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

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Overview

K
K-1
K-2
K-3
K-4I
K-4II
K-5I
K-5II
K-5III
K-6

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Sheet 1: K

4090 (Cont.)					FORM CMS-2552-10							DRAFT
ANALYSIS OF PROVIDER-BASED							PROVIDER NO.: ___________		PERIOD:		WORKSHEET
HOSPICE COSTS									FROM ____________		K
							HOSPICE NO.: ____________		TO _______________
			EMPLOYEE		CONTRACTED
		SALARIES	BENEFITS	TRANSPOR-	SERVICES				SUBTOTAL		TOTAL
	COST CENTER DESCRIPTIONS	(from	(from	TATION	(from		TOTAL	RECLASSI-	(col. 6	ADJUST-	(col. 8
		Wkst. K-1)	Wkst. K-2)	(see inst.)	Wkst. K-3)	OTHER	(cols. 1-5)	FICATION	± col. 7)	MENTS	± col. 9)
		1	2	3	4	5	6	7	8	9	10
	GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Bldg and Fixt.											1
2	Capital Related Costs-Movable Equip.											2
3	Plant Operation and Maintenance											3
4	Transportation - Staff											4
5	Volunteer Service Coordination											5
6	Administrative and General											6
	INPATIENT CARE SERVICE
7	Inpatient - General Care											7
8	Inpatient - Respite Care											8
	VISITING SERVICES
9	Physician Services											9
10	Nursing Care											10
11	Nursing Care-Continuous Home Care											11
12	Physical Therapy											12
13	Occupational Therapy											13
14	Speech/ Language Pathology											14
15	Medical Social Services											15
16	Spiritual Counseling											16
17	Dietary Counseling											17
18	Counseling - Other											18
19	Home Health Aide and Homemaker											19
20	HH Aide & Homemaker - Cont. Home Care											20
21	Other											21
	OTHER HOSPICE SERVICE COSTS
22	Drugs, Biological and Infusion Therapy											22
23	Analgesics											23
24	Sedatives / Hypnotics											25
25	Other - Specify											25
26	Durable Medical Equipment/Oxygen											26
27	Patient Transportation											27
28	Imaging Services											28
29	Labs and Diagnostics											29
30	Medical Supplies											30
31	Outpatient Services (including E/R Dept.)											31
32	Radiation Therapy											32
33	Chemotherapy											33
34	Other											34
	HOSPICE NONREIMBURSABLE SERVICE
35	Bereavement Program Costs											35
36	Volunteer Program Costs											36
37	Fundraising											37
38	Other Program Costs											38
39	Total (sum of lines 1 thru 38)											39
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4057)
40-632												Rev. 1

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Sheet 2: K-1

DRAFT					FORM CMS-2552-10						4090 (Cont.)
HOSICE COMPENSATION ANALYSIS						PROVIDER NO.: _____________		PERIOD:		WORKSHEET K-1
SALARIES AND WAGES								FROM ____________
						HOSPICE NO.: ______________		TO _______________
	COST CENTER DESCRIPTIONS	ADMINIS-		SOCIAL	SUPER-		TOTAL
	(omit cents)	TRATOR	DIRECTOR	SERVICES	VISORS	NURSES	THERAPISTS	AIDES	ALL OTHER	TOTAL (1)
		1	2	3	4	5	6	7	8	9
	GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Bldg and Fixt.										1
2	Capital Related Costs-Movable Equip.										2
3	Plant Operation and Maintenance										3
4	Transportation - Staff										4
5	Volunteer Service Coordination										5
6	Administrative and General										6
	INPATIENT CARE SERVICE
7	Inpatient - General Care										7
8	Inpatient - Respite Care										8
	VISITING SERVICES
9	Physician Services										9
10	Nursing Care										10
11	Nursing Care-Continuous Home Care										11
12	Physical Therapy										12
13	Occupational Therapy										13
14	Speech/ Language Pathology										14
15	Medical Social Services										15
16	Spiritual Counseling										16
17	Dietary Counseling										17
18	Counseling - Other										18
19	Home Health Aide and Homemaker										19
20	HH Aide & Homemaker - Cont. Home Care										20
21	Other										21
	OTHER HOSPICE SERVICE COSTS
22	Drugs, Biological and Infusion Therapy										22
23	Analgesics										23
24	Sedatives / Hypnotics										24
25	Other - Specify										25
26	Durable Medical Equipment/Oxygen										26
27	Patient Transportation										27
28	Imaging Services										28
29	Labs and Diagnostics										29
30	Medical Supplies										30
31	Outpatient Services (including E/R Dept.)										31
32	Radiation Therapy										32
33	Chemotherapy										33
34	Other										34
	HOSPICE NONREIMBURSABLE SERVICE
35	Bereavement Program Costs										35
36	Volunteer Program Costs										36
37	Fundraising										37
38	Other Program Costs										38
39	Total (sum of lines 1 thru 38)										39
(1) Transfer the amount in column 9 to Wkst. K, column 1
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4058)
Rev. 1											40-633

