Form 2552-10 Hospital and Health Care Complex Cost Report

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Overview

S
S2I
S2II
S3I
S3II &III
S3IV
S3V
S4
S5
S6
S7
S8
S9
S10
S-11PI
S-11PII
S-11PIII
A
A6
A7I, II &III
A8
A81
A82
A83
BI
BII
B1
B2
CI
CII
DI
DII
DIII
DIV
DV
D1I
D1II
D1III
D2
D3
D4I
D4II
D4III
D5I
D5II
D5III
D5IV
D6I
D6III
EA
EB
E1
E1II
E2
E3I
E3II
E3III
E3IV
E3V
E3VI
E3VII
E4
E5
E-90
E-95
G
G1
G2
G3
H
H1I
H1II
H2I
H2II
H3
H4
H5
I1
I2
I3
I4
I5
J1I
J1II
J2I
J2II
J3
J4
K
K1
K2
K3
K4I
K4II
K5I
K5II
K5III
K6
L
L1I
L1II
L1III
M1
M2
M3
M4
M5
N1
N2
N3
N4
N5
O
O1
O2
O3
O4
O5
O6I
O6II
O7
O8

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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
									EXPIRES 09-30-2025
HOSPITAL AND HOSPITAL HEALTH CARE							PROVIDER CCN:	PERIOD	WORKSHEET S
COMPLEX COST REPORT CERTIFICATION							______________	FROM __________	PARTS I, II & III
AND SETTLEMENT SUMMARY								TO _____________
PART I - COST REPORT STATUS
Provider use only			1. [ ] Electronically prepared cost report			Date: __________	Time: __________
			2. [ ] Manually prepared cost report
			3. [ ] If this is an amended report enter the number of times the provider resubmitted this cost report
			4. [ ] Medicare Utilization. Enter "F" for full, "L" for low, or "N" for no.
Contractor		5. [ ] Cost Report Status			6. Date Received:_________		10. NPR Date:__________
use only		(1) As Submitted			7. Contractor No.:________		11. Contractor's Vendor Code: ___________
		(2) Settled without audit			8. [ ] Initial Report for this Provider CCN		12. [ ] If line 5, column 1, is 4: Enter number of
		(3) Settled with audit			9. [ ] Final Report for this Provider CCN		times reopened = 0-9.
		(4) Reopened
		(5) Amended
PART II - CERTIFICATION BY A CHIEF FINANCIAL OFFICER OR ADMINISTRATOR OF PROVIDER(S)
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 CHIEF FINANCIAL OFFICER OR ADMINISTRATOR OF PROVIDER(S)
	I HEREBY CERTIFY that I have read the above certification statement and that I have examined the accompanying electronically filed or manually submitted cost report and
	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, this report and statement are true, correct,
	complete and 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, and that the services identified in this cost report were provided in compliance with such laws
	and regulations.
	SIGNATURE OF CHIEF FINANCIAL OFFICER OR ADMINISTRATOR					CHECKBOX	ELECTRONIC
	1					2	SIGNATURE STATEMENT
1							I have read and agree with the above certification statement. I certify that I intend my electronic signature on this certification be the legally binding equivalent of my original signature.			1
2	Signatory Printed Name:									2
3	Signatory Title:									3
4	Signature date:									4
PART III - SETTLEMENT SUMMARY
					TITLE V	TITLE XVIII
						PART A	PART B	HIT	TITLE XIX
					1	2	3	4	5
1	HOSPITAL									1
1.01	HOSPITAL-PARHM									1.01
2	SUBPROVIDER - IPF									2
3	SUBPROVIDER - IRF									3
4	SUBPROVIDER (OTHER)									4
5	SWING-BED SNF									5
5.01	SWING-BED PARHM (CAH ONLY)									5.01
6	SWING-BED NF									6
7	SNF									7
8	NF, ICF/IID									8
9	HOME HEALTH AGENCY									9
10	HOSPITAL-BASED RHC									10
11	HOSPITAL-BASED 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.
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTIONS 4003.1 - 4003.3)
Rev.										40-503

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Sheet 2: S2I

4090 (Cont.)					FORM CMS-2552-10							DRAFT
HOSPITAL AND HOSPITAL HEALTH CARE									PROVIDER CCN:	PERIOD	WORKSHEET S-2
COMPLEX IDENTIFICATION DATA									______________	FROM __________	PART I
										TO _____________
PART I - HOSPITAL AND HOSPITAL HEALTHCARE COMPLEX INDENTIFICATION DATA
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:
				Component	CCN	CBSA	Provider	Date		Payment System (P, T, O, or N)
	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, CORF and OPT)											17
18	Renal Dialysis											18
19	Other											19
20	Cost Reporting Period (mm/dd/yyyy)			From:_______________	To: ______________							20
21	Type of control (see instructions)											21
Inpatient PPS Information									1	2	3
22	Does this facility qualify and is it currently receiving payments for disproportionate share hospital adjustment, in accordance with 42 CFR 412.106? In column 1, enter "Y" for yes or "N" for no.											22
	Is this facility subject to 42 CFR 412.106 (c)(2) (Pickle amendment hospital)? In column 2, enter "Y" for yes or "N" for no.
22.01	Did this hospital receive interim UCPs, including supplemental UCPs, for this cost reporting period? Enter in column 1, "Y" for yes or "N" for no for the portion of the cost reporting period occurring prior to October 1.											22.01
	Enter in column 2, "Y" for yes or "N" for no for the portion of the cost reporting period occurring on or after October 1. (see instructions)
22.02	Is this a newly merged hospital that requires a final UCP to be determined at cost report settlement? (see instructions) Enter in column 1, “Y” for yes or “N” for no,											22.02
	for the portion of the cost reporting period prior to October 1. Enter in column 2, “Y” for yes or “N” for no, for the portion of the cost reporting period on or after October 1.
22.03	Did this hospital receive a geographic redesignation from urban to rural as a result of the OMB standards for delineating statistical areas adopted by CMS? Enter in column 1, “Y” for yes or											22.03
	“N” for no for the portion of the cost reporting period prior to October 1. Enter in column 2, "Y" for yes or "N" for no for the portion of the cost reporting period occurring on or after October 1. (see instructions)
	Does this hospital contain at least 100 but not more than 499 beds (as counted in accordance with 42 CFR 412.105)? Enter in column 3, “Y” for yes or “N” for no.
22.04	Did this hospital receive a geographic reclassification from urban to rural as a result of the revised OMB delineations for statistical areas adopted by CMS in FY 2021? Enter in column 1, “Y” for yes or “N” for											22.04
	no for the portion of the cost reporting period prior to October 1. Enter in column 2, "Y" for yes or "N" for no for the portion of the cost reporting period occurring on or after October 1. (see instructions)
	Does this hospital contain at least 100 but not more than 499 beds (as counted in accordance with 42 CFR 412.105)? Enter in column 3, “Y” for yes or “N” for no.
23	Which method is used to determine Medicaid days on lines 24 and/or 25 below? In column 1, enter 1 if date of admission, 2 if census days, or 3 if date of discharge.											23
	Is the method of identifying the days in this cost reporting period different from the method used in the prior cost reporting period? In column 2, enter "Y" for yes or "N" for no.
						In-State	In-State	Out-of State	Out-of State	Medicaid	Other
						Medicaid	Medicaid eligible	Medicaid	Medicaid eligible	HMO	Medicaid
						paid days	unpaid days	paid days	unpaid days	days	days
						1	2	3	4	5	6
24	If this provider is an IPPS hospital, enter the in-state Medicaid paid days in column 1, in-state Medicaid unpaid days in column 2, out-of-state											24
	Medicaid paid days in column 3, out-of-state Medicaid eligible unpaid days in column 4, Medicaid HMO paid and eligible but unpaid days in
	column 5, and other Medicaid days in column 6.
25	If this provider is an IRF, enter the in-state Medicaid paid days in column 1, in-state Medicaid eligible unpaid days in column 2, out-of-state											25
	Medicaid paid days in column 3, out-of state Medicaid eligible unpaid days in column 4 Medicaid HMO paid and eligible but unpaid days in column 5.
									1	2	3
26	Enter your standard geographic classification (not wage) status at the beginning of the cost reporting period. Enter "1" for urban or "2" for rural.											26
27	Enter your standard geographic classification (not wage) status at the end of the cost reporting period. Enter in column 1, "1" for urban or "2" for rural.											27
	If applicable, enter the effective date of the geographic reclassification in column 2.
35	If this is a sole community hospital (SCH), enter the number of periods SCH status in effect in the cost reporting period.											35
36	Enter applicable beginning and ending dates of SCH status. Subscript line 36 for number of periods in excess of one and enter subsequent dates.								Beginning:_______________	Ending: ______________		36
37	If this is a Medicare dependent hospital (MDH), enter the number of periods MDH status is in effect in the cost reporting period.											37
37.01	Is this hospital a former MDH that is eligible for the MDH transitional payment in accordance with the FY 2016 OPPS final rule? Enter "Y" for yes or "N" for no. (see instructions)											37.01
38	If line 37 is 1, enter the beginning and ending dates of MDH status.  If line 37 is greater than 1, subscript this line for the number of periods in excess of one and enter subsequent dates.								Beginning:_______________	Ending: ______________		38
									Y/N	Y/N
39	Does this facility qualify for the inpatient hospital payment adjustment for low volume hospitals in accordance with 42 CFR 412.101(b)(2)(i), (ii), or (iii). Enter in column 1 “Y” for yes or “N” for no.											39
	Does the facility meet the mileage requirements in accordance with 42 CFR 412.101(b)(2)(i), (ii), or (iii)? Enter in column 2 "Y" for yes or "N" for no.  (see instructions)
40	Is this hospital subject to the HAC program reduction adjustment? Enter "Y" for yes or "N" for no in column 1, for discharges prior to October 1. Enter "Y" for yes or "N" for no in column 2,											40
	for discharges on or after October 1. (see instructions)
FORM CMS-2552-10 (12-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4004.1)
40-504												Rev.
12-22					FORM CMS-2552-10							4090 (Cont.)
HOSPITAL AND HOSPITAL HEALTH CARE									PROVIDER CCN:	PERIOD	WORKSHEET S-2
COMPLEX IDENTIFICATION DATA									______________	FROM __________	PART I (CONT.)
										TO _____________
									V	XVIII	XIX
Prospective Payment System (PPS)-Capital									1	2	3
45	Does this facility qualify and receive capital payment for disproportionate share in accordance with 42 CFR 412.320? (see instructions)											45
46	Is this facility eligible for additional payment exception for extraordinary circumstances pursuant to 42 CFR 412.348(f)? If yes, complete Wkst. L, Pt. III, and Wkst. L-1, Pt. I, through Pt. III.											46
47	Is this a new hospital under 42 CFR 412.300(b) PPS capital? Enter "Y for yes or "N" for no.											47
48	Is the facility electing full federal capital payment? Enter "Y" for yes or "N" for no.											48
Teaching Hospitals									1	2	3
56	Is this a hospital involved in training residents in approved GME programs? For cost reporting periods beginning prior to December 27, 2020, enter "Y" for yes or "N" for no in column 1. For cost reporting periods											56
	beginning on or after December 27, 2020, under 42 CFR 413.78(b)(2), see the instructions. For column 2, if the response to column 1 is “Y”, or if this hospital was involved in training residents in
	approved GME programs in the prior year or penultimate year, and you are impacted by CR 11642 (or applicable CRs) MA residents in approved GME programs in the prior year or penultimate year,
	and you are impacted by CR 11642 (or applicable CRs) MA direct GME payment reduction? Enter “Y” for yes; otherwise, enter “N” for no in column 2.
57	For cost reporting periods beginning prior to December 27, 2020, if line 56, column 1, is yes, is this the first cost reporting period during which residents in approved GME programs trained at this facility? Enter "Y" for yes											57
	or "N" for no in column 1. If column 1 is "Y", did residents start training in the first month of this cost reporting period? Enter "Y" for yes or "N" for no in column 2. If column 2 is "Y", complete Wkst. E-4.
	If column 2 is "N", complete Wkst. D, Parts III & IV and D-2, Pt. II, if applicable. For cost reporting periods beginning on or after December 27, 2020, under 42 CFR 413.77(e )(1)(iv) and (v), regardless of which month(s)
	of the cost report the residents were on duty, if the response to line 56 is “Y” for yes, enter "Y" for yes in column 1, do not complete column 2, and complete Worksheet E-4.
58	If line 56 is yes, did this facility elect cost reimbursement for physicians' services as defined in CMS Pub. 15-1, chapter 21, §2148? If yes, complete Wkst. D-5.											58
59	Are costs claimed on line 100 of Worksheet A? If yes, complete Wkst. D-2, Pt. I.											59
									NAHE 413.85	NAHE MA
									1	2	3
60	Are you claiming nursing and allied health education (NAHE) costs for any programs that meet the criteria under 42 CFR 413.85? (see instructions) Enter "Y" for yes or "N" for no in column 1. If column 1 is “Y”, are you											60
	impacted by CR 11642 (or subsequent CR) NAHE MA payment adjustment? Enter “Y” for yes or “N” for no in column 2.
											Pass-Through
										Worksheet A	Qualification
										Line #	Criterion Code
									1	2	3
60.01	If line 60 is yes, complete columns 2 and 3 for each program. (see instructions)											60.01
							Y/N			IME	Direct GME
							1	2	3	4	5
61	Did your hospital receive FTE slots under ACA section 5503? Enter "Y" for yes or "N" for no in column 1. (see instructions)											61
										IME	Direct GME
									1	2	3
61.01	Enter the average number of unweighted primary care FTEs from the hospital's 3 most recent cost reports ending and submitted before March 23, 2010. (see instructions)											61.01
61.02	Enter the current year total unweighted primary care FTE count (excluding OB/GYN, general surgery FTEs, and primary care FTEs added under section 5503 of ACA). (see instructions)											61.02
61.03	Enter the base line FTE count for primary care and/or general surgery residents, which is used for determining compliance with the 75% test. (see instructions)											61.03
61.04	Enter the number of unweighted primary care/or surgery allopathic and/or osteopathic FTEs in the current cost reporting period. (see instructions)											61.04
61.05	Enter the difference between the baseline primary and/or general surgery FTEs and the current year's primary care and/or general surgery FTE counts (line 61.04 minus line 61.03). (see instructions)											61.05
61.06	Enter the amount of ACA §5503 award that is being used for cap relief and/or FTEs that are nonprimary care or non-general surgery. (see instructions)											61.06
										Unweighted	Unweighted
										IME	Direct GME
								Program Name	Program Code	FTE Count	FTE Count
								1	2	3	4
61.10	Of the FTEs in line 61.05, specify each new program specialty, if any, and the number of FTE residents for each new program. (see instructions)											61.10
	Enter in column 1, the program name. Enter in column 2, the program code. Enter in column 3, the IME FTE unweighted count. Enter in column 4, the direct GME FTE unweighted count.
61.20	Of the FTEs in line 61.05, specify each expanded program specialty, if any, and the number of FTE residents for each expanded program. (see instructions)											61.20
	Enter in column 1, the program name. Enter in column 2, the program code. Enter in column 3, the IME FTE unweighted count. Enter in column 4, the direct GME FTE unweighted count.
ACA Provisions Affecting the Health Resources and Services Administration (HRSA)											1
62	Enter the number of FTE residents that your hospital trained in this cost reporting period for which your hospital received HRSA PCRE funding. (see instructions)											62
62.01	Enter the number of FTE residents that rotated from a Teaching Health Center (THC) into your hospital during in this cost reporting period of HRSA THC program. (see instructions)											62.01
Teaching Hospitals that Claim Residents in Nonprovider Settings									1	2	3
63	Has your facility trained residents in nonprovider settings during this cost reporting period? Enter "Y" for yes or "N" for no. If yes, complete lines 64 through 67. (see instructions)											63
									Unweighted FTEs	Unweighted FTEs	Ratio (col. 1 ÷
									Nonprovider Site	in Hospital	(col. 1 + col. 2))
Section 5504 of the ACA Base Year FTE Residents in Nonprovider Settings--This base year is your cost reporting period that begins on or after July 1, 2009 and before June 30, 2010.									1	2	3
64	Enter in column 1, if line 63 is yes, or your facility trained residents in the base year period, the number of unweighted non-primary care resident FTEs attributable to rotations occurring in all non-provider settings.											64
	Enter in column 2 the number of unweighted non-primary care resident FTEs that trained in your hospital.
	Enter in column 3 the ratio of (column 1 divided by (column 1 + column 2)). (see instructions)
									Unweighted FTEs	Unweighted FTEs	Ratio (col. 1 ÷
							Program Name	Program Code	Nonprovider Site	in Hospital	(col. 3 + col. 4))
							1	2	3	4	5
65	Enter in column 1, if line 63 is yes, or your facility trained residents in the base year period, the program name associated with primary care FTEs for each primary											65
	care FTEs for each primary care program in which you trained residents. Enter in column 2, the program code. Enter in column 3, the number of unweighted primary
	care FTE residents attributable to rotations occurring in all non-provider settings. Enter in column 4, the number of unweighted primary care resident FTEs that
	trained in your hospital. Enter in column 5, the ratio of (column 3 divided by (column 3 + column 4)). (see instructions)
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4004.1)
Rev. 18												40-505
4090 (Cont.)					FORM CMS-2552-10							12-22
HOSPITAL AND HOSPITAL HEALTH CARE									PROVIDER CCN:	PERIOD	WORKSHEET S-2
COMPLEX IDENTIFICATION DATA									______________	FROM __________	PART I (CONT.)
										TO _____________
									Unweighted FTEs	Unweighted FTEs	Ratio (col. 1 ÷
									Nonprovider Site	in Hospital	(col. 1 + col. 2))
Section 5504 of the ACA Current Year FTE Residents in Nonprovider Settings--Effective for cost reporting periods beginning on or after July 1, 2010									1	2	3
66	Enter in column 1, the number of unweighted non-primary care resident FTEs attributable to rotations occurring in all nonprovider settings. Enter in column 2, the number of unweighted non-primary care resident											66
	FTEs that trained in your hospital. Enter in column 3, the ratio of (column 1 divided by (column 1 + column 2)). (see instructions)
									Unweighted FTEs	Unweighted FTEs	Ratio (col. 3/
							Program Name	Program Code	Nonprovider Site	in Hospital	(col. 3 + col. 4))
							1	2	3	4	5
67	Enter in column 1, the program name associated with each of your primary care programs in which you trained residents. Enter in column 2, the program code. Enter											67
	column 3, the number of unweighted primary care FTE residents attributable to rotations occurring in all non-provider settings. Enter in column 4, the number of
	unweighted primary care resident FTEs that trained in your hospital. Enter in column 5, the ratio of (column 3 divided by (column 3 + column 4)). (see instructions)
Direct GME in Accordance with the FY 2023 IPPS Final Rule, 87 FR 49065-49072 (August 10, 2022)											1
68	For a cost reporting period beginning prior to October 1, 2022, did you obtain permission from your MAC to apply the new DGME formula in accordance with the FY 2023 IPPS Final Rule, 87 FR 49065-49072 (August 10, 2022)?											68
Inpatient Psychiatric Facility PPS									1	2	3
70	Is this facility an Inpatient Psychiatric Facility (IPF), or does it contain an IPF subprovider? Enter "Y" for yes or "N" for no.											70
71	If line 70 is yes:											71
	Column 1: Did the facility have an approved GME teaching program in the most recent cost report filed on or before November 15, 2004? Enter "Y" for yes or "N" for no. (see 42 CFR 412.424(d)(1)(iii)(C))
	Column 2: Did this facility train residents in a new teaching program in accordance with 42 CFR 412.424 (d)(1)(iii)(D)? Enter "Y" for yes or "N" for no.
	Column 3: If column 2 is Y, indicate which program year began during this cost reporting period. (see instructions)
Inpatient Rehabilitation Facility PPS									1	2	3
75	Is this facility an Inpatient Rehabilitation Facility (IRF), or does it contain an IRF subprovider? Enter "Y" for yes or "N" for no.											75
76	If line 75 is yes:											76
	Column 1: Did the facility have an approved GME teaching program in the most recent cost reporting period ending on or before November 15, 2004? Enter "Y" for yes or "N" for no.
	Column 2: Did this facility train residents in a new teaching program in accordance with 42 CFR 412.424 (d)(1)(iii)(D)? Enter "Y" for yes or "N" for no.
	Column 3: If column 2 is Y, indicate which program year began during this cost reporting period. (see instructions)
Long Term Care Hospital PPS										1	2
80	Is this a long term care hospital (LTCH)? Enter "Y" for yes or "N" for no.											80
81	Is this a LTCH co-located within another hospital for part or all of the cost reporting period? Enter “Y” for yes and “N” for no.											81
TEFRA Providers										1	2
85	Is this a new hospital under 42 CFR 413.40(f)(1)(i) TEFRA? Enter "Y" for yes or "N" for no.											85
86	Did this facility establish a new Other subprovider (excluded unit) under 42 CFR 413.40(f)(1)(ii)? Enter "Y" for yes or "N" for no.											86
87	Is this hospital an extended neoplastic disease care hospital classified under section 1886(d)(1)(B)(vi)? Enter "Y" for yes or "N" for no.											87
										Approved for	Number of
										Permanent	Approved Permanent
										Adjustment (Y/N)	Adjustments
										1	2
88	Column 1: Is this hospital approved for a permanent adjustment to the TEFRA target amount per discharge? Enter "Y" for yes or "N" for no. If yes, complete col. 2 and line 89. (see instructions)											88
	Column 2: Enter the number of approved permanent adjustments.
											Approved Permanent
											Adjustment Amount
									Wkst. A Line No.	Effective Date	Per Discharge
									1	2	3
89	Column 1: If line 88, column 1 is Y, enter the Worksheet A line number on which the per discharge permanent adjustment approval was based.											89
	Column 2: Enter the effective date (i.e., the cost reporting period beginning date) for the permanent adjustment to the TEFRA target amount per discharge.
	Column 3: Enter the amount of the approved permanent adjustment to the TEFRA target amount per discharge.
										V	XIX
Title V and XIX Services										1	2
90	Does this facility have title V and/or XIX inpatient hospital services? Enter "Y" for yes or "N" for no in applicable column.											90
91	Is this hospital reimbursed for title V and/or XIX through the cost report either in full or in part? Enter "Y" for yes or "N" for no in the applicable column.											91
92	Are title XIX NF patients occupying title XVIII SNF beds (dual certification)? (see instructions) Enter "Y" for yes or "N" for no in the applicable column.											92
93	Does this facility operate an ICF/IID facility for purposes of title V and XIX? Enter "Y" for yes or "N" for no in the applicable column.											93
94	Does title V or title XIX reduce capital cost? Enter "Y" for yes or "N" for no in the applicable column.											94
95	If line 94 is "Y", enter the reduction percentage in the applicable column.											95
96	Does title V or title XIX reduce operating cost? Enter "Y" for yes or "N" for no in the applicable column.											96
97	If line 96 is "Y", enter the reduction percentage in the applicable column.											97
98	Does title V or XIX follow Medicare (title XVIII) for the interns and residents post stepdown adjustments on Wkst. B, Pt. I, col. 25? Enter "Y" for yes or "N" for no in column 1 for title V, and in column 2 for title XIX.											98
98.01	Does title V or XIX follow Medicare (title XVIII) for the reporting of charges on Wkst. C, Pt. I? Enter "Y" for yes or "N" for no in column 1 for title V, and in column 2 for title XIX.											98.01
98.02	Does title V or XIX follow Medicare (title XVIII) for the calculation of observation bed costs on Wkst. D-1, Pt. IV, line 89? Enter "Y" for yes or "N" for no in column 1 for title V, and in column 2 for title XIX.											98.02
98.03	Does title V or XIX follow Medicare (title XVIII) for a critical access hospital (CAH) reimbursed 101% of inpatient services cost? Enter "Y" for yes or "N" for no in column 1 for title V, and in column 2 for title XIX.											98.03
98.04	Does title V or XIX follow Medicare (title XVIII) for a CAH reimbursed 101% of outpatient services cost? Enter "Y" for yes or "N" for no in column 1 for title V, and in column 2 for title XIX.											98.04
98.05	Does title V or XIX follow Medicare (title XVIII) and add back the RCE disallowance on Wkst. C, Pt. I, col. 4? Enter "Y" for yes or "N" for no in column 1 for title V, and in column 2 for title XIX.											98.05
98.06	Does title V or XIX follow Medicare (title XVIII) when cost reimbursed for Wkst. D, Pts. I through IV? Enter "Y" for yes or "N" for no in column 1 for title V, and in column 2 for title XIX.											98.06
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4004.1)
40-506												Rev. 18
DRAFT					FORM CMS-2552-10							4090 (Cont.)
HOSPITAL AND HOSPITAL HEALTH CARE									PROVIDER CCN:	PERIOD	WORKSHEET S-2
COMPLEX IDENTIFICATION DATA									______________	FROM __________	PART I (CONT.)
										TO _____________
Rural Providers										1	2
105	Does this hospital qualify as a CAH?											105
106	If this facility qualifies as a CAH, has it elected the all-inclusive method of payment for outpatient services? (see instructions)											106
107	Column 1: If line 105 is Y, is this facility eligible for cost reimbursement for I&R training programs? Enter "Y" for yes or "N" for no in column 1. (see instructions)											107
	Column 2: If column 1 is Y and line 70 or line 75 is Y, do you train I&Rs in an approved medical education program in the CAH's excluded IPF and/or IRF unit(s)? Enter "Y" for yes or "N" for no in column 2. (see instructions)
107.01	If this facility is a REH (line 3, column 4, is "12"), is it eligible for cost reimbursement for I&R training programs? Enter "Y" for yes or "N" for no. (see instructions)											107.01
108	Is this a rural hospital qualifying for an exception to the CRNA fee schedule? See 42 CFR 412.113(c). Enter "Y" for yes or "N" for no.											108
								Physical	Occupational	Speech	Respiratory
								1	2	3	4
109	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 each therapy.											109
											1
110	Did this hospital participate in the Rural Community Hospital Demonstration project (§410A Demonstration) for the current cost reporting period? Enter "Y" for yes or "N" for no.											110
	If yes, complete Worksheet E, Part A, lines 200 through 218, and Worksheet E-2, lines 200 through 215, as applicable.
										1	2
111	If this facility qualifies as a CAH, did it participate in the Frontier Community Health Integration Project (FCHIP) demonstration for this cost reporting period? Enter "Y" for yes or "N" for no in column 1.											111
	If the response to column 1 is Y, enter the integration prong of the FCHIP demo in which this CAH is participating in column 2. Enter all that apply: "A" for Ambulance services; "B" for additional beds; and/or "C" for tele-health services.
									1	2	3
112	Did this hospital participate in the Pennsylvania Rural Health Model (PARHM) demonstration for any portion of the current cost reporting period? Enter "Y" for yes or "N" for no in column 1. If column 1 is "Y", enter in											112
	column 2, the date the hospital began participating in the demonstration. In column 3, enter the date the hospital ceased participation in the demonstration, if applicable.
Miscellaneous Cost Reporting Information									1	2	3
115	Is this an all-inclusive rate provider? Enter "Y" for yes or "N" for no in column 1. If column 1 is yes, enter the method used (A, B, or E only) in column 2.											115
	If column 2 is "E", enter in column 3 either "93" percent for short term hospital or "98" percent for long term care (includes psychiatric, rehabilitation and long term hospitals
	providers) based on the definition in CMS Pub.15-1, chapter 22, §2208.1.
											1
116	Is this facility classified as a referral center? Enter "Y" for yes or "N" for no.											116
117	Is this facility legally-required to carry malpractice insurance? Enter "Y" for yes or "N" for no.											117
118	Is the malpractice insurance a claims-made or occurrence policy? Enter 1 if the policy is claim- made. Enter 2 if the policy is occurrence.											118
									Premiums	Paid losses	Self insurance
									1	2	3
118.01	List amounts of malpractice premiums and paid losses:											118.01
										1	2
118.02	Are malpractice premiums and paid losses reported in a cost center other than the Administrative and General? If yes, submit supporting schedule listing cost centers and amounts contained therein.											118.02
119	What is the liability limit for the malpractice insurance policy? Enter in column 1 the monetary limit per lawsuit. Enter in column 2 the monetary limit per policy year.											119
120	Is this a SCH or EACH that qualifies for the Outpatient Hold Harmless provision in ACA §3121 and applicable amendments? (see instructions) Enter in column 1, "Y" for yes or "N" for no. Is this a											120
	rural hospital with <100 beds that qualifies for the Outpatient Hold Harmless provision in ACA §3121 and applicable amendments? (see instructions) Enter in column 2, "Y" for yes or "N" for no.
121	Did this facility incur and report costs for high cost implantable devices charged to patients? Enter "Y" for yes or "N" for no.											121
122	Does the cost report contain healthcare related taxes as defined in §1903(w)(3) of the Act? Enter "Y" for yes or "N" for no in column 1. If column 1 is "Y", enter in column 2 the Worksheet A line number where these taxes are included.											122
123	Did the facility and/or its subproviders (if applicable) purchase professional services, e.g., legal, accounting, tax preparation, bookkeeping, payroll, and/or management/consulting services, from an unrelated organization? In column 1,											123
	enter "Y" for yes or "N" for no.
	If column 1 is "Y", were the majority of the expenses, i.e., greater than 50% of total professional services expenses, for services purchased from unrelated organizations located in a CBSA outside of the main hospital CBSA? In column 2,
	enter "Y" for yes or "N" for no.
124	Did the hospital incur cost, either directly or through a contract with an outside supplier, to establish and maintain access to no less than a 6-month buffer stock of one or more essential medicines according											124
	to 42 CFR 412.113(g)? Enter “Y” for yes or “N” for no.
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4004.1)
Rev.												40-507
4090 (Cont.)					FORM CMS-2552-10							DRAFT
HOSPITAL AND HOSPITAL HEALTH CARE									PROVIDER CCN:	PERIOD	WORKSHEET S-2
COMPLEX IDENTIFICATION DATA									______________	FROM __________	PART I (CONT.)
										TO _____________
Certified Transplant Center Information										1	2
125	Does this facility operate a Medicare-certified transplant center? Enter "Y" for yes or "N" for no. If yes, enter certification date(s) (mm/dd/yyyy) below.											125
126	If this is a Medicare-certified kidney transplant program, 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 program, 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 program, 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 program, 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 program, 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 program, enter the certification date in column 1 and termination date, if applicable, in column 2.											131
132	If this is a Medicare certified islet transplant program, enter the certification date in column 1 and termination date, if applicable, in column 2.											132
133	Removed and reserved											133
134	If this is a hospital-based organ procurement organization (OPO), enter the OPO number in column 1 and termination date, if applicable, in column 2.											134
All Providers										1	2
140	Are there any related organization or home office costs as defined in CMS Pub. 15-1, chapter 10? Enter "Y" for yes or "N" for no in column 1.											140
	If yes, and home office costs are claimed, enter in column 2 the home office chain number. (see instructions)
If this facility is part of a chain organization, enter on lines 141 through 143 the name and address of the home office and enter the home office contractor name and contractor number.
141	Name:					Contractor's Name: ___________________			Contractor's Number: __________			141
142	Street:				P. O. Box:							142
143	City:				State:	Zip Code:						143
										1	2
144	Are provider based physicians' costs included in Worksheet A?											144
145	If costs for renal services are claimed on Wkst. A, line 74, are the costs for inpatient services only? Enter "Y" for yes or "N" for no in column 1.											145
	If column 1 is no, does the dialysis facility include Medicare utilization for this cost reporting period? Enter "Y" for yes or "N" for no in column 2.
146	Has the cost allocation methodology changed from the previously filed cost report? Enter "Y" for yes or "N" for no in column 1. (See CMS Pub. 15-2, chapter 40, §4020)											146
	If yes, enter the approval date (mm/dd/yyyy) in column 2.
147	Was there a change in the statistical basis? Enter "Y" for yes or "N" for no.											147
148	Was there a change in the order of allocation? Enter "Y" for yes or "N" for no.											148
149	Was there a change to the simplified cost finding method? Enter "Y" for yes or "N" for no.											149
								Title XVIII
Does this facility contain a provider that qualifies for an exemption from the application of the lower of costs or charges?								Part A	Part B	Title V	Title XIX
Enter "Y" for yes or "N" for no for each component for Part A and Part B. (see 42 CFR 413.13)								1	2	3	4
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 CBSAs? Enter "Y" for yes or "N" for no.											165
166	If line 165 is yes, for each campus enter the name in column 0, county in column 1, state in column 2, ZIP in column 3, CBSA in column 4, FTE/Campus in column 5. (see instructions)											166
				Name			County	State	Zip Code	CBSA	FTE/Campus
				0			1	2	3	4	5
Health Information Technology (HIT) incentive in the American Recovery and Reinvestment Act										1	2
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
168.01	If this provider is a CAH and is not a meaningful user, does this provider qualify for a hardship exception under §413.70(a)(6)(ii)? Enter "Y" for yes or "N" for no. (see instructions)											168.01
169	If this provider is a meaningful user (line 167 is "Y") and is not a CAH (line 105 is "N"), enter the transition factor. (see instructions)											169
170	Enter in columns 1 and 2, the EHR beginning date and ending date for the reporting period, respectively (mm/dd/yyyy)											170
171	If line 167 is "Y", does this provider have any days for individuals enrolled in section 1876 Medicare cost plans reported on Wkst. S-3, Pt. I, line 2, col. 6? Enter “Y” for yes and “N” for no in column 1.											171
	If column 1 is yes, enter the number of section 1876 Medicare days in column 2. (see instructions)
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4004.1)
40-508												Rev.

