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

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Overview

L
L1I
L1II
L1III

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Sheet 1: L

4090 (Cont.)			FORM CMS-2552-10					DRAFT
CALCULATION OF CAPITAL PAYMENT			PROVIDER NO.:		PERIOD:		WORKSHEET L
			______________		FROM __________
			COMPONENT NO.:		TO ____________
			______________
Check		[ ] Title V	[ ] Hospital			[ ] PPS
Applicable		[ ] Title XVIII	[ ] Subprovider			[ ] Cost Method
Boxes		[ ] Title XIX
PART I - FULLY PROSPECTIVE METHOD
	CAPITAL FEDERAL AMOUNT
1	Capital DRG other than outlier							1
2	Capital DRG outlier payments							2
3	Total inpatient days divided by number of days in the cost reporting period (see instructions)							3
4	Number of interns & residents (see instructions)							4
5	Indirect medical education percentage (see instructions)							5
6	Indirect medical education adjustment (sum of lines 1 & 2 times line 5)							6
7	Percentage of SSI recipient patient days to Medicare Part A patient days (Worksheet E, part A line 27 see instructions)							7
8	Percentage of Medicaid patient days to total days reported on Worksheet S-3, Part I (see instructions)							8
9	Sum of lines 3 and 4							9
10	Allowable disproportionate share percentage (see instructions)							10
11	Disproportionate share adjustment (line 6 times the sum of lines 1 and 2)							11
12	Total prospective capital payments (sum of lines 1-2, and 7)							12
PART II - PAYMENT UNDER REASONABLE COST
1	Program inpatient routine capital cost (see instructions)							1
2	Program inpatient ancillary capital cost (see instructions)							2
3	Total inpatient program capital cost (line 1 plus line 2)							3
4	Capital cost payment factor (see instructions)							4
5	Total inpatient program capital cost (line 3 x line 4)							5
PART III - COMPUTATION OF EXCEPTION PAYMENTS
1	Program inpatient capital costs (see instructions)							1
2	Program inpatient capital costs for extraordinary circumstances (see instructions)							2
3	Net program inpatient capital costs (line 1 minus line 2)							3
4	Applicable exception percentage (see instructions)							4
5	Capital cost for comparison to payments (line 3 x line 4)							5
6	Percentage adjustment for extraordinary circumstances (see instructions)							6
7	Adjustment to capital minimum payment level for extraordinary circumstances (line 2 x line 6)							7
8	Capital minimum payment level (line 5 plus line 7)							8
9	Current year capital payments (from Part I, line 8, as applicable)							9
10	Current year comparison of capital minimum payment level to capital payments (line 8 less line 9)							10
11	Carryover of accumulated capital minimum payment level over capital payment							11
	(from prior year Worksheet L, Part III, line 14)
12	Net comparison of capital minimum payment level to capital payments (line 10 plus line 11)							12
13	Current year exception payment (if line 12 is positive, enter the amount on this line)							13
14	Carryover of accumulated capital minimum payment level over capital payment							14
	for the following period (if line 12 is negative, enter the amount on this line)
15	Current year allowable operating and capital payment (see instructions)							15
16	Current year operating and capital costs (see instructions)							16
17	Current year exception offset amount (see instructions)							17
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4064.1 - 4064.3)
40-646								Rev. 1