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Sheet 3: K-2

4090 (Cont.)					FORM CMS-2552-10						DRAFT
HOSPICE COMPENSATION ANALYSIS EMPLOYEE						PROVIDER NO.: _______________		PERIOD:		WORKSHEET K-2
BENEFITS (PAYROLL RELATED)								FROM ____________
						HOSPICE NO.: __________________		TO _______________
	COST CENTER DESCRIPTIONS	ADMINIS-		SOCIAL	SUPER-		TOTAL
	(omit cents)	TRATOR	DIRECTOR	SERVICES	VISORS	NURSES	THERAPISTS	AIDES	ALL OTHER	TOTAL (1)
		1	2	3	4	5	6	7	8	9
	GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Bldg and Fixt.										1
2	Capital Related Costs-Movable Equip.										2
3	Plant Operation and Maintenance										3
4	Transportation - Staff										4
5	Volunteer Service Coordination										5
6	Administrative and General										6
	INPATIENT CARE SERVICE
7	Inpatient - General Care										7
8	Inpatient - Respite Care										8
	VISITING SERVICES
9	Physician Services										9
10	Nursing Care										10
11	Nursing Care-Continuous Home Care										11
12	Physical Therapy										12
13	Occupational Therapy										13
14	Speech/ Language Pathology										14
15	Medical Social Services										15
16	Spiritual Counseling										16
17	Dietary Counseling										17
18	Counseling - Other										18
19	Home Health Aide and Homemaker										19
20	HH Aide & Homemaker - Cont. Home Care										20
21	Other										21
	OTHER HOSPICE SERVICE COSTS
22	Drugs Biological and Infusion Therapy										22
23	Analgesics										23
24	Sedatives / Hypnotics										24
25	Other - Specify										25
26	Durable Medical Equipment/ Oxygen										26
27	Patient Transportation										27
28	Imaging Services										28
29	Labs and Diagnostics										29
30	Medical Supplies										30
31	Outpatient Services (including E/R Dept.)										31
32	Radiation Therapy										32
33	Chemotherapy										33
34	Other										34
	HOSPICE NONREIMBURSABLE SERVICE
35	Bereavement Program Costs										35
36	Volunteer Program Costs										36
37	Fundraising										37
38	Other Program Costs										38
39	Total (sum of lines 1 thru 38)										39
(1) Transfer the amount in column 9 to Wkst. K, column 2
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4059)
40-634											Rev. 1

