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

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Overview

S
S2I
S2II
S3I
S3II &III
S3IV
S3V
S4
S5
S6
S7
S8
S9
S10

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Sheet 1: S

DRAFT						FORM CMS-2552-10				4090 (Cont.)
This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim									FORM APPROVED
payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).									OMB NO. 0938-0050
HOSPITAL AND HOSPITAL HEALTH CARE					PROVIDER NO.:		PERIOD:		WORKSHEET S,
COMPLEX COST REPORT CERTIFICATION							FROM _____________		PARTS I, II & III
AND SETTLEMENT SUMMARY					_____________		TO ________________
PART I - COST REPORT STATUS
Provider use only					[ ] Electronically filed cost report			Date:	Time:
					[ ] Manually submitted cost report
					[ ] If this is an amended report enter the number of times the provider resubmitted this cost report
Contractor		[ ] Cost Report Status			If 3 or 4:			Date Received: _________
use only		(1) As Submitted		(3) Settled	[ ] Desk Reviewed			Contractor No._________
		(2) Amended		(4) Reopened	[ ] Audited			[ ] First Report Processed by Contractor
					If 4, number of times reopened [ ]			[ ] Last Report to be Processed by Contractor
PART II - CERTIFICATION
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL,
CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS
REPORT WERE PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE
ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.
		CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)
	I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying electronically filed or manually submitted cost
	report and the Balance Sheet and Statement of Revenue and Expenses prepared by _________________________{Provider Name(s) and Number(s)}
	for the cost reporting period beginning ______________ and ending ______________ and to the best of my knowledge and belief, it is a true, correct
	and complete statement prepared from the books and records of the provider in accordance with applicable instructions, except as noted. I further
	certify that I am familiar with the laws and regulations regarding the provision of health care services identified in this cost report were provided in
	compliance with such laws and regulations.
					(Signed)________________________________________________
						Officer or Administrator of Provider(s)
						______________________________________________
						Title
						______________________________________________
						Date
PART III - SETTLEMENT SUMMARY
						TITLE XVIII
					TITLE V	PART A	PART B	HIT	TITLE XIX
					1	2	3	4	5
1	HOSPITAL									1
2	SUBPROVIDER - IPF									2
3	SUBPROVIDER - IRF									3
4	SUBPROVIDER (OTHER)									4
5	SWING BED - SNF									5
6	SWING BED - NF									6
7	SKILLED NURSING FACILITY									7
8	NURSING FACILITY									8
9	HOME HEALTH AGENCY									9
10	HEALTH CLINIC - RHC									10
11	HEALTH CLINIC - FQHC									11
	OUTPATIENT REHABILITATION
12	PROVIDER (Specify)									12
200	TOTAL									200
The above amounts represent "due to" or "due from" the applicable program for the element of the above complex indicated.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-0050. The time required to complete this information collection is estimated 673 hours per response, including the time to review instructions,
search existing resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions
for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Report Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 4003.1-4003.3)
Rev. 1										40-503

