Form CMS-2540-24

Skilled Nursing Facility and Skilled Nursing Facility Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, and 413.106 (CMS-2540-24)

R1P249f.xlsx

Skilled Nursing Facility and Skilled Nursing Facility Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, and 413.106

OMB: 0938-0463

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Overview

S
S-2
S-3 I-V
S-4
S-5
A
A-6
A-7
A-8
A-8-1
A-8-2
BI
BII
B-1
B-2
C
C-6
D
D-1
E Pt A
E Pt B
E-1
E-2
G
G-2
G-3
H
H1-I
H1-II
H2-I
H2-II
H-3
H-4
H-5
K
K-1
K-2
K-3
K-4
K-5
K6-I
K6-II
K-7
K-8

Sheet 1: S

DRAFT				FORM CMS-2540-24												4995 (CONT.)
																FORM APPROVED
																OMB NO: 0938-0463
																EXPIRES: MM/DD/YYYY
SKILLED NURSING FACILITY AND SKILLED NURSING FACILITY HEALTHCARE							PROVIDER CCN:				PERIOD:				WORKSHEET S
COMPLEX COST REPORT STATUS, CERTIFICATION, AND SETTLEMENT SUMMARY							________________				FROM:		___________		PARTS I, II, & III
											TO:		___________


PART I - COST REPORT STATUS									1			2			3
1	ELECTRONICALLY PREPARED															1
2	MANUALLY PREPARED															2
3	IF AMENDED, NUMBER OF TIMES AMENDED															3
4	MEDICARE UTILIZATION															4
5	CONTRACTOR: HCRIS STATUS CODE															5
6	CONTRACTOR: COST REPORT RECEIVED DATE															6
7	CONTRACTOR: CONTRACTOR NUMBER															7
8	CONTRACTOR: INITIAL COST REPORT FOR THIS CCN															8
9	CONTRACTOR: FINAL COST REPORT FOR THIS CCN															9
10	CONTRACTOR: NPR DATE															10
11	CONTRACTOR: ADR SOFTWARE VENDOR CODE															11
12	CONTRACTOR: REOPENING NUMBER															12

PART II - CERTIFICATION













	SIGNATURE OF CHIEF FINANCIAL OFFICER OR ADMINISTRATOR				CHECKBOX			ELECTRONIC
	1				2			SIGNATURE STATEMENT
1																1




2	Signatory Printed Name															2
3	Signatory Title															3
4	Signature Date															4

PART III - SETTLEMENT SUMMARY
						TITLE XVIII
		CCN	TITLE V			PART A				PART B				TITLE XIX
	COMPONENT	1	2			3				4				5
1	SNF															1
2	NF															2
3	ICF/IID															3
4	SNF-BASED HHA															4


100	TOTAL															100















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTIONS 4901.10 THROUGH 4901.13)
Rev. 1																49-503

Sheet 2: S-2

4995 (CONT.)											FORM CMS-2540-24																					DRAFT
IDENTIFICATION DATA																				PROVIDER CCN:				PERIOD:					WORKSHEET S-2
																				________________				FROM:		___________
																								TO:		___________


SNF / SNF HEALTHCARE COMPLEX INFORMATION
		STREET ADDRESS													P O BOX
		1													2
1	ADDRESS LINE 1																															1

		CITY					STATE			ZIP CODE			COUNTY
		1					2			3			4
2	ADDRESS LINE 2																															2

													RURAL			DATE	DATE
													OR			CERTIFIED	CERTIFIED
	COMPONENT TYPE	COMPONENT NAME							CCN		CBSA		URBAN			MEDICARE	MEDICAID
	1	2							3		4		5			6	7
3	SNF																															3
4	NF																															4
5	ICF / IID																															5
6	SNF-BASED HHA																															6
7	SNF-BASED HOSPICE																															7
8	OUTPATIENT REHAB (SPECIFY)																															8

		FROM			TO
		1			2
9	COST REPORTING PERIOD																															9

					SPECIFY
		TOC CODE			OTHER
		1			2
10	TYPE OF CONTROL																															10

SNF ORGANIZATION AND OPERATION																														1
11	Is the SNF a distinct part SNF that meets the requirements set forth in 42 CFR section 483.5?																															11
12	Is the SNF a composite distinct part SNF that meets the requirements set forth in 42 CFR 483.5?																															12

				COMPONENT NAME								STREET ADDRESS							P O BOX		CITY						STATE			ZIP CODE
				1								2							3		4						5			6
13	Non-contiguous component locations																															13

																						Y/N			DATE				V OR I
																						1			2				3
14	COLUMN 1: Did the SNF terminate participation in the Medicare Program? COLUMN 2: Termination date. COLUMN 3: Voluntary (V) or involuntary (I) termination.																															14
15	COLUMN 1: Did the SNF change ownership (CHOW) immediately prior to the beginning of the cost reporting period? COLUMN 2: CHOW date.																															15








FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4901.30)
49-504																																Rev. 1
DRAFT											FORM CMS-2540-24																					4995 (CONT.)
IDENTIFICATION DATA																				PROVIDER CCN:				PERIOD:					WORKSHEET S-2
																				________________				FROM:		___________
																								TO:		___________


																						1			2
16	COLUMN 1: Is the SNF part of a HO/CO as defined in CMS Pub. 15-1, chapter 21, §2150?																															16
	COLUMN 2: Enter the number of HO/COs allocating costs to this SNF.

			HO/CO NAME					STREET ADDRESS					P O BOX			CITY		STATE		ZIP CODE			HO/CO CCN				HO/CO CONTRACTOR #
			1					2					3			4		5		6			7				8
17	HO/CO ALLOCATING TO SNF																															17

																											1
18	Did the total number of available beds permanently maintained for lodging inpatients change from the prior cost reporting period?																															18
19	Did this SNF operate a ventilator care unit?																															19

SNF OWNED SERVICES																												1			2
20	COLUMN 1: Did the SNF and/or SNF-based HHA operate a Medicare approved laboratory with its own CLIA number or a CLIA certificate of waiver that meets the requirements in 42 CFR 493?																															20
	COLUMN 2: Enter the CLIA ID number.
21	Did the SNF operate a radiological department that meets the standards required of a hospital furnishing such services under the program at 42 CFR 482.26 or the standards to provide portable x-ray services?																															21
22	COLUMN 1: Did this SNF operate an institutional based ambulance service? COLUMN 2: Enter the ambulance provider number.																															22

																													1
23	Is this SNF involved in business transactions, including management contracts, with individuals or entities that are related to the provider or its officers, medical staff, management personnel,																															23
	or members of the board of directors through ownership, control, or family and other similar relationships?

PROFESSIONAL SERVICES PURCHASED BY THE SNF																								1			2
29	COLUMN 1: Did the SNF and/or its subproviders (if applicable) purchase professional services, e.g., legal, accounting, tax preparation, bookkeeping, payroll, and/or management/consulting																															24
	services, from an unrelated organization? COLUMN 2: Were the majority of the expenses (i.e., greater than 50 percent of the total professional services expenses) for services purchased from
	unrelated organizations located outside of the main hospital’s local area labor market?

SNF-BASED HHA THERAPY COSTS																								1
31	Did the SNF-based HHA contract with outside suppliers for physical therapy services?																															31
32	Did the SNF-based HHA contract with outside suppliers for occupational therapy services?																															32
33	Did the SNF-based HHA contract with outside suppliers for speech therapy services?																															33

MEDICAL MALPRACTICE COST																								1			2			3
34	Is the SNF legally required to carry malpractice insurance?																															34
35	If line 34 is Y, is the malpractice policy a claims-made or occurrence policy? Enter 1 for claims-made, or enter 2 for occurrence based policy.																															35
36	If line 34 is Y, enter the total amount of malpractice premiums paid in column 1, the total amount of paid losses in column 2, and the total amount of self-insurance paid in column 3.																															36
37	Are malpractice premiums and paid losses reported in other than the A&G cost center?																															37

LOWER OF COST OR CHARGE EXEMPTION																								PART A			PART B
																								1			2
40	Did the SNF qualify for an exemption from the application of the lower of costs or charges?																															40
41	Did the SNF-based HHA qualify for an exemption from the application of the lower of costs or charges?																															41







FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4901.30)
Rev. 1																																49-505
4995 (CONT.)											FORM CMS-2540-24																					DRAFT
IDENTIFICATION DATA																				PROVIDER CCN:				PERIOD:					WORKSHEET S-2
																				________________				FROM:		___________
																								TO:		___________


FINANCIAL STATEMENTS																								1			2			3
50	COLUMN 1: Were the financial statements prepared by a CPA? COLUMN 2: If column 1 is Y, enter "A" for audited, "C" for complied,																															50
	or "R" for reviewed in column 2. COLUMN 3: If complete copy of the financial statements not submitted with cost report, enter data available.
51	Do total expenses and total revenues reported on the cost report differ from those on the filed financial statements? If "Y", submit a reconciliation.																															51

BAD DEBTS																								1
52	Is the SNF seeking reimbursement for Medicare bad debts?																															52
53	If line 52 is Y, did the SNF change its bad debt collection policy during this cost reporting period?																															53
54	If line 52 is Y, did the SNF waive patient deductibles and/or coinsurance?																															54

PS&R REPORT DATA																						PART A		PART A			PART B			PART B
																						Y/N		DATE			Y/N			DATE
																						1		2			3			4
55	Is this cost report prepared using only the PS&R? If either col. 1 or 3 is Y, enter the paid-through date of the PS&R used to prepare this cost report in cols. 2 and 4.																															55
56	Is this cost report prepared using the PS&R for totals and the provider's records to prepare this cost report in cols. 2 and 4?																															56
57	If line 55 or 56 is Y, were adjustments made to PS&R data for additional claims that have been billed, but are not included on the PS&R used to file this cost report?																															57
58	If line 55 or 56 is Y, were adjustments made to PS&R data for corrections of other PS&R Report information?																															58
59	If line 55 or 56 is Y, were adjustments made to PS&R data for other reasons? If Y, describe the other adjustment: ___________________________________																															59
60	Is this cost report prepared using only the provider's records?																															60

COST REPORT PREPARER CONTACT INFORMATION						FIRST NAME								LAST NAME								TITLE
						1								2								3
70	PREPARER																															70
						NAME
						1
71	EMPLOYER																															71
						TELEPHONE NUMBER								EMAIL ADDRESS
						1								2
72	CONTACT INFORMATION																															72




















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4901.30)
49-506																																Rev. 1

Sheet 3: S-3 I-V

DRAFT						FORM CMS-2540-24																	4995 (CONT.)
STATISTICAL DATA														PROVIDER CCN:		PERIOD:					WORKSHEET S-3
														________________		FROM:		___________			PART I
																TO:		___________


PART I - VISITS AND CENSUS DATA
			NUMBER	BED DAYS	INPATIENT DAYS								DISCHARGES
			OF BEDS	AVAILABLE	TITLE V		TITLE XVIII	TITLE XIX	OTHER		TOTAL		TITLE V		TITLE XVIII	TITLE XIX			OTHER			TOTAL
			1	2	3		4	5	6		7		8		9	10			11			12
1	SNF - FFS																						1
2	SNF - HMO																						2
3	NF - FFS																						3
4	NF - HMO																						4
5	ICF/IID																						5
6	HOSPICE																						6
7	TOTAL																						7

			AVERAGE LENGTH OF STAY						ADMISSIONS										FTE
			TITLE V	TITLE XVIII	TITLE XIX		OTHER	TOTAL	TITLE V		TITLE XVIII		TITLE XIX		OTHER	TOTAL			EMPLOYEE			NON-PAID
			13	14	15		16	17	18		19		20		21	22			23			24
1	SNF - FFS																						1
2	SNF - HMO																						2
3	NF - FFS																						3
4	NF - HMO																						4
5	ICF/IID																						5
6	HOSPICE																						6
7	TOTAL																						7



























FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTIONS 4901.41)
Rev. 1																							49-507
4995 (CONT.)						FORM CMS-2540-24																	DRAFT
STATISTICAL DATA														PROVIDER CCN:		PERIOD:					WORKSHEET S-3
														________________		FROM:		___________			PART II
																TO:		___________


PART II - SNF WAGE INDEX - DIRECT SALARIES

																					AVERAGE
								AMOUNT		RECLASS-											HOURLY
								REPORTED		IFICATIONS		ADJUSTMENTS			TOTAL		PAID HOURS				WAGE
								1		2		3			4		5				6
		SALARIES
1	TOTAL SALARY (SEE INSTRUCTIONS)																						1
2	PHYSICIAN SALARIES-PART A																						2
3	PHYSICIAN SALARIES-PART B																						3
4	HOME OFFICE PERSONNEL																						4
5	SUM OF LINES 2 THROUGH 4																						5
6	REVISED WAGES (LINE 1 MINUS LINE 5)																						6
7	HOME HEALTH AGENCY																						7
8	HOSPICE																						8
9	OTHER EXCLUDED AREAS																						9
10	SUBTOTAL EXCLUDED SALARY (SUM OF LINES 7 THROUGH 9)																						10
11	TOTAL ADJUSTED SALARIES (LINE 5 MINUS LINE 10)																						11
		OTHER WAGES AND RELATED COST
12	CONTRACT LABOR: PATIENT RELATED & MGMT																						12
13	CONTRACT LABOR: PHYSICIAN SERVICES-PART A																						13
14	HOME OFFICE SALARIES AND WAGE RELATED COSTS																						14
		WAGE RELATED COSTS
15	WAGE RELATED COSTS CORE (SEE PT. IV)																						15
16	WAGE RELATED COSTS (EXCLUDED UNITS)																						16
17	PHYSICIANS PART A - WRC																						17
18	PHYSICIANS PART B - WRC																						18
19	TOTAL ADJUSTED WAGE RELATED COST (SEE INSTRUCTIONS)																						19





















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4901.42)
49-508																							Rev. 1
DRAFT						FORM CMS-2540-24																	4995 (CONT.)
STATISTICAL DATA														PROVIDER CCN:		PERIOD:					WORKSHEET S-3
														________________		FROM:		___________			PART III
																TO:		___________


PART III - SNF WAGE INDEX - OVERHEAD COST - DIRECT SALARIES
																					AVERAGE
								AMOUNT		RECLASS OF		ADJUSTED									HOURLY
								REPORTED		SALARIES		SALARIES			TOTAL		PAID HOURS				WAGE
								1		2		3			4		5				6
1	EMPLOYEE BENEFITS DEPARTMENT																						1
2	ADMINISTRATIVE AND GENERAL																						2
3	PLANT OP, MAINT & REPAIRS																						3
4	LAUNDRY AND LINEN SERVICE																						4
5	HOUSEKEEPING																						5
6	DIETARY																						6
7	NURSING ADMINISTRATION																						7
8	CENTRAL SERVICES AND SUPPLY																						8
9	PHARMACY																						9
10	MEDICAL RECORDS																						10
11	MEDICAL SOCIAL SERVICES																						11
12	ACTIVITIES PROGRAM																						12
13	QA & PERFORMANCE IMPROVEMENT PROGRAM																						13
14	TRAINING AND IN-SERVICE EDUCATION																						14
15	PATIENT TRANSPORTATION PART A																						15





























FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4901.43)
Rev. 1																							49-509
4995 (CONT.)						FORM CMS-2540-24																	DRAFT
STATISTICAL DATA														PROVIDER CCN:		PERIOD:					WORKSHEET S-3
														________________		FROM:		___________			PART IV
																TO:		___________


PART IV - SNF WAGE - RELATED COSTS																				AMOUNT
		RETIREMENT COSTS
1	401k EMPLOYER CONTRIBUTIONS																						1
2	TAX SHELTERED ANNUITY EMPLOYER CONTRIBUTION																						2
3	QUALIFIED AND NON-QUALIFIED PENSION PLAN COST																						3
4	PRIOR YEAR PENSION SERVICE COST																						4
		PLAN ADMINISTRATIVE COSTS
5	401K/TSA PLAN ADMINISTRATION FEES																						5
6	LEGAL/ACCOUNTING/MANAGEMENT FEES-PENSION PLAN																						6
7	EMPLOYEE MANAGED CARE PROGRAM ADMINISTRATION FEES																						7
		HEALTH AND INSURANCE COSTS
8	HEALTH INSURANCE																						8
9	PRESCRIPTION DRUG PLAN																						9
10	DENTAL, HEARING AND VISION PLANS																						10
11	LIFE INSURANCE																						11
12	ACCIDENTAL INSURANCE																						12
13	DISABILITY INSURANCE																						13
14	LONG-TERM CARE INSURANCE																						14
15	WORKERS' COMPENSATION INSURANCE																						15
16	RETIREMENT HEALTH CARE COST																						16
		TAXES
17	FICA - EMPLOYER'S PORTION ONLY																						17
18	MEDICARE TAXES - EMPLOYER'S PORTION ONLY																						18
19	UNEMPLOYMENT INSURANCE																						19
20	STATE OR FEDERAL UNEMPLOYMENT TAXES																						20
		OTHER
21	EXECUTIVE DEFERRED COMPENSATION																						21
22	DAY CARE COST AND ALLOWANCES																						22
23	TUITION REIMBURSEMENT																						23
24	TOTAL WAGE RELATED COST																						24



















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTIONS 4901.44)
49-510																							Rev. 1
DRAFT						FORM CMS-2540-24																	4995 (CONT.)
STATISTICAL DATA														PROVIDER CCN:		PERIOD:					WORKSHEET S-3
														________________		FROM:		___________			PART V
																TO:		___________


PART V - SNF REPORTING OF DIRECT CARE EXPENDITURES
												EMPLOYEE			ADJUSTED		PAID HOURS				AVERAGE
												WAGE-			SALARIES		RELATED				HOURLY WAGE
										AMOUNT		RELATED			(COL.1 +		TO SALARY				(COL. 3 ÷
										REPORTED		COSTS			COL. 2)		IN COL. 3				COL. 4)
DIRECT SALARIES										1		2			3		4				5
		NURSING EMPLOYEES
1	REGISTERED NURSE																						1
2	LICENSED PRACTICAL NURSE																						2
3	CERTIFIED NURSING ASSISTANT																						3
4	TOTAL NURSING EXPENDITURES																						4
		TECHNICAL / PROFESSIONAL EMPLOYEES
5	PHYSICAL THERAPIST																						5
6	PHYSICAL THERAPY ASSISTANT																						6
7	OCCUPATIONAL THERAPIST																						7
8	OCCUPATIONAL THERAPY ASSISTANT																						8
9	SPEECH-LANGUAGE PATHOLOGIST																						9
10	THERAPY AIDES AND STUDENTS																						10
11	RESPIRATORY THERAPIST																						11
12	OTHER MEDICAL STAFF																						12

CONTRACT LABOR
		NURSING EMPLOYEES
15	REGISTERED NURSE																						15
16	LICENSED PRACTICAL NURSE																						16
17	CERTIFIED NURSING ASSISTANT																						17
18	TOTAL NURSING EXPENDITURES																						18
		TECHNICAL / PROFESSIONAL EMPLOYEES
19	PHYSICAL THERAPIST																						19
20	PHYSICAL THERAPY ASSISTANT																						20
21	OCCUPATIONAL THERAPIST																						21
22	OCCUPATIONAL THERAPY ASSISTANT																						22
23	SPEECH-LANGUAGE PATHOLOGIST																						23
24	THERAPY AIDES AND STUDENTS																						24
25	RESPIRATORY THERAPIST																						25
26	OTHER MEDICAL STAFF																						26

HOME OFFICE/CHAIN ORGANIZATION
		NURSING EMPLOYEES
29	REGISTERED NURSE																						29
30	LICENSED PRACTICAL NURSE																						30
31	CERTIFIED NURSING ASSISTANT																						31
32	TOTAL NURSING EXPENDITURES																						32
		TECHNICAL / PROFESSIONAL EMPLOYEES
33	PHYSICAL THERAPIST																						33
34	PHYSICAL THERAPY ASSISTANT																						34
35	OCCUPATIONAL THERAPIST																						35
36	OCCUPATIONAL THERAPY ASSISTANT																						36
37	SPEECH-LANGUAGE PATHOLOGIST																						37
38	THERAPY AIDES AND STUDENTS																						38
39	RESPIRATORY THERAPIST																						39
40	OTHER MEDICAL STAFF																						40

FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTIONS 4901.45)
Rev. 1																							49-511

Sheet 4: S-4

4995 (CONT.)			FORM CMS-2540-24										DRAFT
SNF-BASED HOME HEALTH AGENCY STATISTICAL DATA							PROVIDER CCN:		PERIOD:			WORKSHEET S-4
							________________		FROM:		___________	PARTS I & II
							HHA CCN:		TO:		___________
							________________

PART I - VISITS AND CENSUS DATA
		TITLE XVIII		TITLE XIX		OTHER				TOTAL
			MEDICARE		MEDICAID
		MEDICARE	PATIENT	MEDICAID	PATIENT	OTHER		PATIENT		TOTAL		PATIENT
		VISITS	CENSUS	VISITS	CENSUS	VISITS		CENSUS		VISITS		CENSUS
		1	2	3	4	5		6		7		8
1	SKILLED NURSING CARE - RN												1
2	SKILLED NURSING CARE - LPN												2
3	PHYSICAL THERAPY												3
4	PHYSICAL THERAPY ASSISTANT												4
5	OCCUPATIONAL THERAPY												5
6	CERTIFIED OCCUPATIONAL THERAPY ASSISTANT												6
7	SPEECH-LANGUAGE PATHOLOGY												7
8	MEDICAL SOCIAL SERVICE												8
9	HOME HEALTH AIDE												9
10	ALL OTHER SERVICES												10
11	TOTAL VISITS												11
12	HOME HEALTH AIDE HOURS												12
13	UNDUPLICATED CENSUS COUNT												13

PART II - EMPLOYMENT DATA FTES
1	NUMBER OF HOURS IN YOUR NORMAL WORK WEEK												1
		STAFF	CONTRACT	TOTAL
		1	2	3
2	ADMINISTRATOR AND ASSISTANT ADMINISTRATOR(S)												2
3	DIRECTOR AND ASSISTANT DIRECTOR(S)												3
4	OTHER ADMINISTRATIVE PERSONNEL												4
5	NURSING SUPERVISOR												5
6	REGISTERED NURSES												6
7	LICENSED PRACTICAL NURSES												7
8	PHYSICAL THERAPY SUPERVISOR												8
9	PHYSICAL THERAPISTS												9
10	PHYSICAL THERAPY ASSISTANTS												10
11	OCCUPATIONAL THERAPY SUPERVISOR												11
12	OCCUPATIONAL THERAPISTS												12
13	OCCUPATIONAL THERAPY ASSISTANTS												13
14	SPEECH-LANGUAGE PATHOLOGY SUPERVISOR												14
15	SPEECH-LANGUAGE PATHOLOGISTS												15
16	MEDICAL SOCIAL SERVICES SUPERVISOR												16
17	MEDICAL SOCIAL SERVICES												17
18	HOME HEALTH AIDE SUPERVISOR												18
19	HOME HEALTH AIDES												19
20													20






FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4901.50 THROUGH 4901.54)
49-512													Rev. 1
DRAFT			FORM CMS-2540-24										4995 (CONT.)
SNF-BASED HOME HEALTH AGENCY							PROVIDER CCN:		PERIOD:			WORKSHEET S-4
STATISTICAL DATA							________________		FROM:		___________	PARTS III & IV
							HHA CCN:		TO:		___________
							________________

PART III - CBSA DATA
				1
1	Enter the number of CBSAs where Medicare covered HHA services were provided during the cost reporting period.												1
2	List all CBSA codes where Medicare covered HHA services were provided during the cost reporting period												2

PART IV - PPS ACTIVITY DATA
		FULL PERIODS	FULL PERIODS
		WITHOUT	WITH	LUPA	PEP
		OUTLIERS	OUTLIERS	PERIODS	PERIODS	TOTAL
		1	2	3	4	5
1	SKILLED NURSING CARE VISITS												1
2	SKILLED NURSING CARE CHARGES												2
3	PHYSICAL THERAPY VISITS												3
4	PHYSICAL THERAPY VISIT CHARGES												4
5	OCCUPATIONAL THERAPY VISITS												5
6	OCCUPATIONAL THERAPY VISIT CHARGES												6
7	SPEECH-LANGUAGE PATHOLOGY VISITS												7
8	SPEECH-LANGUAGE PATHOLOGY VISIT CHARGES												8
9	MEDICAL SOCIAL SERVICE VISITS												9
10	MEDICAL SOCIAL SERVICE VISIT CHARGES												10
11	HOME HEALTH AIDE VISITS												11
12	HOME HEALTH AIDE VISIT CHARGES												12
13	TOTAL VISITS												13
14	OTHER CHARGES												14
15	TOTAL CHARGES												15
16	TOTAL NUMBER OF PERIODS												16
17	TOTAL NUMBER OF OUTLIER PERIODS												17
18	TOTAL NON-ROUTINE MEDICAL SUPPLY CHARGES												18





















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4901.50 THROUGH 4901.54)
Rev. 1													49-513

Sheet 5: S-5

4995 (CONT.)

