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

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Overview

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DII
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DIV
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D1I
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D4I
D4II
D4III
D5I
D5II

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Sheet 1: DI

DRAFT			FORM CMS-2552-10						4090 (Cont.)
APPORTIONMENT OF INPATIENT ROUTINE			PROVIDER NO.:			PERIOD:		WORKSHEET D,
SERVICE CAPITAL COSTS						FROM: __________		PART I
			_________________			TO: __________
Check			[ ] Title V			[ ] PPS
applicable			[ ] Title XVIII, Part A			[ ] TEFRA
boxes			[ ] Title XIX
				Reduced				Inpatient
		Capital		Capital				Program
		Related Cost		Related		Per		Capital
		(from Wkst.	Swing	Cost	Total	Diem	Inpatient	Cost
		B, Part II,	Bed	(col. 1 -	Patient	(col. 3 /	Program	(col. 5
	Cost Center Description	col. 26)	Adjustment	col. 2)	Days	col. 4)	days	x col. 6)
		1	2	3	4	5	6	7
(A)	INPATIENT ROUTINE
	SERVICE COST CENTERS
30	Adults & Pediatrics								30
	(General Routine Care)
31	Intensive Care Unit								31
32	Coronary Care Unit								32
33	Burn Intensive Care Unit								33
34	Surgical Intensive Care Unit								34
35	Other Special Care Unit (specify)								35
40	Subprovider IPF								40
41	Subprovider IRF								41
42	Subprovider (Other)								42
43	Nursery								43
200	Total (lines 30-199)								200
	(A) Worksheet A line numbers
							NOTE		IF PPS COL 1 WILL NOT BE COMPLETED - AS CAP REDUCTION ONLY
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4024 - 4024.1)
Rev. 1									40-567

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Sheet 2: DII

4090 (Cont.)		FORM CMS-2552-10						DRAFT
APPORTIONMENT OF INPATIENT ANCILLARY			PROVIDER NO.:______________		PERIOD:		WORKSHEET D,
SERVICE CAPITAL COSTS					FROM____________		PART II
			COMPONENT NO.:____________		TO____________
Check			[ ] Title V		[ ] Hospital	[ ] Subprovider (Other)	[ ] PPS
applicable			[ ] Title XVIII, Part A		[ ] IPF		[ ] TEFRA
boxes			[ ] Title XIX		[ ] IRF
			Capital
			Related Cost		Ratio of Cost		Capital
			(from Wkst.	Total Charges	to Charges	Inpatient	Costs
	Cost Center Description		B, Part II,	(from Wkst. C,	(col. 1 ¯	Program	(col. 3 x
			col. 26)	Part I, col. 8)	col. 2)	Charges	col. 4)
			1	2	3	4	5
(A)	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							60
60	Laboratory							60
61	PBP Clinical Laboratory Services-Prgm. Only							61
62	Whole Blood & Packed Red Blood Cells							62
63	Blood Storing, Processing, & Transfusing							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
88	Rural Health Clinic (RHC)							88
89	Federally Qualified Health Center (FQHC)							89
90	Clinic							90
91	Emergency							91
92	Observation Beds							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
200	Total (sum of lines 50 through 199)							200
(A) Worksheet A line numbers
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4024.2)
40-568								Rev. 1

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Sheet 3: DIII

DRAFT					FORM CMS-2552-10						4090 (Cont.)
APPORTIONMENT OF INPATIENT ROUTINE						PROVIDER NO.:		PERIOD:		WORKSHEET D,
SERVICE OTHER PASS THROUGH COSTS								FROM __________		PART III
						_________________		TO ___________
Check		[ ] Title V			[ ] PPS
applicable		[ ] Title XVIII, Part A			[ ] TEFRA
boxes		[ ] Title XIX
				All	Swing-Bed					Inpatient
				Other	Adjustment	Total Costs		Per		Program
				Medical	Amount	(sum of cols.	Total	Diem	Inpatient	Pass thru
		Nursing	Allied Health	Education	(see	1 through 3,	Patient	(col. 5 ÷	Program	Cost
	Cost Center Description	School	Cost	Cost	instructions)	minus col. 4)	Days	col. 6)	Days	(col. 7 x col. 8)
		1	2	3	4	5	6	7	8	9
(A)	INPATIENT ROUTINE SERVICE
	COST CENTERS
30	Adults & Pediatrics										30
	(General Routine Care)
31	Intensive Care Unit										31
32	Coronary Care Unit										32
33	Burn Intensive Care Unit										33
34	Surgical Intensive Care Unit										34
35	Other Special Care Unit (specify)										35
40	Subprovider IPF										40
41	Subprovider IRF										41
42	Subprovider (Other)										42
43	Nursery										43
44	Skilled Nursing Facility										44
45	Nursing Facility										45
200	Total (sum of lines 30-199)										200
	(A) Worksheet A line numbers
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4024.3)
Rev. 1											40-569

