Hospitals and Health Care Complex Cost Report (CMS-2552-96)

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Overview

A
A6
A7I, II &III
A8
A81
A82
A83

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Sheet 1: A

4090 (Cont.)				FORM CMS-2552-10						DRAFT
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES					PROVIDER NO.:		PERIOD:		WORKSHEET A
							FROM ____________
					_		TO ___________
							RECLASSIFIED		NET EXPENSES
		COST CENTER DESCRIPTIONS			TOTAL	RECLASSIFI-	TRIAL BALANCE		FOR ALLOCATION
		(omit cents)	SALARIES	OTHER	(col. 1 + col. 2)	CATIONS	(col. 3 ± col. 4)	ADJUSTMENTS	(col. 5 ± col. 6)
			1	2	3	4	5	6	7
		GENERAL SERVICE COST CENTERS
1	00100	Capital Related Costs-Buildings and Fixtures								1
2	00200	Capital Related Costs-Movable Equipment								2
3	00300	Other Capital Related Costs							-0-	3
4	00400	Employee Benefits								4
5	00500	Administrative and General								5
6	00600	Maintenance and Repairs								6
7	00700	Operation of Plant								7
8	00800	Laundry and Linen Service								8
9	00900	Housekeeping								9
10	01000	Dietary								10
11	01100	Cafeteria								11
12	01200	Maintenance of Personnel								12
13	01300	Nursing Administration								13
14	01400	Central Services and Supply								14
15	01500	Pharmacy								15
16	01600	Medical Records & Medical Records Library								16
17	01700	Social Service								17
18		Other General Service (specify)								18
19	01900	Nonphysician Anesthetists								19
20	02000	Nursing School								20
21	02100	Intern & Res. Service-Salary & Fringes (Approved)								21
22	02200	Intern & Res. Other Program Costs (Approved)								22
23	02300	Paramedical Ed. Program (specify)								23
		INPATIENT ROUTINE SERVICE COST CENTERS
30	03000	Adults and Pediatrics (General Routine Care)								30
31	03100	Intensive Care Unit								31
32	03200	Coronary Care Unit								32
33	03300	Burn Intensive Care Unit								33
34	03400	Surgical Intensive Care Unit								34
35		Other Special Care (specify)								35
40	04000	Subprovider - IPF								40
41	04100	Subprovider - IRF								41
42	04200	Subprovider (specify)								42
43	04300	Nursery								43
44	04400	Skilled Nursing Facility								44
45	04500	Nursing Facility								45
46	04600	Other Long Term Care								46
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4013)
40-524										Rev. 1
DRAFT				FORM CMS-2552-10						4090 (Cont.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES					PROVIDER NO.:		PERIOD:		WORKSHEET A
							FROM ____________
					_		TO ___________
							RECLASSIFIED		NET EXPENSES
		COST CENTER DESCRIPTIONS			TOTAL	RECLASSIFI-	TRIAL BALANCE		FOR ALLOCATION
		(omit cents)	SALARIES	OTHER	(col. 1 + col. 2)	CATIONS	(col. 3 ± col. 4)	ADJUSTMENTS	(col. 5 ± col. 6)
			1	2	3	4	5	6	7
		ANCILLARY SERVICE COST CENTERS
50	05000	Operating Room								50
51	05100	Recovery Room								51
52	05200	Labor Room and Delivery Room								52
53	05300	Anesthesiology								53
54	05400	Radiology-Diagnostic								54
55	05500	Radiology-Therapeutic								55
56	05600	Radioisotope								56
57	05700	Computed Tomography (CT) Scan								57
58	05800	Magnetic Resonance Imaging (MRI)								58
59	05900	Cardiac Catheterization								59
60	06000	Laboratory								60
61	06100	PBP Clinical Laboratory Services-Program Only								61
62	06200	Whole Blood & Packed Red Blood Cells								62
63	06300	Blood Storing, Processing, & Trans.								63
64	06400	Intravenous Therapy								64
65	06500	Respiratory Therapy								65
66	06600	Physical Therapy								66
67	06700	Occupational Therapy								67
68	06800	Speech Pathology								68
69	06900	Electro cardiology								69
70	07000	Electroencephalography								70
71	07100	Medical Supplies Charged to Patients								71
72	07200	Implantable Devices Charged to Patients								72
73	07300	Drugs Charged to Patients								73
74	07400	Renal Dialysis								74
75	07500	ASC (Non-Distinct Part)								75
76		Other Ancillary (specify)								76
		OUTPATIENT SERVICE COST CENTERS
88	08800	Rural Health Clinic (RHC)								88
89	08900	Federally Qualified Health Center (FQHC)								89
90	09000	Clinic								90
91	09100	Emergency								91
92	09200	Observation Beds								92
93		Other Outpatient Service (specify)								93
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4013)
Rev. 1										40-525
DRAFT				FORM CMS-2552-10						4090 (Cont.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES					PROVIDER NO.:		PERIOD:		WORKSHEET A
							FROM ____________
					_		TO ___________
							RECLASSIFIED		NET EXPENSES
		COST CENTER DESCRIPTIONS			TOTAL	RECLASSIFI-	TRIAL BALANCE		FOR ALLOCATION
		(omit cents)	SALARIES	OTHER	(col. 1 + col. 2)	CATIONS	(col. 3 ± col. 4)	ADJUSTMENTS	(col. 5 ± col. 6)
			1	2	3	4	5	6	7
		OTHER REIMBURSABLE COST CENTERS
94	09400	Home Program Dialysis								94
95	09500	Ambulance Services								95
96	09600	Durable Medical Equipment-Rented								96
97	09700	Durable Medical Equipment-Sold								97
98		Other Reimbursable (specify)								98
99		Outpatient Rehabilitation Provider (specify)								99
100	10000	Intern-Resident Service (not appvd. tchng. prgm.)								100
101	10100	Home Health Agency								101
		SPECIAL PURPOSE COST CENTERS
105	10500	Kidney Acquisition								105
106	10600	Heart Acquisition								106
107	10700	Liver Acquisition								107
108	10800	Lung Acquisition								108
109	10900	Pancreas Acquisition								109
110	11000	Intestinal Acquisition								110
111	11100	Islet Acquisition								111
112		Other Organ Acquisition (specify)								112
113	11300	Interest Expense							- 0 -	113
114	11400	Utilization Review-SNF							- 0 -	114
115	11500	Ambulatory Surgical Center (Distinct Part)								115
116	11600	Hospice								116
117		Other Special Purpose (specify)								117
118		SUBTOTALS (sum of lines 1-117)								118
		NONREIMBURSABLE COST CENTERS
190	19000	Gift, Flower, Coffee Shop, & Canteen								190
191	19100	Research								191
192	19200	Physicians' Private Offices								192
193	19300	Nonpaid Workers								193
194		Other Nonreimbursable (specify)								194
200		TOTAL (sum of lines 118-199)				- 0 -				200
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4013)
40-526										Rev. 1