FORM CMS-2540-24

DRAFT

SNF - BASED HOSPICE STATISTICAL DATA

PROVIDER CCN:

PERIOD:

WORKSHEET S-5

________________

FROM:

___________

HOSPICE CCN:

TO:

___________

________________

PART I - ENROLLMENT DAYS

TITLE XVIII

TITLE XIX

MEDICARE

MEDICAID

OTHER

TOTAL

HOSPICE CONTINUOUS HOME CARE

HOSPICE ROUTINE HOME CARE

HOSPICE INPATIENT RESPITE CARE

HOSPICE GENERAL INPATIENT CARE

TOTAL HOSPICE DAYS

PART II - CONTRACTED SERVICES

TITLE XVIII

TITLE XIX

MEDICARE

MEDICAID

OTHER

TOTAL

HOSPICE INPATIENT RESPITE CARE

HOSPICE GENERAL INPATIENT CARE

TOTAL CONTRACTED HOSPICE DAYS

FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTIONS 4901.60 THROUGH 4901.62)

49-514

Rev. 1

Sheet 6: A

DRAFT				FORM CMS-2540-24										4995 (CONT.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES								PROVIDER CCN:		PERIOD:			WORKSHEET A
								________________		FROM:	___________
										TO:	___________



						CONTRACT
					SALARIES	LABOR	LABOR		OTHER
					& WAGES	COSTS	SUBTOTAL		COSTS			SUBTOTAL
					1	2	3		4			5
		GENERAL SERVICE COST CENTERS
1	0100		CAPITAL RELATED - BUILDINGS & FIXTURES											1
2	0200		CAPITAL RELATED - MOVABLE EQUIPMENT											2
3	0300		EMPLOYEE BENEFITS DEPARTMENT											3
4	0400		ADMINISTRATIVE AND GENERAL											4
5	0500		PLANT OP, MAINT & REPAIRS											5
6	0600		LAUNDRY AND LINEN SERVICE											6
7	0700		HOUSEKEEPING											7
8	0800		DIETARY											8
9	0900		NURSING ADMINISTRATION											9
10	1000		CENTRAL SERVICES AND SUPPLY											10
11	1100		PHARMACY											11
12	1200		MEDICAL RECORDS											12
13	1300		MEDICAL SOCIAL SERVICES											13
14	1400		ACTIVITIES PROGRAM											14
15	1500		QA & PERFORMANCE IMPROVEMENT PROGRAM											15
16	1600		TRAINING AND IN-SERVICE EDUCATION											16
17	1700		PATIENT TRANSPORTATION PART A											17
18	1800													18
		INPATIENT ROUTINE NURSING COST CENTERS
25	2500		SKILLED NURSING FACILITY											25
26	2600		NURSING FACILITY											26
27	2700		ICF/IID											27
		ANCILLARY SERVICE COST CENTERS
30	3000		RADIOLOGY - DIAGNOSTIC											30
31	3100		RADIOLOGY - THERAPEUTIC/CHEMOTHERAPY											31
32	3200		LABORATORY											32
33	3300		IV THERAPY											33
34	3400		RESPIRATORY THERAPY											34
35	3500		PHYSICAL THERAPY											35
36	3600		OCCUPATIONAL THERAPY											36
37	3700		SPEECH LANGUAGE PATHOLOGIST											37
38	3800		AUDIOLOGY											38
39	3900		ELECTROCARDIOLOGY											39
40	4000		MEDICAL SUPPLIES CHARGED TO PATIENTS											40
41	4100		DRUGS: DRUGS CHARGED TO PATIENTS											41
42	4200		DRUGS: IV SOLUTIONS											42
43	4300		DENTAL CARE											43
44	4400		APPLIANCES AND EQUIPMENT											44
45	4500		BLOOD AND BLOOD PRODUCTS											45
46	4600		BLOOD TRANSFUSION/PROCESSING/STORAGE											46
47	4700													47


FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4902.10)
Rev. 1														49-515
4995 (CONT.)				FORM CMS-2540-24										DRAFT
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES								PROVIDER CCN:		PERIOD:			WORKSHEET A
								________________		FROM:	___________
										TO:	___________


												EXPENSES
							RECLASSIFIED					FOR
						RECLASS-	TRIAL		ADJUST-			COST
						IFICATIONS	BALANCE		MENTS			ALLOCATION
						6	7		8			9
		GENERAL SERVICE COST CENTERS
1	0100		CAPITAL RELATED - BUILDINGS & FIXTURES											1
2	0200		CAPITAL RELATED - MOVABLE EQUIPMENT											2
3	0300		EMPLOYEE BENEFITS DEPARTMENT											3
4	0400		ADMINISTRATIVE AND GENERAL											4
5	0500		PLANT OP, MAINT & REPAIRS											5
6	0600		LAUNDRY AND LINEN SERVICE											6
7	0700		HOUSEKEEPING											7
8	0800		DIETARY											8
9	0900		NURSING ADMINISTRATION											9
10	1000		CENTRAL SERVICES AND SUPPLY											10
11	1100		PHARMACY											11
12	1200		MEDICAL RECORDS											12
13	1300		MEDICAL SOCIAL SERVICES											13
14	1400		ACTIVITIES PROGRAM											14
15	1500		QA & PERFORMANCE IMPROVEMENT PROGRAM											15
16	1600		TRAINING AND IN-SERVICE EDUCATION											16
17	1700		PATIENT TRANSPORTATION PART A											17
18	1800													18
		INPATIENT ROUTINE NURSING COST CENTERS
25	2500		SKILLED NURSING FACILITY											25
26	2600		NURSING FACILITY											26
27	2700		ICF/IID											27
		ANCILLARY SERVICE COST CENTERS
30	3000		RADIOLOGY - DIAGNOSTIC											30
31	3100		RADIOLOGY - THERAPEUTIC/CHEMOTHERAPY											31
32	3200		LABORATORY											32
33	3300		INTRAVENOUS THERAPY											33
34	3400		RESPIRATORY THERAPY											34
35	3500		PHYSICAL THERAPY											35
36	3600		OCCUPATIONAL THERAPY											36
37	3700		SPEECH LANGUAGE PATHOLOGIST											37
38	3800		AUDIOLOGY											38
39	3900		ELECTROCARDIOLOGY											39
40	4000		MEDICAL SUPPLIES CHARGED TO PATIENTS											40
41	4100		DRUGS: DRUGS CHARGED TO PATIENTS											41
42	4200		DRUGS: IV SOLUTIONS											42
43	4300		DENTAL CARE											43
44	4400		APPLIANCES AND EQUIPMENT											44
45	4500		BLOOD AND BLOOD PRODUCTS											45
46	4600		BLOOD TRANSFUSION/PROCESSING/STORAGE											46
47	4700													47


FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4902.10)
49-516														Rev. 1
DRAFT				FORM CMS-2540-24										4995 (CONT.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES								PROVIDER CCN:		PERIOD:			WORKSHEET A
								________________		FROM:	___________
										TO:	___________



						CONTRACT
					SALARIES	LABOR	LABOR		OTHER
					& WAGES	COSTS	SUBTOTAL		COSTS			SUBTOTAL
					1	2	3		4			5
		OUTPATIENT SERVICE COST CENTERS
60	6000		SCREENING & PREVENTATIVE SERVICES											60
61	6100		OUTPATIENT LABORATORY											61
62	6200		PORTABLE X-RAY SERVICES											62
63	6300		OUTPATIENT DURABLE MEDICAL EQUIPMENT											63
64	6400													64
		OUTPATIENT REIMBURSABLE COST CENTERS
70	7000		HOME HEALTH AGENCY											70
71	7100		AMBULANCE											71
72	7200		HOSPICE											72
73	7300		OUTPATIENT REHABILITATION (SPECIFY)											73
74	7400
		COST REIMBURSED COST CENTERS
80	8000		PREVENTIVE VACCINES											80
81	8100													81
89	8900		SUBTOTALS											89
		NONREIMBURSABLE COST CENTERS
90	9000		GIFT, FLOWER, COFFEE SHOPS & CANTEEN											90
91	9100		NONPAID WORKERS											91
92	9200		PHYSICIAN PRIVATE OFFICES											92
93	9300													93
100			TOTAL											100






















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4902.10)
Rev. 1														49-517
4995 (CONT.)				FORM CMS-2540-24										DRAFT
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES								PROVIDER CCN:		PERIOD:			WORKSHEET A
								________________		FROM:	___________
										TO:	___________


												EXPENSES
							RECLASSIFIED					FOR
						RECLASS-	TRIAL		ADJUST-			COST
						IFICATIONS	BALANCE		MENTS			ALLOCATION
						6	7		8			9
		OUTPATIENT SERVICE COST CENTERS
60	6000		SCREENING & PREVENTATIVE SERVICES											60
61	6100		OUTPATIENT LABORATORY											61
62	6200		PORTABLE X-RAY SERVICES											62
63	6300		OUTPATIENT DURABLE MEDICAL EQUIPMENT											63
64	6400													64
		OUTPATIENT REIMBURSABLE COST CENTERS
70	7000		HOME HEALTH AGENCY											70
71	7100		AMBULANCE											71
72	7200		HOSPICE											72
73	7300		OUTPATIENT REHABILITATION (SPECIFY)											73
74	7400
		COST REIMBURSED SERVICES
80	8000		PREVENTIVE VACCINES											80
81	8100													81
89	8900		SUBTOTALS											89
		NONREIMBURSABLE COST CENTERS
90	9000		GIFT, FLOWER, COFFEE SHOPS & CANTEEN											90
91	9100		NONPAID WORKERS											91
92	9200		PHYSICIAN PRIVATE OFFICES											92
93	9300													93
100			TOTAL											100






















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4902.10)
49-518														Rev. 1

Sheet 7: A-6

DRAFT				FORM CMS-2540-24													4995 (CONT.)
RECLASSIFICATIONS									PROVIDER CCN:		PERIOD:				WORKSHEET A-6
									________________		FROM:		___________
											TO:		___________


			INCREASES					DECREASES								WKST
			COST					COST								A-7
		CODE	CENTER		LINE #	SALARY	OTHER	CENTER		LINE #		SALARY		OTHER		REF
	EXPLANATION OF RECLASSIFICATION	1	2		3	4	5	6		7		8		9		10
1																	1
2																	2
3																	3
4																	4
5																	5
6																	6
7																	7
8																	8
9																	9
10																	10
11																	11
12																	12
13																	13
14																	14
15																	15
16																	16
17																	17
18																	18
19																	19
20																	20
21																	21
22																	22
23																	23
24																	24
25																	25
26																	26
27																	27
28																	28
29																	29
30																	30
31																	31
32																	32
33																	33
34																	34
35																	35
500	TOTAL RECLASSIFICATIONS																500









FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4902.70)
Rev. 1																	49-519

Sheet 8: A-7

4995 (CONT.)				FORM CMS-2540-24															DRAFT
RECONCILIATION OF CAPITAL COST CENTERS										PROVIDER CCN:			PERIOD:				WORKSHEET A-7
										________________			FROM:		___________
													TO:		___________


PART I - ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCES
											DISPOSALS							FULLY
		BEGINNING				ACQUISITIONS					AND			ENDING				DEPRECIATED
		BALANCE		PURCHASES		DONATIONS		TOTAL			RETIREMENTS			BALANCE				ASSETS
		1	2		3		4		5			6				7
1	LAND																		1
2	LAND IMPROVEMENTS																		2
3	BUILDINGS AND FIXTURES																		3
4	BUILDING IMPROVEMENTS																		4
5	FIXED EQUIPMENT																		5
6	MOVABLE EQUIPMENT																		6
7	SUBTOTAL																		7
8	RECONCILING ITEMS																		8
9	TOTAL																		9

PART II - RECONCILIATION OF CAPTIAL COST CENTERS (SUMMARY OF CAPITAL)
												OTHER CAPITAL
												RELATED
		DEPRECIATION		LEASE		INTEREST		INSURANCE			TAXES	COSTS						TOTAL
		1	2		3		4		5			6				7
1	CAPITAL RELATED COSTS - BUILDINGS & FIXTURES																		1
2	CAPITAL RELATED COSTS - MOVABLE EQUIPMENT																		2
3	TOTAL																		3


























FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4902.80 THROUGH 4902.82)
49-520																			Rev. 1

Sheet 9: A-8

DRAFT		FORM CMS-2540-24										4995 (CONT.)
ADJUSTMENTS TO EXPENSES						PROVIDER CCN:		PERIOD:		WORKSHEET A-8
						________________		FROM:	___________
								TO:	___________


							WORKSHEET A
											LINE
			BASIS		AMOUNT		COST CENTER				NO.
	DESCRIPTION OF ADJUSTMENT		1		2		3				4
1	INVESTMENT INCOME ON RESTRICTED FUNDS (CMS PUB. 15-1, CHAPTER 2)											1
2	TRADE, QUANTITY, TIME, AND OTHER DISCOUNTS ON PURCHASES (CMS PUB. 15-1, CHAPTER 8)											2
3	REBATES AND REFUNDS OF EXPENSES (CMS PUB. 15-1, CHAPTER 8)											3
4	RENTAL OF PROVIDER SPACE BY SUPPLIERS (CMS PUB. 15-1, CHAPTER 8)											4
5	TELEPHONE SERVICES (CMS PUB. 15-1, CHAPTER 21)											5
6	TELEVISION AND RADIO SERVICES (CMS PUB. 15-1, CHAPTER 21)											6
7	PARKING LOT (CMS PUB. 15-1, CHAPTER 21)											7
8	REMUNERATION APPLICABLE TO PROVIDER-BASED PHYSICIAN ADJUSTMENT			WKST A-8-2								8
9	SALE OF SCRAP, WASTE, ETC. (CMS PUB. 15-1, CHAPTER 23)											9
10	RELATED ORGANIZATION AND HOME OFFICE COST TRANSACTIONS (CMS PUB. 15-1, CHAPTER 10)			WKST A-8-1								10
11	LAUNDRY AND LINEN SERVICE											11
12	REVENUE - EMPLOYEE MEALS											12
13	COST OF MEALS - GUESTS											13
14	SALE OF MEDICAL SUPPLIES TO OTHER THAN PATIENTS											14
15	SALE OF DRUGS TO OTHER THAN PATIENTS											15
16	REVENUE - COPYING COSTS OF MEDICAL RECORDS AND ABSTRACTS											16
17	VENDING MACHINES											17
18	INCOME FROM IMPOSITION OF INTEREST, FINANCE, OR PENALTY CHARGES (CMS PUB. 15-1, CHAPTER 21)											18
19	INTEREST EXPENSE ON MEDICARE OVERPAYMENTS AND BORROWINGS TO REPAY MEDICARE OVERPAYMENTS											19
20	DEPRECIATION--BUILDINGS AND FIXTUES						CRC-B&F				1	20
21	DEPRECIATION--MOVABLE EQUIPMENT						CRC-ME				2	21
22	SHORT TERM INPATIENT HOSPICE CARE											22
23	HOSPICE NON-CORE CONTRACTED SERVICES											23
24												24
25												25
26												26
27												27
28												28
29												29
30												30






100	TOTAL											100








FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4902.90)
Rev. 1												49-521

Sheet 10: A-8-1

4995 (CONT.)					FORM CMS-2540-24										DRAFT
RELATED ORGANIZATIONS AND HOME OFFICE COSTS								PROVIDER CCN:			PERIOD:			WORKSHEET A-8-1
								________________			FROM:	___________		PARTS I & II
											TO:	___________


PART I - COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS OR CLAIMED HOME OFFICE COSTS
						LINE #	AMOUNT			AMOUNT
	WORKSHEET A COST CENTER					ON	ALLOWABLE			INCLUDED IN			NET
	LINE #	DESCRIPTION	EXPENSE ITEM			PART II	IN COST			WKST. A, COL. 10			ADJUSTMENT
	1	2	3			4	5			6			7
1															1
2															2
3															3
4															4
5															5
6															6
7															7
8															8
9															9
10															10





100	TOTAL														100

PART II - INTERRELATIONSHIP BETWEEN RELATED ORGANIZATIONS AND / OR HOME OFFICE
	INTERRELA-				RELATED ORGANIZATION(S)
	TIONSHIP			PERCENTAGE		MEDICARE	PERCENTAGE
	INDICATOR	NAME		OF OWNERSHIP	NAME	HOME OFFICE #	OF OWNERSHIP		TYPE OF BUSINESS
	1	2		3	4	5	6		7
1															1
2															2
3															3
4															4
5															5
6															6
7															7
8															8
9															9
10															10




50															50







FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTIONS 4902.100 THROUGH 4902.102)
49-522															Rev. 1

Sheet 11: A-8-2

DRAFT				FORM CMS-2540-24										4995 (CONT.)
PROVIDER - BASED PHYSICIAN ADJUSTMENTS								PROVIDER CCN:		PERIOD:			WORKSHEET A-8-2
								________________		FROM:		___________
										TO:		___________


	WKST												FIVE
	A						ACTUAL HOURS						PERCENT OF
	LINE		TOTAL	PROFESSIONAL	PROVIDER	RCE	PROFESSIONAL		PROVIDER		UNADJUSTED		UNADJUSTED
	NO.	SPECIALTY / PHYSICIAN IDENTIFIER	REMUNERATION	COMPONENT	COMPONENT	AMOUNT	SERVICES		SERVICES		RCE LIMIT		RCE LIMIT
	1	2	3	4	5	6	7		8		9		10
1														1
2														2
3														3
4														4
5														5
6														6
7														7
8														8
9														9
10														10




100		TOTAL												100

			MEMBERSHIPS &		MALPRACTICE
	WKST		CONTINUING ED		INSURANCE				RCE
	A			PROVIDER		PROVIDER	ADJUSTED		DISALLOW-
	NO.	SPECIALTY / PHYSICIAN IDENTIFIER	COST	COMPONENT	COST	COMPONENT	RCE LIMIT		ANCE		ADJUSTMENT
	1	2	11	12	13	14	15		16		17
1														1
2														2
3														3
4														4
5														5
6														6
7														7
8														8
9														9
10														10




100		TOTAL												100








FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4902.110)
Rev. 1														49-523

Sheet 12: BI

4995 (CONT.)				FORM CMS-2540-24										DRAFT
ALLOCATION OF GENERAL SERVICES COSTS								PROVIDER CCN:		PERIOD:			WORKSHEET B
								________________		FROM:		___________	PART I
										TO:		___________


