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

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Overview

J1I
J1II
J2I
J2II
J3
J4

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Sheet 1: J1I

4090 (Cont.)					FORM CMS-2552-10								DRAFT	DRAFT				FORM CMS-2552-10									4090 (Cont.)	4090 (Cont.)			FORM CMS-2552-10								DRAFT
HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND						PROVIDER NO.: ______________			PERIOD:		WORKSHEET J-1,			HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND						PROVIDER NO.: ________________			PERIOD:		WORKSHEET J-1,			HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND				PROVIDER NO.: ________________			PERIOD:		WORKSHEET J-1,
OTHER OUTPATIENT REHABILITATION						COMPONENT NO.: ___________			FROM______________		PART I			OTHER OUTPATIENT REHABILITATION						COMPONENT NO.: _____________			FROM_______________		PART I (CONT.)			OTHER OUTPATIENT REHABILITATION				COMPONENT NO.: _____________			FROM________________		PART I (CONT.)
PROVIDER STATISTICAL DATA									TO _________________					PROVIDER STATISTICAL DATA									TO __________________					PROVIDER STATISTICAL DATA							TO ___________________
Check		[ ] Title V		[ ] Title XVIII		[ ] Title XIX			[ ] CMHC [ ] OOT					Check		[ ] Title V		[ ] Title XVIII		[ ] Title XIX			[ ] CMHC [ ] OOT					Check		[ ] Title V		[ ] Title XVIII		[ ] Title XIX			[ ] CMHC [ ] OOT
									[ ] CORF [ ] OSP														[ ] CORF [ ] OSP														[ ] CORF [ ] OSP
Applicable Box:									[ ] OPT					Applicable Box:									[ ] OPT					Applicable Box:									[ ] OPT
				NET																															INTERN &
				EXPENSES	CAPITAL														MAIN-		CENTRAL		MEDICAL			NON-							PARA-		RESIDENT		ALLOCATED
	COMPONENT COST CENTER			FOR COST	RELATED COSTS				ADMINIS-	MAIN-		LAUNDRY			COMPONENT COST CENTER				TENANCE	NURSING	SERVICES		RECORDS		OTHER	PHYSICIAN			COMPONENT COST CENTER		INTERNS & RESIDENTS		MEDICAL	SUBTOTAL	COST & POST	SUBTOTAL	COMPONENT	TOTAL
	(omit cents)			ALLOCATION	BLDGS. &	MOVABLE	EMPLOYEE	SUBTOTAL	TRATIVE &	TENANCE	OPERATION	& LINEN			(omit cents)	HOUSE-			OF	ADMINIS-	&		&	SOCIAL	GENERAL	ANES-			(omit cents)	NURSING	SALARY &	PROGRAM	EDUCATION	(sum of	STEPDOWN	(sum of cols.	A&G (see	(sum of cols.
				(see instru.)	FIXTURES	EQUIPMENT	BENEFITS	(cols. 0-4)	GENERAL	& REPAIRS	OF PLANT	SERVICE				KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE	SERVICE	THETISTS				SCHOOL	FRINGES	COSTS	(SPECIFY)	cols. 4A-23)	ADJ.	24 ± 25)	Part II) (2)	26 ± 27)
				0	1	2	4	4A	5	6	7	8				9	10	11	12	13	14	15	16	17	18	19				20	21	22	23	24	25	26	27	28
1	Administrative and General												1	1	Administrative and General												1	1	Administrative and General										1
2	Skilled Nursing Care												2	2	Skilled Nursing Care												2	2	Skilled Nursing Care										2
3	Physical Therapy												3	3	Physical Therapy												3	3	Physical Therapy										3
4	Occupational Therapy												4	4	Occupational Therapy												4	4	Occupational Therapy										4
