application/pdf |
| File Title | Part 2, Provider Cost Reporting Forms and Instructions, Chapter 47, Form CMS-1728-20 |
| Subject | Part 2, Provider Cost Reporting Forms and Instructions, Chapter 47, Form CMS-1728-20 |
| Author | CMS |
| File Modified | 2023-06-01 |
| File Created | 2023-03-13 |