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Sheet 2: A6

DRAFT			FORM CMS-2552-10									4090 (Cont.)
RECLASSIFICATIONS				PROVIDER NO.:			PERIOD:			WORKSHEET A-6
							FROM ___________
				____________________			TO ______________
				INCREASES				DECREASES			Wkst.
		CODE									A-7
	EXPLANATION OF RECLASSIFICATION(S)	(1)	COST CENTER	LINE #	SALARY	OTHER	COST CENTER	LINE #	SALARY	OTHER	Ref.
		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 (sum of columns 4 and 5											500
	must equal sum of columns 8 and 9)
(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
Transfer the amounts in columns 4, 5, 8, and 9 to Worksheet A, column 4, lines as appropriate.
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4014)
Rev. 1												40-527

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Sheet 3: A7I, II &III

4090 (Cont.)			FORM CMS-2552-10							DRAFT
RECONCILIATION OF CAPITAL COSTS CENTERS					PROVIDER NO.:		PERIOD:		WORKSHEET A-7,
							FROM _________		PARTS I, II & III
					_____________		TO __________
PART I - ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCES
					Acquisitions		Disposals		Fully
			Beginning				and	Ending	Depreciated
	Description		Balances	Purchases	Donation	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	HIT designated Assets									7
8	Subtotal (sum of lines 1-7)									8
9	Reconciling Items									9
10	Total (line 7 minus line 9)									10
PART II - RECONCILIATION OF AMOUNTS FROM WORKSHEET A, COLUMN 2, LINES 1 and 2
					SUMMARY OF CAPITAL
								Other Capital-	Total (1)
						Insurance	Taxes	Related Costs	(sum of
	Description		Depreciation	Lease	Interest	(see instru.)	(see instru.)	(see instru.)	cols. 9-14)
*			9	10	11	12	13	14	15
1	Capital Related Costs-Buildings and Fixtures									1
2	Capital Related Costs-Movable Equipment									2
3	Total (sum of lines 1-2)									3
(1)	The amount in columns 9 thru 14 must equal the amount on Worksheet A, column 2, lines 1 and 2. Enter in each column the appropriate amounts including any directly assigned cost
	which may have been included in Worksheet A, column 2, lines 1 and 2.
*	All lines numbers are to be consistent with Worksheet A line numbers for capital cost centers.
PART III - RECONCILIATION OF CAPITAL COSTS CENTERS
			COMPUTATION OF RATIOS				ALLOCATION OF OTHER CAPITAL
				Gross Assets					Total
			Capitalized	for Ratio	Ratio			Other Capital-	(sum of
	Description	Gross Assets	Leases	(col. 1 - col. 2)	(see instru.)	Insurance	Taxes	Related Costs	cols. 5-7)
*		1	2	3	4	5	6	7	8
1	Capital Related Costs-Buildings and Fixtures									1
2	Capital Related Costs-Movable Equipment									2
3	Total (sum of lines 1-2)				1.000000					3
					SUMMARY OF CAPITAL
								Other Capital-	Total (1)
						Insurance	Taxes	Related Costs	(sum of
	Description		Depreciation	Lease	Interest	(see instru.)	(see instru.)	(see instru.)	cols. 9-14)
*			9	10	11	12	13	14	15
1	Capital Related Costs-Buildings and Fixtures									1
2	Capital Related Costs-Movable Equipment									2
3	Total (sum of lines 1-2)									3
(1) The amounts on lines 1 and 2 must equal the corresponding amounts on Worksheet A, column 7, lines 1 and 2. Columns 9 through 14 should include related
	Worksheet A-6 reclassifications, Worksheet A-8 adjustments, and Worksheet A-8-1 related organizations and home office costs. (See instructions.)