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Sheet 2: S2I

4090 (Cont.)			FORM CMS-2552-10							DRAFT
HOSPITAL AND HOSPITAL HEALTH CARE				PROVIDER NO.:		PERIOD:		WORKSHEET S-2																							.													.
COMPLEX IDENTIFICATION DATA						FROM_____________		Part I
				______________		TO________________
Hospital and Hospital Health Care Complex Address:
1	Street:		P.O. Box:							1
2	City:	State:	Zip Code:	County:						2
Hospital and Hospital-Based Component Identification:							Payment System
			Provider	CBSA	Provider	Date	(P, T, O, or N)
	Component	Component Name	Number	Number	Type	Certified	V	XVIII	XIX
	0	1	2	3	4	5	6	7	8
3	Hospital									3
4	Subprovider- IPF									4
5	Subprovider- IRF									5
6	Subprovider- (Other)									6
7	Swing Beds-SNF									7
8	Swing Beds-NF									8
9	Hospital-Based SNF									9
10	Hospital-Based NF									10
11	Hospital-Based OLTC									11
12	Hospital-Based HHA									12
13	Separately Certified ASC									13
14	Hospital-Based Hospice									14
15	Hospital-Based Health Clinic-RHC									15
16	Hospital-Based Health Clinic-FQHC									16
17	Hospital-Based (CMHC)									17
18	Renal Dialysis									18
19	Other									19
20	Cost Reporting Period (mm/dd/yyyy)			From:_______________		To: ______________				20
							1	2
21	Type of Control (see instructions)									21
Inpatient PPS Information
22	Does your facility qualify and is currently receiving disproportionate share hospital payment in accordance with 42 CFR §412.106, or low income payment in accordance with									22
	42 CFR §412.624 (e)(2)? Enter in column 1, "Y" for yes and "N" for no. Is this facility subject to 42 CFR §412.06 (c )(2) (Pickle amendment hospital?)
	Enter in column 2 Y"Y for yes or "N" for no.
23	Which method is used to determine Medicaid days on Worksheet S-3, Part I column 7? Enter in column 1, 1 if it is based on date of admission, 2 if it is based on census days,									23
	or 3 if it is based on date of discharge. Enter in column 2 "Y" for yes or "N" for no.
				In-State	In-State	Out-of State	Out-of State	Medicaid	Other
				Medicaid	Medicaid	Medicaid	Medicaid	HMO	Medicaid
	If line 22 is "yes", and this provider is an IPPS hospital enter the in-state Medicaid paid days in col. 1, in-state			paid days	eligible days	paid days	eligible days	days	days
	Medicaid eligible days in col. 2 out-of-state Medicaid paid days in col. 3, out-of-state Medicaid eligible days			1	2	3	4	5	6
24	in col. 4, Medicaid HMO days in col. 5, and other Medicaid days in col. 6.									24
	If line 22 is "yes", and this provider is an IRF then, enter the in-state Medicaid paid days in col. 1, in-state
	Medicaid eligible days in col. 2, out-of-state Medicaid days in col. 3, out-of state Medicaid eligible days
25	in col. 4 Medicaid HMO days in col. 5 and other Medicaid days in col. 6.									25
26	For standard Geographic classification ( not wage), what is your status at the beginning of the cost reporting period. Enter (1) for urban and (2) for rural.									26
27	For standard Geographic classification ( not wage), what is your status at the end of the cost reporting period. Enter (1) for urban and (2) for rural.									27
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4004.1)
40-504										Rev. 1
DRAFT			FORM CMS-2552-10							4090 (Cont.)
HOSPITAL AND HOSPITAL HEALTH CARE				PROVIDER NO.:		PERIOD:		WORKSHEET S-2
COMPLEX IDENTIFICATION DATA						FROM_____________		Part I (CONT.)
				______________		TO________________
	If this is a sole community hospital (SCH), enter the number of periods SCH status in effect in the C/R period.
35	Enter beginning and ending dates of SCH status on line 36. Subscript line 36 for number of periods in excess of one and enter subsequent dates.									35
36	Enter the applicable SCH dates:			Beginning:_______________		Ending: ______________				36
	If you are a Medicare dependent hospital (MDH), enter the number of periods MDH status in effect in this C/R period.
37	Enter beginning and ending dates of MDH status on line 38. Subscript line 38 for number of periods in excess of one and enter subsequent dates.									37
38	MDH period			Beginning:_______________		Ending: ______________				38
							V	XVIII	XIX
Prospective Payment System (PPS)-Capital							1	2	3
45	Does your facility qualify and receive Capital payment for disproportionate share in accordance with 42 CFR §412.320? (see instructions)									45
46	If you are eligible for the special exceptions payment pursuant to 42 CFR §412.348(g)? If yes, Worksheet L, Part III and L-1, Parts I-III									46
47	Is this a new hospital under 42 CFR §412.300 PPS capital? Enter "Y for yes and "N" for no in column 1.									47
	Are you electing full federal payment? Enter "Y" for yes and "N" for no in col. 2
							V	XVIII	XIX
Teaching Hospitals							1	2	3
55	Is this a teaching hospital? Enter "Y" for yes or "N" for no.									55
56	Is this teaching program approved in accordance with CMS Pub. 15-1, chapter 4?									5
57	If line 56 is yes, was Medicare participation and approved teaching program status in effect during the first month of the cost reporting period?									57
	If yes, complete Worksheet E-4 . If no, complete Worksheet D, Part III & IV D-2, Parts II if applicable.
58	As a teaching hospital, did you elect cost reimbursement for physicians' services as defined									58
	in CMS Pub. 15-I, section 2148? If yes, complete Worksheet D-4.
59	Are you claiming costs on line 100 of Worksheet A? If yes, complete Worksheet D-2, Part I.									59
60	Has your facility direct GME FTE cap (column 1) or IME FTE cap (column 2) been reduced under 42 CFR §413.79(c)(3) or42 CFR §412.105(f)(1)(iv)(B)?									60
	Enter "Y" for yes and "N" for no in the applicable columns (see instructions)
61	Has your facility received additional direct GME FTE resident cap slots or IME FTE residents cap slots under 42 CFR §413.79(c)(4)or 42 CFR §412.105(f)(1)(iv)(C)?									61
	Enter "Y" for yes and "N" for no in the applicable columns (see instructions)
62	Are you claiming nursing and allied health costs? (see instructions)									62
Inpatient Psychiatric Facility PPS
70	Are you an Inpatient Psychiatric Facility (IPF), or are you an IPF Subprovider? Enter in column 1 "Y" for yes and "N" for no.									70
71	If line 70 column 1 is Y, does the facility have a teaching program in the most recent cost report filed on or before November 15, 2004?									71
	Enter in column 1 "Y" for yes or "N" for no. Is this facility training residents in a new teaching program in accordance with 42 CFR §412.424 (d)(1)(iii)(D )?
	Enter in column 2 "Y" for yes and "N" for no.
	If column 2 is Y, enter 1, 2 or 3 respectively in column 3. (see instructions). If the current cost reporting period covers the beginning of the fourth year enter 4 in column 3,
	or if the subsequent academic years of the new teaching program in existence, enter 5 . (see instructions)
Inpatient Rehabilitation Facility PPS
75	Are you an Inpatient Rehabilitation Facility (IRF), or do you contain an IRF subprovider? Enter in column 1 "Y" for yes and "N" for no.									75
76	If line 70 column 1 is Y, does the facility have a teaching program in the most recent cost reporting period ending on or before November 15, 2004?									76
	Enter in column 1 "Y" for yes or "N" for no. Is the facility training residents in a new teaching programs in accordance with 42 CFR § 412.424 (d)(1)(iii)(2)?
	Enter in column 2 "Y" for yes or "N" for no. If column 2 is Y, enter 1, 2 or 3 respectively in column 3. (see instructions). If the current cost reporting period covers
	the beginning of the fourth enter 4 in column 3, or if the subsequent academic years of the teaching program in existence, enter 5. (see instructions)
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4004.1)