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Sheet 2: L1I

DRAFT			FORM CMS-2552-10							4090 (Cont.)	4090 (Cont.)				FORM CMS-2552-10								DRAFT	4090 (Cont.)				FORM CMS-2552-10							DRAFT
ALLOCATION OF ALLOWABLE COSTS FOR					PROVIDER NO.:		PERIOD:		WORKSHEET L-1,		ALLOCATION OF ALLOWABLE COSTS FOR							PROVIDER NO.:		PERIOD:		WORKSHEET L-1,		ALLOCATION OF ALLOWABLE COSTS FOR						PROVIDER NO.:		PERIOD:		WORKSHEET L-1,
EXTRAORDINARY CIRCUMSTANCES							FROM_____________		PART I		EXTRAORDINARY CIRCUMSTANCES									FROM_____________		PART I		EXTRAORDINARY CIRCUMSTANCES								FROM_____________		PART I
					________________		TO________________											________________		TO________________										________________		TO________________
		EXTRA-	CAPITAL																														INTERN &
		ORDINARY	RELATED COSTS																								NON-		INTERNS &	INTERNS &	PARA-		RESIDENT
		CAPITAL			SUBTOTAL		ADMINIS-	MAIN-					LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL					OTHER	PHYSICIAN		RESIDENTS	RESIDENTS	MEDICAL		COST & POST
	Cost Center Descriptions	RELATED	BLDGS. &	MOVABLE	(sum of	EMPLOYEE	TRATIVE &	TENANCE &	OPERATION			Cost Center Descriptions	& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL			Cost Center Descriptions	GENERAL	ANES-	NURSING	SALARY &	PROGRAM	EDUCATION		STEPDOWN
		COSTS	FIXTURES	EQUIPMENT	cols. 0-2)	BENEFITS	GENERAL	REPAIRS	OF PLANT				SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE				SERVICE	THETISTS	SCHOOL	FRINGES	COSTS	(SPECIFY)	SUBTOTAL	ADJUSTMENTS	TOTAL
		0	1	2	2A	4	5	6	7				8	9	10	11	12	13	14	15	16	17				18	19	20	21	22	23	24	25	26
	GENERAL SERVICE COST CENTERS									0	0	GENERAL SERVICE COST CENTERS													GENERAL SERVICE COST CENTERS										0
1	Capital Related Costs-Buildings and Fixtures									1	1	Capital Related Costs-Buildings and Fixtures											1	1	Capital Related Costs-Buildings and Fixtures										1
2	Capital Related Costs-Movable Equipment									2	2	Capital Related Costs-Movable Equipment											2	2	Capital Related Costs-Movable Equipment										2
4	Employee Benefits									4	4	Employee Benefits											4	4	Employee Benefits										4
5	Administrative and General									5	5	Administrative and General											5	5	Administrative and General										5
6	Maintenance and Repairs									6	6	Maintenance and Repairs											6	6	Maintenance and Repairs										6
7	Operation of Plant									7	7	Operation of Plant											7	7	Operation of Plant										7
8	Laundry and Linen Service									8	8	Laundry and Linen Service											8	8	Laundry and Linen Service										8
9	Housekeeping									9	9	Housekeeping											9	9	Housekeeping										9
10	Dietary									10	10	Dietary											10	10	Dietary										10
11	Cafeteria									11	11	Cafeteria											11	11	Cafeteria										11
12	Maintenance of Personnel									12	12	Maintenance of Personnel											12	12	Maintenance of Personnel										12
13	Nursing Administration									13	13	Nursing Administration											13	13	Nursing Administration										13
14	Central Services and Supply									14	14	Central Services and Supply											14	14	Central Services and Supply										14
15	Pharmacy									15	15	Pharmacy											15	15	Pharmacy										15
16	Medical Records & Medical Records Library									16	16	Medical Records & Medical Records Library											16	16	Medical Records & Medical Records Library										16
17	Social Service									17	17	Social Service											17	17	Social Service										17
18	Other General Service (specify)									18	18	Other General Service (specify)											18	18	Other General Service (specify)										18
19	Nonphysician Anesthetists									19	19	Nonphysician Anesthetists											19	19	Nonphysician Anesthetists										19
20	Nursing School									20	20	Nursing School											20	20	Nursing School										20
21	Intern & Res. Service-Salary & Fringes (Approved)									21	21	Intern & Res. Service-Salary & Fringes (Approved)											21	21	Intern & Res. Service-Salary & Fringes (Approved)										21
22	Intern & Res. Other Program Costs (Approved)									22	22	Intern & Res. Other Program Costs (Approved)											22	22	Intern & Res. Other Program Costs (Approved)										22
23	Paramedical Ed. Program (specify)									23	23	Paramedical Ed. Program (specify)											23	23	Paramedical Ed. Program (specify)										23
	INPATIENT ROUTINE SERVICE COST CENTERS									0	0	INPATIENT ROUTINE SERVICE COST CENTERS													INPATIENT ROUTINE SERVICE COST CENTERS										0