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4015)
40-528										Rev. 1

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Sheet 4: A8

DRAFT		FORM CMS-2552-10							4090 (Cont.)
ADJUSTMENTS TO EXPENSES			PROVIDER NO.		PERIOD:		WORKSHEET A-8
					FROM ____________
			________________		TO _______________
					EXPENSE CLASSIFICATION ON
					WORKSHEET A TO/FROM WHICH			Wkst.
	DESCRIPTION (1)		(2)		THE AMOUNT IS TO BE ADJUSTED			A-7
			BASIS/CODE	AMOUNT	COST CENTER		LINE #	Ref.
			1	2	3		4	5
1	Investment income - buildings and fixtures (chapter 2)				Buildings and Fixtures		1		1
2	Investment income - movable equipment (chapter 2)				Movable Equipment		2		2
3	Investment income - other (chapter 2)								3
4	Trade, quantity, and time discounts (chapter 8)								4
5	Refunds and rebates of expenses (chapter 8)								5
6	Rental of provider space by suppliers (chapter 8)								6
7	Telephone services (pay stations excluded) (chapter 21)								7
8	Television and radio service (chapter 21)								8
9	Parking lot (chapter 21)								9
10	Provider-based physician adjustment		Wkst A-8-2						10
11	Sale of scrap, waste, etc. (chapter 23)								11
12	Related organization transactions (chapter 10)		Wkst A-8-1						12
13	Laundry and linen service								13
14	Cafeteria-employees and guests								14
15	Rental of quarters to employee and others								15
16	Sale of medical and surgical								16
	supplies to other than patients
17	Sale of drugs to other than patients								17
18	Sale of medical records and abstracts								18
19	Nursing school (tuition, fees, books, etc.)								19
20	Vending machines								20
21	Income from imposition of interest,								21
	finance or penalty charges (chapter 21)
22	Interest expense on Medicare overpayments and								22
	borrowings to repay Medicare overpayments
23	Adjustment for respiratory therapy								23
	costs in excess of limitation (chapter 14)		Wkst A-8-3		Respiratory Therapy		62
24	Adjustment for physical therapy costs								24
	in excess of limitation (chapter 14)		Wkst A-8-3		Physical Therapy		63
25	Utilization review - physicians' compensation (chapter 21)				Utilization Review - SNF		114		25
26	Depreciation - buildings and fixtures				Buildings and Fixtures		1		26
27	Depreciation - movable equipment				Movable Equipment		2		27
28	Non-physician Anesthetist				Nonphysician Anesthetist		19		28
29	Physicians' assistant								29
30	Adjustment for occupational therapy costs								30
	in excess of limitation (chapter 14)		Wkst A-8-3		Occupational Therapy		64
31	Adjustment for speech pathology costs								31
	in excess of limitation (chapter 14)		Wkst A-8-3		Speech Pathology		65
	CAH HIT Adjustment for Depreciation
32	and Interest								32
33	Other adjustments (specify) (3)								33
50	TOTAL (sum of lines 1 thru 49)								50
	(Transfer to Worksheet A, column 6, line 200.)
(1) Description - all chapter references in this column pertain to CMS Pub. 15-1.
(2) Basis for adjustment (see instructions).
A. Costs - if cost, including applicable overhead, can be determined.
B. Amount Received - if cost cannot be determined.
(3) Additional adjustments may be made on lines 32 thru 49 and subscripts thereof.
Note: See instructions for column 5 referencing to Worksheet A-7.
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4016)
Rev. 1									40-529