5	Speech Pathology												5	5	Speech Pathology												5	5	Speech Pathology										5
6	Medical Social Services												6	6	Medical Social Services												6	6	Medical Social Services										6
7	Respiratory Therapy												7	7	Respiratory Therapy												7	7	Respiratory Therapy										7
8	Psychiatric/Psychological Services												8	8	Psychiatric/Psychological Services												8	8	Psychiatric/Psychological Services										8
9	Individual Therapy												9	9	Individual Therapy												9	9	Individual Therapy										9
10	Group Therapy												10	10	Group Therapy												10	10	Group Therapy										10
11	Individualized Activity Therapies												11	11	Individualized Activity Therapies												11	11	Individualized Activity Therapies										11
12	Family Counseling												12	12	Family Counseling												12	12	Family Counseling										12
13	Diagnostic Services												13	13	Diagnostic Services												13	13	Diagnostic Services										13
14	Approved Patient Training & Education												14	14	Approved Patient Training & Education												14	14	Approved Patient Training & Education										14
15	Prosthetic and Orthotic Devices												15	15	Prosthetic and Orthotic Devices												15	15	Prosthetic and Orthotic Devices										15
16	Drugs and Biologicals												16	16	Drugs and Biologicals												16	16	Drugs and Biologicals										16
17	Medical Supplies												17	17	Medical Supplies												17	17	Medical Supplies										17
18	Medical Appliances												18	18	Medical Appliances												18	18	Medical Appliances										18
19	Durable Medical Equipment-Rented												19	19	Durable Medical Equipment-Rented												19	19	Durable Medical Equipment-Rented										19
20	Durable Medical Equipment-Sold												20	20	Durable Medical Equipment-Sold												20	20	Durable Medical Equipment-Sold										20
21	All Others												21	21	All Others												21	21	All Others										21
22	Totals (sum of lines 1-21)(1)												22	22	Totals (sum of lines 1-21)(1)												22	22	Totals (sum of lines 1-21)(1)										22
23	Unit Cost Multiplier (see instructions)												23	23	Unit Cost Multiplier (see instructions)												23	23	Unit Cost Multiplier (see instructions)										23
(1) Columns 0 through 25, line 22 must agree with the corresponding columns of Wkst. B, Part I, lines as appropriate. See instructions.														(1) Columns 0 through 25, line 22 must agree with the corresponding columns of Wkst. B, Part I, lines as appropriate. See instructions.														(1) Columns 0 through 25, line 22 must agree with the corresponding columns of Wkst. B, Part I, lines as appropriate. See instructions.
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4053.1)														FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4053.1)														FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4053.1)
40-622													Rev. 1	Rev. 1													40-623	40-624											Rev. 1