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Sheet 4: K-3

DRAFT					FORM CMS-2552-10						4090 (Cont.)
HOSPICE COMPENSATION ANALYSIS						PROVIDER NO.: _______________		PERIOD:		WORKSHEET K-3
CONTRACTED SERVICES/PURCHASED SERVICES								FROM ____________
						HOSPICE NO.: ________________		TO _______________
	COST CENTER DESCRIPTIONS	ADMINIS-		SOCIAL	SUPER-		TOTAL
	(omit cents)	TRATOR	DIRECTOR	SERVICES	VISORS	NURSES	THERAPISTS	AIDES	ALL OTHER	TOTAL (1)
		1	2	3	4	5	6	7	8	9
	GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Bldg and Fixt.										1
2	Capital Related Costs-Movable Equip.										2
3	Plant Operation and Maintenance										3
4	Transportation - Staff										4
5	Volunteer Service Coordination										5
6	Administrative and General										6
	INPATIENT CARE SERVICE
7	Inpatient - General Care										7
8	Inpatient - Respite Care										8
	VISITING SERVICES
9	Physician Services										9
10	Nursing Care										10
11	Nursing Care-Continuous Home Care										11
12	Physical Therapy										12
13	Occupational Therapy										13
14	Speech/ Language Pathology										14
15	Medical Social Services										15
16	Spiritual Counseling										16
17	Dietary Counseling										17
18	Counseling - Other										18
19	Home Health Aide and Homemaker										19
20	HH Aide & Homemaker - Cont. Home Care										20
21	Other										21
	OTHER HOSPICE SERVICE COSTS
22	Drugs, Biological and Infusion Therapy										22
23	Analgesics										23
24	Sedatives / Hypnotics										24
25	Other - Specify										25
26	Durable Medical Equipment/Oxygen										26
27	Patient Transportation										27
28	Imaging Services										28
29	Labs and Diagnostics										29
30	Medical Supplies										30
31	Outpatient Services (including E/R Dept.)										31
32	Radiation Therapy										32
33	Chemotherapy										33
34	Other										34
	HOSPICE NONREIMBURSABLE SERVICE
35	Bereavement Program Costs										35
36	Volunteer Program Costs										36
37	Fundraising										37
38	Other Program Costs										38
39	Total (sum of lines 1 thru 38)										39
(1) Transfer the amount in column 9 to Wkst. K, column 4
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4060)
Rev. 1											40-635

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Sheet 5: K-4I

4090 (Cont.)				FORM CMS-2552-10							DRAFT
COST ALLOCATION - HOSPICE GENERAL SERVICE COST						PROVIDER NO.: ________________		PERIOD:		WORKSHEET K-4,
								FROM ____________		PART I
						HOSPICE NO.: _________________		TO _______________
		NET					VOLUNTEER
		EXPENSES	CAPITAL RELATED COST		PLANT		SERVICES		ADMINIS-	TOTAL
	COST CENTER DESCRIPTIONS	FOR COST	BUILDINGS	MOVABLE	OPERATION	TRANS-	COORDI-	SUBTOTAL	TRATIVE &	(col. 5
		ALLOCATION	& FIXTURES	EQUIPMENT	& MAINT.	PORTATION	NATOR	(cols. 0 - 5)	GENERAL	± col. 6)
		0	1	2	3	4	5	5A	6	7
	GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Bldg and Fixt.										1
2	Capital Related Costs-Movable Equip.										2
3	Plant Operation and Maintenance										3
4	Transportation - Staff										4
5	Volunteer Service Coordination										5
6	Administrative and General										6
	INPATIENT CARE SERVICE
7	Inpatient - General Care										7
8	Inpatient - Respite Care										8
	VISITING SERVICES
9	Physician Services										9
10	Nursing Care										10
11	Nursing Care-Continuous Home Care										11
12	Physical Therapy										12
13	Occupational Therapy										13
14	Speech/ Language Pathology										14
15	Medical Social Services - Direct										15
16	Spiritual Counseling										16
17	Dietary Counseling										17
18	Counseling - Other										18
19	Home Health Aide and Homemakers										19
20	HH Aide & Homemaker - Cont. Home Care										20
21	Other										21
	OTHER HOSPICE SERVICE COSTS
22	Drugs, Biologicals and Infusion										22
23	Analgesics										23
24	Sedatives / Hypnotics										24
25	Other - Specify										25
26	Durable Medical Equipment/Oxygen										26
27	Patient Transportation										27
28	Imaging Services										28
29	Labs and Diagnostics										29
30	Medical Supplies										30
31	Outpatient Services (including E/R Dept.)										31
32	Radiation Therapy										32
33	Chemotherapy										33
34	Other										34
	HOSPICE NONREIMBURSABLE SERVICE
35	Bereavement Program Costs										35
36	Volunteer Program Costs										36
37	Fundraising										37
38	Other Program Costs										38
39	Total (sum of lines 1 thru 38)										39
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4061)
40-636											Rev. 1