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Sheet 4: DIV

4090 (Cont.)			FORM CMS-2552-10						DRAFT
APPORTIONMENT OF INPATIENT/OUTPATIENT ANCILLARY			PROVIDER NO.:___________			PERIOD:		WORKSHEET D,
SERVICE OTHER PASS THROUGH COSTS						FROM_____________		PART IV
			COMPONENT NO.:____________			TO_______________
Check		[ ] Title V		[ ] Hospital	[ ] Subprovider (Other)		[ ] ICF/MR	[ ] PPS
applicable		[ ] Title XVIII, Part A		[ ] IPF	[ ] SNF			[ ] TEFRA
boxes		[ ] Title XIX		[ ] IRF	[ ] NF
						All		Total
			Non			Other		Outpatient
			Physician			Medical	Total cost	Cost
	Cost Center Description		Anesthetist	Nursing	Allied	Education	(sum of col. 1	(sum of col. 2,
			Cost	School	Health	Cost	thru col. 4)	3 and 4)
			1	2	3	4	5	6
(A)	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, & Transfusing								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
	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								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
200	Total (sum of lines 50 through 199)								200
	(A) Worksheet A line numbers
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4024.4)
40-570									Rev. 1
DRAFT			FORM CMS-2552-10						4090 (Cont.)
APPORTIONMENT OF INPATIENT/OUTPATIENT ANCILLARY			PROVIDER NO.:___________			PERIOD:		WORKSHEET D,
SERVICE OTHER PASS THROUGH COSTS						FROM_____________		PART IV (Cont.)
			COMPONENT NO.:____________			TO_______________
Check		[ ] Title V		[ ] Hospital	[ ] Subprovider (Other)		[ ] ICF/MR	[ ] PPS
applicable		[ ] Title XVIII, Part A		[ ] IPF	[ ] SNF			[ ] TEFRA
boxes		[ ] Title XIX		[ ] IRF	[ ] NF
						Inpatient		Outpatient
				Outpatient		Program		Program
		Total	Ratio	Ratio		Pass		Pass
		Charges	of Cost	of Cost	Inpatient	Through	Outpatient	Through
	Cost Center Description	(from Wkst. C,	to Charges	to Charges	Program	Costs	Program	Costs
		Part I, col. 8)	(col. 5 ÷ col. 7)	(col. 6 ÷ col. 7)	Charges	(col. 8 x col. 10)	Charges	(col. 9 x col. 12)
		7	8	9	10	11	12	13
(A)	ANCILLARY SERVICE COST CENTERS
50	Operating Room								50
51	Recovery Room								51
52	Delivery Room and Labor 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
64	PBP Clinical Laboratory Services-Prgm. Only								61
62	Whole Blood & Packed Red Blood Cells								62
63	Blood Storing, Processing, & Transfusing								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
	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								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
200	Total (sum of lines 50 through 199)								200
	(A) Worksheet A line numbers
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4024.4)
Rev. 1									40-571

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Sheet 5: DV

4090 (Cont.)			FORM CMS-2552-10						DRAFT
APPORTIONMENT OF MEDICAL, OTHER				PROVIDER NO.:		PERIOD:		WORKSHEET D,
HEALTH SERVICES AND VACCINE COST				__________________		FROM___________		PARTS V
				COMPONENT NO.:		TO____________
				__________________
Check		[ ] Title V - O/P		[ ] Hospital	[ ] Subprovider (Other)		[ ] Swing Bed SNF
Applicable		[ ] Title XVIII, Part B		[ ] IPF	[ ] SNF		[ ] Swing Bed NF
Boxes		[ ] Title XIX - O/P		[ ] IRF	[ ] NF		[ ] ICF/MR
PART V - APPORTIONMENT OF MEDICAL AND OTHER HEALTH SERVICES COSTS
			PROGRAM CHARGES			PROGRAM COST
		Cost to		Cost	Cost		Cost	Cost
		Charge		Services	Services Not		Services	Services Not
	Cost Center Description	Ratio From	PPS	Subject To	Subject To	PPS	Subject To	Subject To
		Worksheet C,	Services	Ded. & Coin.	Ded. & Coin.	Services	Ded. & Coin.	Ded. & Coin.
		Part I, col. 9	(see inst.)	(see inst.)	(see inst.)	(see inst.)	(see inst.)	(see inst.)
		1	2	3	4	5	6	7
(A)	ANCILLARY SERVICE COST CENTERS
50	Operating Room								50
51	Recovery Room								51
52	Labor & 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 Clinic Laboratory Services-Prgm. Only								61
62	Whole Blood & Packed Red Blood Cells								62
63	Blood Storing, Processing, & Transfusing								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
	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 Bed								92
93	Other Outpatient Service (specify)								93
	OTHER REIMBURSABLE COST CENTERS
94	Home Program Dialysis								94
95	Ambulance								95
96	Durable Medical Equipment-Rented								96
97	Durable Medical Equipment-Sold								97
98	Other Reimbursable Cost Center								98
200	Subtotal (see instructions)								200
201	Less PBP Clinic Lab. Services-Program								201
	Only Charges
202	Net Charges (line 200 ± line 201 )								202
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4024.5)
40-572									Rev. 1