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Sheet 5: A81

4090 (Cont.)			FORM CMS-2552-10					DRAFT
STATEMENT OF COSTS OF SERVICES			PROVIDER NO:	PERIOD:		WORKSHEET A-8-1
FROM RELATED ORGANIZATIONS AND				FROM____________
HOME OFFICE COSTS			_______________	TO_______________
A. Costs incurred and adjustments required as a result of transactions with related organizations or the claiming of home office costs:
					Amount	Net
				Amount of	included in	Adjustments	Wkst.
				Allowable	Wkst. A,	(col. 4 minus	A-7
	Line No.	Cost Center	Expense Items	Cost	column 5	col. 5) *	Ref.
	1	2	3	4	5	6	7
1								1
2								2
3								3
4								4
5	TOTALS (sum of lines 1-4) Transfer column 6, line 5 to Worksheet							5
	A-8, column 2, line 12.
* The amounts on lines 1-4 and subscripts as appropriate are transferred in detail to Worksheet A, column 6, lines as appropriate.
Positive amounts increase cost and negative amounts decrease cost. For related organizational or home office cost which has not
been posted to Worksheet A, columns 1 and/or 2, the amount allowable should be indicated in column 4 of this part.
B. Interrelationship to related organization(s) and/or home office:
The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires that you furnish
the information requested under Part B of this worksheet.
This information is used by the Centers for Medicare and Medicaid Services and its intermediaries/contractors in determining that the costs applicable to
services, facilities, and supplies furnished by organizations related to you by common ownership or control represent reasonable costs
as determined under section 1861 of the Social Security Act. If you do not provide all or any part of the requested information, the cost
report is considered incomplete and not acceptable for purposes of claiming reimbursement under title XVIII.
				Related Organization(s) and/or Home Office
			Percentage		Percentage
	Symbol		of		of	Type of
	(1)	Name	Ownership	Name	Ownership	Business
	1	2	3	4	5	6
6								6
7								7
8								8
9								9
10								10
	(1) Use the following symbols to indicate interrelationship to related organizations:
		A. Individual has financial interest (stockholder, partner, etc.) in both related
		organization and in provider.
		B. Corporation, partnership, or other organization has financial interest in provider.
		C. Provider has financial interest in corporation, partnership, or other organization.
		D. Director, officer, administrator, or key person of provider or relative of such
		person has financial interest in related organization.
		E. Individual is director, officer, administrator, or key person of provider and
		related organization.
		F. Director, officer, administrator, or key person of related organization or relative
		of such person has financial interest in provider.
		G. Other (financial or non-financial) specify __________________________________________________
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4017)
40-530								Rev. 1

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Sheet 6: A82

DRAFT				FORM CMS-2552-10						4090 (Cont.)
PROVIDER-BASED PHYSICIANS ADJUSTMENTS					PROVIDER NO.:		PERIOD:		WORKSHEET A-8-2
							FROM _________
					_____________		TO ___________
		Cost Center/					Physician/		5 Percent of
	Wkst. A	Physician	Total	Professional	Provider	RCE	Provider	Unadjusted	Unadjusted
	Line #	Identifier	Remuneration	Component	Component	Amount	Component Hours	RCE Limit	RCE Limit
	1	2	3	4	5	6	7	8	9
1										1
2										2
3										3
4										4
5										5
6										6
7										7
8										8
9										9
10										10
11										11
200	TOTAL									101
			Cost of	Provider	Physician	Provider
		Cost Center/	Memberships	Component	Cost of	Component
	Wkst. A	Physician	& Continuing	Share of	Malpractice	Share of	Adjusted	RCE
	Line #	Identifier	Education	col. 12	Insurance	col. 14	RCE Limit	Disallowance	Adjustment
	10	11	12	13	14	15	16	17	18
1										1
2										2
3										3
4										4
5										5
6										6
7										7
8										8
9										9
10										10
11										11
200	TOTAL									200
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4018)
Rev. 1										40-531