---

Sheet 3: S2II

12-24				FORM CMS-2552-10						4090 (Cont.)
HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX					PROVIDER CCN:	PERIOD		WORKSHEET S-2
REIMBURSEMENT QUESTIONNAIRE					______________	FROM __________		PART II
						TO _____________
PART II - HOSPITAL AND HOSPITAL HEALTHCARE COMPLEX REIMBURSEMENT QUESTIONNAIRE
General Instruction: Enter Y for all YES responses. Enter N for all NO responses.
		Enter all dates in the mm/dd/yyyy format.
COMPLETED BY ALL HOSPITALS
							Y/N	Date
Provider Organization and Operation							1	2
1	Has the provider changed ownership immediately prior to the beginning of the cost reporting period?									1
	If yes, enter the date of the change in column 2. (see instructions)
							Y/N	Date	V/I
							1	2	3
2	Has the provider terminated participation in the Medicare Program?									2
	If 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)
							Y/N	Type	Date
Financial Data and Reports							1	2	3
4	Column 1: Were the financial statements prepared by a Certified Public Accountant?									4
	Column 2: If yes, enter "A" for Audited, "C" for Compiled, or "R" for Reviewed. Submit complete copy or enter
	date available in column 3. (see instructions) If no, see instructions.
5	Are the cost report total expenses and total revenues different from those on the filed financial statements?									5
	If yes, submit reconciliation.
								Y/N	Y/N
Approved Educational Activities								1	2
6	Column 1: Are costs claimed for a nursing program?									6
	Column 2: If yes, is the provider the legal operator of the program?
7	Are costs claimed for allied health programs? If yes, see instructions.									7
8	Were nursing programs and/or allied health programs approved and/or renewed during the cost reporting period?									8
	If yes, see instructions.
9	Are costs claimed for Interns and Residents in approved GME programs in the current cost report? If yes, see instructions.									9
10	Was an approved Intern and Resident GME program initiated or renewed in the current cost reporting period? If yes, see instructions.									10
11	Are GME costs directly assigned to cost centers other than I & R in an Approved Teaching Program on Worksheet A?									11
	If yes, see instructions.
Bad Debts									Y/N
12	Is the provider seeking reimbursement for bad debts? If yes, see instructions.									12
13	If line 12 is yes, did the provider's bad debt collection policy change during this cost reporting period? If yes, submit copy.									13
14	If line 12 is yes, were patient deductibles and/or coinsurance amounts waived? If yes, see instructions.									14
Bed Complement
15	Did total beds available change from the prior cost reporting period? If yes, see instructions.									15
						Part A		Part B
						Y/N	Date	Y/N	Date
PS&R Report Data						1	2	3	4
16	Was the cost report prepared using the PS&R Report only? If either column 1 or 3 is yes, in columns 2 and 4,									16
	from the PS&R used to prepare this cost report, enter the "Paid Claims Verified Current
	As Of" date, if present, or the paid-through date. (see instructions)
17	Was the cost report prepared using the PS&R Report for totals and the provider's records for allocation?									17
	If either column 1 or 3 is yes, in columns 2 and 4, enter the "Paid Claims Verified Current
	As Of" date, if present, or the paid-through date. (see instructions)
18	If line 16 or 17 is yes, were adjustments made to PS&R Report data for additional claims that have been									18
	billed but are not included on the PS&R Report used to file the cost report? If yes, see instructions.
19	If line 16 or 17 is yes, were adjustments made to PS&R Report data for corrections of other									19
	PS&R Report information? If yes, see instructions.
20	If line 16 or 17 is yes, were adjustments made to PS&R Report data for Other?									20
	Describe the other adjustments:	_________________________________
21	Was the cost report prepared only using the provider's records? If yes, see instructions.									21
FORM CMS-2552-10 (12-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTIONS 4004.2)
Rev. 23										40-509
4090 (Cont.)				FORM CMS-2552-10						12-24
HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX					PROVIDER CCN:	PERIOD		WORKSHEET S-2
REIMBURSEMENT QUESTIONNAIRE					______________	FROM __________		Part II (CONT.)
						TO _____________
General Instruction: Enter Y for all YES responses. Enter N for all NO responses.
		Enter all dates in the mm/dd/yyyy format.
COMPLETED BY COST REIMBURSED AND TEFRA HOSPITALS ONLY (EXCEPT CHILDRENS HOSPITALS)
Capital Related Cost
22	Have assets been relifed for Medicare purposes? If yes, see instructions.									22
23	Have changes occurred in the Medicare depreciation expense due to appraisals made during the cost reporting period?									23
	If yes, see instructions.
24	Were new leases and/or amendments to existing leases entered into during this cost reporting period? If yes, see instructions.									24
25	Have there been new capitalized leases entered into during the cost reporting period? If yes, see instructions.									25
26	Were assets subject to Sec.2314 of DEFRA acquired during the cost reporting period? If yes, see instructions.									26
27	Has the provider's capitalization policy changed during the cost reporting period? If yes, see instructions.									27
Interest Expense
28	Were new loans, mortgage agreements or letters of credit entered into during the cost reporting period? If yes, see instructions.									28
29	Did the provider have a funded depreciation account and/or bond funds (Debt Service Reserve Fund) treated as a funded depreciation									29
	account? If yes, see instructions.
30	Has existing debt been replaced prior to its scheduled maturity with new debt? If yes, see instructions.									30
31	Has debt been recalled before scheduled maturity without issuance of new debt? If yes, see instructions.									31
Purchased Services
32	Have changes or new agreements occurred in patient care services furnished through contractual arrangements with suppliers of services?									32
	If yes, see instructions.
33	If line 32 is yes, were the requirements of Sec. 2135.2 applied pertaining to competitive bidding?									33
	If no, see instructions.
Provider-Based Physicians
34	Were services furnished at the provider facility under an arrangement with provider-based physicians? If "Y" see instructions.									34
35	If line 34 is yes, were there new agreements or amended existing agreements with the provider-based physicians during the cost									35
	reporting period? If yes, see instructions.
								Y/N	Date
Home Office Costs								1	2
36	Are home office costs claimed on the cost report?									36
37	If line 36 is yes, has a home office cost statement been prepared by the home office? If yes, see instructions.									37
38	If line 36 is yes , was the fiscal year end of the home office different from that of the provider?									38
	If yes, enter in column 2 the fiscal year end of the home office.
39	If line 36 is yes, did the provider render services to other chain components? If yes, see instructions.									39
40	If line 36 is yes, did the provider render services to the home office? If yes, see instructions.									40
Cost Report Preparer Contact Information
41	First name:		Last name:			Title:				41
42	Employer:									42
43	Phone number:			E-mail Address:						43
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTIONS 4004.2)
40-510										Rev. 23

---

Sheet 4: S3I

12-24						FORM CMS-2552-10											4090 (Cont.)
HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX											PROVIDER CCN:		PERIOD		WORKSHEET S-3
STATISTICAL DATA											______________		FROM __________		PART I
													TO _____________
PART I - STATISTICAL DATA
						Inpatient Days / Outpatient Visits / Trips				Full Time Equivalents			Discharges
		Worksheet
		A							Total	Total	Employees					Total
		Line	No. of	Bed Days	CAH/REH		Title	Title	All	Interns &	On	Nonpaid		Title	Title	All
	Component	No.	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, 6, 7, and 8, exclude Swing																1
	Bed, Observation Bed and Hospice days) (see instructions for
	col. 2 for the portion of LDP room available beds)
2	HMO and other (see instructions)																2
3	HMO IPF Subprovider																3
4	HMO IRF Subprovider																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
15.10	REH hours and visits																15.10
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
24.10	Hospice (non-distinct part)																24.10
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 instructions)																30
31	Employee discount days - IRF																31
32	Labor & delivery (see instructions)																32
32.01	Total ancillary labor & delivery room																32.01
	outpatient days (see instructions)
33	LTCH non-covered days																33
33.01	LTCH site neutral days and discharges																33.01
34	Temporary Expansion COVID-19 PHE Acute Care																34
FORM CMS-2552-10 (04-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4005.1)
Rev. 23																	40-511

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Sheet 5: S3II &III

4090 (Cont.)		FORM CMS-2552-10						12-24
HOSPITAL WAGE INDEX INFORMATION					PROVIDER CCN:	PERIOD	WORKSHEET S-3
					______________	FROM ___________	PART II
						TO _____________
Part II - Wage Data
				Reclassification	Adjusted	Paid Hours	Average
		Wkst. A		of Salaries	Salaries	Related	Hourly Wage
		Line	Amount	(from	(col. 2 ±	to Salaries	(col. 4 ÷
		Number	Reported	Wkst. A-6)	col. 3)	in column 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 - Administrative							4
4.01	Physician-Part A - Teaching							4.01
5	Physician and Non Physician-Part B							5
6	Non-physician-Part B for hospital-based RHC and FQHC services							6
7	Interns & residents (in an approved program)							7
7.01	Contracted interns & residents (in an approved program)							7.01
8	Home office and/or related organization personnel							8
9	SNF							9
10	Excluded area salaries (see instructions)							10
	OTHER WAGES AND RELATED COSTS
11	Contract labor: Direct Patient Care							11
12	Contract labor: Top level management and other management and							12
	administrative services
13	Contract labor: Physician-Part A - Administrative							13
14	Home office and/or related organization salaries and wage-related costs							14
14.01	Home office salaries							14.01
14.02	Related organization salaries							14.02
15	Home office: Physician Part A - Administrative							15
15.01	Home office Physicians Part A - Administrative							15.01
15.02	Home office contract Physicians Part A - Administrative							15.02
16	Home office & Contract Physicians Part A - Teaching							16
16.01	Home office Physicians Part A - Teaching							16.01
16.02	Home office contract Physicians Part A - Teaching							16.02
	WAGE-RELATED COSTS
17	Wage-related costs (core) (see instructions)							17
18	Wage-related costs (other) (see instructions)							18
19	Excluded areas							19
20	Non-physician anesthetist Part A							20
21	Non-physician anesthetist Part B							21
22	Physician Part A - Administrative							22
22.01	Physician Part A - Teaching							22.01
23	Physician Part B							23
24	Wage-related costs (RHC/FQHC)							24
25	Interns & residents (in an approved program)							25
25.50	Home office wage-related (core)							25.50
25.51	Related organization wage-related (core)							25.51
25.52	Home office: Physician Part A - Administrative - wage-related (core)							25.52
25.53	Home office: Physicians Part A - Teaching - wage-related (core)							25.53
FORM CMS-2552-10 (12-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4005.2 - 4005.3)
40-512								Rev. 23
11-16			FORM CMS-2552-10					4090 (Cont.)
HOSPITAL WAGE INDEX INFORMATION					PROVIDER CCN:	PERIOD	WORKSHEET S-3
					______________	FROM __________	PART II & III
						TO _____________
Part II - Wage Data
		Worksheet		Reclassification	Adjusted	Paid Hours	Average
		A		of Salaries	Salaries	Related	Hourly Wage
		Line	Amount	(from	(column 2 ±	to Salaries	(column 4 ÷
		Number	Reported	Worksheet A-6)	column 3)	in column 4	column 5)
		1	2	3	4	5	6
	OVERHEAD COSTS - DIRECT SALARIES
26	Employee Benefits Department	4						26
27	Administrative & General	5						27
28	Administrative & General under contract (see instructions)							28
29	Maintenance & Repairs	6						29
30	Operation of Plant	7						30
31	Laundry & Linen Service	8						31
32	Housekeeping	9						32
33	Housekeeping under contract (see instructions)							33
34	Dietary	10						34
35	Dietary under contract (see instructions)							35
36	Cafeteria	11						36
37	Maintenance of Personnel	12						37
38	Nursing Administration	13						38
39	Central Services and Supply	14						39
40	Pharmacy	15						40
41	Medical Records & Medical Records Library	16						41
42	Social Service	17						42
43	Other General Service	18						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 and related costs (see instructions)							4
5	Subtotal wage-related costs (see instructions)							5
6	Total (sum of lines 3 through 5)							6
7	Total overhead cost (see instructions)							7
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4005.2 - 4005.3)
Rev. 10								40-513

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Sheet 6: S3IV

4090 (Cont.)				FORM CMS-2552-10				11-16
HOSPITAL WAGE RELATED COSTS					PROVIDER CCN:	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	Nonqualified Defined Benefit Plan Cost (see instructions)							3
4	Qualified Defined Benefit Plan Cost (see instructions)							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
8.01	Health Insurance (Self Funded without a Third Party Administrator)							8.01
8.02	Health Insurance (Self Funded with a Third Party Administrator)							8.02
8.03	Health Insurance (Purchased)							8.03
9	Prescription Drug Plan							9
10	Dental, Hearing and Vision Plan							10
11	Life Insurance (If employee is owner or beneficiary)							11
12	Accident 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 Noncumulative 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 (Other Than Retirement Cost Reported on lines 1 through 4 above)(see instructions)							21
22	Day Care Cost and Allowances							22
23	Tuition Reimbursement							23
24	Total Wage Related cost (Sum of lines 1 through 23)							24
Part B - Other than Core Related Cost
25	Other Wage Related Costs (specify) _________________________________________							25
FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4005.4)
40-514								Rev. 10

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Sheet 7: S3V

10-12				FORM CMS-2552-10				4090 (Cont.)
HOSPITAL CONTRACT LABOR AND BENEFIT COST					PROVIDER CCN:	PERIOD:	WORKSHEET S-3
					______________	FROM __________	PART V
						TO _____________
Part V - Contract Labor and Benefit Cost
Hospital and Hospital-Based Component Identification:
						Contract	Benefit
	Component					Labor	Cost
	0					1	2
1	Total facility 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
18	Other							18
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4005.5)
Rev. 3								40-515

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Sheet 8: S4

4090 (Cont.)		FORM CMS-2552-10							10-12
HOSPITAL-BASED HOME HEALTH AGENCY			PROVIDER CCN:		PERIOD:		WORKSHEET S-4
STATISTICAL DATA			______________		FROM __________
			HHA CCN:		TO _____________
			______________
	HOME HEALTH AGENCY STATISTICAL DATA				County: __________________
				Title V	Title XVIII	Title XIX	Other	Total
	Description			1	2	3	4	5
1	Home Health Aide Hours								1
2	Unduplicated Census Count (see instructions)								2
	HOME HEALTH AGENCY - NUMBER OF EMPLOYEES
						Number of Employees
	Enter the number of hours in					(Full Time Equivalent)
	your normal work week _______					Staff	Contract	Total
						1	2	3
3	Administrator and Assistant Administrator(s)								3
4	Director(s) 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
19	Enter the number of CBSAs where you provided services during the cost reporting period.								19
20	List those CBSA code(s) serviced during this cost reporting period (line 20 contains the first code).								20
	PPS ACTIVITY
				Full Episodes				Total
				Without	With	LUPA	PEP only	(columns 1
				Outliers	Outliers	Episodes	Episodes	through 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 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4006)
40-516									Rev. 3

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Sheet 9: S5

11-16				FORM CMS-2552-10				4090 (Cont.)
HOSPITAL RENAL DIALYSIS DEPARTMENT					PROVIDER CCN:	PERIOD:	WORKSHEET S-5
STATISTICAL DATA					______________	FROM ___________
						TO ______________
	RENAL DIALYSIS STATISTICS
		Outpatient		Training		Home
				Hemo-	CAPD	Hemo-	CAPD
		Regular	High Flux	dialysis	CCPD	dialysis	CCPD
	DESCRIPTION	1	2	3	4	5	6
1	Number of patients in							1
	program at end of cost
	reporting period
2	Number of times per							2
	week patient receives
	dialysis
3	Average patient dialysis							3
	time including setup
4	CAPD exchanges per day							4
5	Number of days in year							5
	dialysis furnished
6	Number of stations							6
7	Treatment capacity per							7
	day per station
8	Utilization (see instructions)							8
9	Average times							9
	dialyzers re-used
10	Percentage of patients							10
	re-using dialyzers
	ESRD PPS					1	2
10.01	Is the dialysis facility approved as a low-volume facility for this cost reporting period?							10.01
	Enter "Y" for yes or "N" for no. (see instructions)
10.02	Did your facility elect 100% PPS effective January 1, 2011? Enter "Y" for yes or "N" for no.							10.02
	(See instructions for "new" providers.)
10.03	If you responded "N" to line 10.02, enter in column 1 the year of transition for periods prior to January 1 and							10.03
	enter in column 2 the year of transition for periods after December 31. (see instructions)
	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" for applicable method(s))
21	MCP_________	INITIAL METHOD__________						21
				Net Cost of	Net Cost of	Number of ESA	Number of ESA
			ESA	ESAs for	ESAs for	Units - Renal	Units - Home
			Description	Renal Patients	Home Patients	Dialysis Dept.	Dialysis Dept.
	Erythropoiesis-Stimulating Agents (ESA) Statistics:		1	2	3	4	5
22	Enter in column 1 the ESA description.							22
	Enter in column 2 the net costs of ESAs furnished
	to all renal dialysis patients.
	Enter in column 3 the net cost of ESAs furnished
	to all home dialysis program patients.
	Enter in column 4 the number of ESA units
	furnished to patients in the renal dialysis
	department.
	Enter in column 5 the number of units furnished
	to patients in the home dialysis program.
	(see instructions)
						CCN	Treatments
	LOW VOLUME					1	2
23	If line 10.01 is yes, enter in column 1 the CCN for each renal dialysis facility listed on Worksheet S-2, Part I, line 18, and							23
	its subscripts. Enter in column 2, the total treatments for each CCN. (see instructions)
FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4007)
Rev. 10								40-517

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Sheet 10: S6

4090 (Cont.)				FORM CMS-2552-10				11-16
HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND					PROVIDER CCN:	PERIOD:	WORKSHEET S-6
OTHER OUTPATIENT REHABILITATION					_______________	FROM ___________
PROVIDER STATISTICAL DATA					COMPONENT CCN:	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 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4008)
40-518								Rev. 10

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Sheet 11: S7

10-12				FORM CMS-2552-10				4090 (Cont.)
PROSPECTIVE PAYMENT FOR SNF					PROVIDER CCN:	PERIOD:	WORKSHEET S-7
STATISTICAL DATA					________________	FROM ____________
						TO ______________
						Y/N	Date
						1	2
1	If this facility contains a hospital-based SNF, were all patients under managed care or was there no Medicare utilization?							1
	Enter "Y" for yes and do not complete the rest of this worksheet.
2	Does this hospital have an agreement under either section 1883 or section 1913 for swing beds? Enter "Y" for yes or							2
	"N" for no in column 1. If yes, enter the agreement date (mm/dd/yyyy) in column 2.
					SNF	Swing Bed SNF	TOTAL
		Group			Days	Days	(sum of col. 2 + 3)
		1			2	3	4
3	RUX							3
4	RUL							4
5	RVX							5
6	RVL							6
7	RHX							7
8	RHL							8
9	RMX							9
10	RML							10
11	RLX							11
12	RUC							12
13	RUB							13
14	RUA							14
15	RVC							15
16	RVB							16
17	RVA							17
18	RHC							18
19	RHB							19
20	RHA							20
21	RMC							21
22	RMB							22
23	RMA							23
24	RLB							24
25	RLA							25
26	ES3							26
27	ES2							27
28	ES1							28
29	HE2							29
30	HE1							30
31	HD2							31
32	HD1							32
33	HC2							33
34	HC1							34
35	HB2							35
36	HB1							36
37	LE2							37
38	LE1							38
39	LD2							39
40	LD1							40
41	LC2							41
42	LC1							42
43	LB2							43
44	LB1							44
45	CE2							45
46	CE1							46
47	CD2							47
48	CD1							48
49	CC2							49
50	CC1							50
51	CB2							51
52	CB1							52
53	CA2							53
54	CA1							54
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4009)
Rev. 3								40-519
4090 (Cont.)				FORM CMS-2552-10				10-12
PROSPECTIVE PAYMENT FOR SNF					PROVIDER CCN:	PERIOD:	WORKSHEET S-7
STATISTICAL DATA					________________	FROM ____________	(CONT.)
						TO ______________
					SNF	Swing Bed SNF	TOTAL
		Group			Days	Days	(sum of col. 2 + 3)
		1			2	3	4
55	SE3							55
56	SE2							56
57	SE1							57
58	SSC							58
59	SSB							59
60	SSA							60
61	IB2							61
62	IB1							62
63	IA2							63
64	IA1							64
65	BB2							65
66	BB1							66
67	BA2							67
68	BA1							68
69	PE2							69
70	PE1							70
71	PD2							71
72	PD1							72
73	PC2							73
74	PC1							74
75	PB2							75
76	PB1							76
77	PA2							77
78	PA1							78
199	AAA							199
200	TOTAL							200
SNF SERVICES
						CBSA at	CBSA on/after
						Beginning of	October 1 of the
						Cost Reporting	Cost Reporting
						Period	Period (if applicable)
						1	2
201	Enter in column 1 the SNF CBSA code, or 5 character non-CBSA code if a rural facility, in effect at the beginning of the							201
	cost reporting period.
	Enter in column 2 the code in effect on or after October 1 of the cost reporting period (if applicable).
A notice published in the Federal Register Volume 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. For lines 202 through 207: 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 7, column 3. In column 3, enter "Y" or "N" for no if the spending reflects increases associated with direct patient care
and related expenses for each category. (see instructions)
							Associated with
							Direct Patient Care
					Expenses	Percentage	and Related Expenses?
					1	2	3
202	Staffing							202
203	Recruitment							203
204	Retention of employees							204
205	Training							205
206	Other (Specify)							206
207	Total SNF revenue (Worksheet G-2, Part I, line 7, column 3)							207
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4009)
40-520								Rev. 3

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Sheet 12: S8

12-24								FORM CMS-2552-10										4090 (Cont.)
HOSPITAL-BASED RHC/FQHC STATISTICAL DATA										PROVIDER CCN:			PERIOD:			WORKSHEET S-8
										________________			FROM ___________
										COMPONENT CCN:			TO __________
										________________
Check		[ ] Hospital-based RHC
applicable box:		[ ] Hospital-based FQHC
Clinic Address and Identification:
1	Street:																	1
2	City:			State:			Zip Code:				County:							2
3	HOSPITAL-BASED FQHCs ONLY: Designation - 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
																1	2
10	Does this facility operate as other than a hospital-based RHC or FQHC? Enter "Y" for yes or "N" for no in column 1.																	10
	If yes, indicate the number of other operations in column 2.
Facility hours of operations1
				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
	Enter clinic hours of operation on line 11 and other type operations on subscripts of line 11 (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.
															1	2	3
12	Have you received an approval for an exception to the productivity standard?																	12
13	Is this worksheet prepared for a consolidated group as defined in CMS Pub. 100-04, chapter 9, section 30.8? Enter "Y" for yes or "N" for																	13
	no in column 1.
	If column 1 is Y, enter in column 2 the number of providers included in the group. List the provider name and provider number of each member
	in the consolidated group on line 14.
	If column 1 is Y, in column 3, enter G or N to identify the grouping as grandfathered or non-grandfathered, respectively.
13.01	Reserved																	13.01
14	RHC/FQHC name: _______________________________________________										CCN: ________________							14
																	Total
													Y/N	V	XVIII	XIX	Visits
													1	2	3	4	5
15	Have you provided all or substantially all GME cost? Enter "Y" for yes or "N" for no in column 1.																	15
	If yes, enter in columns 2, 3 and 4 the number of program visits performed by Intern & Residents for titles V,
	XVIII, and XIX, as applicable. Enter in column 5 the number of total visits for this provider. (see instructions)
FORM CMS-2552-10 (12-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4010)
Rev. 23																		40-521

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Sheet 13: S9

4090 (Cont.)				FORM CMS-2552-10					12-24
HOSPITAL-BASED HOSPICE IDENTIFICATION DATA						PROVIDER CCN:	PERIOD:	WORKSHEET S-9
						________________	FROM __________	PARTS I THROUGH IV
						HOSPICE CCN:	TO __________
						________________
PART I - ENROLLMENT DAYS FOR COST REPORTING PERIODS BEGINNING BEFORE OCTOBER 1, 2015
			Unduplicated Days
					Title XVIII	Title XIX		Total
					Skilled Nursing	Nursing	All	(sum of
			Title XVIII	Title XIX	Facility	Facility	Other	cols. 1, 2 and 5)
			1	2	3	4	5	6
1	Hospice Continuous Home Care								1
2	Hospice Routine Home Care								2
3	Hospice Inpatient Respite Care								3
4	Hospice General Inpatient Care								4
5	Total Hospice Days								5
PART II - CENSUS DATA FOR COST REPORTING PERIODS BEGINNING BEFORE OCTOBER 1, 2015
					Title XVIII	Title XIX		Total
					Skilled Nursing	Nursing	All	(sum of
			Title XVIII	Title XIX	Facility	Facility	Other	cols. 1, 2 and 5)
			1	2	3	4	5	6
6	Number of patients receiving								6
	hospice care
7	Total number of unduplicated contin-								7
	uous care hours billable to Medicare
8	Average length of stay (line 5/line 6)								8
9	Unduplicated census count								9
PART III - ENROLLMENT DAYS FOR COST REPORTING PERIODS BEGINNING ON OR AFTER OCTOBER 1, 2015
					Unduplicated Days
								Total
								(sum of
					Title XVIII	Title XIX	Other	cols. 1 through 3)
					1	2	3	4
10	Hospice Continuous Home Care								10
11	Hospice Routine Home Care								11
12	Hospice Inpatient Respite Care								12
13	Hospice General Inpatient Care								13
14	Total Hospice Days								14
PART IV - CONTRACTED STATISTICAL DATA FOR COST REPORTING PERIODS BEGINNING ON OR AFTER OCTOBER 1, 2015
								Total
								(sum of
					Title XVIII	Title XIX	Other	cols. 1 through 3)
					1	2	3	4
15	Hospice Inpatient Respite Care								15
16	Hospice General Inpatient Care								16
NOTE: Parts I and II, columns 1 and 2, also include the days reported in columns 3 and 4 .
FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4011)
40-522									Rev. 23

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Sheet 14: S10

12-22				FORM CMS-2552-10				4090 (Cont.)
HOSPITAL UNCOMPENSATED AND INDIGENT					PROVIDER CCN:	PERIOD:	WORKSHEET S-10
CARE DATA					________________	FROM ___________	PART I
						TO ___________
PART I - HOSPITAL AND HOSPITAL COMPLEX DATA
Uncompensated and Indigent Care Cost-to-Charge Ratio
1	Cost to charge ratio (see instructions)							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 and/or supplemental payments from Medicaid?							4
5	If line 4 is no, enter DSH and/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 (see instructions)							8
Children's Health Insurance Program (CHIP) (see instructions for each line)
9	Net revenue from stand-alone CHIP							9
10	Stand-alone CHIP charges							10
11	Stand-alone CHIP cost (line 1 times line 10)							11
12	Difference between net revenue and costs for stand-alone CHIP (see instructions)							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 (see instructions)							16
Grants, donations and total unreimbursed cost for Medicaid, CHIP and state/local indigent care programs (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, CHIP, and state and local indigent care programs (sum of lines 8, 12, and 16)							19
Uncompensated care cost (see instructions for each line)
					Uninsured	Insured	Total
					patients	patients	(col. 1 + col. 2)
					1	2	3
20	Charity care charges and uninsured discounts (see instructions)							20
21	Cost of patients approved for charity care and uninsured discounts (see instructions)							21
	Payments received from patients for amounts previously written off as charity care							22
23	Cost of charity care (see instructions)							23
24	Does the amount on line 20, col. 2, include charges for patient days beyond a length-of-stay limit imposed on patients covered							24
	by Medicaid or other indigent care program?
25	If line 24 is yes, enter the charges for patient days beyond the indigent care program's length-of-stay limit (see instructions)							25
25.01	Charges for insured patients' liability (see instructions)							25.01
26	Bad debt amount (see instructions)							26
27	Medicare reimbursable bad debts (see instructions)							27
27.01	Medicare allowable bad debts (see instructions)							27.01
28	Non-Medicare bad debt amount (see instructions)							28
29	Cost of non-Medicare and non-reimbursable Medicare bad debt amounts (see instructions)							29
30	Cost of uncompensated care (line 23, col. 3, plus line 29)							30
31	Total unreimbursed and uncompensated care cost (line 19 plus line 30)							31
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4012)
Rev. 18								40-522.1
4090 (Cont.)				FORM CMS-2552-10				12-22
HOSPITAL UNCOMPENSATED AND INDIGENT					PROVIDER CCN:	PERIOD:	WORKSHEET S-10,
CARE DATA					________________	FROM ___________	PART II
						TO ___________
PART II - HOSPITAL DATA
Uncompensated and Indigent Care Cost-to-Charge Ratio
1	Cost to charge ratio (see instructions)							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 and/or supplemental payments from Medicaid?							4
5	If line 4 is no, enter DSH and/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 (see instructions)							8
Children's Health Insurance Program (CHIP) (see instructions for each line)
9	Net revenue from stand-alone CHIP							9
10	Stand-alone CHIP charges							10
11	Stand-alone CHIP cost (line 1 times line 10)							11
12	Difference between net revenue and costs for stand-alone CHIP (see instructions)							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 (see instructions)							16
Grants, donations and total unreimbursed cost for Medicaid, CHIP and state/local indigent care programs (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, CHIP, and state and local indigent care programs (sum of lines 8, 12, and 16)							19
Uncompensated care cost (see instructions for each line)
					Uninsured	Insured	Total
					Patients	Patients	(col. 1 + col. 2)
					1	2	3
20	Charity care charges and uninsured discounts (see instructions)							20
21	Cost of patients approved for charity care and uninsured discounts (see instructions)							21
22	Payments received from patients for amounts previously written off as charity care							22
23	Cost of charity care (see instructions)							23
24	Does the amount on line 20, col. 2, include charges for patient days beyond a length-of-stay limit imposed on patients covered							24
	by Medicaid or other indigent care program?
25	If line 24 is yes, enter the charges for patient days beyond the indigent care program's length-of-stay limit (see instructions)							25
25.01	Charges for insured patients' liability (see instructions)							25.01
26	Bad debt amount (see instructions)							26
27	Medicare reimbursable bad debts (see instructions)							27
27.01	Medicare allowable bad debts (see instructions)							27.01
28	Non-Medicare bad debt amount (see instructions)							28
29	Cost of non-Medicare and non-reimbursable Medicare bad debt amounts (see instructions)							29
30	Cost of uncompensated care (line 23, col. 3, plus line 29)							30
31	Total unreimbursed and uncompensated care cost (line 19 plus line 30)							31
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4012)
40-522.2								Rev. 18
12-22				FORM CMS-2552-10				4090 (Cont.)
This page is reserved for future use.
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4012)
Rev. 18								40-523

---

Sheet 15: S-11PI

4090 (Cont.)					FORM CMS-2552-10						12-22
HOSPITAL-BASED FQHC IDENTIFICATION DATA								PROVIDER CCN:	PERIOD:	WORKSHEET S-11
								______________	FROM: ___________	PART I
								COMPONENT CCN:	TO: ___________
								______________
PART I - HOSPITAL-BASED FQHC IDENTIFICATION DATA
							Type of control	Date	V/I	Date of
							(see instructions)	Decertified	Decertification	CHOW
	1						2	3	4	5
1	Site Name:										1
2	Street:		P.O. Box:								2
3	City:	State:	ZIP Code:	County:		Designation - Enter "R" for rural or "U" for urban:					3
4	Is this hospital-based FQHC part of an entity that owns, leases or controls multiple FQHCs? Enter "Y" for yes or "N" for no. If yes,										4
	enter the entity's information below.
5	Name of Entity:										5
6	Street:	P.O. Box:		HRSA Award Number:							6
7	City:	State:		ZIP Code:							7
							Y/N	Date Requested	Date Approved	Number of FQHCs
Consolidated Cost Report							1	2	3	4
8	Is this hospital-based FQHC filing a consolidated cost report per CMS Pub. 100-04, chapter 9, §30.8? Enter "Y" for yes or "N" for no in column 1.										8
	If column 1 is yes, complete columns 2 through 4, and line 9 beginning with line 9.01. If column 1 is no, leave line 9 blank. (see instructions)
							CCN	CBSA	Date Requested	Date Approved
	1						2	3	4	5
9	List of Consolidated Providers:										9
9.01	Site Name:										9.01
Hospital-Based FQHC Operations								1	2	3
10	What type of organization is this hospital-based FQHC? If you operate as more than one sub-type of an organization, enter only the applicable alpha										10
	characters in column 2. (see instructions)
11	Did this hospital-based FQHC receive a grant under §330 of the PHS Act during this cost reporting period? If this is a consolidated cost report, did the hospital-based FQHC reported										11
	on line 1, column 1, receive a grant under §330 of the PHS Act during this cost reporting period? Enter "Y" for yes or "N" for no. (complete line 12)
12	If the response to line 11 is yes, indicate in column 1, the type of HRSA grant that was awarded (see instructions). Enter the date of the grant award in										12
	column 2, and enter the grant award number in column 3. If you received more than one grant subscript this line accordingly.
Medical Malpractice
13	Did this hospital-based FQHC submit an initial deeming or annual redeeming application for medical malpractice coverage under the FTCA with HRSA? Enter "Y" for										13
	yes or "N" for no in column 1. If column 1 is yes, enter the effective date of coverage in column 2.
Interns and Residents
14	Did this hospital-based FQHC receive a THC development grant authorized under Part C of Title VII of the PHS Act from HRSA? Enter "Y" for										14
	yes or "N" for no in column 1. If yes, enter in column 2, the number of FTE residents that your hospital-based FQHC trained and received funding through your
	THC grant in this cost reporting period and in column 3, enter the total number of visits performed by residents funded by the THC grant in this cost reporting
	period. (see instructions)
FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4010.1)
40-523.1											Rev. 18

---

Sheet 16: S-11PII

02-24				FORM CMS-2552-10						4090 (Cont.)
HOSPITAL-BASED FQHC IDENTIFICATION DATA							PROVIDER CCN:	PERIOD:	WORKSHEET S-11
							______________	FROM ___________	PART II
							COMPONENT CCN:	TO ___________
							______________
							SUBCOMPONENT CCN:
							______________
PART II - HOSPITAL-BASED FQHC CONSOLIDATED COST REPORT PARTICIPANT IDENTIFICATION DATA
					Date	Type of control	Date	V/I	Date of
					Certified	(see instructions)	Decertified	Decertification	CHOW
	1				2	3	4	5	6
1	Site Name:									1
2	Street:	P.O. Box:								2
3	City:	State:	ZIP Code:	County:		Designation - Enter "R" for rural or "U" for urban:				3
Hospital-Based FQHC Operations							1	2	3
4	What type of organization is this hospital-based FQHC? If you operate as more than one sub-type of an organization, enter only the applicable									4
	alpha characters in column 2. (see instructions)
5	Did this hospital-based FQHC receive a grant under §330 of the PHS Act during this cost reporting period? Enter "Y" for yes or "N" for no. (complete line 6)									5
6	If the response to line 5 is yes, indicate in column 1, the type of HRSA grant that was awarded (see instructions). Enter the date of the grant award in									6
	column 2 and enter the grant award number in column 3. If you received more than one grant subscript this line accordingly.
Medical Malpractice
7	Did this hospital-based FQHC submit an initial deeming or annual redeeming application for medical malpractice coverage under the FTCA with HRSA?									7
	Enter "Y" for yes or "N" for no in column 1. If column 1 is yes, enter the effective date of coverage in column 2.
Interns and Residents
8	Did this hospital-based FQHC receive a THC development grant authorized under Part C of Title VII of the PHS Act from HRSA?									8
	Enter "Y" for yes or "N" for no in column 1. If yes, enter in column 2 the number of FTE residents that your FQHC trained and received funding through
	your THC grant in this cost reporting period and in column 3, enter the total number of visits performed by residents funded by the THC grant
	in this cost reporting period. (see instructions)
FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4010.2)
Rev. 22										40-523.2

---

Sheet 17: S-11PIII

4090 (Cont.)				FORM CMS-2552-10					02-24
HOSPITAL-BASED FQHC IDENTIFICATION DATA						PROVIDER CCN:	PERIOD:	WORKSHEET S-11
						___________	FROM ___________	PART III
						COMPONENT CCN:	TO ___________
						______________
PART III - HOSPITAL-BASED FQHC STATISTICAL DATA
								Total
			COMPONENT		Title	Title		All
			CCN	Title V	XVIII	XIX	Other	Patients
			0	1	2	3	4	5
1	Medical Visits								1
2	Total Medical Visits								2
3	Mental Health Visits								3
4	Total Mental Health Visits								4
5	IOP Visits								5
6	Total IOP Visits								6
7	Total FQHC Visits (sum of lines 2, 4, and 6)								7
FORM CMS-2552-10 (02-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4010.3)
40-523.3									Rev. 22
01-22				FORM CMS-2552-10					4090 (Cont.)
This page is reserved for future use.
FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4010.3)
Rev. 17									40-523.4

---

Sheet 18: A

4090 (Cont.)							FORM CMS-2552-10						01-22
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES										PROVIDER CCN:	PERIOD:	WORKSHEET A
										________________	FROM ____________
											TO _______________
										RECLASSIFIED		NET EXPENSES
		COST CENTER DESCRIPTIONS						TOTAL	RECLASSIFI-	TRIAL BALANCE		FOR ALLOCATION
		(omit cents)				SALARIES	OTHER	(col. 1 + col. 2)	CATIONS	(col. 3 ± col. 4)	ADJUSTMENTS	(col. 5 ± col. 6)
						1	2	3	4	5	6	7
		GENERAL SERVICE COST CENTERS
1	00100	Capital Related Costs-Buildings and Fixtures											1
2	00200	Capital Related Costs-Movable Equipment											2
3	00300	Other Capital Related Costs										-0-	3
4	00400	Employee Benefits Department											4
5	00500	Administrative and General											5
6	00600	Maintenance and Repairs											6
7	00700	Operation of Plant											7
8	00800	Laundry and Linen Service											8
9	00900	Housekeeping											9
10	01000	Dietary											10
11	01100	Cafeteria											11
12	01200	Maintenance of Personnel											12
13	01300	Nursing Administration											13
14	01400	Central Services and Supply											14
15	01500	Pharmacy											15
16	01600	Medical Records & Medical Records Library											16
17	01700	Social Service											17
18		Other General Service (specify)											18
19	01900	Nonphysician Anesthetists											19
20	02000	Nursing Program											20
21	02100	Intern & Res. Service-Salary & Fringes (Approved)											21
22	02200	Intern & Res. Other Program Costs (Approved)											22
23		Paramedical Ed. Program (specify)											23
		INPATIENT ROUTINE SERVICE COST CENTERS
30	03000	Adults and Pediatrics (General Routine Care)											30
31	03100	Intensive Care Unit											31
32	03200	Coronary Care Unit											32
33	03300	Burn Intensive Care Unit											33
34	03400	Surgical Intensive Care Unit											34
35		Other Special Care (specify)											35
40	04000	Subprovider - IPF											40
41	04100	Subprovider - IRF											41
42		Subprovider (specify)											42
43	04300	Nursery											43
44	04400	Skilled Nursing Facility											44
45	04500	Nursing Facility											45
46	04600	Other Long Term Care											46
FORM CMS-2552-10 (01-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4013)
40-524													Rev. 17
12-22							FORM CMS-2552-10						4090 (Cont.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES										PROVIDER CCN:	PERIOD:	WORKSHEET A
										________________	FROM ____________
											TO _______________
										RECLASSIFIED		NET EXPENSES
		COST CENTER DESCRIPTIONS						TOTAL	RECLASSIFI-	TRIAL BALANCE		FOR ALLOCATION
		(omit cents)				SALARIES	OTHER	(col. 1 + col. 2)	CATIONS	(col. 3 ± col. 4)	ADJUSTMENTS	(col. 5 ± col. 6)
						1	2	3	4	5	6	7
		ANCILLARY SERVICE COST CENTERS
50	05000	Operating Room											50
51	05100	Recovery Room											51
52	05200	Labor Room and Delivery Room											52
53	05300	Anesthesiology											53
54	05400	Radiology-Diagnostic											54
55	05500	Radiology-Therapeutic											55
56	05600	Radioisotope											56
57	05700	Computed Tomography (CT) Scan											57
58	05800	Magnetic Resonance Imaging (MRI)											58
59	05900	Cardiac Catheterization											59
60	06000	Laboratory											60
61	06100	PBP Clinical Laboratory Services-Program Only											61
62	06200	Whole Blood & Packed Red Blood Cells											62
63	06300	Blood Storing, Processing, & Trans.											63
64	06400	Intravenous Therapy											64
65	06500	Respiratory Therapy											65
66	06600	Physical Therapy											66
67	06700	Occupational Therapy											67
68	06800	Speech Pathology											68
69	06900	Electrocardiology											69
70	07000	Electroencephalography											70
71	07100	Medical Supplies Charged to Patients											71
72	07200	Implantable Devices Charged to Patients											72
73	07300	Drugs Charged to Patients											73
74	07400	Renal Dialysis											74
75	07500	ASC (Non-Distinct Part)											75
76		Other Ancillary (specify)											76
77	07700	Allogeneic HSCT Acquisition											77
78	07800	CAR T-Cell Immunotherapy											78
		OUTPATIENT SERVICE COST CENTERS
88	08800	Rural Health Clinic (RHC)											88
89	08900	Federally Qualified Health Center (FQHC)											89
90	09000	Clinic											90
91	09100	Emergency											91
92	09200	Observation Beds											92
93		Other Outpatient Service (specify)											93
93.99	09399	Partial Hospitalization Program											93.99
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4013)
Rev. 18													40-525
4090 (Cont.)							FORM CMS-2552-10						12-22
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES										PROVIDER CCN:	PERIOD:	WORKSHEET A
										________________	FROM ____________
											TO _____________
										RECLASSIFIED		NET EXPENSES
		COST CENTER DESCRIPTIONS						TOTAL	RECLASSIFI-	TRIAL BALANCE		FOR ALLOCATION
		(omit cents)				SALARIES	OTHER	(col. 1 + col. 2)	CATIONS	(col. 3 ± col. 4)	ADJUSTMENTS	(col. 5 ± col. 6)
						1	2	3	4	5	6	7
		OTHER REIMBURSABLE COST CENTERS
94	09400	Home Program Dialysis											94
95	09500	Ambulance Services											95
96	09600	Durable Medical Equipment-Rented											96
97	09700	Durable Medical Equipment-Sold											97
98		Other Reimbursable (specify)											98
99		Outpatient Rehabilitation Provider (specify)											99
100	10000	Intern-Resident Service (not appvd. tchng. prgm.)											100
101	10100	Home Health Agency											101
102	10200	Opioid Treatment Program											102
		SPECIAL PURPOSE COST CENTERS
105	10500	Kidney Acquisition											105
106	10600	Heart Acquisition											106
107	10700	Liver Acquisition											107
108	10800	Lung Acquisition											108
109	10900	Pancreas Acquisition											109
110	11000	Intestinal Acquisition											110
111	11100	Islet Acquisition											111
112		Other Organ Acquisition (specify)											112
113	11300	Interest Expense										- 0 -	113
114	11400	Utilization Review-SNF										- 0 -	114
115	11500	Ambulatory Surgical Center (Distinct Part)											115
116	11600	Hospice											116
117		Other Special Purpose (specify)											117
118		SUBTOTALS (sum of lines 1 through 117)											118
		NONREIMBURSABLE COST CENTERS
190	19000	Gift, Flower, Coffee Shop, & Canteen											190
191	19100	Research											191
192	19200	Physicians' Private Offices											192
193	19300	Nonpaid Workers											193
194		Other Nonreimbursable (specify)											194
200		TOTAL (sum of lines 118 through 199)							- 0 -				200
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4013)
40-526													Rev. 18