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Sheet 6: D1I

DRAFT				FORM CMS-2552-10						4090 (Cont.)
COMPUTATION OF INPATIENT				PROVIDER NO.:	COMPONENT NO.:	PERIOD:			WORKSHEET D-1,
OPERATING COST						FROM __________			PART I
				__________________	__________________	TO ____________
Check		[ ] Title V - I/P		[ ] Hospital [ ] SUBPROVIDER (other) [ ] ICF/MR			[ ] PPS
applicable		[ ] Title XVIII, Part A		[ ] IPF [ ] SNF			[ ] TEFRA
boxes		[ ] Title XIX - I/P		[ ] IRF [ ] NF			[ ] Other
PART I - ALL PROVIDER COMPONENTS
				INPATIENT DAYS
1	Inpatient days (including private room days and swing-bed days, excluding newborn)									1
2	Inpatient days (including private room days, excluding swing-bed and newborn days)									2
3	Private room days (excluding swing-bed and observation bed days)									3
4	Semi-private room days (excluding swing-bed and observation bed days)									4
5	Total swing-bed SNF type inpatient days (including private room days) through December 31 of the cost reporting period									5
6	Total swing-bed SNF type inpatient days (including private room days) after December 31 of the cost reporting period (if									6
	calendar year, enter 0 on this line)
7	Total swing-bed NF type inpatient days (including private room days) through December 31 of the cost reporting period									7
8	Total swing-bed NF type inpatient days (including private room days) after December 31 of the cost reporting period (if									8
	calendar year, enter 0 on this line)
9	Total inpatient days including private room days applicable to the Program (excluding swing-bed and newborn days)									9
10	Swing-bed SNF type inpatient days applicable to title XVIII only (including private room days) through December 31 of the									10
	cost reporting period (see instructions).
11	Swing-bed SNF type inpatient days applicable to title XVIII only (including private room days) after December 31 of the									11
	cost reporting period (if calendar year, enter 0 on this line)
12	Swing-bed NF type inpatient days applicable to titles V or XIX only (including private room days) through December 31 of									12
	the cost reporting period.
13	Swing-bed NF type inpatient days applicable to titles V or XIX only (including private room days) after December 31 of the									13
	cost reporting period (if calendar year, enter 0 on this line)
14	Medically necessary private room days applicable to the Program ( excluding swing-bed days)									14
15	Total nursery days (title V or XIX only)									15
16	Nursery days (title V or XIX only)									16
				SWING BED ADJUSTMENT
17	Medicare rate for swing-bed SNF services applicable to services through December 31 of the cost reporting period									17
18	Medicare rate for swing-bed SNF services applicable to services after December 31 of the cost reporting period									18
19	Medicaid rate for swing-bed NF services applicable to services through December 31 of the cost reporting period									19
20	Medicaid rate for swing-bed NF services applicable to services after December 31 of the cost reporting period									20
21	Total general inpatient routine service cost (see instructions)									21
22	Swing-bed cost applicable to SNF type services through December 31 of the cost reporting period (line 5 x line 17)									22
23	Swing-bed cost applicable to SNF type services after December 31 of the cost reporting period (line 6 x line 18)									23
24	Swing-bed cost applicable to NF type services through December 31 of the cost reporting period (line 7 x line 19)									24
25	Swing-bed cost applicable to NF type services after December 31 of the cost reporting period (line 8 x line 20)									25
26	Total swing-bed cost (see instructions)									26
27	General inpatient routine service cost net of swing-bed cost (line 21 minus line 26)									27
				PRIVATE ROOM DIFFERENTIAL ADJUSTMENT
28	General inpatient routine service charges (excluding swing-bed charges)									28
29	Private room charges (excluding swing-bed charges)									29
30	Semi-private room charges (excluding swing-bed charges)									30
31	General inpatient routine service cost/charge ratio (line 27 ÷ line 28)									31
32	Average private room per diem charge (line 29 ÷ line 3)									32
33	Average semi-private room per diem charge (line 30 ÷ line 4)									33
34	Average per diem private room charge differential (line 32 minus line 33)(see instructions)									34
35	Average per diem private room cost differential (line 34 x line 31)									35
36	Private room cost differential adjustment (line 3 x line 35)									36
37	General inpatient routine service cost net of swing-bed cost and private room cost differential (line 27 minus line 36)									37
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4025.1)
Rev. 1										40-573