30	Adults and Pediatrics (General Routine Care)									30	30	Adults and Pediatrics (General Routine Care)											30	30	Adults and Pediatrics (General Routine Care)										30
31	Intensive Care Unit									31	31	Intensive Care Unit											31	31	Intensive Care Unit										31
32	Coronary Care Unit									32	32	Coronary Care Unit											32	32	Coronary Care Unit										32
33	Burn Intensive Care Unit									33	33	Burn Intensive Care Unit											33	33	Burn Intensive Care Unit										33
34	Surgical Intensive Care Unit									34	34	Surgical Intensive Care Unit											34	34	Surgical Intensive Care Unit										34
35	Other Special Care Unit (specify)									35	35	Other Special Care Unit (specify)											35	35	Other Special Care Unit (specify)										35
40	Subprovider IPF									40	40	Subprovider IPF											40	40	Subprovider IPF										40
41	Subprovider IRF									41	41	Subprovider IRF											41	41	Subprovider IRF										41
42	Subprovider									42	42	Subprovider											42	42	Subprovider										42
43	Nursery									43	43	Nursery											43	43	Nursery										43
44	Skilled Nursing Facility									44	44	Skilled Nursing Facility											44	44	Skilled Nursing Facility										44
45	Nursing Facility									45	45	Nursing Facility											45	45	Nursing Facility										45
46	Other Long Term Care									46	46	Other Long Term Care											46	46	Other Long Term Care										46
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4065.1)											FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4065.1)													FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4065.1)
Rev. 1										40-647	40-648												Rev. 1	Rev. 1											40-649
4690 (Cont.)			FORM CMS-2552-10							DRAFT	DRAFT				FORM CMS-2552-10								4090 (Cont.)	4690 (Cont.)				FORM CMS-2552-10							DRAFT
ALLOCATION OF ALLOWABLE COSTS FOR					PROVIDER NO.:		PERIOD:		WORKSHEET L-1,		ALLOCATION OF ALLOWABLE COSTS FOR							PROVIDER NO.:		PERIOD:		WORKSHEET L-1,		ALLOCATION OF ALLOWABLE COSTS FOR						PROVIDER NO.:		PERIOD:		WORKSHEET L-1,
EXTRAORDINARY CIRCUMSTANCES							FROM_____________		PART I		EXTRAORDINARY CIRCUMSTANCES									FROM_____________		PART I		EXTRAORDINARY CIRCUMSTANCES								FROM_____________		PART I
					________________		TO________________											________________		TO________________										________________		TO________________
		EXTRA-	CAPITAL																														INTERN &
		ORDINARY	RELATED COSTS																										INTERNS &	INTERNS &			RESIDENT
		CAPITAL			SUBTOTAL		ADMINIS-	MAIN-					LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL					OTHER			RESIDENTS	RESIDENTS	PARAMEDICAL		COST & POST
	Cost Center Descriptions	RELATED	BLDGS. &	MOVABLE	(sum of	EMPLOYEE	TRATIVE &	TENANCE &	OPERATION			Cost Center Descriptions	& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL			Cost Center Descriptions	GENERAL	NONPHYSICIAN	NURSING	SALARY AND	PROGRAM	EDUCATION		STEPDOWN
		COSTS	FIXTURES	EQUIPMENT	cols. 0-2)	BENEFITS	GENERAL	REPAIRS	OF PLANT				SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE				SERVICE	ANESTHETISTS	SCHOOL	FRINGES	COSTS	(SPECIFY)	SUBTOTAL	ADJUSTMENTS	TOTAL
		0	1	2	2A	4	5	6	7				8	9	10	11	12	13	14	15	16	17				18	19	20	21	22	23	24	25	26
	ANCILLARY SERVICE COST CENTERS										0	ANCILLARY SERVICE COST CENTERS													ANCILLARY SERVICE COST CENTERS
50	Operating Room									50	50	Operating Room											50	50	Operating Room										50
51	Recovery Room									51	51	Recovery Room											51	51	Recovery Room										51
52	Labor Room and Delivery Room									52	52	Labor Room and Delivery Room											52	52	Labor Room and Delivery Room										52
53	Anesthesiology									53	53	Anesthesiology											53	53	Anesthesiology										53
54	Radiology-Diagnostic									54	54	Radiology-Diagnostic											54	54	Radiology-Diagnostic										54
55	Radiology-Therapeutic									55	55	Radiology-Therapeutic											55	55	Radiology-Therapeutic										55
56	Radioisotope									56	56	Radioisotope											56	56	Radioisotope										56
57	Computed Tomography (CT) Scan									57	57	Computed Tomography (CT) Scan											57	57	Computed Tomography (CT) Scan										57
58	Magnetic Resonance Imaging (MRI)									58	58	Magnetic Resonance Imaging (MRI)											58	58	Magnetic Resonance Imaging (MRI)										58
59	Cardiac Catherization									59	59	Cardiac Catherization											59	59	Cardiac Catherization										59
60	Laboratory									60	60	Laboratory											60	60	Laboratory										60