---

Sheet 19: A6

10-12																																FORM CMS-2552-10																																												4090 (Cont.)
RECLASSIFICATIONS																																																				PROVIDER CCN:								PERIOD:								WORKSHEET A-6
																																																				________________								FROM ____________
																																																												TO _______________
																								INCREASES																								DECREASES
																					CODE											WKST. A																								WKST. A																WKST. A-7
	EXPLANATION OF RECLASSIFICATION(S)																				(1)			COST CENTER								LINE #				SALARY						OTHER						COST CENTER								LINE #				SALARY						OTHER						REF.
																					1			2								3				4						5						6								7				8						9						10
1																																																																												1
2																																																																												2
3																																																																												3
4																																																																												4
5																																																																												5
6																																																																												6
7																																																																												7
8																																																																												8
9																																																																												9
10																																																																												10
11																																																																												11
12																																																																												12
13																																																																												13
14																																																																												14
15																																																																												15
16																																																																												16
17																																																																												17
18																																																																												18
19																																																																												19
20																																																																												20
21																																																																												21
22																																																																												22
23																																																																												23
24																																																																												24
25																																																																												25
26																																																																												26
27																																																																												27
28																																																																												28
29																																																																												29
30																																																																												30
31																																																																												31
32																																																																												32
33																																																																												33
34																																																																												34
35																																																																												35
500	Total reclassifications (sum of columns 4 and 5																																																																											500
	must equal sum of columns 8 and 9)
(1)	A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
	Transfer the amounts in columns 4, 5, 8, and 9 to Worksheet A, column 4, lines as appropriate.
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4014)
Rev. 3																																																																												40-527

---

Sheet 20: A7I, II &III

4090 (Cont.)						FORM CMS-2552-10						10-12
RECONCILIATION OF CAPITAL COSTS CENTERS									PROVIDER CCN:	PERIOD:	WORKSHEET A-7,
									________________	FROM ____________	PARTS I, II & III
										TO _______________
PART I - ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCES
						Acquisitions			Disposals		Fully
					Beginning				and	Ending	Depreciated
	Description				Balances	Purchases	Donation	Total	Retirements	Balance	Assets
					1	2	3	4	5	6	7
1	Land											1
2	Land Improvements											2
3	Buildings and Fixtures											3
4	Building Improvements											4
5	Fixed Equipment											5
6	Movable Equipment											6
7	HIT-designated Assets											7
8	Subtotal (sum of lines 1 through 7)											8
9	Reconciling Items											9
10	Total (line 7 minus line 9)											10
PART II - RECONCILIATION OF AMOUNTS FROM WORKSHEET A, COLUMN 2, LINES 1 AND 2
					SUMMARY OF CAPITAL
										Other Capital-	Total (1)
								Insurance	Taxes	Related Costs	(sum of
	Description				Depreciation	Lease	Interest	(see instructions)	(see instructions)	(see instructions)	cols. 9 through 14)
*					9	10	11	12	13	14	15
1	Capital Related Costs-Buildings and Fixtures											1
2	Capital Related Costs-Movable Equipment											2
3	Total (sum of lines 1 and 2)											3
(1)	The amount in columns 9 through 14 must equal the amount on Worksheet A, column 2, lines 1 and 2. Enter in each column the appropriate amounts including any directly assigned cost that may have been included in Worksheet A,
	column 2, lines 1 and 2.
*	All lines numbers are to be consistent with Worksheet A line numbers for capital cost centers.
PART III - RECONCILIATION OF CAPITAL COSTS CENTERS
				COMPUTATION OF RATIOS				ALLOCATION OF OTHER CAPITAL
						Gross Assets					Total
					Capitalized	for Ratio	Ratio			Other Capital-	(sum of
	Description			Gross Assets	Leases	(col. 1 - col. 2)	(see instructions)	Insurance	Taxes	Related Costs	cols. 5 through 7)
*				1	2	3	4	5	6	7	8
1	Capital Related Costs-Buildings and Fixtures											1
2	Capital Related Costs-Movable Equipment											2
3	Total (sum of lines 1 and 2)						1.000000					3
					SUMMARY OF CAPITAL
										Other Capital-	Total (2)
								Insurance	Taxes	Related Costs	(sum of
	Description				Depreciation	Lease	Interest	(see instructions)	(see instructions)	(see instructions)	cols. 9 through 14)
*					9	10	11	12	13	14	15
1	Capital Related Costs-Buildings and Fixtures											1
2	Capital Related Costs-Movable Equipment											2
3	Total (sum of lines 1 and 2)											3
(2)	The amounts on lines 1 and 2 must equal the corresponding amounts on Worksheet A, column 7, lines 1 and 2. Columns 9 through 14 should include related
	Worksheet A-6 reclassifications, Worksheet A-8 adjustments, and Worksheet A-8-1 related organizations and home office costs. (See instructions.)
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4015)
40-528												Rev. 3

---

Sheet 21: A8

03-18		FORM CMS-2552-10									4090 (Cont.)
ADJUSTMENTS TO EXPENSES			PROVIDER CCN:		PERIOD:			WORKSHEET A-8
			________________		FROM ____________
					TO _______________
				EXPENSE CLASSIFICATION ON
	DESCRIPTION (1)			WORKSHEET A TO/FROM WHICH						Wkst.
		BASIS /		THE AMOUNT IS TO BE ADJUSTED						A-7
		CODE (2)	AMOUNT	COST CENTER					LINE #	Ref.
		1	2	3					4	5
1	Investment income - buildings and fixtures (chapter 2)			Buildings and Fixtures					1		1
2	Investment income - movable equipment (chapter 2)			Movable Equipment					2		2
3	Investment income - other (chapter 2)										3
4	Trade, quantity, and time discounts (chapter 8)										4
5	Refunds and rebates of expenses (chapter 8)										5
6	Rental of provider space by suppliers (chapter 8)										6
7	Telephone services (pay stations excluded) (chapter 21)										7
8	Television and radio service (chapter 21)										8
9	Parking lot (chapter 21)										9
10	Provider-based physician adjustment	Worksheet A-8-2									10
11	Sale of scrap, waste, etc. (chapter 23)										11
12	Related organization transactions (chapter 10)	Worksheet A-8-1									12
13	Laundry and linen service										13
14	Cafeteria-employees and guests										14
15	Rental of quarters to employee and others										15
16	Sale of medical and surgical										16
	supplies to other than patients
17	Sale of drugs to other than patients										17
18	Sale of medical records and abstracts										18
19	Nursing and allied health education (tuition,										19
	fees, books, etc.)
20	Vending machines										20
21	Income from imposition of interest,										21
	finance or penalty charges (chapter 21)
22	Interest expense on Medicare overpayments and										22
	borrowings to repay Medicare overpayments
23	Adjustment for respiratory therapy										23
	costs in excess of limitation (chapter 14)	Worksheet A-8-3		Respiratory Therapy					65
24	Adjustment for physical therapy costs										24
	in excess of limitation (chapter 14)	Worksheet A-8-3		Physical Therapy					66
25	Utilization review - physicians' compensation (chapter 21)			Utilization Review - SNF					114		25
26	Depreciation - buildings and fixtures			Buildings and Fixtures					1		26
27	Depreciation - movable equipment			Movable Equipment					2		27
28	Non-physician Anesthetist			Nonphysician Anesthetist					19		28
29	Physicians' assistant										29
30	Adjustment for occupational therapy costs										30
	in excess of limitation (chapter 14)	Worksheet A-8-3		Occupational Therapy					67
30.99	Hospice (non-distinct) (see instructions)			Adults and Pediatrics					30		30.99
31	Adjustment for speech pathology costs										31
	in excess of limitation (chapter 14)	Worksheet A-8-3		Speech Pathology					68
32	CAH HIT adjustment for depreciation										32
33	Other adjustments (specify) (3)										33
50	TOTAL (sum of lines 1 through 49)										50
	(Transfer to Worksheet A, column 6, line 200)
(1)	Description - all chapter references in this column pertain to CMS Pub. 15-1
(2)	Basis for adjustment (see instructions)
	A. Costs - if cost, including applicable overhead, can be determined
	B. Amount Received - if cost cannot be determined
(3)	Additional adjustments may be made on lines 33 through 49 and subscripts thereof.
	Note: See instructions for column 5 referencing to Worksheet A-7.
FORM CMS-2552-10 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4016)
Rev. 14											40-529

---

Sheet 22: A81

4090 (Cont.)

FORM CMS-2552-10

03-18

STATEMENT OF COSTS OF SERVICES

PROVIDER CCN:

PERIOD:

WORKSHEET A-8-1

FROM RELATED ORGANIZATIONS AND

________________

FROM ____________

HOME OFFICE COSTS

TO _______________

A.

COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS

OR CLAIMED HOME OFFICE COSTS:

Amount

Net

Amount of

included in

Adjustments

Allowable

Wkst. A

(col. 4 minus

Wkst. A-7

Line No.

Cost Center

Expense Items

Cost

column 5

col. 5) *

Ref.

1

2

3

4

5

6

7

1

1

2

2

3

3

4

4

5

TOTALS (sum of lines 1 through 4) Transfer column 6, line 5, to Worksheet A-8, column 2, line 12.

5

*

The amounts on lines 1 through 4 (and subscripts as appropriate) are transferred in detail to Worksheet A, column 6, lines as appropriate.

Positive amounts increase cost and negative amounts decrease cost. For related organization or home office cost which have not

been posted to Worksheet A, columns 1 and/or 2, the amount allowable should be indicated in column 4 of this part.

B.

INTERRELATIONSHIP TO RELATED ORGANIZATION(S) AND/OR HOME OFFICE:

The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires that you furnish

the information requested under Part B of this worksheet.

This information is used by the Centers for Medicare and Medicaid Services and its intermediaries/contractors in determining that the costs applicable to

services, facilities, and supplies furnished by organizations related to you by common ownership or control represent reasonable costs as determined under

section 1861 of the Social Security Act. If you do not provide all or any part of the requested information, the cost report is considered incomplete and not

acceptable for purposes of claiming reimbursement under title XVIII.

Related Organization(s) and/or Home Office

Percentage

Percentage

Symbol

of

of

Type of

(1)

Name

Ownership

Name

Ownership

Business

1

2

3

4

5

6

6

6

7

7

8

8

9

9

10

10

(1)

Use the following symbols to indicate interrelationship to related organizations:

A. Individual has financial interest (stockholder, partner, etc.) in both related

organization and in provider.

B. Corporation, partnership, or other organization has financial interest in provider.

C. Provider has financial interest in corporation, partnership, or other organization.

D. Director, officer, administrator, or key person of provider or relative of such

person has financial interest in related organization.

E. Individual is director, officer, administrator, or key person of provider and

related organization.

F. Director, officer, administrator, or key person of related organization or relative

of such person has financial interest in provider.

G. Other (financial or non-financial) specify __________________________________________________

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4017)

40-530

Rev. 14

---

Sheet 23: A82

10-12						FORM CMS-2552-10						4090 (Cont.)
PROVIDER-BASED PHYSICIANS ADJUSTMENTS									PROVIDER CCN:	PERIOD:	WORKSHEET A-8-2
									________________	FROM ____________
										TO _______________
		Cost Center/							Physician/		5 Percent of
	Wkst. A	Physician			Total	Professional	Provider	RCE	Provider	Unadjusted	Unadjusted
	Line #	Identifier			Remuneration	Component	Component	Amount	Component Hours	RCE Limit	RCE Limit
	1	2			3	4	5	6	7	8	9
1												1
2												2
3												3
4												4
5												5
6												6
7												7
8												8
9												9
10												10
11												11
200	TOTAL											200
					Cost of	Provider	Physician	Provider
		Cost Center/			Memberships	Component	Cost of	Component
	Wkst. A	Physician			& Continuing	Share of	Malpractice	Share of	Adjusted	RCE
	Line #	Identifier			Education	col. 12	Insurance	col. 14	RCE Limit	Disallowance	Adjustment
	10	11			12	13	14	15	16	17	18
1												1
2												2
3												3
4												4
5												5
6												6
7												7
8												8
9												9
10												10
11												11
200	TOTAL											200
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4018)
Rev. 3												40-531

---

Sheet 24: A83

4090 (Cont.)						FORM CMS-2552-10						10-12
REASONABLE COST DETERMINATION FOR THERAPY SERVICES									PROVIDER CCN:	PERIOD:	WORKSHEET A-8-3,
FURNISHED BY OUTSIDE SUPPLIERS									________________	FROM ____________	PARTS I & II
										TO _______________
Check applicable box:		[ ] Occupational [ ] Physical [ ] Respiratory [ ] Speech Pathology
PART I - GENERAL INFORMATION
1	Total number of weeks worked (excluding aides) (see instructions)											1
2	Line 1 multiplied by 15 hours per week											2
3	Number of unduplicated days in which supervisor or therapist was on provider site (see instructions)											3
4	Number of unduplicated days in which therapy assistant was on provider site but neither supervisor nor therapist was on provider site (see instructions)											4
5	Number of unduplicated offsite visits - supervisors or therapists (see instructions)											5
6	Number of unduplicated offsite visits - therapy assistants (include only visits made by therapy assistant and on which											6
	supervisor and/or therapist was not present during the visit(s)) (see instructions)
7	Standard travel expense rate											7
8	Optional travel expense rate per mile											8
							Supervisors	Therapists	Assistants	Aides	Trainees
							1	2	3	4	5
9	Total hours worked											9
10	AHSEA (see instructions)											10
11	Standard travel allowance (columns 1 and 2, one-half of column 2,											11
	line 10; column 3, one-half of column 3, line 10)
12	Number of travel hours (see instructions)											12
13	Number of miles driven (see instructions)											13
PART II - SALARY EQUIVALENCY COMPUTATION
14	Supervisors (column 1, line 9 times column 1, line 10)											14
15	Therapists (column 2, line 9 times column 2, line 10)											15
16	Assistants (column 3, line 9 times column 3, line10)											16
17	Subtotal allowance amount (sum of lines 14 and 15 for respiratory therapy or lines 14-16 for all others)											17
18	Aides (column 4, line 9 times column 4, line 10)											18
19	Trainees (column 5, line 9 times column 9, line 10)											19
20	Total allowance amount (sum of lines 17-19 for respiratory therapy or lines 17 and 18 for all others)											20
	If the sum of columns 1 and 2 for respiratory therapy or columns 1 through 3 for physical therapy, speech pathology or occupational therapy, line 9, is greater than line 2, make no entries on lines 21 and 2, and enter on line 23
	the amount from line 20. Otherwise complete lines 21 through 23.
21	Weighted average rate excluding aides and trainees (line 17 divided by sum of columns 1 and 2, line 9 for respiratory therapy or columns 1 through 3, line 9 for all others)											21
22	Weighted allowance excluding aides and trainees (line 2 times line 21)											22
23	Total salary equivalency (see instructions)											23
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4019)
40-532												Rev. 3
03-16						FORM CMS-2552-10						4090 (Cont.)
REASONABLE COST DETERMINATION FOR THERAPY SERVICES									PROVIDER CCN:	PERIOD:	WORKSHEET A-8-3,
FURNISHED BY OUTSIDE SUPPLIERS									________________	FROM ____________	PARTS III & IV
										TO _______________
Check applicable box:		[ ] Occupational [ ] Physical [ ] Respiratory [ ] Speech Pathology
PART III - STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - PROVIDER SITE
Standard Travel Allowance
24	Therapists (line 3 times column 2, line 11)											24
25	Assistants (line 4 times column 3, line 11)											25
26	Subtotal (line 24 for respiratory therapy or sum of lines 24 and 25 for all others)											26
27	Standard travel expense (line 7 times line 3 for respiratory therapy or sum of lines 3 and 4 for all others)											27
28	Total standard travel allowance and standard travel expense at the provider site (sum of lines 26 and 27)											28
Optional Travel Allowance and Optional Travel Expense
29	Therapists (column 2, line 10 times the sum of columns 1 and 2, line 12 )											29
30	Assistants (column 3, line 10 times column 3, line 12)											30
31	Subtotal (line 29 for respiratory therapy or sum of lines 29 and 30 for all others)											31
32	Optional travel expense (line 8 times columns 1 and 2, line 13 for respiratory therapy or sum of columns 1-3, line 13 for all others)											32
33	Standard travel allowance and standard travel expense (line 28)											33
34	Optional travel allowance and standard travel expense (sum of lines 27 and 31)											34
35	Optional travel allowance and optional travel expense (sum of lines 31 and 32)											35
PART IV - STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - SERVICES OUTSIDE PROVIDER SITE
Standard Travel Expense
36	Therapists (line 5 times column 2, line 11)											36
37	Assistants (line 6 times column 3, line 11)											37
38	Subtotal (sum of lines 36 and 37)											38
39	Standard travel expense (line 7 times the sum of lines 5 and 6)											39
Optional Travel Allowance and Optional Travel Expense
40	Therapists (sum of columns 1 and 2, line 12.01 times column 2, line 10)											40
41	Assistants (column 3, line 12.01 times column 3, line 10)											41
42	Subtotal (sum of lines 40 and 41)											42
43	Optional travel expense (line 8 times the sum of columns 1-3, line 13.01)											43
Total Travel Allowance and Travel Expense - Offsite Services: Complete one of the following three lines 44, 45, or 46, as appropriate.
44	Standard travel allowance and standard travel expense (sum of lines 38 and 39) (see instructions)											44
45	Optional travel allowance and standard travel expense (sum of lines 39 and 42) (see instructions)											45
46	Optional travel allowance and optional travel expense (sum of lines 42 and 43) (see instructions)											46
FORM CMS-2552-10 (03-2016) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4019)
Rev. 9												40-533
4090 (Cont.)						FORM CMS-2552-10						03-16
REASONABLE COST DETERMINATION FOR THERAPY SERVICES									PROVIDER CCN:	PERIOD:	WORKSHEET A-8-3,
FURNISHED BY OUTSIDE SUPPLIERS									________________	FROM ____________	PARTS V-VI
										TO _______________
Check applicable box:		[ ] Occupational [ ] Physical [ ] Respiratory [ ] Speech Pathology
PART V - OVERTIME COMPUTATION
							Therapists	Assistants	Aides	Trainees	Total
							1	2	3	4	5
47	Overtime hours worked during reporting period (if column 5, line 47, is zero or equal to or great than 2,080, do not complete											47
	lines 48-55 and enter zero in each column of line 56)
48	Overtime rate (see instructions)											48
49	Total overtime (including base and overtime allowance) (multiply line 47 times line 48)											49
CALCULATION OF LIMIT
50	Percentage of overtime hours by category (divide the hours in each column on line 47 by the total overtime worked in column 5, line 47.											50
51	Allocation of provider's standard work year for one full-time employee times the percentages on line 50) (see instructions)											51
DETERMINATION OF OVERTIME ALLOWANCE
52	Adjusted hourly salary equivalency amount (see instructions)											52
53	Overtime cost limitation (line 51 times line 52)											53
54	Maximum overtime cost (enter the lesser of line 49 or line 53)											54
55	Portion of overtime already included in hourly computation at the AHSEA (multiply											55
	line 47 times line 52)
56	Overtime allowance (line 54 minus line 55 - if negative enter zero) ( Enter in column 5, the sum of columns 1, 3, and 4, for respiratory											56
	therapy, and columns 1 through 3 for all others.)
PART VI - COMPUTATION OF THERAPY LIMITATION AND EXCESS COST ADJUSTMENT
57	Salary equivalency amount (from line 23)											57
58	Travel allowance and expense - provider site (from lines 33, 34, or 35))											58
59	Travel allowance and expense - Offsite services (from lines 44, 45, or 46)											59
60	Overtime allowance (from column 5, line 56)											60
61	Equipment cost (see instructions)											61
62	Supplies (see instructions)											62
63	Total allowance (sum of lines 57-62)											63
64	Total cost of outside supplier services (from provider records)											64
65	Excess over limitation (line 64 minus line 63; if negative, enter zero)											65
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4019)
40-534												Rev. 9

---

Sheet 25: BI

12-22						FORM CMS-2552-10						4090 (Cont.)	4090 (Cont.)							FORM CMS-2552-10							12-22	12-22						FORM CMS-2552-10							4090 (Cont.)
COST ALLOCATION - GENERAL SERVICE COSTS									PROVIDER CCN:	PERIOD:	WORKSHEET B,		COST ALLOCATION - GENERAL SERVICE COSTS											PROVIDER CCN:	PERIOD:	WORKSHEET B,		COST ALLOCATION - GENERAL SERVICE COSTS										PROVIDER CCN:	PERIOD:	WORKSHEET B,
									________________	FROM ____________	PART I													________________	FROM ____________	PART I												________________	FROM ____________	PART I
										TO _______________															TO _______________														TO _______________
				NET EXPENSES	CAPITAL																																		INTERN &
				FOR COST	RELATED COSTS																												NON-		INTERNS &	INTERNS &			RESIDENT
				ALLOCATION			EMPLOYEE		ADMINIS-	MAIN-							LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL							OTHER	PHYSICIAN		RESIDENTS	RESIDENTS	PARAMEDICAL		COST & POST
	COST CENTER DESCRIPTIONS			(from Wkst.	BLDGS. &	MOVABLE	BENEFITS	SUBTOTAL	TRATIVE &	TENANCE &	OPERATION			COST CENTER DESCRIPTIONS			& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL			COST CENTER DESCRIPTIONS			GENERAL	ANES-	NURSING	SALARY AND	PROGRAM	EDUCATION		STEPDOWN
				A col. 7)	FIXTURES	EQUIPMENT	DEPARTMENT	(cols. 0-4)	GENERAL	REPAIRS	OF PLANT						SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE						SERVICE	THETISTS	PROGRAM	FRINGES	COSTS	(SPECIFY)	SUBTOTAL	ADJUSTMENTS	TOTAL
				0	1	2	4	4A	5	6	7						8	9	10	11	12	13	14	15	16	17						18	19	20	21	22	23	24	25	26
	GENERAL SERVICE COST CENTERS													GENERAL SERVICE COST CENTERS															GENERAL SERVICE COST CENTERS
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 Department											4	4	Employee Benefits Department													4	4	Employee Benefits Department												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 Program											20	20	Nursing Program													20	20	Nursing Program												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 Education Program (specify)											23	23	Paramedical Education Program (specify)													23	23	Paramedical Education Program (specify)												23
	INPATIENT ROUTINE SERVICE COST CENTERS													INPATIENT ROUTINE SERVICE COST CENTERS															INPATIENT ROUTINE SERVICE COST CENTERS
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 (specify)											42	42	Subprovider (specify)													42	42	Subprovider (specify)												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 (01-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)													FORM CMS-2552-10 (01-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)															FORM CMS-2552-10 (01-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)
Rev. 18												40-535	40-538														Rev. 18	Rev. 18													40-541
4090 (Cont.)						FORM CMS-2552-10						12-22	12-22							FORM CMS-2552-10							4090 (Cont.)	4090 (Cont.)						FORM CMS-2552-10							12-22
COST ALLOCATION - GENERAL SERVICE COSTS									PROVIDER CCN:	PERIOD:	WORKSHEET B,		COST ALLOCATION - GENERAL SERVICE COSTS											PROVIDER CCN:	PERIOD:	WORKSHEET B,		COST ALLOCATION - GENERAL SERVICE COSTS										PROVIDER CCN:	PERIOD:	WORKSHEET B,
									________________	FROM ____________	PART I													________________	FROM ____________	PART I												________________	FROM ____________	PART I
										TO _______________															TO _______________														TO _______________
				NET EXPENSES	CAPITAL																																		INTERN &
				FOR COST	RELATED COSTS																												NON-		INTERNS &	INTERNS &			RESIDENT
				ALLOCATION			EMPLOYEE		ADMINIS-	MAIN-							LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL							OTHER	PHYSICIAN		RESIDENTS	RESIDENTS	PARAMEDICAL		COST & POST
	COST CENTER DESCRIPTIONS			(from Wkst.	BLDGS. &	MOVABLE	BENEFITS	SUBTOTAL	TRATIVE &	TENANCE &	OPERATION			COST CENTER DESCRIPTIONS			& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL			COST CENTER DESCRIPTIONS			GENERAL	ANES-	NURSING	SALARY AND	PROGRAM	EDUCATION		STEPDOWN
				A col. 7)	FIXTURES	EQUIPMENT	DEPARTMENT	(cols. 0-4)	GENERAL	REPAIRS	OF PLANT						SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE						SERVICE	THETISTS	PROGRAM	FRINGES	COSTS	(SPECIFY)	SUBTOTAL	ADJUSTMENTS	TOTAL
				0	1	2	4	4A	5	6	7						8	9	10	11	12	13	14	15	16	17						18	19	20	21	22	23	24	25	26
	ANCILLARY SERVICE COST CENTERS													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 Catheterization											59	59	Cardiac Catheterization													59	59	Cardiac Catheterization												59
60	Laboratory											60	60	Laboratory													60	60	Laboratory												60
61	PBP Clinical Laboratory Services-Program Only											61	61	PBP Clinical Laboratory Services-Program Only													61	61	PBP Clinical Laboratory Services-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											82	72	Implantable Devices Charged to Patients													82	72	Implantable Devices Charged to Patients												82
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
77	Allogeneic HSCT Acquisition											77	77	Allogeneic HSCT Acquisition													77	77	Allogeneic HSCT Acquisition												77
78	CAR T-Cell Immunotherapy											78	78	CAR T-Cell Immunotherapy													78	78	CAR T-Cell Immunotherapy												78
	OUTPATIENT SERVICE COST CENTERS													OUTPATIENT SERVICE COST CENTERS															OUTPATIENT SERVICE COST CENTERS
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 Service (specify)											93	93	Other Outpatient Service (specify)													93	93	Other Outpatient Service (specify)												93
93.99	Partial Hospitalization Program											93.99	93.99	Partial Hospitalization Program													93.99	93.99	Partial Hospitalization Program												93.99
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)													FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)															FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)
40-536												Rev. 18	Rev. 18														40-539	40-542													Rev. 18
12-22						FORM CMS-2552-10						4090 (Cont.)	4090 (Cont.)							FORM CMS-2552-10							12-22	12-22						FORM CMS-2552-10							4090 (Cont.)
COST ALLOCATION - GENERAL SERVICE COSTS									PROVIDER CCN:	PERIOD:	WORKSHEET B,		COST ALLOCATION - GENERAL SERVICE COSTS											PROVIDER CCN:	PERIOD:	WORKSHEET B,		COST ALLOCATION - GENERAL SERVICE COSTS										PROVIDER CCN:	PERIOD:	WORKSHEET B,
									________________	FROM ____________	PART I													________________	FROM ____________	PART I												________________	FROM ____________	PART I
										TO _______________															TO _______________														TO _______________
				NET EXPENSES	CAPITAL																																		INTERN &
				FOR COST	RELATED COSTS																												NON-		INTERNS &	INTERNS &			RESIDENT
				ALLOCATION			EMPLOYEE		ADMINIS-	MAIN-							LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL							OTHER	PHYSICIAN		RESIDENTS	RESIDENTS	PARAMEDICAL		COST & POST
	COST CENTER DESCRIPTIONS			(from Wkst.	BLDGS. &	MOVABLE	BENEFITS	SUBTOTAL	TRATIVE &	TENANCE &	OPERATION			COST CENTER DESCRIPTIONS			& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL			COST CENTER DESCRIPTIONS			GENERAL	ANES-	NURSING	SALARY AND	PROGRAM	EDUCATION		STEPDOWN
				A col. 7)	FIXTURES	EQUIPMENT	DEPARTMENT	(cols. 0-4)	GENERAL	REPAIRS	OF PLANT						SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE						SERVICE	THETISTS	PROGRAM	FRINGES	COSTS	(SPECIFY)	SUBTOTAL	ADJUSTMENTS	TOTAL
				0	1	2	4	4A	5	6	7						8	9	10	11	12	13	14	15	16	17						18	19	20	21	22	23	24	25	26
	OTHER REIMBURSABLE COST CENTERS													OTHER REIMBURSABLE COST CENTERS															OTHER REIMBURSABLE COST CENTERS
94	Home Program Dialysis											94	94	Home Program Dialysis													94	94	Home Program Dialysis												94
95	Ambulance Services											95	95	Ambulance Services													95	95	Ambulance Services												95
96	Durable Medical Equipment-Rented											96	96	Durable Medical Equipment-Rented													96	96	Durable Medical Equipment-Rented												96
97	Durable Medical Equipment-Sold											97	97	Durable Medical Equipment-Sold													97	97	Durable Medical Equipment-Sold												97
98	Other Reimbursable (specify)											98	98	Other Reimbursable (specify)													98	98	Other Reimbursable (specify)												98
99	Outpatient Rehabilitation Provider (specify)											99	99	Outpatient Rehabilitation Provider (specify)													99	99	Outpatient Rehabilitation Provider (specify)												99
100	Intern-Resident Service (not appvd. tchng. prgm.)											100	100	Intern-Resident Service (not appvd. tchng. prgm.)													100	100	Intern-Resident Service (not appvd. tchng. prgm.)												100
101	Home Health Agency											101	101	Home Health Agency													101	101	Home Health Agency												101
102	Opioid Treatment Program											102	102	Opioid Treatment Program													102	102	Opioid Treatment Program												102
	SPECIAL PURPOSE COST CENTERS													SPECIAL PURPOSE COST CENTERS															SPECIAL PURPOSE COST CENTERS
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 through 117)											118	118	SUBTOTALS (sum of lines 1 through 117)													118	118	SUBTOTALS (sum of lines 1 through 117)												118
	NONREIMBURSABLE COST CENTERS													NONREIMBURSABLE COST CENTERS															NONREIMBURSABLE COST CENTERS
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
200	Cross Foot Adjustments											200	200	Cross Foot Adjustments													200	200	Cross Foot Adjustments												200
201	Negative Cost Centers											201	201	Negative Cost Centers													201	201	Negative Cost Centers												201
202	TOTAL (sum lines 118 through 201)											202	202	TOTAL (sum lines 118 through 201)													202	202	TOTAL (sum lines 118 through 201)												202
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)													FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)															FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)
Rev. 18												40-537	40-540														Rev. 18	Rev. 18													40-543

---

Sheet 26: BII

4090 (Cont.)						FORM CMS-2552-10						12-22	12-22							FORM CMS-2552-10							4090 (Cont.)	4090 (Cont.)						FORM CMS-2552-10							12-22
ALLOCATION OF CAPITAL-RELATED COSTS									PROVIDER CCN:	PERIOD:	WORKSHEET B,		ALLOCATION OF CAPITAL-RELATED COSTS											PROVIDER CCN:	PERIOD:	WORKSHEET B,		ALLOCATION OF CAPITAL-RELATED COSTS										PROVIDER CCN:	PERIOD:	WORKSHEET B,
									________________	FROM ____________	PART II													________________	FROM ____________	PART II												________________	FROM ____________	PART II
										TO _______________															TO _______________														TO _______________
				DIRECTLY	CAPITAL																																		INTERN &
				ASSIGNED	RELATED COSTS																												NON-		INTERNS &	INTERNS &			RESIDENT
				NEW CAPITAL			SUBTOTAL	EMPLOYEE	ADMINIS-	MAIN-							LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL							OTHER	PHYSICIAN		RESIDENTS	RESIDENTS	PARAMEDICAL		COST & POST
	COST CENTER DESCRIPTIONS			RELATED	BLDGS. &	MOVABLE	(sum of	BENEFITS	TRATIVE &	TENANCE &	OPERATION			COST CENTER DESCRIPTIONS			& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL			COST CENTER DESCRIPTIONS			GENERAL	ANES-	NURSING	SALARY AND	PROGRAM	EDUCATION		STEPDOWN
				COSTS	FIXTURES	EQUIPMENT	(cols. 0-2)	DEPARTMENT	GENERAL	REPAIRS	OF PLANT						SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE						SERVICE	THETISTS	PROGRAM	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													GENERAL SERVICE COST CENTERS															GENERAL SERVICE COST CENTERS
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 Department											4	4	Employee Benefits Department													4	4	Employee Benefits Department												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 Program											20	20	Nursing Program													20	20	Nursing Program												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 Education Program (specify)											23	23	Paramedical Education Program (specify)													23	23	Paramedical Education Program (specify)												23
	INPATIENT ROUTINE SERVICE COST CENTERS													INPATIENT ROUTINE SERVICE COST CENTERS															INPATIENT ROUTINE SERVICE COST CENTERS
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)											36	35	Other Special Care Unit (specify)													36	35	Other Special Care Unit (specify)												36
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 (specify)											42	42	Subprovider (specify)													42	42	Subprovider (specify)												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 (01-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)													FORM CMS-2552-10 (01-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)															FORM CMS-2552-10 (01-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)
40-544												Rev. 18	Rev. 18														40-547	40-550													Rev. 18
12-22						FORM CMS-2552-10						4090 (Cont.)	4090 (Cont.)							FORM CMS-2552-10							12-22	12-22						FORM CMS-2552-10							4090 (Cont.)
ALLOCATION OF CAPITAL-RELATED COSTS									PROVIDER CCN:	PERIOD:	WORKSHEET B,		ALLOCATION OF CAPITAL-RELATED COSTS											PROVIDER CCN:	PERIOD:	WORKSHEET B,		ALLOCATION OF CAPITAL-RELATED COSTS										PROVIDER CCN:	PERIOD:	WORKSHEET B,
									________________	FROM ____________	PART II													________________	FROM ____________	PART II												________________	FROM ____________	PART II
										TO _______________															TO _______________														TO _______________
				DIRECTLY	CAPITAL																																		INTERN &
				ASSIGNED	RELATED COSTS																												NON-		INTERNS &	INTERNS &			RESIDENT
				NEW CAPITAL			SUBTOTAL	EMPLOYEE	ADMINIS-	MAIN-							LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL							OTHER	PHYSICIAN		RESIDENTS	RESIDENTS	PARAMEDICAL		COST & POST
	COST CENTER DESCRIPTIONS			RELATED	BLDGS. &	MOVABLE	(sum of	BENEFITS	TRATIVE &	TENANCE &	OPERATION			COST CENTER DESCRIPTIONS			& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL			COST CENTER DESCRIPTIONS			GENERAL	ANES-	NURSING	SALARY AND	PROGRAM	EDUCATION		STEPDOWN
				COSTS	FIXTURES	EQUIPMENT	(cols. 0-2)	DEPARTMENT	GENERAL	REPAIRS	OF PLANT						SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE						SERVICE	THETISTS	PROGRAM	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													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 Catheterization											59	59	Cardiac Catheterization													59	59	Cardiac Catheterization												59
60	Laboratory											60	60	Laboratory													60	60	Laboratory												60
61	PBP Clinical Laboratory Services-Program Only											61	61	PBP Clinical Laboratory Services-Program Only													61	61	PBP Clinical Laboratory Services-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
77	Allogeneic HSCT Acquisition											77	77	Allogeneic HSCT Acquisition													77	77	Allogeneic HSCT Acquisition												77
78	CAR T-Cell Immunotherapy											78	78	CAR T-Cell Immunotherapy													78	78	CAR T-Cell Immunotherapy												78
	OUTPATIENT SERVICE COST CENTERS													OUTPATIENT SERVICE COST CENTERS															OUTPATIENT SERVICE COST CENTERS
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 Service (specify)											93	93	Other Outpatient Service (specify)													93	93	Other Outpatient Service (specify)												93
93.99	Partial Hospitalization Program											93.99	93.99	Partial Hospitalization Program													93.99	93.99	Partial Hospitalization Program												93.99
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)													FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)															FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)
Rev. 18												40-545	40-548														Rev. 18	Rev. 18													40-551
4090 (Cont.)						FORM CMS-2552-10						12-22	12-22							FORM CMS-2552-10							4090 (Cont.)	4090 (Cont.)						FORM CMS-2552-10							12-22
ALLOCATION OF CAPITAL-RELATED COSTS									PROVIDER CCN:	PERIOD:	WORKSHEET B,		ALLOCATION OF CAPITAL-RELATED COSTS											PROVIDER CCN:	PERIOD:	WORKSHEET B,		ALLOCATION OF CAPITAL-RELATED COSTS										PROVIDER CCN:	PERIOD:	WORKSHEET B,
									________________	FROM ____________	PART II													________________	FROM ____________	PART II												________________	FROM ____________	PART II
										TO _______________															TO _______________														TO _______________
				DIRECTLY	CAPITAL																																		INTERN &
				ASSIGNED	RELATED COSTS																												NON-		INTERNS &	INTERNS &			RESIDENT
				NEW CAPITAL			SUBTOTAL	EMPLOYEE	ADMINIS-	MAIN-							LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL							OTHER	PHYSICIAN		RESIDENTS	RESIDENTS	PARAMEDICAL		COST & POST
	COST CENTER DESCRIPTIONS			RELATED	BLDGS. &	MOVABLE	(sum of	BENEFITS	TRATIVE &	TENANCE &	OPERATION			COST CENTER DESCRIPTIONS			& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL			COST CENTER DESCRIPTIONS			GENERAL	ANES-	NURSING	SALARY AND	PROGRAM	EDUCATION		STEPDOWN
				COSTS	FIXTURES	EQUIPMENT	(cols. 0-2)	DEPARTMENT	GENERAL	REPAIRS	OF PLANT						SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE						SERVICE	THETISTS	PROGRAM	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													OTHER REIMBURSABLE COST CENTERS															OTHER REIMBURSABLE COST CENTERS
94	Home Program Dialysis											94	94	Home Program Dialysis													94	94	Home Program Dialysis												94
95	Ambulance Services											95	95	Ambulance Services													95	95	Ambulance Services												95
96	Durable Medical Equipment-Rented											96	96	Durable Medical Equipment-Rented													96	96	Durable Medical Equipment-Rented												96
97	Durable Medical Equipment-Sold											97	97	Durable Medical Equipment-Sold													97	97	Durable Medical Equipment-Sold												97
98	Other Reimbursable (specify)											98	98	Other Reimbursable (specify)													98	98	Other Reimbursable (specify)												98
99	Outpatient Rehabilitation Provider (specify)											99	99	Outpatient Rehabilitation Provider (specify)													99	99	Outpatient Rehabilitation Provider (specify)												99
100	Intern-Resident Service (not appvd. tchng. prgm.)											100	100	Intern-Resident Service (not appvd. tchng. prgm.)													100	100	Intern-Resident Service (not appvd. tchng. prgm.)												100
101	Home Health Agency											101	101	Home Health Agency													101	101	Home Health Agency												101
102	Opioid Treatment Program											102	102	Opioid Treatment Program													102	102	Opioid Treatment Program
	SPECIAL PURPOSE COST CENTERS													SPECIAL PURPOSE COST CENTERS															SPECIAL PURPOSE COST CENTERS
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											113	116	Hospice													113	116	Hospice												113
117	Other Special Purpose (specify)											117	117	Other Special Purpose (specify)													117	117	Other Special Purpose (specify)												117
118	SUBTOTALS (sum of lines 1 through 117)											118	118	SUBTOTALS (sum of lines 1 through 117)													118	118	SUBTOTALS (sum of lines 1 through 117)												118
	NONREIMBURSABLE COST CENTERS													NONREIMBURSABLE COST CENTERS															NONREIMBURSABLE COST CENTERS
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
200	Cross Foot Adjustments											200	200	Cross Foot Adjustments													200	200	Cross Foot Adjustments												200
201	Negative Cost Centers											201	201	Negative Cost Centers													201	201	Negative Cost Centers												201
202	TOTAL (sum lines 118 through 201)											202	202	TOTAL (sum lines 118 through 201)													202	202	TOTAL (sum lines 118 through 201)												202
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)													FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)															FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4021)
40-546												Rev. 18	Rev. 18														40-549	40-552													Rev. 18