			NET
			EXPENSES			EMPLOYEE					PLANT OP,		LAUNDRY
			FOR COST	CRC-	CRC-	BENEFITS					MAINT &		& LINEN
			ALLOCATION	B&F	ME	DEPARTMENT	SUBTOTAL		A&G		REPAIRS		SERVICE
			0	1	2	3	3A		4		5		6
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS & FIXTURES													1
2	CAPITAL RELATED - MOVABLE EQUIPMENT													2
3	EMPLOYEE BENEFITS DEPARTMENT													3
4	ADMINISTRATIVE AND GENERAL													4
5	PLANT OP, MAINT & REPAIRS													5
6	LAUNDRY AND LINEN SERVICE													6
7	HOUSEKEEPING													7
8	DIETARY													8
9	NURSING ADMINISTRATION													9
10	CENTRAL SERVICES AND SUPPLY													10
11	PHARMACY													11
12	MEDICAL RECORDS													12
13	MEDICAL SOCIAL SERVICES													13
14	ACTIVITIES PROGRAM													14
15	QA & PERFORMANCE IMPROVEMENT PROGRAM													15
16	TRAINING AND IN-SERVICE EDUCATION													16
17	PATIENT TRANSPORTATION PART A													17
18														18
		INPATIENT ROUTINE NURSING COST CENTERS
25	SKILLED NURSING FACILITY													24
26	NURSING FACILITY													25
27	ICF/IID													26
		ANCILLARY SERVICE COST CENTERS
30	RADIOLOGY - DIAGNOSTIC													30
31	RADIOLOGY - THERAPEUTIC/CHEMOTHERAPY													31
32	LABORATORY													32
33	IV THERAPY													33
34	RESPIRATORY THERAPY													34
35	PHYSICAL THERAPY													35
36	OCCUPATIONAL THERAPY													36
37	SPEECH LANGUAGE PATHOLOGIST													37
38	AUDIOLOGY													38
39	ELECTROCARDIOLOGY													39
40	MEDICAL SUPPLIES CHARGED TO PATIENTS													40
41	DRUGS: DRUGS CHARGED TO PATIENTS													41
42	DRUGS: IV SOLUTIONS													42
43	DENTAL CARE													43
44	APPLIANCES AND EQUIPMENT													44
45	BLOOD AND BLOOD PRODUCTS													45
46	BLOOD TRANSFUSION/PROCESSING/STORAGE													46
47														47


FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4903.10)
49-524														Rev. 1
DRAFT				FORM CMS-2540-24										4995 (CONT.)
ALLOCATION OF GENERAL SERVICES COSTS								PROVIDER CCN:		PERIOD:			WORKSHEET B
								________________		FROM:		___________	PART I
										TO:		___________


			NET
			EXPENSES			EMPLOYEE					PLANT OP,		LAUNDRY
			FOR COST	CRC-	CRC-	BENEFITS					MAINT &		& LINEN
			ALLOCATION	B&F	ME	DEPARTMENT	SUBTOTAL		A&G		REPAIRS		SERVICE
			0	1	2	3	3A		4		5		6
		OUTPATIENT SERVICE COST CENTERS
60	SCREENING & PREVENTATIVE SERVICES													60
61	OUTPATIENT LABORATORY													61
62	PORTABLE X-RAY SERVICES													62
63	OUTPATIENT DURABLE MEDICAL EQUIPMENT													63
64														64
		OUTPATIENT REIMBURSABLE COST CENTERS
70	HOME HEALTH AGENCY													70
71	AMBULANCE													71
72	HOSPICE													72
73	OUTPATIENT REHAB (SPECIFY)													73
74
		COST REIMBURSED COST CENTERS
80	PREVENTIVE VACCINES													80
81														81
89	SUBTOTAL													89
		NONREIMBURSABLE COST CENTERS
90	GIFT, FLOWER, COFFEE SHOPS & CANTEEN													90
91	NONPAID WORKERS													91
92	PHYSICIAN PRIVATE OFFICES													92
93														93
99	NEGATIVE COST CENTER													99
100	TOTAL													100





















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4903.10)
Rev. 1														49-525
4995 (CONT.)				FORM CMS-2540-24										DRAFT
ALLOCATION OF GENERAL SERVICES COSTS								PROVIDER CCN:		PERIOD:			WORKSHEET B
								________________		FROM:		___________	PART I
										TO:		___________



						CENTRAL					MEDICAL
			HOUSE-		NURSING	SERVICE			MEDICAL		SOCIAL		ACTIVITIES
			KEEPING	DIETARY	ADMIN	& SUPPLY	PHARMACY		RECORDS		SERVICE		PROGRAM
			7	8	9	10	11		12		13		14
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS & FIXTURES													1
2	CAPITAL RELATED - MOVABLE EQUIPMENT													2
3	EMPLOYEE BENEFITS DEPARTMENT													3
4	ADMINISTRATIVE AND GENERAL													4
5	PLANT OP, MAINT & REPAIRS													5
6	LAUNDRY AND LINEN SERVICE													6
7	HOUSEKEEPING													7
8	DIETARY													8
9	NURSING ADMINISTRATION													9
10	CENTRAL SERVICES AND SUPPLY													10
11	PHARMACY													11
12	MEDICAL RECORDS													12
13	MEDICAL SOCIAL SERVICES													13
14	ACTIVITIES PROGRAM													14
15	QA & PERFORMANCE IMPROVEMENT PROGRAM													15
16	TRAINING AND IN-SERVICE EDUCATION													16
17	PATIENT TRANSPORTATION PART A													17
18														18
		INPATIENT ROUTINE NURSING COST CENTERS
25	SKILLED NURSING FACILITY													24
26	NURSING FACILITY													25
27	ICF/IID													26
		ANCILLARY SERVICE COST CENTERS
30	RADIOLOGY - DIAGNOSTIC													30
31	RADIOLOGY - THERAPEUTIC/CHEMOTHERAPY													31
32	LABORATORY													32
33	IV THERAPY													33
34	RESPIRATORY THERAPY													34
35	PHYSICAL THERAPY													35
36	OCCUPATIONAL THERAPY													36
37	SPEECH LANGUAGE PATHOLOGIST													37
38	AUDIOLOGY													38
39	ELECTROCARDIOLOGY													39
40	MEDICAL SUPPLIES CHARGED TO PATIENTS													40
41	DRUGS: DRUGS CHARGED TO PATIENTS													41
42	DRUGS: IV SOLUTIONS													42
43	DENTAL CARE													43
44	APPLIANCES AND EQUIPMENT													44
45	BLOOD AND BLOOD PRODUCTS													45
46	BLOOD TRANSFUSION/PROCESSING/STORAGE													46
47														47


FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4903.10)
49-526														Rev. 1
DRAFT				FORM CMS-2540-24										4995 (CONT.)
ALLOCATION OF GENERAL SERVICES COSTS								PROVIDER CCN:		PERIOD:			WORKSHEET B
								________________		FROM:		___________	PART I
										TO:		___________



						CENTRAL					MEDICAL
			HOUSE-		NURSING	SERVICE			MEDICAL		SOCIAL		ACTIVITIES
			KEEPING	DIETARY	ADMIN	& SUPPLY	PHARMACY		RECORDS		SERVICE		PROGRAM
			7	8	9	10	11		12		13		14
		OUTPATIENT SERVICE COST CENTERS
60	SCREENING & PREVENTATIVE SERVICES													60
61	OUTPATIENT LABORATORY													61
62	PORTABLE X-RAY SERVICES													62
63	OUTPATIENT DURABLE MEDICAL EQUIPMENT													63
64														64
		OUTPATIENT REIMBURSABLE COST CENTERS
70	HOME HEALTH AGENCY													70
71	AMBULANCE													71
72	HOSPICE													72
73	OUTPATIENT REHAB (SPECIFY)													73
74
		COST REIMBURSED COST CENTERS
80	PREVENTIVE VACCINES													80
81														81
89	SUBTOTAL													89
		NONREIMBURSABLE COST CENTERS
90	GIFT, FLOWER, COFFEE SHOPS & CANTEEN													90
91	NONPAID WORKERS													91
92	PHYSICIAN PRIVATE OFFICES													92
93														93
99	NEGATIVE COST CENTER													99
100	TOTAL													100





















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4903.10)
Rev. 1														49-527
4995 (CONT.)				FORM CMS-2540-24										DRAFT
ALLOCATION OF GENERAL SERVICES COSTS								PROVIDER CCN:		PERIOD:			WORKSHEET B
								________________		FROM:		___________	PART I
										TO:		___________



			QUALITY &	TRAINING &	PATIENT	OTHER			POST
			PERFORM	IN-SERVICE	TRANSPORT	GENERAL			STEPDOWN
			IMPROV PGM	EDUCATION	PART A	SERVICE	SUBTOTAL		ADJ		TOTAL
			15	16	17	18	19		20		21
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS & FIXTURES													1
2	CAPITAL RELATED - MOVABLE EQUIPMENT													2
3	EMPLOYEE BENEFITS DEPARTMENT													3
4	ADMINISTRATIVE AND GENERAL													4
5	PLANT OP, MAINT & REPAIRS													5
6	LAUNDRY AND LINEN SERVICE													6
7	HOUSEKEEPING													7
8	DIETARY													8
9	NURSING ADMINISTRATION													9
10	CENTRAL SERVICES AND SUPPLY													10
11	PHARMACY													11
12	MEDICAL RECORDS													12
13	MEDICAL SOCIAL SERVICES													13
14	ACTIVITIES PROGRAM													14
15	QA & PERFORMANCE IMPROVEMENT PROGRAM													15
16	TRAINING AND IN-SERVICE EDUCATION													16
17	PATIENT TRANSPORTATION PART A													17
18														18
		INPATIENT ROUTINE NURSING COST CENTERS
25	SKILLED NURSING FACILITY													24
26	NURSING FACILITY													25
27	ICF/IID													26
		ANCILLARY SERVICE COST CENTERS
30	RADIOLOGY - DIAGNOSTIC													30
31	RADIOLOGY - THERAPEUTIC/CHEMOTHERAPY													31
32	LABORATORY													32
33	IV THERAPY													33
34	RESPIRATORY THERAPY													34
35	PHYSICAL THERAPY													35
36	OCCUPATIONAL THERAPY													36
37	SPEECH LANGUAGE PATHOLOGIST													37
38	AUDIOLOGY													38
39	ELECTROCARDIOLOGY													39
40	MEDICAL SUPPLIES CHARGED TO PATIENTS													40
41	DRUGS: DRUGS CHARGED TO PATIENTS													41
42	DRUGS: IV SOLUTIONS													42
43	DENTAL CARE													43
44	APPLIANCES AND EQUIPMENT													44
45	BLOOD AND BLOOD PRODUCTS													45
46	BLOOD TRANSFUSION/PROCESSING/STORAGE													46
47														47


FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4903.10)
49-528														Rev. 1
DRAFT				FORM CMS-2540-24										4995 (CONT.)
ALLOCATION OF GENERAL SERVICES COSTS								PROVIDER CCN:		PERIOD:			WORKSHEET B
								________________		FROM:		___________	PART I
										TO:		___________



			QUALITY &	TRAINING &	PATIENT	OTHER			POST
			PERFORM	IN-SERVICE	TRANSPORT	GENERAL			STEPDOWN
			IMPROV PGM	EDUCATION	PART A	SERVICE	SUBTOTAL		ADJ		TOTAL
			15	16	17	18	19		20		21
		OUTPATIENT SERVICE COST CENTERS
60	SCREENING & PREVENTATIVE SERVICES													60
61	OUTPATIENT LABORATORY													61
62	PORTABLE X-RAY SERVICES													62
63	OUTPATIENT DURABLE MEDICAL EQUIPMENT													63
64														64
		OUTPATIENT REIMBURSABLE COST CENTERS
70	HOME HEALTH AGENCY													70
71	AMBULANCE													71
72	HOSPICE													72
73	OUTPATIENT REHAB (SPECIFY)													73
74
		COST REIMBURSED COST CENTERS
80	PREVENTIVE VACCINES													80
81														81
89	SUBTOTAL													89
		NONREIMBURSABLE COST CENTERS
90	GIFT, FLOWER, COFFEE SHOPS & CANTEEN													90
91	NONPAID WORKERS													91
92	PHYSICIAN PRIVATE OFFICES													92
93														93
99	NEGATIVE COST CENTER													99
100	TOTAL													100





















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4903.10)
Rev. 1														49-529

Sheet 13: BII

4995 (CONT.)				FORM CMS-2540-24										DRAFT
ALLOCATION OF CAPITAL RELATED COSTS								PROVIDER CCN:		PERIOD:			WORKSHEET B
								________________		FROM:		___________	PART II
										TO:		___________


			DIRECTLY
			ASSIGNED				EMPLOYEE				PLANT OP,		LAUNDRY
			CAPITAL	CRC-	CRC-		BENEFITS				MAINT &		& LINEN
			RELATED COST	B&F	ME	SUBTOTAL	DEPARTMENT		A&G		REPAIRS		SERVICE
			0	1	2	2A	3		4		5		6
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS & FIXTURES													1
2	CAPITAL RELATED - MOVABLE EQUIPMENT													2
3	EMPLOYEE BENEFITS DEPARTMENT													3
4	ADMINISTRATIVE AND GENERAL													4
5	PLANT OP, MAINT & REPAIRS													5
6	LAUNDRY AND LINEN SERVICE													6
7	HOUSEKEEPING													7
8	DIETARY													8
9	NURSING ADMINISTRATION													9
10	CENTRAL SERVICES AND SUPPLY													10
11	PHARMACY													11
12	MEDICAL RECORDS													12
13	MEDICAL SOCIAL SERVICES													13
14	ACTIVITIES PROGRAM													14
15	QA & PERFORMANCE IMPROVEMENT PROGRAM													15
16	TRAINING AND IN-SERVICE EDUCATION													16
17	PATIENT TRANSPORTATION PART A													17
18														18
		INPATIENT ROUTINE NURSING COST CENTERS
25	SKILLED NURSING FACILITY													24
26	NURSING FACILITY													25
27	ICF/IID													26
		ANCILLARY SERVICE COST CENTERS
30	RADIOLOGY - DIAGNOSTIC													30
31	RADIOLOGY - THERAPEUTIC/CHEMOTHERAPY													31
32	LABORATORY													32
33	INTRAVENOUS THERAPY													33
34	RESPIRATORY THERAPY													34
35	PHYSICAL THERAPY													35
36	OCCUPATIONAL THERAPY													36
37	SPEECH LANGUAGE PATHOLOGIST													37
38	AUDIOLOGY													38
39	ELECTROCARDIOLOGY													39
40	MEDICAL SUPPLIES CHARGED TO PATIENTS													40
41	DRUGS: DRUGS CHARGED TO PATIENTS													41
42	DRUGS: IV SOLUTIONS													42
43	DENTAL CARE													43
44	APPLIANCES AND EQUIPMENT													44
45	BLOOD AND BLOOD PRODUCTS													45
46	BLOOD TRANSFUSION/PROCESSING/STORAGE													46
47														47


FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTIONS 4903.20)
49-530														Rev. 1
DRAFT				FORM CMS-2540-24										4995 (CONT.)
ALLOCATION OF CAPITAL RELATED COSTS								PROVIDER CCN:		PERIOD:			WORKSHEET B
								________________		FROM:		___________	PART II
										TO:		___________


			DIRECTLY
			ASSIGNED				EMPLOYEE				PLANT OP,		LAUNDRY
			CAPITAL	CRC-	CRC-		BENEFITS				MAINT &		& LINEN
			RELATED COST	B&F	ME	SUBTOTAL	DEPARTMENT		A&G		REPAIRS		SERVICE
			0	1	2	2A	3		4		5		6
		OUTPATIENT SERVICE COST CENTERS
60	SCREENING & PREVENTATIVE SERVICES													60
61	OUTPATIENT LABORATORY													61
62	PORTABLE X-RAY SERVICES													62
63	OUTPATIENT DURABLE MEDICAL EQUIPMENT													63
64														64
		OUTPATIENT REIMBURSABLE COST CENTERS
70	HOME HEALTH AGENCY													70
71	AMBULANCE													71
72	HOSPICE													72
73	OUTPATIENT REHAB (SPECIFY)													73
74
		COST REIMBURSED COST CENTERS
80	PREVENTIVE VACCINES													80
81														81
89	SUBTOTALS													89
		NONREIMBURSABLE COST CENTERS
90	GIFT, FLOWER, COFFEE SHOPS & CANTEEN													90
91	NONPAID WORKERS													91
92	PHYSICIAN PRIVATE OFFICES													92
93														93
99	NEGATIVE COST CENTER													99
100	TOTAL													100





















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTIONS 4903.20)
Rev. 1														49-531
4995 (CONT.)				FORM CMS-2540-24										DRAFT
ALLOCATION OF CAPITAL RELATED COSTS								PROVIDER CCN:		PERIOD:			WORKSHEET B
								________________		FROM:		___________	PART II
										TO:		___________



						CENTRAL					MEDICAL
			HOUSE-		NURSING	SERVICE			MEDICAL		SOCIAL		ACTIVITIES
			KEEPING	DIETARY	ADMIN	& SUPPLY	PHARMACY		RECORDS		SERVICE		PROGRAM
			7	8	9	10	11		12		13		14
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS & FIXTURES													1
2	CAPITAL RELATED - MOVABLE EQUIPMENT													2
3	EMPLOYEE BENEFITS DEPARTMENT													3
4	ADMINISTRATIVE AND GENERAL													4
5	PLANT OP, MAINT & REPAIRS													5
6	LAUNDRY AND LINEN SERVICE													6
7	HOUSEKEEPING													7
8	DIETARY													8
9	NURSING ADMINISTRATION													9
10	CENTRAL SERVICES AND SUPPLY													10
11	PHARMACY													11
12	MEDICAL RECORDS													12
13	MEDICAL SOCIAL SERVICES													13
14	ACTIVITIES PROGRAM													14
15	QA & PERFORMANCE IMPROVEMENT PROGRAM													15
16	TRAINING AND IN-SERVICE EDUCATION													16
17	PATIENT TRANSPORTATION PART A													17
18														18
		INPATIENT ROUTINE NURSING COST CENTERS
25	SKILLED NURSING FACILITY													24
26	NURSING FACILITY													25
27	ICF/IID													26
		ANCILLARY SERVICE COST CENTERS
30	RADIOLOGY - DIAGNOSTIC													30
31	RADIOLOGY - THERAPEUTIC/CHEMOTHERAPY													31
32	LABORATORY													32
33	INTRAVENOUS THERAPY													33
34	RESPIRATORY THERAPY													34
35	PHYSICAL THERAPY													35
36	OCCUPATIONAL THERAPY													36
37	SPEECH LANGUAGE PATHOLOGIST													37
38	AUDIOLOGY													38
39	ELECTROCARDIOLOGY													39
40	MEDICAL SUPPLIES CHARGED TO PATIENTS													40
41	DRUGS: DRUGS CHARGED TO PATIENTS													41
42	DRUGS: IV SOLUTIONS													42
43	DENTAL CARE													43
44	APPLIANCES AND EQUIPMENT													44
45	BLOOD AND BLOOD PRODUCTS													45
46	BLOOD TRANSFUSION/PROCESSING/STORAGE													46
47														47


FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTIONS 4903.20)
49-532														Rev. 1
DRAFT				FORM CMS-2540-24										4995 (CONT.)
ALLOCATION OF CAPITAL RELATED COSTS								PROVIDER CCN:		PERIOD:			WORKSHEET B
								________________		FROM:		___________	PART II
										TO:		___________



						CENTRAL					MEDICAL
			HOUSE-		NURSING	SERVICE			MEDICAL		SOCIAL		ACTIVITIES
			KEEPING	DIETARY	ADMIN	& SUPPLY	PHARMACY		RECORDS		SERVICE		PROGRAM
			7	8	9	10	11		12		13		14
		OUTPATIENT SERVICE COST CENTERS
60	SCREENING & PREVENTATIVE SERVICES													60
61	OUTPATIENT LABORATORY													61
62	PORTABLE X-RAY SERVICES													62
63	OUTPATIENT DURABLE MEDICAL EQUIPMENT													63
64														64
		OUTPATIENT REIMBURSABLE COST CENTERS
70	HOME HEALTH AGENCY													70
71	AMBULANCE													71
72	HOSPICE													72
73	OUTPATIENT REHAB (SPECIFY)													73
74
		COST REIMBURSED COST CENTERS
80	PREVENTIVE VACCINES													80
81														81
89	SUBTOTALS													89
		NONREIMBURSABLE COST CENTERS
90	GIFT, FLOWER, COFFEE SHOPS & CANTEEN													90
91	NONPAID WORKERS													91
92	PHYSICIAN PRIVATE OFFICES													92
93														93
99	NEGATIVE COST CENTER													99
100	TOTAL													100





















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTIONS 4903.20)
Rev. 1														49-533
4995 (CONT.)				FORM CMS-2540-24										DRAFT
ALLOCATION OF CAPITAL RELATED COSTS								PROVIDER CCN:		PERIOD:			WORKSHEET B
								________________		FROM:		___________	PART II
										TO:		___________



			QUALITY &	TRAINING &	PATIENT	OTHER			POST
			PERFORM	IN-SERVICE	TRANSPORT	GENERAL			STEPDOWN
			IMPROV PGM	EDUCATION	PART A	SERVICE	SUBTOTAL		ADJ		TOTAL
			15	16	17	18	19		20		21
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS & FIXTURES													1
2	CAPITAL RELATED - MOVABLE EQUIPMENT													2
3	EMPLOYEE BENEFITS DEPARTMENT													3
4	ADMINISTRATIVE AND GENERAL													4
5	PLANT OP, MAINT & REPAIRS													5
6	LAUNDRY AND LINEN SERVICE													6
7	HOUSEKEEPING													7
8	DIETARY													8
9	NURSING ADMINISTRATION													9
10	CENTRAL SERVICES AND SUPPLY													10
11	PHARMACY													11
12	MEDICAL RECORDS													12
13	MEDICAL SOCIAL SERVICES													13
14	ACTIVITIES PROGRAM													14
15	QA & PERFORMANCE IMPROVEMENT PROGRAM													15
16	TRAINING AND IN-SERVICE EDUCATION													16
17	PATIENT TRANSPORTATION PART A													17
18														18
		INPATIENT ROUTINE NURSING COST CENTERS
25	SKILLED NURSING FACILITY													24
26	NURSING FACILITY													25
27	ICF/IID													26
		ANCILLARY SERVICE COST CENTERS
30	RADIOLOGY - DIAGNOSTIC													30
31	RADIOLOGY - THERAPEUTIC/CHEMOTHERAPY													31
32	LABORATORY													32
33	INTRAVENOUS THERAPY													33
34	RESPIRATORY THERAPY													34
35	PHYSICAL THERAPY													35
36	OCCUPATIONAL THERAPY													36
37	SPEECH LANGUAGE PATHOLOGIST													37
38	AUDIOLOGY													38
39	ELECTROCARDIOLOGY													39
40	MEDICAL SUPPLIES CHARGED TO PATIENTS													40
41	DRUGS: DRUGS CHARGED TO PATIENTS													41
42	DRUGS: IV SOLUTIONS													42
43	DENTAL CARE													43
44	APPLIANCES AND EQUIPMENT													44
45	BLOOD AND BLOOD PRODUCTS													45
46	BLOOD TRANSFUSION/PROCESSING/STORAGE													46
47														47


FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTIONS 4903.20)
49-534														Rev. 1
DRAFT				FORM CMS-2540-24										4995 (CONT.)
ALLOCATION OF CAPITAL RELATED COSTS								PROVIDER CCN:		PERIOD:			WORKSHEET B
								________________		FROM:		___________	PART II
										TO:		___________



			QUALITY &	TRAINING &	PATIENT	OTHER			POST
			PERFORM	IN-SERVICE	TRANSPORT	GENERAL			STEPDOWN
			IMPROV PGM	EDUCATION	PART A	SERVICE	SUBTOTAL		ADJ		TOTAL
			15	16	17	18	19		20		21
		OUTPATIENT SERVICE COST CENTERS
60	SCREENING & PREVENTATIVE SERVICES													60
61	OUTPATIENT LABORATORY													61
62	PORTABLE X-RAY SERVICES													62
63	OUTPATIENT DURABLE MEDICAL EQUIPMENT													63
64														64
		OUTPATIENT REIMBURSABLE COST CENTERS
70	HOME HEALTH AGENCY													70
71	AMBULANCE													71
72	HOSPICE													72
73	OUTPATIENT REHAB (SPECIFY)													73
74
		COST REIMBURSED COST CENTERS
80	PREVENTIVE VACCINES													80
81														81
89	SUBTOTALS													89
		NONREIMBURSABLE COST CENTERS
90	GIFT, FLOWER, COFFEE SHOPS & CANTEEN													90
91	NONPAID WORKERS													91
92	PHYSICIAN PRIVATE OFFICES													92
93														93
99	NEGATIVE COST CENTER													99
100	TOTAL													100





















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTIONS 4903.20)
Rev. 1														49-535

Sheet 14: B-1

4995 (CONT.)				FORM CMS-2540-24										DRAFT
COST ALLOCATIONS - STATISTICAL BASES								PROVIDER CCN:		PERIOD:			WORKSHEET B-1
								________________		FROM:		___________
										TO:		___________


						EMPLOYEE					PLANT OP,		LAUNDRY
				CRC-	CRC-	BENEFITS	RECONCIL-				MAINT &		& LINEN
				B&F	ME	DEPARTMENT	IATION		A&G		REPAIRS		SERVICE
				(SQUARE	(DOLLAR	(GROSS			(ACCUM		(SQUARE		(POUNDS OF
				FEET)	VALUE)	SALARIES)			COST)		FEET)		LAUNDRY)
				1	2	3	4A		4		5		6
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS & FIXTURES													1
2	CAPITAL RELATED - MOVABLE EQUIPMENT													2
3	EMPLOYEE BENEFITS DEPARTMENT													3
4	ADMINISTRATIVE AND GENERAL													4
5	PLANT OP, MAINT & REPAIRS													5
6	LAUNDRY AND LINEN SERVICE													6
7	HOUSEKEEPING													7
8	DIETARY													8
9	NURSING ADMINISTRATION													9
10	CENTRAL SERVICES AND SUPPLY													10
11	PHARMACY													11
12	MEDICAL RECORDS													12
13	MEDICAL SOCIAL SERVICES													13
14	ACTIVITIES PROGRAM													14
15	QA & PERFORMANCE IMPROVEMENT PROGRAM													15
16	TRAINING AND IN-SERVICE EDUCATION													16
17	PATIENT TRANSPORTATION PART A													17
18														18
		INPATIENT ROUTINE NURSING COST CENTERS
25	SKILLED NURSING FACILITY													24
26	NURSING FACILITY													25
27	ICF/IID													26
		ANCILLARY SERVICE COST CENTERS
30	RADIOLOGY - DIAGNOSTIC													30
31	RADIOLOGY - THERAPEUTIC/CHEMOTHERAPY													31
32	LABORATORY													32
33	INTRAVENOUS THERAPY													33
34	RESPIRATORY THERAPY													34
35	PHYSICAL THERAPY													35
36	OCCUPATIONAL THERAPY													36
37	SPEECH LANGUAGE PATHOLOGIST													37
38	AUDIOLOGY													38
39	ELECTROCARDIOLOGY													39
40	MEDICAL SUPPLIES CHARGED TO PATIENTS													40
41	DRUGS: DRUGS CHARGED TO PATIENTS													41
42	DRUGS: IV SOLUTIONS													42
43	DENTAL CARE													43
44	APPLIANCES AND EQUIPMENT													44
45	BLOOD AND BLOOD PRODUCTS													45
46	BLOOD TRANSFUSION/PROCESSING/STORAGE													46
47														47

FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4903.10)
49-536														Rev. 1
DRAFT				FORM CMS-2540-24										4995 (CONT.)
COST ALLOCATIONS - STATISTICAL BASES								PROVIDER CCN:		PERIOD:			WORKSHEET B-1
								________________		FROM:		___________
										TO:		___________


						EMPLOYEE					PLANT OP,		LAUNDRY
				CRC-	CRC-	BENEFITS	RECONCIL-				MAINT &		& LINEN
				B&F	ME	DEPARTMENT	IATION		A&G		REPAIRS		SERVICE
				(SQUARE	(DOLLAR	(GROSS			(ACCUM		(SQUARE		(POUNDS OF
				FEET)	VALUE)	SALARIES)			COST)		FEET)		LAUNDRY)
				1	2	3	4A		4		5		6
		OUTPATIENT SERVICE COST CENTERS
60	SCREENING & PREVENTATIVE SERVICES													60
61	OUTPATIENT LABORATORY													61
62	PORTABLE X-RAY SERVICES													62
63	OUTPATIENT DURABLE MEDICAL EQUIPMENT													63
64														64
		OUTPATIENT REIMBURSABLE COST CENTERS
70	HOME HEALTH AGENCY													70
71	AMBULANCE													71
72	HOSPICE													72
73	OUTPATIENT REHAB (SPECIFY)													73
74
		COST REIMBURSED COST CENTERS
80	PREVENTIVE VACCINES													80
81														81
89	SUBTOTAL													89
		NONREIMBURSABLE COST CENTERS
90	GIFT, FLOWER, COFFEE SHOPS & CANTEEN													90
91	NONPAID WORKERS													91
92	PHYSICIAN PRIVATE OFFICES													92
93														93
98	CROSS FOOT ADJUSTMENT													98
99	NEGATIVE COST CENTER													99
102	COST TO BE ALLOCATED - WKST B, PART I													102
103	UNIT COST MULTIPLIER - WKST B, PART I													103
104	COST TO BE ALLOCATED - WKST B, PART II													104
105	UNIT COST MULTIPLIER - WKST B, PART II													105
















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4903.10)
Rev. 1														49-537
4995 (CONT.)				FORM CMS-2540-24										DRAFT
COST ALLOCATIONS - STATISTICAL BASES								PROVIDER CCN:		PERIOD:			WORKSHEET B-1
								________________		FROM:		___________
										TO:		___________


						CENTRAL					MEDICAL
			HOUSE-		NURSING	SERVICE			MEDICAL		SOCIAL		ACTIVITIES
			KEEPING	DIETARY	ADMIN	& SUPPLY	PHARMACY		RECORDS		SERVICE		PROGRAM
			(HOURS OF	(MEALS	(DIRECT	(COSTED	(COSTED		(TIME		(TIME		(TIME
			SERVICE)	SERVED)	NURSING HRS)	REQUIS)	REQUIS)		SPENT)		SPENT)		SPENT)
			7	8	9	10	11		12		13		14
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS & FIXTURES													1
2	CAPITAL RELATED - MOVABLE EQUIPMENT													2
3	EMPLOYEE BENEFITS DEPARTMENT													3
4	ADMINISTRATIVE AND GENERAL													4
5	PLANT OP, MAINT & REPAIRS													5
6	LAUNDRY AND LINEN SERVICE													6
7	HOUSEKEEPING													7
8	DIETARY													8
9	NURSING ADMINISTRATION													9
10	CENTRAL SERVICES AND SUPPLY													10
11	PHARMACY													11
12	MEDICAL RECORDS													12
13	MEDICAL SOCIAL SERVICES													13
14	ACTIVITIES PROGRAM													14
15	QA & PERFORMANCE IMPROVEMENT PROGRAM													15
16	TRAINING AND IN-SERVICE EDUCATION													16
17	PATIENT TRANSPORTATION PART A													17
18														18
		INPATIENT ROUTINE NURSING COST CENTERS
25	SKILLED NURSING FACILITY													24
26	NURSING FACILITY													25
27	ICF/IID													26
		ANCILLARY SERVICE COST CENTERS
30	RADIOLOGY - DIAGNOSTIC													30
31	RADIOLOGY - THERAPEUTIC/CHEMOTHERAPY													31
32	LABORATORY													32
33	INTRAVENOUS THERAPY													33
34	RESPIRATORY THERAPY													34
35	PHYSICAL THERAPY													35
36	OCCUPATIONAL THERAPY													36
37	SPEECH LANGUAGE PATHOLOGIST													37
38	AUDIOLOGY													38
39	ELECTROCARDIOLOGY													39
40	MEDICAL SUPPLIES CHARGED TO PATIENTS													40
41	DRUGS: DRUGS CHARGED TO PATIENTS													41
42	DRUGS: IV SOLUTIONS													42
43	DENTAL CARE													43
44	APPLIANCES AND EQUIPMENT													44
45	BLOOD AND BLOOD PRODUCTS													45
46	BLOOD TRANSFUSION/PROCESSING/STORAGE													46
47														47

FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4903.10)
49-538														Rev. 1
DRAFT				FORM CMS-2540-24										4995 (CONT.)
COST ALLOCATIONS - STATISTICAL BASES								PROVIDER CCN:		PERIOD:			WORKSHEET B-1
								________________		FROM:		___________
										TO:		___________


						CENTRAL					MEDICAL
			HOUSE-		NURSING	SERVICE			MEDICAL		SOCIAL		ACTIVITIES
			KEEPING	DIETARY	ADMIN	& SUPPLY	PHARMACY		RECORDS		SERVICE		PROGRAM
			(HOURS OF	(MEALS	(DIRECT	(COSTED	(COSTED		(TIME		(TIME		(TIME
			SERVICE)	SERVED)	NURSING HRS)	REQUIS)	REQUIS)		SPENT)		SPENT)		SPENT)
			7	8	9	10	11		12		13		14
		OUTPATIENT SERVICE COST CENTERS
60	SCREENING & PREVENTATIVE SERVICES													60
61	OUTPATIENT LABORATORY													61
62	PORTABLE X-RAY SERVICES													62
63	OUTPATIENT DURABLE MEDICAL EQUIPMENT													63
64														64
		OUTPATIENT REIMBURSABLE COST CENTERS
70	HOME HEALTH AGENCY													70
71	AMBULANCE													71
72	HOSPICE													72
73	OUTPATIENT REHAB (SPECIFY)													73
74
		COST REIMBURSED COST CENTERS
80	PREVENTIVE VACCINES													80
81														81
89	SUBTOTAL													89
		NONREIMBURSABLE COST CENTERS
90	GIFT, FLOWER, COFFEE SHOPS & CANTEEN													90
91	NONPAID WORKERS													91
92	PHYSICIAN PRIVATE OFFICES													92
93														93
98	CROSS FOOT ADJUSTMENT													98
99	NEGATIVE COST CENTER													99
102	COST TO BE ALLOCATED - WKST B, PART I													102
103	UNIT COST MULTIPLIER - WKST B, PART I													103
104	COST TO BE ALLOCATED - WKST B, PART II													104
105	UNIT COST MULTIPLIER - WKST B, PART II													105
















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4903.10)
Rev. 1														49-539
4995 (CONT.)				FORM CMS-2540-24										DRAFT
COST ALLOCATIONS - STATISTICAL BASES								PROVIDER CCN:		PERIOD:			WORKSHEET B-1
								________________		FROM:		___________
										TO:		___________


			QUALITY &	TRAINING &	PATIENT	OTHER
			PERFORM	IN-SERVICE	TRANSPORT	GENERAL
			IMPROV PGM	EDUCATION	PART A	SERVICE
			(TIME	(TIME	(NUMBER OF
			SPENT)	SPENT)	TRANSPRTS)	(SPECIFY)
			15	16	17	18
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS & FIXTURES													1
2	CAPITAL RELATED - MOVABLE EQUIPMENT													2
3	EMPLOYEE BENEFITS DEPARTMENT													3
4	ADMINISTRATIVE AND GENERAL													4
5	PLANT OP, MAINT & REPAIRS													5
6	LAUNDRY AND LINEN SERVICE													6
7	HOUSEKEEPING													7
8	DIETARY													8
9	NURSING ADMINISTRATION													9
10	CENTRAL SERVICES AND SUPPLY													10
11	PHARMACY													11
12	MEDICAL RECORDS													12
13	MEDICAL SOCIAL SERVICES													13
14	ACTIVITIES PROGRAM													14
15	QA & PERFORMANCE IMPROVEMENT PROGRAM													15
16	TRAINING AND IN-SERVICE EDUCATION													16
17	PATIENT TRANSPORTATION PART A													17
18														18
		INPATIENT ROUTINE NURSING COST CENTERS
25	SKILLED NURSING FACILITY													24
26	NURSING FACILITY													25
27	ICF/IID													26
		ANCILLARY SERVICE COST CENTERS
30	RADIOLOGY - DIAGNOSTIC													30
31	RADIOLOGY - THERAPEUTIC/CHEMOTHERAPY													31
32	LABORATORY													32
33	INTRAVENOUS THERAPY													33
34	RESPIRATORY THERAPY													34
35	PHYSICAL THERAPY													35
36	OCCUPATIONAL THERAPY													36
37	SPEECH LANGUAGE PATHOLOGIST													37
38	AUDIOLOGY													38
39	ELECTROCARDIOLOGY													39
40	MEDICAL SUPPLIES CHARGED TO PATIENTS													40
41	DRUGS: DRUGS CHARGED TO PATIENTS													41
42	DRUGS: IV SOLUTIONS													42
43	DENTAL CARE													43
44	APPLIANCES AND EQUIPMENT													44
45	BLOOD AND BLOOD PRODUCTS													45
46	BLOOD TRANSFUSION/PROCESSING/STORAGE													46
47														47

FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4903.10)
49-540														Rev. 1
DRAFT				FORM CMS-2540-24										4995 (CONT.)
COST ALLOCATIONS - STATISTICAL BASES								PROVIDER CCN:		PERIOD:			WORKSHEET B-1
								________________		FROM:		___________
										TO:		___________


			QUALITY &	TRAINING &	PATIENT	OTHER
			PERFORM	IN-SERVICE	TRANSPORT	GENERAL
			IMPROV PGM	EDUCATION	PART A	SERVICE
			(TIME	(TIME	(NUMBER OF
			SPENT)	SPENT)	TRANSPRTS)	(SPECIFY)
			15	16	17	18
		OUTPATIENT SERVICE COST CENTERS
60	SCREENING & PREVENTATIVE SERVICES													60
61	OUTPATIENT LABORATORY													61
62	PORTABLE X-RAY SERVICES													62
63	OUTPATIENT DURABLE MEDICAL EQUIPMENT													63
64														64
		OUTPATIENT REIMBURSABLE COST CENTERS
70	HOME HEALTH AGENCY													70
71	AMBULANCE													71
72	HOSPICE													72
73	OUTPATIENT REHAB (SPECIFY)													73
74
		COST REIMBURSED COST CENTERS
80	PREVENTIVE VACCINES													80
81														81
89	SUBTOTAL													89
		NONREIMBURSABLE COST CENTERS
90	GIFT, FLOWER, COFFEE SHOPS & CANTEEN													90
91	NONPAID WORKERS													91
92	PHYSICIAN PRIVATE OFFICES													92
93														93
98	CROSS FOOT ADJUSTMENT													98
99	NEGATIVE COST CENTER													99
102	COST TO BE ALLOCATED - WKST B, PART I													102
103	UNIT COST MULTIPLIER - WKST B, PART I													103
104	COST TO BE ALLOCATED - WKST B, PART II													104
105	UNIT COST MULTIPLIER - WKST B, PART II													105
















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4903.10)
Rev. 1														49-541

Sheet 15: B-2

4995 (CONT.)		FORM CMS-2540-24								DRAFT
POST STEP - DOWN ADJUSTMENTS				PROVIDER CCN:		PERIOD:			WORKSHEET B-2
				________________		FROM:	___________
						TO:	___________


			WORKSHEET B		WORKSHEET B
	DESCRIPTION		PART NUMBER		LINE NUMBER			AMOUNT
	1		2		3			4
1										1
2										2
3										3
4										4
5										5
6										6
7										7
8										8
9										9
10										10
11										11
12										12
13										13
14										14
15										15
16										16
17										17
18										18
19										19
20										20
21										21
22										22
23										23
24										24
25										25
26										26
27										27
28										28
29										29
30										30
31										31
32										32
33										33
34										34
35										35
36										36
37										37
38										38
39										39
40										40
41										41
42										42
43										43
44										44
45										45
46										46
47										47
48										48
49										49
50										50















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4903.30)
49-542										Rev. 1

Sheet 16: C

DRAFT				FORM CMS-2540-24								4995 (CONT.)
RATIO OF COST TO CHARGES FOR ANCILLARY AND OUTPATIENT COST CENTERS						PROVIDER CCN:		PERIOD:			WORKSHEET C
						________________		FROM:		___________
								TO:		___________


					CHARGES						COST TO
			TOTAL		TOTAL		RECLASS-		RECLASSIFIED		CHARGE
			COST		CHARGES		IFICATIONS		CHARGES		RATIO
			1		2		3		4		5
		INPATIENT ROUTINE NURSING COST CENTERS
25	SKILLED NURSING FACILITY											25
26	NURSING FACILITY											26
27	ICF/IID											27
		ANCILLARY SERVICE COST CENTERS
30	RADIOLOGY - DIAGNOSTIC											30
31	RADIOLOGY - THERAPEUTIC/CHEMOTHERAPY											31
32	LABORATORY											32
33	INTRAVENOUS THERAPY											33
34	RESPIRATORY THERAPY											34
35	PHYSICAL THERAPY											35
36	OCCUPATIONAL THERAPY											36
37	SPEECH LANGUAGE PATHOLOGIST											37
38	AUDIOLOGY											38
39	ELECTROCARDIOLOGY											39
40	MEDICAL SUPPLIES CHARGED TO PATIENTS											40
41	DRUGS: DRUGS CHARGED TO PATIENTS											41
42	DRUGS: IV SOLUTIONS											42
43	DENTAL CARE											43
44	APPLIANCES AND EQUIPMENT											44
45	BLOOD AND BLOOD PRODUCTS											45
46	BLOOD TRANSFUSION/PROCESSING/STORAGE											46
47												47
		OUTPATIENT SERVICE COST CENTERS
64												64
		OUTPATIENT REIMBURSABLE COST CENTERS
71	AMBULANCE											71
		COST REIMBURSED COST CENTERS
80	PREVENTIVE VACCINES											80
81												81
100	TOTAL											100

































FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4904.10)
Rev. 1												49-543

Sheet 17: C-6

4995 (CONT.)				FORM CMS-2540-24											DRAFT
RECLASSIFICATIONS OF CHARGES									PROVIDER CCN:	PERIOD:			WORKSHEET C-6
									________________	FROM:		___________
										TO:		___________


					INCREASES						DECREASES
			WORKSHEET C			WKST C		WORKSHEET C				WKST C
	EXPLANATION OF RECLASSIFICATION	CODE	COST CENTER			LINE NO.	AMOUNT	COST CENTER				LINE NO.		AMOUNT
	1	2	3			4	5	6				7		8
1															1
2															2
3															3
4															4
5															5
6															6
7															7
8															8
9															9
10															10
11															11
12															12
13															13
14															14
15															15
16															16
17															17
18															18
19															19
20															20
21															21
22															22
23															23
24															24
25															25
26															26
27															27
28															28
29															29
30															30
31															31
32															32
33															33
34															34
35															35
500	TOTAL RECLASSIFICATIONS														500









FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4904.70)
49-544															Rev. 1

Sheet 18: D

DRAFT										FORM CMS-2540-24										4995 (CONT.)
APPORTIONMENT OF ANCILLARY AND OUTPATIENT COSTS													PROVIDER CCN:		PERIOD:			WORKSHEET D
													________________		FROM:		___________
															TO:		___________


SELECT PROGRAM			[ ]	TITLE V	[ ]	TITLE XVIII		[ ]	TITLE XIX
SELECT COMPONENT			[ ]	SNF	[ ]	NF		[ ]	ICF / IID

							RATIO OF				HEALTHCARE CHARGES					HEALTHCARE COSTS
								COST TO				PREVENTIVE							PREVENTIVE
								CHARGES		INPATIENT	OUTPATIENT	VACCINES		INPATIENT		OUTPATIENT			VACCINES
								1		2	3	4		5		6			7
		ANCILLARY SERVICE COST CENTERS
30	RADIOLOGY - DIAGNOSTIC																			30
31	RADIOLOGY - THERAPEUTIC/CHEMOTHERAPY																			31
32	LABORATORY																			32
33	IV THERAPY																			33
34	RESPIRATORY THERAPY																			34
35	PHYSICAL THERAPY																			35
36	OCCUPATIONAL THERAPY																			36
37	SPEECH LANGUAGE PATHOLOGIST																			37
38	AUDIOLOGY																			38
39	ELECTROCARDIOLOGY																			39
40	MEDICAL SUPPLIES CHARGED TO PATIENTS																			40
41	DRUGS: DRUGS CHARGED TO PATIENTS																			41
42	DRUGS: IV SOLUTIONS																			42
43	DENTAL CARE																			43
44	APPLIANCES AND EQUIPMENT																			44
45	BLOOD AND BLOOD PRODUCTS																			45
46	BLOOD TRANSFUSION/PROCESSING/STORAGE																			46
47																				47
		OUTPATIENT SERVICE COST CENTERS
65																				65
		OUTPATIENT REIMBURSABLE COST CENTERS
71	AMBULANCE																			71
		COST REIMBURSED COST CENTERS
80	PREVENTIVE VACCINES																			80
81																				81
100	TOTAL																			100