Rev. 1										40-505
DRAFT			FORM CMS-2552-10							4090 (Cont.)
HOSPITAL AND HOSPITAL HEALTH CARE				PROVIDER NO.:		PERIOD:		WORKSHEET S-2
COMPLEX IDENTIFICATION DATA						FROM_____________		Part I (CONT.)
				______________		TO________________
Long Term Care Hospital PPS
80	Are you a Long Term Care Hospital (LTCH)? Enter "Y" for yes or "N" for no.									80
TEFRA Providers
85	Is this a new hospital under 42 CFR §413.40(f)(1)(i) TEFRA? Enter "Y" for yes, and "N" for no.									85
86	Have you established a new Other subprovider (excluded unit) under 42 CFR §413.40(f)(1)(ii)? Enter "Y" for yes, and "N" for no.									86
							V	XIX
Title V or XIX Inpatient Services							1	2
90	Do you have title V and XIX inpatient hospital services?									90
91	Is this hospital reimbursed for title V and XIX through the cost report either in full or in part?									91
92	Does the title V and XIX program reduce capital following the Medicare methodology?									92
93	Do you operate an ICF\MR facility for purposes of title V and XIX?									94
94	Does Title XIX reduces Capital Cost? Enter "Y" for yes or "N" for no.									94
95	If line 95 is "Y", by what percentage?									95
96	Does Title XIX reduces Operating Cost? Enter "Y" for yes or "N" for no.									96
97	If line 97 is "Y", by what percentage?									97
Rural Providers
105	Does this hospital qualify as a Critical Access Hospital (CAH)?									105
106	If this facility qualifies as an CAH, has it elected the all-inclusive method of payment for outpatient services? (see instructions)									106
107	If this facility qualifies as a CAH, is it eligible for cost reimbursement for I &R training programs? Enter "Y" for yes and "N" for no. If yes, the GME elimination would not be on									107
	Worksheet B, Part I, column 26 and the program would be cost reimbursed. If yes complete Worksheet D-2, Part II.
	If this facility is a CAH, do I&Rs in an approved medical education program train in the CAH's excluded IPF and/or IRF unit? Enter "Y" for yes or "N" for no in column 2. (see inst.)
108	Is this a rural hospital qualifying for an exception to the CRNA fee schedule? See 42 CFR §412.113(c).									108
						Physical	Occupational	Speech	Respiratory
	If this hospital qualifies as a CAH or a cost provider, are therapy services provided by outside supplier? Enter "Y" for yes, or "N" for no for the type of
109	therapy as follow: physical therapy in column 1, occupational therapy in column 2, speech therapy in column 3 and respiratory therapy in column 4.									109
Miscellaneous Cost Reporting Information
115	Is this an all-inclusive provider? If yes, enter the method used (A, B, or E only) in column 2.									115
116	Are you classified as a referral center?									116
117	Are you legally-required to carry malpractice insurance?									117
118	Is the malpractice a claims-made or occurrence policy? If the policy is claims made enter 1. If the policy is occurrence, enter 2.									118
119	What is the liability limit for the malpractice insurance policy?									119
	Enter in column 1 the monetary limit per lawsuit. Enter in column 2 the monetary limit per policy year.
	Is this a SCH or EACH that qualifies for the Outpatient Hold Harmless provision in PPACA §3121?Enter in column 1 "Y" for yes or "N" for no.
120	Is this a rural hospital with <100 beds which qualifies for the Outpatient Hold Harmless provision in PPACA §3221?. Enter in column 2 "Y" for yes or "N" for no.									120
Transplant Center Information
125	Does this facility operate a transplant center? If yes, enter certification date(s) (mm/dd/yyyy) below.									125
126	If this is a Medicare certified kidney transplant center, enter the certification date in column 1 and termination date if applicable in column 2.									126
127	If this is a Medicare certified heart transplant center, enter the certification date in column 1 and termination date if applicable in column 2.									127
128	If this is a Medicare certified liver transplant center, enter the certification date in column 1 and termination date if applicable in column 2.									128
129	If this is a Medicare certified lung transplant center, enter the certification date in column 1 and termination date if applicable in column 2.									129
130	If this is a Medicare certified pancreas transplant center, enter the certification date in column 1 and termination date if applicable in column 2.									130
131	If this is a Medicare certified intestinal transplant center, enter the certification date in column 1 and termination if applicable in column 2.									131
132	If this is a Medicare certified islet transplant center, enter the certification date in column 1 and termination date if applicable in column 2.									132
133	If this is a Medicare certified other transplant center, enter the certification date in column 1 and termination date if applicable in column 2.									133
134	If this is an organ procurement organization (OPO), enter the OPO number in column 1 and termination date if applicable in column 2.									134
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4004.1)
40-506										Rev. 1
4090 (Cont.)			FORM CMS-2552-10							DRAFT
HOSPITAL AND HOSPITAL HEALTH CARE				PROVIDER NO.:		PERIOD:		WORKSHEET S-2
COMPLEX IDENTIFICATION DATA						FROM_____________		Part I (CONT.)
				______________		TO________________
All Providers
140	Are there any related organization or home office costs as defined in CMS Pub. 15-1, chapter 10? If yes, and there are home office cost, enter in column 2 the home									140
	office chain number. (See instructions.) If this is facility is part of a chain organization enter the name and address of the home office on lines 111-113.
141	Name:			Contractor's Name: ___________________			Contractor's Number: __________			141
142	Street:						P. O. Box			142
143	City:						State:	Zip Code:		143
144	Are provider based physicians' costs included in Worksheet A?									144
145	If you are claiming cost for renal services on Worksheet A, are they inpatient services only?									145
146	Have you changed your cost allocation methodology from the previously filed cost report? See									146
	CMS Pub. 15-2, section 4020. If yes, enter the approval date (mm/dd/yyyy) in column 2.
147	Was there a change in the statistical basis?									147
148	Was there a change in the order of allocation?									148
149	Was the change to the simplified cost finding method?									149
If this facility contains a provider that qualifies for an exemption from the application of the lower of costs or charges, enter "Y" for each component and type of service that qualifies for exemption.
Enter "N" if not exempt in the applicable columns below. (See 42 CFR §413.13.)
								Part A	Part B
								1	2
155	Hospital									155
156	Subprovider - IPF									156
157	Subprovider - IRF									157
158	Subprovider - Other									158
159	SNF									159
160	HHA									160
161	CMHC									161
Multicampus
165	Is this hospital part of a Multicampus hospital that has one or more campuses in different CBSA? Enter "Y" for yes and "N" for no.									165
	If line 165 is yes, enter the name in col. 0, county in column 1, state in column 2, zip in column 3, CBSA in column 4,				County	State	Zip Code	CBSA	FTE/Campus
	FTE/Campus in col. 5.				1	2	3	4	5
166	Name:									166
Health Information Technology incentive in the American Recovery and Reinvestment Act (HIT)
167	Is this provider a meaningful user under §1886 (n)? Enter "Y" for yes or "N" for no.									167
168	If this provider is a CAH, line 105 is "Y" and is a meaningful user, line 167 is "Y" enter the reasonable cost incurred for the HIT assets (see instructions)									168
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4004.1)
Rev. 1										40-507