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Sheet 7: A83

4090 (Cont.)			FORM CMS-2552-10					DRAFT
REASONABLE COST DETERMINATION FOR THERAPY SERVICES					PROVIDER NO.:	PERIOD:	WORKSHEET A-8-3,
FURNISHED BY OUTSIDE SUPPLIERS						FROM __________	PARTS I & II
					__________	TO ___________
Check applicable box:		[ ] Occupational [ ] Physical [ ] Respiratory [ ] Speech Pathology
PART I - GENERAL INFORMATION
1	Total number of weeks worked (excluding aides) (see instructions)							1
2	Line 1 multiplied by 15 hours per week							2
3	Number of unduplicated days in which supervisor or therapist was on provider site (see instructions)							3
4	Number of unduplicated days in which therapy assistant was on provider site but neither supervisor nor therapist was on provider site (see instructions)							4
5	Number of unduplicated offsite visits - supervisors or therapists (see instructions)							5
6	Number of unduplicated offsite visits - therapy assistants (include only visits made by therapy assistant and on which							6
	supervisor and/or therapist was not present during the visit(s)) (see instructions)
7	Standard travel expense rate							7
8	Optional travel expense rate per mile							8
			Supervisors	Therapists	Assistants	Aides	Trainees
			1	2	3	4	5
9	Total hours worked							9
10	AHSEA (see instructions)							10
11	Standard travel allowance (columns 1 and 2, one-half of column 2,							11
	line 10; column 3, one-half of column 3, line 10)
12	Number of travel hours (see instructions)							12
13	Number of miles driven (see instructions)							13
PART II - SALARY EQUIVALENCY COMPUTATION
14	Supervisors (column 1, line 9 times column 1, line 10)							14
15	Therapists (column 2, line 9 times column 2, line 10)							15
16	Assistants (column 3, line 9 times column 3, line10)							16
17	Subtotal allowance amount (sum of lines 14 and 15 for respiratory therapy or lines 14-16 for all others)							17
18	Aides (column 4, line 9 times column 4, line 10)							18
19	Trainees (column 5, line 9 times column 9, line 10)							19
20	Total allowance amount (sum of lines 17-19 for respiratory therapy or lines 17 and 18 for all others)							20
	If the sum of columns 1 and 2 for respiratory therapy or columns 1-3 for physical therapy, speech pathology or occupational therapy, line 9, is greater than line 2,
	make no entries on lines 21 and 22 and enter on line 23 the amount from line 20. Otherwise complete lines 21-23.
21	Weighted average rate excluding aides and trainees (line 17 divided by sum of columns 1 and 2, line 9 for respiratory therapy or columns 1 thru 3, line 9 for all others)							21
22	Weighted allowance excluding aides and trainees (line 2 times line 21)							22
23	Total salary equivalency (see instructions)							23
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4019)
40-532								Rev. 1
DRAFT			FORM CMS-2552-10					4090 (Cont.)
REASONABLE COST DETERMINATION FOR THERAPY SERVICES					PROVIDER NO.:	PERIOD:	WORKSHEET A-8-3,
FURNISHED BY OUTSIDE SUPPLIERS						FROM _________	PARTS III & IV
					_____________	TO ___________
Check applicable box:		[ ] Occupational [ ] Physical [ ] Respiratory [ ] Speech Pathology
PART III - STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - PROVIDER SITE
Standard Travel Allowance
24	Therapists (line 3 times column 2, line 11)							24
25	Assistants (line 4 times column 3, line 11)							25
26	Subtotal (line 24 for respiratory therapy or sum of lines 24 and 25 for all others)							26
27	Standard travel expense (line 7 times line 3 for respiratory therapy or sum of lines 3 and 4 for all others)							27
28	Total standard travel allowance and standard travel expense at the provider site (sum of lines 26 and 27)							28
Optional Travel Allowance and Optional Travel Expense
29	Therapists (column 2, line 10 times the sum of columns 1 and 2, line 12 )							29
30	Assistants (column 3, line 10 times column 3, line 12)							30
31	Subtotal (line 29 for respiratory therapy or sum of lines 29 and 30 for all others)							31