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4905.10)
Rev. 1																				49-545

Sheet 19: D-1

4995 (CONT.)									FORM CMS-2540-24						DRAFT
COMPUTATION OF INPATIENT ROUTINE COSTS										PROVIDER CCN:	PERIOD:		WORKSHEET D-1
										________________	FROM:	___________
											TO:	___________


SELECT PROGRAM			[ ]	TITLE V	[ ]	TITLE XVIII	[ ]	TITLE XIX
SELECT COMPONENT			[ ]	SNF	[ ]	NF	[ ]	ICF / IID

														1
		INPATIENT DAYS
1	INPATIENT DAYS, INCLUDING PRIVATE ROOM DAYS														1
2	PRIVATE ROOM DAYS														2
3	INPATIENT DAYS, INCLUDING PRIVATE ROOM DAYS, APPLICABLE TO THE PROGRAM														3
4	MEDICALLY NECESSARY PRIVATE ROOM DAYS APPLICABLE TO THE PROGRAM														4
5	TOTAL GENERAL INPATIENT ROUTINE SERVICE COST														5
		PRIVATE ROOM DIFFERENTIAL ADJUSTMENT
6	GENERAL INPATIENT ROUTINE SERVICE CHARGES														6
7	GENERAL INPATIENT ROUTINE SERVICE COST/CHARGE RATIO														7
8	PRIVATE ROOM CHARGES														8
9	AVERAGE PRIVATE ROOM PER DIEM CHARGE														9
10	SEMI-PRIVATE ROOM CHARGES														10
11	AVERAGE SEMI-PRIVATE ROOM PER DIEM CHARGE														11
12	AVERAGE PER DIEM PRIVATE ROOM CHARGE DIFFERENTIAL														12
13	AVERAGE PER DIEM PRIVATE ROOM COST DIFFERENTIAL														13
14	PRIVATE ROOM COST DIFFERENTIAL ADJUSTMENT														14
15	GENERAL INPATIENT ROUTINE SERVICE COST NET OF PRIVATE ROOM COST DIFFERENTIAL														15
		PROGRAM INPATIENT ROUTINE SERVICE COSTS
16	ADJUSTED GENERAL INPATIENT SERVICE COST PER DIEM														16
17	PROGRAM ROUTINE SERVICE COST														17
18	MEDICALLY NECESSARY PRIVATE ROOM COST APPLICABLE TO PROGRAM														18
19	TOTAL PROGRAM GENERAL INPATIENT ROUTINE SERVICE COST														19
20	CAPITAL RELATED COST ALLOCATED TO INPATIENT ROUTINE SERVICE COSTS														20
21	PER DIEM CAPITAL RELATED COSTS														21
22	PROGRAM CAPITAL RELATED COST														22
23	INPATIENT ROUTINE SERVICE COST														23
24	AGGREGATE CHARGES TO BENEFICIARIES FOR EXCESS COSTS														24
25	TOTAL PROGRAM ROUTINE SERVICE COSTS FOR COMPARISON TO THE COST LIMITATION														25
26	PER DIEM LIMITATION														26
27	INPATIENT ROUTINE SERVICE COST LIMITATION														27
28	REIMBURSABLE INPATIENT ROUTINE SERVICE COSTS														28

































FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4905.20)
49-546															Rev. 1

Sheet 20: E Pt A

DRAFT		FORM CMS-2540-24					4995 (CONT.)
CALCULATION OF REIMBURSEMENT SETTLEMENT - MEDICARE PART A			PROVIDER CCN:	PERIOD:		WORKSHEET E
			________________	FROM:	___________	PART A
				TO:	___________


1	INPATIENT PPS AMOUNT						1
2	ALLOWABLE BAD DEBTS						2
3	ALLOWABLE BAD DEBTS FOR INDIGENT DUAL ELIGIBLE BENEFICIARIES						3
4	REIMBURSABLE BAD DEBTS						4
5	TOTAL REIMBURSABLE COST						5
6	PRIMARY PAYER AMOUNTS						6
7	COINSURANCE						7
8							8
9	DEMONSTRATION PAYMENT ADJUSTMENT AMOUNT BEFORE SEQUESTRATION						9
10	SEQUESTRATION AMOUNT FOR NON-CLAIMS BASED ITEMS						10
11	SEQUESTRATION AMOUNT						11
12	DEMONSTRATION PAYMENT ADJUSTMENT AMOUNT AFTER SEQUESTRATION						12
13	NET REIMBURSABLE COST						13
14	INTERIM PAYMENTS						14
15	TENTATIVE ADJUSTMENT						15
16	BALANCE DUE PROVIDER/PROGRAM						16
17	PROTESTED AMOUNTS						17



















































FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4906.11)
Rev. 1							49-547

Sheet 21: E Pt B

4995 (CONT.)		FORM CMS-2540-24					DRAFT
CALCULATION OF REIMBURSEMENT SETTLEMENT - MEDICARE PART B			PROVIDER CCN:	PERIOD:		WORKSHEET E
			________________	FROM:	___________	PART B
				TO:	___________


1	PART B ANCILLARY SERVICE COSTS						1
2	PREVENTIVE VACCINES						2
3	TOTAL REASONABLE COSTS						3
4	MEDICARE PART B ANCILLARY CHARGES						4
5	COST OF COVERED SERVICES						5
6	ALLOWABLE BAD DEBTS						6
7	ALLOWABLE BAD DEBTS FOR INDIGENT DUAL-ELIGIBLE BENEFICIARIES						7
8	REIMBURSABLE BAD DEBTS						8
9	TOTAL REIMBURSABLE COST						9
10	PRIMARY PAYER AMOUNTS						10
11	COINSURANCE AND DEDUCTIBLES						11
12							12
13	DEMONSTRATION PAYMENT ADJUSTMENT AMOUNT BEFORE SEQUESTRATION						13
14	SEQUESTRATION AMOUNT						14
15	DEMONSTRATION PAYMENT ADJUSTMENT AMOUNT AFTER SEQUESTRATION						15
16	NET REIMBURSABLE COST						16
17	INTERIM PAYMENTS						17
18	TENTATIVE ADJUSTMENT						18
19	BALANCE DUE PROVIDER/PROGRAM						19
20	PROTESTED AMOUNTS						20
















































FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4906.12)
49-548							Rev. 1

Sheet 22: E-1

DRAFT			FORM CMS-2540-24												4995 (CONT.)
ANALYSIS OF PAYMENTS TO PROVIDERS FOR SERVICES RENDERED TO					PROVIDER CCN:				PERIOD:				WORKSHEET E-1
MEDICARE BENEFICIARIES					________________				FROM:	___________
									TO:	___________


							PART A				PART B
							DATE		AMOUNT		DATE			AMOUNT
							1		2		3			4
1	TOTAL INTERIM PAYMENTS PAID TO PROVIDER														1
2	INTERIM PAYMENTS PAYABLE														2
3	RETROACTIVE LUMP SUM ADJUSTMENTS			PROGRAM TO PROVIDER		.01									3.01
						.02									3.02
						.03									3.03
						.04									3.04
						.05									3.05
				PROVIDER TO PROGRAM		.50									3.50
						.51									3.51
						.52									3.52
						.53									3.53
						.54									3.54
	SUBTOTAL					.99									3.99
4	TOTAL INTERIM PAYMENTS														4

5	CONTRACTOR: TENTATIVE SETTLEMENT PAYMENTS			PROGRAM TO PROVIDER		.01									5.01
						.02									5.02
						.03									5.03
						.04									5.04
						.05									5.05
				PROVIDER TO PROGRAM		.50									5.50
						.51									5.51
						.52									5.52
						.53									5.53
						.54									5.54
	SUBTOTAL					.99									5.99
6	CONTRACTOR: NET SETTLEMENT AMOUNT	PROGRAM TO PROVIDER				.01									6.01
		PROVIDER TO PROGRAM				.02									6.02
7	CONTRACTOR: TOTAL MEDICARE PROGRAM LIABILITY														7

								CONTRACTOR
	NAME OF CONTRACTOR							NUMBER				DATE OF NPR
	1							2				3
8															8































FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4906.20)
Rev. 1															49-549

Sheet 23: E-2

4995 (CONT.)								FORM CMS-2540-24					DRAFT
CALCULATION OF REIMBURSEMENT SETTLEMENT - OTHER									PROVIDER CCN:	PERIOD:		WORKSHEET E-2
									________________	FROM:	___________
										TO:	___________


SELECT PROGRAM		[ ]	TITLE V	[ ]	TITLE XIX
SELECT COMPONENT		[ ]	SNF	[ ]	NF	[ ]	ICF / IID

COMPUTATION OF NET COST OF COVERED SERVICES
1	INPATIENT ANCILLARY SERVICES												1
2	OUTPATIENT SERVICES												2
3	INPATIENT ROUTINE SERVICES												3
4	COST OF COVERED SERVICES												4
5	DIFFERENTIAL IN CHARGES BETWEEN SEMIPRIVATE ACCOMMODATINS AND LESS THAN SEMIPRIVATE ACCOMMODATIONS												5
6	SUBTOTAL												6
7	PRIMARY PAYER AMOUNTS												7
8	TOTAL REASONABLE COST												8
REASONABLE CHARGES
9	INPATIENT ANCILLARY SERVICES CHARGES												9
10	OUTPATIENT SERVICES CHARGES												10
11	INPATIENT ROUTINE SERVICES CHARGES												11
12	DIFFERENTIAL IN CHARGES BETWEEN SEMIPRIVATE ACCOMMODATIONS AND LESS THAN SEMIPRIVATE ACCOMMODATIONS												12
13	TOTAL REASONABLE CHARGES												13
CUSTOMARY CHARGES
14	AGGREGATE AMOUNT ACTUALLY COLLECTED FROM PATIENTS LIABLE FOR PAYMENT FOR SERVICES ON A CHARGE BASIS												14
15	AMOUNTS THAT WOULD HAVE BEEN REALIZED FROM PATIENTS LIABLE FOR PAYMENT FOR SERVICES ON A CHARGE BASIS												15
	HAD SUCH PAYMENT BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(e)
16	RATIO OF LINE 14 TO LINE 15 (NOT TO EXCEED 1.000000)												16
17	TOTAL CUSTOMARY CHARGES												17
COMPUTATION OF REIMBURSEMENT SETTLEMENT
18	COST OF COVERED SERVICES												18
19	COST SHARING												19
20	SUBTOTAL												20
21	ALLOWABLE BAD DEBTS												21
22	SUBTOTAL												22
23													23
24	SUBTOTAL												24
25	INTERIM PAYMENTS												25
26	BALANCE DUE PROVIDER/PROGRAM (INDICATE OVERPAYMENT IN PARENTHESES)												26


































FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4906.30)
49-550													Rev. 1

Sheet 24: G

DRAFT			FORM CMS-2540-24					4995 (CONT.)
BALANCE SHEET				PROVIDER CCN:	PERIOD:		WORKSHEET G
				________________	FROM:	___________
					TO:	___________


		ASSETS					AMOUNT
		CURRENT ASSETS
1	CASH ON HAND AND IN BANKS							1
2	TEMPORARY INVESTMENTS							2
3	NOTES RECEIVABLE							3
4	ACCOUNTS RECEIVABLE							4
5	OTHER RECEIVABLES							5
6	LESS: ALLOWANCES FOR UNCOLLECTIBLE NOTES AND ACCOUNTS RECEIVABLE							6
7	INVENTORY							7
8	PREPAID EXPENSES							8
9	OTHER CURRENT ASSETS							9
10	DUE FROM OTHER FUNDS							10
11	TOTAL CURRENT ASSETS							11
		FIXED ASSETS
12	LAND							12
13	LAND IMPROVEMENTS							13
14	LESS: ACCUMULATED DEPRECIATION							14
15	BUILDINGS							15
16	LESS: ACCUMULATED DEPRECIATION							16
17	LEASEHOLD IMPROVEMENTS							17
18	LESS: ACCUMULATED DEPRECIATION							18
19	FIXED EQUIPMENT							19
20	LESS: ACCUMULATED DEPRECIATION							20
21	AUTOMOBILES AND TRUCKS							21
22	LESS: ACCUMULATED DEPRECIATION							22
23	MAJOR MOVABLE EQUIPMENT							23
24	LESS: ACCUMULATED DEPRECIATION							24
25	MINOR EQUIPMENT - DEPRECIABLE							25
26	MINOR EQUIPMENT - NONDEPRECIABLE							26
27	OTHER FIXED ASSETS							27
28	TOTAL FIXED ASSETS							28
		OTHER ASSETS
29	INVESTMENTS							29
30	DEPOSITS ON LEASES							30
31	DUE FROM OWNERS/OFFICERS							31
32	OTHER ASSETS							32
33	TOTAL OTHER ASSETS							33
34	TOTAL ASSETS							34

		LIABILITIES					AMOUNT
		CURRENT LIABILITIES
35	ACCOUNTS PAYABLE							35
36	SALARIES, WAGES & FEES PAYABLE							36
37	PAYROLL TAXES PAYABLE							37
38	NOTES & LOANS PAYABLE (SHORT TERM)							38
39	DEFERRED INCOME							39
40	ACCELERATED PAYMENTS							40
41	DUE TO OTHER FUNDS							41
42	OTHER CURRENT LIABILITIES							42
43	TOTAL CURRENT LIABILITIES							43
		LONG TERM LIABILITIES
44	MORTGAGE PAYABLE							44
45	NOTES PAYABLE							45
46	UNSECURED LOANS							46
47	LOANS FROM OWNERS							47
48	OTHER LONG TERM LIABILITIES							48
49	TOTAL LONG TERM LIABILITIES							49
50	TOTAL LIABILITIES							50
		CAPITAL ACCOUNTS
51	FUND BALANCES							51
52	TOTAL LIABILITIES AND FUND BALANCES							52







FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4908.10.)
Rev. 1								49-551

Sheet 25: G-2

4995 (CONT.)					FORM CMS-2540-24													DRAFT
STATEMENT OF PATIENT REVENUES AND OPERATING EXPENSES											PROVIDER CCN:		PERIOD:			WORKSHEET G-2
											________________		FROM:	___________
													TO:	___________


PART I - PATIENT REVENUES
			INPATIENT						OUTPATIENT
			MEDICARE	MEDICARE			MEDICAID		MEDICARE	MEDICARE			MEDICAID
			FFS	HMO		MEDICAID	HMO	OTHER	FFS	HMO		MEDICAID	HMO		OTHER		TOTAL
			1	2		3	4	5	6	7		8	9		10		11
		GENERAL INPATIENT ROUTINE CARE SERVICES
1	SKILLED NURSING FACILITY																	1
2	NURSING FACILITY																	2
3	ICF/IID																	3
4	TOTAL GENERAL INPATIENT CARE SERVICES																	4
		ALL OTHER SERVICES
5	ANCILLARY SERVICES																	5
6	HOME HEALTH AGENCY																	6
7	AMBULANCE																	7
8	HOSPICE																	8
9	ALL OTHER REVENUES																	9
10	TOTAL PATIENT REVENUES																	10

PART II - OPERATING EXPENSES
			TOTAL
			1
11	OPERATING EXPENSES																	11
12																		12
13	TOTAL ADDITIONS																	13
14																		14
15	TOTAL DEDUCTIONS																	15
16	TOTAL OPERATING EXPENSES																	16






















FORM CMS-2540-24 draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTIONS 4908.30 THROUGH 4908.32)
49-552																		Rev. 1

Sheet 26: G-3

DRAFT			FORM CMS-2540-24						4995 (CONT.)
STATEMENT OF REVENUES AND EXPENSES				PROVIDER CCN:	PERIOD:			WORKSHEET G-3
				________________	FROM:	___________
					TO:	___________


							AMOUNT
		INCOME FROM SERVICES TO PATIENTS
1	TOTAL PATIENT REVENUES								1
2	LESS: CONTRACTUAL ALLOWANCES AND DISCOUNTS ON PATIENT ACCOUNTS								2
3	NET PATIENT REVENUES								3
4	LESS: TOTAL OPERATING EXPENSES								4
5	NET INCOME FROM SERVICES TO PATIENTS								5
		OTHER INCOME
6	CONTRIBUTIONS, DONATIONS, BEQUESTS, ETC.								6
7	INCOME FROM INVESTMENTS								7
8	REVENUES FROM COMMUNICATIONS (TELEPHONE AND INTERNET SERVICES)								8
9	REVENUE FROM TELEVISION AND RADIO SERVICES								9
10	PURCHASE DISCOUNTS								10
11	REBATES AND REFUNDS OF EXPENSES								11
12	PARKING LOT RECEIPTS								12
13	REVENUE FROM LAUNDRY AND LINEN SERVICE								13
14	REVENUE FROM MEALS SOLD TO EMPLOYEES AND GUESTS								14
15	REVENUE FROM RENTAL OF LIVING QUARTERS								15
16	REVENUE FROM SALE OF MEDICAL AND SURGICAL SUPPLIES TO OTHER THAN PATIENTS								16
17	REVENUE FROM SALE OF DRUGS TO OTHER THAN PATIENTS								17
18	REVENUE FROM SALE OF MEDICAL RECORDS AND ABSTRACTS								18
19	TUITION (FEES, SALE OF TEXTBOOKS, UNIFORMS, ETC.)								19
20	REVENUE FROM GIFTS, FLOWER, COFFEE SHOPS, CANTEEN								20
21	RENTAL OF VENDING MACHINES								21
22	RENTAL OF SKILLED NURSING SPACE								22
23	GOVERNMENTAL APPROPRIATIONS								23
24	OTHER MISCELLANEOUS REVENUE (SPECIFY ______________)								24
25	PHE FUNDING								25
26	TOTAL OTHER INCOME								26
27	TOTAL INCOME								27
		EXPENSES
28	OTHER EXPENSES (SPECIFY ________________)								28
29									29
30									30
31	TOTAL OTHER EXPENSES								31
32	NET INCOME (LOSS) FOR THE PERIOD								32
































FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4908.40)
Rev. 1									49-553

Sheet 27: H

4995 (CONT.)			FORM CMS-2540-24										DRAFT
ANALYSIS OF SNF - BASED HHA COSTS							PROVIDER CCN:		PERIOD:			WORKSHEET H
							________________		FROM:		___________
							HHA CCN:		TO:		___________
							________________

						CONTRACTED/
				EMPLOYEE	TRANSPOR-	PURCHASED		OTHER				RECLASS-
			SALARIES	BENEFITS	TATION	SERVICES		COSTS		TOTAL		IFICATIONS
			1	2	3	4		5		6		7
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS AND FIXTURES												1
2	CAPITAL RELATED - MOVABLE EQUIPMENT												2
3	PLANT OPERATIONS & MAINTENANCE												3
4	TRANSPORTATION												4
5	TELECOMMUNICATION TECHNOLOGY												5
6	ADMINISTRATIVE & GENERAL												6
7	NURSING ADMINISTRATION												7
8													8
		HHA REIMBURSABLE SERVICES
16	SKILLED NURSING CARE - RN												16
17	SKILLED NURSING CARE - LPN												17
18	PT - PHYSICAL THERAPIST												18
19	PT - PHYSICAL THERAPY ASSISTANT												19
20	OT - OCCUPATIONAL THERAPIST												20
21	OT - OCCUPATIONAL THERAPY ASSISTANT												21
22	SPEECH LANGUAGE PATHOLOGIST												22
23	MEDICAL SOCIAL SERVICES												23
24	HOME HEALTH AIDE												24
25	MEDICAL SUPPLIES CHARGED TO PATIENTS												25
26	DRUGS CHARGED TO PATIENTS												26
27	COST OF ADMINISTERING VACCINES												27
28	DURABLE MEDICAL EQUIPMENT/OXYGEN												28
29	DISPOSABLE DEVICES												29
30													30
		HHA NON-REIMBURSABLE SERVICES
39	HOME DIALYSIS AIDE SERVICES												39
40	RESPIRATORY THERAPY												40
41	PRIVATE DUTY NURSING												41
42	CLINIC												42
43	HEALTH PROMOTION ACTIVITIES												43
44	DAY CARE PROGRAM												44
45	HOME DELIVERED MEALS PROGRAM												45
46	HOMEMAKER SERVICES												46
47	ADVERTISING												47
48	FUNDRAISING												48
49													49

100	TOTAL												100







FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4909.10)
49-554													Rev. 1
DRAFT			FORM CMS-2540-24										4995 (CONT.)
ANALYSIS OF SNF - BASED HHA COSTS							PROVIDER CCN:		PERIOD:			WORKSHEET H
							________________		FROM:		___________
							HHA CCN:		TO:		___________
							________________