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Sheet 3: S2II

4090 (Cont.)			FORM CMS-2552-10						DRAFT
HOSPITAL AND HOSPITAL HEALTH CARE				PROVIDER NO.:	PERIOD:		WORKSHEET S-2
REIMBURSEMENT QUESTIONNAIRE					FROM		Part II
					TO
General Instruction: For all column 1 responses enter in column 1, "Y" for Yes or "N" for No
		For all the dates responses the format will be (mm/dd/yyyy)
Completed by All Hospitals, Provider Organization and Operation
						1	2
						Y/N	Date
1	Has the Provider changed ownership immediately prior to the beginning of the cost reporting period?								1
	If column 1 is "Y", enter the date of the change in column 2. (see instructions)
						1	2	3
						Y/N	Date	V/I
2	Has the provider terminated participation in the Medicare Program?								2
	If column 1 is yes enter in column 2 the date of termination and in column 3, "V" for voluntary or "I" for involuntary
3	Is the provider involved in business transactions, including management contracts, with individuals or entities								3
	(e.g., chain home offices, drug or medical supply companies) that are related to the provider or its officers,
	medical staff, management personnel, or members of the board of directors through ownership, control, or
	family and other similar relationships? (see instructions)
Financial Data and Reports
						1	2	3
						Y/N	Type	Date
4	Were the financial statements prepared by a Certified Public Accountant? If column 1 is "Y" enter "A" for Audited,								4
	"C" for Compiled, or "R" for Reviewed in column 2. Submit complete copy or enter date available
	in column 3. (see instructions)If column 1 is "N" see instructions.
5	Are the cost report total expenses and total revenues different from those on the filed financial statements?								5
	If column 1 is "Y", submit reconciliation.
							1	2
Approved Educational Activities							Y/N	Legal Oper.
6	Were costs claimed for Nursing School? If column 1 is "Y", enter "Y" or "N" in column 2 to indicate whether the provider is the								6
	legal operator of the program
7	Were costs claimed for Allied Health Programs? If "Y" see instructions.								7
8	Were approvals and/or renewals obtained during the cost reporting period for Nursing School and/or Allied Health Programs?								8
	If "Y", see instructions.
9	Are Intern-Resident costs claimed on the current cost report? If "Y" see instructions.								9
10	Has an Intern-Resident program been initiated or renewed in the current cost reporting period? If "Y" see instructions.								10
Bad Debts
								1
								Y/N
11	Is the provider seeking reimbursement for bad debts? If "Y", see instructions.								11
12	If line 11 is "Y", did the provider's bad debt collection policy change during this cost reporting period? If "Y", submit copy.								12
13	If line 11 is "Y", are patient deductibles and/or co-payments waived? If "Y", see instructions.								13
Bed Complement
14	Have total beds available changed from prior cost reporting period? If "Y", see instructions.								14
					1	2	3	4
					Y/N	Date	Y/N	Date
PS&R Data					Part A	Part A	Part B	Part B
15	Was the cost report prepared using the PS&R only? If either col. 1 or 3 is "Y", enter the paid through								15
	date of the PS&R used to prepare this cost report in cols. 2 and 4 .(see Instructions.)
16	Was the cost report prepared using the PS&R for total and the provider's records for allocation?								16
	If either col. 1 or 3 is "Y" enter the paid through date in cols. 2 and 4. (see Instructions)
17	If line 15 or 16 is "Y", were adjustments made to PS&R data for additional claims that have been								17
	billed but are not included on the PS&R used to file this cost report? If "Y", see Instructions.
18	If line 15 or 16 is "Y", then were adjustments made to PS&R data for corrections of other								18
	PS&R information? If "Y", see Instructions.
19	If line 15 or 16 is "Y", then were adjustments made to PS&R data for Other?								19
	Describe the other adjustments:		_________________________________
20	Was the cost report prepared only using the provider's records? If "Y" see Instructions.								20
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 4004.2)
40-508									Rev. 1
DRAFT			FORM CMS-2552-10						4090 (Cont.)
HOSPITAL AND HOSPITAL HEALTH CARE				PROVIDER NO.:	PERIOD:		WORKSHEET S-2
REIMBURSEMENT QUESTIONNAIRE					FROM		Part II
					TO
General Instruction: For all column 1 responses enter in column 1, "Y" for Yes or "N" for No
		For all the dates responses the format will be (mm/dd/yyyy)
COMPLETED BY COST REIMBURSED AND TEFRA HOSPITALS ONLY
Capital Related Cost
21	Have assets been relifed for Medicare purposes? If "Y" see instructions								21
22	Have changes occurred in the Medicare depreciation expense due to appraisals made during the cost reporting period?								22
	If "Y", see instructions.
23	Were new leases and/or amendments to existing leases entered into during this cost reporting period? If "Y", see instructions								23
24	Have there been new capitalized leases entered into during the cost reporting period? If "Y" see instructions.								24
25	Were assets subject to Sec.2314 of DEFRA acquired during the cost reporting period? If "Y", see instructions.								25
26	Has the provider's capitalization policy changed during the cost reporting period? If "Y", submit copy.								26
Interest Expense
27	Were new loans, mortgage agreements or letters of credit entered into during the cost reporting period? If "Y", see instructions.								27
28	Does the provider have a funded depreciation account and/or bond funds (Debt Service Reserve Fund) treated as a funded depreciation								28
	account? If "Y" see instructions
29	Has existing debt been replaced prior to its scheduled maturity with new debt? If "Y" see instructions.								29
30	Has debt been recalled before scheduled maturity without issuance of new debt? If "Y" see instructions.								30
Purchased Services
31	Have changes or new agreements occurred in patient care services furnished through contractual arrangements with suppliers of services?								31
	If "Y" see instructions.
32	If line 31 is "Y", were the requirements of Sec. 2135.2 applied pertaining to competitive bidding?.								32
	If "N" see instructions.
33	Are GME costs directly assigned to cost centers other than I/R Services in an Approved Teaching Program on Worksheet A?								33
	If "Y", see instructions.
Provider-Based Physicians
34	Are services furnished at the provider facility under an arrangement with provider-based physicians? If "Y" see instructions.								34
35	If line 34 is "Y", are there new agreements or amended existing agreements with the provider-based physicians during the cost								35
	reporting period? If "Y" (see instructions)
							1	2
Home Office Costs							Y/N	Date
36	Are Home Office Cost claimed on the cost report?								36
37	If line 36 is "Y", has a home office cost statement been prepared by the home office? If "Y" see instructions.								37
38	If line 36 "Y", is the fiscal year end of the home office different from that of the provider?								38
	If column 1 is "Y", enter in column 2 the fiscal year end of the home office.
39	If line 36 is "Y", does the provider render services to other chain components? If "Y" see instructions.								39
40	If line 36 is "Y", does the provider render services to the home office? If "Y" see instructions.								40
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 4004.2)
Rev. 1									40-509