32	Optional travel expense (line 8 times columns 1 and 2, line 13 for respiratory therapy or sum of columns 1-3, line 13 for all others)							32
33	Standard travel allowance and standard travel expense (line 28)							33
34	Optional travel allowance and standard travel expense (sum of lines 27 and 31)							34
35	Optional travel allowance and optional travel expense (sum of lines 31 and 32)							35
PART IV - STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - SERVICES OUTSIDE PROVIDER SITE
Standard Travel Expense
36	Therapists (line 5 times column 2, line 11)							36
37	Assistants (line 6 times column 3, line 11)							37
38	Subtotal (sum of lines 36 and 37)							38
39	Standard travel expense (line 7 times the sum of lines 5 and 6)							39
Optional Travel Allowance and Optional Travel Expense
40	Therapists (sum of columns 1 and 2, line 12 .01 times column 2, line 10)							40
41	Assistants (column 3, line 12.01 times column 3, line 10)							41
42	Subtotal (sum of lines 40 and 41)							42
43	Optional travel expense (line 8 times the sum of columns 1-3, line 13.01)							43
Total Travel Allowance and Travel Expense - Offsite Services; Complete one of the following
three lines 44, 45, or 46, as appropriate.
44	Standard travel allowance and standard travel expense (sum of lines 38 and 39 - see instructions)							44
45	Optional travel allowance and standard travel expense (sum of lines 39 and 42 - see instructions)							45
46	Optional travel allowance and optional travel expense (sum of lines 42 and 43 - see instructions)							46
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4019)
Rev. 1								40-533
4090 (Cont.)			FORM CMS-2552-10					DRAFT
REASONABLE COST DETERMINATION FOR THERAPY SERVICES					PROVIDER NO.:	PERIOD:	WORKSHEET A-8-3,
FURNISHED BY OUTSIDE SUPPLIERS						FROM _________	PARTS V-VII
					____________	TO ___________
Check applicable box:		[ ] Occupational [ ] Physical [ ] Respiratory [ ] Speech Pathology
PART V - OVERTIME COMPUTATION
			Therapists	Assistants	Aides	Trainees	Total
			1	2	3	4	5
47	Overtime hours worked during reporting period (if column 5,							47
	line 47, is zero or equal to or greater than 2,080, do not complete
	lines 48-55 and enter zero in each column of line 56)
48	Overtime rate (see instructions)							48
49	Total overtime (including base and overtime allowance) (multiply							49
	line 47 times line 48)
CALCULATION OF LIMIT
50	Percentage of overtime hours by category (divide the hours in each							50
	column on line 47 by the total overtime worked - column 4, line 47)
51	Allocation of provider's standard work year for one full-time							51
	employee times the percentages on line 50) (see instructions)
DETERMINATION OF OVERTIME ALLOWANCE
52	Adjusted hourly salary equivalency amount (see instructions)							52
53	Overtime cost limitation (line 51 times line 52)							53
54	Maximum overtime cost (enter the lesser of line 49 or line 53)							54
55	Portion of overtime already included in hourly computation at the AHSEA (multiply							55
	line 47 times line 52)
56	Overtime allowance (line 54 minus line 55 - if negative enter zero) ( Enter in column 5 the							56
	sum of columns 1, 3, and 4 for respiratory therapy and columns 1 through 3 for all others.)
PART VI - COMPUTATION OF THERAPY LIMITATION AND EXCESS COST ADJUSTMENT
57	Salary equivalency amount (from line 23)							57
58	Travel allowance and expense - provider site (from lines 33, 34, or 35))							58
59	Travel allowance and expense - Offsite services (from lines 44, 45, or 46)							59
60	Overtime allowance (from column 5, line 56)							60
61	Equipment cost (see instructions)							61
62	Supplies (see instructions)							62
63	Total allowance (sum of lines 57-62)							63
64	Total cost of outside supplier services (from your records)							64
65	Excess over limitation (line 64 minus line 63 - if negative, enter zero)							65
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4019)
40-534								Rev. 1