61	PBP Clinical Laboratory Service-Program Only									61	61	PBP Clinical Laboratory Service-Program Only											61	61	PBP Clinical Laboratory Service-Program Only										61
62	Whole Blood & Packed Red Blood Cells									62	62	Whole Blood & Packed Red Blood Cells											62	62	Whole Blood & Packed Red Blood Cells										62
63	Blood Storing, Processing, & Trans.									63	63	Blood Storing, Processing, & Trans.											63	63	Blood Storing, Processing, & Trans.										63
64	Intravenous Therapy									64	64	Intravenous Therapy											64	64	Intravenous Therapy										64
65	Respiratory Therapy									65	65	Respiratory Therapy											65	65	Respiratory Therapy										65
66	Physical Therapy									66	66	Physical Therapy											66	66	Physical Therapy										66
67	Occupational Therapy									67	67	Occupational Therapy											67	67	Occupational Therapy										67
68	Speech Pathology									68	68	Speech Pathology											68	68	Speech Pathology										68
69	Electrocardiology									69	69	Electrocardiology											69	69	Electrocardiology										69
70	Electroencephalography									70	70	Electroencephalography											70	70	Electroencephalography										70
71	Medical Supplies Charged to Patients									71	71	Medical Supplies Charged to Patients											71	71	Medical Supplies Charged to Patients										71
72	Implantable Devices Charged to Patients									72	72	Implantable Devices Charged to Patients											72	72	Implantable Devices Charged to Patients										72
73	Drugs Charged to Patients									73	73	Drugs Charged to Patients											73	73	Drugs Charged to Patients										73
74	Renal Dialysis									74	74	Renal Dialysis											74	74	Renal Dialysis										74
75	ASC (Non-Distinct Part)									75	75	ASC (Non-Distinct Part)											75	75	ASC (Non-Distinct Part)										75
76	Other Ancillary (specify)									76	76	Other Ancillary (specify)											76	76	Other Ancillary (specify)										76
	OUTPATIENT SERVICE COST CENTERS									0	0	OUTPATIENT SERVICE COST CENTERS													OUTPATIENT SERVICE COST CENTERS										0
88	Rural Health Clinic (RHC)									88	88	Rural Health Clinic (RHC)											88	88	Rural Health Clinic (RHC)										88
89	Federally Qualified Health Center (FQHC)									89	89	Federally Qualified Health Center (FQHC)											89	89	Federally Qualified Health Center (FQHC)										89
90	Clinic									90	90	Clinic											90	90	Clinic										90
91	Emergency									91	91	Emergency											91	91	Emergency										91
92	Observation Beds									92	92	Observation Beds											92	92	Observation Beds										92
93	Other Outpatient (specify)									93	93	Other Outpatient (specify)											93	93	Other Outpatient (specify)										93
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4065.1)											FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4065.1)													FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4065.1)
40-650										Rev. 1	Rev. 1												40-651	40-652											Rev. 1
DRAFT			FORM CMS-2552-10							4090 (Cont.)	4090 (Cont.)				FORM CMS-2552-10								DRAFT	DRAFT				FORM CMS-2552-10							4090 (Cont.)
ALLOCATION OF ALLOWABLE COSTS FOR					PROVIDER NO.:		PERIOD:		WORKSHEET L-1,		ALLOCATION OF ALLOWABLE COSTS FOR							PROVIDER NO.:		PERIOD:		WORKSHEET L-1,		ALLOCATION OF ALLOWABLE COSTS FOR						PROVIDER NO.:		PERIOD:		WORKSHEET L-1,
EXTRAORDINARY CIRCUMSTANCES							FROM_____________		PART I		EXTRAORDINARY CIRCUMSTANCES									FROM_____________		PART I		EXTRAORDINARY CIRCUMSTANCES								FROM_____________		PART I
					________________		TO________________											________________		TO________________										________________		TO________________
		EXTRA-	CAPITAL																														INTERN &
		ORDINARY	RELATED COSTS																										INTERNS &	INTERNS &			RESIDENT
		CAPITAL			SUBTOTAL		ADMINIS-	MAIN-					LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL					OTHER			RESIDENTS	RESIDENTS	PARAMEDICAL		COST & POST
	Cost Center Descriptions	RELATED	BLDGS. &	MOVABLE	(sum of	EMPLOYEE	TRATIVE &	TENANCE &	OPERATION			Cost Center Descriptions	& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL			Cost Center Descriptions	GENERAL	NONPHYSICIAN	NURSING	SALARY AND	PROGRAM	EDUCATION		STEPDOWN
		COSTS	FIXTURES	EQUIPMENT	cols. 0-4)	BENEFITS	GENERAL	REPAIRS	OF PLANT				SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE				SERVICE	ANESTHETISTS	SCHOOL	FRINGES	COSTS	(SPECIFY)	SUBTOTAL	ADJUSTMENTS	TOTAL