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Sheet 6: K-4II

DRAFT				FORM CMS-2552-10					4090 (Cont.)
COST ALLOCATION - HOSPICE STATISTICAL BASIS				PROVIDER NO.: _________________		PERIOD:		WORKSHEET K-4,
						FROM ____________		PART II
				HOSPICE NO.: ________________		TO _______________
		CAPITAL RELATED COST		PLANT		VOLUNTEER		ADMINIS-
		BUILDINGS	MOVABLE	OPERATION	TRANS-	SERVICES		TRATIVE &
	COST CENTER DESCRIPTIONS	& FIXTURES	EQUIPMENT	& MAINT.	PORTATION	COORDINATOR	RECONCIL-	GENERAL
		(SQ. FT.)	($ VALUE)	(SQ. FT.)	(MILEAGE)	(HOURS)	IATION	(ACC. COST)
		1	2	3	4	5	6A	6
	GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Buildings and Fixtures								1
2	Capital Related Costs-Movable Equipment								2
3	Plant Operation and Maintenance								3
4	Transportation-staff								5
5	Volunteer Service Coordination								5
6	Administrative and General								6
	INPATIENT CARE SERVICE
7	Inpatient - General Care								7
8	Inpatient - Respite Care								8
	VISITING SERVICES
9	Physician Services								9
10	Nursing Care								10
11	Nursing Care-Continuous Home Care								11
12	Physical Therapy								12
13	Occupational Therapy								13
14	Speech/ Language Pathology								14
15	Medical Social Services - Direct								15
16	Spiritual Counseling								16
17	Dietary Counseling								17
18	Counseling - Other								18
19	Home Health Aide and Homemakers								19
20	HH Aide & Homemaker - Cont. Home Care								20
21	Other								21
	OTHER HOSPICE SERVICE COSTS
22	Drugs, Biologicals and Infusion								22
23	Analgesics								23
24	Sedatives / Hypnotics								24
25	Other - Specify								25
26	Durable Medical Equipment/Oxygen								26
27	Patient Transportation								27
28	Imaging Services								28
29	Labs and Diagnostics								29
30	Medical Supplies								30
31	Outpatient Services (including E/R Dept.)								31
32	Radiation Therapy								32
33	Chemotherapy								33
34	Other								34
	HOSPICE NONREIMBURSABLE SERVICE
35	Bereavement Program Costs								35
36	Volunteer Program Costs								36
37	Fundraising								37
38	Other Program Costs								38
39	Cost To be Allocated (per Wkst. K-4, Part I)								39
40	Unit Cost Multiplier								40
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4061)
Rev. 1									40-637

