CMS-2552-10 Crosswalk

FORM CMS-2552-10 HOSPITAL AND HOSPITAL HEALTHCARE COMPLEX

FORMS AND INSTRUCTIONS

The Form CMS-2552-10, Hospital and Hospital Healthcare Complex Cost Report, updates the existing Form CMS-2552-10 by subsuming the Supplemental to Form CMS-2552-10 Payment Adjustment for Establishing and Maintaining Access to a Buffer Stock of Essential Medicines (OMB Control No. 0938-1473) and the Supplemental to Form CMS-2552-10 Payment Adjustment for Domestic NIOSH-Approved Surgical N95 Respirators (OMB Control No. 0938-1425). Subsuming the worksheets results in an increase to the burden for the Hospital and Hospital Healthcare Complex Cost Report of 1 hour. Changes to the revised cost report forms and instructions include:

1. Added Worksheet E-90, Payment Adjustment for Establishing and Maintaining Access to a Buffer Stock of Essential Medicines, and instructions

2. Added Worksheet E-95, Payment Adjustment for Domestic NIOSH-Approved Surgical N95 Respirators, and instructions

#	FORM CMS‑2552‑10 CURRENTLY APPROVED	PROPOSED FORM CMS‑2552‑10				REASON FOR THE CHANGE / APPLICATION OF THE INSTRUCTIONS AND ACCOMPANYING WORKSHEETS	BURDEN EFFECT
		WORKSHEET		INSTRUCTIONS
		WORKSHEET	PAGE #	SECTION #	PAGE #
1.	N/A (currently approved as OMB Control No. 0938-1473)	Worksheet E-90	40-599.2 - 40-599.3	4038 - 4038.2	40-216.8 - 40-216.9	Added Worksheet E-90, Payment Adjustment for Establishing and Maintaining Access to a Buffer Stock of Essential Medicines	.75
2.	N/A (currently approved as OMB Control No. 0938-1425)	Worksheet E-95	40-599.4	4039 - 4039.3	40-216.10 - 40-216.12	Added Worksheet E-95, Payment Adjustment for Domestic NIOSH-Approved Surgical N95 Respirators	.25