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Sheet 4: S3I

4090 (Cont.)						FORM CMS-2552-10											DRAFT
HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX									PROVIDER NO.:			PERIOD			WORKSHEET S-3,
STATISTICAL DATA												FROM ____________			PART I
									____________________			TO _______________
						I/P Days / O/P Visits / Trips				Full Time Equivalents			Discharges
		Worksheet
		A							Total	Total	Employees					Total
		Line	No. of	Bed Days	CAH		Title	Title	All	Interns &	On	Nonpaid		Title	Title	All
	Component	Number	Beds	Available	Hours	Title V	XVIII	XIX	Patients	Residents	Payroll	Workers	Title V	XVIII	XIX	Patients
		1	2	3	4	5	6	7	8	9	10	11	12	13	14	15
1	Hospital Adults & Peds. (columns 5,																1
	6, 7 and 8 exclude Swing Bed,
	Observation Bed and Hospice days)
2	HMO																2
3	HMO IPF																3
4	HMO IRF																4
5	Hospital Adults & Peds. Swing Bed SNF																5
6	Hospital Adults & Peds.Swing Bed NF																6
7	Total Adults and Peds. (exclude																7
	observation beds) (see instructions)
8	Intensive Care Unit																8
9	Coronary Care Unit																9
10	Burn Intensive Care Unit																10
11	Surgical Intensive Care Unit																11
12	Other Special Care																12
13	Nursery																13
14	Total (see instructions)																14
15	CAH visits																15
16	Subprovider - IPF																16
17	Subprovider - IRF																17
18	Subprovider - Other																18
19	Skilled Nursing Facility																19
20	Nursing Facility																20
21	Other Long Term Care																21
22	Home Health Agency																22
23	ASC (Distinct Part)																23
24	Hospice (Distinct Part)																24
25	CMHC																25
26	RHC/FQHC (specify)																26
27	Total (sum of lines 14-26)																27
28	Observation Bed Days																28
29	Ambulance Trips																29
30	Employee discount days (see instruction)																30
31	Employee discount days -IRF																31
32	Labor & delivery days (see instructions)																32
33	LTCH non-covered days																33
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4005.1)
40-510																	Rev. 1
4090 (Cont.)						FORM CMS-2552-10											DRAFT
					This page is reserved for future use
Rev. 1																	40-511

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Sheet 5: S3II &III

4090 (Cont.)			FORM CMS-2552-10					DRAFT
HOSPITAL WAGE INDEX INFORMATION			PROVIDER NO.:		PERIOD:		WORKSHEET S-3,
					FROM __________		PART II
			______________		TO _____________
PART II - WAGE DATA
		Worksheet		Reclass.	Adjusted	Paid Hours	Average
		A		of Salaries	Salaries	Related	Hourly Wage
		Line	Amount	(from	(col. 2 ±	to Salaries	(col. 4 ÷
		Number	Reported	Wkst. A-6)	col. 3)	in col. 4	col. 5)
		1	2	3	4	5	6
	SALARIES
1	Total salaries (see instructions)							1
2	Non-physician anesthetist Part A							2
3	Non-physician anesthetist Part B							3
4	Physician-Part A							4
5	Physician-Part B							5
6	Non-physician-Part B							6
7	Interns & residents (in an approved program)							7
8	Home office personnel							8
9	SNF							9
10	Excluded area salaries (see instructions)							10
	OTHER WAGES & RELATED COSTS
11	Contract labor (see instructions)							11
12	Management and administrative services							12
13	Contract labor: physician-Part A							13
14	Home office salaries & wage-related costs							14
15	Home office: physician Part A							15
16	Teaching physician salaries (see instructions)							16
	WAGE-RELATED COSTS
17	Wage-related costs (core) Wkst S-3, Part IV line 24							17
18	Wage-related costs (other)Wkst S-3, Part IV line 25							18
19	Excluded areas							19
20	Non-physician anesthetist Part A							20
21	Non-physician anesthetist Part B							21
22	Physician Part A							22
23	Physician Part B							23
24	Wage-related costs (RHC/FQHC)							24
25	Interns & residents (in an approved program)							25
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4005.2 - 4005.3)
46-512								Rev. 1
DRAFT			FORM CMS-2552-10					4090 (Cont.)
HOSPITAL WAGE INDEX INFORMATION			PROVIDER NO.:		PERIOD:		WORKSHEET S-3,
					FROM __________		PART II & III
			______________		TO _____________
PART II - WAGE DATA
		Worksheet		Reclass.	Adjusted	Paid Hours	Average
		A		of Salaries	Salaries	Related	Hourly Wage
		Line	Amount	(from	(col. 2 ±	to Salaries	(col. 4 ÷
		Number	Reported	Wkst. A-6)	col. 3)	in col. 4	col. 5)
		1	2	3	4	5	6
	OVERHEAD COSTS - DIRECT SALARIES
26	Employee Benefits							26
27	Administrative & General							27
28	Administrative & General under contract (see inst.)							28
29	Maintenance & Repairs							29
30	Operation of Plant							30
31	Laundry & Linen Service							31
32	Housekeeping							32
33	Housekeeping under contract (see instructions)							33
34	Dietary							34
35	Dietary under contract (see instructions)							35
36	Cafeteria							36
37	Maintenance of Personnel							37
38	Nursing Administration							38
39	Central Services and Supply							39
40	Pharmacy							40
41	Medical Records & Medical Records Library							41
42	Social Service							42
43	Other General Service							43
PART III - HOSPITAL WAGE INDEX SUMMARY
1	Net salaries (see instructions)							1
2	Excluded area salaries (see instructions)							2
3	Subtotal salaries (line 1 minus line 2)							3
4	Subtotal other wages & related costs (see inst.)							4
5	Subtotal wage-related costs (see inst.)							5
6	Total (sum of lines 3 thru 5)							6
7	Total overhead cost (see instructions							7
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4005.2 - 4005.3)
Rev. 1								40-513

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Sheet 6: S3IV

4090 (Cont.)			FORM CMS-2552-10					DRAFT
HOSPITAL WAGE RELATED COSTS			PROVIDER NO.:		PERIOD:		WORKSHEET S-3,
					FROM __________		PART IV
			______________		TO _____________
PART IV - Wage Related Cost
Part A - Core List
							Amount
							Reported
	RETIREMENT COST
1	401K Employer Contributions							1
2	Tax Sheltered Annuity (TSA) Employer Contribution							2
3	Qualified and Non-Qualified Pension Plan Cost							3
4	Prior Year Pension Service Cost							4
	PLAN ADMINISTRATIVE COSTS (Paid to External Organization):
5	401K/TSA Plan Administration fees							5
6	Legal/Accounting/Management Fees-Pension Plan							6
7	Employee Managed Care Program Administration Fees							7
	HEALTH AND INSURANCE COST
8	Health Insurance (Purchased or Self Funded)							8
9	Prescription Drug Plan							9
10	Dental, Hearing and Vision Plan							10
11	Life Insurance (If employee is owner or beneficiary)							11
12	Accidental Insurance (If employee is owner or beneficiary)							12
13	Disability Insurance (If employee is owner or beneficiary)							13
14	Long-Term Care Insurance (If employee is owner or beneficiary)							14
15	Workers' Compensation Insurance							15
16	Retirement Health Care Cost (Only current year, not the extraordinary accrual required by FASB 106. Non cumulative portion)							16
	TAXES
17	FICA-Employers Portion Only							17
18	Medicare Taxes - Employers Portion Only							18
19	Unemployment Insurance							19
20	State or Federal Unemployment Taxes							20
	OTHER
21	Executive Deferred Compensation							21
22	Day Care Cost and Allowances							22
23	Tuition Reimbursement							23
24	Total Wage Related cost (Sum of lines 1 -23)							24
Part B Other than Core Related Cost
25	Other Wage Related Costs (specify)_________________________________________							25
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4005.4)
40-514								Rev. 1