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Sheet 7: D1II

4090 (Cont.)				FORM CMS-2552-10						DRAFT
COMPUTATION OF INPATIENT				PROVIDER NO.:		COMPONENT NO.:		PERIOD:	WORKSHEET D-1,																							.
OPERATING COST								FROM __________	PART II
				______________		______________		TO __________
Check		[ ] Title V - I/P			[ ] Hospital [ ]Subprovider (other)			[ ] PPS
applicable		[ ] Title XVIII, Part A			[ ] IPF			[ ] TEFRA
boxes		[ ] Title XIX - I/P			[ ] IRF			[ ] Other
PART II - HOSPITAL AND SUBPROVIDERS ONLY
		PROGRAM INPATIENT OPERATING COST BEFORE
		PASS THROUGH COST ADJUSTMENTS							1
38	Adjusted general inpatient routine service cost per diem (see instructions)									38
39	Program general inpatient routine service cost (line 9 x line 38)									39
40	Medically necessary private room cost applicable to the Program (line 14 x line 35)									40
41	Total Program general inpatient routine service cost (line 39 + line 40)									41
							Average
				Total	Total		Per Diem	Program	Program Cost
				Inpatient Cost	Inpatient Days		(col. 1 ÷ col. 2)	Days	(col. 3 x col. 4)
				1		2	3	4	5
42	Nursery (title V & XIX only)									42
	Intensive Care Type Inpatient
	Hospital Units
43	Intensive Care Unit									43
44	Coronary Care Unit									44
45	Burn Intensive Care Unit									45
46	Surgical Intensive Care Unit									46
47	Other Special Care Unit (specify)									47
									1
48	Program inpatient ancillary service cost (Wkst. D-3, col. 3, line 200)									48
49	Total Program inpatient costs (sum of lines 41 through 48) (see instructions)									49
		PASS THROUGH COST ADJUSTMENTS
50	Pass through costs applicable to Program inpatient routine services (from Wkst. D, sum of Parts I and III)									50
51	Pass through costs applicable to Program inpatient ancillary services (from Wkst. D, sum of Parts II and IV)									51
52	Total Program excludable cost (sum of lines 50 and 51)									52
53	Total Program inpatient operating cost excluding capital related, nonphysician anesthetist, and medical education costs									53
	(line 49 minus line 52)
		TARGET AMOUNT AND LIMIT COMPUTATION
54	Program discharges									54
55	Target amount per discharge									55
56	Target amount (line 54 x line 55)									56
57	Difference between adjusted inpatient operating cost and target amount (line 56 minus line 53)									57
58	Bonus payment (see instructions)									58
59	Lesser of lines 53/54 or 55 from the cost reporting period ending 1996, updated and compounded by the market basket.									59
60	Lesser of lines 53/54 or 55 from prior year cost report, updated by the market basket.									60
61	If line 53/54 is less than the lower of lines 55, 59 or 60 enter the lesser of 50% of the amount by which operating costs									61
	(line 53) are less than expected costs (lines 54 x 60), or 1 % of the target amount (line 56), otherwise enter zero.
	(see instructions)
62	Relief payment (see instructions)									62
63	Allowable Inpatient cost plus incentive payment (see instructions)									63
		PROGRAM INPATIENT ROUTINE SWING BED COST
64	Medicare swing-bed SNF inpatient routine costs through December 31 of the cost reporting period (See instructions)									64
	(title XVIII only)
65	Medicare swing-bed SNF inpatient routine costs after December 31 of the cost reporting period (See instructions)									65
	(title XVIII only)
66	Total Medicare swing-bed SNF inpatient routine costs ( line 64 plus line 65) (title XVIII only). For CAH (see instructions)									66
67	Title V or XIX swing-bed NF inpatient routine costs through December 31 of the cost reporting period (line 12 x line 19)									67
68	Title V or XIX swing-bed NF inpatient routine costs after December 31 of the cost reporting period (line 13 x line 20)									68
69	Total title V or XIX swing-bed NF inpatient routine costs ( line 67 + line 68)									69
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4025.2)
40-574										Rev. 1

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Sheet 8: D1III

DRAFT				CMS FORM-2552-10				4090 (Cont.)
COMPUTATION OF INPATIENT				PROVIDER NO.:	COMPONENT NO.:	PERIOD:	WORKSHEET D-1,																							.
OPERATING COST						FROM ________	PARTS III & IV
				_______________	_________________	TO ___________
Check		[ ] Title V - I/P		[ ] Hospital [ ] Subprovider (other) [ ] ICF/MR			[ ] PPS
applicable		[ ] Title XVIII, Part A		[ ] IPF [ ] SNF			[ ] TEFRA
boxes		[ ] Title XIX - I/P		[ ] IRF [ ] NF			[ ] Other
PART III - SKILLED NURSING FACILITY, OTHER NURSING FACILITY, AND ICF/MR ONLY
70	Skilled nursing facility/other nursing facility/ICF/MR routine service cost (line 37)							70
71	Adjusted general inpatient routine service cost per diem (line 70 ÷ line 2)							71
72	Program routine service cost (line 9 x line 71)							72
73	Medically necessary private room cost applicable to Program (line 14 x line 35)							73
74	Total Program general inpatient routine service costs (line 72 + line 73)							74
	Capital-related cost allocated to inpatient routine service costs
75	(from Worksheet B, sum of Parts II, column 26)							75
76	Per diem capital-related costs (line 75 ÷ line 2)							76
77	Program capital-related costs (line 9 x line 76)							77
78	Inpatient routine service cost (line 70 minus line 73)							78
79	Aggregate charges to beneficiaries for excess costs (from provider records)							79
80	Total Program routine service costs for comparison to the cost limitation (line 78 minus line 79)							80
81	Inpatient routine service cost per diem limitation							81
82	Inpatient routine service cost limitation (line 9 x line 81)							82
83	Reasonable inpatient routine service costs (see instructions)							83
84	Program inpatient ancillary services (see instructions)							84
85	Utilization review - physician compensation (see instructions)							85
86	Total Program inpatient operating costs (sum of lines 74 through 85)							86
PART IV - COMPUTATION OF OBSERVATION BED PASS THROUGH COST
87	Total observation bed days (see instructions)							87
88	Adjusted general inpatient routine cost per diem (line 27 ÷ line 2)							88
89	Observation bed cost (line 87 x line 88) (see instructions)							89
		COMPUTATION OF OBSERVATION BED PASS THROUGH COST
						Total	Observation Bed
				Routine		Observation	Pass Through Cost
				Cost		Bed Cost	(col. 3 x col. 4)
			Cost	(from line 27)	col. 1 ÷ col. 2	(from line 89)	(see instructions)
			1	2	3	4	5
90	Capital-related cost							90
91	Nursing School cost							91
92	Allied Health cost							92
93	All other Medical Education							93
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4025.3 - 4025.4)
Rev. 1								40-575