		0	1	2	2A	4	5	6	7				8	9	10	11	12	13	14	15	16	17				18	19	20	21	22	23	24	25	26
	OTHER REIMBURSABLE COST CENTERS										0	OTHER REIMBURSABLE COST CENTERS													OTHER REIMBURSABLE COST CENTERS										0
95	Home Program Dialysis									95	95	Home Program Dialysis											95	95	Home Program Dialysis										95
96	Ambulance Services									96	96	Ambulance Services											96	96	Ambulance Services										96
97	Durable Medical Equipment-Rented									97	97	Durable Medical Equipment-Rented											97	97	Durable Medical Equipment-Rented										97
98	Durable Medical Equipment-Sold									98	98	Durable Medical Equipment-Sold											98	98	Durable Medical Equipment-Sold										98
99	Other Reimbursable (specify)									99	99	Other Reimbursable (specify)											99	99	Other Reimbursable (specify)										99
100	Outpatient Rehabilitation Provider (specify)									100	100	Outpatient Rehabilitation Provider (specify)											100	100	Outpatient Rehabilitation Provider (specify)										100
101	Intern-Resident Service (not appvd. tchng. prgm.)									101	101	Intern-Resident Service (not appvd. tchng. prgm.)											101	101	Intern-Resident Service (not appvd. tchng. prgm.)										101
102	Home Health Agency									102	102	Home Health Agency											102	102	Home Health Agency										102
	SPECIAL PURPOSE COST CENTERS									0	0	SPECIAL PURPOSE COST CENTERS													SPECIAL PURPOSE COST CENTERS										0
105	Kidney Acquisition									105	105	Kidney Acquisition											105	105	Kidney Acquisition										105
106	Heart Acquisition									106	106	Heart Acquisition											106	106	Heart Acquisition										106
107	Liver Acquisition									107	107	Liver Acquisition											107	107	Liver Acquisition										107
108	Lung Acquisition									108	108	Lung Acquisition											108	108	Lung Acquisition										108
109	Pancreas Acquisition									109	109	Pancreas Acquisition											109	109	Pancreas Acquisition										109
110	Intestinal Acquisition									110	110	Intestinal Acquisition											110	110	Intestinal Acquisition										110
111	Islet Acquisition									111	111	Islet Acquisition											111	111	Islet Acquisition										111
112	Other Organ Acquisition (specify)									112	112	Other Organ Acquisition (specify)											112	112	Other Organ Acquisition (specify)										112
115	Ambulatory Surgical Center (Distinct Part)									115	115	Ambulatory Surgical Center (Distinct Part)											115	115	Ambulatory Surgical Center (Distinct Part)										115
116	Hospice									116	116	Hospice											116	116	Hospice										116
117	Other Special Purpose (specify)									117	117	Other Special Purpose (specify)											117	117	Other Special Purpose (specify)										117
118	SUBTOTALS (sum of lines 1-117)									118	118	SUBTOTALS (sum of lines 1-117)											118	118	SUBTOTALS (sum of lines 1-117)										118
	NONREIMBURSABLE COST CENTERS									0	0	NONREIMBURSABLE COST CENTERS											0		NONREIMBURSABLE COST CENTERS										0
190	Gift, Flower, Coffee Shop, & Canteen									190	190	Gift, Flower, Coffee Shop, & Canteen											190	190	Gift, Flower, Coffee Shop, & Canteen										190
191	Research									191	191	Research											191	191	Research										191
192	Physicians' Private Offices									192	192	Physicians' Private Offices											192	192	Physicians' Private Offices										192
193	Nonpaid Workers									193	193	Nonpaid Workers											193	193	Nonpaid Workers										193
194	Other Nonreimbursable (specify)									194	194	Other Nonreimbursable (specify)											194	194	Other Nonreimbursable (specify)										194
195	Cross Foot Adjustments									195	195	Cross Foot Adjustments											195	195	Cross Foot Adjustments										195
196	Negative Cost Centers									196	196	Negative Cost Centers											196	196	Negative Cost Centers										196
197	Total (sum of lines190-196)									197	197	Total (sum of lines190-196)											197	197	Total (sum of lines190-196)										197
198	Total Statistical Basis									198	198	Total Statistical Basis											198	198	Total Statistical Basis										198
200	Unit Cost Multiplier									200	200	Unit Cost Multiplier											200	200	Unit Cost Multiplier										200
											0	0																							0
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4065.1)											FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4065.1)													FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4065.1)
Rev. 1										40-653	40-654												Rev. 1	Rev. 1											40-655