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Sheet 2: J1II

DRAFT					FORM CMS-2552-10								4090 (Cont.)	4090 (Cont.)					FORM CMS-2552-10								DRAFT	DRAFT				FORM CMS-2552-10							4090 (Cont.)
HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND						PROVIDER NO.: ________________			PERIOD:		WORKSHEET J-1,			HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND						PROVIDER NO.: ________________			PERIOD:		WORKSHEET J-1,			HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND				PROVIDER NO.: ______________			PERIOD:		WORKSHEET J-1,
OTHER OUTPATIENT REHABILITATION						COMPONENT NO.: _____________			FROM_____________		PART II			OTHER OUTPATIENT REHABILITATION						COMPONENT NO.: _____________			FROM_____________		PART II (CONT.)			OTHER OUTPATIENT REHABILITATION				COMPONENT NO.: ___________			FROM_____________		PART II (CONT.)
PROVIDER STATISTICAL DATA									TO________________					PROVIDER STATISTICAL DATA									TO________________					PROVIDER STATISTICAL DATA							TO________________
Check		[ ] Title V		[ ] Title XVIII		[ ] Title XIX			[ ] CMHC [ ] OOT							[ ] Title V		[ ] Title XVIII		[ ] Title XIX			[ ] CMHC [ ] OOT							[ ] Title V		[ ] Title XVIII		[ ] Title XIX			[ ] CMHC [ ] OOT
									[ ] CORF [ ] OSP														[ ] CORF [ ] OSP														[ ] CORF [ ] OSP
Applicable Box:									[ ] OPT														[ ] OPT														[ ] OPT
					CAPITAL														MAIN-							NON-							PARA-
					RELATED COST				ADMINIS-	MAIN-		LAUNDRY							TENANCE	NURSING	CENTRAL		MEDICAL			PHYSICIAN					INTERNS & RESIDENTS		MEDICAL
					BLDGS &	MOVABLE	EMPLOYEE		TRATIVE &	TENANCE &	OPERATION	& LINEN				HOUSE-			OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL	OTHER	ANES-				NURSING	SALARY &	PROGRAM	EDUCATION
	CMHC COST CENTER				FIXTURES	EQUIPMENT	BENEFITS		GENERAL	REPAIRS	OF PLANT	SERVICE			CORF COST CENTER	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE	GENERAL	THETISTS			CORF COST CENTER	SCHOOL	FRINGES	COSTS	(SPECIFY)
	(omit cents)				(SQUARE	(SQUARE	(GROSS	RECONCIL-	(ACCUM.	(SQUARE	(SQUARE	(POUNDS OF			(omit cents)	(HOURS OF	(MEALS	(MEALS	(NUMBER	(DIRECT	(COSTED	(COSTED	(TIME	(TIME	SERVICE	(ASSIGNED			(omit cents)	(ASSIGNED	(ASSIGNED	(ASSIGNED	(ASSIGNED
					FEET)	FEET)	SALARIES)	IATION	COST)	FEET)	FEET)	LAUNDRY)				SERVICE)	SERVED)	SERVED)	HOUSED)	NURS. HRS)*	REQUIS.)	REQUIS.)	SPENT)	SPENT)	(SPECIFY)	TIME)				TIME)	TIME)	TIME)	TIME)
				0	1	2	4	4A	5	6	7	8				9	10	11	12	13	14	15	16	17	18	19				20	21	22	23	24	25	26	27	28
1	Administrative and General												1	1	Administrative and General												1	1	Administrative and General										1
2	Skilled Nursing Care												2	2	Skilled Nursing Care												2	2	Skilled Nursing Care										2
3	Physical Therapy												3	3	Physical Therapy												3	3	Physical Therapy										3
4	Occupational Therapy												4	4	Occupational Therapy												4	4	Occupational Therapy										4
5	Speech Pathology												5	5	Speech Pathology												5	5	Speech Pathology										5
6	Medical Social Services												6	6	Medical Social Services												6	6	Medical Social Services										6
7	Respiratory Therapy												7	7	Respiratory Therapy												7	7	Respiratory Therapy										7
8	Psychiatric/Psychological Services												8	8	Psychiatric/Psychological Services												8	8	Psychiatric/Psychological Services										8
9	Individual Therapy												9	9	Individual Therapy												9	9	Individual Therapy										9
10	Group Therapy												10	10	Group Therapy												10	10	Group Therapy										10
11	Individualized Activity Therapies												11	11	Individualized Activity Therapies												11	11	Individualized Activity Therapies										11
12	Family Counseling												12	12	Family Counseling												12	12	Family Counseling										12
13	Diagnostic Services												13	13	Diagnostic Services												13	13	Diagnostic Services										13
14	Approved Patient Training & Education												14	14	Approved Patient Training & Education												14	14	Approved Patient Training & Education										14
15	Prosthetic and Orthotic Devices												15	15	Prosthetic and Orthotic Devices												15	15	Prosthetic and Orthotic Devices										15
16	Drugs and Biologicals												16	16	Drugs and Biologicals												16	16	Drugs and Biologicals										16
17	Medical Supplies												17	17	Medical Supplies												17	17	Medical Supplies										17
18	Medical Appliances												18	18	Medical Appliances												18	18	Medical Appliances										18
19	Durable Medical Equipment-Rented												19	19	Durable Medical Equipment-Rented												19	19	Durable Medical Equipment-Rented										19
20	Durable Medical Equipment-Sold												20	20	Durable Medical Equipment-Sold												20	20	Durable Medical Equipment-Sold										20
21	All Others												21	21	All Others												21	21	All Others										21
22	Totals (sum of lines 1-21)												22	22	Totals (sum of lines 1-21)												22	22	Totals (sum of lines 1-21)										22
23	Total Cost to be Allocated												23	23	Total Cost to be Allocated												23	23	Total Cost to be Allocated										23
24	Unit Cost Multiplier (see instructions)												24	24	Unit Cost Multiplier (see instructions)												24	24	Unit Cost Multiplier (see instructions)										24
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4053.2)														FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4053.2)														FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4053.2)
Rev. 1													40-625	40-626													Rev. 1	Rev. 1											40-627