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Sheet 7: S3V

DRAFT		FORM CMS-2552-10				4090 (Cont.)
HOSPITAL CONTRACT LABOR AND BENEFIT COST			PROVIDER NO.:	PERIOD:	WORKSHEET S-3,
				FROM __________	PART V
			______________	TO _____________
PART V - Contract Labor and Benefit Cost
Hospital and Hospital-Based Component Identification:
			Provider	Contract	Benefit
	Component	Component Name	Number	Labor	Cost
	0	1	2	3	4
1	Total facility's contract labor and benefit cost					1
2	Hospital					2
3	Subprovider- IPF					3
4	Subprovider- IRF					4
5	Subprovider- (Other)					5
6	Swing Beds-SNF					6
7	Swing Beds-NF					7
8	Hospital-Based SNF					8
9	Hospital-Based NF					9
10	Hospital-Based OLTC					10
11	Hospital-Based HHA					11
12	Separately Certified ASC					12
13	Hospital-Based Hospice					13
14	Hospital-Based Health Clinic RHC					14
15	Hospital-Based Health Clinic FQHC					15
16	Hospital-Based-CMHC					16
17	Renal Dialysis					17
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4005.5)
Rev. 1						40-515

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Sheet 8: S4

4090 (Cont.)					FORM CMS-2552-10							DRAFT
HOSPITAL-BASED HOME HEALTH AGENCY						PROVIDER NO.:		PERIOD:		WORKSHEET S-4																{APP4}IALLWAYS~/PCOPB1~Q/PGQ/1
STATISTICAL DATA						_______________		FROM ____________
						HHA NO.:		TO _______________
						_______________
	HOME HEALTH AGENCY STATISTICAL DATA							County: __________________
							Title	Title	Title
	DESCRIPTION						V	XVIII	XIX	Other	Total
							1	2	3	4	5
1	Home Health Aide Hours											1
2	Unduplicated Census Count (see instructions)											2
	HOME HEALTH AGENCY - NUMBER OF EMPLOYEES
	(FULL TIME EQUIVALENT)
	Enter the number of hours in
	your normal work week _______								Staff	Contract	Total
									1	2	3
3	Administrator and Assistant Administrator(s)											3
4	Directors and Assistant Director(s)											4
5	Other Administrative Personnel											5
6	Direct Nursing Service											6
7	Nursing Supervisor											7
8	Physical Therapy Service											8
9	Physical Therapy Supervisor											9
10	Occupational Therapy Service											10
11	Occupational Therapy Supervisor											11
12	Speech Pathology Service											12
13	Speech Pathology Supervisor											13
14	Medical Social Service											14
15	Medical Social Service Supervisor											15
16	Home Health Aide											16
17	Home Health Aide Supervisor											17
18	Other (specify)											18
	HOME HEALTH AGENCY CBSA CODES
											1
19	How many CBSAs in column 1 did you provide services to during this cost reporting period.											19
20	List those CBSA code(s) in column 1 serviced during this cost reporting period (line 20 contains the first code).											20
	PPS ACTIVITY DATA
							Full Episodes
							Without	With	LUPA	PEP only	Total
							Outliers	Outliers	Episodes	Episodes	(cols. 1-4)
							1	2	3	4	5
21	Skilled Nursing Visits											21
22	Skilled Nursing Visit Charges											22
23	Physical Therapy Visits											23
24	Physical Therapy Visit Charges											24
25	Occupational Therapy Visits											25
26	Occupational Therapy Visit Charges											26
27	Speech Pathology Visits											27
28	Speech Pathology Visit Charges											28
29	Medical Social Service Visits											29
30	Medical Social Service Visit Charges											30
31	Home Health Aide Visits											31
32	Home Health Aide Visit Charges											32
33	Total visits (sum of lines 21, 23, 25, 27, 29, and 31)											33
34	Other Charges											34
35	Total Charges (sum of lines 22, 24, 26, 28, 30, 32, and 34)											35
36	Total Number of Episodes (standard/non outlier)											36
37	Total Number of Outlier Episodes											37
38	Total Non-Routine Medical Supply Charges											38
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4006)
40-516												Rev. 1

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Sheet 9: S5

DRAFT			FORM CMS-2552-10						4090 (Cont.)
HOSPITAL RENAL DIALYSIS DEPARTMENT				PROVIDER NO.:		PERIOD:		WORKSHEET S-5																																																																																																	{APP4}IALLWAYS~/PCOPB1~Q/PGQ/1
STATISTICAL DATA				________________		FROM ___________
						TO ______________
	RENAL DIALYSIS STATISTICS
			Outpatient		Training		Home
					Hemo-	CAPD	Hemo-	CAPD
		DESCRIPTION	Regular	High Flux	dialysis	CCPD	dialysis	CCPD
			1	2	3	4	5	6
1	Number of patients in program at								1
	end of cost reporting period
2	Number of times per week patient								2
	receives dialysis
3	Average patient dialysis time including setup								3
4	CAPD exchanges per day								4
5	Number of days in year dialysis furnished								5
6	Number of stations								6
7	Treatment capacity per day per station								7
8	Utilization (see instructions)								8
9	Average times dialyzers re-used								9
10	Percentage of patients re-using dialyzers								10
	TRANSPLANT INFORMATION
11	Number of patients on transplant list								11
12	Number of patients transplanted during the cost reporting period								12
	EPOETIN
13	Net costs of Epoetin furnished to all maintenance dialysis patients by the provider.								13
14	Epoetin amount from Worksheet A for Home Dialysis program								14
15	Number of EPO units furnished relating to the renal dialysis department								15
16	Number of EPO units furnished relating to the home dialysis department								16
	ARANESP
17	Net costs of ARANESP furnished to all maintenance dialysis patients by the provider.								17
18	ARANESP amount from Worksheet A for Home Dialysis program								18
19	Number of ARANESP units furnished relating to the renal dialysis department								19
20	Number of ARANESP units furnished relating to the home dialysis department								20
	PHYSICIAN PAYMENT METHOD (enter "X" if method(s) is applicable)
21	MCP_________		INITIAL METHOD__________						21
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4007)
Rev. 1									40-517