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Sheet 7: K-5I

4090 (Cont.)					FORM CMS-2552-10							DRAFT	DRAFT					FORM CMS-2552-10							4090 (Cont.)	4090 (Cont.)						FORM CMS-2552-10							DRAFT
ALLOCATION OF GENERAL SERVICE							PROVIDER NO.: ___________		PERIOD:		WORKSHEET K-5,		ALLOCATION OF GENERAL SERVICE							PROVIDER NO.: ___________		PERIOD:		WORKSHEET K-5,		ALLOCATION OF GENERAL SERVICE								PROVIDER NO.: ___________		PERIOD:		WORKSHEET K-5,
COSTS TO HOSPICE COST CENTERS									FROM__________________		PART I		COSTS TO HOSPICE COST CENTERS									FROM__________________		PART I (Cont.)		COSTS TO HOSPICE COST CENTERS										FROM__________________		PART I (Cont.)
							HOSPICE NO.: _____________		TO ___________________											HOSPICE NO.: _____________		TO ___________________												HOSPICE NO.: _____________		TO ___________________
																																			INTERN &
			From	HOSPICE	CAPITAL																								NON-				PARA-		RESIDENT		ALLOCATED	TOTAL
	HOSPICE COST CENTER		Wkst. K-4	TRIAL	RELATED COSTS				ADMINIS-	MAIN-				HOSPICE COST CENTER	LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL				HOSPICE COST CENTER	OTHER	PHYSICIAN		INTERNS & RESIDENTS		MEDICAL		COST & POST		HOSPICE	HOSPICE
	(omit cents)		Part I,	BALANCE	BLDGS. &	MOVABLE	EMPLOYEE	SUBTOTAL	TRATIVE &	TENANCE &	OPERATION			(omit cents)	& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL			(omit cents)	GENERAL	ANES-	NURSING	SALARY &	PROGRAM	EDUCATION	SUBTOTAL	STEPDOWN	SUBTOTAL	A&G (see	COSTS
			col. 7,	(1)	FIXTURES	EQUIPMENT	BENEFITS	(cols. 0-3)	GENERAL	REPAIRS	OF PLANT				SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE				SERVICE	THETISTS	SCHOOL	FRINGES	COSTS	(SPECIFY)	(cols. 3a-22)	ADJUST.	(cols. 23 ± 24)	Part II)	(cols. 25 ± 26)
			line	0	1	2	3	3A	4	5	6				7	8	9	10	11	12	13	14	15	16				17	18	19	20	21	22	23	24	25	26	27
1	Administrative and General		6									1	1	Administrative and General											1	1	Administrative and General												1
2	Inpatient - General Care		7									2	2	Inpatient - General Care											2	2	Inpatient - General Care												2
3	Inpatient - Respite Care		8									3	3	Inpatient - Respite Care											3	3	Inpatient - Respite Care												3
4	Physician Services		9									4	4	Physician Services											4	4	Physician Services												4
5	Nursing Care		10									5	5	Nursing Care											5	5	Nursing Care												5
6	Nursing Care-Continuous Home Care		11									6	6	Nursing Care-Continuous Home Care											6	6	Nursing Care-Continuous Home Care												6
7	Physical Therapy		12									7	7	Physical Therapy											7	7	Physical Therapy												7
8	Occupational Therapy		13									8	8	Occupational Therapy											8	8	Occupational Therapy												8
9	Speech/ Language Pathology		14									9	9	Speech/ Language Pathology											9	9	Speech/ Language Pathology												9
10	Medical Social Services - Direct		15									10	10	Medical Social Services - Direct											10	10	Medical Social Services - Direct												10
11	Spiritual Counseling		16									11	11	Spiritual Counseling											11	11	Spiritual Counseling												11
12	Dietary Counseling		17									12	12	Dietary Counseling											12	12	Dietary Counseling												12
13	Counseling - Other		18									13	13	Counseling - Other											13	13	Counseling - Other												13