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Sheet 3: J2I

4090 (Cont.)				FORM CMS-2552-10							DRAFT
HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND					PROVIDER NO.:______________			PERIOD:		WORKSHEET J-2,
OTHER OUTPATIENT REHABILITATION					COMPONENT NO.:____________			FROM______________		PART I
PROVIDER STATISTICAL DATA								TO_________________
Check		[ ] Title V		[ ] Title XVIII		[ ] Title XIX	[ ] CMHC [ ] OOT
							[ ] CORF [ ] OSP
Applicable Box:							[ ] OPT
PART I -APPORTIONMENT OF OUTPATIENT REHABILITATION PROVIDER COST CENTERS
		(From		Ratio of		Title V		Title XVIII		Title XIX
		Wkst. J-1,	Total	Costs to	Title V	Component	Title XVIII	Component	Title XIX	Component
		Part I,	Component	Charges	Component	Costs (col. 3	Component	Costs (col. 3	Component	Costs (col. 3
		col. 29)	Charges	(col. 1 ÷ col. 2)	Charges	x col. 4)	Charges	x col. 6)	Charges	x col. 8)
		1	2	3	4	5	6	7	8	9
1	Administrative and General										1
2	Skilled Nursing Care										2
3	Physical Therapy										3
4	Occupational Therapy										4
5	Speech Pathology										5
6	Medical Social Services										6
7	Respiratory Therapy										7
8	Psychiatric/Psychological Services										8
9	Individual Therapy										9
10	Group Therapy										10
11	Individualized Activity Therapy										11
12	Family Counseling										12
13	Diagnostic Services										13
14	Approved Patient Training & Education										14
15	Prosthetic and Orthotic Devices										15
16	Drugs and Biologicals										16
17	Medical Supplies										17
18	Medical Appliances										18
19	All Others (1)										19
20	Totals (sum of lines 1-19)										20
(1)	Enter amount in column 1 from Worksheet J-1, Part I, column 29, line 21.
FORM CMS-2552-10(DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4054.1)
40-628											Rev. 1

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Sheet 4: J2II

DRAFT			FORM CMS-2552-10								4090 (Cont.)
HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND					PROVIDER NO.:______________			PERIOD:		WORKSHEET J-2,
OTHER OUTPATIENT REHABILITATION					COMPONENT NO.:____________			FROM______________		PART II
PROVIDER STATISTICAL DATA								TO_________________
Check		[ ] Title V		[ ] Title XVIII		[ ] Title XIX	[ ] CMHC [ ] OOT
							[ ] CORF [ ] OSP
Applicable Box:							[ ] OPT
PART II - APPORTIONMENT OF COST OF OUTPATIENT REHABILITATION PROVIDER SERVICES FURNISHED BY SHARED HOSPITAL DEPARTMENTS
		(From				Title V		Title XVIII		Title XIX
		Wkst. J-1,	Total	Ratio of	Title V	Component	Title XVIII	Component	Title XIX	Component
		Part I,	Component	Costs to	Component	costs (col. 3	Component	costs (col. 3	Component	costs (col. 3
		col. 29)	Charges	Charges (1)	Charges (2)	x col. 4)	Charges (2)	x col. 6)	Charges (2)	x col. 8)
		1	2	3	4	5	6	7	8	9
21	Respiratory Therapy										21
22	Physical Therapy										22
23	Occupational Therapy										23
24	Speech Pathology										24
25	Medical Supplies Charged to Patients										25
26	Implantable Devices Charged to Patients										26
27	Drugs Charged to Patients										27
28	Total (sum of lines 21-28)										28
29	Total component costs. Add the amount from Part I, line 20										29
	and the amounts from line 29, columns 5, 7, and 9. (3)
(1)	From Worksheet C, Part I, column 9, lines as appropriate
(2)	Charges for columns 4, 6, and 8 are obtained from your records.
(3)	Transfer the amounts on line 29, columns 5, 7, and 9, as appropriate, to Worksheet J-3, line 1.
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4054.2)
Rev. 1											40-629