---

Sheet 27: B1

12-22						FORM CMS-2552-10						4090 (Cont.)	4090 (Cont.)							FORM CMS-2552-10							12-22	12-22						FORM CMS-2552-10							4090 (Cont.)
COST ALLOCATION - STATISTICAL BASIS									PROVIDER CCN:	PERIOD:	WORKSHEET B-1		COST ALLOCATION - STATISTICAL BASIS											PROVIDER CCN:	PERIOD:	WORKSHEET B-1		COST ALLOCATION - STATISTICAL BASIS										PROVIDER CCN:	PERIOD:	WORKSHEET B-1
									________________	FROM ____________														________________	FROM ____________													________________	FROM ____________
										TO _______________															TO _______________														TO _______________
					CAPITAL RELATED COST		EMPLOYEE		ADMINIS-	MAIN-							LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL								NON-		INTERNS & RESIDENTS		PARA-		INTERN &
					BLDGS. &	MOVABLE	BENEFITS		TRATIVE &	TENANCE &	OPERATION						& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL						OTHER	PHYSICIAN	NURSING	SALARY AND	PROGRAM	MEDICAL		RESIDENT
					FIXTURES	EQUIPMENT	DEPARTMENT		GENERAL	REPAIRS	OF PLANT						SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE						GENERAL	ANES-	PROGRAM	FRINGES	COSTS	EDUCATION		COST & POST
	COST CENTER DESCRIPTIONS				(SQUARE	(DOLLAR	(GROSS	RECONCIL-	(ACCUM.	(SQUARE	(SQUARE			COST CENTER DESCRIPTIONS			(POUNDS OF	(HOURS OF	(MEALS	(MEALS	(NUMBER	(DIRECT	(COSTED	(COSTED	(TIME	(TIME			COST CENTER DESCRIPTIONS			SERVICE	THETISTS	(ASSIGNED	(ASSIGNED	(ASSIGNED	(ASSIGNED		STEPDOWN
					FEET)	VALUE)	SALARIES)	IATION	COST)	FEET)	FEET)						LAUNDRY)	SERVICE)	SERVED)	SERVED)	HOUSED)	NURS. HRS)	REQUIS.)	REQUIS.)	SPENT)	SPENT)						(SPECIFY)	(ASGND TIME)	TIME)	TIME)	TIME)	TIME)	SUBTOTAL	ADJUSTMENTS	TOTAL
					1	2	4	5A	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													GENERAL SERVICE COST CENTERS															GENERAL SERVICE COST CENTERS
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 Department											4	4	Employee Benefits Department													4	4	Employee Benefits Department												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 Program											20	20	Nursing Program													20	20	Nursing Program												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 Education Program (specify)											23	23	Paramedical Education Program (specify)													23	23	Paramedical Education Program (specify)												23
	INPATIENT ROUTINE SERVICE COST CENTERS													INPATIENT ROUTINE SERVICE COST CENTERS															INPATIENT ROUTINE SERVICE COST CENTERS
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 (specify)											42	42	Subprovider (specify)													42	42	Subprovider (specify)												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 (01-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)													FORM CMS-2552-10 (01-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)															FORM CMS-2552-10 (01-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)
Rev. 18												40-553	40-556														Rev. 18	Rev. 18													40-559
4090 (Cont.)						FORM CMS-2552-10						12-22	12-22							FORM CMS-2552-10							4090 (Cont.)	4090 (Cont.)						FORM CMS-2552-10							12-22
COST ALLOCATION - STATISTICAL BASIS									PROVIDER CCN:	PERIOD:	WORKSHEET B-1		COST ALLOCATION - STATISTICAL BASIS											PROVIDER CCN:	PERIOD:	WORKSHEET B-1		COST ALLOCATION - STATISTICAL BASIS										PROVIDER CCN:	PERIOD:	WORKSHEET B-1
									________________	FROM ____________														________________	FROM ____________													________________	FROM ____________
										TO _______________															TO _______________														TO _______________
					CAPITAL RELATED COST		EMPLOYEE		ADMINIS-	MAIN-							LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL								NON-		INTERNS & RESIDENTS		PARA-		INTERN &
					BLDGS. &	MOVABLE	BENEFITS		TRATIVE &	TENANCE &	OPERATION						& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL						OTHER	PHYSICIAN	NURSING	SALARY AND	PROGRAM	MEDICAL		RESIDENT
					FIXTURES	EQUIPMENT	DEPARTMENT		GENERAL	REPAIRS	OF PLANT						SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE						GENERAL	ANES-	PROGRAM	FRINGES	COSTS	EDUCATION		COST & POST
	COST CENTER DESCRIPTIONS				(SQUARE	(DOLLAR	(GROSS	RECONCIL-	(ACCUM.	(SQUARE	(SQUARE			COST CENTER DESCRIPTIONS			(POUNDS OF	(HOURS OF	(MEALS	(MEALS	(NUMBER	(DIRECT	(COSTED	(COSTED	(TIME	(TIME			COST CENTER DESCRIPTIONS			SERVICE	THETISTS	(ASSIGNED	(ASSIGNED	(ASSIGNED	(ASSIGNED		STEPDOWN
					FEET)	VALUE)	SALARIES)	IATION	COST)	FEET)	FEET)						LAUNDRY)	SERVICE)	SERVED)	SERVED)	HOUSED)	NURS. HRS)	REQUIS.)	REQUIS.)	SPENT)	SPENT)						(SPECIFY)	(ASGND TIME)	TIME)	TIME)	TIME)	TIME)	SUBTOTAL	ADJUSTMENTS	TOTAL
					1	2	4	5A	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													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 Catheterization											59	59	Cardiac Catheterization													59	59	Cardiac Catheterization												59
60	Laboratory											60	60	Laboratory													60	60	Laboratory												60
61	PBP Clinical Laboratory Services-Program Only											61	61	PBP Clinical Laboratory Services-Program Only													61	61	PBP Clinical Laboratory Services-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
77	Allogeneic HSCT Acquisition											77	77	Allogeneic HSCT Acquisition													77	77	Allogeneic HSCT Acquisition												77
78	CAR T-Cell Immunotherapy											78	78	CAR T-Cell Immunotherapy													78	78	CAR T-Cell Immunotherapy												78
	OUTPATIENT SERVICE COST CENTERS													OUTPATIENT SERVICE COST CENTERS															OUTPATIENT SERVICE COST CENTERS
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 Service (specify)											93	93	Other Outpatient Service (specify)													93	93	Other Outpatient Service (specify)												93
93.99	Partial Hospitalization Program											93.99	93.99	Partial Hospitalization Program													93.99	93.99	Partial Hospitalization Program												93.99
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)													FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)															FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)
40-554												Rev. 18	Rev. 18														40-557	40-560													Rev. 18
12-22						FORM CMS-2552-10						4090 (Cont.)	4090 (Cont.)							FORM CMS-2552-10							12-22	12-22						FORM CMS-2552-10							4090 (Cont.)
COST ALLOCATION - STATISTICAL BASIS									PROVIDER CCN:	PERIOD:	WORKSHEET B-1		COST ALLOCATION - STATISTICAL BASIS											PROVIDER CCN:	PERIOD:	WORKSHEET B-1		COST ALLOCATION - STATISTICAL BASIS										PROVIDER CCN:	PERIOD:	WORKSHEET B-1
									________________	FROM ____________														________________	FROM ____________													________________	FROM ____________
										TO _______________															TO _______________														TO _______________
					CAPITAL RELATED COST		EMPLOYEE		ADMINIS-	MAIN-							LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL								NON-		INTERNS & RESIDENTS		PARA-		INTERN &
					BLDGS. &	MOVABLE	BENEFITS		TRATIVE &	TENANCE &	OPERATION						& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL						OTHER	PHYSICIAN	NURSING	SALARY AND	PROGRAM	MEDICAL		RESIDENT
					FIXTURES	EQUIPMENT	DEPARTMENT		GENERAL	REPAIRS	OF PLANT						SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE						GENERAL	ANES-	PROGRAM	FRINGES	COSTS	EDUCATION		COST & POST
	COST CENTER DESCRIPTIONS				(SQUARE	(DOLLAR	(GROSS	RECONCIL-	(ACCUM.	(SQUARE	(SQUARE			COST CENTER DESCRIPTIONS			(POUNDS OF	(HOURS OF	(MEALS	(MEALS	(NUMBER	(DIRECT	(COSTED	(COSTED	(TIME	(TIME			COST CENTER DESCRIPTIONS			SERVICE	THETISTS	(ASSIGNED	(ASSIGNED	(ASSIGNED	(ASSIGNED		STEPDOWN
					FEET)	VALUE)	SALARIES)	IATION	COST)	FEET)	FEET)						LAUNDRY)	SERVICE)	SERVED)	SERVED)	HOUSED)	NURS. HRS)	REQUIS.)	REQUIS.)	SPENT)	SPENT)						(SPECIFY)	(ASGND TIME)	TIME)	TIME)	TIME)	TIME)	SUBTOTAL	ADJUSTMENTS	TOTAL
					1	2	4	5A	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													OTHER REIMBURSABLE COST CENTERS															OTHER REIMBURSABLE COST CENTERS
94	Home Program Dialysis											94	94	Home Program Dialysis													94	94	Home Program Dialysis												94
95	Ambulance Services											95	95	Ambulance Services													95	95	Ambulance Services												95
96	Durable Medical Equipment-Rented											96	96	Durable Medical Equipment-Rented													96	96	Durable Medical Equipment-Rented												96
97	Durable Medical Equipment-Sold											97	97	Durable Medical Equipment-Sold													97	97	Durable Medical Equipment-Sold												97
98	Other Reimbursable (specify)											98	98	Other Reimbursable (specify)													98	98	Other Reimbursable (specify)												98
99	Outpatient Rehabilitation Provider (specify)											99	99	Outpatient Rehabilitation Provider (specify)													99	99	Outpatient Rehabilitation Provider (specify)												99
100	Intern-Resident Service (not appvd. tchng. prgm.)											100	100	Intern-Resident Service (not appvd. tchng. prgm.)													100	100	Intern-Resident Service (not appvd. tchng. prgm.)												100
101	Home Health Agency											101	101	Home Health Agency													101	101	Home Health Agency												101
102	Opioid Treatment Program											102	102	Opioid Treatment Program													102	102	Opioid Treatment Program												102
	SPECIAL PURPOSE COST CENTERS													SPECIAL PURPOSE COST CENTERS															SPECIAL PURPOSE COST CENTERS
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 through 117)											118	118	SUBTOTALS (sum of lines 1 through 117)													118	118	SUBTOTALS (sum of lines 1 through 117)												118
	NONREIMBURSABLE COST CENTERS													NONREIMBURSABLE COST CENTERS															NONREIMBURSABLE COST CENTERS
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
200	Cross foot adjustments											200	200	Cross foot adjustments													200	200	Cross foot adjustments												200
201	Negative cost centers											201	201	Negative cost centers													201	201	Negative cost centers												201
202	Cost to be allocated (per Worksheet B, Part I)											202	202	Cost to be allocated (per Worksheet B, Part I)													202	202	Cost to be allocated (per Worksheet B, Part I)												202
203	Unit cost multiplier (Worksheet B, Part I)											203	203	Unit cost multiplier (Worksheet B, Part I)													203	203	Unit cost multiplier (Worksheet B, Part I)												203
204	Cost to be allocated (per Worksheet B, Part II)											204	204	Cost to be allocated (per Worksheet B, Part II)													204	204	Cost to be allocated (per Worksheet B, Part II)												204
205	Unit cost multiplier (Worksheet B, Part II)											205	205	Unit cost multiplier (Worksheet B, Part II)													205	205	Unit cost multiplier (Worksheet B, Part II)												205
206	NAHE adjustment amount to be allocated (per Wkst. B-2)											206	206	NAHE adjustment amount to be allocated (per Wkst. B-2)													206	206	NAHE adjustment amount to be allocated (per Wkst. B-2)												206
207	NAHE unit cost multiplier (Wkst. D, Parts III and IV)											207	207	NAHE unit cost multiplier (Wkst. D, Parts III and IV)													207	207	NAHE unit cost multiplier (Wkst. D, Parts III and IV)												207
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)													FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)															FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)
Rev. 18												40-555	40-558														Rev. 18	Rev. 18													40-561

---

Sheet 28: B2

4090 (Cont.)				FORM CMS-2552-10					12-22
POST STEPDOWN ADJUSTMENTS					PROVIDER CCN:	PERIOD:		WORKSHEET B-2
					________________	FROM ____________
						TO _______________
						WORKSHEET
	DESCRIPTION					CODE	LINE NO.	AMOUNT
	1					2	3	4
1	Adjustment for EPO costs in Renal Dialysis cost center					1	74		1
2	Adjustment for EPO costs in Home Program Dialysis cost center					1	94		2
3	Adjustment for ARANESP costs in Renal Dialysis cost center					1	74		3
4	Adjustment for ARANESP costs in Home Program Dialysis cost center					1	94		4
5	Adjustment for ESA costs in Renal Dialysis cost center (see instructions)					1	74		5
6	Adjustment for ESA costs in Home Program Dialysis cost center (see instructions)					1	94		6
7									7
8									8
9									9
10									10
11									11
12									12
13									13
14									14
15									15
16									16
17									17
18									18
19									19
20									20
21									21
22									22
23									23
24									24
25									25
26									26
27									27
28									28
29									29
30									30
31									31
32									32
33									33
34									34
35									35
36									36
37									37
38									38
39									39
40									40
41									41
42									42
43									43
44									44
45									45
46									46
47									47
48									48
49									49
50									50
51									51
52									52
53									53
54									54
55									55
56									56
57									57
58									58
59									59
FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4022)
40-562									Rev. 18

---

Sheet 29: CI

12-22								FORM CMS-2552-10								4090 (Cont.)
COMPUTATION OF RATIO OF COSTS TO CHARGES											PROVIDER CCN:		PERIOD:		WORKSHEET C
											________________		FROM ____________		PART I
													TO _______________
							Costs			Charges
					Total Cost	Therapy		RCE				Total		TEFRA	PPS
	COST CENTER DESCRIPTIONS				(from Wkst. B,	Limit	Total	Dis-	Total			(column 6	Cost or	Inpatient	Inpatient
					Part I,, col. 26)	Adj.	Costs	allowance	Costs	Inpatient	Outpatient	+ column 7)	Other Ratio	Ratio	Ratio
					1	2	3	4	5	6	7	8	9	10	11
	INPATIENT ROUTINE SERVICE COST CENTERS
30	Adults and Pediatrics (General Routine Care)															30
31	Intensive Care Unit															31
32	Coronary Care Unit															32
33	Burn Intensive Care Unit															33
34	Surgical Intensive Care Unit															34
35	Other Special Care (specify)															35
40	Subprovider IPF															40
41	Subprovider IRF															41
42	Subprovider (Specify)															42
43	Nursery															43
44	Skilled Nursing Facility															44
45	Nursing Facility															45
46	Other Long Term Care															46
	ANCILLARY SERVICE COST CENTERS
50	Operating Room															50
51	Recovery Room															51
52	Labor Room and Delivery Room															52
53	Anesthesiology															53
54	Radiology-Diagnostic															54
55	Radiology-Therapeutic															55
56	Radioisotope															56
57	Computed Tomography (CT) Scan															57
58	Magnetic Resonance Imaging (MRI)															58
59	Cardiac Catheterization															59
60	Laboratory															60
61	PBP Clinical Laboratory Services-Prgm. Only															61
62	Whole Blood & Packed Red Blood Cells															62
63	Blood Storing, Processing, & Trans.															63
64	Intravenous Therapy															64
65	Respiratory Therapy															65
66	Physical Therapy															66
67	Occupational Therapy															67
68	Speech Pathology															68
FORM CMS-2552-10 (10-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4023)
Rev. 18																40-563
4090 (Cont.)								FORM CMS-2552-10								12-22
COMPUTATION OF RATIO OF COSTS TO CHARGES											PROVIDER CCN:		PERIOD:		WORKSHEET C
											________________		FROM ____________		PART I
													TO _______________
							Costs			Charges
					Total Cost	Therapy		RCE				Total		TEFRA	PPS
	COST CENTER DESCRIPTIONS				(from Wkst. B,	Limit	Total	Dis-	Total			(column 6	Cost or	Inpatient	Inpatient
					Part I,, col. 26)	Adj.	Costs	allowance	Costs	Inpatient	Outpatient	+ column 7)	Other Ratio	Ratio	Ratio
					1	2	3	4	5	6	7	8	9	10	11
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
77	Allogeneic HSCT Acquisition															77
78	CAR T-Cell Immunotherapy															78
	OUTPATIENT SERVICE COST CENTERS
88	Rural Health Clinic (RHC)															88
89	Federally Qualified Health Center (FQHC)															89
90	Clinic															90
91	Emergency															91
92	Observation Beds (see instructions)															92
93	Other Outpatient Service (specify)															93
93.99	Partial Hospitalization Program															93.99
	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
99	Outpatient Rehabilitation Provider (specify)															99
100	Intern-Resident Service (not appvd. tchng. prgm.)															100
101	Home Health Agency															101
102	Opioid Treatment Program															102
	SPECIAL PURPOSE COST CENTERS
105	Kidney Acquisition															105
106	Heart Acquisition															106
107	Liver Acquisition															107
108	Lung Acquisition															108
109	Pancreas Acquisition															109
110	Intestinal Acquisition															110
111	Islet Acquisition															111
112	Other Organ Acquisition (specify)															112
115	Ambulatory Surgical Center (Distinct Part)															115
116	Hospice															116
117	Other Special Purpose (specify)															117
200	Subtotal (see instructions)															200
201	Less Observation Beds															201
202	Total (see instructions)															202
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4023)
40-564																Rev. 18

---

Sheet 30: CII

12-22						FORM CMS-2552-10						4090 (Cont.)
CALCULATION OF OUTPATIENT SERVICE COST TO									PROVIDER CCN:	PERIOD:	WORKSHEET C,
CHARGE RATIOS NET OF REDUCTIONS FOR MEDICAID ONLY									________________	FROM ____________	PART II
										TO _______________
Check applicable box:		[ ] Title V	[ ] Title XIX
					Capital Cost	Operating Cost			Cost Net of	Total
				Total Cost	(Wkst B,	Net of		Operating Cost	Capital and	Charges	Outpatient Cost
	Cost Center Descriptions			(Wkst. B,	Part II,	Capital Cost	Capital	Reduction	Operating Cost	(Worksheet C,	to Charge Ratio
				Part I, col. 26)	col. 26)	(col. 1 - col. 2)	Reduction	Amount	Reduction	Part I, column 8)	(col. 6 ÷ col. 7)
				1	2	3	4	5	6	7	8
	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 Services-Prgm. Only											61
62	Whole Blood & Packed Red Blood Cells											62
63	Blood Storing, Processing, & Trans.											63
64	Intravenous Therapy											64
65	Respiratory Therapy											65
66	Physical Therapy											66
67	Occupational Therapy											67
68	Speech Pathology											68
69	Electrocardiology											69
70	Electroencephalography											70
71	Medical Supplies Charged to Patients											71
72	Implantable Devices Charged to Patients											72
73	Drugs Charged to Patients											73
74	Renal Dialysis											74
75	ASC (Non-Distinct Part)											75
76	Other Ancillary (specify)											76
77	Allogeneic HSCT Acquisition											77
78	CAR T-Cell Immunotherapy											78
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4023 & 4023.2)
Rev. 18												40-565
4090 (Cont.)						FORM CMS-2552-10						12-22
CALCULATION OF OUTPATIENT SERVICE COST TO									PROVIDER CCN:	PERIOD:	WORKSHEET C.
CHARGE RATIOS NET OF REDUCTIONS FOR MEDICAID ONLY									________________	FROM ____________	PART II (CONT.)
										TO _______________
Check applicable box:		[ ] Title V	[ ] Title XIX
					Capital Cost	Operating Cost			Cost Net of	Total
				Total Cost	(Wkst B,	Net of		Operating Cost	Capital and	Charges	Outpatient Cost
	Cost Center Descriptions			(Wkst. B,	Part II,	Capital Cost	Capital	Reduction	Operating Cost	(Worksheet C,	to Charge Ratio
				Part I, col. 26)	col. 26)	(col. 1 - col. 2)	Reduction	Amount	Reduction	Part I, column 8)	(col. 6 ÷ col. 7)
				1	2	3	4	5	6	7	8
	OUTPATIENT SERVICE COST CENTERS
88	Rural Health Clinic (RHC)											88
89	Federally Qualified Health Center (FQHC)											89
90	Clinic											90
91	Emergency											91
92	Observation Beds (see instructions)											92
93	Other Outpatient Service (specify)											93
93.99	Partial Hospitalization Program											93.99
	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
99	Outpatient Rehabilitation Provider (specify)											99
100	Intern-Resident Service (not appvd. tchng. prgm.)											100
101	Home Health Agency											101
102	Opioid Treatment Program											102
105	Kidney Acquisition											105
106	Heart Acquisition											106
107	Liver Acquisition											107
108	Lung Acquisition											108
109	Pancreas Acquisition											109
110	Intestinal Acquisition											110
111	Islet Acquisition											111
112	Other Organ Acquisition (specify)											112
115	Ambulatory Surgical Center (Distinct Part)											115
116	Hospice											116
117	Other Special Purpose (specify)											117
200	Subtotal (sum of lines 50 through 199)											200
201	Less Observation Beds											201
202	Total (line 200 minus line 201)											202
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4023 & 4023.2)
40-566												Rev. 18

---

Sheet 31: DI

07-23					FORM CMS-2552-10						4090 (Cont.)
APPORTIONMENT OF INPATIENT ROUTINE						PROVIDER CCN:		PERIOD:		WORKSHEET D,
SERVICE CAPITAL COSTS						________________		FROM ____________		PART I
								TO _______________
Check		[ ] Title V	[ ] Hospital		[ ] PPS
applicable		[ ] Title XVIII, Part A	[ ] PARHM Demonstration		[ ] TEFRA
boxes:		[ ] Title XIX
						Reduced				Inpatient
						Capital				Program
				Capital		Related		Per		Capital
				Related Cost	Swing	Cost	Total	Diem	Inpatient	Cost
				(from Wkst. B,	Bed	(col. 1 minus	Patient	(col. 3 ÷	Program	(col. 5
				Part II, col. 26)	Adjustment	col. 2)	Days	col. 4)	Days	x col. 6)
(A)	Cost Center Description			1	2	3	4	5	6	7
	INPATIENT ROUTINE SERVICE COST CENTERS
	Adults & Pediatrics
30	(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
44	Skilled Nursing Facility										44
45	Nursing Facility										45
200	Total (lines 30 through 199)										200
(A) Worksheet A line numbers
FORM CMS-2552-10 (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4024 - 4024.1)
Rev. 21											40-567

---

Sheet 32: DII

4090 (Cont.)					FORM CMS-2552-10				07-23
APPORTIONMENT OF INPATIENT ANCILLARY						PROVIDER CCN:	PERIOD:	WORKSHEET D
SERVICE CAPITAL COSTS						______________	FROM ____________	PART II
						COMPONENT CCN:	TO _______________
						______________
Check		[ ] Title V	[ ] Hospital	[ ] Subprovider (Other)		[ ] PPS
applicable		[ ] Title XVIII, Part A	[ ] IPF	[ ] PARHM Demonstration		[ ] TEFRA
boxes:		[ ] Title XIX	[ ] IRF
				Capital
				Related Cost	Total Charges	Ratio of Cost	Inpatient
				(from Wkst. B	(from Wkst. C,	to Charges	Program	Capital Costs
				Part II, col. 26)	Pt .I, col. 8)	(col .1 ÷ col. 2)	Charges	(col. 3 x col. 4)
(A)	Cost Center Description			1	2	3	4	5
	ANCILLARY SERVICE COST CENTERS
50	Operating Room								50
51	Recovery Room								51
52	Labor Room and Delivery Room								52
53	Anesthesiology								53
54	Radiology-Diagnostic								54
55	Radiology-Therapeutic								55
56	Radioisotope								56
57	Computed Tomography (CT) Scan								57
58	Magnetic Resonance Imaging (MRI)								58
59	Cardiac Catheterization								60
60	Laboratory								60
61	PBP Clinical Laboratory Services-Prgm. Only								61
62	Whole Blood & Packed Red Blood Cells								62
63	Blood Storing, Processing, & Transfusing								63
64	Intravenous Therapy								64
65	Respiratory Therapy								65
66	Physical Therapy								66
67	Occupational Therapy								67
68	Speech Pathology								68
69	Electrocardiology								69
70	Electroencephalography								70
71	Medical Supplies Charged to Patients								71
72	Implantable Devices Charged to Patients								72
73	Drugs Charged to Patients								73
74	Renal Dialysis								74
75	ASC (Non-Distinct Part)								75
76	Other Ancillary (specify)								76
77	Allogeneic HSCT Acquisition								77
78	CAR T-Cell Immunotherapy								78
	OUTPATIENT SERVICE COST CENTERS
88	Rural Health Clinic (RHC)								88
89	Federally Qualified Health Center (FQHC)								89
90	Clinic								90
91	Emergency								91
92	Observation Beds								92
93	Other Outpatient Service (specify)								93
93.99	Partial Hospitalization Program								93.99
	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 (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4024.2)
40-568									Rev. 21

---

Sheet 33: DIII

07-23

FORM CMS-2552-10

4090 (Cont.)

APPORTIONMENT OF INPATIENT ROUTINE

PROVIDER CCN:

PERIOD

WORKSHEET D,

SERVICE OTHER PASS-THROUGH COSTS

______________

FROM __________

PART III

TO _____________

Check

[ ] Title V

[ ] Hospital

[ ] PPS

applicable

[ ] Title XVIII, Part A

[ ] PARHM Demonstration

[ ] TEFRA

boxes:

[ ] Title XIX

[ ] Other

Nursing

Allied

All

Swing-Bed

Inpatient

Program

Health

Other

Adjustment

Total Costs

Per

Program

Post-

Post-

Medical

Amount

(sum of cols.

Total

Diem

Inpatient

Pass-Through

Stepdown

Nursing

Stepdown

Allied Health

Education

(see

1, 2, and 3,

Patient

(col. 5 ÷

Program

Cost

Adjustments

Program

Adjustments

Cost

Cost

instructions)

minus col. 4)

Days

col. 6)

Days

(col. 7 x col. 8)

(A)

Cost Center Description

1A

1

2A

2

3

4

5

6

7

8

9

INPATIENT ROUTINE SERVICE COST CENTERS

Adults & Pediatrics

30

(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

44

Skilled Nursing Facility

44

45

Nursing Facility

45

200

Total (sum of lines 30 through 199)

200

(A) Worksheet A line numbers

FORM CMS-2552-10 (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4024.3)

Rev. 21

40-569

---

Sheet 34: DIV

4090 (Cont.)

FORM CMS-2552-10

07-23

APPORTIONMENT OF INPATIENT/OUTPATIENT ANCILLARY

PROVIDER CCN:

PERIOD:

WORKSHEET D,

SERVICE OTHER PASS-THROUGH COSTS

______________

FROM ____________

PART IV

COMPONENT CCN:

TO _______________

______________

Check

[ ] Title V

[ ] Hospital

[ ] SNF

[ ] PARHM Demonstration

[ ] PPS

applicable

[ ] Title XVIII, Part A

[ ] IPF

[ ] NF

[ ] PARHM CAH Swing Bed-SNF

[ ] TEFRA

boxes:

[ ] Title XIX

[ ] IRF

[ ] ICF/IID

[ ] Other

[ ] Subprovider (Other)

[ ] Swing-Bed SNF

Nursing

Allied

All

Total

Non

Program

Health

Other

Outpatient

Physician

Post-

Post-

Medical

Total cost

Cost

Anesthetist

Stepdown

Nursing

Stepdown

Allied

Education

(sum of cols. 1, 2

(sum of cols. 2,

Cost

Adjustments

Program

Adjustments

Health

Cost

3, and 4)

3, and 4)

(A)

Cost Center Description

1

2A

2

3A

3

4

5

6

ANCILLARY SERVICE COST CENTERS

50

Operating Room

50

51

Recovery Room

51

52

Labor room and Delivery Room

52

53

Anesthesiology

53

54

Radiology-Diagnostic

54

55

Radiology-Therapeutic

55

56

Radioisotope

56

57

Computed Tomography (CT) Scan

57

58

Magnetic Resonance Imaging (MRI)

58

59

Cardiac Catheterization

59

60

Laboratory

60

61

PBP Clinical Laboratory Serv.-Prgm. Only

61

62

Whole Blood & Packed Red Blood Cells

62

63

Blood Storing, Processing, & Transfusing

63

64

Intravenous Therapy

64

65

Respiratory Therapy

65

66

Physical Therapy

66

67

Occupational Therapy

67

68

Speech Pathology

68

69

Electrocardiology

69

70

Electroencephalography

70

71

Medical Supplies Charged To Patients

71

72

Implantable Devices Charged to Patients

72

73

Drugs Charged to Patients

73

74

Renal Dialysis

74

75

ASC (Non-Distinct Part)

75

76

Other Ancillary (specify)

76

77

Allogeneic HSCT Acquisition

77

78

CAR T-Cell Immunotherapy

78

OUTPATIENT SERVICE COST CENTERS

88

Rural Health Clinic (RHC)

88

89

Federally Qualified Health Center (FQHC)

89

90

Clinic

90

91

Emergency

91

92

Observation Beds

92

93

Other Outpatient Service (specify)

93

93.99

Partial Hospitalization Program

93.99

FORM CMS-2552-10 (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4024.4)

40-570

Rev. 21

07-23

FORM CMS-2552-10

4090 (Cont.)

APPORTIONMENT OF INPATIENT/OUTPATIENT ANCILLARY

PROVIDER CCN:

PERIOD:

WORKSHEET D,

SERVICE OTHER PASS THROUGH COSTS

______________

FROM ____________

PART IV (Cont.)

COMPONENT CCN:

TO _______________

______________

Check

[ ] Title V

[ ] Hospital

[ ] SNF

[ ] PARHM Demonstration

[ ] PPS

applicable

[ ] Title XVIII, Part A

[ ] IPF

[ ] NF

[ ] PARHM CAH Swing-Bed SNF

[ ] TEFRA

boxes:

[ ] Title XIX

[ ] IRF

[ ] ICF/IID

[ ] Other

[ ] Subprovider (Other)

[ ] Swing-Bed SNF

All

Total

Non

Nursing

Allied

Other

Outpatient

Physician

Program

Health

Medical

Total cost

Cost

Anesthetist

Post-Stepdown

Nursing

Post-Stepdown

Allied

Education

(sum of cols. 1, 2

(sum of cols. 2,

Cost

Adjustments

Program

Adjustments

Health

Cost

3, and 4)

3, and 4)

(A)

Cost Center Description

1

2A

2

3A

3

4

5

6

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 (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4024.4)

Rev. 21

40-570.1

4090 (Cont.)

FORM CMS-2552-10

07-23

APPORTIONMENT OF INPATIENT/OUTPATIENT ANCILLARY

PROVIDER CCN:

PERIOD:

WORKSHEET D,

SERVICE OTHER PASS THROUGH COSTS

______________

FROM ____________

PART IV (Cont.)

COMPONENT CCN:

TO _______________

______________

Check

[ ] Title V

[ ] Hospital

[ ] SNF

[ ] PARHM Demonstration

[ ] PPS

applicable

[ ] Title XVIII, Part A

[ ] IPF

[ ] NF

[ ] PARHM CAH Swing-Bed SNF

[ ] TEFRA

boxes:

[ ] Title XIX

[ ] IRF

[ ] ICF/IID

[ ] Other

[ ] Subprovider (Other)

[ ] Swing-Bed SNF

Inpatient

Outpatient

Ratio

Outpatient

Program

Program

Total

of Cost

Ratio

Pass-

Pass-

Charges

to Charges

of Cost

Inpatient

Through

Outpatient

Through

(from Wkst. C,

(col. 5 ÷ col. 7)

to Charges

Program

Costs

Program

Costs

Part I, col. 8)

(see instructions)

(col. 6 ÷ col. 7)

Charges

(col. 8 x col. 10)

Charges

(col. 9 x col. 12)

(A)

Cost Center Description

7

8

9

10

11

12

13

ANCILLARY SERVICE COST CENTERS

50

Operating Room

50

51

Recovery Room

51

52

Delivery Room and Labor Room

52

53

Anesthesiology

53

54

Radiology-Diagnostic

54

55

Radiology-Therapeutic

55

56

Radioisotope

56

57

Computed Tomography (CT) Scan

57

58

Magnetic Resonance Imaging (MRI)

58

59

Cardiac Catheterization

59

60

Laboratory

60

61

PBP Clinical Laboratory Serv.-Prgm. Only

61

62

Whole Blood & Packed Red Blood Cells

62

63

Blood Storing, Processing, & Transfusing

63

64

Intravenous Therapy

64

65

Respiratory Therapy

65

66

Physical Therapy

66

67

Occupational Therapy

67

68

Speech Pathology

68

69

Electrocardiology

69

70

Electroencephalography

70

71

Medical Supplies Charged To Patients

71

72

Implantable Devices Charged to Patients

72

73

Drugs Charged to Patients

73

74

Renal Dialysis

74

75

ASC (Non-Distinct Part)

75

76

Other Ancillary (specify)

76

77

Allogeneic HSCT Acquisition

77

78

CAR T-Cell Acquisition

78

OUTPATIENT SERVICE COST CENTERS

88

Rural Health Clinic (RHC)

88

89

Federally Qualified Health Center (FQHC)

89

90

Clinic

90

91

Emergency

91

92

Observation Beds

92

93

Other Outpatient Service (specify)

93

93.99

Partial Hospitalization Program

93.99

FORM CMS-2552-10 (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4024.4)

40-570.2

Rev. 21

07-23

FORM CMS-2552-10

4090 (Cont.)

APPORTIONMENT OF INPATIENT/OUTPATIENT ANCILLARY

PROVIDER CCN:

PERIOD:

WORKSHEET D,

SERVICE OTHER PASS THROUGH COSTS

______________

FROM ____________

PART IV (Cont.)

