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

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Overview

CI
CII

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Sheet 1: CI

DRAFT				FORM CMS-2552-10									4090 (Cont.)
COMPUTATION OF RATIO OF COSTS TO CHARGES								PROVIDER NO.:		PERIOD:		WORKSHEET C
										FROM ___________		PART I
								______________		TO ______________
		Total Cost		Costs				Charges
		(from Wkst.	Therapy		RCE				Total		TEFRA	PPS
	COST CENTER DESCRIPTIONS	B, Part I,	Limit	Total	Dis-	Total			(col. 6	Cost or	Inpatient	Inpatient
		col. 24)	Adj.	Costs	allowance	Costs	Inpatient	Outpatient	+ col. 7)	Other Ratio	Ratio	Ratio
		1	2	3	4	5	6	7	8	9	10	11
	INPATIENT ROUTINE SERVICE COST CENTERS
30	Adults and Pediatrics (General Routine Care)												30
31	Intensive Care Unit												31
32	Coronary Care Unit												32
33	Burn Intensive Care Unit												33
34	Surgical Intensive Care Unit												34
36	Other Special Care (specify)												36
40	Subprovider IPF												40
41	Subprovider IRF												41
42	Subprovider (Specify)												42
43	Nursery												43
44	Skilled Nursing Facility												44
45	Nursing Facility												45
46	Other Long Term Care												46
	ANCILLARY SERVICE COST CENTERS
50	Operating Room												50
51	Recovery Room												51
52	Labor Room and Delivery Room												52
53	Anesthesiology												53
54	Radiology-Diagnostic												54
55	Radiology-Therapeutic												55
56	Radioisotope												56
57	Computed Tomography (CT) Scan												57
58	Magnetic Resonance Imaging (MRI)												58
59	Cardiac Catheterization												59
60	Laboratory												60
61	PBP Clinical Laboratory Services-Prgm. Only												61
62	Whole Blood & Packed Red Blood Cells												62
63	Blood Storing, Processing, & Trans.												63
64	Intravenous Therapy												64
65	Respiratory Therapy												65
66	Physical Therapy												66
67	Occupational Therapy												67
68	Speech Pathology												68
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4023)
Rev. 1													40-563
4090 (Cont.)				FORM CMS-2552-10									DRAFT
COMPUTATION OF RATIO OF COSTS TO CHARGES								PROVIDER NO.:		PERIOD:		WORKSHEET C
										FROM ___________		PART I (CONT.)
								______________		TO ______________
		Total Cost						Charges
		(from Wkst.	Therapy		RCE				Total		TEFRA	PPS
	COST CENTER DESCRIPTIONS	B, Part I,	Limit	Total	Dis-	Total			(col. 6	Cost or	Inpatient	Inpatient
		col. 24)	Adj.	Costs	allowance	Costs	Inpatient	Outpatient	+ col. 7)	Other Ratio	Ratio	Ratio
		1	2	3	4	5	6	7	8	9	10	11
	OUTPATIENT SERVICE COST CENTERS
69	Electrocardiology												69
70	Electroencephalography												70
71	Medical Supplies Charged to Patients												71
72	Implantable Devices Charged to Patients												72
73	Drugs Charged to Patients												73
74	Renal Dialysis												74
75	ASC (Non-Distinct Part)												75
76	Other Ancillary (specify)												76
88	Rural Health Clinic (RHC)												88
89	Federally Qualified Health Center (FQHC)												89
90	Clinic												90
91	Emergency												91
92	Observation Beds (see instructions)												92
93	Other Outpatient Service (specify)												93
	OTHER REIMBURSABLE COST CENTERS
94	Home Program Dialysis												94
95	Ambulance Services												95
96	Durable Medical Equipment-Rented												96
97	Durable Medical Equipment-Sold												97
98	Other Reimbursable (specify)												98
99	Outpatient Rehabilitation Provider (specify)												99
100	Intern-Resident Service (not appvd. tchng. prgm.)												100
101	Home Health Agency												101
	SPECIAL PURPOSE COST CENTERS
105	Kidney Acquisition												105
106	Heart Acquisition												106
107	Liver Acquisition												107
108	Lung Acquisition												108
109	Pancreas Acquisition												109
110	Intestinal Acquisition												110
111	Islet Acquisition												111
112	Other Organ Acquisition (specify)												112
115	Ambulatory Surgical Center (Distinct Part)												115
116	Hospice												116
117	Other Special Purpose (specify)												117
200	Subtotal (sum of lines 30 thru 199)												200
201	Less Observation Beds												201
202	Total (line 200 minus line 201)												202
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4023)
40-564													Rev. 1