14	Home Health Aide and Homemakers		19									14	14	Home Health Aide and Homemakers											14	14	Home Health Aide and Homemakers												14
15	HH Aide & Homemaker - Cont. Home Care		20									15	15	HH Aide & Homemaker - Cont. Home Care											15	15	HH Aide & Homemaker - Cont. Home Care												15
16	Other		21									16	16	Other											16	16	Other												16
17	Drugs, Biologicals and Infusion		22									17	17	Drugs, Biologicals and Infusion											17	17	Drugs, Biologicals and Infusion												17
18	Analgesics		23									18	18	Analgesics											18	18	Analgesics												18
19	Sedatives / Hypnotics		24									19	19	Sedatives / Hypnotics											19	19	Sedatives / Hypnotics												19
20	Other - Specify		25									20	20	Other - Specify											20	20	Other - Specify												20
21	Durable Medical Equipment/Oxygen		26									21	21	Durable Medical Equipment/Oxygen											21	21	Durable Medical Equipment/Oxygen												21
22	Patient Transportation		27									22	22	Patient Transportation											22	22	Patient Transportation												22
23	Imaging Services		28									23	23	Imaging Services											23	23	Imaging Services												23
24	Labs and Diagnostics		29									24	24	Labs and Diagnostics											24	24	Labs and Diagnostics												24
25	Medical Supplies		30									25	25	Medical Supplies											25	25	Medical Supplies												25
26	Outpatient Services (including E/R Dept.)		31									26	26	Outpatient Services (including E/R Dept.)											26	26	Outpatient Services (including E/R Dept.)												26
27	Radiation Therapy		32									27	27	Radiation Therapy											27	27	Radiation Therapy												27
28	Chemotherapy		33									28	28	Chemotherapy											28	28	Chemotherapy												28
29	Other		34									29	29	Other											29	29	Other												29
30	Bereavement Program Costs		35									30	30	Bereavement Program Costs											30	30	Bereavement Program Costs												30
31	Volunteer Program Costs		36									31	31	Volunteer Program Costs											31	31	Volunteer Program Costs												31
32	Fundraising		37									32	32	Fundraising											32	32	Fundraising												32
33	Other Program Costs		38									33	33	Other Program Costs											33	33	Other Program Costs												33
34	Totals (sum of lines 1-33) (2)											34	34	Totals (sum of lines 1-33) (2)											34	34	Totals (sum of lines 1-31) (2)												34
35	Unit Cost Multiplier (see instructions)											35	35	Unit Cost Multiplier (see instructions)											35	35	Unit Cost Multiplier (see instructions)												35
(1) Column 0, line 34 must agree with Wkst. A, column 7, line 116.													(1) Column 0, line 34 must agree with Wkst. A, column 7, line 116.													(1) Column 0, line 34 must agree with Wkst. A, column 7, line 116.
(2) Columns 0 through 25, line 34 must agree with the corresponding columns of Wkst. B, Part I, line 116.													(2) Columns 0 through 25, line 34 must agree with the corresponding columns of Wkst. B, Part I, line 116.													(2) Columns 0 through 25, line 34 must agree with the corresponding columns of Wkst. B, Part I, line 116.
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4062.1)													FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4062.1)													FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4062.1)
40-638												Rev. 1	Rev. 1												40-639	40-640													Rev. 1