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Sheet 3: L1II

4090 (Cont.)

FORM CMS-2552-10

DRAFT

COMPUTATION OF PROGRAM INPATIENT ROUTINE SERVICE

PROVIDER NO.:

PERIOD:

WORKSHEET L-1,

CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES

FROM __________

PART II

__________________

TO ______________

Check

[ ] Title V

-

-

-

-

-

-

-

-

applicable

[ ] Title XVIII, Part A

PROVIDER NO.

PERIOD

TITLE XIX

box

[ ] Title XIX

FROM 7-1-85

HOSPITAL

Capital Cost

Reduced

for Extraordinary

Capital Cost

OO-OOO1

TO 6-30-85

TEFRA

Circumstances

for Extraordinary

Inpatient Program

-

-

-

-

-

-

-

-

-

-

-

(from Wkst. L-1,

Swing Bed

Circumstances

Total

Per Diem

Inpatient

Capital Cost

CAPITAL

REDUCED

SWING-BED

TOTAL

INPATIENT

PROGRAM

Cost Center Description

Part I, col. 26)

Adjustment

(col. 1 - col. 2)

Patient Days

(col. 3 ÷ col. 4)

Program Days

(col. 5 x col. 6)

CAPITAL

REDUCTION

CAPITAL

NONPHYSICIAN

MEDICAL

ADJUSTMENT

PATIENT

PER DIEM

PROGRAM

PASS THROUGH

1

2

3

4

5

6

7

(A)

INPATIENT ROUTINE SERVICE

COST CENTERS

30

Adults & 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 Unit (specify)

35

40

Subprovider IPF

40

41

Subprovider IRF

41

42

Subprovider (Other)

42

43

Nursery

43

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 4065.2)

40-656

Rev. 1

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Sheet 4: L1III

DRAFT			FORM CMS-2552-10						4090 (Cont.)
COMPUTATION OF PROGRAM INPATIENT ANCILLARY SERVICE						PROVIDER NO.:	PERIOD:	WORKSHEET L-1,
CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES						_________________	FROM _________	PART III
						COMPONENT NO.:	TO ____________
						_________________
Check		[ ] Hospital		[ ] Title V
applicable		[ ] Subprovider		[ ] Title XVIII, Part A
boxes				[ ] Title XIX
				Capital Cost for
				Extraordinary				Program
				Circumstances	Total Charges	Ratio of Cost		Extraordinary
	Cost Center Description			(from Wkst. L-1,	(from Wkst. C,	to Charges	Inpatient	Capital Cost
				Part I, col. 26)	Part I, col. 6)	(col. 1 ÷ col. 2)	Program Charges	(col. 3 x 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 Catherization								59
60	Laboratory								60
61	PBP Clinical Laboratory Service-Program 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
	(A) Worksheet A line numbers
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4065.3)
Rev. 1									40-657
4090 (Cont.)			FORM CMS-2552-10						DRAFT
COMPUTATION OF PROGRAM INPATIENT ANCILLARY SERVICE						PROVIDER NO.:	PERIOD:	WORKSHEET L-1,
CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES						_________________	FROM _________	PART III (CONT.)
						COMPONENT NO.:	TO ____________
						_________________
Check		[ ] Hospital		[ ] Title V
applicable		[ ] Subprovider		[ ] Title XVIII, Part A
boxes				[ ] Title XIX
				Capital Cost for
				Extraordinary				Program
				Circumstances	Total Charges	Ratio of Cost		Extraordinary
	Cost Center Description			(from Wkst. L-1,	(from Wkst. C,	to Charges	Inpatient	Capital Cost
				Part I, col. 26)	Part I, col. 6)	(col. 1 ÷ col. 2)	Program Charges	(col. 3 x col. 4)
				1	2	3	4	5
	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 (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, SECTIONS 4065.3)
40-658									Rev. 1