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Sheet 5: J3

4090 (Cont.)			FORM CMS-2552-10				DRAFT
HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND				PROVIDER NO.:	PERIOD:	WORKSHEET J-3																								.
OTHER OUTPATIENT REHABILITATION				_______________	FROM___________
PROVIDER STATISTICAL DATA				COMPONENT NO.:	TO____________
				_______________
Check		[ ] Title V	[ ] CMHC [ ] OOT
Applicable		[ ] Title XVIII	[ ] CORF [ ] OSP
Box:		[ ] Title XIX	[ ] OPT
						PROGRAM
						COST
						1
1	Cost of component services (from Worksheet J-2, Part II, line 30)						1
2	PPS payments received excluding outliers						2
3	Outlier Payments						3
4	Primary payer payments						4
5	Total reasonable cost (see instructions)						5
6	Total charges for program services						6
	CUSTOMARY CHARGES
7	Aggregate amount actually collected from patients liable for services on a charge basis						7
	Amount that would have been realized from patients liable for payment for services on a charge
8	basis had such payment been made in accordance with 42 CFR 413.13(e)						8
9	Ratio of line 7 to line 8 (not to exceed 1.000000) (see instructions)						9
10	Total customary charges (see instructions)						10
11	Excess of customary charges over reasonable cost (see instructions)						11
12	Excess of reasonable cost over customary charges (see instructions)						12
	COMPUTATION OF REIMBURSEMENT SETTLEMENT
13	Total reasonable cost (from line 5)						13
14	Part B deductible billed to program patients						14
15	Net cost (line 13 minus line 14)						15
16	Excess of reasonable cost over customary charges (from line 12)						16
17	Subtotal (line 15 minus line 16)						17
18	80 percent of costs (80% of line 17) (see instructions)						18
19	Actual coinsurance billed to program patients (from provider records)						19
20	Net cost less actual billed coinsurance (line 17 minus line 19)						20
21	Reimbursable bad debts (from provider records) (see instructions)						21
22							22
23	Reimbursable bad debts for dual eligible beneficiaries (see instructions)						23
24	Net reimbursable amount (see instructions)						24
25	Other adjustments (see instructions) (specify)						25
26	Total cost (line 24 plus or minus line 25)						26
27	Interim payments (see instructions)						27
28	Tentative settlement (for contractor use only)						28
29	Balance due component/program (line 26 minus lines 27 and 28)						29
30	Protested amounts (nonallowable cost report items in accordance with CMS Pub. 15-II, section 115.2)						30
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4055)
40-630							Rev. 1

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Sheet 6: J4

DRAFT		FORM CMS-2552-10						4090 (Cont.)
HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND			PROVIDER NO.:			PERIOD	WORKSHEET J-4																								.
OTHER OUTPATIENT REHABILITATION						FROM__________
PROVIDER STATISTICAL DATA			COMPONENT NO.:			TO_____________
BENEFICIARIES
Check		[ ] Title V		[ ] CMHC [ ] OOT
Applicable		[ ] Title XVIII		[ ] CORF [ ] OSP
Box:		[ ] Title XIX		[ ] OPT
						Part B
	DESCRIPTION					1	2
						mm/dd/yyyy	Amount
1	Total interim payments paid to providers							1
2	Interim payments payable on individual bills, either							2
	submitted or to be submitted to the intermediary, for
	services rendered in the cost reporting periods. If
	none, write "NONE", or enter zero.
3	List separately each retroactive				.01			3.01
	lump sum adjustment amount			Program	.02			3.02
	based on subsequent revision of			to	.03			3.03
	the interim rate for the			Provider	.04			3.04
	cost reporting period. Also show				.05			3.05
	date of each payment.				.50			3.50
	If none, write "NONE",			Provider	.51			3.51
	or enter zero (1).			to	.52			3.52
				Program	.53			3.53
					.54			3.54
	Subtotal (sum of lines 3.01-3.49
	minus sum of lines 3.50-3.98)				.99			3.99
4	Total interim payments (sum of lines 1, 2, and 3.99)							4
	(transfer to Worksheet J-3, line 35)
	TO BE COMPLETED BY INTERMEDIARY
5	List separately each tentative			Program	.01			5.01
	settlement payment after desk review.			to	.02			5.02
	Also show date of each payment.			Provider	.03			5.03
	If none, write "NONE,"			Provider	.50			5.50
	or enter zero (1).			to	.51			5.51
				Program	.52			5.52
	Subtotal (sum of lines 5.01-5.49 minus
	sum of lines 5.50-5.98)				.99			5.99
6	Determine net settlement amount			Program
	(balance due) based on the cost			to
	report (see instructions). (1)			Provider	.01			6.01
				Provider
				to
				Program	.02			6.02
7	Total Medicare liability (see instructions)							7
8	Name of Contractor	Contractor Number			(Month, Day, Year)			8
(1) On lines 3, 5, and 6, where an amount is due provider to program, show the amount and date on which you agree to the amount of
	repayment, even though the total repayment is not accomplished until a later date.
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4056)
Rev. 1								40-631