			RECLASSIFIED		NET EXPENSES
			TRIAL		FOR
			BALANCE	ADJUSTMENTS	ALLOCATION
			8	9	10
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS AND FIXTURES												1
2	CAPITAL RELATED - MOVABLE EQUIPMENT												2
3	PLANT OPERATIONS & MAINTENANCE												3
4	TRANSPORTATION												4
5	TELECOMMUNICATION TECHNOLOGY												5
6	ADMINISTRATIVE & GENERAL												6
7	NURSING ADMINISTRATION												7
8													8
		HHA REIMBURSABLE SERVICES
16	SKILLED NURSING CARE - RN												16
17	SKILLED NURSING CARE - LPN												17
18	PT - PHYSICAL THERAPIST												18
19	PT - PHYSICAL THERAPY ASSISTANT												19
20	OT - OCCUPATIONAL THERAPIST												20
21	OT - OCCUPATIONAL THERAPY ASSISTANT												21
22	SPEECH LANGUAGE PATHOLOGIST												22
23	MEDICAL SOCIAL SERVICES												23
24	HOME HEALTH AIDE												24
25	MEDICAL SUPPLIES CHARGED TO PATIENTS												25
26	DRUGS CHARGED TO PATIENTS												26
27	COST OF ADMINISTERING VACCINES												27
28	DURABLE MEDICAL EQUIPMENT/OXYGEN												28
29	DISPOSABLE DEVICES												29
30													30
		HHA NON-REIMBURSABLE SERVICES
39	HOME DIALYSIS AIDE SERVICES												39
40	RESPIRATORY THERAPY												40
41	PRIVATE DUTY NURSING												41
42	CLINIC												42
43	HEALTH PROMOTION ACTIVITIES												43
44	DAY CARE PROGRAM												44
45	HOME DELIVERED MEALS PROGRAM												45
46	HOMEMAKER SERVICES												46
47	ADVERTISING												47
48	FUNDRAISING												48
49													49

100	TOTAL												100







FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4909.10)
Rev. 1													49-555

Sheet 28: H1-I

4995 (CONT.)			FORM CMS-2540-24										DRAFT
ALLOCATION OF SNF-BASED HHA GENERAL SERVICE COSTS							PROVIDER CCN:		PERIOD:			WORKSHEET H-1
							________________		FROM:		___________	PART I
							HHA CCN:		TO:		___________
							________________

			NET EXPENSE			PLANT OP,						TELECOM-
			FOR			MAINT &		TRANS-				MUNICATION
			ALLOCATION	CRC-B&F	CRC-ME	REPAIRS		PORTATION		SUBTOTAL		TECHNOLOGY
			0	1	2	3		4		4A		5
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS AND FIXTURES												1
2	CAPITAL RELATED - MOVABLE EQUIPMENT												2
3	PLANT OPERATIONS & MAINTENANCE												3
4	TRANSPORTATION												4
5	TELECOMMUNICATION TECHNOLOGY												5
6	ADMINISTRATIVE & GENERAL												6
7	NURSING ADMINISTRATION												7
8													8
		HHA REIMBURSABLE SERVICES
16	SKILLED NURSING CARE - RN												16
17	SKILLED NURSING CARE - LPN												17
18	PT - PHYSICAL THERAPIST												18
19	PT - PHYSICAL THERAPY ASSISTANT												19
20	OT - OCCUPATIONAL THERAPIST												20
21	OT - OCCUPATIONAL THERAPY ASSISTANT												21
22	SPEECH LANGUAGE PATHOLOGIST												22
23	MEDICAL SOCIAL SERVICES												23
24	HOME HEALTH AIDE												24
25	MEDICAL SUPPLIES CHARGED TO PATIENTS												25
26	DRUGS CHARGED TO PATIENTS												26
27	COST OF ADMINISTERING VACCINES												27
28	DURABLE MEDICAL EQUIPMENT/OXYGEN												28
29	DISPOSABLE DEVICES												29
30	OTHER REIMBURSABLE												30
		HHA NON-REIMBURSABLE SERVICES
39	HOME DIALYSIS AIDE SERVICES												39
40	RESPIRATORY THERAPY												40
41	PRIVATE DUTY NURSING												41
42	CLINIC												42
43	HEALTH PROMOTION ACTIVITIES												43
44	DAY CARE PROGRAM												44
45	HOME DELIVERED MEALS PROGRAM												45
46	HOMEMAKER SERVICES												46
47	ADVERTISING												47
48	FUNDRAISING												48
49													49
99	NEGATIVE COST CENTER												99
100	TOTAL												100






FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4909.20)
49-556													Rev. 1
DRAFT			FORM CMS-2540-24										4995 (CONT.)
ALLOCATION OF SNF-BASED HHA GENERAL SERVICE COSTS							PROVIDER CCN:		PERIOD:			WORKSHEET H-1
							________________		FROM:		___________	PART I
							HHA CCN:		TO:		___________
							________________

						OTHER
					NURSING	GENERAL
			SUBTOTAL	A&G	ADMIN	SERVICE		TOTAL
			5A	6	7	8		9
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS AND FIXTURES												1
2	CAPITAL RELATED - MOVABLE EQUIPMENT												2
3	PLANT OPERATIONS & MAINTENANCE												3
4	TRANSPORTATION												4
5	TELECOMMUNICATION TECHNOLOGY												5
6	ADMINISTRATIVE & GENERAL												6
7	NURSING ADMINISTRATION												7
8													8
		HHA REIMBURSABLE SERVICES
16	SKILLED NURSING CARE - RN												16
17	SKILLED NURSING CARE - LPN												17
18	PT - PHYSICAL THERAPIST												18
19	PT - PHYSICAL THERAPY ASSISTANT												19
20	OT - OCCUPATIONAL THERAPIST												20
21	OT - OCCUPATIONAL THERAPY ASSISTANT												21
22	SPEECH LANGUAGE PATHOLOGIST												22
23	MEDICAL SOCIAL SERVICES												23
24	HOME HEALTH AIDE												24
25	MEDICAL SUPPLIES CHARGED TO PATIENTS												25
26	DRUGS CHARGED TO PATIENTS												26
27	COST OF ADMINISTERING VACCINES												27
28	DURABLE MEDICAL EQUIPMENT/OXYGEN												28
29	DISPOSABLE DEVICES												29
30	OTHER REIMBURSABLE												30
		HHA NON-REIMBURSABLE SERVICES
39	HOME DIALYSIS AIDE SERVICES												39
40	RESPIRATORY THERAPY												40
41	PRIVATE DUTY NURSING												41
42	CLINIC												42
43	HEALTH PROMOTION ACTIVITIES												43
44	DAY CARE PROGRAM												44
45	HOME DELIVERED MEALS PROGRAM												45
46	HOMEMAKER SERVICES												46
47	ADVERTISING												47
48	FUNDRAISING												48
49													49
99	NEGATIVE COST CENTER												99
100	TOTAL												100






FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4909.20)
Rev. 1													49-557

Sheet 29: H1-II

4995 (CONT.)			FORM CMS-2540-24										DRAFT
ALLOCATION OF SNF-BASED HHA GENERAL SERVICE COSTS - STATISTICAL BASIS							PROVIDER CCN:		PERIOD:			WORKSHEET H-1
							________________		FROM:		___________	PART II
							HHA CCN:		TO:		___________
							________________

						PLANT						TELECOM-
			NET			OPERATION		TRANS-		RECONCIL-		MUNICATION
			EXPENSES	CRC-B&F	CRC-ME	& MAINT		PORTATION		IATION		TECHNOLOGY
			FOR	(SQUARE	(DOLLAR	(SQUARE		(MILEAGE)				(ACCUM
			ALLOCATION	FEET)	VALUE)	FEET)						COST)
			0	1	2	3		4		5A		5
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS AND FIXTURES												1
2	CAPITAL RELATED - MOVABLE EQUIPMENT												2
3	PLANT OPERATIONS & MAINTENANCE												3
4	TRANSPORTATION												4
5	TELECOMMUNICATION TECHNOLOGY												5
6	ADMINISTRATIVE & GENERAL												6
7	NURSING ADMINISTRATION												7
8													8
		HHA REIMBURSABLE SERVICES
16	SKILLED NURSING CARE - RN												16
17	SKILLED NURSING CARE - LPN												17
18	PT - PHYSICAL THERAPIST												18
19	PT - PHYSICAL THERAPY ASSISTANT												19
20	OT - OCCUPATIONAL THERAPIST												20
21	OT - OCCUPATIONAL THERAPY ASSISTANT												21
22	SPEECH LANGUAGE PATHOLOGIST												22
23	MEDICAL SOCIAL SERVICES												23
24	HOME HEALTH AIDE												24
25	MEDICAL SUPPLIES CHARGED TO PATIENTS												25
26	DRUGS CHARGED TO PATIENTS												26
27	COST OF ADMINISTERING VACCINES												27
28	DURABLE MEDICAL EQUIPMENT/OXYGEN												28
29	DISPOSABLE DEVICES												29
30	OTHER REIMBURSABLE												30
		HHA NON-REIMBURSABLE SERVICES
39	HOME DIALYSIS AIDE SERVICES												39
40	RESPIRATORY THERAPY												40
41	PRIVATE DUTY NURSING												41
42	CLINIC												42
43	HEALTH PROMOTION ACTIVITIES												43
44	DAY CARE PROGRAM												44
45	HOME DELIVERED MEALS PROGRAM												45
46	HOMEMAKER SERVICES												46
47	ADVERTISING												47
48	FUNDRAISING												48
49													49
99	NEGATIVE COST CENTER												99
100	TOTAL STATISTIC
101	COST TO BE ALLOCATED												101
102	UNIT COST MULTIPLIER												102


FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4909.20)
49-558													Rev. 1
DRAFT			FORM CMS-2540-24										4995 (CONT.)
ALLOCATION OF SNF-BASED HHA GENERAL SERVICE COSTS - STATISTICAL BASIS							PROVIDER CCN:		PERIOD:			WORKSHEET H-1
							________________		FROM:		___________	PART II
							HHA CCN:		TO:		___________
							________________

						OTHER
			RECONCIL-		NURSING	GENERAL
			ILATION	A&G	ADMIN	SERVICE		TOTAL
				(ACCUM	(DIRECT	(SPECIFY)
				COST)	NURS HRS)
			6A	6	7	8		9
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS AND FIXTURES												1
2	CAPITAL RELATED - MOVABLE EQUIPMENT												2
3	PLANT OPERATIONS & MAINTENANCE												3
4	TRANSPORTATION												4
5	TELECOMMUNICATION TECHNOLOGY												5
6	ADMINISTRATIVE & GENERAL												6
7	NURSING ADMINISTRATION												7
8													8
		HHA REIMBURSABLE SERVICES
16	SKILLED NURSING CARE - RN												16
17	SKILLED NURSING CARE - LPN												17
18	PT - PHYSICAL THERAPIST												18
19	PT - PHYSICAL THERAPY ASSISTANT												19
20	OT - OCCUPATIONAL THERAPIST												20
21	OT - OCCUPATIONAL THERAPY ASSISTANT												21
22	SPEECH LANGUAGE PATHOLOGIST												22
23	MEDICAL SOCIAL SERVICES												23
24	HOME HEALTH AIDE												24
25	MEDICAL SUPPLIES CHARGED TO PATIENTS												25
26	DRUGS CHARGED TO PATIENTS												26
27	COST OF ADMINISTERING VACCINES												27
28	DURABLE MEDICAL EQUIPMENT/OXYGEN												28
29	DISPOSABLE DEVICES												29
30	OTHER REIMBURSABLE												30
		HHA NON-REIMBURSABLE SERVICES
39	HOME DIALYSIS AIDE SERVICES												39
40	RESPIRATORY THERAPY												48
41	PRIVATE DUTY NURSING												41
42	CLINIC												42
43	HEALTH PROMOTION ACTIVITIES												43
44	DAY CARE PROGRAM												44
45	HOME DELIVERED MEALS PROGRAM												45
46	HOMEMAKER SERVICES												46
47	ADVERTISING												47
48	FUNDRAISING												48
49													49
99	NEGATIVE COST CENTER												99
100	TOTAL STATISTIC												100
101	COST TO BE ALLOCATED												101



FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4909.20)
Rev. 1													49-559

Sheet 30: H2-I

4995 (CONT.)				FORM CMS-2540-24										DRAFT
ALLOCATION OF SNF GENERAL SERVICE COSTS TO SNF - BASED HHA								PROVIDER CCN:		PERIOD:			WORKSHEET H-2
								________________		FROM:		___________	PART I
								HHA CCN:		TO:		___________
								________________

		WKST H-1,	HHA										LAUNDRY
		PT I, COL 9,	TRIAL			EMPLOYEE					OPERATION		& LINEN
		LINE	BALANCE	CRC-B&F	CRC-ME	BENEFITS	SUBTOTAL		A&G		OF PLANT		SERVICE
		NUMBER:	0	1	2	3	3A		4		5		6
1	ADMINISTRATIVE & GENERAL													1
2	SKILLED NURSING CARE - RN	16												2
3	SKILLED NURSING CARE - LPN	17												3
4	PT - PHYSICAL THERAPIST	18												4
5	PT - PHYSICAL THERAPY ASSISTANT	19												5
6	OT - OCCUPATIONAL THERAPIST	20												6
7	OT - OCCUPATIONAL THERAPY ASSISTANT	21												7
8	SPEECH LANGUAGE PATHOLOGIST	22												8
9	MEDICAL SOCIAL SERVICES	23												9
10	HOME HEALTH AIDE	24												10
11	MEDICAL SUPPLIES CHARGED TO PATIENTS	25												11
12	DRUGS CHARGED TO PATIENTS	26												12
13	COST OF ADMINISTERING VACCINES	27												13
14	DURABLE MEDICAL EQUIPMENT/OXYGEN	28												14
15	DISPOSABLE DEVICES	29												15
16	OTHER REIMBURSABLE	30												16
17	HOME DIALYSIS AIDE SERVICES	39												17
18	RESPIRATORY THERAPY	40												18
19	PRIVATE DUTY NURSING	41												19
20	CLINIC	42												20
21	HEALTH PROMOTION ACTIVITIES	43												21
22	DAY CARE PROGRAM	44												22
23	HOME DELIVERED MEALS PROGRAM	45												23
24	HOMEMAKER SERVICES	46												24
25	ADVERTISING	47												25
26	FUNDRAISING	48												26
27		49												27
100	TOTALS													100
101	UNIT COST MULTIPLIER - COLUMN 22													101
















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4909.31)
49-560														Rev. 1
DRAFT				FORM CMS-2540-24										4995 (CONT.)
ALLOCATION OF SNF GENERAL SERVICE COSTS TO SNF - BASED HHA								PROVIDER CCN:		PERIOD:			WORKSHEET H-2
								________________		FROM:		___________	PART I
								HHA CCN:		TO:		___________
								________________

					CENTRAL								QUALITY &
		HOUSE-		NURSING	SERVICE		MEDICAL		SOCIAL		ACTIVITIES		PERFORM
		KEEPING	DIETARY	ADMIN	& SUPPLY	PHARMACY	RECORDS		SERVICE		PROGRAM		IMPROV PGM
		7	8	9	10	11	12		13		14		15
1	ADMINISTRATIVE & GENERAL													1
2	SKILLED NURSING CARE - RN													2
3	SKILLED NURSING CARE - LPN													3
4	PT - PHYSICAL THERAPIST													4
5	PT - PHYSICAL THERAPY ASSISTANT													5
6	OT - OCCUPATIONAL THERAPIST													6
7	OT - OCCUPATIONAL THERAPY ASSISTANT													7
8	SPEECH LANGUAGE PATHOLOGIST													8
9	MEDICAL SOCIAL SERVICES													9
10	HOME HEALTH AIDE													10
11	MEDICAL SUPPLIES CHARGED TO PATIENTS													11
12	DRUGS CHARGED TO PATIENTS													12
13	COST OF ADMINISTERING VACCINES													13
14	DURABLE MEDICAL EQUIPMENT/OXYGEN													14
15	DISPOSABLE DEVICES													15
16	OTHER REIMBURSABLE													16
17	HOME DIALYSIS AIDE SERVICES													17
18	RESPIRATORY THERAPY													18
19	PRIVATE DUTY NURSING													19
20	CLINIC													20
21	HEALTH PROMOTION ACTIVITIES													21
22	DAY CARE PROGRAM													22
23	HOME DELIVERED MEALS PROGRAM													23
24	HOMEMAKER SERVICES													24
25	ADVERTISING													25
26	FUNDRAISING													26
27														27
100	TOTALS													100
101	UNIT COST MULTIPLIER - COLUMN 22													101
















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4909.31)
Rev. 1														49-561
4995 (CONT.)				FORM CMS-2540-24										DRAFT
ALLOCATION OF SNF GENERAL SERVICE COSTS TO SNF - BASED HHA								PROVIDER CCN:		PERIOD:			WORKSHEET H-2
								________________		FROM:		___________	PART I
								HHA CCN:		TO:		___________
								________________

		TRAINING &	PATIENT	OTHER		POST-
		IN-SERVICE	TRANSPORT	GENERAL		STEPDOWN			ALLOCATED		TOTAL
		EDUCATION	PART A	SERVICE	SUBTOTAL	ADJ	SUBTOTAL		HHA A&G		HHA COSTS
		16	17	18	19	20	21		22		23
1	ADMINISTRATIVE & GENERAL													1
2	SKILLED NURSING CARE - RN													2
3	SKILLED NURSING CARE - LPN													3
4	PHYSICAL THERAPIST													4
5	PHYSICAL THERAPY ASSISTANT													5
6	OCCUPATIONAL THERAPIST													6
7	OCCUPATIONAL THERAPY ASSISTANT													7
8	SPEECH LANGUAGE PATHOLOGIST													8
9	MEDICAL SOCIAL SERVICES													9
10	HOME HEALTH AIDE													10
11	MEDICAL SUPPLIES CHARGED TO PATIENTS													11
12	DRUGS CHARGED TO PATIENTS													12
13	COST OF ADMINISTERING VACCINES													13
14	DURABLE MEDICAL EQUIPMENT/OXYGEN													14
15	DISPOSABLE DEVICES													15
16	OTHER REIMBURSABLE													16
17	HOME DIALYSIS AIDE SERVICES													17
18	RESPIRATORY THERAPY													18
19	PRIVATE DUTY NURSING													19
20	CLINIC													20
21	HEALTH PROMOTION ACTIVITIES													21
22	DAY CARE PROGRAM													22
23	HOME DELIVERED MEALS PROGRAM													23
24	HOMEMAKER SERVICES													24
25	ADVERTISING													25
26	FUNDRAISING													26
27														27
100	TOTALS													100
101	UNIT COST MULTIPLIER - COLUMN 22													101
















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4909.31)
49-562														Rev. 1

Sheet 31: H2-II

DRAFT				FORM CMS-2540-24										DRAFT
ALLOCATION OF SNF GENERAL SERVICE COSTS TO SNF - BASED HHA - STATISTICAL BASIS								PROVIDER CCN:		PERIOD:			WORKSHEET H-2
								________________		FROM:		___________	PART II
								HHA CCN:		TO:		___________
								________________

													LAUNDRY
						EMPLOYEE	RECON-				OPERATION		& LINEN
				CRC-B&F	CRC-ME	BENEFITS	CILIATION		A&G		OF PLANT		SERVICE
				(SQUARE	(DOLLAR	(GROSS			(ACCUM		(SQUARE		(POUNDS OF
				FEET)	VALUE)	SALARIES)			COST)		FEET)		LAUNDRY)
				1	2	3	4A		4		5		6
1	ADMINISTRATIVE & GENERAL													1
2	SKILLED NURSING CARE - RN													2
3	SKILLED NURSING CARE - LPN													3
4	PT - PHYSICAL THERAPIST													4
5	PT - PHYSICAL THERAPY ASSISTANT													5
6	OT - OCCUPATIONAL THERAPIST													6
7	OT - OCCUPATIONAL THERAPY ASSISTANT													7
8	SPEECH LANGUAGE PATHOLOGIST													8
9	MEDICAL SOCIAL SERVICES													9
10	HOME HEALTH AIDE													10
11	MEDICAL SUPPLIES CHARGED TO PATIENTS													11
12	DRUGS CHARGED TO PATIENTS													12
13	COST OF ADMINISTERING VACCINES													13
14	DURABLE MEDICAL EQUIPMENT/OXYGEN													14
15	DISPOSABLE DEVICES													15
16	OTHER REIMBURSABLE													16
17	HOME DIALYSIS AIDE SERVICES													17
18	RESPIRATORY THERAPY													18
19	PRIVATE DUTY NURSING													19
20	CLINIC													20
21	HEALTH PROMOTION ACTIVITIES													21
22	DAY CARE PROGRAM													22
23	HOME DELIVERED MEALS PROGRAM													23
24	HOMEMAKER SERVICES													24
25	ADVERTISING													25
26	FUNDRAISING													26
27														27
100	TOTAL STATISTIC													100
101	TOTAL COST TO BE ALLOCATED													101
102	UNIT COST MULTIPLIER													102













FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4909.32)
Rev. 1														49-563
4995 (CONT.)				FORM CMS-2540-24										DRAFT
ALLOCATION OF SNF GENERAL SERVICE COSTS TO SNF - BASED HHA - STATISTICAL BASIS								PROVIDER CCN:		PERIOD:			WORKSHEET H-2
								________________		FROM:		___________	PART II
								HHA CCN:		TO:		___________
								________________

					CENTRAL								QUALITY &
		HOUSE-		NURSING	SERVICE		MEDICAL		SOCIAL		ACTIVITIES		PERFORM
		KEEPING	DIETARY	ADMIN	& SUPPLY	PHARMACY	RECORDS		SERVICE		PROGRAM		IMPROV PGM
		(HOURS OF	(MEALS	(DIRECT	(COSTED	(COSTED	(TIME		(TIME		(TIME		(TIME
		SERVICE)	SERVED)	NURS HRS)	REQUIS)	REQUIS)	SPENT)		SPENT)		SPENT)		SPENT)
		7	8	9	10	11	12		13		14		15
1	ADMINISTRATIVE & GENERAL													1
2	SKILLED NURSING CARE - RN													2
3	SKILLED NURSING CARE - LPN													3
4	PHYSICAL THERAPIST													4
5	PHYSICAL THERAPY ASSISTANT													5
6	OCCUPATIONAL THERAPIST													6
7	OCCUPATIONAL THERAPY ASSISTANT													7
8	SPEECH LANGUAGE PATHOLOGIST													8
9	MEDICAL SOCIAL SERVICES													9
10	HOME HEALTH AIDE													10
11	MEDICAL SUPPLIES CHARGED TO PATIENTS													11
12	DRUGS CHARGED TO PATIENTS													12
13	COST OF ADMINISTERING VACCINES													13
14	DURABLE MEDICAL EQUIPMENT/OXYGEN													14
15	DISPOSABLE DEVICES													15
16	OTHER REIMBURSABLE													16
17	HOME DIALYSIS AIDE SERVICES													17
18	RESPIRATORY THERAPY													18
19	PRIVATE DUTY NURSING													19
20	CLINIC													20
21	HEALTH PROMOTION ACTIVITIES													21
22	DAY CARE PROGRAM													22
23	HOME DELIVERED MEALS PROGRAM													23
24	HOMEMAKER SERVICES													24
25	ADVERTISING													25
26	FUNDRAISING													26
27														27
100	TOTAL STATISTIC													100
101	TOTAL COST TO BE ALLOCATED													125
102	UNIT COST MULTIPLIER													102













FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4909.32)
49-564														Rev. 1
DRAFT				FORM CMS-2540-24										4995 (CONT.)
ALLOCATION OF SNF GENERAL SERVICE COSTS TO SNF - BASED HHA - STATISTICAL BASIS								PROVIDER CCN:		PERIOD:			WORKSHEET H-2
								________________		FROM:		___________	PART II
								HHA CCN:		TO:		___________
								________________

		TRAINING &	PATIENT	OTHER
		IN-SERVICE	TRANSPORT	GENERAL
		EDUCATION	PART A	SERVICE
		(TIME	(NUMBER OF	(SPECIFY)
		SPENT)	TRANSPORT)
		16	17	18
1	ADMINISTRATIVE & GENERAL													1
2	SKILLED NURSING CARE - RN													2
3	SKILLED NURSING CARE - LPN													3
4	PHYSICAL THERAPIST													4
5	PHYSICAL THERAPY ASSISTANT													5
6	OCCUPATIONAL THERAPIST													6
7	OCCUPATIONAL THERAPY ASSISTANT													7
8	SPEECH LANGUAGE PATHOLOGIST													8
9	MEDICAL SOCIAL SERVICES													9
10	HOME HEALTH AIDE													10
11	MEDICAL SUPPLIES CHARGED TO PATIENTS													11
12	DRUGS CHARGED TO PATIENTS													12
13	COST OF ADMINISTERING VACCINES													13
14	DURABLE MEDICAL EQUIPMENT/OXYGEN													14
15	DISPOSABLE DEVICES													15
16	OTHER REIMBURSABLE													16
17	HOME DIALYSIS AIDE SERVICES													17
18	RESPIRATORY THERAPY													18
19	PRIVATE DUTY NURSING													19
20	CLINIC													20
21	HEALTH PROMOTION ACTIVITIES													21
22	DAY CARE PROGRAM													22
23	HOME DELIVERED MEALS PROGRAM													23
24	HOMEMAKER SERVICES													24
25	ADVERTISING													25
26	FUNDRAISING													26
27														27
100	TOTALS													100
101	TOTAL COST TO BE ALLOCATED													101
102	UNIT COST MULTIPLIER													102













FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4909.32)
Rev. 1														49-565

Sheet 32: H-3

4995 (CONT.)