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Sheet 9: D2

4090 (Cont.)			FORM CMS-2552-10					DRAFT	DRAFT				FORM CMS-2552-10				4090 (Cont.)								.
APPORTIONMENT OF COST OF					PROVIDER NO.:	PERIOD:	WORKSHEET D-2,		APPORTIONMENT OF COST OF			PROVIDER NO.:		PERIOD:		WORKSHEET D-2,
SERVICES RENDERED BY						FROM ___________	PARTS I-III		SERVICES RENDERED BY					FROM ____________		PARTS I-III (Cont.)
INTERNS AND RESIDENTS					__________________	TO _____________			INTERNS AND RESIDENTS			_____________		TO _______________
PART I - NOT IN APPROVED TEACHING PROGRAM									PART I - NOT IN APPROVED TEACHING PROGRAM
					Percent of	Expense	Total Inpatient Days			Average Cost		Health Care Program Inpatient Days		Title V	Title XVIII	Title XIX
		Cost Centers			Assigned Time	Allocation	All Patients			Per Day	Title V	Title XVIII, Part B	Title XIX	(col. 4 x col. 5)	(col. 4 x col. 6)	(col. 4 x col. 7)
					1	2	3			4	5	6	7	8	9	10
1	Total cost of services rendered				100.00			1	1								1
	Hospital Inpatient Routine Services:
2		Adults & pediatrics (general routine care)						2	2								2
3		Intensive care unit						3	3								3
4		Coronary care unit						4	4								4
5		Burn Intensive Care Unit						5	5								5
6		Surgical Intensive Care Unit						6	6								6
7		Other Special Care (specify)						7	7								7
8		Nursery						8	8								8
9	Subtotal (sum of lines 2 through 8)							9	9								9
10	IPF - Inpatient routine service							10	10								10
11	IRF - Inpatient routine service							11	11								11
12	Subprovider (Other) - Inpatient routine service							12	12								12
13	Skilled Nursing Facility							13	13								13
14	Nursing Facility							14	14								14
15	Other Long Term Care							15	15								15
16	Home Health Agency							16	16								16
17	Outpatient Rehabilitation Providers							17	17								17
18	Ambulatory Surgical Center							18	18								18
19	Hospice							19	19								19
20	Subtotal (sum of lines 9 through 19)							20	20								20
							Total Charges			Ratio of Cost		Titles V and XIX Outpatient and			Titles V and XIX Outpatient and
							(from Wkst. C.			to Charges		Title XVIII Part B Charges			Title XVIII Part B Cost
							Part I, col. 8,			(col. 2 ÷	Title	Title XVIII	Title	Title	Title XVIII	Title
	Hospital Outpatient Services:						lines 88 thru 93)			col. 3)	V	Part B	XIX	V	Part B	XIX
21		Rural Health Clinic (RHC)						21	21								21
22		Federally Qualified Health Center (FQHC)						22	22								22
23		Clinic						23	23								23
24		Emergency						24	24								24
25		Observation beds						25	25								25
26		Other Outpatient Service (specify)						26	26								26
27	Subtotal (sum of lines 21 through 26)							27	27								27
28	Total (sum of lines 20 and 27)				100.00			28	28								28
PART II - IN AN APPROVED TEACHING PROGRAM (TITLE XVIII, PART B INPATIENT ROUTINE COSTS ONLY)									PART II - IN AN APPROVED TEACHING PROGRAM (TITLE XVIII, PART B INPATIENT ROUTINE COSTS ONLY)
					Expenses Allocated								Expenses
					To cost centers		Net cost			Total	Average Cost	Title XVIII	Applicable
					on Wkst B, Part I	Swing bed	(col. 1 plus			Inpatient Days -	Per Day	Part B	to Title XVIII
					cols. 21 & 22	Amount	col. 2 )			All Patients	(col. 3 ÷ col. 4)	Inpatient Days	(col. 5 x col. 6)
	Hospital Inpatient Routine Services:				1	2	3			4	5	6	7
29		Adults & Pediatrics (general routine care)						29	29								29
30		Swing Bed - SNF						30	30								30
31		Swing Bed - NF						31	31								31
32		Intensive care unit						32	32								32
33		Coronary care unit						33	33								33
34		Burn Intensive Care Unit						34	34								34
35		Surgical Intensive Care Unit						35	35								35
36		Other Special Care (specify)						36	36								36
37	Subtotal (sum of lines 28, and 29 through 36)							37	37								37
38	IPF - Inpatient routine service							38	38								38
39	IRF - Inpatient routine service							39	39								39
40	Subprovider (Other)- Inpatient routine service							40	40								40
41	Skilled Nursing Facility							41	41								41
42	Total (sum of lines 37 through 41)							42	42								42
PART III - SUMMARY FOR TITLE XVIII (TO BE COMPLETED ONLY IF BOTH PARTS I AND II ARE USED)									PART III - SUMMARY FOR TITLE XVIII (TO BE COMPLETED ONLY IF BOTH PARTS I AND II ARE USED)
						Not In Approved Teaching Program				In Approved Teaching Program		Total Title XVIII Costs
						(from Part I:)	Amount			(from Part II, col. 7, - )	Amount	(to Wkst. E, Part B - )	(col. 2 + col. 4)
	Hospital					1	2			3	4	5	6
43	Inpatient					col. 9, lines 9		43	43	line 37							43
44	Outpatient					col. 9, line 26		44	44								44
45	Total Hospital (sum of lines 41 and 42)							45	45			line 2					45
46	IPF - Inpatient routine service					col. 9, line 10		46	46	line 38		line 2					46
47	IRF - Inpatient routine service					col. 9, line 11		47	47	line 39		line 2					47
48	Subprovider (Other)- Inpatient routine service					col. 9, line 12		48	48	line 40		line 2					48
49	Skilled Nursing Facility					col. 9, line 13		49	49	line 41		line 2					49
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4026)									FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4026)
40-576								Rev. 1	Rev. 1								40-577