COMPONENT CCN:

TO _______________

______________

Check

[ ] Title V

[ ] Hospital

[ ] SNF

[ ] PARHM Demonstration

[ ] PPS

applicable

[ ] Title XVIII, Part A

[ ] IPF

[ ] NF

[ ] PARHM CAH Swing Bed-SNF

[ ] TEFRA

boxes:

[ ] Title XIX

[ ] IRF

[ ] ICF/IID

[ ] Other

[ ] Subprovider (Other)

[ ] Swing-Bed SNF

Inpatient

Outpatient

Outpatient

Program

Program

Total

Ratio

Ratio

Pass-

Pass-

Charges

of Cost

of Cost

Inpatient

Through

Outpatient

Through

(from Wkst. C,

to Charges

to Charges

Program

Costs

Program

Costs

Part I, col. 8)

(col. 5 ÷ col. 7)

(col. 6 ÷ col. 7)

Charges

(col. 8 x col. 10)

Charges

(col. 9 x col. 12)

(A)

Cost Center Description

7

8

9

10

11

12

13

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 (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4024.4)

Rev. 21

40-571

---

Sheet 35: DV

4090 (Cont.)						FORM CMS-2552-10											07-23
APPORTIONMENT OF MEDICAL AND OTHER									PROVIDER CCN:			PERIOD:			WORKSHEET D,
HEALTH SERVICES COSTS									______________			FROM ____________			PART V
									COMPONENT CCN:			TO _______________
									______________
Check		[ ] Title V - O/P	[ ] Hospital		[ ] Subprovider (Other)				[ ] Swing-Bed SNF			[ ] PARHM Demonstration
applicable		[ ] Title XVIII, Part B	[ ] IPF		[ ] SNF				[ ] Swing-Bed NF			[ ] PARHM CAH Swing-Bed SNF
boxes:		[ ] Title XIX - O/P	[ ] IRF		[ ] NF				[ ] ICF/IID
PART V - APPORTIONMENT OF MEDICAL AND OTHER HEALTH SERVICES COSTS
					Program Charges						Program Cost
				Cost			Cost		Cost				Cost		Cost
				to			Reimbursed		Reimbursed				Reimbursed		Reimbursed
				Charge	PPS		Services		Services Not		PPS		Services		Services Not
				Ratio from	Reimbursed		Subject to		Subject to		Services		Subject to		Subject to
				Wkst. C,	Services		Ded. & Coins.		Ded. & Coins.		(see		Ded. & Coins.		Ded. & Coins.
				Pt. I, col. 9	(see inst.)		(see inst.)		(see inst.)		(see inst.)		(see inst.)		(see inst.)
(A)	Cost Center Description			1	2		3		4		5		6		7
	ANCILLARY SERVICE COST CENTERS
50	Operating Room																50
51	Recovery Room																51
52	Labor & Delivery Room																52
53	Anesthesiology																53
54	Radiology-Diagnostic																54
55	Radiology-Therapeutic																55
56	Radioisotope																56
57	Computed Tomography (CT) Scan																57
58	Magnetic Resonance Imaging (MRI)																58
59	Cardiac Catheterization																59
60	Laboratory																60
61	PBP Clinical Laboratory Serv.-Prgm. Only																61
62	Whole Blood & Packed Red Blood Cells																62
63	Blood Storing, Processing, & Transfusing																63
64	Intravenous Therapy																64
65	Respiratory Therapy																65
66	Physical Therapy																66
67	Occupational Therapy																67
68	Speech Pathology																68
69	Electrocardiology																69
70	Electroencephalography																70
71	Medical Supplies Charged To Patients																71
72	Implantable Devices Charged to Patients																72
73	Drugs Charged to Patients																73
74	Renal Dialysis																74
75	ASC (Non-Distinct Part)																75
76	Other Ancillary (specify)																76
77	Allogeneic HSCT Acquisition																77
78	CAR T-Cell Immunotherapy																78
	OUTPATIENT SERVICE COST CENTERS
88	Rural Health Clinic (RHC)																88
89	Federally Qualified Health Center (FQHC)																89
90	Clinic																90
91	Emergency																91
92	Observation Bed																92
93	Other Outpatient Service (specify)																93
93.99	Partial Hospitalization Program																93.99
	OTHER REIMBURSABLE COST CENTERS
94	Home Program Dialysis																94
95	Ambulance																95
96	Durable Medical Equipment-Rented																96
97	Durable Medical Equipment-Sold																97
98	Other Reimbursable Cost Center																98
200	Subtotal (see instructions)																200
201	Less PBP Clinic Lab. Services-Program																201
	Only Charges
202	Net Charges (line 200 - line 201 )																202
FORM CMS-2552-10 (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4024.5)
40-572																	Rev. 21

---

Sheet 36: D1I

12-24				FORM CMS-2552-10				4090 (Cont.)
COMPUTATION OF INPATIENT					PROVIDER CCN:	PERIOD:	WORKSHEET D-1,
OPERATING COST					______________	FROM ____________	PART I
					COMPONENT CCN:	TO _______________
					______________
Check		[ ] Title V - I/P	[ ] Hospital	[ ] NF		[ ] PPS
applicable		[ ] Title XVIII, Part A	[ ] IPF	[ ] ICF/IID		[ ] TEFRA
boxes:		[ ] Title XIX - I/P	[ ] IRF	[ ] PARHM Demonstration		[ ] Other
			[ ] Subprovider (other)
			[ ] SNF
PART I - ALL PROVIDER COMPONENTS
	INPATIENT DAYS
1	Inpatient days (including private room days and swing-bed days, excluding newborn)							1
2	Inpatient days (including private room days, excluding swing-bed and newborn days)							2
3	Private room days (excluding swing-bed and observation bed days). If you have only private room days, do not complete this line.							3
4	Semi-private room days (excluding swing-bed and observation bed days)							4
5	Total swing-bed SNF type inpatient days (including private room days) through December 31 of the cost reporting period							5
6	Total swing-bed SNF type inpatient days (including private room days) after December 31 of the cost reporting period (if							6
	calendar year, enter 0 on this line)
7	Total swing-bed NF type inpatient days (including private room days) through December 31 of the cost reporting period							7
8	Total swing-bed NF type inpatient days (including private room days) after December 31 of the cost reporting period (if							8
	calendar year, enter 0 on this line)
9	Total inpatient days including private room days applicable to the Program (excluding swing-bed and newborn days) (see instructions)							9
10	Swing-bed SNF type inpatient days applicable to title XVIII only (including private room days) through December 31 of the							10
	cost reporting period (see instructions).
11	Swing-bed SNF type inpatient days applicable to title XVIII only (including private room days) after December 31 of the							11
	cost reporting period (if calendar year, enter 0 on this line)
12	Swing-bed NF type inpatient days applicable to titles V or XIX only (including private room days) through December 31 of							12
	the cost reporting period.
13	Swing-bed NF type inpatient days applicable to titles V or XIX only (including private room days) after December 31 of the							13
	cost reporting period (if calendar year, enter 0 on this line)
14	Medically necessary private room days applicable to the Program (excluding swing-bed days)							14
15	Total nursery days (title V or XIX only)							15
16	Nursery days (title V or XIX only)							16
	SWING BED ADJUSTMENT
17	Medicare rate for swing-bed SNF services applicable to services through December 31 of the cost reporting period							17
18	Medicare rate for swing-bed SNF services applicable to services after December 31 of the cost reporting period							18
19	Medicaid rate for swing-bed NF services applicable to services through December 31 of the cost reporting period							19
20	Medicaid rate for swing-bed NF services applicable to services after December 31 of the cost reporting period							20
21	Total general inpatient routine service cost (see instructions)							21
22	Swing-bed cost applicable to SNF type services through December 31 of the cost reporting period (line 5 x line 17)							22
23	Swing-bed cost applicable to SNF type services after December 31 of the cost reporting period (line 6 x line 18)							23
24	Swing-bed cost applicable to NF type services through December 31 of the cost reporting period (line 7 x line 19)							24
25	Swing-bed cost applicable to NF type services after December 31 of the cost reporting period (line 8 x line 20)							25
26	Total swing-bed cost (see instructions)							26
27	General inpatient routine service cost net of swing-bed cost (line 21 minus line 26)							27
	PRIVATE ROOM DIFFERENTIAL ADJUSTMENT
28	General inpatient routine service charges (excluding swing-bed and observation bed charges)							28
29	Private room charges (excluding swing-bed charges)							29
30	Semi-private room charges (excluding swing-bed charges)							30
31	General inpatient routine service cost/charge ratio (line 27 ÷ line 28)							31
32	Average private room per diem charge (line 29 ÷ line 3)							32
33	Average semi-private room per diem charge (line 30 ÷ line 4)							33
34	Average per diem private room charge differential (line 32 minus line 33) (see instructions)							34
35	Average per diem private room cost differential (line 34 x line 31)							35
36	Private room cost differential adjustment (line 3 x line 35)							36
37	General inpatient routine service cost net of swing-bed cost and private room cost differential (line 27 minus line 36)							37
FORM CMS-2552-10 (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4025.1)
Rev. 23								40-573

---

Sheet 37: D1II

4090 (Cont.)		FORM CMS-2552-10																12-24
COMPUTATION OF INPATIENT												PROVIDER CCN:		PERIOD:		WORKSHEET D-1,
OPERATING COST												______________		FROM ____________		PART II
												COMPONENT CCN:		TO _______________
												______________
Check		[ ] Title V - I/P				[ ] Hospital			[ ] PARHM Demonstration				[ ] PPS
applicable		[ ] Title XVIII, Part A				[ ] IPF							[ ] TEFRA
boxes:		[ ] Title XIX - I/P				[ ] IRF							[ ] Other
						[ ] Subprovider (other)
PART II - HOSPITAL AND SUBPROVIDERS ONLY
	PROGRAM INPATIENT OPERATING COST BEFORE
	PASS-THROUGH COST ADJUSTMENTS															1
38	Adjusted general inpatient routine service cost per diem (see instructions)																	38
39	Program general inpatient routine service cost (line 9 x line 38)																	39
40	Medically necessary private room cost applicable to the Program (line 14 x line 35)																	40
41	Total Program general inpatient routine service cost (line 39 + line 40)																	41
												Average
								Total		Total		Per Diem		Program		Program Cost
								Inpatient Cost		Inpatient Days		(col. 1 ÷ col. 2)		Days		(col. 3 x col. 4)
								1		2		3		4		5
42	Nursery (title V & XIX only)																	42
	Intensive Care Type Inpatient
	Hospital Units
43	Intensive Care Unit																	43
44	Coronary Care Unit																	44
45	Burn Intensive Care Unit																	45
46	Surgical Intensive Care Unit																	46
47	Other Special Care Unit (specify)																	47
																1
48	Program inpatient ancillary service cost (Worksheet D-3, column 3, line 200)																	48
48.01	Program inpatient cellular therapy acquisition cost (Worksheet D-6, Part III, line 10, column 1)																	48.01
49	Total Program inpatient costs (sum of lines 41 through 48.01) (see instructions)																	49
	PASS-THROUGH COST ADJUSTMENTS
50	Pass through costs applicable to Program inpatient routine services (from Worksheet D, sum of Parts I and III)																	50
51	Pass through costs applicable to Program inpatient ancillary services (from Worksheet D, sum of Parts II and IV)																	51
52	Total Program excludable cost (sum of lines 50 and 51)																	52
53	Total Program inpatient operating cost excluding capital related, nonphysician anesthetist, and medical education costs (line 49 minus line 52)																	53
	TARGET AMOUNT AND LIMIT COMPUTATION
54	Program discharges																	54
55	Target amount per discharge																	55
55.01	Permanent adjustment amount per discharge																	55.01
55.02	Adjustment amount per discharge (contractor use only)																	55.02
55.03	CAR T-cell amount paid as an interim payment																	55.03
56	Target amount ((line 54 x sum of lines 55, 55.01, and 55.02) plus line 55.03)																	56
57	Difference between adjusted inpatient operating cost and target amount (line 56 minus line 53)																	57
58	Bonus payment (see instructions)																	58
59	Trended costs (lesser of line 53 ÷ line 54, or line 55 from the cost reporting period ending 1996, updated and compounded by the market basket)																	59
60	Expected costs (lesser of line 53 ÷ line 54, or line 55 from prior year cost report, updated by the market basket)																	60
61	Continuous improvement bonus payment (if line 53 ÷ line 54 is less than the lowest of lines 55 plus 55.01, or line 59, or line 60, enter the lesser of 50% of the																	61
	amount by which operating costs (line 53) are less than expected costs (lines 54 x 60), or 1 % of the target amount (line 56), otherwise enter zero. (see instructions)
62	Relief payment (see instructions)																	62
63	Allowable Inpatient cost plus incentive payment (see instructions)																	63
	PROGRAM INPATIENT ROUTINE SWING BED COST
64	Medicare swing-bed SNF inpatient routine costs through December 31 of the cost reporting period (see instructions)																	64
	(title XVIII only)
65	Medicare swing-bed SNF inpatient routine costs after December 31 of the cost reporting period (see instructions)																	65
	(title XVIII only)
66	Total Medicare swing-bed SNF inpatient routine costs (line 64 plus line 65) (title XVIII only; for CAH, see instructions)																	66
67	Title V or XIX swing-bed NF inpatient routine costs through December 31 of the cost reporting period (line 12 x line 19)																	67
68	Title V or XIX swing-bed NF inpatient routine costs after December 31 of the cost reporting period (line 13 x line 20)																	68
69	Total title V or XIX swing-bed NF inpatient routine costs (line 67 + line 68)																	69
FORM CMS-2552-10 (12-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4025.2)
40-574																		Rev. 23

---

Sheet 38: D1III

01-22																				FORM CMS-2552-10																																4090 (Cont.)
COMPUTATION OF INPATIENT																												PROVIDER CCN:								PERIOD:								WORKSHEET D-1,
OPERATING COST																												______________								FROM ____________								PARTS III & IV
																												COMPONENT CCN:								TO _______________
																												______________
Check					[ ] Title V - I/P										[ ] Hospital										[ ] SNF									[ ] ICF/IID	[ ] PPS
applicable					[ ] Title XVIII, Part A										[ ] IPF										[ ] NF										[ ] TEFRA
boxes:					[ ] Title XIX - I/P										[ ] IRF										[ ] ICF/IID										[ ] Other
															[ ] Subprovider (Other)
PART III - SNF, NF, AND ICF/IID ONLY
70	SNF / NF / ICF/IID routine service cost (line 37)																																																			70
71	Adjusted general inpatient routine service cost per diem (line 70 ÷ line 2)																																																			71
72	Program routine service cost (line 9 x line 71)																																																			72
73	Medically necessary private room cost applicable to Program (line 14 x line 35)																																																			73
74	Total Program general inpatient routine service costs (line 72 + line 73)																																																			74
75	Capital-related cost allocated to inpatient routine service costs (from Worksheet B, Part II, column 26, line 45)																																																			75
76	Per diem capital-related costs (line 75 ÷ line 2)																																																			76
77	Program capital-related costs (line 9 x line 76)																																																			77
78	Inpatient routine service cost (line 74 minus line 77)																																																			78
79	Aggregate charges to beneficiaries for excess costs (from provider records)																																																			79
80	Total Program routine service costs for comparison to the cost limitation (line 78 minus line 79)																																																			80
81	Inpatient routine service cost per diem limitation																																																			81
82	Inpatient routine service cost limitation (line 9 x line 81)																																																			82
83	Reasonable inpatient routine service costs (see instructions)																																																			83
84	Program inpatient ancillary services (see instructions)																																																			84
85	Utilization review - physician compensation (see instructions)																																																			85
86	Total Program inpatient operating costs (sum of lines 83 through 85)																																																			86
PART IV - COMPUTATION OF OBSERVATION BED PASS-THROUGH COST
87	Total observation bed days (see instructions)																																																			87
88	Adjusted general inpatient routine cost per diem (line 27 ÷ line 2)																																																			88
89	Observation bed cost (line 87 x line 88) (see instructions)																																																			89
	COMPUTATION OF OBSERVATION BED PASS THROUGH COST
																																				Total								Observation Bed
																				Routine																Observation								Pass-Through Cost
																				Cost								column 1 ÷								Bed Cost								(col. 3 x col. 4)
																				(from line 21)								column 2								(from line 89)								(see instructions)
																				2								3								4								5
90	Capital-related cost																																																			90
91	Nursing Program cost																																																			91
92	Allied Health cost																																																			92
93	All other Medical Education																																																			93
FORM CMS-2552-10 (01-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4025.3 - 4025.4)
Rev. 17																																																				40-575

---

Sheet 39: D2

4090 (Cont.)					FORM CMS-2552-10				01-22	07-23				FORM CMS-2552-10				4090 (Cont.)
APPORTIONMENT OF COST OF						PROVIDER CCN:	PERIOD:	WORKSHEET D-2,		APPORTIONMENT OF COST OF					PROVIDER CCN:	PERIOD:	WORKSHEET D-2,
SERVICES RENDERED BY						________________	FROM ____________	PARTS I-III		SERVICES RENDERED BY					________________	FROM ____________	PARTS I-III (Cont.)
INTERNS AND RESIDENTS							TO _______________			INTERNS AND RESIDENTS						TO _______________
PART I - NOT IN APPROVED TEACHING PROGRAM										PART I - NOT IN APPROVED TEACHING PROGRAM
						Percent of	Expense	Total Inpatient Days			Average Cost		Health Care Program Inpatient Days		Title V	Title XVIII	Title XIX
		Cost Centers				Assigned Time	Allocation	All Patients			Per Day	Title V	Title XVIII, Part B	Title XIX	(col. 4 x col. 5)	(col. 4 x col. 6)	(col. 4 x col. 7)
						1	2	3			4	5	6	7	8	9	10
1	Total cost of services rendered					100.00			1	1								1
	Hospital Inpatient Routine Services:
2		Adults & pediatrics (general routine care)							2	2								2
3		Intensive care unit							3	3								3
4		Coronary care unit							4	4								4
5		Burn Intensive Care Unit							5	5								5
6		Surgical Intensive Care Unit							6	6								6
7		Other Special Care (specify)							7	7								7
8		Nursery							8	8								8
9	Subtotal (sum of lines 2 through 8)								9	9								9
10	IPF - Inpatient routine service								10	10								10
11	IRF - Inpatient routine service								11	11								11
12	Subprovider (Other) - Inpatient routine service								12	12								12
13	Skilled Nursing Facility								13	13								13
14	Nursing Facility								14	14								14
15	Other Long Term Care								15	15								15
16	Home Health Agency								16	16								16
17	Outpatient Rehabilitation Providers								17	17								17
18	Ambulatory Surgical Center								18	18								18
19	Hospice								19	19								19
20	Subtotal (sum of lines 9 through 19)								20	20								20
								Total Charges					Titles V and XIX Outpatient and			Titles V and XIX Outpatient and
								(from Wkst. C, Pt. I,			Ratio of Cost		Title XVIII Part B Charges			Title XVIII Part B Cost
								col. 8, lines 88			to Charges	Title	Title XVIII	Title	Title	Title XVIII	Title
	Hospital Outpatient Services:							through 93)			(col. 2 ÷ col. 3)	V	Part B	XIX	V	Part B	XIX
21		Rural Health Clinic (RHC)							21	21								21
22		Federally Qualified Health Center (FQHC)							22	22								22
23		Clinic							23	23								23
24		Emergency							24	24								24
25		Observation beds							25	25								25
26		Other Outpatient Service (specify)							26	26								26
27	Subtotal (sum of lines 21 through 26)								27	27								27
28	Total (sum of lines 20 and 27)					100.00			28	28								28
PART II - IN AN APPROVED TEACHING PROGRAM (TITLE XVIII, PART B INPATIENT ROUTINE COSTS ONLY)										PART II - IN AN APPROVED TEACHING PROGRAM (TITLE XVIII, PART B INPATIENT ROUTINE COSTS ONLY)
						Expenses Allocated								Expenses
						to cost centers					Total	Average Cost	Title XVIII	Applicable
						on Wkst. B, Pt. I	Swing Bed	Net Cost			Inpatient Days -	Per Day	Part B	to Title XVIII
						cols. 21 and 22	Amount	(col. 1 plus col. 2)			All Patients	(col. 3 ÷ col. 4)	Inpatient Days	(col. 5 x col. 6)
	Hospital Inpatient Routine Services:					1	2	3			4	5	6	7
29		Adults & Pediatrics (general routine care)							29	29								29
30		Swing Bed - SNF							30	30								30
31		Swing Bed - NF							31	31								31
32		Intensive care unit							32	32								32
33		Coronary care unit							33	33								33
34		Burn Intensive Care Unit							34	34								34
35		Surgical Intensive Care Unit							35	35								35
36		Other Special Care (specify)							36	36								36
37	Subtotal (sum of lines 29, and 32 through 36)								37	37								37
38	IPF - Inpatient routine service								38	38								38
39	IRF - Inpatient routine service								39	39								39
40	Subprovider (Other)- Inpatient routine service								40	40								40
41	Skilled Nursing Facility								41	41								41
42	Total (sum of lines 37 through 41)								42	42								42
PART III - SUMMARY FOR TITLE XVIII (TO BE COMPLETED ONLY IF BOTH PARTS I AND II ARE USED)										PART III - SUMMARY FOR TITLE XVIII (TO BE COMPLETED ONLY IF BOTH PARTS I AND II ARE USED)
							Not In Approved Teaching Program				In Approved Teaching Program		Total Title XVIII Costs
							(from Part I)	Amount			(from Part II, col. 7)	Amount	(to Wkst. E, Part B)	(col. 2 + col. 4)
	Hospital						1	2			3	4	5	6
43	Inpatient						col. 9, line 9		43	43	line 37							43
44	Outpatient						col. 9, line 27		44	44								44
45	Total Hospital (sum of lines 43 and 44)								45	45			line 22					45
46	IPF - Inpatient routine service						col. 9, line 10		46	46	line 38		line 22					46
47	IRF - Inpatient routine service						col. 9, line 11		47	47	line 39		line 22					47
48	Subprovider (Other)- Inpatient routine service						col. 9, line 12		48	48	line 40		line 22					48
49	Skilled Nursing Facility						col. 9, line 13		49	49	line 41		line 22					49
FORM CMS-2552-10 (04-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4026)										FORM CMS-2552-10 (04-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4026)
40-576									Rev. 17	Rev. 21								40-577

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Sheet 40: D3

4090 (Cont.)									FORM CMS-2552-10						07-23
INPATIENT ANCILLARY SERVICE												PROVIDER CCN:	PERIOD:	WORKSHEET D-3
COST APPORTIONMENT												________________	FROM ____________
												COMPONENT CCN:	TO ____________
												________________
Check		[ ] Title V			[ ] Hospital		[ ] SNF			[ ] ICF/IID			[ ] PPS
applicable		[ ] Title XVIII, Part A			[ ] IPF		[ ] NF			[ ] PARHM Demonstration			[ ] TEFRA
boxes:		[ ] Title XIX			[ ] IRF		[ ] Swing-Bed SNF			[ ] PARHM CAH Swing-Bed SNF			[ ] Other
					[ ] Subprovider (Other)		[ ] Swing-Bed NF
												Ratio of Cost	Inpatient	Inpatient Program Costs
	COST CENTER DESCRIPTION											to Charges	Program Charges	(col. 1 x col. 2)
(A)												1	2	3
	INPATIENT ROUTINE SERVICE COST CENTERS
30	Adults and Pediatrics (General Routine Care)														30
31	Intensive Care Unit														31
32	Coronary Care Unit														32
33	Burn Intensive Care Unit														33
34	Surgical Intensive Care Unit														34
35	Other Special Care (specify)														35
40	Subprovider IPF														40
41	Subprovider IRF														41
42	Subprovider (Specify)														42
43	Nursery														43
	ANCILLARY SERVICE COST CENTERS
50	Operating Room														50
51	Recovery Room														51
52	Labor Room and Delivery Room														52
53	Anesthesiology														53
54	Radiology-Diagnostic														54
55	Radiology-Therapeutic														55
56	Radioisotope														56
57	Computed Tomography (CT) Scan														57
58	Magnetic Resonance Imaging (MRI)														58
59	Cardiac Catheterization														59
60	Laboratory														60
61	PBP Clinical Laboratory Services-Prgm. Only														61
62	Whole Blood & Packed Red Blood Cells														62
63	Blood Storing, Processing, & Trans.														63
64	Intravenous Therapy														64
65	Respiratory Therapy														65
66	Physical Therapy														66
67	Occupational Therapy														67
68	Speech Pathology														68
69	Electrocardiology														69
70	Electroencephalography														70
71	Medical Supplies Charged to Patients														71
72	Implantable Devices Charged to Patients														72
73	Drugs Charged to Patients														73
74	Renal Dialysis														74
75	ASC (Non-Distinct Part)														75
76	Other Ancillary (specify)														76
77	Allogeneic HSCT Acquisition														77
78	CAR T-Cell Immunotherapy														78
	OUTPATIENT SERVICE COST CENTERS
88	Rural Health Clinic (RHC)														88
89	Federally Qualified Health Center (FQHC)														89
90	Clinic														90
91	Emergency														91
92	Observation Beds (see instructions)														92
93	Other Outpatient Service (specify)														93
93.99	Partial Hospitalization Program														93.99
	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 94 and 96 through 98)														200
201	Less PBP Clinic Laboratory Services-Program only charges (line 61)														201
202	Net charges (line 200 minus line 201)														202
(A) Worksheet A line numbers
FORM CMS-2552-10 (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4027)
40-578															Rev. 21

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Sheet 41: D4I

04-20					FORM CMS-2552-10					4090 (Cont.)
COMPUTATION OF ORGAN ACQUISITION COSTS AND CHARGES							PROVIDER CCN:	PERIOD:	WORKSHEET D-4,
FOR A TRANSPLANT HOSPITAL WITH A MEDICARE-CERTIFIED							________________	FROM ____________	PART I
TRANSPLANT PROGRAM							OPO CCN:	TO _______________
							________________
Check		[ ] HEART	[ ] LIVER	[ ] PANCREAS		[ ] ISLET
applicable box:		[ ] KIDNEY	[ ] LUNG	[ ] INTESTINE
PART I - COMPUTATION OF ORGAN ACQUISITION COSTS (INPATIENT ROUTINE AND ANCILLARY SERVICES)
					Inpatient			Organ
Computation of Inpatient					Routine Organ		Per Diem Costs	Acquisition	Cost
Routine Service Costs					Charges		(from Wkst. D-1, Part II)	Days	(col. 2 x col. 3)
Applicable to Organ Acquisition					1	D	2	3	4
1	Adults and Pediatrics					38				1
2	Intensive Care					43				2
3	Coronary Care					44				3
4	Burn Intensive Care Unit					45				4
5	Surgical Intensive Care Unit					46				5
6	Other Special Care (specify)					47				6
7	TOTAL (sum of lines 1 through 6)									7
							Ratio of Cost	Organ	Organ
							to Charges	Acquisition	Acquisition
Computation of Ancillary							(from	Ancillary	Ancillary
Service Costs Applicable							Wkst. C)	Charges	Costs
to Organ Acquisition						C	1	2	3
8	Operating Room					50				8
9	Recovery Room					51				9
10	Labor Room & Delivery Room					52				10
11	Anesthesiology					53				11
12	Radiology-Diagnostic					54				12
13	Radiology-Therapeutic					55				13
14	Radioisotope					56				14
15	Computed Tomography (CT) Scan					57				15
16	Magnetic Resonance Imaging (MRI)					58				16
17	Cardiac Catheterization					59				17
18	Laboratory					60				18
19	PBP Clinical Laboratory Services-Program Only					61				19
20	Whole Blood & Packed Red Blood Cells					62				20
21	Blood Storage, Processing, & Transfusing					63				21
22	IV Therapy					64				22
23	Respiratory Therapy					65				23
24	Physical Therapy					66				24
25	Occupational Therapy					67				25
26	Speech Pathology					68				26
27	Electrocardiology					69				27
28	Electroencephalography					70				28
29	Medical Supplies Charged to Patients					71				29
30	Implantable Devices Charged to Patients					72				30
31	Drugs Charged to Patients					73				31
32	Renal Dialysis					74				32
33	ASC (non-distinct part)					75				33
34	Other Ancillary (specify)					76				34
35	Rural Health Clinic (RHC)					88				35
36	Federally Qualified Health Center (FQHC)					89				36
37	Clinic					90				37
38	Emergency Room					91				38
39	Observation Beds					92				39
40	Other Outpatient Service (specify)					93				40
41	TOTAL (sum of lines 8 through 40)									41
	C = Worksheet C line numbers		D = Worksheet D-1 line numbers
FORM CMS-2552-10 (04-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4028.1)
Rev. 16										40-579

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Sheet 42: D4II

4090 (Cont.)					FORM CMS-2552-10						04-20
COMPUTATION OF ORGAN ACQUISITION COSTS AND CHARGES						PROVIDER CCN:		PERIOD:		WORKSHEET D-4,
FOR A TRANSPLANT HOSPITAL WITH A MEDICARE-CERTIFIED						________________		FROM ____________		PART II
TRANSPLANT PROGRAM						OPO CCN:		TO _______________
						________________
Check		[ ] HEART	[ ] LIVER	[ ] PANCREAS	[ ] ISLET
applicable box:		[ ] KIDNEY	[ ] LUNG	[ ] INTESTINE
PART II - COMPUTATION OF ORGAN ACQUISITION COSTS (OTHER THAN INPATIENT ROUTINE AND
	ANCILLARY SERVICE COSTS)
						Average Cost				Organ
	Computation of the Cost of Inpatient					Per Day				Acquisition
	Services of Interns and Residents Not					(from Wkst. D-2,		Organ		Costs
	In Approved Teaching Program					Part I, col. 4)		Acquisition Days		(col. 1 x col. 2)
						D	1	2		3
42	Adults & Pediatrics (General routine care)					2					42
43	Intensive Care Unit					3					43
44	Coronary Care Unit					4					44
45	Burn Intensive Care Unit					5					45
46	Surgical Intensive Care Unit					6					46
47	Other Special Care (specify)					7					47
48	TOTAL (sum of lines 42 through 47)										48
								Ratio of Cost		Organ
	Computation of the Cost of Outpatient					Organ		to Charges		Acquisition
	Services of Interns and Residents Not					Charges		from Wkst. D-2,		Costs
	In Approved Teaching Program					(see instructions)		Part I, col. 4)		(col. 1 x col. 2)
						1		D	2	3
49	Rural Health Clinic (RHC)							21			49
50	Federally Qualified Health Center (FQHC)							22			50
51	Clinic							23			51
52	Emergency							24			52
53	Observation Beds							25			53
54	Other Outpatient Service (specify)							26			54
55	TOTAL (sum of lines 49 through 54)										55
D = Worksheet D-2, Part I, line numbers
FORM CMS-2552-10 (04-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4028.2)
40-580											Rev. 16

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Sheet 43: D4III

03-23				FORM CMS-2552-10					4090 (Cont.)
COMPUTATION OF ORGAN ACQUISITION COSTS AND CHARGES						PROVIDER CCN:	PERIOD:	WORKSHEET D-4,
FOR A TRANSPLANT HOSPITAL WITH A MEDICARE-CERTIFIED						________________	FROM ____________	PARTS III & IV
TRANSPLANT PROGRAM						OPO CCN:	TO _____________
						________________
Check		[ ] HEART	[ ] LIVER	[ ] PANCREAS	[ ] ISLET
applicable box:		[ ] KIDNEY	[ ] LUNG	[ ] INTESTINE
PART III - SUMMARY OF COSTS AND CHARGES
					Cost		Charges
					Part A	Part B	Part A	Part B
					1	2	3	4
56	Routine and ancillary from Part I								56
57	Interns and Residents (inpatient)								57
58	Interns and Residents (outpatient)								58
59	Direct organ acquisition (see instructions)								59
60	Cost of physicians' services in a teaching hospital (see instructions)								60
61	Total (see instructions)								61
						Usable Organs
					1	2	3	4
62	Total usable organs (see instructions)								62
63	Medicare usable organs (see instructions)								63
64	Ratio of Medicare usable organs to total usable organs (see instructions)								64
					Cost		Charges
					Part A	Part B	Part A	Part B
					1	2	3	4
65	Medicare Cost and Charges (see instructions)								65
66	Revenue for organs sold (see instructions)								66
66.01	Partial primary payor amounts applicable to organ acquisition								66.01
66.02	Partial primary payor amounts applicable to transplants (informational only)								66.02
67	Subtotal (see instructions)								67
68	Organs Furnished Part B								68
69	Net Organ Acquisition Cost and Charges (see instructions)								69
PART IV - STATISTICS
						Living Related	Cadaveric	Revenue
						1	2	3
70	Organs excised in provider (1)								70
71	Organs purchased from other transplant hospitals (2)								71
72	Organs purchased from non-transplant hospitals								72
73	Organs purchased from OPOs (see instructions)								73
74	Total (sum of lines 70 through 73)								74
75	Organs transplanted								75
75.01	Organs transplanted into Medicare beneficiaries								75.01
75.02	Kidneys transplanted into MA beneficiaries								75.02
75.03	Organs transplanted, Medicare secondary payer								75.03
75.04	Organs transplanted, Other (see instructions)								75.04
76	Organs sold to other hospitals								76
77	Organs sold to OPOs								77
78	Organs sold to transplant hospitals								78
79	Organs sold to MRTC without an agreement or VA hospitals								79
79.01	Kidneys sold to MRTC with an agreement								79.01
80	Organs sold outside the U.S.								80
81	Organs sent outside the U.S. (no revenue received)								81
82	Organs used for research								82
83	Unusable/Discarded organs (see instructions)								83
84	Total (see instructions)								84
(1)	Organs procured outside your center by a procurement team from your center are not included in the count.
(2)	Organs procured outside your center by a procurement team from your center are included in the count.
FORM CMS-2552-10 (03-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4028.3)
Rev. 19									40-581

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Sheet 44: D5I

4090 (Cont.)						FORM CMS-2552-10						03-23
APPORTIONMENT OF COST FOR PHYSICIANS' SERVICES IN A TEACHING HOSPITAL									PROVIDER CCN:	PERIOD:	WORKSHEET D-5,
									________________	FROM ____________	PART I
										TO _______________
Check applicable box:		[ ] Hospital Staff [ ] Medical Staff
PART I - REASONABLE COMPENSATION EQUIVALENT COMPUTATION FOR COST REPORTING PERIODS ENDING BEFORE JUNE 30, 2014
									Physician/		5 Percent
Line	Specialty					Total	Professional	RCE	Professional	Unadjusted	of Unadjusted
No.	Description/Physician Identifier					Remuneration	Component	Amount	Component Hours	RCE Limit	RCE Limit
1	2					3	4	5	6	7	8
1	General Practitioner Family Practice											1
2	Internal Medicine											2
3	Surgery											3
4	Pediatrics											4
5	Obstetrics-Gynecology											5
6	Radiology											6
7	Psychiatry											7
8	Anesthesiology											8
9	Pathology											9
10	All Other											10
11	Total											11
						Cost of		Cost of			Adjust Cost
						Membership	Professional	Physician	Professional		of Physician's
Line	Specialty					& Continuing	Component	Malpractice	Component	Adjusted	Direct Medical &
No.	Description/Physician Identifier					Education	Share of col. 11	Insurance	Share of col. 13	RCE Limit	Surgical Services
9	10					11	12	13	14	15	16
1	General Practitioner Family Practice											1
2	Internal Medicine											2
3	Surgery											3
4	Pediatrics											4
5	Obstetrics-Gynecology											5
6	Radiology											6
7	Psychiatry											7
8	Anesthesiology											8
9	Pathology											9
10	All Other											10
11	Total (transfer the amount in column 16, line 11, to Part II, line 1, column 1 or 2, as appropriate)											11
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4029.1)
40-582												Rev. 19

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Sheet 45: D5II

09-14					FORM CMS-2552-10					4090 (Cont.)
APPORTIONMENT OF COST FOR PHYSICIANS' SERVICES IN A TEACHING HOSPITAL							PROVIDER CCN:	PERIOD:	WORKSHEET D-5,
							________________	FROM ____________	PART II
								TO _______________
Check		[ ] Hospital
applicable		[ ] IPF
box:		[ ] IRF
PART II - APPORTIONMENT OF COST FOR PHYSICIANS' SERVICES IN A TEACHING HOSPITAL FOR COST REPORTING PERIODS ENDING BEFORE JUNE 30, 2014
								Medical School	Total
							Hospital Staff	Faculty	(col 1 + col 2)
							1	2	3
1	Adjusted Cost of Physician's Direct Medical and Surgical Services									1
2	Total Inpatient Days and Outpatient Visit Days									2
3	Average Per Diem (line 1 ÷ line 2)									3
	HEALTH CARE PROGRAM REIMBURSABLE DAYS
4	Title V - Inpatient									4
5	Title V - Outpatient									5
6	Title XVIII - Part A									6
7	Title XVIII - Part B									7
8	Title XIX - Inpatient									8
9	Title XIX - Outpatient									9
10	Inpatient and Outpatient Kidney Acquisition									10
11	Inpatient and Outpatient Liver Acquisition									11
12	Inpatient and Outpatient Heart Acquisition									12
13	Inpatient and Outpatient Lung Acquisition									13
14	Inpatient and Outpatient Pancreas Acquisition									14
15	Inpatient and Outpatient Intestine Acquisition									15
16	Inpatient and Outpatient Islet Acquisition									16
17	Other Organ Acquisition									17
	HEALTH CARE PROGRAM REIMBURSABLE COST
18	Title V - Inpatient (line 3 x line 4)									18
19	Title V - Outpatient (line 3 x line 5)									19
20	Title XVIII - Part A (line 3 x line 6)									20
21	Title XVIII - Part B (line 3 x line 7)									21
22	Title XIX - Inpatient (line 3 x line 8)									22
23	Title XIX - Outpatient (line 3 x line 9)									23
24	Inpatient and Outpatient Kidney Acquisition (line 3 x line 10)									24
25	Inpatient and Outpatient Liver Acquisition (line 3 x line 11)									25
26	Inpatient and Outpatient Heart Acquisition (line 3 x line 12)									26
27	Inpatient and Outpatient Lung Acquisition (line 3 x line 13)									27
28	Inpatient and Outpatient Pancreas Acquisition (line 3 x line 14)									28
29	Inpatient and Outpatient Intestine Acquisition (line 3 x line 15)									29
30	Inpatient and Outpatient Islet Acquisition (line 3 x line 16)									30
31	Inpatient and Outpatient Other Organ Acquisition (line 3 x line 17)									31
	Transfer the amounts in column 3 as follows:
	Add lines 18 and 19, and transfer to Worksheet E-3, Part VII
	Line 20 to Worksheet E, Part A, or Worksheet E-3, Part I to IV as appropriate
	Line 21 to Worksheet E, Part B
	Add lines 22 and 23, and transfer to Worksheet E-3, Part VII, as appropriate
	Sum of lines 24 through 30 to Worksheet D-4, Part III, line 60
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4029.2)
Rev. 6										40-583

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Sheet 46: D5III

4090 (Cont.)							FORM CMS-2552-10						09-14
APPORTIONMENT OF COST FOR PHYSICIANS' SERVICES IN A TEACHING HOSPITAL										PROVIDER CCN:	PERIOD:	WORKSHEET D-5,
										________________	FROM ____________	PART III
											TO _______________
PART III - REASONABLE COMPENSATION EQUIVALENT COMPUTATION FOR COST REPORTING PERIODS ENDING ON OR AFTER JUNE 30, 2014
		Cost Center / Physician Identifier								Physician/		5 Percent
	Wkst. A						Total	Professional	RCE	Professional	Unadjusted	of Unadjusted
	Line #						Remuneration	Component	Amount	Component Hours	RCE Limit	RCE Limit
	1	2					3	4	5	6	7	8
1													1
2													2
3													3
4													4
5													5
6													6
7													7
8													8
9													9
10													10
200		Total											200
		Cost Center / Physician Identifier					Cost of		Cost of			Adjust Cost
							Membership	Professional	Physician	Professional		of Physician's
	Wkst. A						& Continuing	Component	Malpractice	Component	Adjusted	Direct Medical &
	Line #						Education	Share of Column 11	Insurance	Share of Column 13	RCE Limit	Surgical Services
	9	10					11	12	13	14	15	16
1													1
2													2
3													3
4													4
5													5
6													6
7													7
8													8
9													9
10													10
200		Total (transfer the amount in column 16, line 200, to Part IV, line 1)											200
FORM CMS-2552-10 (09-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4029.3)
40-583.1													Rev. 6

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Sheet 47: D5IV

04-23					FORM CMS-2552-10					4090 (Cont.)
APPORTIONMENT OF COST FOR PHYSICIANS' SERVICES IN A TEACHING HOSPITAL							PROVIDER CCN:	PERIOD:	WORKSHEET D-5,
							________________	FROM ____________	PART IV
								TO _______________
Check		[ ] Hospital
applicable		[ ] IPF
box:		[ ] IRF
PART IV - APPORTIONMENT OF COST FOR PHYSICIANS' SERVICES IN A TEACHING HOSPITAL FOR COST REPORTING PERIODS ENDING ON OR AFTER JUNE 30, 2014
1	Adjusted cost of physicians' direct medical and surgical services									1
2	Total inpatient days and outpatient visit days									2
3	Average per diem (line 1 ÷ line 2)									3
	HEALTH CARE PROGRAM REIMBURSABLE DAYS
4	Title V - Inpatient									4
5	Title V - Outpatient									5
6	Title XVIII - Part A									6
7	Title XVIII - Part B									7
8	Title XIX - Inpatient									8
9	Title XIX - Outpatient									9
10	Inpatient and outpatient kidney acquisition									10
11	Inpatient and outpatient liver acquisition									11
12	Inpatient and outpatient heart acquisition									12
13	Inpatient and outpatient lung acquisition									13
14	Inpatient and outpatient pancreas acquisition									14
15	Inpatient and outpatient intestine acquisition									15
16	Inpatient and outpatient islet acquisition									16
17										17
17.01	Inpatient allogeneic HSCT acquisition									17.01
17.02	Outpatient allogeneic HSCT acquisition									17.02
	HEALTH CARE PROGRAM REIMBURSABLE COST
18	Title V - Inpatient (line 3 x line 4)									18
19	Title V - Outpatient (line 3 x line 5)									19
20	Title XVIII - Part A (line 3 x line 6)									20
21	Title XVIII - Part B (line 3 x line 7)									21
22	Title XIX - Inpatient (line 3 x line 8)									22
23	Title XIX - Outpatient (line 3 x line 9)									23
24	Inpatient and outpatient kidney acquisition (line 3 x line 10)									24
25	Inpatient and outpatient liver acquisition (line 3 x line 11)									25
26	Inpatient and outpatient heart acquisition (line 3 x line 12)									26
27	Inpatient and outpatient lung acquisition (line 3 x line 13)									27
28	Inpatient and outpatient pancreas acquisition (line 3 x line 14)									28
29	Inpatient and outpatient intestine acquisition (line 3 x line 15)									29
30	Inpatient and outpatient islet acquisition (line 3 x line 16)									30
31										31
31.01	Inpatient allogeneic HSCT acquisition (line 3 x line 17.01)									31.01
31.02	Outpatient allogeneic HSCT acquisition (line 3 x line 17.02)									31.02
	Transfer amounts as follows:
	Add lines 18 and 19, and transfer to Worksheet E-3, Part VII, line 20 (title V hospital or component)
	Line 20 to Worksheet E, Part A, line 56 (Medicare IPPS); Worksheet E-3, Part I, line 3 (TEFRA); Worksheet E-3, Part II, line 15 (IPF);
	Worksheet E-3, Part III, line 16 (IRF); Worksheet E-3, Part IV, line 6 (LTCH); or, Worksheet E-3, Part V, line 17 (cost reimbursement)
	Line 21 to Worksheet E, Part B , line 23 (Medicare Part B Medical and Other Health Services)
	Add lines 22 and 23, and transfer to Worksheet E-3, Part VII, line 20 (title XIX hospital or component)
	Sum of lines 24 through 30 to Worksheet D-4, Part III, line 60
	Line 31.01 to Worksheet D‑6, Part III, line 5, col. 1
	Line 31.02 to Worksheet D‑6, Part III, line 5, col. 2
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4029.4)
Rev. 20										40-583.2