FORM CMS-2540-24

DRAFT

APPORTIONMENT OF SNF - BASED HHA PATIENT SERVICE COSTS

PROVIDER CCN:

PERIOD:

WORKSHEET H-3

________________

FROM:

___________

PARTS I, II & III

HHA CCN:

TO:

___________

________________

SELECT PROGRAM

[ ]

TITLE V

[ ]

TITLE XVIII

[ ]

TITLE XIX

PART I - APPORTIONMENT OF COST OF SNF-BASED HHA SERVICES FURNISHED BY SHARED SNF DEPARTMENTS

HHA

FROM

COST TO

TOTAL

SHARED

WKST C,

CHARGE

HHA

ANCILLARY

COL 5,

RATIO

CHARGES

COSTS

LINE #

PHYSICAL THERAPY

OCCUPATIONAL THERAPY

SPEECH LANGUAGE PATHOLOGIST

MEDICAL SUPPLIES CHARGED TO PATIENTS

DRUGS CHARGED TO PATIENTS

PART II - SNF-BASED HHA COST PER VISIT AND PROGRAM COST COMPUTATION

FROM

WKST H-2,

SHARED

TOTAL

AVERAGE

HHA

PT I,

FACILITY

ANCILLARY

HHA

TOTAL

COST

PROGRAM

COL 23,

COSTS

VISITS

PER VISIT

VISITS

COSTS

LINE #

SKILLED NURSING CARE - RN

SKILLED NURSING CARE - LPN

PT - PHYSICAL THERAPIST

PT - PHYSICAL THERAPY ASSISTANT

OT - OCCUPATIONAL THERAPIST

OT - OCCUPATIONAL THERAPY ASSISTANT

SPEECH LANGUAGE PATHOLOGIST

MEDICAL SOCIAL SERVICES

HOME HEALTH AIDE

TOTAL

PART III - MEDICAL SUPPLIES, DRUGS, AND DISPOSABLE DEVICES COST COMPUTATION

FROM

PROGRAM COVERED CHARGES

PROGRAM COST OF SERVICES

WKST H-2,

SHARED

TOTAL

OPPS

NOT SUBJ

SUBJECT

OPPS

NOT SUBJ

SUBJECT

PT I,

FACILITY

ANCILLARY

HHA

TOTAL

REIMB

TO DED &

REIMB

TO DED &

COL 23,

COSTS

CHARGES

RATIO

SERVICES

COINSUR

SERVICES

COINSUR

LINE #

MEDICAL SUPPLIES CHARGED TO PATIENTS

DRUGS CHARGED TO PATIENTS

COST OF ADMINISTERING VACCINES

DISPOSABLE DEVICES

FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTIONS 4908.40 THROUGH 4909.43)

49-566

Rev. 1

Sheet 33: H-4

DRAFT								FORM CMS-2540-24							4995 (CONT.)
CALCULATION OF SNF - BASED HHA REIMBURSEMENT SETTLEMENT									PROVIDER CCN:		PERIOD:			WORKSHEET H-4
									________________		FROM:	___________		PARTS I & II
									HHA CCN:		TO:	___________
									________________

SELECT PROGRAM		[ ]	TITLE V	[ ]	TITLE XVIII	[ ]	TITLE XIX

PART I - COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES
										NOT SUBJECT TO			SUBJECT TO
										DEDUCTIBLES AND			DEDUCTIBLES AND
										COINSURANCE			COINSURANCE
										1			2
1	REASONABLE COST OF SERVICES														1
2	TOTAL CHARGES														2
3	EXCESS OF TOTAL CUSTOMARY CHARGES OVER TOTAL REASONABLE COST														3
4	EXCESS OF REASONABLE COST OVER CUSTOMARY CHARGES														4
5	TOTAL OF REASONABLE COST														5

PART II - COMPUTATION OF SNF - BASED HHA REIMBURSEMENT SETTLEMENT
										1
1	TOTAL PPS PAYMENT - FULL PERIODS WITHOUT OUTLIERS														1
2	TOTAL PPS PAYMENT - FULL PERIODS WITH OUTLIERS														2
3	TOTAL PPS PAYMENT - LUPA PERIODS														3
4	TOTAL PPS PAYMENT - PEP PERIODS														4
5	TOTAL PPS OUTLIER PAYMENT - FULL PERIODS WITH OUTLIERS														5
6	TOTAL PPS OUTLIER PAYMENT - PEP PERIODS														6
7	PROSTHETICS AND ORTHOTICS PAYMENT														7
8	DME PAYMENT														8
9	OXYGEN PAYMENT														9
10	PAYMENT FOR SERVICES REIMBURSED UNDER OPPS														10
11	TOTAL REIMBURABLE COST														11
12	DEDUCTIBLES BILLED TO PROGRAM PATIENTS														12
13	COINSURANCE BILLED TO PROGRAM PATIENTS														13
14	PRIMARY PAYER PAYMENTS														14
15	SUBTOTAL OF REIMBURSABLE COSTS														15
16	ALLOWABLE BAD DEBTS														16
17	ADJUSTED REIMBURSABLE BAD DEBTS														17
18	ALLOWABLE BAD DEBTS FOR DUAL ELIGIBLE BENEFICIARIES														18
19	NET REIMBURSABLE AMOUNT BEFORE DEMONSTRATION PAYMENT ADJUSTMENTS														19
20	OTHER DEMONSTRATION PAYMENT ADJUSTMENT AMOUNTS BEFORE SEQUESTRATION														20
21	AMOUNT DUE HHA PRIOR TO SEQUESTRATION ADJUSTMENT														21
22	SEQUESTRATION ADJUSTMENT FOR CLAIMS-BASED AMOUNTS														22
23	SEQUESTRATION ADJUSTMENT FOR NON-CLAIMS-BASED AMOUNTS														23
24	OTHER DEMONSTRATION PAYMENT ADJUSTMENT AMOUNTS AFTER SEQUESTRATION														24
25	OTHER ADJUSTMENTS														25
26	SUBTOTAL OF AMOUNT DUE HHA / MEDICARE PROGRAM														26
27	TOTAL INTERIM PAYMENTS														27
28	TENTATIVE SETTLEMENT AMOUNTS														28
29	BALANCE DUE HHA / MEDICARE PROGRAM														29
30	PROTESTED AMOUNTS														30























FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTIONS 4909.50 - 4909.52)
Rev. 1															49-567

Sheet 34: H-5

4995 (CONT.)		FORM CMS-2540-24									DRAFT
ANALYSIS OF PAYMENTS TO SNF - BASED HOME HEALTH AGENCY FOR SERVICES			PROVIDER CCN:		PERIOD:				WORKSHEET H-5
RENDERED TO MEDICARE BENEFICIARIES			________________		FROM:	___________
			HHA CCN:		TO:	___________
			________________

							DATE			AMOUNT
							1			2
1	TOTAL INTERIM PAYMENTS PAID TO PROVIDER										1
2	INTERIM PAYMENTS PAYABLE										2
3	RETROACTIVE LUMP SUM ADJUSTMENTS			PROGRAM TO PROVIDER		.01					3.01
						.02					3.02
						.03					3.03
						.04					3.04
						.05					3.05
				PROVIDER TO PROGRAM		.50					3.50
						.51					3.51
						.52					3.52
						.53					3.53
						.54					3.54
	SUBTOTAL					.99					3.99
4	TOTAL INTERIM PAYMENTS										4

5	CONTRACTOR: TENTATIVE SETTLEMENT PAYMENTS			PROGRAM TO PROVIDER		.01					5.01
						.02					5.02
						.03					5.03
						.04					5.04
						.05					5.05
				PROVIDER TO PROGRAM		.50					5.50
						.51					5.51
						.52					5.52
						.53					5.53
						.54					5.54
	SUBTOTAL					.99					5.99
6	CONTRACTOR: NET SETTLEMENT AMOUNT		PROGRAM TO PROVIDER			.01					6.01
			PROVIDER TO PROGRAM			.02					6.02
7	CONTRACTOR: TOTAL MEDICARE PROGRAM LIABILITY										7

				CONTRACTOR
	NAME OF CONTRACTOR			NUMBER				DATE OF NPR
	1			2				3
8											8

































FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4909.60)
49-568											Rev. 1

Sheet 35: K

DRAFT			FORM CMS-2540-24										4995 (CONT.)
ANALYSIS OF SNF - BASED HOSPICE COSTS							PROVIDER CCN:		PERIOD:			WORKSHEET K
							________________		FROM:		___________
							HOSPICE CCN:		TO:		___________
							________________

						RECLASS-				ADJUST-
			SALARIES	OTHER	SUBTOTAL	IFICATIONS		SUBTOTAL		MENTS		TOTAL
			1	2	3	4		5		6		7
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS & FIXTURES												1
2	CAPITAL RELATED - MOVABLE EQUIPMENT												2
3	EMPLOYEE BENEFITS												3
4	ADMINISTRATIVE & GENERAL												4
5	PLANT OPERATION & MAINTENANCE												5
6	LAUNDRY & LINEN SERVICE												6
7	HOUSEKEEPING												7
8	DIETARY												8
9	NURSING ADMINISTRATION												9
10	ROUTINE MEDICAL SUPPLIES												10
11	MEDICAL RECORDS												11
12	STAFF TRANSPORTATION												12
13	VOLUNTEER SERVICE COORDINATION												13
14	PHARMACY												14
15	PHYSICIAN ADMINISTRATIVE SERVICES												15
16	OTHER GENERAL SERVICE												16
17	PATIENT/RESIDENTIAL CARE SERVICES												17
		DIRECT PATIENT CARE SERVICES COST CENTERS
25	INPATIENT CARE-CONTRACTED												25
26	PHYSICIAN SERVICES												26
27	NURSE PRACTITIONER												27
28	REGISTERED NURSE												28
29	LICENSED PRACTICAL NURSE												29
30	PHYSICAL THERAPY												30
31	OCCUPATIONAL THERAPY												31
32	SPEECH-LANGUAGE PATHOLOGY												32
33	MEDICAL SOCIAL SERVICES												33
34	SPIRITUAL COUNSELING												34
35	DIETARY COUNSELING												35
36	COUNSELING-OTHER												36
37	HOSPICE AIDE & HOMEMAKER SERVICES												37
38	DURABLE MEDICAL EQUIPMENT/OXYGEN												38
39	PATIENT TRANSPORTATION												39
40	IMAGING SERVICES												40
41	LABS & DIAGNOSTICS												41
42	MEDICAL SUPPLIES CHARGED TO PATIENTS												42
43	DRUGS CHARGED TO PATIENTS												43
44	OUTPATIENT SERVICES												44
45	PALLIATIVE RADIATION THERAPY												45
46	PALLIATIVE CHEMOTHERAPY												46
47	OTHER DIRECT PATIENT CARE SERVICES												47




FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4912.10)
Rev. 1													49-569
4995 (CONT.)			FORM CMS-2540-24										DRAFT
ANALYSIS OF SNF - BASED HOSPICE COSTS							PROVIDER CCN:		PERIOD:			WORKSHEET K
							________________		FROM:		___________
							HOSPICE CCN:		TO:		___________
							________________

						RECLASS-				ADJUST-
			SALARIES	OTHER	SUBTOTAL	IFICATIONS		SUBTOTAL		MENTS		TOTAL
			1	2	3	4		5		6		7
		NONREIMBURSABLE SERVICES COST CENTERS
60	BEREAVEMENT PROGRAM												60
61	VOLUNTEER PROGRAM												61
62	FUNDRAISING												62
63	HOSPICE/PALLIATIVE MEDICINE FELLOWS												63
64	PALLIATIVE CARE PROGRAM												64
65	OTHER PHYSICIAN SERVICES												65
66	RESIDENTIAL CARE												66
67	ADVERTISING												67
68	TELEHEALTH/TELEMONITORING												68
69	THRIFT STORE												69
70	NURSING FACILITY ROOM & BOARD												70
71	OTHER NONREIMBURSABLE												71
100	TOTAL												100
































FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4912.10)
49-570													Rev. 1

Sheet 36: K-1

DRAFT			FORM CMS-2540-24										4995 (CONT.)
ANALYSIS OF SNF - BASED HOSPICE CONTINUOUS HOME CARE							PROVIDER CCN:		PERIOD:			WORKSHEET K-1
							________________		FROM:		___________
							HOSPICE CCN:		TO:		___________
							________________

						RECLASS-				ADJUST-
			SALARIES	OTHER	SUBTOTAL	IFICATIONS		SUBTOTAL		MENTS		TOTAL
			1	2	3	4		5		6		7
		DIRECT PATIENT CARE SERVICES COST CENTERS
25	INPATIENT CARE - CONTRACTED												25
26	PHYSICIAN SERVICES												26
27	NURSE PRACTITIONER												27
28	REGISTERED NURSE												28
29	LICENSED PRACTICAL NURSE												29
30	PHYSICAL THERAPY												30
31	OCCUPATIONAL THERAPY												31
32	SPEECH-LANGUAGE PATHOLOGY												32
33	MEDICAL SOCIAL SERVICES												33
34	SPIRITUAL COUNSELING												34
35	DIETARY COUNSELING												35
36	COUNSELING - OTHER												36
37	HOSPICE AIDE & HOMEMAKER SERVICES												37
38	DURABLE MEDICAL EQUIPMENT/OXYGEN												38
39	PATIENT TRANSPORTATION												39
40	IMAGING SERVICES												40
41	LABS & DIAGNOSTICS												41
42	MEDICAL SUPPLIES-NON-ROUTINE												42
43	DRUGS CHARGED TO PATIENTS												43
44	OUTPATIENT SERVICES												44
45	PALLIATIVE RADIATION THERAPY												45
46	PALLIATIVE CHEMOTHERAPY												46
47	OTHER DIRECT PATIENT CARE SERVICE COST CENTER												47
100	TOTAL												100





















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4912.20)
Rev. 1													49-571

Sheet 37: K-2

4995 (CONT.)			FORM CMS-2540-24										DRAFT
ANALYSIS OF SNF - BASED HOSPICE ROUTINE HOME CARE							PROVIDER CCN:		PERIOD:			WORKSHEET K-2
							________________		FROM:		___________
							HOSPICE CCN:		TO:		___________
							________________

						RECLASS-				ADJUST-
			SALARIES	OTHER	SUBTOTAL	IFICATIONS		SUBTOTAL		MENTS		TOTAL
			1	2	3	4		5		6		7
		DIRECT PATIENT CARE SERVICES COST CENTERS
25	INPATIENT CARE - CONTRACTED												25
26	PHYSICIAN SERVICES												26
27	NURSE PRACTITIONER												27
28	REGISTERED NURSE												28
29	LICENSED PRACTICAL NURSE												29
30	PHYSICAL THERAPY												30
31	OCCUPATIONAL THERAPY												31
32	SPEECH-LANGUAGE PATHOLOGY												32
33	MEDICAL SOCIAL SERVICES												33
34	SPIRITUAL COUNSELING												34
35	DIETARY COUNSELING												35
36	COUNSELING - OTHER												36
37	HOSPICE AIDE & HOMEMAKER SERVICES												37
38	DURABLE MEDICAL EQUIPMENT/OXYGEN												38
39	PATIENT TRANSPORTATION												39
40	IMAGING SERVICES												40
41	LABS & DIAGNOSTICS												41
42	MEDICAL SUPPLIES-NON-ROUTINE												42
43	DRUGS CHARGED TO PATIENTS												43
44	OUTPATIENT SERVICES												44
45	PALLIATIVE RADIATION THERAPY												45
46	PALLIATIVE CHEMOTHERAPY												46
47	OTHER DIRECT PATIENT CARE SERVICE COST CENTER												47
100	TOTAL												100





















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4912.20)
49-572													Rev. 1

Sheet 38: K-3

DRAFT			FORM CMS-2540-24										4995 (CONT.)
ANALYSIS OF SNF - BASED HOSPICE INPATIENT RESPITE CARE							PROVIDER CCN:		PERIOD:			WORKSHEET K-3
							________________		FROM:		___________
							HOSPICE CCN:		TO:		___________
							________________

						RECLASS-				ADJUST-
			SALARIES	OTHER	SUBTOTAL	IFICATIONS		SUBTOTAL		MENTS		TOTAL
			1	2	3	4		5		6		7
		DIRECT PATIENT CARE SERVICES COST CENTERS
25	INPATIENT CARE - CONTRACTED												25
26	PHYSICIAN SERVICES												26
27	NURSE PRACTITIONER												27
28	REGISTERED NURSE												28
29	LICENSED PRACTICAL NURSE												29
30	PHYSICAL THERAPY												30
31	OCCUPATIONAL THERAPY												31
32	SPEECH-LANGUAGE PATHOLOGY												32
33	MEDICAL SOCIAL SERVICES												33
34	SPIRITUAL COUNSELING												34
35	DIETARY COUNSELING												35
36	COUNSELING - OTHER												36
37	HOSPICE AIDE & HOMEMAKER SERVICES												37
38	DURABLE MEDICAL EQUIPMENT/OXYGEN												38
39	PATIENT TRANSPORTATION												39
40	IMAGING SERVICES												40
41	LABS & DIAGNOSTICS												41
42	MEDICAL SUPPLIES-NON-ROUTINE												42
43	DRUGS CHARGED TO PATIENTS												43
44	OUTPATIENT SERVICES												44
45	PALLIATIVE RADIATION THERAPY												45
46	PALLIATIVE CHEMOTHERAPY												46
47	OTHER DIRECT PATIENT CARE SERVICE COST CENTER												47
100	TOTAL												100





















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4912.20)
Rev. 1													49-573

Sheet 39: K-4

4995 (CONT.)			FORM CMS-2540-24										DRAFT
ANALYSIS OF SNF - BASED HOSPICE GENERAL INPATIENT CARE							PROVIDER CCN:		PERIOD:			WORKSHEET K-4
							________________		FROM:		___________
							HOSPICE CCN:		TO:		___________
							________________

						RECLASS-				ADJUST-
			SALARIES	OTHER	SUBTOTAL	IFICATIONS		SUBTOTAL		MENTS		TOTAL
			1	2	3	4		5		6		7
		DIRECT PATIENT CARE SERVICES COST CENTERS
25	INPATIENT CARE - CONTRACTED												25
26	PHYSICIAN SERVICES												26
27	NURSE PRACTITIONER												27
28	REGISTERED NURSE												28
29	LICENSED PRACTICAL NURSE												29
30	PHYSICAL THERAPY												30
31	OCCUPATIONAL THERAPY												31
32	SPEECH-LANGUAGE PATHOLOGY												32
33	MEDICAL SOCIAL SERVICES												33
34	SPIRITUAL COUNSELING												34
35	DIETARY COUNSELING												35
36	COUNSELING - OTHER												36
37	HOSPICE AIDE & HOMEMAKER SERVICES												37
38	DURABLE MEDICAL EQUIPMENT/OXYGEN												38
39	PATIENT TRANSPORTATION												39
40	IMAGING SERVICES												40
41	LABS & DIAGNOSTICS												41
42	MEDICAL SUPPLIES-NON-ROUTINE												42
43	DRUGS CHARGED TO PATIENTS												43
44	OUTPATIENT SERVICES												44
45	PALLIATIVE RADIATION THERAPY												45
46	PALLIATIVE CHEMOTHERAPY												46
47	OTHER DIRECT PATIENT CARE SERVICE COST CENTER												47
100	TOTAL												100





















FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4912.20)
49-574													Rev. 1

Sheet 40: K-5

DRAFT			FORM CMS-2540-24							4995 (CONT.)
DETERMINATION OF SNF - BASED HOSPICE TOTAL EXPENSES FOR ALLOCATION				PROVIDER CCN:		PERIOD:			WORKSHEET K-5
				________________		FROM:		___________
				HOSPICE CCN:		TO:		___________
				________________

							GENERAL
					HOSPICE		SERVICES
					DIRECT		EXPENSES		TOTAL
					EXPENSES		FROM WKST B		EXPENSES
					1		2		3
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS & FIXTURES									1
2	CAPITAL RELATED - MOVABLE EQUIPMENT									2
3	EMPLOYEE BENEFITS									3
4	ADMINISTRATIVE & GENERAL									4
5	PLANT OPERATION & MAINTENANCE									5
6	LAUNDRY & LINEN SERVICE									6
7	HOUSEKEEPING									7
8	DIETARY									8
9	NURSING ADMINISTRATION									9
10	ROUTINE MEDICAL SUPPLIES									10
11	MEDICAL RECORDS									11
12	STAFF TRANSPORTATION									12
13	VOLUNTEER SERVICE COORDINATION									13
14	PHARMACY									14
15	PHYSICIAN ADMINISTRATIVE SERVICES									15
16	OTHER GENERAL SERVICE									16
17	PATIENT/RESIDENTIAL CARE SERVICES									17
		LEVEL OF CARE
50	HOSPICE CONTINUOUS HOME CARE									50
51	HOSPICE ROUTINE HOME CARE									51
52	HOSPICE INPATIENT RESPITE CARE									52
53	HOSPICE GENERAL INPATIENT CARE									53
		NONREIMBURSABLE SERVICES COST CENTERS
60	BEREAVEMENT PROGRAM									60
61	VOLUNTEER PROGRAM									61
62	FUNDRAISING									62
63	HOSPICE/PALLIATIVE MEDICINE FELLOWS									63
64	PALLIATIVE CARE PROGRAM									64
65	OTHER PHYSICIAN SERVICES									65
66	RESIDENTIAL CARE									66
67	ADVERTISING									67
68	TELEHEALTH/TELEMONITORING									68
69	THRIFT STORE									69
70	NURSING FACILITY ROOM & BOARD									70
71	OTHER NONREIMBURSABLE COST CENTER									71
100	TOTAL									100


























FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4912.60)
Rev. 1										49-575

Sheet 41: K6-I

4995 (CONT.)				FORM CMS-2540-24										DRAFT
COST ALLOCATION SNF - BASED HOSPICE GENERAL SERVICE COST								PROVIDER CCN:		PERIOD:			WORKSHEET K-6
								________________		FROM:		___________	PART I
								HOSPICE CCN:		TO:		___________
								________________

			TOTAL	CRC-	CRC-	EMPLOYEE	SUBTOTAL		A&G		PLANT		LAUNDRY
			EXPENSES	B&F	ME	BENEFITS					OP &		& LINEN
						DEPARTMENT					MAINT
			0	1	2	3	3A		4		5		6
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS & FIXTURES													1
2	CAPITAL RELATED - MOVABLE EQUIPMENT													2
3	EMPLOYEE BENEFITS DEPARTMENT													3
4	ADMINISTRATIVE & GENERAL													4
5	PLANT OPERATION & MAINTENANCE													5
6	LAUNDRY & LINEN SERVICE													6
7	HOUSEKEEPING													7
8	DIETARY													8
9	NURSING ADMINISTRATION													9
10	ROUTINE MEDICAL SUPPLIES													10
11	MEDICAL RECORDS													11
12	STAFF TRANSPORTATION													12
13	VOLUNTEER SERVICE COORDINATION													13
14	PHARMACY													14
15	PHYSICIAN ADMINISTRATIVE SERVICES													15
16	OTHER GENERAL SERVICE													16
17	PATIENT/RESIDENTIAL CARE SERVICES													17
		LEVEL OF CARE
50	HOSPICE CONTINUOUS HOME CARE													50
51	HOSPICE ROUTINE HOME CARE													51
52	HOSPICE INPATIENT RESPITE CARE													52
53	HOSPICE GENERAL INPATIENT CARE													53
		NONREIMBURSABLE SERVICES COST CENTERS
60	BEREAVEMENT PROGRAM													60
61	VOLUNTEER PROGRAM													61
62	FUNDRAISING													62
63	HOSPICE/PALLIATIVE MEDICINE FELLOWS													63
64	PALLIATIVE CARE PROGRAM													64
65	OTHER PHYSICIAN SERVICES													65
66	RESIDENTIAL CARE													66
67	ADVERTISING													67
68	TELEHEALTH/TELEMONITORING													68
69	THRIFT STORE													69
70	NURSING FACILITY ROOM & BOARD													70
71	OTHER NONREIMBURSABLE													71
99	NEGATIVE COST CENTER													99
100	TOTAL													100







FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4912.70)
49-576														Rev. 1
DRAFT				FORM CMS-2540-24										4995 (CONT.)
COST ALLOCATION SNF - BASED HOSPICE GENERAL SERVICE COST								PROVIDER CCN:		PERIOD:			WORKSHEET K-6
								________________		FROM:		___________	PART I
								HOSPICE CCN:		TO:		___________
								________________

			HOUSE-	DIETARY	NURSING	ROUTINE	MEDICAL		STAFF		VOLUNTEER		PHARMACY
			KEEPING		ADMIN	MEDICAL	RECORDS		TRANS-		SVC COOR-
						SUPPLIES			PORTATION		DINATOR
			7	8	9	10	11		12		13		14
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS & FIXTURES													1
2	CAPITAL RELATED - MOVABLE EQUIPMENT													2
3	EMPLOYEE BENEFITS DEPARTMENT													3
4	ADMINISTRATIVE & GENERAL													4
5	PLANT OPERATION & MAINTENANCE													5
6	LAUNDRY & LINEN SERVICE													6
7	HOUSEKEEPING													7
8	DIETARY													8
9	NURSING ADMINISTRATION													9
10	ROUTINE MEDICAL SUPPLIES													10
11	MEDICAL RECORDS													11
12	STAFF TRANSPORTATION													12
13	VOLUNTEER SERVICE COORDINATION													13
14	PHARMACY													14
15	PHYSICIAN ADMINISTRATIVE SERVICES													15
16	OTHER GENERAL SERVICE													16
17	PATIENT/RESIDENTIAL CARE SERVICES													17
		LEVEL OF CARE
50	HOSPICE CONTINUOUS HOME CARE													50
51	HOSPICE ROUTINE HOME CARE													51
52	HOSPICE INPATIENT RESPITE CARE													52
53	HOSPICE GENERAL INPATIENT CARE													53
		NONREIMBURSABLE SERVICES COST CENTERS
60	BEREAVEMENT PROGRAM													60
61	VOLUNTEER PROGRAM													61
62	FUNDRAISING													62
63	HOSPICE/PALLIATIVE MEDICINE FELLOWS													63
64	PALLIATIVE CARE PROGRAM													64
65	OTHER PHYSICIAN SERVICES													65
66	RESIDENTIAL CARE													66
67	ADVERTISING													67
68	TELEHEALTH/TELEMONITORING													68
69	THRIFT STORE													69
70	NURSING FACILITY ROOM & BOARD													70
71	OTHER NONREIMBURSABLE													71
99	NEGATIVE COST CENTER													99
100	TOTAL													100







FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4912.70)
Rev. 1														49-577
4995 (CONT.)				FORM CMS-2540-24										DRAFT
COST ALLOCATION SNF - BASED HOSPICE GENERAL SERVICE COST								PROVIDER CCN:		PERIOD:			WORKSHEET K-6
								________________		FROM:		___________	PART I
								HOSPICE CCN:		TO:		___________
								________________

			PHYSICIAN	OTHER	PATIENT /	TOTAL
			ADMIN	GENERAL	RESIDENT
			SERVICES	SERVICE	CARE SVCS
			15	16	17	18
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS & FIXTURES													1
2	CAPITAL RELATED - MOVABLE EQUIPMENT													2
3	EMPLOYEE BENEFITS DEPARTMENT													3
4	ADMINISTRATIVE & GENERAL													4
5	PLANT OPERATION & MAINTENANCE													5
6	LAUNDRY & LINEN SERVICE													6
7	HOUSEKEEPING													7
8	DIETARY													8
9	NURSING ADMINISTRATION													9
10	ROUTINE MEDICAL SUPPLIES													10
11	MEDICAL RECORDS													11
12	STAFF TRANSPORTATION													12
13	VOLUNTEER SERVICE COORDINATION													13
14	PHARMACY													14
15	PHYSICIAN ADMINISTRATIVE SERVICES													15
16	OTHER GENERAL SERVICE													16
17	PATIENT/RESIDENTIAL CARE SERVICES													17
		LEVEL OF CARE
50	HOSPICE CONTINUOUS HOME CARE													50
51	HOSPICE ROUTINE HOME CARE													51
52	HOSPICE INPATIENT RESPITE CARE													52
53	HOSPICE GENERAL INPATIENT CARE													53
		NONREIMBURSABLE SERVICES COST CENTERS
60	BEREAVEMENT PROGRAM													60
61	VOLUNTEER PROGRAM													61
62	FUNDRAISING													62
63	HOSPICE/PALLIATIVE MEDICINE FELLOWS													63
64	PALLIATIVE CARE PROGRAM													64
65	OTHER PHYSICIAN SERVICES													65
66	RESIDENTIAL CARE													66
67	ADVERTISING													67
68	TELEHEALTH/TELEMONITORING													68
69	THRIFT STORE													69
70	NURSING FACILITY ROOM & BOARD													70
71	OTHER NONREIMBURSABLE													71
99	NEGATIVE COST CENTER													99
100	TOTAL													100







FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4912.70)
49-578														Rev. 1

Sheet 42: K6-II

DRAFT				FORM CMS-2540-24										4995 (CONT.)
COST ALLOCATION - SNF - BASED HOSPICE GENERAL SERVICE COSTS STATISTICAL BASES								PROVIDER CCN:		PERIOD:			WORKSHEET K-6
								________________		FROM:		___________	PART II
								HOSPICE CCN:		TO:		___________
								________________

						EMPLOYEE					PLANT
				CRC-	CRC-	BENEFITS	RECONCIL-				OP &		LAUNDRY
				B&F	ME	DEPARTMENT	IATION		A&G		MAINT		& LINEN
				(SQUARE	(DOLLAR	(GROSS			(ACCUM		(SQUARE		(IN-FACIL-
				FEET)	VALUE)	SALARIES)			COST)		FEET)		ITY DAYS)
				1	2	3	4A		4		5		6
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS & FIXTURES													1
2	CAPITAL RELATED - MOVABLE EQUIPMENT													2
3	EMPLOYEE BENEFITS DEPARTMENT													3
4	ADMINISTRATIVE & GENERAL													4
5	PLANT OPERATION & MAINTENANCE													5
6	LAUNDRY & LINEN SERVICE													6
7	HOUSEKEEPING													7
8	DIETARY													8
9	NURSING ADMINISTRATION													9
10	ROUTINE MEDICAL SUPPLIES													10
11	MEDICAL RECORDS													11
12	STAFF TRANSPORTATION													12
13	VOLUNTEER SERVICE COORDINATION													13
14	PHARMACY													14
15	PHYSICIAN ADMINISTRATIVE SERVICES													15
16	OTHER GENERAL SERVICE													16
17	PATIENT/RESIDENTIAL CARE SERVICES													17
		LEVEL OF CARE
50	HOSPICE CONTINUOUS HOME CARE													50
51	HOSPICE ROUTINE HOME CARE													51
52	HOSPICE INPATIENT RESPITE CARE													52
53	HOSPICE GENERAL INPATIENT CARE													53
		NONREIMBURSABLE SERVICES COST CENTERS
60	BEREAVEMENT PROGRAM													60
61	VOLUNTEER PROGRAM													61
62	FUNDRAISING													62
63	HOSPICE/PALLIATIVE MEDICINE FELLOWS													63
64	PALLIATIVE CARE PROGRAM													64
65	OTHER PHYSICIAN SERVICES													65
66	RESIDENTIAL CARE													66
67	ADVERTISING													67
68	TELEHEALTH/TELEMONITORING													68
69	THRIFT STORE													69
70	NURSING FACILITY ROOM & BOARD													70
71	OTHER NONREIMBURSABLE													71
99	NEGATIVE COST CENTER													99
101	COST TO BE ALLOCATED													101
102	UNIT COST MULTIPLIER													102




FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4912.70)
Rev. 1														49-579
4995 (CONT.)				FORM CMS-2540-24										DRAFT
COST ALLOCATION - SNF - BASED HOSPICE GENERAL SERVICE COSTS STATISTICAL BASES								PROVIDER CCN:		PERIOD:			WORKSHEET K-6
								________________		FROM:		___________	PART II
								HOSPICE CCN:		TO:		___________
								________________

						ROUTINE			STAFF		VOLUNTEER
			HOUSE-		NURSING	MEDICAL	MEDICAL		TRANS-		SVC COOR-
			KEEPING	DIETARY	ADMIN	SUPPLIES	RECORDS		PORTATION		DINATOR		PHARMACY
			(SQUARE	(IN-FACIL-	(DIRECT	(PATIENT	(PATIENT		(MILEAGE)		(HOURS OF		(CHARGES)
			FEET)	ITY DAYS)	NURS HRS)	DAYS)	DAYS)				SERVICE)
			7	8	9	10	11		12		13		14
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS & FIXTURES													1
2	CAPITAL RELATED - MOVABLE EQUIPMENT													2
3	EMPLOYEE BENEFITS DEPARTMENT													3
4	ADMINISTRATIVE & GENERAL													4
5	PLANT OPERATION & MAINTENANCE													5
6	LAUNDRY & LINEN SERVICE													6
7	HOUSEKEEPING													7
8	DIETARY													8
9	NURSING ADMINISTRATION													9
10	ROUTINE MEDICAL SUPPLIES													10
11	MEDICAL RECORDS													11
12	STAFF TRANSPORTATION													12
13	VOLUNTEER SERVICE COORDINATION													13
14	PHARMACY													14
15	PHYSICIAN ADMINISTRATIVE SERVICES													15
16	OTHER GENERAL SERVICE													16
17	PATIENT/RESIDENTIAL CARE SERVICES													17
		LEVEL OF CARE
50	HOSPICE CONTINUOUS HOME CARE													50
51	HOSPICE ROUTINE HOME CARE													51
52	HOSPICE INPATIENT RESPITE CARE													52
53	HOSPICE GENERAL INPATIENT CARE													53
		NONREIMBURSABLE SERVICES COST CENTERS
60	BEREAVEMENT PROGRAM													60
61	VOLUNTEER PROGRAM													61
62	FUNDRAISING													62
63	HOSPICE/PALLIATIVE MEDICINE FELLOWS													63
64	PALLIATIVE CARE PROGRAM													64
65	OTHER PHYSICIAN SERVICES													65
66	RESIDENTIAL CARE													66
67	ADVERTISING													67
68	TELEHEALTH/TELEMONITORING													68
69	THRIFT STORE													69
70	NURSING FACILITY ROOM & BOARD													70
71	OTHER NONREIMBURSABLE													71
99	NEGATIVE COST CENTER													99
101	COST TO BE ALLOCATED													101
102	UNIT COST MULTIPLIER													102




FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4912.70)
49-580														Rev. 1
DRAFT				FORM CMS-2540-24										4995 (CONT.)
COST ALLOCATION - SNF - BASED HOSPICE GENERAL SERVICE COSTS STATISTICAL BASES								PROVIDER CCN:		PERIOD:			WORKSHEET K-6
								________________		FROM:		___________	PART II
								HOSPICE CCN:		TO:		___________
								________________

			PHYSICIAN	OTHER	PATIENT /
			ADMIN	GENERAL	RESIDENT
			SERVICES	SERVICE	CARE SVCS
			(PATIENT	(SPECIFY	(IN-FACIL-
			DAYS)	BASIS)	ITY DAYS)
			15	16	17
		GENERAL SERVICE COST CENTERS
1	CAPITAL RELATED - BUILDINGS & FIXTURES													1
2	CAPITAL RELATED - MOVABLE EQUIPMENT													2
3	EMPLOYEE BENEFITS DEPARTMENT													3
4	ADMINISTRATIVE & GENERAL													4
5	PLANT OPERATION & MAINTENANCE													5
6	LAUNDRY & LINEN SERVICE													6
7	HOUSEKEEPING													7
8	DIETARY													8
9	NURSING ADMINISTRATION													9
10	ROUTINE MEDICAL SUPPLIES													10
11	MEDICAL RECORDS													11
12	STAFF TRANSPORTATION													12
13	VOLUNTEER SERVICE COORDINATION													13
14	PHARMACY													14
15	PHYSICIAN ADMINISTRATIVE SERVICES													15
16	OTHER GENERAL SERVICE													16
17	PATIENT/RESIDENTIAL CARE SERVICES													17
		LEVEL OF CARE
50	HOSPICE CONTINUOUS HOME CARE													50
51	HOSPICE ROUTINE HOME CARE													51
52	HOSPICE INPATIENT RESPITE CARE													52
53	HOSPICE GENERAL INPATIENT CARE													53
		NONREIMBURSABLE SERVICES COST CENTERS
60	BEREAVEMENT PROGRAM													60
61	VOLUNTEER PROGRAM													61
62	FUNDRAISING													62
63	HOSPICE/PALLIATIVE MEDICINE FELLOWS													63
64	PALLIATIVE CARE PROGRAM													64
65	OTHER PHYSICIAN SERVICES													65
66	RESIDENTIAL CARE													66
67	ADVERTISING													67
68	TELEHEALTH/TELEMONITORING													68
69	THRIFT STORE													69
70	NURSING FACILITY ROOM & BOARD													70
71	OTHER NONREIMBURSABLE													71
99	NEGATIVE COST CENTER													99
101	COST TO BE ALLOCATED													101
102	UNIT COST MULTIPLIER													102




FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4912.70)
Rev. 1														49-581

Sheet 43: K-7

4995 (CONT.)			FORM CMS-2540-24													DRAFT
APPORTIONMENT OF SNF - BASED HOSPICE SHARED SERVICES COSTS BY LEVEL OF CARE									PROVIDER CCN:		PERIOD:			WORKSHEET K-7
									________________		FROM:	___________
									HOSPICE CCN:		TO:	___________
									________________

				COST TO
		WKST C,		CHARGE	CHARGES BY LOC					SHARED SERVICE COSTS BY LOC
		COL 3,		RATIO	HCHC	HRHC	HIRC	HCIP		HCHC	HRHC		HIRC		HCIP
		LINE #		1	2	3	4	5		6	7		8		9
1	RADIOLOGY - DIAGNOSTIC	30														1
2	RADIOLOGY - THERAPEUTIC/CHEMOTHERAPY	31														2
3	LABORATORY	32														3
4	INTRAVENOUS THERAPY	33														4
5	RESPIRATORY THERAPY	34														5
6	PHYSICAL THERAPY	35														6
7	OCCUPATIONAL THERAPY	36														7
8	SPEECH LANGUAGE PATHOLOGIST	37														8
9	MEDICAL SUPPLIES CHARGED TO PATIENTS	40														9
10	DRUGS: DRUGS CHARGED TO PATIENTS	41														10
11	DRUGS: IV SOLUTIONS	42														11
12	BLOOD AND BLOOD PRODUCTS	45														12
13	BLOOD TRANSFUSION/PROCESSING/STORAGE	46														13
20	TOTAL															20































FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4916.80)
49-582																Rev. 1

Sheet 44: K-8

DRAFT			FORM CMS-2540-24								4995 (CONT.)
CALCULATION OF SNF - BASED HOSPICE PER DIEM COST					PROVIDER CCN:		PERIOD:			WORKSHEET K-8
					________________		FROM:	___________
					HOSPICE CCN:		TO:	___________
					________________

				TITLE XVIII		TITLE XIX
				MEDICARE		MEDICAID			TOTAL
				1		2			3
		HOSPICE CONTINUOUS HOME CARE
1	TOTAL COST										1
2	TOTAL UNDUPLICATED DAYS										2
3	TOTAL AVERAGE COST PER DIEM										3
4	UNDUPLICATED PROGRAM DAYS										4
5	PROGRAM COST										5
		HOSPICE ROUTINE HOME CARE
6	TOTAL COST										6
7	TOTAL UNDUPLICATED DAYS										7
8	TOTAL AVERAGE COST PER DIEM										8
9	UNDUPLICATED PROGRAM DAYS										9
10	PROGRAM COST										10
		HOSPICE INPATIENT RESPITE CARE
11	TOTAL COST										11
12	TOTAL UNDUPLICATED DAYS										12
13	TOTAL AVERAGE COST PER DIEM										13
14	UNDUPLICATED PROGRAM DAYS										14
15	PROGRAM COST										15
		HOSPICE GENERAL INPATIENT CARE
16	TOTAL COST										16
17	TOTAL UNDUPLICATED DAYS										17
18	TOTAL AVERAGE COST PER DIEM										18
19	UNDUPLICATED PROGRAM DAYS										19
20	PROGRAM COST										20
		TOTAL HOSPICE CARE
21	TOTAL COST										21
22	TOTAL UNDUPLICATED DAYS										22
23	AVERAGE COST PER DIEM										23





































FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4916.90)
Rev. 1											49-583
DRAFT			FORM CMS-2540-24								4995 (CONT.)

























			THIS PAGE IS RESERVED FOR FUTURE USE















































FORM CMS-2540-24 (draft) (INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB. 15-2, SECTION 4916.90)
49-584											Rev. 1

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