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Sheet 10: D3

4090 (Cont.)			FORM CMS-2552-10				DRAFT
INPATIENT ANCILLARY SERVICE				PROVIDER NO.:	PERIOD:	WORKSHEET D-3																							.
COST APPORTIONMENT				_______________	FROM_________
				COMPONENT NO.:	TO____________
				_______________
Check		[ ] Title V	[ ] Hospital	[ ] Subprovider (other)	[ ] Swing-Bed SNF	[ ] PPS
Applicable		[ ] Title XVIII, Part A	[ ] IPF	[ ] SNF	[ ] Swing-Bed NF	[ ] TEFRA
Boxes		[ ] Title XIX	[ ] IRF	[ ] NF	[ ] ICF/MR	[ ] Other
				Ratio of Cost	Inpatient	Inpatient Program Costs
	COST CENTER DESCRIPTION			To Charges	Program Charges	(col. 1 x col. 2)
				1	2	3
	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
35	Other Special Care (specify)						35
40	Subprovider IPF						40
41	Subprovider IRF						41
42	Subprovider (Specify)						42
43	Nursery						43
	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
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
	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
200	Total (sum of lines 30-94 and 96-98)						200
201	Less PBP Clinic Laboratory Services-Program only charges (line 58)						201
202	Net Charges (line 200 minus line 201)						202
	(A) Worksheet A line numbers
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4027)
40-578							Rev. 1

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Sheet 11: D4I

DRAFT			FORM CMS-2552-10					4090 (Cont.)
COMPUTATION OF ORGAN ACQUISITION				PROVIDER NO.:		PERIOD:	WORKSHEET D-4,
COSTS AND CHARGES				_______________		FROM ___________	PART I
				OPO NO.:		TO ______________
				_______________
Check		[ ] HEART	[ ] LIVER	[ ] PANCREAS		[ ] ISLET
Applicable Box		[ ] KIDNEY	[ ] LUNG	[ ] INTESTINE		[ ] OTHER (specify)
PART I - COMPUTATION OF ORGAN ACQUISITION COSTS (INPATIENT ROUTINE AND ANCILLARY SERVICES)
Computation of Inpatient			Inpatient			Organ
Routine Service Costs			Routine Organ		Per Diem Costs	Acquisition	Cost
Applicable to Organ Acquisition			Charges		(from Wkst. D-1,Part II)	Days	(col. 2 x col. 3)
			1	D	2	3	4
1	Adults and Pediatrics			38				1
2	Intensive Care			43				2
3	Coronary Care			44				3
4	Burn Intensive Care Unit			45				4
5	Surgical Intensive Care Unit			46				5
6	Other Special Care (specify)			47				6
7	TOTAL (sum of lines 1-6)							7
Computation of Ancillary					Ratio of Cost/	Organ	Organ
Service Cost Applicable					Charges	Acquisition	Acquisition
to Organ Acquisition					(from	Ancillary	Ancillary
					Wkst. C)	Charges	Costs
				C	1	2	3
8	Operating Room			50				8
9	Recovery Room			51				9
10	Labor Room & Delivery Room			52				10
11	Anesthesiology			53				11
12	Radiology-Diagnostic			54				12
13	Radiology-Therapeutic			55				13
14	Radioisotope			56				14
15	Computed Tomography (CT) Scan			57				15
16	Magnetic Resonance Imaging (MRI)			58				16
17	Cardiac Catheterization			59				17
18	Laboratory			60				18
19	PBP Clinical Laboratory Services-Program Only			61				19
20	Whole Blood & Packed Red Blood Cells			62				20
21	Blood Storage, Processing, & Transfusing			63				21
22	IV Therapy			64				22
23	Respiratory Therapy			65				23
24	Physical Therapy			66				24
25	Occupational Therapy			67				25
26	Speech Pathology			68				26
27	Electrocardiology			69				27
28	Electroencephalography			70				28
29	Medical Supplies Charged to Patients			71				29
30	Implantable Devices Charged to Patients			72				30
31	Drugs Charged to Patients			73				31
32	Renal Dialysis			74				32
33	ASC (non-distinct part)			75				33
34	Other Ancillary (specify)			76				34
35	Rural Health Clinic (RHC)			88				35
36	Federally Qualified Health Center (FQHC)			89				36
37	Clinic			90				37
38	Emergency Room			91				38
39	Observation Beds			92				39
40	Other Outpatient Service (specify)			93				40
41	TOTAL (sum of lines 8-40)							41
	C = Worksheet C line numbers		D = Worksheet D-1 line numbers
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4028.1)
Rev. 1								40-579