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Sheet 10: S6

4090 (Cont.)		FORM CMS-2552-10					DRAFT
HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND				PROVIDER NO.:	PERIOD:	WORKSHEET S-6																								.
OTHER OUTPATIENT REHABILITATION				_______________	FROM__________
PROVIDER STATISTICAL DATA				COMPONENT NO.:	TO_____________
				_______________
COMMUNITY MENTAL HEALTH & OTHER OUTPATIENT REHABILITATION PROVIDER- NUMBER OF EMPLOYEES (FULL TIME EQUIVALENT)
Check		[ ] CMHC [ ] OOT
Applicable		[ ] CORF [ ] OSP
Box		[ ] OPT
Enter the number of hours in your normal workweek ________
						Total
				Staff	Contract	(col. 1 + col. 2)
				1	2	3
1	Administrator and Assistant Administrator(s)						1
2	Director(s) and Assistant Director(s)						2
3	Other Administrative Personnel						3
4	Direct Nursing Service						4
5	Nursing Supervisor						5
6	Physical Therapy Service						6
7	Physical Therapy Supervisor						7
8	Occupational Therapy Service						8
9	Occupational Therapy Supervisor						9
10	Speech Pathology Service						10
11	Speech Pathology Supervisor						11
12	Medical Social Service						12
13	Medical Social Service Supervisor						13
14	Respiratory Therapy Service						14
15	Respiratory Therapy Supervisor						15
16	Psychiatric/Psychological Service						16
17	Psychiatric/Psychological Service Supervisor						17
18	Other (specify)						18
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4008)
40-518							Rev. 1

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Sheet 11: S7

DRAFT				FORM CMS-2552-10								4090 (Cont.)
PROSPECTIVE PAYMENT FOR SNF					PROVIDER NO.:			PERIOD:			WORKSHEET S-7
STATISTICAL DATA								FROM ____________
					________________			TO _______________
	If this facility contains a hospital-based SNF, are all patients are under managed care or there was no
1	Medicare utilization enter "Y" and do not complete the rest of this worksheet.											1
	Does this hospital have an agreement under either section 1883 or section 1913 for swing
2	beds? If yes, enter the agreement date (mm/dd/yyyy) in column 2.											2
									SNF	Swing Bed SNF	TOTAL
				GROUP					Days	Days	(sum of col. 2 + 3)
				1					2	3	4
3	RUC											3
4	RUB											4
5	RUA											5
6	RUX											6
7	RUL											7
8	RVC											8
9	RVB											9
10	RVA											10
11	RVX											11
12	RVL											12
13	RHC											13
14	RHB											14
15	RHA											15
16	RHX											16
17	RHL											17
18	RMC											18
19	RMB											19
20	RMA											20
21	RMX											21
22	RML											22
23	RLB											23
24	RLA											24
25	RLX											25
26	SE3											26
27	SE2											27
28	SE1											28
29	SSC											29
30	SSB											30
31	SSA											31
32	CC2											32
33	CC1											33
34	CB2											34
35	CB1											35
36	CA2											36
37	CA1											37
38	IB2											38
39	IB1											39
40	IA2											40
41	IA1											41
42	BB2											42
43	BB1											43
44	BA2											44
45	BA1											45
46	PE2											46
47	PE1											47
48	PD2											48
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4009)
Rev. 1												40-519
4090 (Cont.)				FORM CMS-2552-10								DRAFT
PROSPECTIVE PAYMENT FOR SNF					PROVIDER NO.:			PERIOD:			WORKSHEET S-7
STATISTICAL DATA								FROM ____________
					________________			TO _______________
									SNF	Swing Bed SNF	TOTAL
				GROUP					Days	Days	(sum of col. 2 + 3)
				1					2	3	4
49	PD1											49
50	PC2											50
51	PC1											51
52	PB2											52
53	PB1											53
54	PA2											54
55	PA1											55
56	Default rate											56
57	TOTAL											57
SNF SERVICES
	Enter in column 1 the SNF CBSA code or 5 character code if Rural based facility, in effect at the beginning of the cost
58	reporting period. Enter in column 2, the code in effect on or after October 1, of the cost reporting period (if applicable).											58
	A notice published in the "Federal Register" Vol. 68, No. 149 August 4, 2003 provided for an increase in the RUG payments beginning 10/01/2003. Congress
	expected this increase to be used for direct patient care and related expenses. Enter in column 1 the amount of the expense for each category. Enter in
	column 2 the percentage of total expenses for each category to total SNF revenue from Worksheet G-2, Part I, line 6, column 3. Indicate in column 3 "Y"
	for yes or "N" for no if the spending reflects increases associated with direct patient care and related expenses for each category. (See instructions)
									Expenses	Percentage	Y/N
59	Staffing											59
60	Recruitment											60
61	Retention of employees											61
62	Training											62
63	Other (Specify)											63
64	Total SNF revenue (Worksheet G-2, Part I, line 6, column 3)											64
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4009)
40-520												Rev. 1