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Sheet 48: D6I

4090 (Cont.)						FORM CMS-2552-10				04-23
COMPUTATION OF CELLULAR THERAPY ACQUISITION COSTS							PROVIDER CCN:	PERIOD:	WORKSHEET D-6,
							________________	FROM ____________	PARTS I & II
								TO _______________
PART I - INPATIENT ROUTINE AND ANCILLARY SERVICES CELLULAR THERAPY ACQUISITION COSTS
			Routine Services			Inpatient
			Acquisition		Per Diem Costs	Acquisition	Acquisition Costs
Inpatient Routine Services			Charges		(see instructions)	Days	(col. 2 x col. 3)
Acquisition Costs			1	D-1	2	3	4
1	Adults and Pediatrics			38						1
2	Intensive Care			43						2
3	Coronary Care			44						3
4	Burn Intensive Care Unit			45						4
5	Surgical Intensive Care Unit			46						5
6	Other Special Care (specify)			47						6
7	Total (sum of lines 1 through 6)									7
						Inpatient	Outpatient	Inpatient	Outpatient
					Ratio of Cost	Ancillary Services	Ancillary Services	Ancillary Services	Ancillary Services
					to Charges	Acquisition	Acquisition	Acquisition	Acquisition
					(from Wkst. C, Pt. I, col. 9)	Charges	Charges	Cost	Cost
Ancillary Services Acquisition Costs				C	1	2	3	4	5
8	Operating Room			50						8
9	Recovery Room			51						9
10	Labor Room & Delivery Room			52						10
11	Anesthesiology			53						11
12	Radiology-Diagnostic			54						12
13	Radiology-Therapeutic			55						13
14	Radioisotope			56						14
15	Computed Tomography (CT) Scan			57						15
16	Magnetic Resonance Imaging (MRI)			58						16
17	Cardiac Catheterization			59						17
18	Laboratory			60						18
19	PBP Clinical Laboratory Services-Program Only			61						19
20	Whole Blood & Packed Red Blood Cells			62						20
21	Blood Storage, Processing, & Transfusing			63						21
22	IV Therapy			64						22
23	Electrocardiology			69						23
24	Medical Supplies Charged to Patients			71						24
25	Drugs Charged to Patients			73						25
26	ASC (non-distinct part)			75						26
27	Other Ancillary (specify)			76						27
28	Clinic			90						28
30	Total (sum of lines 8 through 28)									30
PART II - INTERNS AND RESIDENTS NOT IN AN APPROVED TEACHING PROGRAM CELLULAR THERAPY ACQUISITION COSTS
					Average Cost Per Day	Inpatient	Inpatient Part B
					(from Wkst. D-2,	Acquisition	Acquisition Costs
Interns and Residents Not in Approved Teaching					Pt. I, col. 4)	Days	(col. 1 x col. 2)
Program Acquisition Costs				D-2	1	2	3
1	Adults & Pediatrics			2						1
2	Intensive Care Unit			3						2
3	Coronary Care Unit			4						3
4	Burn Intensive Care Unit			5						4
5	Surgical Intensive Care Unit			6						5
6	Other Special Care (specify)			7						6
7	Total (sum of lines 1 through 6)									7
FORM CMS-2552-10 (04-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4029.6 and 4029.7)
40-583.3										Rev. 20

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Sheet 49: D6III

12-24					FORM CMS-2552-10					4090 (Cont.)
COMPUTATION OF CELLULAR THERAPY ACQUISITION COSTS							PROVIDER CCN:	PERIOD:	WORKSHEET D-6,
							________________	FROM ____________	PART III
								TO _______________
PART III - SUMMARY OF CELLULAR THERAPY ACQUISITION COSTS
								Amount
1	Acquisition cost from Worksheet B, col. 26 (see instructions)									1
								Inpatient	Outpatient
Acquisition Services Total Costs								1	2
2	Routine and ancillary									2
3	Interns and residents									3
4	Apportionment of acquisition cost from line 1									4
5	Cost of physicians' services in a teaching hospital (see instructions)									5
6	Total acquisition cost (sum of lines 2 through 5)									6
							Inpatient	Outpatient	Total
Determine Ratio of Medicare Transplants to Total Transplants							1	2	3
7	Total transplants (see instructions)									7
8	Medicare transplants (see instructions)									8
9	Medicare ratio (line 8 ÷ line 7)									9
10	Medicare cost (see instructions)									10
PART IV - STATISTICS
1	Number of recipients intended for allogeneic HSCT where the acquisition cost was incurred but the transplant did not occur (see instructions)									1
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4029.8 and 4029.9)
Rev. 23										40-583.4

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Sheet 50: EA

4090 (Cont.)				FORM CMS-2552-10				12-24
CALCULATION OF REIMBURSEMENT					PROVIDER CCN:	PERIOD:	WORKSHEET E,
SETTLEMENT					________________	FROM ___________	PART A
					COMPONENT CCN:	TO ___________
					________________
Check applicable box:		[ ] Hospital [ ] PARHM Demonstration
PART A - INPATIENT HOSPITAL SERVICES UNDER IPPS
1	DRG amounts other than outlier payments							1
1.01	DRG amounts other than outlier payments for discharges occurring prior to October 1 (see instructions)							1.01
1.02	DRG amounts other than outlier payments for discharges occurring on or after October 1 (see instructions)							1.02
1.03	DRG for federal specific operating payment for Model 4 BPCI for discharges occurring prior to October 1 (see instructions)							1.03
1.04	DRG for federal specific operating payment for Model 4 BPCI for discharges occurring on or after October 1 (see instructions)							1.04
2	Outlier payments for discharges (see instructions)							2
2.01	Outlier reconciliation amount							2.01
2.02	Outlier payment for discharges for Model 4 BPCI (see instructions)							2.02
2.03	Outlier payments for discharges occurring prior to October 1 (see instructions)							2.03
2.04	Outlier payments for discharges occurring on or after October 1 (see instructions)							2.04
3	Managed care simulated payments							3
4	Bed days available divided by number of days in the cost reporting period (see instructions)							4
	Indirect Medical Education Adjustment Calculation for Hospitals
5	FTE count for allopathic and osteopathic programs for the most recent cost reporting period ending on or before 12/31/1996 (see instructions)							5
5.01	FTE cap adjustment for qualifying hospitals under §131 of the CAA 2021 (see instructions)							5.01
6	FTE count for allopathic and osteopathic programs that meet the criteria for an add-on to the cap for new programs in accordance with 42 CFR 413.79(e)							6
6.26	Rural track program FTE cap limitation adjustment after the cap-building window closed under §127 of the CAA 2021 (see instructions)							6.26
7	MMA §422 reduction amount to the IME cap as specified under 42 CFR 412.105(f)(1)(iv)(B)(1)							7
7.01	ACA §5503 reduction amount to the IME cap as specified under 42 CFR 412.105(f)(1)(iv)(B)(2). If the cost report straddles July 1, 2011, see instructions.							7.01
7.02	Adjustment (increase or decrease) to the hospital's rural track program FTE limitation(s) for rural track programs with a rural track for Medicare GME affiliated							7.02
	programs in accordance with 413.75(b) and 87 FR 49075 (August 10, 2022) (see instructions)
8	Adjustment (increase or decrease) to the FTE count for allopathic and osteopathic programs for affiliated programs in accordance							8
	with 42 CFR 413.75(b), 413.79(c)(2)(iv), 64 FR 26340 (May 12, 1998), and 67 FR 50069 (August 1, 2002).
8.01	The amount of increase if the hospital was awarded FTE cap slots under §5503 of the ACA. If the cost report straddles July 1, 2011, see instructions.							8.01
8.02	The amount of increase if the hospital was awarded FTE cap slots from a closed teaching hospital under §5506 of ACA. (see instructions)							8.02
8.21	The amount of increase if the hospital was awarded FTE cap slots under §126 of the CAA 2021 (see instructions)							8.21
8.28	The amount of increase if the hospital was awarded FTE cap slots under §4122 of the CAA 2023 (see instructions)							8.28
9	Sum of lines 5 and 5.01, plus line 6, plus lines 6.26 through 6.49, minus lines 7 and 7.01, plus or minus line 7.02, plus/minus line 8,							9
	plus lines 8.01 through 8.28 (see instructions)
10	FTE count for allopathic and osteopathic programs in the current year from your records							10
11	FTE count for residents in dental and podiatric programs							11
12	Current year allowable FTE (see instructions)							12
13	Total allowable FTE count for the prior year							13
14	Total allowable FTE count for the penultimate year if that year ended on or after September 30, 1997; otherwise enter zero.							14
15	Sum of lines 12 through 14 divided by 3							15
16	Adjustment for residents in initial years of the program (see instructions)							16
17	Adjustment for residents displaced by program or hospital closure							17
18	Adjusted rolling average FTE count							18
19	Current year resident to bed ratio (line 18 divided by line 4)							19
20	Prior year resident to bed ratio (see instructions)							20
21	Enter the lesser of lines 19 or 20 (see instructions)							21
22	IME payment adjustment (see instructions)							22
22.01	IME payment adjustment - Managed Care (see instructions)							22.01
	Indirect Medical Education Adjustment for the Add-on for §422 of the MMA
23	Number of additional allopathic and osteopathic IME FTE resident cap slots under 42 CFR 412.105 (f)(1)(iv)(C ).							23
24	IME FTE resident count over cap (see instructions)							24
25	If the amount on line 24 is greater than -0-, then enter the lower of line 23 or line 24 (see instructions)							25
26	Resident to bed ratio (divide line 25 by line 4)							26
27	IME payments adjustment factor (see instructions)							27
28	IME add-on adjustment amount (see instructions)							28
28.01	IME add-on adjustment amount - Managed Care (see instructions)							28.01
29	Total IME payment (sum of lines 22 and 28)							29
29.01	Total IME payment - Managed Care (sum of lines 22.01 and 28.01)							29.01
	Disproportionate Share Adjustment
30	Percentage of SSI recipient patient days to Medicare Part A patient days (see instructions)							30
31	Percentage of Medicaid patient days to total patient days (see instructions)							31
32	Sum of lines 30 and 31							32
33	Allowable disproportionate share percentage (see instructions)							33
34	Disproportionate share adjustment (see instructions)							34
	Uncompensated Care Payment Adjustment					Prior to October 1	On or after October 1
35	Total uncompensated care amount (see instructions)							35
35.01	Factor 3 (see instructions)							35.01
35.02	Hospital UCP, including supplemental UCP (see instructions)							35.02
35.03	Pro rata share of the hospital UCP, including supplemental UCP (see instructions)							35.03
35.04	Pro rata share of the MDH's UCP, including supplemental UCP (see instructions)							35.04
35.05	Pro rata share of the SCH's UCP, including supplemental UCP (see instructions)							35.05
36	Total UCP adjustment (sum of columns 1 and 2 on line 35.03)							36
FORM CMS-2552-10 (12-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4030.1)
40-584								Rev. 23
DRAFT				FORM CMS-2552-10				4090 (Cont.)
CALCULATION OF REIMBURSEMENT					PROVIDER CCN:	PERIOD:	WORKSHEET E,
SETTLEMENT					________________	FROM ___________	PART A (Cont.)
					COMPONENT CCN:	TO ___________
					________________
Check applicable box:		[ ] Hospital [ ] PARHM Demonstration
PART A - INPATIENT HOSPITAL SERVICES UNDER IPPS (Cont.)
	Additional Payment for High Percentage of ESRD Beneficiary Discharges (lines 40 through 46)
40	Total Medicare discharges (see instructions)							40
41	Total ESRD Medicare discharges (see instructions)							41
41.01	Total ESRD Medicare covered and paid discharges (see instructions)							41.01
42	Divide line 41 by line 40 (if less than 10%, you do not qualify for adjustment)							42
43	Total Medicare ESRD inpatient days (see instructions)							43
44	Ratio of average length of stay to one week (line 43 divided by line 41.01 divided by 7 days)							44
45	Average weekly cost for dialysis treatments (see instructions)							45
46	Total additional payment (line 45 times line 44 times line 41.01)							46
47	Subtotal (see instructions)							47
48	Hospital specific payments (to be completed by SCH and MDH, small rural hospitals only (see instructions)							48
49	Total payment for inpatient operating costs (see instructions)							49
50	Payment for inpatient program capital (from Wkst. L, Pt. I, or Pt. II, as applicable)							50
51	Exception payment for inpatient program capital (Wkst. L, Pt. III) (see instructions)							51
52	Direct graduate medical education payment (from Wkst. E-4, line 49) (see instructions).							52
53	Nursing and allied health managed care payment							53
54	Special add-on payments for new technologies							54
54.01	Islet isolation add-on payment							54.01
55	Net organ acquisition cost (Wkst. D-4, Pt. III, col. 1, line 69)							55
55.01	Cellular therapy acquisition cost (see instructions)							55.01
56	Cost of physicians' services in a teaching hospital (see instructions)							56
57	Routine service other pass through costs (from Wkst. D, Pt. III, col. 9, lines 30 through 35)							57
58	Ancillary service other pass through costs (from Wkst. D, Pt. IV, col. 11, line 200)							58
59	Total (sum of amounts on lines 49 through 58)							59
60	Primary payer payments							60
61	Total amount payable for program beneficiaries (line 59 minus line 60)							61
62	Deductibles billed to program beneficiaries							62
63	Coinsurance billed to program beneficiaries							63
64	Allowable bad debts (see instructions)							64
65	Adjusted reimbursable bad debts (see instructions)							65
66	Allowable bad debts for dual eligible beneficiaries (see instructions)							66
67	Subtotal (line 61 plus line 65 minus lines 62 and 63)							67
68	Credits received from manufacturers for replaced devices for applicable MS-DRGs (see instructions)							68
69	Outlier payments reconciliation (sum of lines 93, 95 and 96) (for SCH see instructions)							69
70	Other adjustments (specify) (see instructions)							70
70.50	Rural Community Hospital Demonstration Project (§410A Demonstration) adjustment (see instructions)							70.50
70.75	N95 respirator payment adjustment amount (see instructions)							70.75
70.76	Essential medicines payment adjustment amount (see instructions)							70.76
70.87	Demonstration payment adjustment amount before sequestration							70.87
70.88	SCH or MDH volume decrease adjustment (contractor use only)							70.88
70.89	Pioneer ACO demonstration payment adjustment amount (see instructions)							70.89
70.90	HSP bonus payment HVBP adjustment amount (see instructions)							70.90
70.91	HSP bonus payment HRR adjustment amount (see instructions)							70.91
70.92	Bundled Model 1 discount amount (see instructions)							70.92
70.93	HVBP payment adjustment amount (see instructions)							70.93
70.94	HRR adjustment amount (see instructions)							70.94
70.95	Recovery of accelerated depreciation							70.95
70.96	Low volume adjustment for federal fiscal year (yyyy)							70.96
70.97	Low volume adjustment for federal fiscal year (yyyy)							70.97
70.99	HAC adjustment amount (see instructions)							70.99
71	Amount due provider (see instructions)							71
71.01	Sequestration adjustment (see instructions)							71.01
71.02	Demonstration payment adjustment amount after sequestration							71.02
71.03	Sequestration adjustment-PARHM pass-throughs							71.03
72	Interim payments							72
72.01	Interim payments-PARHM							72.01
73	Tentative settlement (for contractor use only)							73
73.01	Tentative settlement-PARHM (for contractor use only)							73.01
74	Balance due provider/program (line 71 minus lines 71.01, 71.02, 72, and 73)							74
74.01	Balance due provider/program-PARHM (see instructions)							74.01
75	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2							75
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4030.1)
Rev.								40-585
4090 (Cont.)				FORM CMS-2552-10				DRAFT
CALCULATION OF REIMBURSEMENT					PROVIDER CCN:	PERIOD:	WORKSHEET E,
SETTLEMENT					________________	FROM ___________	PART A
					COMPONENT CCN:	TO ___________
					________________
Check applicable box:		[ ] Hospital [ ] PARHM Demonstration
PART A - INPATIENT HOSPITAL SERVICES UNDER IPPS (Cont.)
	TO BE COMPLETED BY CONTRACTOR (lines 90 through 96)
90	Operating outlier amount from Wkst. E, Pt. A, line 2, or sum of 2.03 plus 2.04 (see instructions)							90
91	Capital outlier from Wkst. L, Pt. I, line 2							91
92	Operating outlier reconciliation adjustment amount (see instructions)							92
93	Capital outlier reconciliation adjustment amount (see instructions)							93
94	The rate used to calculate the time value of money (see instructions)							94
95	Time value of money for operating expenses (see instructions)							95
96	Time value of money for capital related expenses (see instructions)							96
	HSP Bonus Payment Amount					Prior to 10/1	On or After 10/1
100	HSP bonus amount (see instructions)							100
	HVBP Adjustment for HSP Bonus Payment					Prior to 10/1	On or After 10/1
101	HVBP adjustment factor (see instructions)							101
102	HVBP adjustment amount for HSP bonus payment (see instructions)							102
	HRR Adjustment for HSP Bonus Payment					Prior to 10/1	On or After 10/1
103	HRR adjustment factor (see instructions)							103
104	HRR adjustment amount for HSP bonus payment (see instructions)							104
	Rural Community Hospital Demonstration Project (§410A Demonstration) Adjustment
200	Is this the first year of the current 5-year demonstration period under the 21st Century Cures Act? Enter "Y" for yes or "N" for no.							200
	Cost Reimbursement
201	Medicare inpatient service costs (from Wkst. D-1, Pt. II, line 49)							201
202	Medicare discharges (see instructions)							202
203	Case-mix adjustment factor (see instructions)							203
	Computation of Demonstration Target Amount Limitation (N/A in first year of the current 5-year demonstration period)
204	Medicare target amount							204
205	Case-mix adjusted target amount (line 203 times line 204)							205
206	Medicare inpatient routine cost cap (line 202 times line 205)							206
	Adjustment to Medicare Part A Inpatient Reimbursement
207	Program reimbursement under the §410A Demonstration (see instructions)							207
208	Medicare Part A inpatient service costs (from Wkst. E, Pt. A, line 59)							208
209	Adjustment to Medicare IPPS payments (see instructions)							209
210	Reserved for future use							210
211	Total adjustment to Medicare IPPS payments (see instructions)							211
	Comparison of PPS versus Cost Reimbursement
212	Total adjustment to Medicare Part A IPPS payments (from line 211)							212
213	Low-volume adjustment (see instructions)							213
218	Net Medicare Part A IPPS adjustment (difference between PPS and cost reimbursement) (line 212 minus line 213) (see instructions)							218
FORM CMS-2552-10 (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4030.1)
40-585.1								Rev.
DRAFT				FORM CMS-2552-10				4090 (Cont.)
This page is reserved for future use.
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4030.1)
Rev.								40-585.2

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Sheet 51: EB

4090 (Cont.)					FORM CMS-2552-10					DRAFT
CALCULATION OF							PROVIDER CCN:	PERIOD:	WORKSHEET E,
REIMBURSEMENT SETTLEMENT							________________	FROM ____________	PART B
							COMPONENT CCN:	TO ______________
							________________
Check		[ ] Hospital	[ ] Subprovider (Other)
applicable		[ ] IPF	[ ] SNF
box:		[ ] IRF	[ ] PARHM Demonstration
PART B - MEDICAL AND OTHER HEALTH SERVICES
1	Medical and other services (see instructions)									1
2	Medical and other services reimbursed under OPPS (see instructions)									2
3	OPPS or REH payments									3
4	Outlier payment (see instructions)									4
4.01	Outlier reconciliation amount (see instructions)									4.01
5	Enter the hospital specific payment to cost ratio (see instructions)									5
6	Line 2 times line 5									6
7	Sum of lines 3, 4, and 4.01, divided by line 6									7
8	Transitional corridor payment (see instructions)									8
9	Ancillary service other pass through costs including REH direct graduate medical education costs from Wkst. D, Pt. IV, col. 13, line 200									9
10	Organ acquisition									10
11	Total cost (sum of lines 1 and 10) (see instructions)									11
	COMPUTATION OF LESSER OF COST OR CHARGES
	Reasonable charges
12	Ancillary service charges									12
13	Organ acquisition charges (from Wkst. D-4, Part III, col. 4, line 69)									13
14	Total reasonable charges (sum of lines 12 and 13)									14
	Customary charges
15	Aggregate amount actually collected from patients liable for payment for services on a charge basis									15
16	Amounts that would have been realized from patients liable for payment for services on a charge									16
	basis had such payment been made in accordance with 42 CFR §413.13(e)
17	Ratio of line 15 to line 16 (not to exceed 1.000000)									17
18	Total customary charges (see instructions)									18
19	Excess of customary charges over reasonable cost (complete only if line 18 exceeds line 11) (see instructions)									19
20	Excess of reasonable cost over customary charges (complete only if line 11 exceeds line 18) (see instructions)									20
21	Lesser of cost or charges (see instructions)									21
22	Interns and residents (see instructions)									22
23	Cost of physicians' services in a teaching hospital (see instructions)									23
24	Total prospective payment (sum of lines 3, 4, 4.01, 8, and 9)									24
	COMPUTATION OF REIMBURSEMENT SETTLEMENT
25	Deductibles and coinsurance amounts (see instructions)									25
26	Deductibles and Coinsurance amounts relating to amount on line 24 (see instructions)									26
27	Subtotal [(lines 21 and 24 minus the sum of lines 25 and 26) plus the sum of lines 22 and 23] (see instructions)									27
28	Direct graduate medical education payments (from Wkst. E-4, line 50)									28
28.50	REH facility payment amount (see instructions)									28.50
29	ESRD direct medical education costs (from Wkst. E-4, line 36)									29
30	Subtotal (sum of lines 27, 28, 28.50, and 29)									30
31	Primary payer payments									31
32	Subtotal (line 30 minus line 31)									32
	ALLOWABLE BAD DEBTS (EXCLUDE BAD DEBTS FOR PROFESSIONAL SERVICES)
33	Composite rate ESRD (from Wkst. I-5, line 11)									33
34	Allowable bad debts (see instructions)									34
35	Adjusted reimbursable bad debts (see instructions)									35
36	Allowable bad debts for dual eligible beneficiaries (see instructions)									36
37	Subtotal (see instructions)									37
38	MSP-LCC reconciliation amount from PS&R									38
39	Other adjustments (specify) (see instructions)									39
39.50	Pioneer ACO demonstration payment adjustment (see instructions)									39.50
39.75	N95 respirator payment adjustment amount (see instructions)									39.75
39.97	Demonstration payment adjustment amount before sequestration									39.97
39.98	Partial or full credits received from manufacturers for replaced devices (see instructions)									39.98
39.99	Recovery of Accelerated depreciation									39.99
40	Subtotal (see instructions)									40
40.01	Sequestration adjustment (see instructions)									40.01
40.02	Demonstration payment adjustment amount after sequestration									40.02
40.03	Sequestration adjustment-PARHM pass-throughs									40.03
41	Interim payments									41
41.01	Interim payments-PARHM									41.01
42	Tentative settlement (for contractors use only)									42
42.01	Tentative settlement-PARHM (for contractors use only)									42.01
43	Balance due provider/program (see instructions)									43
43.01	Balance due provider/program-PARHM (see instructions)									43.01
44	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2									44
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4030.2)
40-586										Rev.
07-23					FORM CMS-2552-10					4090 (Cont.)
CALCULATION OF							PROVIDER CCN:	PERIOD:	WORKSHEET E,
REIMBURSEMENT SETTLEMENT							________________	FROM ____________	PART B (Cont.)
							COMPONENT CCN:	TO ______________
							________________
Check		[ ] Hospital	[ ] Subprovider (Other)
applicable		[ ] IPF	[ ] SNF
box:		[ ] IRF	[ ] PARHM Demonstration
PART B - MEDICAL AND OTHER HEALTH SERVICES
	TO BE COMPLETED BY CONTRACTOR
90	Original outlier amount (see instructions)									90
91	Outlier reconciliation adjustment amount (see instructions)									91
92	The rate used to calculate the Time Value of Money									92
93	Time Value of Money (see instructions)									93
94	Total (sum of lines 91 and 93)									94
FORM CMS-2552-10 (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4030.2)
Rev. 21										40-587

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Sheet 52: E1

4090 (Cont.)						FORM CMS-2552-10							07-23
ANALYSIS OF PAYMENTS TO PROVIDERS										PROVIDER CCN:	PERIOD:	WORKSHEET E-1,
FOR SERVICES RENDERED										________________	FROM ____________	PART I
										COMPONENT CCN:	TO _______________
										________________
Check		[ ] Hospital	[ ] Subprovider (Other)		[ ] PARHM Demonstration
applicable		[ ] IPF	[ ] SNF		[ ] PARHM CAH Swing-Bed SNF
box:		[ ] IRF	[ ] Swing-Bed SNF
									Inpatient
									Part A		Part B
									mm/dd/yyyy	Amount	mm/dd/yyyy	Amount
	Description								1	2	3	4
1	Total interim payments paid to provider												1
2	Interim payments payable on individual bills, either submitted or to be submitted to the intermediary												2
	for services rendered in the cost reporting period. If none, write "NONE" or enter a zero
3	List separately each retroactive						Program to Provider	.01					3.01
	lump sum adjustment amount based							.02					3.02
	on subsequent revision of the							.03					3.03
	interim rate for the cost reporting period.							.04					3.04
	Also show date of each payment.							.05					3.05
	If none, write "NONE" or enter a zero. (1)						Provider to Program	.50					3.50
								.51					3.51
								.52					3.52
								.53					3.53
								.54					3.54
	Subtotal (sum of lines 3.01- 3.49 minus sum of lines 3.50-3.98)							.99					3.99
4	Total interim payments (sum of lines 1, 2, and 3.99)												4
	(transfer to Wkst. E or Wkst. E-3, line
	and column as appropriate)
5	List separately each tentative settlement						Program to Provider	.01					5.01
	payment after desk review. Also show							.02					5.02
	date of each payment.							.03					5.03
	If none, write "NONE" or enter a zero. (1)						Provider to Program	.50					5.50
								.51					5.51
								.52					5.52
	Subtotal (sum of lines 5.01-5.49 minus sum of lines 5.50 -5.98)							.99					5.99
6	Determined net settlement amount (balance						Program to Provider	.01					6.01
	due) based on the cost report (1)						Provider to Program	.02					6.02
7	Total Medicare program liability (see instructions)												7
8	Name of Contractor								Contractor Number		NPR Date (Month/Day/Year)		8
(1) On lines 3, 5, and 6, where an amount is due provider to program, show the amount and date on which the provider agrees to the amount of repayment
even though total repayment is not accomplished until a later date.
FORM CMS-2552-10 (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4031.1)
40-588													Rev. 21

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Sheet 53: E1II

07-23					FORM CMS-2552-10					4090 (Cont.)
CALCULATION OF REIMBURSEMENT							PROVIDER CCN:	PERIOD:	WORKSHEET E-1,
SETTLEMENT FOR HIT							________________	FROM ____________	PART II
							COMPONENT CCN:	TO _______________
							________________
Check		[ ] Hospital
applicable		[ ] CAH
box:
HEALTH INFORMATION TECHNOLOGY DATA COLLECTION AND CALCULATION
1	Total hospital discharges as defined in ARRA §4102 (Wkst. S-3, Pt. I, col. 15, line 14)									1
2	Medicare days (see instructions)									2
3	Medicare HMO days (Wkst. S-3, Pt. I, col. 6, line 2)									3
4	Total inpatient days (see instructions)									4
5	Total hospital charges (Wkst. C, Pt. I, col. 8, line 200)									5
6	Total hospital charity care charges (Wkst. S-10, col. 3, line 20)									6
7	CAH only - The reasonable cost incurred for the purchase of certified HIT technology (Wkst. S-2, Pt. I, line 168)									7
8	Calculation of the HIT incentive payment (see instructions)									8
9	Sequestration adjustment amount (see instructions)									9
10	Calculation of the HIT incentive payment after sequestration (see instructions)									10
INPATIENT HOSPITAL SERVICES UNDER THE IPPS & CAH
30	Initial/interim HIT payment(s).									30
31	Initial/interim HIT payment adjustments (see instructions)									31
32	Balance due provider (line 8 or line 10 minus line 30 and line 31) (see instructions)									32
*	This worksheet is completed by the contractor for standard and non-standard cost reporting periods at cost report settlement. Providers may
	may complete this worksheet for a standard cost reporting period.
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4031.2)
Rev. 21										40-589

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Sheet 54: E2

4090 (Cont.)					FORM CMS-2552-10					07-23
CALCULATION OF REIMBURSEMENT							PROVIDER CCN:	PERIOD:	WORKSHEET E-2
SETTLEMENT - SWING BEDS							________________	FROM ____________
							COMPONENT CCN:	TO _______________
							________________
Check		[ ] Title V	[ ] Swing-Bed SNF
applicable		[ ] Title XVIII	[ ] Swing-Bed NF
boxes:		[ ] Title XIX	[ ] PARHM CAH Swing-Bed SNF
								PART A	PART B
	COMPUTATION OF NET COST OF COVERED SERVICES							1	2
1	Inpatient routine services - swing bed-SNF (see instructions)									1
2	Inpatient routine services - swing bed-NF (see instructions)									2
3	Ancillary services (from Wkst. D-3, col. 3, line 200, for Part A; and sum of Wkst. D, Pt. V,									3
	cols. 6 and 7, line 202, for Part B) (For CAH and swing-bed pass-through, see instructions)
3.01	Nursing and allied health payment-PARHM (see instructions)									3.01
4	Per diem cost for interns and residents not in approved teaching program (see instructions)									4
5	Program days									5
6	Interns and residents not in approved teaching program (see instructions)									6
7	Utilization review - physician compensation - SNF optional method only									7
8	Subtotal (sum of lines 1 through 3 plus lines 6 and 7)									8
9	Primary payer payments (see instructions)									9
10	Subtotal (line 8 minus line 9)									10
11	Deductibles billed to program patients (exclude amounts applicable to physician professional services)									11
12	Subtotal (line 10 minus line 11)									12
13	Coinsurance billed to program patients (from provider records) (exclude coinsurance for physician professional services)									13
14	80% of Part B costs (line 12 x 80%)									14
15	Subtotal (see instructions)									15
16	Other adjustments (specify) (see instructions)									16
16.50	Pioneer ACO demonstration payment adjustment (see instructions)									16.50
16.55	Rural community hospital demonstration project (§410A Demonstration) payment adjustment (see instructions)									16.55
16.99	Demonstration payment adjustment amount before sequestration									16.99
17	Allowable bad debts (see instructions)									17
17.01	Adjusted reimbursable bad debts (see instructions)									17.01
18	Allowable bad debts for dual eligible beneficiaries (see instructions)									18
19	Total (see instructions)									19
19.01	Sequestration adjustment (see instructions)									19.01
19.02	Demonstration payment adjustment amount after sequestration									19.02
19.03	Sequestration adjustment-PARHM pass-throughs									19.03
19.25	Sequestration for non-claims based amounts (see instructions)									19.25
20	Interim payments									20
20.01	Interim payments-PARHM									20.01
21	Tentative settlement (for contractor use only)									21
21.01	Tentative settlement-PARHM (for contractor use only)									21.01
22	Balance due provider/program (line 19 minus lines 19.01, 19.02, 19.25, 20, and 21)									22
22.01	Balance due provider/program-PARHM (see instructions)									22.01
23	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2									23
	Rural Community Hospital Demonstration Project (§410A Demonstration) Adjustment
200	Is this the first year of the current 5-year demonstration period under the 21st Century Cures Act? Enter "Y" for yes or "N" for no.									200
	Cost Reimbursement
201	Medicare swing-bed SNF inpatient routine service costs (from Wkst. D-1, Pt. II, line 66 (title XVIII hospital))									201
202	Medicare swing-bed SNF inpatient ancillary service costs (from Wkst. D-3, col. 3, line 200 (title XVIII swing-bed SNF))									202
203	Total (sum of lines 201 and 202)									203
204	Medicare swing-bed SNF discharges (see instructions)									204
	Computation of Demonstration Target Amount Limitation (N/A in first year of the current 5-year demonstration period)
205	Medicare swing-bed SNF target amount									205
206	Medicare swing-bed SNF inpatient routine cost cap (line 205 times line 204)									206
	Adjustment to Medicare Part A Swing-Bed SNF Inpatient Reimbursement
207	Program reimbursement under the §410A Demonstration (see instructions)									207
208	Medicare swing-bed SNF inpatient service costs (from Wkst. E-2, col. 1, sum of lines 1 and 3)									208
209	Adjustment to Medicare swing-bed SNF PPS payments (see instructions)									209
210	Reserved for future use									210
	Comparison of PPS versus Cost Reimbursement
215	Total adjustment to Medicare swing-bed SNF PPS payment (line 209 plus line 210) (see instructions)									215
FORM CMS-2552-10 (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4032)
40-590										Rev. 21

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Sheet 55: E3I

04-20				FORM CMS-2552-10				4090 (Cont.)
CALCULATION OF REIMBURSEMENT SETTLEMENT					PROVIDER CCN:	PERIOD:	WORKSHEET E-3,
					________________	FROM ____________	PART I
						TO _______________
PART I - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER TEFRA
1	Inpatient hospital services (see instructions)							1
1.01	Nursing and allied health managed care payment (see instructions)							1.01
2	Organ acquisition							2
3	Cost of physicians' services in a teaching hospital (see instructions)							3
4	Subtotal (sum of lines 1 through 3)							4
5	Primary payer payments							5
6	Subtotal (line 4 less line 5).							6
7	Deductibles							7
8	Subtotal (line 6 minus line 7)							8
9	Coinsurance							9
10	Subtotal (line 8 minus line 9)							10
11	Allowable bad debts (exclude bad debts for professional services) (see instructions)							11
12	Adjusted reimbursable bad debts (see instructions)							12
13	Allowable bad debts for dual eligible beneficiaries (see instructions)							13
14	Subtotal (sum of lines 10 and 12)							14
15	Direct graduate medical education payments (from Wkst. E-4, line 49)							15
16	Other pass through costs (see instructions). DO NOT USE THIS LINE.							16
17	Other adjustments (specify) (see instructions)							17
17.50	Pioneer ACO demonstration payment adjustment (see instructions)							17.50
17.99	Demonstration payment adjustment amount before sequestration							17.99
18	Total amount payable to the provider (see instructions)							18
18.01	Sequestration adjustment (see instructions)							18.01
18.02	Demonstration payment adjustment amount after sequestration							18.02
19	Interim payments							19
20	Tentative settlement (for contractor use only)							20
21	Balance due provider/program (line 18 minus lines 18.01, 18.02,19, and 20)							21
22	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2							22
FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.1)
Rev. 16								40-591

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Sheet 56: E3II

4090 (Cont.)					FORM CMS-2552-10					04-20
CALCULATION OF REIMBURSEMENT SETTLEMENT							PROVIDER CCN:	PERIOD:	WORKSHEET E-3,
							________________	FROM ____________	PART II
							COMPONENT CCN:	TO _______________
							________________
Check		[ ] Hospital
applicable		[ ] Subprovider IPF
box:
PART II - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER IPF PPS
1	Net Federal IPF PPS payment (excluding outlier, ECT, and medical education payments)									1
2	Net IPF PPS Outlier payment									2
3	Net IPF PPS ECT payment									3
4	Unweighted intern and resident FTE count in the most recent cost report filed on or before November 15, 2004 (see instructions)									4
4.01	Cap increases for the unweighted intern and resident FTE count for residents that were displaced by program or hospital closure,									4.01
	that would not be counted without a temporary cap adjustment under 42 CFR §412.424(d)(1)(iii)(F)(1) or (2) (see instructions)
5	New teaching program adjustment (see instructions)									5
6	Current year unweighted FTE count of I&R excluding FTEs in the new program growth period									6
	of a "new teaching program" (see instructions)
7	Current year unweighted I&R FTE count for residents within the new program growth period									7
	of a "new teaching program" (see instructions)
8	Intern and resident count for IPF PPS medical education adjustment (see instructions)									8
9	Average daily census (see instructions)									9
10	Teaching Adjustment Factor {((1 + (line 8/line 9)) raised to the power of .5150 -1}.									10
11	Teaching Adjustment (line 1 multiplied by line 10).									11
12	Adjusted Net IPF PPS Payments (sum of lines 1, 2, 3, and 11)									12
13	Nursing and allied health managed care payment (see instructions)									13
14	Organ acquisition DO NOT USE THIS LINE									14
15	Cost of physicians' services in a teaching hospital (see instructions)									15
16	Subtotal (see instructions)									16
17	Primary payer payments									17
18	Subtotal (line 16 less line 17).									18
19	Deductibles									19
20	Subtotal (line 18 minus line 19)									20
21	Coinsurance									21
22	Subtotal (line 20 minus line 21)									22
23	Allowable bad debts (exclude bad debts for professional services) (see instructions)									23
24	Adjusted reimbursable bad debts (see instructions)									24
25	Allowable bad debts for dual eligible beneficiaries (see instructions)									25
26	Subtotal (sum of lines 22 and 24)									26
27	Direct graduate medical education payments (from Wkst. E-4, line 49) (see instructions)									27
28	Other pass through costs (see instructions)									28
29	Outlier payments reconciliation									29
30	Other adjustments (specify) (see instructions)									30
30.50	Pioneer ACO demonstration payment adjustment (see instructions)									30.50
30.99	Demonstration payment adjustment amount before sequestration									30.99
31	Total amount payable to the provider (see instructions)									31
31.01	Sequestration adjustment (see instructions)									31.01
31.02	Demonstration payment adjustment amount after sequestration									31.02
32	Interim payments									32
33	Tentative settlement (for contractor use only)									33
34	Balance due provider/program (line 31 minus lines 31.01, 31.02, 32, and 33)									34
35	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2									35
	TO BE COMPLETED BY CONTRACTOR
50	Original outlier amount from Worksheet E-3, Part II, line 2 (see instructions)									50
51	Outlier reconciliation adjustment amount (see instructions)									51
52	The rate used to calculate the Time Value of Money (see instructions)									52
53	Time Value of Money (see instructions)									53
FORM CMS-2552-10 (04-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.2)
40-592										Rev. 16