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Sheet 12: D4II

4090 (Cont.)			FORM CMS-2552-10					DRAFT
COMPUTATION OF ORGAN ACQUISITION			PROVIDER NO.:		PERIOD:		WORKSHEET D-4,
COSTS AND CHARGES			_________________		FROM ___________		PART II
			OPO NO.:		TO ______________
			_________________
Check		[ ] HEART	[ ] LIVER		[ ] PANCREAS		[ ] ISLET
Applicable Box		[ ] KIDNEY	[ ] LUNG		[ ] INTESTINE		[ ] OTHER (specify)																		[ ] LIVER											[ ] HEART
PART II - COMPUTATION OF ORGAN ACQUISITION COSTS (OTHER THAN INPATIENT ROUTINE AND
ANCILLARY SERVICES COSTS)
				Average Cost			Organ
	Computation of the Cost of Inpatient			Per Day			Acquisition
	Services of Interns and Residents Not			(from Wkst. D-2,	Organ		Costs
	In Approved Teaching Program			Part I, col. 4)	Acquisition Days		(col. 1 x col. 2)
			D	1	2		3													1									2									3
42	Adults & Pediatrics (General routine care)		2					42
43	Intensive Care Unit		3					43
44	Coronary Care Unit		4					44
45	Burn Intensive Care Unit		5					45
46	Surgical Intensive Care Unit		6					46
47	Other Special Care (specify)		7					47
48	TOTAL (sum of lines 42 through 47)							48
	Computation of the Cost of					Ratio of Cost	Organ
	Outpatient Services of Interns		Organ			To Charges	Acquisition
	and Residents Not In Approved		Charges			from Wkst. D-2,	Costs
	Teaching Program		(see instructions)			Part I, col. 4)	(col. 1 x col. 2)																				Ratio of Cost
			1		D	2	3
49	Rural Health Clinic (RHC)				21			49																		Supp. Wkst. D-2,
50	Federally Qualified Health Center (FQHC)				22			50												1								2										3
51	Clinic				23			51
52	Emergency				24			52
53	Observation Beds				25			53
54	Other Outpatient Service (specify)				26			54
55	TOTAL (sum of lines 49 through 52)							55
D = Worksheet D-2, Part I, line numbers
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4028.2)
40-580								Rev. 1

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Sheet 13: D4III

DRAFT			FORM CMS-2552-10				4090 (Cont.)
COMPUTATION OF ORGAN ACQUISITION				PROVIDER NO.:	PERIOD:	WORKSHEET D-4,
COSTS AND CHARGES				_____________	FROM ________	PARTS III & IV
				OPO NO.:	TO __________
				_____________
Check		[ ] HEART	[ ] LIVER	[ ] PANCREAS	[ ] ISLET
Applicable Box		[ ] KIDNEY	[ ] LUNG	[ ] INTESTINE	[ ] OTHER (specify)
PART III - SUMMARY OF COSTS AND CHARGES
			Cost		Charges
			Part A	Part B	Part A	Part B
			1	2	3	4
56	Routine and Ancillary from Part I						56
57	Interns and Residents (inpatient)						57
58	Interns and Residents (outpatient)						58
59	Direct Organ Acquisition (see instructions)						59
60	Cost of Services of Teaching Physicians (Wkst. D-5, Part II)						60
61	Total (sum of lines 56 thru 60)						61
62	Total Usable Organs (see instructions)						62
63	Medicare Usable Organs (see instructions)						63
64	Ratio of Medicare Usable Organs to Total Usable						64
	Organs (line 63 ÷ line 62)
65	Medicare Cost/Charges (see instructions)						65
66	Revenue for Organs Sold						66
67	Subtotal (line 65 minus line 66)						67
68	Organs Furnished Part B						68
69	Net Organ Acquisition Cost and Charges (see instructions)						69
PART IV - STATISTICS
				Living Related	Cadaveric	Revenue
				1	2	3
70	Organs Excised in Provider (1)						70
71	Organs Purchased from Other Transplant Hospitals (2)						71
72	Organs Purchased from Non-Transplant Hospitals						72
74	Organs Purchased from OPOs						74
75	Total (sum of lines 70 thru 74)						75
76	Organs Transplanted						76
77	Organs Sold to Other Hospitals						77
78	Organs Sold to OPOs						78
79	Organs Sold to Transplant Hospitals						79
80	Organs Sold to Military or VA Hospitals						80
81	Organs Sold Outside the U.S.						81
82	Organs Sent Outside the U.S. (no revenue received)						82
83	Organs Used for Research						83
84	Unusable/Discarded Organs						84
85	Total (sum of lines 76 thru 84 should equal line 75)						85
	(1) Organs procured outside your center by a procurement team from your center are not to be included in the count.
	(2) Organs procured outside your center by a procurement team are included in the count.
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4028.3)
Rev. 1							40-581
																										{EDIT}{HOME}{R}{DEL}{D}