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Sheet 2: CII

DRAFT			FORM CMS-2552-10								4090 (Cont.)
CALCULATION OF OUTPATIENT SERVICE COST TO						PROVIDER NO.:		PERIOD:		WORKSHEET C,
CHARGE RATIOS NET OF REDUCTIONS FOR MEDICAID ONLY								FROM __________		PART II
						______________		TO ___________
				Capital Cost	Operating Cost			Cost Net of	Total
			Total Cost	(Wkst. B,	Net of		Operating Cost	Capital and	Charges	Outpatient Cost
	Cost Center Descriptions		(Wkst. B,	Parts II	Capital Cost	Capital	Reduction	Operating Cost	(Wkst. C,	to Charge Ratio
			Part I, col. 24)	col. 27)	(col. 1 - col. 2)	Reduction	Amount	Reduction	Part I, col. 8)	(col. 6 ÷ col. 7)
			1	2	3	4	5	6	7	8
	ANCILLARY SERVICE COST CENTERS
50	Operating Room										50
51	Recovery Room										51
52	Labor Room and Delivery Room										52
53	Anesthesiology										53
54	Radiology-Diagnostic										54
55	Radiology-Therapeutic										55
56	Radioisotope										56
57	Computed Tomography (CT) Scan										57
58	Magnetic Resonance Imaging (MRI)										58
59	Cardiac Catherization										59
60	Laboratory										60
61	PBP Clinical Laboratory Services-Prgm. Only										61
62	Whole Blood & Packed Red Blood Cells										62
63	Blood Storing, Processing, & Trans.										63
64	Intravenous Therapy										64
65	Respiratory Therapy										65
66	Physical Therapy										66
67	Occupational Therapy										67
68	Speech Pathology										68
69	Electrocardiology										69
70	Electroencephalography										70
71	Medical Supplies Charged to Patients										71
72	Implantable Devices Charged to Patients										72
73	Drugs Charged to Patients										73
74	Renal Dialysis										74
75	ASC (Non-Distinct Part)										75
76	Other Ancillary (specify)										76
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4023 & 4023.2)
Rev. 1											40-565
4090 (Cont.)			FORM CMS-2552-10								DRAFT
CALCULATION OF OUTPATIENT SERVICE COST TO						PROVIDER NO.:		PERIOD		WORKSHEET C,
CHARGE RATIOS NET OF REDUCTIONS FOR MEDICAID ONLY								FROM: __________		PART II (CONT.)
						______________		TO: __________
				Capital Cost	Operating Cost			Cost Net of	Total
			Total Cost	(Wkst. B,	Net of		Operating Cost	Capital and	Charges	Outpatient Cost
	Cost Center Descriptions		(Wkst. B,	Parts II	Capital Cost	Capital	Reduction	Operating Cost	(Wkst. C,	to Charge Ratio
			Part I, col. 24)	col. 27)	(col. 1 - col. 2)	Reduction	Amount	Reduction	Part I, col. 8)	(col. 6 ÷ col. 7)
			1	2	3	4	5	6	7	8
	OUTPATIENT SERVICE COST CENTERS
88	Rural Health Clinic (RHC)										88
89	Federally Qualified Health Center (FQHC)										89
90	Clinic										90
91	Emergency										91
92	Observation Beds (see instructions)										92
93	Other Outpatient Service (specify)										93
	OTHER REIMBURSABLE COST CENTERS
94	Home Program Dialysis										94
95	Ambulance Services										95
96	Durable Medical Equipment-Rented										96
97	Durable Medical Equipment-Sold										97
98	Other Reimbursable (specify)										98
99	Outpatient Rehabilitation Provider (specify)										99
100	Intern-Resident Service (not appvd. tchng. prgm.)										100
101	Home Health Agency										101
105	Kidney Acquisition										105
106	Heart Acquisition										106
107	Liver Acquisition										107
108	Lung Acquisition										108
109	Pancreas Acquisition										109
110	Intestinal Acquisition										110
111	Islet Acquisition										111
112	Other Organ Acquisition (specify)										112
115	Ambulatory Surgical Center (Distinct Part)										115
116	Hospice										116
117	Other Special Purpose (specify)										117
200	Subtotal (sum of lines 30 thru 199)										200
201	Less Observation Beds										201
202	Total (line 200 minus line 201)										202
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4023 & 4023.2)
40-566											Rev. 1