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Sheet 57: E3III

04-20					FORM CMS-2552-10					4090 (Cont.)
CALCULATION OF REIMBURSEMENT SETTLEMENT							PROVIDER CCN:	PERIOD:	WORKSHEET E-3,
							________________	FROM ____________	PART III
							COMPONENT CCN:	TO _______________
							________________
Check		[ ] Hospital
applicable		[ ] Subprovider IRF
box:
PART III - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER IRF PPS
1	Net Federal PPS payment (see instructions)									1
2	Medicare SSI ratio (IRF PPS only) (see instructions)									2
3	Inpatient Rehabilitation LIP payments (see instructions)									3
4	Outlier payments									4
5	Unweighted intern and resident FTE count in the most recent cost reporting period ending									5
	on or prior to November 15, 2004 (see instructions)
5.01	Cap increases for the unweighted intern and resident FTE count for residents that were displaced by program or hospital									5.01
	closure, that would not be counted without a temporary cap adjustment under 42 CFR §412.424(d)(1)(iii)(F)(1) or (2)
6	New teaching program adjustment (see instructions)									6
7	Current year unweighted FTE count of I&R excluding FTEs in the new program growth period									7
	of a "new teaching program" (see instructions)
8	Current year unweighted I&R FTE count for residents within the new program growth period									8
	of a “new teaching program” (see instructions)
9	Intern and resident count for IRF PPS medical education adjustment (see instructions)									9
10	Average daily census (see instructions)									10
11	Teaching Adjustment Factor (see instructions)									11
12	Teaching Adjustment (see instructions)									12
13	Total PPS Payment (see instructions)									13
14	Nursing and allied health managed care payments (see instructions)									14
15	Organ acquisition DO NOT USE THIS LINE									15
16	Cost of physicians' services in a teaching hospital (see instructions)									16
17	Subtotal (see instructions)									17
18	Primary payer payments									18
19	Subtotal (line 17 less line 18)									19
20	Deductibles									20
21	Subtotal (line 19 minus line 20)									21
22	Coinsurance									22
23	Subtotal (line 21 minus line 22)									23
24	Allowable bad debts (exclude bad debts for professional services) (see instructions)									24
25	Adjusted reimbursable bad debts (see instructions)									25
26	Allowable bad debts for dual eligible beneficiaries (see instructions)									26
27	Subtotal (sum of lines 23 and 25)									27
28	Direct graduate medical education payments (from Wkst. E-4, line 49) (see instructions)									28
29	Other pass through costs (see instructions)									29
30	Outlier payments reconciliation									30
31	Other adjustments (specify) (see instructions)									31
31.50	Pioneer ACO demonstration payment adjustment (see instructions)									31.50
31.99	Demonstration payment adjustment amount before sequestration									31.99
32	Total amount payable to the provider (see instructions)									32
32.01	Sequestration adjustment (see instructions)									32.01
32.02	Demonstration payment adjustment amount after sequestration									32.02
33	Interim payments									33
34	Tentative settlement (for contractor use only)									34
35	Balance due provider/program (line 32 minus lines 32.01, 32.02, 33, and 34)									35
36	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2									36
	TO BE COMPLETED BY CONTRACTOR
50	Original outlier amount from Wkst. E-3, Pt. III, line 4 (see instructions)									50
51	Outlier reconciliation adjustment amount (see instructions)									51
52	The rate used to calculate the Time Value of Money (see instructions)									52
53	Time Value of Money (see instructions)									53
FORM CMS-2552-10 (04-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.3)
Rev. 16										40-593

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Sheet 58: E3IV

4090 (Cont.)				FORM CMS-2552-10				04-20
CALCULATION OF REIMBURSEMENT SETTLEMENT					PROVIDER CCN:	PERIOD:	WORKSHEET E-3,
					________________	FROM ____________	PART IV
						TO _____________
PART IV - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER LTCH PPS
1	Net Federal PPS payment (see instructions)							1
1.01	Full standard payment amount							1.01
1.02	Short stay outlier standard payment amount							1.02
1.03	Site neutral payment amount - Cost							1.03
1.04	Site neutral payment amount - IPPS comparable							1.04
2	Outlier payments							2
3	Total PPS payments (sum of lines 1 and 2)							3
4	Nursing and allied health managed care payments (see instructions)							4
5	Organ acquisition DO NOT USE THIS LINE							5
6	Cost of physicians' services in a teaching hospital (see instructions)							6
7	Subtotal (see instructions)							7
8	Primary payer payments							8
9	Subtotal (line 7 less line 8)							9
10	Deductibles							10
11	Subtotal (line 9 minus line 10)							11
12	Coinsurance							12
13	Subtotal (line 11 minus line 12)							13
14	Allowable bad debts (exclude bad debts for professional services) (see instructions)							14
15	Adjusted reimbursable bad debts (see instructions)							15
16	Allowable bad debts for dual eligible beneficiaries (see instructions)							16
17	Subtotal (sum of lines 13 and 15)							17
18	Direct graduate medical education payments (from Wkst. E-4, line 49)							18
19	Other pass through costs (see instructions)							19
20	Outlier payments reconciliation							20
21	Other adjustments (specify) (see instructions)							21
21.50	Pioneer ACO demonstration payment adjustment (see instructions)							21.50
21.99	Demonstration payment adjustment amount before sequestration							21.99
22	Total amount payable to the provider (see instructions)							22
22.01	Sequestration adjustment (see instructions)							22.01
22.02	Demonstration payment adjustment amount after sequestration							22.02
23	Interim payments							23
24	Tentative settlement (for contractor use only)							24
25	Balance due provider/program (line 22 minus lines 22.01, 22.02, 23, and 24)							25
26	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2							26
	TO BE COMPLETED BY CONTRACTOR
50	Original outlier amount (see instructions)							50
51	Outlier reconciliation adjustment amount (see instructions)							51
52	The rate used to calculate the Time Value of Money (see instructions)							52
53	Time Value of Money (see instructions)							53
FORM CMS-2552-10 (04-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.4)
40-594								Rev. 16

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Sheet 59: E3V

07-23				FORM CMS-2552-10					4090 (Cont.)
CALCULATION OF REIMBURSEMENT SETTLEMENT						PROVIDER CCN:	PERIOD:	WORKSHEET E-3,
						________________	FROM ____________	PART V
							TO _____________
Check		[ ] Hospital
applicable		[ ] PARHM Demonstration
box:
PART V - CALCULATION OF REIMBURSEMENT SETTLEMENT FOR MEDICARE PART A SERVICES - COST REIMBURSEMENT
1	Inpatient services								1
2	Nursing and allied health managed care payment (see instructions)								2
3	Organ acquisition								3
3.01	Cellular therapy acquisition cost (see instructions)								3.01
4	Subtotal (sum of lines 1 through 3.01)								4
5	Primary payer payments								5
6	Total cost (see instructions)								6
	COMPUTATION OF LESSER OF COST OR CHARGES
	Reasonable charges
7	Routine service charges								7
8	Ancillary service charges								8
9	Organ acquisition charges, net of revenue								9
10	Total reasonable charges								10
	Customary charges
11	Aggregate amount actually collected from patients liable for payment for services on a charge basis								11
12	Amounts that would have been realized from patients liable for payment for services on								12
	a charge basis had such payment been made in accordance with 42 CFR §413.13(e)
13	Ratio of line 11 to line 12 (not to exceed 1.000000)								13
14	Total customary charges (see instructions)								14
15	Excess of customary charges over reasonable cost (complete only if line 14 exceeds line 6) (see instructions)								15
16	Excess of reasonable cost over customary charges (complete only if line 6 exceeds line 14) (see instructions)								16
17	Cost of physicians' services in a teaching hospital (see instructions)								17
	COMPUTATION OF REIMBURSEMENT SETTLEMENT
18	Direct graduate medical education payments								18
19	Cost of covered services (sum of lines 6 and 17)								19
20	Deductibles (exclude professional component)								20
21	Excess reasonable cost (from line 16)								21
22	Subtotal (line 19 minus lines 20 and 21)								22
23	Coinsurance								23
24	Subtotal (line 22 minus line 23)								24
25	Allowable bad debts (exclude bad debts for professional services) (see instructions)								25
26	Adjusted reimbursable bad debts (see instructions)								26
27	Allowable bad debts for dual eligible beneficiaries (see instructions)								27
28	Subtotal (sum of lines 24 and 25 or 26)								28
29	Other adjustments (specify) (see instructions)								29
29.50	Pioneer ACO demonstration payment adjustment (see instructions)								29.50
29.99	Demonstration payment adjustment amount before sequestration								29.99
30	Subtotal (see instructions)								30
30.01	Sequestration adjustment (see instructions)								30.01
30.02	Demonstration payment adjustment amount after sequestration								30.02
30.03	Sequestration adjustment-PARHM								30.03
31	Interim payments								31
31.01	Interim payments-PARHM								31.01
32	Tentative settlement (for contractor use only)								32
32.01	Tentative settlement-PARHM (for contractor use only)								32.01
33	Balance due provider/program (line 30 minus lines 30.01, 30.02, 31, and 32)								33
33.01	Balance due provider/program-PARHM (lines 2, 3, 18, and 26, minus lines 30.03, 31.01, and 32.01 )								33.01
34	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2								34
FORM CMS-2552-10 (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.5)
Rev. 21									40-595

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Sheet 60: E3VI

4090 (Cont.)				FORM CMS-2552-10				07-23
CALCULATION OF REIMBURSEMENT SETTLEMENT					PROVIDER CCN:	PERIOD:	WORKSHEET E-3,
					________________	FROM ____________	PART VI
					COMPONENT CCN.:	TO _______________
					________________
PART VI - CALCULATION OF REIMBURSEMENT SETTLEMEMENT - TITLE XVIII PART A PPS SNF SERVICES
	PROSPECTIVE PAYMENT AMOUNT (SEE INSTRUCTIONS)
1	Resource Utilization Group (RUGS) payment							1
2	Routine service other pass through costs							2
3	Ancillary service other pass through costs							3
4	Subtotal (sum of lines 1 through 3)							4
	COMPUTATION OF NET COST OF COVERED SERVICES
5	Medical and other services. Do not use this line. (see instructions)							5
6	Deductibles							6
7	Coinsurance							7
8	Allowable bad debts (see instructions)							8
9	Reimbursable bad debts for dual eligible beneficiaries (see instructions)							9
10	Adjusted reimbursable bad debts (see instructions)							10
11	Utilization review							11
12	Subtotal (sum of lines 4 and 5, minus lines 6 and 7, plus lines 10 and 11) (see instructions)							12
13	Inpatient primary payer payments							13
14	Other adjustments (specify) (see instructions)							14
14.50	Pioneer ACO demonstration payment adjustment (see instructions)							14.50
14.99	Demonstration payment adjustment amount before sequestration							14.99
15	Subtotal (see instructions)							15
15.01	Sequestration adjustment (see instructions)							15.01
15.02	Demonstration payment adjustment amount after sequestration							15.02
15.75	Sequestration for non-claims based amounts (see instructions)							15.75
16	Interim payments							16
17	Tentative settlement (for contractor use only)							17
18	Balance due provider/program (line 15 minus lines 15.01, 15.02, 15.75, 16, and 17)							18
19	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2							19
FORM CMS-2552-10 (01-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.6)
40-596								Rev. 21

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Sheet 61: E3VII

12-24				FORM CMS-2552-10					4090 (Cont.)
CALCULATION OF REIMBURSEMENT SETTLEMENT						PROVIDER CCN:	PERIOD:	WORKSHEET E-3,
						________________	FROM ____________	PART VII
						COMPONENT CCN.:	TO _______________
						________________
Check		[ ] Title V	[ ] Hospital	[ ] NF	[ ] PPS
applicable		[ ] Title XIX	[ ] Subprovider	[ ] ICF/IID	[ ] TEFRA
boxes:			[ ] SNF		[ ] Other
PART VII - CALCULATION OF REIMBURSEMENT - ALL OTHER HEALTH SERVICES FOR TITLES V OR XIX SERVICES
							Inpatient	Outpatient
							Title V or	Title V or
	COMPUTATION OF NET COST OF COVERED SERVICES						Title XIX	Title XIX
1	Inpatient hospital/SNF/NF services								1
2	Medical and other services								2
3	Organ acquisition (certified transplant programs only)								3
4	Subtotal (sum of lines 1, 2 and 3)								4
5	Inpatient primary payer payments								5
6	Outpatient primary payer payments								6
7	Subtotal (line 4 less sum of lines 5 and 6)								7
	COMPUTATION OF LESSER OF COST OR CHARGES
	Reasonable Charges
8	Routine service charges								8
9	Ancillary service charges								9
10	Organ acquisition charges, net of revenue								10
11	Incentive from target amount computation								11
12	Total reasonable charges (sum of lines 8 through 11)								12
	CUSTOMARY CHARGES
13	Amount actually collected from patients liable for payment for services on a charge basis								13
14	Amounts that would have been realized from patients liable for payment for services								14
	on a charge basis had such payment been made in accordance with 42 CFR §413.13(e)
15	Ratio of line 13 to line 14 (not to exceed 1.000000)								15
16	Total customary charges (see instructions)								16
17	Excess of customary charges over reasonable cost (complete only if line 16								17
	exceeds line 4) (see instructions)
18	Excess of reasonable cost over customary charges (complete only if line 4 exceeds line 16) (see instructions)								18
19	Interns and residents (see instructions)								19
20	Cost of physicians' service in a teaching hospital (see instructions)								20
21	Cost of covered services (enter the lesser of line 4 or line 16)								21
	PROSPECTIVE PAYMENT AMOUNT
22	Other than outlier payments								22
23	Outlier payments								23
24	Program capital payments								24
25	Capital exception payments (see instructions)								25
26	Routine and ancillary service other pass through costs								26
27	Subtotal (sum of lines 22 through 26)								27
28	Customary charges (title V or XIX PPS covered services only)								28
29	Titles V or XIX (sum of lines 21 and 27)								29
	COMPUTATION OF REIMBURSEMENT SETTLEMENT
30	Excess of reasonable cost (from line 18)								30
31	Subtotal (sum of lines 19 and 20, plus 29 minus lines 5 and 6)								31
32	Deductibles								32
33	Coinsurance								33
34	Allowable bad debts (see instructions)								34
35	Utilization review								35
36	Subtotal (sum of lines 31, 34 and 35 minus the sum of lines 32 and 33)								36
37	Other adjustments (specify) (see instructions)								37
38	Subtotal (line 36 ± line 37)								38
39	Direct graduate medical education payments (from Wkst. E-4)								39
40	Total amount payable to the provider (sum of lines 38 and 39)								40
41	Interim payments								41
42	Balance due provider/program (line 40 minus line 41)								42
43	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2								43
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.7)
Rev. 23									40-597

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Sheet 62: E4

4090 (Cont.)				FORM CMS-2552-10					12-24
DIRECT GRADUATE MEDICAL EDUCATION (GME)						PROVIDER CCN:	PERIOD:	WORKSHEET E-4
& ESRD OUTPATIENT DIRECT MEDICAL						________________	FROM ____________
EDUCATION COSTS							TO _______________
Check		[ ] Title V		[ ] Hospital		[ ] CAH-Based IPF
applicable		[ ] Title XVIII		[ ] PARHM Demonstration		[ ] CAH-Based IRF
box:		[ ] Title XIX
	COMPUTATION OF TOTAL DIRECT GME AMOUNT
1	Unweighted resident FTE count for allopathic and osteopathic programs for cost reporting periods ending on or before December 31, 1996								1
1.01	FTE cap adjustment under §131 of the CAA 2021 (see instructions)								1.01
2	Unweighted FTE resident cap add-on for new programs per 42 CFR 413.79(e) (see instructions)								2
2.26	Rural track program FTE cap limitation adjustment after the cap-building window closed under §127 of the CAA 2021 (see instructions)								2.26
3	Amount of reduction to Direct GME cap under §422 of MMA								3
3.01	Direct GME cap reduction amount under ACA §5503 in accordance with 42 CFR §413.79 (m). (see instructions								3.01
	for cost reporting periods straddling 7/1/2011)
3.02	Adjustment (increase or decrease) to the hospital’s rural track FTE limitation(s) for rural track programs with a rural track Medicare GME								3.02
	affiliation agreement in accordance with 413.75(b) and 87 FR 49075 (August 10, 2022) (see instructions)
4	Adjustment (plus or minus) to the FTE cap for allopathic and osteopathic programs due to a Medicare GME								4
	affiliation agreement (42 CFR §413.75(b) and § 413.79 (f))
4.01	ACA §5503 increase to the direct GME FTE cap (see instructions for cost reporting periods straddling 7/1/2011)								4.01
4.02	ACA §5506 number of additional direct GME FTE cap slots (see instructions for cost reporting periods straddling 7/1/2011)								4.02
4.21	The amount of increase if the hospital was awarded FTE cap slots under §126 of the CAA 2021 (see instructions)								4.21
4.28	The amount of increase if the hospital was awarded FTE cap slots under §4122 of the CAA 2023 (see instructions)								4.28
5	FTE adjusted cap (line 1 plus and 1.01, plus line 2, plus lines 2.26 through 2.49, minus lines 3 and 3.01, plus or minus line 3.02, plus or minus								5
	line 4, plus lines 4.01 through 4.28
6	Unweighted resident FTE count for allopathic and osteopathic programs for the current year from your records (see instructions)								6
7	Enter the lesser of line 5 or line 6								7
						Primary Care	Other	Total
						1	2	3
8	Weighted FTE count for physicians in an allopathic and osteopathic program for								8
	the current year
9	If line 6 is less than 5 enter the amount from line 8, otherwise multiply line 8 times								9
	the result of line 5 divided by the amount on line 6. For cost reporting periods beginning
	on or after October 1, 2022, or if Worksheet S-2, Part I, line 68, is “Y”, see instructions.
10	Weighted dental and podiatric resident FTE count for the current year								10
10.01	Unweighted dental and podiatric resident FTE count for the current year								10.01
11	Total weighted FTE count								11
12	Total weighted resident FTE count for the prior cost reporting year (see instructions)								12
13	Total weighted resident FTE count for the penultimate cost reporting year (see instr.)								13
14	Rolling average FTE count (sum of lines 11 through 13 divided by 3)								14
15	Adjustment for residents in initial years of new programs								15
15.01	Unweighted adjustment for residents in initial years of new programs								15.01
16	Adjustment for residents displaced by program or hospital closure								16
16.01	Unweighted adjustment for residents displaced by program or hospital closure								16.01
17	Adjusted rolling average FTE count								17
18	Per resident amount								18
18.01	Per resident amount under §131 of the CAA 2021								18.01
19	Approved amount for resident costs								19
20	Additional unweighted allopathic and osteopathic direct GME FTE resident cap slots received under 42 §413.79(c)(4)								20
21	Direct GME FTE unweighted resident count over cap (see instructions)								21
22	Allowable additional direct GME FTE resident count (see instructions)								22
23	Enter the locality adjustment national average per resident amount (see instructions)								23
24	Multiply line 22 time line 23								24
25	Total direct GME amount (sum of lines 19 and 24)								25
					Inpatient Part A	Managed Care	Managed Care	Total
						Prior to 1/1	On or after 1/1
	COMPUTATION OF PROGRAM PATIENT LOAD				1	2	2.01	3
26	Inpatient days (see instructions)								26
27	Total inpatient days (see instructions)								27
28	Ratio of inpatient days to total inpatient days								28
29	Program direct GME amount								29
29.01	Percent reduction for MA DGME								29.01
30	Reduction for direct GME payments for Medicare Advantage								30
31	Net Program direct GME amount								31
	DIRECT MEDICAL EDUCATION COSTS FOR ESRD COMPOSITE RATE - TITLE XVIII ONLY (NURSING PROGRAM AND
	PARAMEDICAL EDUCATION COSTS)
32	Renal dialysis direct medical education costs (from Wkst. B, Pt. I, sum of col. 20 and 23, lines 74 and 94)								32
33	Renal dialysis and home dialysis total charges (Wkst. C, Pt. I, col. 8, sum of lines 74 and 94)								33
34	Ratio of direct medical education costs to total charges (line 32 ÷ line 33)								34
35	Medicare outpatient ESRD charges (see instructions)								35
36	Medicare outpatient ESRD direct medical education costs (line 34 x line 35)								36
FORM CMS-2552-10 (12-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4034)
40-598									Rev. 23
07-23				FORM CMS-2552-10					4090 (Cont.)
DIRECT GRADUATE MEDICAL EDUCATION (GME)						PROVIDER CCN:	PERIOD:	WORKSHEET E-4
& ESRD OUTPATIENT DIRECT MEDICAL						________________	FROM ____________
EDUCATION COSTS							TO _______________
Check		[ ] Title V		[ ] Hospital		[ ] CAH-Based IPF
applicable		[ ] Title XVIII		[ ] PARHM Demonstration		[ ] CAH-Based IRF
box:		[ ] Title XIX
	APPORTIONMENT OF MEDICARE REASONABLE COST OF GME
	Part A Reasonable Cost
37	Reasonable cost (see instructions)								37
38	Organ acquisition and HSCT acquisition costs (see instructions)								38
39	Cost of physicians' services in a teaching hospital (see instructions)								39
40	Primary payer payments (see instructions)								40
41	Total Part A reasonable cost (sum of lines 37 through 39 minus line 40)								41
	Part B Reasonable Cost
42	Reasonable cost (see instructions)								42
43	Primary payer payments (see instructions)								43
44	Total Part B reasonable cost (line 42 minus line 43)								44
45	Total reasonable cost (sum of lines 41 and 44)								45
46	Ratio of Part A reasonable cost to total reasonable cost (line 41 ÷ line 45)								46
47	Ratio of Part B reasonable cost to total reasonable cost (line 44 ÷ line 45)								47
	ALLOCATION OF MEDICARE DIRECT GME COSTS BETWEEN PART A AND PART B
48	Total program GME payment (line 31)								48
49	Part A Medicare GME payment (line 46 x 48) (title XVIII only) (see instructions)								49
50	Part B Medicare GME payment (line 47 x 48) (title XVIII only) (see instructions)								50
FORM CMS-2552-10 (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4034)
Rev. 21									40-599

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Sheet 63: E5

4090 (Cont.)				FORM CMS-2552-10				07-23
OUTLIER RECONCILIATION AT TENTATIVE SETTLEMENT					PROVIDER CCN:	PERIOD:	WORKSHEET E-5
					________________	FROM ____________
						TO _______________
	TO BE COMPLETED BY CONTRACTOR
1	Operating outlier amount from Wkst. E, Pt. A, line 2, or sum of 2.03 plus 2.04 (see instructions)							1
2	Capital outlier from Wkst. L, Pt. I, line 2							2
3	Operating outlier reconciliation adjustment amount (see instructions)							3
4	Capital outlier reconciliation adjustment amount (see instructions)							4
5	The rate used to calculate the time value of money (see instructions)							5
6	Time value of money for operating expenses (see instructions)							6
7	Time value of money for capital related expenses (see instructions)							7
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4035)
40-599.1								Rev. 21

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Sheet 64: E-90

DRAFT																		FORM CMS-2552-10																		4090 (Cont.)
PAYMENT ADJUSTMENT FOR ESTABLISHING AND MAINTAINING ACCESS TO																					PROVIDER CCN:					PERIOD:					WORKSHEET E-90
A BUFFER STOCK OF ESSENTIAL MEDICINES																					________________					FROM:		______________
																										TO:		______________
PART I - ADDITIONAL RESOURCE COST OF ESSENTIAL MEDICINES
1	COST TO ESTABLISH AND MAINTAIN BUFFER STOCK OF ESSENTIAL MEDICINES - DIRECTLY INCURRED																																			1
2	COST TO ESTABLISH AND MAINTAIN BUFFER STOCK OF ESSENTIAL MEDICINES - CONTRACT																																			2
3	TOTAL COST TO ESTABLISH AND MAINTAIN BUFFER STOCK OF ESSENTIAL MEDICINES																																			3
PART II - CALCULATION OF MEDICARE PAYMENT ADJUSTMENT FOR ESSENTIAL MEDICINES
1	MEDICARE ROUTINE/ANCILLARY COST																																			1
2	MEDICARE ACQUISITION COST																																			2
3	COST OF PHYSICIANS' SERVICES IN A TEACHING HOSPITAL																																			3
4	TOTAL MEDICARE REASONABLE COST																																			4
5	TOTAL FACILITY COST																																			5
6	MEDICARE PERCENTAGE																																			6
7	ESSENTIAL MEDICINES PAYMENT ADJUSTMENT																																			7
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4038)
Rev. XX																																				40-599.2
4090 (Cont.)																		FORM CMS-2552-10																		DRAFT
This page is reserved for future use.
FORM CMS-2552-10 (12-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4038)
40-599.3																																				Rev. XX

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Sheet 65: E-95

DRAFT			FORM CMS-2552-10						4090 (Cont.)
PAYMENT ADJUSTMENTS FOR DOMESTIC NIOSH-APPROVED						PROVIDER CCN:	PERIOD:	WORKSHEET E-95
SURGICAL N95 RESPIRATORS						_______________	FROM __________
							TO _____________
PART I - DOMESTIC NIOSH-APPROVED SURGICAL N95 RESPIRATORS PAYMENT ADJUSTMENT ELIGIBILITY AND DATA
							DOMESTIC	NON-DOMESTIC
							RESPIRATORS	RESPIRATORS
							1	2
1	Did the hospital or hospital healthcare complex purchase domestic (column 1) or non-domestic (column 2) respirators? Enter "Y" for yes or								1
	"N" for no in each column. If "Y" for either column, complete line 2.
					DOMESTIC RESPIRATORS		NON-DOMESTIC RESPIRATORS
					TOTAL	NUMBER	TOTAL	NUMBER
					COST	PURCHASED	COST	PURCHASED
					1	2	3	4
2	Enter the total cost of domestic respirators purchased in column 1 and the number of domestic								2
	respirators purchased in column 2.
	Enter the total cost of non-domestic respirators purchased in column 3 and the number of
	non-domestic respirators purchased in column 4.
PART II - CALCULATION OF COST DIFFERENTIAL FOR DOMESTIC NIOSH-APPROVED SURGICAL N95 RESPIRATORS
						DOMESTIC	NON-DOMESTIC	COST
						RESPIRATORS	RESPIRATORS	DIFFERENTIAL
						1	2	3
1	Total cost of NIOSH-approved surgical N95 respirators purchased								1
2	Number of NIOSH-approved surgical N95 respirators purchased								2
3	Average cost per respirator								3
4	Hospital-specific unit cost differential for domestic respirators								4
5	Total cost differential for domestic respirators								5
PART III - CALCULATION OF PAYMENT ADJUSTMENT FOR DOMESTIC NIOSH-APPROVED SURGICAL N95 RESPIRATORS
						IPF	IRF
				HOSPITAL	HOSPITAL	SUBPROVIDER	SUBPROVIDER
				PART A	PART B	PART B	PART B	TOTAL
				1	2	3	4	5
1	Medicare routine/ancillary costs								1
1.01	Medicare acquisition costs								1.01
1.02	Cost of physicians' services in a teaching hospital								1.02
1.15	Total Medicare reasonable costs								1.15
2	Total facility costs								2
3	Medicare percentage								3
4	Domestic NIOSH-approved surgical N95 respirators payment adjustment								4
FORM CMS-2552-10 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4039)
Rev. XX									40-599.4

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Sheet 66: G

4090 (Cont.)					FORM CMS-2552-10				DRAFT
BALANCE SHEET						PROVIDER CCN:	PERIOD:	WORKSHEET G
(If you are nonproprietary and do not maintain fund-type						________________	FROM ____________
accounting records, complete the General Fund column only)							TO _______________
						Specific
					General	Purpose	Endowment	Plant
	Assets				Fund	Fund	Fund	Fund
	(Omit cents)				1	2	3	4
	CURRENT ASSETS
1	Cash on hand and in banks								1
2	Temporary investments								2
3	Notes receivable								3
4	Accounts receivable								4
5	Other receivables								5
6	Allowances for uncollectible notes and								6
	accounts receivable
7	Inventory								7
8	Prepaid expenses								8
9	Other current assets								9
10	Due from other funds								10
11	Total current assets (sum of lines 1 through 10)								11
	FIXED ASSETS
12	Land								12
13	Land improvements								13
14	Accumulated depreciation								14
15	Buildings								15
16	Accumulated depreciation								16
17	Leasehold improvements								17
18	Accumulated depreciation								18
19	Fixed equipment								19
20	Accumulated depreciation								20
21	Automobiles and trucks								21
22	Accumulated depreciation								22
23	Major movable equipment								23
24	Accumulated depreciation								24
25	Minor equipment depreciable								25
26	Accumulated depreciation								26
27	HIT designated Assets								27
28	Accumulated depreciation								28
29	Minor equipment-nondepreciable								29
30	Total fixed assets (sum of lines 12 through 29)								30
	OTHER ASSETS
31	Investments								31
32	Deposits on leases								32
33	Due from owners/officers								33
34	Other assets								34
35	Total other assets (sum of lines 31 through 34)								35
36	Total assets (sum of lines 11, 30, and 35)								36
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4040)
40-600									Rev. XX
10-12					FORM CMS-2552-10				4090 (Cont.)
BALANCE SHEET						PROVIDER CCN:	PERIOD:	WORKSHEET G
(If you are nonproprietary and do not maintain fund-type						________________	FROM ____________	(CONT.)
accounting records, complete the General Fund column only)							TO _______________
						Specific
	Liabilities and Fund				General	Purpose	Endowment	Plant
	Balances				Fund	Fund	Fund	Fund
	(Omit cents)				1	2	3	4
	CURRENT LIABILITIES
37	Accounts payable								37
38	Salaries, wages, and fees payable								38
39	Payroll taxes payable								39
40	Notes and loans payable (short term)								40
41	Deferred income								41
42	Accelerated payments								42
43	Due to other funds								43
44	Other current liabilities								44
45	Total current liabilities (sum of								45
	lines 37 thru 44)
	LONG TERM LIABILITIES
46	Mortgage payable								46
47	Notes payable								47
48	Unsecured loans								48
49	Other long term liabilities								49
50	Total long term liabilities (sum of								50
	lines 46 thru 49)
51	Total liabilities (sum of lines 45 and 50)								51
	CAPITAL ACCOUNTS
52	General fund balance								52
53	Specific purpose fund								53
54	Donor created - endowment fund								54
	balance - restricted
55	Donor created - endowment fund								55
	balance - unrestricted
56	Governing body created - endowment								56
	fund balance
57	Plant fund balance - invested in plant								57
58	Plant fund balance - reserve for plant								58
	improvement, replacement, and expansion
59	Total fund balances (sum of lines 52 thru 58)								59
60	Total liabilities and fund balances (sum of								60
	lines 51 and 59)
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4040)
Rev. 3									40-601

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Sheet 67: G1

4090 (Cont.)						FORM CMS-2552-10						10-12
STATEMENT OF CHANGES IN FUND BALANCES									PROVIDER CCN:	PERIOD:	WORKSHEET G-1
									________________	FROM ____________
										TO _______________
				GENERAL FUND		SPECIFIC PURPOSE FUND		ENDOWMENT FUND		PLANT FUND
				1	2	3	4	5	6	7	8
1	Fund balances at beginning of period											1
2	Net income (loss) (from Worksheet G-3, line 29)											2
3	Total (sum of line 1 and line 2)											3
4	Additions (credit adjustments) (specify)											4
5												5
6												6
7												7
8												8
9												9
10	Total additions (sum of lines 4 through 9)											10
11	Subtotal (line 3 plus line 10)											11
12	Deductions (debit adjustments) (specify)											12
13												13
14												14
15												15
16												16
17												17
18	Total deductions (sum of lines 12 through 17)											18
19	Fund balance at end of period per balance											19
	sheet (line 11 minus line 18)
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4040)
40-602												Rev. 3

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Sheet 68: G2

01-22				FORM CMS-2552-10				4090 (Cont.)
STATEMENT OF PATIENT REVENUES					PROVIDER CCN:	PERIOD:	WORKSHEET G-2,
AND OPERATING EXPENSES					________________	FROM ____________	PARTS I & II
						TO _______________
PART I - PATIENT REVENUES
					INPATIENT	OUTPATIENT	TOTAL
	REVENUE CENTER				1	2	3
	GENERAL INPATIENT ROUTINE CARE SERVICES
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	Other long term care							9
10	Total general inpatient care services (sum of lines 1 through 9)							10
	INTENSIVE CARE TYPE INPATIENT HOSPITAL SERVICES
11	Intensive care unit							11
12	Coronary care unit							12
13	Burn intensive care unit							13
14	Surgical intensive care unit							14
15	Other special care (specify)							15
16	Total intensive care type inpatient hospital services (sum of							16
	of lines 11-15)
17	Total inpatient routine care services (sum of lines 10 and 16)							17
18	Ancillary services							18
19	Outpatient services							19
20	Rural Health Clinic (RHC)							20
21	Federally Qualified Health Center (FQHC)							21
22	Home health agency							22
23	Ambulance							23
24	Outpatient rehabilitation providers							24
25	ASC							25
26	Hospice							26
27	Other (specify)							27
28	Total patient revenues (sum of lines 17 through 27) (transfer column 3 to							28
	Worksheet G-3, line 1)
PART II - OPERATING EXPENSES
						1	2
29	Operating expenses (per Wkst. A, column 3, line 200)							29
30	Add (specify)							30
31								31
32								32
33								33
34								34
35								35
36	Total additions (sum of lines 30 through 35)							36
37	Deduct (specify)							37
38								38
39								39
40								40
41								41
42	Total deductions (sum of lines 37 through 41)							42
43	Total operating expenses (sum of lines 29 and 36 minus line 42) (transfer to Worksheet G-3, line 4)							43
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4040)
Rev. 17								40-603

---

Sheet 69: G3

4090 (Cont.)				FORM CMS-2552-10				01-22
STATEMENT OF REVENUES					PROVIDER CCN:	PERIOD:	WORKSHEET G-3
AND EXPENSES					________________	FROM ____________
						TO _______________
	Description
1	Total patient revenues (from Worksheet G-2, Part I, column 3, line 28)							1
2	Less contractual allowances and discounts on patients' accounts							2
3	Net patient revenues (line 1 minus line 2)							3
4	Less total operating expenses (from Worksheet G-2, Part II, line 43)							4
5	Net income from service to patients (line 3 minus line 4)							5
	OTHER INCOME
6	Contributions, donations, bequests, etc.							6
7	Income from investments							7
8	Revenues from telephone and other miscellaneous communication services							8
9	Revenue from television and radio service							9
10	Purchase discounts							10
11	Rebates and refunds of expenses							11
12	Parking lot receipts							12
13	Revenue from laundry and linen service							13
14	Revenue from meals sold to employees and guests							14
15	Revenue from rental of living quarters							15
16	Revenue from sale of medical and surgical supplies to other than patients							16
17	Revenue from sale of drugs to other than patients							17
18	Revenue from sale of medical records and abstracts							18
19	Tuition (fees, sale of textbooks, uniforms, etc.)							19
20	Revenue from gifts, flowers, coffee shops, and canteen							20
21	Rental of vending machines							21
22	Rental of hospital space							22
23	Governmental appropriations							23
24	Other (specify)							24
24.50	COVID-19 PHE Funding							24.50
25	Total other income (sum of lines 6-24)							25
26	Total (line 5 plus line 25)							26
27	Other expenses (specify)							27
28	Total other expenses (sum of line 27 and subscripts)							28
29	Net income (or loss) for the period (line 26 minus line 28)							29
FORM CMS-2552-10 (01-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4040)
40-604								Rev. 17

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Sheet 70: H

11-16																																FORM CMS-2552-10																																												4090 (Cont.)
ANALYSIS OF HOSPITAL-BASED																																																				PROVIDER CCN:								PERIOD:								WORKSHEET H
HOME HEALTH AGENCY COSTS																																																				________________								FROM ____________
																																																				HHA CCN:								TO _______________
																																																				________________
																												TRANSPOR-						CONTRACTED/																								RECLASSIFIED												NET
																SALARIES						EMPLOYEE						TATION						PURCHASED												TOTAL												TRIAL												EXPENSES FOR
	COST CENTER DESCRIPTIONS																					BENEFITS						(see						SERVICES												(sum of cols.						RECLASS-						BALANCE												ALLOCATION
	(omit cents)																											instructions)												OTHER COSTS						1 thru 5)						IFICATIONS						(col. 6 + col. 7)						ADJUSTMENTS						(col. 8 + col. 9)
																1						2						3						4						5						6						7						8						9						10
	GENERAL SERVICE COST CENTERS
1	Capital Related-Bldgs. and Fixtures																																																																											1
2	Capital Related-Movable Equipment																																																																											2
3	Plant Operation & Maintenance																																																																											3
4	Transportation (see instructions)																																																																											4
5	Administrative and General																																																																											5
	HHA REIMBURSABLE SERVICES
6	Skilled Nursing Care																																																																											6
7	Physical Therapy																																																																											7
8	Occupational Therapy																																																																											8
9	Speech Pathology																																																																											9
10	Medical Social Services																																																																											10
11	Home Health Aide																																																																											11
12	Supplies (see instructions)																																																																											12
13	Drugs																																																																											13
14	DME																																																																											14
	HHA NONREIMBURSABLE SERVICES
15	Home Dialysis Aide Services																																																																											15
16	Respiratory Therapy																																																																											16
17	Private Duty Nursing																																																																											17
18	Clinic																																																																											18
19	Health Promotion Activities																																																																											19
20	Day Care Program																																																																											20
21	Home Delivered Meals Program																																																																											21
22	Homemaker Service																																																																											22
23	All Others																																																																											23
24	Total (sum of lines 1 through 23)																																																																											24
Column, 6 line 24, should agree with the Worksheet A, column 3, line 101, or subscript as applicable.
FORM CMS 2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4041)
Rev. 10																																																																												40-605

---

Sheet 71: H1I

4090 (Cont.)																																FORM CMS-2552-10																																												11-16
COST ALLOCATION - HHA GENERAL SERVICE COST																																																				PROVIDER CCN:								PERIOD:								WORKSHEET H-1
																																																				________________								FROM ____________								PART I
																																																				HHA CCN:								TO _______________
																																																				________________
																				NET EXPENSES
																				FOR COST							CAPITAL
																				ALLOCATION							RELATED COSTS														PLANT																					ADMINIS-
																				(from Wkst.							BLDGS. &							MOVABLE							OPERATION &							TRANS-							SUBTOTAL							TRATIVE							TOTAL
																				H, col. 10)							FIXTURES							EQUIPMENT							MAINTENANCE							PORTATION							(cols. 0-4)							& GENERAL							(cols. 4a + 5)
																				0							1							2							3							4							4a							5							6
	GENERAL SERVICE COST CENTERS
1	Capital Related-Bldgs. and Fixtures																																																																											1
2	Capital Related-Movable Equipment																																																																											2
3	Plant Operation & Maintenance																																																																											3
4	Transportation (see instructions)																																																																											4
5	Administrative and General																																																																											5
	HHA REIMBURSABLE SERVICES
6	Skilled Nursing Care																																																																											6
7	Physical Therapy																																																																											7
8	Occupational Therapy																																																																											8
9	Speech Pathology																																																																											9
10	Medical Social Services																																																																											10
11	Home Health Aide																																																																											11
12	Supplies (see instructions)																																																																											12
13	Drugs																																																																											13
14	DME																																																																											14
	HHA NONREIMBURSABLE SERVICES
15	Home Dialysis Aide Services																																																																											15
16	Respiratory Therapy																																																																											16
17	Private Duty Nursing																																																																											17
18	Clinic																																																																											18
19	Health Promotion Activities																																																																											19
20	Day Care Program																																																																											20
21	Home Delivered Meals Program																																																																											21
22	Homemaker Service																																																																											22
23	All Others																																																																											23
24	Totals (sum of lines 1 through 23)																																																																											24
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4042)
40-606																																																																												Rev. 10