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Sheet 12: S8

DRAFT		FORM CMS-2552-10																4090 (Cont.)
PROVIDER-BASED RURAL HEALTH CLINIC/									PROVIDER NO.:				PERIOD:			WORKSHEET S-8
FEDERALLY QUALIFIED HEALTH CENTER									_____________				FROM________
PROVIDER STATISTICAL DATA									COMPONENT NO.:				TO___________
									_____________
Check			[ ] RHC
Applicable Box:			[ ] FQHC
Clinic Address and Identification:
1	Street:																	1
2	City:			State:			Zip Code:				County:							2
3	Designation (for FQHCs only) - Enter "R" for rural or "U" for urban																	3
Source of Federal Funds:												Grant Award				Date
												1				2
4	Community Health Center (Section 330(d), PHS Act)																	4
5	Migrant Health Center (Section 329(d), PHS Act)																	5
6	Health Services for the Homeless (Section 340(d), PHS Act)																	6
7	Appalachian Regional Commission																	7
8	Look-Alikes																	8
9	Other (specify)																	9
10	Does this facility operate as other than an RHC or FQHC? Enter "Y" for yes and "N" for no in column 1. If yes, indicate number of																	10
	other operations in column 2.(Enter in subscripts of line 12 the type of other operation(s) and the operating hours.)
Facility hours of operations (1)
				Sunday		Monday		Tuesday		Wednesday		Thursday		Friday		Saturday
	Type Operation			from	to	from	to	from	to	from	to	from	to	from	to	from	to
	0			1	2	3	4	5	6	7	8	9	10	11	12	13	14
11	Clinic																	11
(1) Enter clinic hours of operation on line 13 and other type operations on subscripts of line 13 (both type and hours of operation).
List hours of operation based on a 24 hour clock. For example: 8:00am is 0800, 6:30pm is 1830, and midnight is 2400.
12	Have you received an approval for an exception to the productivity standard?																	12
13	Is this a consolidated cost report as defined in CMS Pub. 27, section 508(D)? If yes, enter in column 2 the																	13
	number of providers included in this report. List the names of all providers and numbers below.
14	Provider name: _______________________________________________										CCN number: ________________							14
														1	2	3	4
														Y/N	V	XVIII	XIX
	Have you provided all or substantially all GME costs. Enter in column 1 ,"Y" for yes and "N" for no col. 1.
15	If yes, enter in col. 2, 3 and 4 the number of program visits performed by Intern & Residents. (See instructions)																	15
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4010)
Rev. 1																		40-521

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Sheet 13: S9

4090 (Cont.)			FORM CMS-2552-10					DRAFT
HOSPICE IDENTIFICATION DATA			PROVIDER NO.:__________		PERIOD:		WORKSHEET S-9,
					FROM _____________		PARTS I & II
			HOSPICE NO.:___________		TO ________________
PART I - ENROLLMENT DAYS
		Unduplicated Days
				Title XVIII
				Skilled	Title XIX		Total
				Nursing	Nursing	All	(sum of
	Enrollment Days	Title XVIII	Title XIX	Facility	Facility	Other	cols. 1, 2 & 5)
		1	2	3	4	5	6
1	Continuous Home Care							1
2	Routine Home Care							2
3	Inpatient Respite Care							3
4	General Inpatient Care							4
5	Total Hospice Days							5
PART II - CENSUS DATA
				Title XVIII
				Skilled	Title XIX		Total
				Nursing	Nursing	All	(sum of
		Title XVIII	Title XIX	Facility	Facility	Other	cols. 1, 2 & 5)
		1	2	3	4	5	6
6	Number of Patients Receiving Hospice Care							6
7	Total Number of Unduplicated Continuous							7
	Care Hours Billable to Medicare
8	Average Length of Stay (line 5/line 6)							8
9	Unduplicated Census Count							9
NOTE: Parts I & II, columns 1 and 2 also include the days reported in columns 3 and 4 .
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 4011)
40-522								Rev. 1

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Sheet 14: S10

DRAFT		FORM CMS-2552-10						4090 (Cont.)
HOSPITAL UNCOMPENSATED AND INDIGENT				PROVIDER NO.:	PERIOD:		WORKSHEET S-10
CARE DATA					FROM_____________
				______________	TO________________
Uncompensated and indigent care cost computation							1
1	Cost to charge ratio (Worksheet C, Part I line 200 column 3 divided by line 200 column 8)							1
Medicaid (see instructions for each line)
2	Net revenue from Medicaid							2
3	Did you receive DSH or supplemental payments from Medicaid?							3
4	If line 3 is "yes", does line 2 include all DSH or supplemental payments from Medicaid?							4
5	If line 4 is "no", then enter DSH or supplemental payments from Medicaid							5
6	Medicaid charges							6
7	Medicaid cost (line 1 times line 6)							7
8	Difference between net revenue and costs for Medicaid program (line 2 plus line 5 minus line 7)							8
State Children's Health Insurance Program (SCHIP) (see instructions for each line)
9	Net revenue from stand-alone SCHIP							9
10	Stand-alone SCHIP charges							10
11	Stand-alone SCHIP cost (line 1 times line 10)							11
12	Difference between net revenue and costs for stand-alone SCHIP (line 9 minus line 11)							12
Other state or local government indigent care program (see instructions for each line)
13	Net revenue from state or local indigent care program (Not included on lines 2, 5 or 9)							13
14	Charges for patients covered under state or local indigent care program (Not included in lines 6 or 10)							14
15	State or local indigent care program cost (line 1 times line 14)							15
16	Difference between net revenue and costs for state or local indigent care program (line 13 minus line 15)							16
Uncompensated care (see instructions for each line)
17	Private grants, donations, or endowment income restricted to funding charity care							17
18	Government grants, appropriations or transfers for support of hospital operations							18
19	Total unreimbursed cost for Medicaid , SCHIP and state and local indigent care programs (sum of lines 8, 12 and 16)							19
					Uninsured	Insured	Total
					patients	patients	(col. 1 + col. 2)
					1	2	3
20	Total initial obligation of patients approved for charity care (at full charges excluding							20
	non-reimbursable cost centers) for the entire facility
21	Cost of initial obligation of patients approved for charity care (line 1 times line 20)							21
22	Partial payment by patients approved for charity care							22
23	Cost of charity care (line 21 minus line 22)							23
							1
	Does the amount in line 20 column 2 include charges for patient days beyond a length of stay limit imposed on
24	patients covered by Medicaid or other indigent care program?							24
25	If line 24 is "yes," charges for patient days beyond an indigent care program's length of stay limit							25
26	Total bad debt expense for the entire facility (see instructions)							26
27	Medicare bad debts for §1886(d) hospitals fromWorksheets E, Part A and E, Part B, or CAHs from Worksheet E-3, Part V.							27
28	Non-Medicare and Non-Reimbursable bad debt expense (line 26 minus line 27)							28
29	Cost of non-Medicare bad debt expense (line 1 times line 28)							29
30	Cost of non-Medicare uncompensated care (line 23 column 3 plus line 29)							30
31	Total unreimbursed and uncompensated care cost (line 19 plus line 30)							31
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4012)
Rev. 1								40-523