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Sheet 8: K-5II

DRAFT			FORM CMS-2552-10							4090 (Cont.)	4090 (Cont.)				FORM CMS-2552-10							DRAFT	DRAFT		FORM CMS-2552-10							4090 (Cont.)
ALLOCATION OF GENERAL SERVICE COSTS TO					PROVIDER NO.: ___________		PERIOD:		WORKSHEET K-5,		ALLOCATION OF GENERAL SERVICE COSTS TO						PROVIDER NO.: ______________		PERIOD:		WORKSHEET K-5,		ALLOCATION OF GENERAL SERVICE COSTS TO				PROVIDER NO.: __________		PERIOD:		WORKSHEET K-5,
HOSPICE COST CENTERS STATISTICAL BASIS							FROM__________________		PART II		HOSPICE COST CENTERS STATISTICAL BASIS								FROM__________________		PART II (Cont.)		HOSPICE COST CENTERS STATISTICAL BASIS						FROM__________________		PART II (Cont.)
					HOSPICE NO.: _____________		TO ___________________										HOSPICE NO.: _____________		TO ___________________								HOSPICE NO.: _____________		TO ___________________
			CAPITAL																								NON-				PARA-
			RELATED COST				ADMINIS-	MAIN-					LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL						PHYSICIAN		INTERNS & RESIDENTS		MEDICAL
			BLDGS. &	MOVABLE	EMPLOYEE		TRATIVE &	TENANCE &	OPERATION				& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &				SOCIAL	OTHER	ANES-	NURSING	SALARY &	PROGRAM	EDUCATION
	HOSPICE COST CENTER		FIXTURES	EQUIPMENT	BENEFITS		GENERAL	REPAIRS	OF PLANT			HOSPICE COST CENTER	SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY			HOSPICE COST CENTER	SERVICE	GENERAL	THETISTS	SCHOOL	FRINGES	COSTS	(SPECIFY)
			(SQUARE	(DOLLAR	(GROSS	RECONCIL-	(ACCUM.	(SQUARE	(SQUARE				(POUNDS OF	(HOURS OF	(MEALS	(MEALS	(NUMBER	(DIRECT	(COSTED	(COSTED	(TIME				(TIME	SERVICE	(ASSIGNED	(ASSIGNED	(ASSIGNED	(ASSIGNED	(ASSIGNED
			FEET)	VALUE)	SALARIES)	IATION	COST)	FEET)	FEET)				LAUNDRY)	SERVICE)	SERVED)	SERVED)	HOUSED)	NURS. HRS)	REQUIS.)	REQUIS.)	SPENT)				SPENT)	(SPECIFY)	TIME)	TIME)	TIME)	TIME)	TIME)
			1	2	4	4A	5	6	7				8	9	10	11	12	13	14	14	16				17	18	19	20	21	22	23
1	Administrative and General									1	1	Administrative and General										1	1	Administrative and General								1
2	Inpatient - General Care									2	2	Inpatient - General Care										2	2	Inpatient - General Care								2
3	Inpatient - Respite Care									3	3	Inpatient - Respite Care										3	3	Inpatient - Respite Care								3
4	Physician Services									4	4	Physician Services										4	4	Physician Services								4
5	Nursing Care									5	5	Nursing Care										5	5	Nursing Care								5
6	Nursing Care-Continuous Home Care									6	6	Nursing Care-Continuous Home Care										6	6	Nursing Care-Continuous Home Care								6
7	Physical Therapy									7	7	Physical Therapy										7	7	Physical Therapy								7
8	Occupational Therapy									8	8	Occupational Therapy										8	8	Occupational Therapy								8
9	Speech/ Language Pathology									9	9	Speech/ Language Pathology										9	9	Speech/ Language Pathology								9
10	Medical Social Services - Direct									10	10	Medical Social Services - Direct										10	10	Medical Social Services - Direct								10
11	Spiritual Counseling									11	11	Spiritual Counseling										11	11	Spiritual Counseling								11
12	Dietary Counseling									12	12	Dietary Counseling										12	12	Dietary Counseling								12
13	Counseling - Other									13	13	Counseling - Other										13	13	Counseling - Other								13
14	Home Health Aide and Homemakers									14	14	Home Health Aide and Homemakers										14	14	Home Health Aide and Homemakers								14
15	HH Aide & Homemaker - Cont. Home Care									15	15	HH Aide & Homemaker - Cont. Home Care										15	15	HH Aide & Homemaker - Cont. Home Care								15
16	Other									16	16	Other										16	16	Other								16
17	Drugs, Biologicals and Infusion									17	17	Drugs, Biologicals and Infusion										17	17	Drugs, Biologicals and Infusion								17
18	Analgesics									18	18	Analgesics										18	18	Analgesics								18
19	Sedatives / Hypnotics									19	19	Sedatives / Hypnotics										19	19	Sedatives / Hypnotics								19
20	Other - Specify									20	20	Other - Specify										20	20	Other - Specify								20
21	Durable Medical Equipment/Oxygen									21	21	Durable Medical Equipment/Oxygen										21	21	Durable Medical Equipment/Oxygen								21
22	Patient Transportation									22	22	Patient Transportation										22	22	Patient Transportation								22
23	Imaging Services									23	23	Imaging Services										23	23	Imaging Services								23
24	Labs and Diagnostics									24	24	Labs and Diagnostics										24	24	Labs and Diagnostics								24
25	Medical Supplies									25	25	Medical Supplies										25	25	Medical Supplies								25
26	Outpatient Services (including E/R Dept.)									26	26	Outpatient Services (including E/R Dept.)										26	26	Outpatient Services (including E/R Dept.)								26
27	Radiation Therapy									27	27	Radiation Therapy										27	27	Radiation Therapy								27
28	Chemotherapy									28	28	Chemotherapy										28	28	Chemotherapy								28
29	Other									29	29	Other										29	29	Other								29
30	Bereavement Program Costs									30	30	Bereavement Program Costs										30	30	Bereavement Program Costs								30
31	Volunteer Program Costs									31	31	Volunteer Program Costs										31	31	Volunteer Program Costs								31
32	Fundraising									32	32	Fundraising										32	32	Fundraising								32
33	Other Program Costs									33	33	Other Program Costs										33	33	Other Program Costs								33
34	Totals (sum of lines 1-33) (2)									34	34	Totals (sum of lines 1-33) (2)										34	34	Totals (sum of lines 1-33) (2)								34
35	Total cost to be allocated									35	35	Total cost to be allocated										35	35	Total cost to be allocated								35
36	Unit Cost Multiplier (see instructions)									36	36	Unit Cost Multiplier (see instructions)										36	36	Unit Cost Multiplier (see instructions)								36
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4062.2)											FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4062.2)												FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4062.2)
Rev. 1										40-641	40-642											Rev. 1	Rev. 1									40-643