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Sheet 14: D5I

4090 (Cont.)			FORM CMS-2552-10							DRAFT
APPORTIONMENT OF COST FOR THE SERVICES OF TEACHING PHYSICIANS					PROVIDER NO.:		PERIOD:		WORKSHEET D-5,
REASONABLE COMPENSATION EQUIVALENT COMPUTATION							FROM ________________		PART I
					__________________		TO ____________________
Check applicable box:		[ ] Hospital Staff [ ] Medical Staff
							Physician/		5 Percent
Line	Specialty			Total	Professional	RCE	Professional	Unadjusted	of Unadjusted
No.	Description/Physician Identifier			Remuneration	Component	Amount	Component Hours	RCE Limit	RCE Limit
1	2			3	4	5	6	7	8
1	General Practitioner Family Practice									1
2	Internal Medicine									2
3	Surgery									3
4	Pediatrics									4
5	Obstetrics-Gynecology									5
6	Radiology									6
7	Psychiatry									7
8	Anesthesiology									8
9	Pathology									9
10	All Other									10
11	Total									11
				Cost of		Cost of			Adjust Cost
				Membership	Professional	Physician	Professional		of Physician's
Line	Specialty			& Continuing	Component	Malpractice	Component	Adjusted	Direct Medical &
No.	Description/Physician Identifier			Education	Share of col. 11	Insurance	Share of col. 13	RCE Limit	Surgical Services
9	10			11	12	13	14	15	16
1	General Practitioner Family Practice									1
2	Internal Medicine									2
3	Surgery									3
4	Pediatrics									4
5	Obstetrics-Gynecology									5
6	Radiology									6
7	Psychiatry									7
8	Anesthesiology									8
9	Pathology									9
10	All Other									10
11	Total (transfer the amount in column 16, line 11, to									11
	Part II, line 1, column 1 or 2, as appropriate)
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4029.1)
40-582										Rev. 1

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Sheet 15: D5II

DRAFT		FORM CMS-2552-10				4090 (Cont.)
APPORTIONMENT OF COST FOR THE			PROVIDER NO.:	PERIOD:	WORKSHEET D-5,																								.
SERVICES OF TEACHING PHYSICIANS				FROM________	PART II
			________________	TO___________
Check		[ ] Hospital	[ ] IPF
Applicable Box:		[ ] IRF	[ ] Subprovider (other)
				Medical School	Total
			Hospital Staff	Faculty	(col 1 + col 2)
			1	2	3
1	Adjusted Cost of Physician's Direct Medical and Surgical Services					1
2	Total Inpatient Days and Outpatient Visit Days					2
3	Average Per Diem (line 1 ÷ line 2)					3
	HEALTH CARE PROGRAM REIMBURSABLE DAYS
4	Title V - Inpatient					4
5	Title V - Outpatient					5
6	Title XVIII - Part A					6
7	Title XVIII - Part B					7
8	Title XIX - Inpatient					8
9	Title XIX - Outpatient					9
10	Inpatient and Outpatient Kidney Acquisition					10
11	Inpatient and Outpatient Liver Acquisition					11
12	Inpatient and Outpatient Heart Acquisition					12
13	Inpatient and Outpatient Lung Acquisition					13
14	Inpatient and Outpatient Pancreas Acquisition					14
15	Inpatient and Outpatient Intestine Acquisition					15
16	Inpatient and Outpatient Islet Acquisition					16
17	Other Organ Acquisition					17
	HEALTH CARE PROGRAM REIMBURSABLE COST
18	Title V - Inpatient (line 3 x line 4)					18
19	Title V - Outpatient (line 3 x line 5)					19
20	Title XVIII - Part A (line 3 x line 6)					20
21	Title XVIII - Part B (line 3 x line 7)					21
22	Title XIX - Inpatient (line 3 x line 8)					22
23	Title XIX - Outpatient (line 3 x line 9)					23
24	Inpatient and Outpatient Kidney Acquisition (line 3 x line 10)					24
25	Inpatient and Outpatient Liver Acquisition (line 3 x line 11)					25
26	Inpatient and Outpatient Heart Acquisition (line 3 x line 12)					26
27	Inpatient and Outpatient Lung Acquisition (line 3 x line 13)					27
28	Inpatient and Outpatient Pancreas Acquisition (line 3 x line 14)					28
29	Inpatient and Outpatient Intestine Acquisition (line 3 x line 15)					29
30	Inpatient and Outpatient Islet Acquisition (line 3 x line 16)					30
31	Inpatient and Outpatient Other Organ Acquisition (line 3 x line 17)					31
	Transfer the amounts in column 3 as follows:
	Add lines 18 and 19, and transfer to Worksheet E-3, Part VII
	Line 20 to Worksheet E, Part A, or Worksheet E-3, Part I to V as appropriate
	Line 21 to Worksheet E, Part B
	Add lines 22 and 23, and transfer to Worksheet E-3, Part VI, as appropriate
	Sum of lines 24 through 31 to Worksheet D-4, Part III, line 53
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4029.2)
Rev. 1						40-583