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Sheet 9: K-5III

4090 (Cont.)			FORM CMS-2552-10					DRAFT
APPORTIONMENT OF HOSPICE SHARED SERVICES			PROVIDER NO.:__________		PERIOD:		WORKSHEET K-5,
					FROM _____________		PART III
			HOSPICE NO.:___________		TO _____________
PART III - COMPUTATION OF TOTAL HOSPICE SHARED COSTS
						Total	Hospice
				Wkst. C,		Hospice	Shared
				Part I,	Cost to	Charges	Ancillary
				col. 9,	Charge	(Provider	Costs
	COST CENTER			line	Ratio	Records)	(cols. 1 x 2)
				0	1	2	3
	ANCILLARY SERVICE COST CENTERS
1	Physical Therapy			63				1
2	Occupational Therapy			64				2
3	Speech/Language Pathology			65				3
4	Drugs, Biologicals and Infusion			70				4
5	Durable Medical Equipment/Oxygen			96				5
6	Labs and Diagnostics			57				6
7	Medical Supplies			68				7
8	Outpatient Services (including E/R Dept.)			93				8
9	Radiation Therapy			54				9
10	Other			73				10
11	Totals (sum of lines 1-10)							11
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4062.3)
40-644								Rev. 1

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Sheet 10: K-6

DRAFT		FORM CMS-2552-10					4090 (Cont.)
CALCULATION OF HOSPICE PER DIEM COST		PROVIDER NO.:___________		PERIOD:		WORKSHEET K-6
				FROM ________________
		HOSPICE NO.: ____________		TO ________________
	COMPUTATION OF PER DIEM COST		TITLE XVIII	TITLE XIX	OTHER	TOTAL
			1	2	3	4
1	Total cost (see instructions)						1
2	Total Unduplicated Days (Worksheet S-9, column 6, line 5)						2
3	Average cost per diem (line 1 divided by line 2)						3
4	Unduplicated Medicare Days (Worksheet S-9, column 1, line 5)						4
5	Aggregate Medicare cost (line 3 times line 4)						5
6	Unduplicated Medicaid Days (Worksheet S-9, column 2, line 5)						6
7	Aggregate Medicaid cost (line 3 times line 6)						7
8	Unduplicated SNF days (Worksheet S-9, column 3, line 5)						8
9	Aggregate SNF cost (line 3 times line 8)						9
10	Unduplicated NF days (Worksheet S-9, column 4, line 5)						10
11	Aggregate NF cost (line 3 times line 10)						11
12	Other Unduplicated days (Worksheet S-9, column 5, line 5)						12
13	Aggregate cost for other days (line 3 times line 12)						13
Note: The data for the SNF and NF on lines 8 through 11 are included in the Medicare and Medicaid lines 4 through 7.
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4063)
Rev. 1							40-645