---

Sheet 72: H1II

09-13						FORM CMS-2552-10						4090 (Cont.)
COST ALLOCATION - HHA STATISTICAL BASIS									PROVIDER CCN:	PERIOD:	WORKSHEET H-1,
									________________	FROM ____________	PART II
									HHA CCN:	TO _______________
									________________
						CAPITAL
						RELATED COSTS		PLANT			ADMINIS-
						BLDGS. &	MOVABLE	OPERATION &			TRATIVE
						FIXTURES	EQUIPMENT	MAINTENANCE	TRANS-		& GENERAL
						(SQUARE	(DOLLAR	(SQUARE	PORTATION	RECONCIL-	(ACCUM.
						FEET)	VALUE)	FEET)	(MILEAGE)	IATION	COST)
						1	2	3	4	5a	5
	GENERAL SERVICE COST CENTERS
1	Capital Related-Bldgs. and Fixtures											1
2	Capital Related-Movable Equipment											2
3	Plant Operation & Maintenance											3
4	Transportation (see instructions)											4
5	Administrative and General											5
	HHA REIMBURSABLE SERVICES
6	Skilled Nursing Care											6
7	Physical Therapy											7
8	Occupational Therapy											8
9	Speech Pathology											9
10	Medical Social Services											10
11	Home Health Aide											11
12	Supplies (see instructions)											12
13	Drugs											13
14	DME											14
	HHA NONREIMBURSABLE SERVICES
15	Home Dialysis Aide Services											15
16	Respiratory Therapy											16
17	Private Duty Nursing											17
18	Clinic											18
19	Health Promotion Activities											19
20	Day Care Program											20
21	Home Delivered Meals Program											21
22	Homemaker Service											22
23	All Others											23
24	Total (sum of lines 1-23)											24
25	Cost To Be Allocated (per Worksheet H-1, Part I)											25
26	Unit Cost Multiplier											26
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4042)
Rev. 4												40-607

---

Sheet 73: H2I

4090 (Cont.)						FORM CMS-2552-10						09-13	01-22							FORM CMS-2552-10							4090 (Cont.)	4090 (Cont.)						FORM CMS-2552-10						01-22
ALLOCATION OF GENERAL SERVICE									PROVIDER CCN:	PERIOD:	WORKSHEET H-2,		ALLOCATION OF GENERAL SERVICE											PROVIDER CCN:	PERIOD:	WORKSHEET H-2,		ALLOCATION OF GENERAL SERVICE									PROVIDER CCN:	PERIOD:	WORKSHEET H-2,
COSTS TO HHA COST CENTERS									________________	FROM ____________	PART I		COSTS TO HHA COST CENTERS											________________	FROM ____________	PART I (CONT.)		COSTS TO HHA COST CENTERS									________________	FROM ____________	PART I
									HHA CCN:	TO _______________														HHA CCN:	TO _______________												HHA CCN:	TO _______________
									________________															________________													________________
				CAPITAL																																INTERN &
		From	HHA	RELATED COSTS																						NON-										RESIDENT		ALLOCATED
	HHA COST CENTER	Wkst. H-1	TRIAL			EMPLOYEE		ADMINIS-	MAIN-		LAUNDRY			HHA COST CENTER					MAIN-	NURSING	CENTRAL		MEDICAL		OTHER	PHYSICIAN			HHA COST CENTER			INTERNS & RESIDENTS		PARAMEDICAL	SUBTOTAL	COST & POST		HHA
	(omit cents)	Part I,	BALANCE	BLDGS. &	MOVABLE	BENEFITS	SUBTOTAL	TRATIVE &	TENANCE &	OPERATION	& LINEN			(omit cents)		HOUSE			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL	GENERAL	ANES-			(omit cents)		NURSING	SALARY AND	PROGRAM	EDUCATION	(sum of cols.	STEPDOWN	SUBTOTAL	A&G (see	TOTAL
		col. 6,	(1)	FIXTURES	EQUIPMENT	DEPARTMENT	(cols. 0-4)	GENERAL	REPAIRS	OF PLANT	SERVICE					KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE	SERVICE	THETISTS					PROGRAM	FRINGES	COSTS	(SPECIFY)	4a-23)	ADJUSTMENTS	(cols. 23 ± 24)	Part II)	HHA COSTS
		line	0	1	2	4	4A	5	6	7	8					9	10	11	12	13	14	15	16	17	18	19					20	21	22	23	24	25	26	27	28
1	Administrative and General	5										1	1	Administrative and General													1	1	Administrative and General											1
2	Skilled Nursing Care	6										2	2	Skilled Nursing Care													2	2	Skilled Nursing Care											2
3	Physical Therapy	7										3	3	Physical Therapy													3	3	Physical Therapy											3
4	Occupational Therapy	8										4	4	Occupational Therapy													4	4	Occupational Therapy											4
5	Speech Pathology	9										5	5	Speech Pathology													5	5	Speech Pathology											5
6	Medical Social Services	10										6	6	Medical Social Services													6	6	Medical Social Services											6
7	Home Health Aide	11										7	7	Home Health Aide													7	7	Home Health Aide											7
8	Supplies	12										8	8	Supplies													8	8	Supplies											8
9	Drugs	13										9	9	Drugs													9	9	Drugs											9
10	DME	14										10	10	DME													10	10	DME											10
11	Home Dialysis Aide Services	15										11	11	Home Dialysis Aide Services													11	11	Home Dialysis Aide Services											11
12	Respiratory Therapy	16										12	12	Respiratory Therapy													12	12	Respiratory Therapy											12
13	Private Duty Nursing	17										13	13	Private Duty Nursing													13	13	Private Duty Nursing											13
14	Clinic	18										14	14	Clinic													14	14	Clinic											14
15	Health Promotion Activities	19										15	15	Health Promotion Activities													15	15	Health Promotion Activities											15
16	Day Care Program	20										16	16	Day Care Program													16	16	Day Care Program											16
17	Home Delivered Meals Program	21										17	17	Home Delivered Meals Program													17	17	Home Delivered Meals Program											17
18	Homemaker Service	22										18	18	Homemaker Service													18	18	Homemaker Service											18
19	All Others	23										19	19	All Others													19	19	All Others											19
20	Totals (sum of lines 1-19) (2)											20	20	Totals (sum of lines 1-19) (2)													20	20	Totals (sum of lines 1-19) (2)											20
21	Unit Cost Multiplier: column 26, line 1, divided by the sum of column 26,											21	21	Unit Cost Multiplier: column 26, line 1, divided by the sum of column 26,													21	21	Unit Cost Multiplier: column 26, line 1, divided by the sum of column 26,											21
	line 20, minus column 26, line 1, rounded to 6 decimal places.													line 20, minus column 26, line 1, rounded to 6 decimal places.															line 20, minus column 26, line 1, rounded to 6 decimal places.
(1)	Column 0, line 20 must agree with Wkst. A, column 7, line 101.												(2)	Columns 0 through 26, line 20 must agree with the corresponding columns of Wkst. B, Part I, line 101.														(2)	Columns 0 through 26, line 20 must agree with the corresponding columns of Wkst. B, Part I, line 101.
(2)	Columns 0 through 26, line 20 must agree with the corresponding columns of Wkst. B, Part I, line 101.
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4043.1)													FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4043.1)															FORM CMS-2552-10 (01-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4043.1)
40-608												Rev. 4	Rev. 17														40-609	40-610												Rev. 17

---

Sheet 74: H2II

09-13						FORM CMS-2552-10						4090 (Cont.)	4090 (Cont.)						FORM CMS-2552-10						09-13	01-22						FORM CMS-2552-10						4090 (Cont.)
ALLOCATION OF GENERAL SERVICE									PROVIDER CCN:	PERIOD:	WORKSHEET H-2,		ALLOCATION OF GENERAL SERVICE									PROVIDER CCN:	PERIOD:	WORKSHEET H-2,		ALLOCATION OF GENERAL SERVICE									PROVIDER CCN:	PERIOD:	WORKSHEET H-2,
COSTS TO HHA COST CENTERS									________________	FROM ____________	PART II		COSTS TO HHA COST CENTERS									________________	FROM ____________	PART II (CONT.)		COSTS TO HHA COST CENTERS									________________	FROM ____________	PART II (CONT.)
STATISTICAL BASIS									HHA CCN:	TO _______________			STATISTICAL BASIS									HHA CCN:	TO _______________			STATISTICAL BASIS									HHA CCN:	TO _______________
									________________													________________													________________
					CAPITAL																												NON-				PARA-
					RELATED COST		EMPLOYEE		ADMINIS-	MAIN-						LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL									PHYSICIAN		INTERNS & RESIDENTS		MEDICAL
					BLDGS. &	MOVABLE	BENEFITS		TRATIVE &	TENANCE &	OPERATION					& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &							SOCIAL	OTHER	ANES-	NURSING	SALARY &	PROGRAM	EDUCATION
	HHA COST CENTER				FIXTURES	EQUIPMENT	DEPARTMENT		GENERAL	REPAIRS	OF PLANT			HHA COST CENTER		SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY			HHA COST CENTER				SERVICE	GENERAL	THETISTS	PROGRAM	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	15	16							17	18	19	20	21	22	23
1	Administrative and General											1	1	Administrative and General											1	1	Administrative and General											1
2	Skilled Nursing Care											2	2	Skilled Nursing Care											2	2	Skilled Nursing Care											2
3	Physical Therapy											3	3	Physical Therapy											3	3	Physical Therapy											3
4	Occupational Therapy											4	4	Occupational Therapy											4	4	Occupational Therapy											4
5	Speech Pathology											5	5	Speech Pathology											5	5	Speech Pathology											5
6	Medical Social Services											6	6	Medical Social Services											6	6	Medical Social Services											6
7	Home Health Aide											7	7	Home Health Aide											7	7	Home Health Aide											7
8	Supplies											8	8	Supplies											8	8	Supplies											8
9	Drugs											9	9	Drugs											9	9	Drugs											9
10	DME											10	10	DME											10	10	DME											10
11	Home Dialysis Aide Services											11	11	Home Dialysis Aide Services											11	11	Home Dialysis Aide Services											11
12	Respiratory Therapy											12	12	Respiratory Therapy											12	12	Respiratory Therapy											12
13	Private Duty Nursing											13	13	Private Duty Nursing											13	13	Private Duty Nursing											13
14	Clinic											14	14	Clinic											14	14	Clinic											14
15	Health Promotion Activities											15	15	Health Promotion Activities											15	15	Health Promotion Activities											15
16	Day Care Program											16	16	Day Care Program											16	16	Day Care Program											16
17	Home Delivered Meals Program											17	17	Home Delivered Meals Program											17	17	Home Delivered Meals Program											17
18	Homemaker Service											18	18	Homemaker Service											18	18	Homemaker Service											18
19	All Others											19	19	All Others											19	19	All Others											19
20	Totals (sum of lines 1-19)											20	20	Totals (sum of lines 1-19)											20	20	Totals (sum of lines 1-19)											20
21	Total cost to be allocated											21	21	Total cost to be allocated											21	21	Total cost to be allocated											21
22	Unit Cost Multiplier											22	22	Unit Cost Multiplier											22	22	Unit Cost Multiplier											22
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4043.2)													FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4043.2)													FORM CMS-2552-10 (01-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4043.2)
Rev. 4												40-611	40-612												Rev. 4	Rev. 17												40-613

---

Sheet 75: H3

4090 (Cont.)

FORM CMS-2552-10

01-22

APPORTIONMENT OF PATIENT SERVICE COSTS

PROVIDER CCN:

PERIOD:

WORKSHEET H-3,

________________

FROM ____________

Parts I & II

HHA CCN:

TO _______________

________________

Check applicable box:

[ ] Title V [ ] Title XVIII [ ] Title XIX

PART I - COMPUTATION OF THE AGGREGATE PROGRAM COST

Cost Per Visit Computation

Program Visits

Cost of Services

Total

Part B

Part B

From,

Facility

Shared

HHA

Average

Not

Not

Total

Wkst.

Costs

Ancillary

Costs

Cost

Subject to

Subject to

Subject to

Subject to

Program

H-2,

(from

Costs

(sum of

Per Visit

Deductibles

Deductibles

Deductibles

Deductibles

Cost

Part I,

Wkst. H-2,

(from

col. 1

Total

(col. 3

&

&

&

&

(sum of

Patient Services

col. 28,

Part I)

Part II)

+ col. 2)

Visits

÷ col. 4)

Part A

Coinsurance

Coinsurance

Part A

Coinsurance

Coinsurance

cols. 9-10)

line

1

2

3

4

5

6

7

8

9

10

11

12

1

Skilled Nursing Care

2

1

2

Physical Therapy

3

2

3

Occupational Therapy

4

3

4

Speech Pathology

5

4

5

Medical Social Services

6

5

6

Home Health Aide

7

6

7

Total (sum of lines 1 through 6)

7

Limitation Cost Computation

CBSA NO. (1)

Program Visits

Part A

Part B

Not Subject to Deductibles & Coinsurance

Subject to Deductibles & Coinsurance

Patient Services

1

2

3

4

8

Skilled Nursing Care

8

9

Physical Therapy

9

10

Occupational Therapy

10

11

Speech Pathology

11

12

Medical Social Services

12

13

Home Health Aide

13

14

Total (sum of lines 8 through 13)

14

Supplies and Drugs Cost

Program Covered Charges

Cost of Services

Computations

Part B

Part B

Facility

Shared

Not Subject

Not Subject

From

Costs

Ancillary

Total

to

Subject to

to

Subject to

Wkst. H-2

(from

Costs

Total

Charges

Ratio

Deductibles

Deductibles

Deductibles

Deductibles

Part I,

Wkst. H-2,

(from

HHA Costs

(from HHA

(col. 3

&

&

&

&

Other Patient Services

col. 28,

Part I)

Part II)

(cols. 1 + 2)

Records)

÷ col. 4)

Part A

Coinsurance

Coinsurance

Part A

Coinsurance

Coinsurance

line

1

2

3

4

5

6

7

8

9

10

11

15

Cost of Medical Supplies

8

15

16

Cost of Drugs

9

16

PART II - APPORTIONMENT OF COST OF HHA SERVICES FURNISHED BY SHARED HOSPITAL DEPARTMENTS

HHA Shared

Cost to Charge

Total HHA Charges

Ancillary Costs

Transfer to Part I

From Wkst. C, Part I,

Ratio

(from provider records)

(col. 1 x col. 2)

as Indicated

col. 9, line:

1

3

3

4

1

Physical Therapy

66

col. 2, line 2

1

2

Occupational Therapy

67

col. 2, line 3

2

3

Speech Pathology

68

col. 2, line 4

3

4

Cost of Medical Supplies

71

col. 2, line 15

4

5

Cost of Drugs

73

col. 2, line 16

5

FORM CMS-2552-10 (03-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4044)

40-614

Rev. 17

---

Sheet 76: H4

12-22				FORM CMS-2552-10				4090 (Cont.)
CALCULATION OF HHA REIMBURSEMENT					PROVIDER CCN:	PERIOD:	WORKSHEET H-4,
SETTLEMENT					________________	FROM ____________	Parts I & II
					HHA CCN:	TO _____________
					________________
Check applicable box:		[ ] Title V	[ ] Title XVIII	[ ] Title XIX
PART I - COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES
						Part B
						Not Subject to	Subject to
						Deductibles	Deductibles
					Part A	& Coinsurance	& Coinsurance
	Description				1	2	3
	Reasonable Cost of Part A & Part B Services
1	Reasonable cost of services (see instructions)							1
2	Total charges							2
	Customary Charges
3	Amount actually collected from patients liable for payment for services on a							3
	charge basis (from your records)
4	Amount that would have been realized from patients liable for payment for services on a							4
	charge basis had such payment been made in accordance with 42 CFR 413.13(b)
5	Ratio of line 3 to line 4 (not to exceed 1.000000)							5
6	Total customary charges (see instructions)							6
7	Excess of total customary charges over total reasonable cost (complete only if line 6 exceeds line 1)							7
8	Excess of reasonable cost over customary charges (complete only if line 1 exceeds line 6)							8
9	Primary payer amounts							9
PART II - COMPUTATION OF HHA REIMBURSEMENT SETTLEMENT
						Part A Services	Part B Services
	Description					1	2
10	Total reasonable cost (see instructions)							10
11	Total PPS Reimbursement - Full Episodes without Outliers							11
12	Total PPS Reimbursement - Full Episodes with Outliers							12
13	Total PPS Reimbursement - LUPA Episodes							13
14	Total PPS Reimbursement - PEP Episodes							14
15	Total PPS Outlier Reimbursement - Full Episodes with Outliers							15
16	Total PPS Outlier Reimbursement - PEP Episodes							16
17	Total Other Payments							17
18	DME Payments							18
19	Oxygen Payments							19
20	Prosthetic and Orthotic Payments							20
21	Part B deductibles billed to Medicare patients (exclude coinsurance)							21
22	Subtotal (sum of lines 10 thru 20 minus line 21)							22
23	Excess reasonable cost (from line 8)							23
24	Subtotal (line 22 minus line 23)							24
25	Coinsurance billed to program patients (from your records)							25
26	Net cost (line 24 minus line 25)							26
27	Allowable bad debts (from your records)							27
27.01	Adjusted reimbursable bad debts (see instructions)							27.01
28	Allowable bad debts for dual eligible (see instructions)							28
29	Total costs - current cost reporting period (see instructions)							29
30	Other adjustments (see instructions) (specify)							30
30.50	Pioneer ACO demonstration payment adjustment (see instructions)							30.50
30.99	Demonstration payment adjustment amount before sequestration							30.99
31	Subtotal (see instructions)							31
31.01	Sequestration adjustment (see instructions)							31.01
31.02	Demonstration payment adjustment amount after sequestration							31.02
31.75	Sequestration adjustment for non-claims based amounts (see instructions)							31.75
32	Interim payments (see instructions)							32
33	Tentative settlement (for contractor use only)							33
34	Balance due provider/program (line 31 minus lines 31.01, 31.02, 31.75, 32, and 33)							34
35	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2							35
FORM CMS-2552-12 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4045.1 - 4045.2)
Rev. 18								40-615

---

Sheet 77: H5

4090 (Cont.)				FORM CMS-2552-10					12-22
ANALYSIS OF PAYMENTS TO HOSPITAL-						PROVIDER CCN:	PERIOD:	WORKSHEET H-5
BASED HHAs FOR SERVICES						________________	FROM ____________
RENDERED TO PROGRAM BENEFICIARIES						HHA CCN:	TO _______________
						________________
					Part A		Part B
		Description			mm/dd/yyyy	Amount	mm/dd/yyyy	Amount
					1	2	3	4
1	Total interim payments paid to provider								1
2	Interim payments payable on individual bills either submitted or								2
	to be submitted to the intermediary for services rendered in the
	cost reporting period. If none, write "NONE" or enter a zero.
3	List separately each retroactive lump sum		Program	.01					3.01
	adjustment amount based on subsequent revision		to	.02					3.02
	of the interim rate for the cost reporting period.		Provider	.03					3.03
	Also show date of each payment. If none, write			.04					3.04
	"NONE" or enter a zero.(1)			.05					3.05
			Provider	.50					3.50
			to	.51					3.51
			Program	.52					3.52
				.53					3.53
				.54					3.54
	Subtotal (sum of lines 3.01-3.49 minus sum
	of lines 3.50-3.98)			.99					3.99
4	Total interim payments (sum of lines 1, 2, and 3.99)								4
	(transfer to Wkst. H-4, Part II, column as appropriate, line 32)
	TO BE COMPLETED BY INTERMEDIARY
5	List separately each tentative settlement payment		Program	.01					5.01
	after desk review. Also show date of each		to	.02					5.02
	payment. If none, write "NONE" or enter		Provider	.03					5.03
	a zero. (1)		Provider	.50					5.50
			to	.51					5.51
			Program	.52					5.52
	Subtotal (sum of lines 5.01-5.49 minus sum
	of lines 5.50-5.98)			.99					5.99
6	Determine net settlement amount (balance due)		Program
	based on the cost report (see instructions)		to	.01
			Provider						6.01
			Provider
			to	.02
			Program						6.02
7	TOTAL MEDICARE PROGRAM LIABILITY								7
	(see instructions)
8	Name of Contractor		Contractor Number			NPR Date: Month, Day, Year			8
(1) On lines 3, 5, and 6, where an amount is due provider to program, show the amount and date on which the provider
agrees to the amount of repayment, even though total repayment is not accomplished until a later date.
FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4046)
40-616									Rev. 18

---

Sheet 78: I1

12-24					FORM CMS-2552-10				4090 (Cont.)
ANALYSIS OF RENAL DIALYSIS DEPARTMENT COSTS						PROVIDER CCN:	PERIOD:	WORKSHEET I-1
						________________	FROM ____________
							TO _______________
Check applicable box:		[ ] Renal Dialysis Department [ ] Home Program Dialysis
					TOTAL			FTEs per
					COSTS	BASIS	STATISTICS	2080 Hours
					1	2	3	4
1	Registered Nurses					Hours of Service			1
2	Licensed Practical Nurses					Hours of Service			2
3	Nurses Aides					Hours of Service			3
4	Technicians					Hours of Service			4
5	Social Workers					Hours of Service			5
6	Dieticians					Hours of Service			6
7	Physicians					Accumulated Cost			7
8	Non-patient Care Salary					Accumulated Cost			8
9	Subtotal (sum of lines 1-8)								9
10	Employee Benefits					Salary			10
11	Capital Related Costs-Bldgs. & Fixtures					Square Feet			11
12	Capital Related Costs-Mov. Equip.					Percentage of Time			12
13	Machine Costs & Repairs					Percentage of Time			13
14	Supplies					Requisitions			14
14.01	Pediatric Medical Supplies					Requisitions			14.01
15	Drugs					Requisitions			15
16	Other					Accumulated Cost			16
17	Subtotal (sum of lines 9-16)*								17
18	Capital Related Costs-Bldgs. & Fixtures					Square Feet			18
19	Capital Related Costs-Mov. Equip.					Percentage of Time			19
20	Employee Benefits Department					Salary			20
21	Administrative and General					Accumulated Cost			21
22	Maint./Repairs-Operation-Housekeeping					Square Feet			22
23	Medical Education Program Costs								23
24	Central Services & Supplies					Requisitions			24
25	Pharmacy					Requisitions			25
26	Other Allocated Costs					Accumulated Cost			26
27	Subtotal (sum of lines 17-26)*								27
28	Laboratory (see instructions)					Charges			28
29	Respiratory Therapy (see instructions)					Charges			29
30	Other (see instructions)					Charges			30
31	Total costs (sum of lines 27-30)								31
	* Line 17, column 1, should agree with Worksheet A, column 7 for line 74 or line 94, as appropriate,
	and line 27, column 1, should agree with Worksheet B, Part I, column 24, less the sum of columns 21 and 22, for line 74 or line 94, as appropriate.
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4048)
Rev. 23									40-617

---

Sheet 79: I2

4090 (Cont.)							FORM CMS-2552-10								12-24
ALLOCATION OF RENAL DEPARTMENT COSTS TO TREATMENT MODALITIES												PROVIDER CCN:	PERIOD:	WORKSHEET I-2
												________________	FROM ____________
													TO _______________
Check applicable box:		[ ] Renal Dialysis Department [ ] Home Program Dialysis
OUTPATIENT SERVICES
COMPOSITE PAYMENT RATE			CAPITAL AND		DIRECT PATIENT		EMPLOYEE			PEDIATRIC	ROUTINE	SUBTOTAL		TOTAL
			RELATED COSTS		CARE SALARY		BENEFITS		MEDICAL	MEDICAL	ANCILLARY	(sum of		(col. 9 +
			BUILDING	EQUIPMENT	RNs	OTHER	DEPARTMENT	DRUGS	SUPPLIES	SUPPLIES	SERVICES	cols. 1-8)	OVERHEAD	col. 10)
			1	2	3	4	5	6	7	7.01	8	9	10	11
1	Total Renal Department Costs														1
	MAINTENANCE
2	Hemodialysis														2
2.01	AKI-Hemodialysis														2.01
2.02	Hemodialysis-Pediatric														2.02
3	Intermittent Peritoneal														3
3.01	AKI-Intermittent Peritoneal														3.01
3.02	IPD-Pediatric														3.02
	TRAINING
4	Hemodialysis														4
4.01	Hemodialysis-Pediatric														4.01
4.02	Hemodialysis-AKI														4.02
5	Intermittent Peritoneal														5
5.01	IPD-Pediatric														5.01
5.02	IPD-AKI														5.02
6	CAPD														6
6.01	CAPD-Pediatric														6.01
6.02	CAPD-AKI														6.02
7	CCPD														7
7.01	CCPD-Pediatric														7.01
7.02	CCPD-AKI														7.02
	HOME
8	Hemodialysis														8
8.01	Hemodialysis-Pediatric														8.01
8.02	Hemodialysis-AKI														8.02
9	Intermittent Peritoneal														9
9.01	IPD-Pediatric														9.01
9.02	IPD-AKI														9.02
10	CAPD														10
10.01	CAPD-Pediatric														10.01
10.02	CAPD-AKI														10.02
11	CCPD														11
11.01	CCPD-Pediatric														11.01
11.02	CCPD-AKI														11.02
	OTHER BILLABLE SERVICES
12	Inpatient Dialysis														12
13	Method II Home Patient														13
14	ESAs (included in Renal Department)														14
15	ARANESP (see instructions)														15
16	Other														16
17	Total (sum of lines 2 through 16)														17
18	Medical Educational Program Costs														18
19	Total Renal Costs (line 17 plus line 18)														19
FORM CMS-2552-10 (12-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4049)
40-618															Rev. 23

---

Sheet 80: I3

12-24							FORM CMS-2552-10								4090 (Cont.)
DIRECT AND INDIRECT RENAL DIALYSIS COST ALLOCATION -												PROVIDER CCN:	PERIOD:	WORKSHEET I-3
STATISTICAL BASIS												________________	FROM ____________
													TO _______________
Check applicable box:		[ ] Renal Dialysis Department [ ] Home Program Dialysis
				CAPITAL AND
				RELATED COSTS		DIRECT PATIENT		EMPLOYEE			PEDIATRIC	ROUTINE
				BUILDING	EQUIPMENT	CARE SALARY		BENEFITS		MEDICAL	MEDICAL	ANCILLARY		OVERHEAD
	COMPOSITE PAYMENT SERVICES			(SQUARE	(% OF	RNs	OTHERS	DEPARTMENT	DRUGS	SUPPLIES	SUPPLIES	SERVICES	SUB-	(ACCUM.
				FEET)	TIME)	(HOURS)	(HOURS)	(SALARY)	(REQUIST.)	(REQUIST.)	(REQUIST.)	(CHARGES)	TOTAL	COST)
				1	2	3	4	5	6	7	7.01	8	9	10
1	Total Renal Department Costs														1
	MAINTENANCE
2	Hemodialysis														2
2.01	AKI-Hemodialysis														2.01
2.02	Hemodialysis-Pediatric														2.02
3	Intermittent Peritoneal														3
3.01	AKI- Intermittent Peritoneal														3.01
3.02	IPD-Pediatric														3.02
	TRAINING
4	Hemodialysis														4
4.01	Hemodialysis-Pediatric														4.01
4.02	Hemodialysis-AKI														4.02
5	Intermittent Peritoneal														5
5.01	IPD-Pediatric														5.01
5.02	IPD-AKI														5.02
6	CAPD														6
6.01	CAPD-Pediatric														6.01
6.02	CAPD-AKI														6.02
7	CCPD														7
7.01	CCPD-Pediatric														7.01
7.02	CCPD-AKI														7.02
	HOME
8	Hemodialysis														8
8.01	Hemodialysis-Pediatric														8.01
8.02	Hemodialysis-AKI														8.02
9	Intermittent Peritoneal														9
9.01	IPD-Pediatric														9.01
9.02	IPD-AKI														9.02
10	CAPD														10
10.01	CAPD-Pediatric														10.01
10.02	CAPD-AKI														10.02
11	CCPD														11
11.01	CCPD-Pediatric														11.01
11.02	CCPD-AKI														11.02
	OTHER BILLABLE SERVICES
12	Inpatient Dialysis Treatments __________														12
13	Method II Home Patient														13
14	ESAs														14
15	ARANESP (see instructions)														15
16	Other														16
17	Total Statistical Basis														17
18	Unit Cost Multiplier (line 1 ÷ line 17)														18
FORM CMS-2552-10 (12-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4050)
Rev. 23															40-619

---

Sheet 81: I4

4090 (Cont.)

FORM CMS-2552-10

12-24

COMPUTATION OF AVERAGE COST PER TREATMENT

PROVIDER CCN:

PERIOD:

WORKSHEET I-4

FOR OUTPATIENT RENAL DIALYSIS

________________

FROM ____________

TO _______________

Check applicable box:

[ ] Renal Dialysis Department [ ] Home Program Dialysis

Average Cost

Total

Average

Total Cost

of

Program

Payment

Average

Average

Number

(from

Treatments

Number

Number

Number

Expenses

Total

Total

Total

Rate

Payment Rate

Payment Rate

of Total

Wkst. I-2,

(col. 2 ÷

of Program

of Program

of Program

(see

Program

Program

Program

(col. 6 ÷

(col. 6.01 ÷

(col. 6.02 ÷

Treatments

col. 11)

col. 1)

Treatments

Treatments

Treatments

instructions)

Payment

Payment

Payment

col. 4)

col. 4.01)

col. 4.02)

1

2

3

4

4.01

4.02

5

6

6.01

6.02

7

7.01

7.02

1

Maintenance - Hemodialysis

1

1.01

Maintenance - AKI Hemodialysis

1.01

2

Maintenance - Peritoneal Dialysis

2

2.01

Maintenance - AKI Peritoneal Dialysis

2.01

3

Training - Hemodialysis

3

3.01

Training - AKI Hemodialysis

3.01

4

Training - Peritoneal Dialysis

4

4.01

Training - AKI Peritoneal Dialysis

4.01

5

Training - CAPD

5

5.01

Training - AKI CAPD

5.01

6

Training - CCPD

6

6.01

Training - AKI CCPD

6.01

7

Home Program - Hemodialysis

7

7.01

Home Program - AKI Hemodialysis

7.01

8

Home Program - Peritoneal Dialysis

8

8.01

Home Program - AKI Peritoneal Dialysis

8.01

Patient Weeks

Patient Weeks

Patient Weeks

Patient Weeks

9

Home Program - CAPD

9

9.01

Home Program - AKI CAPD

9.01

10

Home Program - CCPD

10

10.01

Home Program - AKI CCPD

10.01

11

Totals (sum of lines 1 through 8, cols. 1 and 4)

11

(sum of lines 1 through 10, cols. 2, 5, and 6)

(see instructions)

12

Total treatments (sum of lines 1 through 8

12

plus (sum of lines 9 and 10 times 3))

(see instructions)

FORM CMS-2552-10 (12-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4051)

40-620

Rev. 23

---

Sheet 82: I5

12-22				FORM CMS-2552-10				4090 (Cont.)
CALCULATION OF REIMBURSABLE					PROVIDER CCN:	PERIOD:	WORKSHEET I-5
BAD DEBTS - TITLE XVIII - PART B					________________	FROM ____________
						TO _______________
	Description
1	Total expenses related to care of program beneficiaries (see instructions)							1
						1	2
2	Total payment due (from Wkst. I-4, col. 6, line 11) (see instructions)							2
2.01	Total payment due (from Wkst. I-4, col. 6.01, line 11) (see instructions)							2.01
2.02	Total payment due(from Wkst. I-4, col. 6.02, line 11) (see instructions)							2.02
2.03	Total payment due (see instructions)							2.03
2.04	Outlier payments							2.04
3	Deductibles billed to Medicare (Part B) patients (see instructions)							3
3.01	Deductibles billed to Medicare (Part B) patients (see instructions)							3.01
3.02	Deductibles billed to Medicare (Part B) patients (see instructions)							3.02
3.03	Total deductibles billed to Medicare (Part B) patients (see instructions)							3.03
4	Coinsurance billed to Medicare (Part B) patients (see instructions)							4
4.01	Coinsurance billed to Medicare (Part B) patients (see instructions)							4.01
4.02	Coinsurance billed to Medicare (Part B) patients (see instructions)							4.02
4.03	Total coinsurance billed to Medicare (Part B) patients (see instructions)							4.03
5	Bad debts for deductibles and coinsurance, net of bad debt recoveries							5
5.01	Transition period 1 (75-25%) bad debts for deductibles and coinsurance net of bad debt recoveries for							5.01
	services rendered on or after 1/1/2011 but before 1/1/2012
5.02	Transition period 2 (50-50%) bad debts for deductibles and coinsurance net of bad debt recoveries for							5.02
	services rendered on or after 1/1/2012 but before 1/1/2013
5.03	Transition period 3 (25-75%) bad debts for deductibles and coinsurance net of bad debt recoveries for							5.03
	services rendered on or after 1/1/2013 but before 1/1/2014
5.04	100% PPS bad debts for deductibles and coinsurance net of bad debt recoveries for							5.04
	services rendered on or after 1/1/2014
5.05	Allowable bad debts (sum of lines 5 through line 5.04)							5.05
6	Adjusted reimbursable bad debts (see instructions)							6
7	Allowable bad debts for dual eligible beneficiaries (see instructions)							7
8	Net deductibles and coinsurance billed to Medicare (Part B) patients (see instructions)							8
9	Program payment (see instructions)							9
10	Unrecovered from Medicare (Part B) patients (see instructions)							10
11	Reimbursable bad debts (see instructions) (transfer to Worksheet E, Part B, line 33)							11
PART II - CALCULATION OF FACILITY SPECIFIC COMPOSITE COST PERCENTAGE
12	Total allowable expenses (see instructions)							12
13	Total composite costs (from Wkst. I-4, col. 2, line 11)							13
14	Facility specific composite cost percentage (line 13 divided by line 12)							14
PART III - ESRD PAYMENTS - INFORMATION ONLY
15	Low volume payment amount (see instructions)							15
16	TDAPA							16
17	TPNIES							17
18	CRA TPNIES							18
19	HDPA							19
20	PPA							20
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4052)
Rev. 18								40-621

---

Sheet 83: J1I

4090 (Cont.)						FORM CMS-2552-10						12-22	01-22							FORM CMS-2552-10							4090 (Cont.)	4090 (Cont.)						FORM CMS-2552-10						01-22
ALLOCATION OF GENERAL SERVICE COSTS TO									PROVIDER CCN:	PERIOD:	WORKSHEET J-1,		ALLOCATION OF GENERAL SERVICE COSTS TO											PROVIDER CCN:	PERIOD:	WORKSHEET J-1,		ALLOCATION OF GENERAL SERVICE COSTS TO									PROVIDER CCN:	PERIOD:	WORKSHEET J-1,
COMMUNITY MENTAL HEALTH CENTERS									________________	FROM ____________	PART I		COMMUNITY MENTAL HEALTH CENTERS											________________	FROM ____________	PART I (CONT.)		COMMUNITY MENTAL HEALTH CENTERS									________________	FROM ____________	PART I
									COMPONENT CCN:	TO _______________														COMPONENT CCN:	TO _______________												COMPONENT CCN:	TO _______________
									________________															________________													________________
PART I - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS													PART I - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS															PART I - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS
			NET																																	INTERN &
			EXPENSES	CAPITAL															MAIN-		CENTRAL		MEDICAL			NON-								PARA-		RESIDENT		ALLOCATED
	COMPONENT COST CENTER		FOR COST	RELATED COSTS		EMPLOYEE		ADMINIS-	MAIN-		LAUNDRY			COMPONENT COST CENTER					TENANCE	NURSING	SERVICES		RECORDS		OTHER	PHYSICIAN			COMPONENT COST CENTER			INTERNS & RESIDENTS		MEDICAL	SUBTOTAL	COST & POST	SUBTOTAL	COMPONENT	TOTAL
	(omit cents)		ALLOCATION	BLDGS. &	MOVABLE	BENEFITS	SUBTOTAL	TRATIVE &	TENANCE	OPERATION	& LINEN			(omit cents)		HOUSE-			OF	ADMINIS-	&		&	SOCIAL	GENERAL	ANES-			(omit cents)		NURSING	SALARY &	PROGRAM	EDUCATION	(sum of	STEPDOWN	(sum of cols.	A&G (see	(sum of cols.
			(see instru.)	FIXTURES	EQUIPMENT	DEPARTMENT	(cols. 0-4)	GENERAL	& REPAIRS	OF PLANT	SERVICE					KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE	SERVICE	THETISTS					PROGRAM	FRINGES	COSTS	(SPECIFY)	cols. 4A-23)	ADJ.	24 ± 25)	Part II) (2)	26 ± 27)
			0	1	2	4	4A	5	6	7	8					9	10	11	12	13	14	15	16	17	18	19					20	21	22	23	24	25	26	27	28
1	Administrative and General											1	1	Administrative and General													1	1	Administrative and General											1
2	Skilled Nursing Care											2	2	Skilled Nursing Care													2	2	Skilled Nursing Care											2
3	Physical Therapy											3	3	Physical Therapy													3	3	Physical Therapy											3
4	Occupational Therapy											4	4	Occupational Therapy													4	4	Occupational Therapy											4
5	Speech Pathology											5	5	Speech Pathology													5	5	Speech Pathology											5
6	Medical Social Services											6	6	Medical Social Services													6	6	Medical Social Services											6
7	Respiratory Therapy											7	7	Respiratory Therapy													7	7	Respiratory Therapy											7
8	Psychiatric/Psychological Services											8	8	Psychiatric/Psychological Services													8	8	Psychiatric/Psychological Services											8
9	Individual Therapy											9	9	Individual Therapy													9	9	Individual Therapy											9
10	Group Therapy											10	10	Group Therapy													10	10	Group Therapy											10
11	Individualized Activity Therapies											11	11	Individualized Activity Therapies													11	11	Individualized Activity Therapies											11
12	Family Counseling											12	12	Family Counseling													12	12	Family Counseling											12
13	Diagnostic Services											13	13	Diagnostic Services													13	13	Diagnostic Services											13
14	Approved Patient Training & Education											14	14	Approved Patient Training & Education													14	14	Approved Patient Training & Education											14
15	Prosthetic and Orthotic Devices											15	15	Prosthetic and Orthotic Devices													15	15	Prosthetic and Orthotic Devices											15
16	Drugs and Biologicals											16	16	Drugs and Biologicals													16	16	Drugs and Biologicals											16
17	Medical Supplies											17	17	Medical Supplies													17	17	Medical Supplies											17
18	Medical Appliances											18	18	Medical Appliances													18	18	Medical Appliances											18
19	Durable Medical Equipment-Rented											19	19	Durable Medical Equipment-Rented													19	19	Durable Medical Equipment-Rented											19
20	Durable Medical Equipment-Sold											20	20	Durable Medical Equipment-Sold													20	20	Durable Medical Equipment-Sold											20
21	All Others											21	21	All Others													21	21	All Others											21
22	Totals (sum of lines 1-21)(1)											22	22	Totals (sum of lines 1-21)(1)													22	22	Totals (sum of lines 1-21)(1)											22
23	Unit Cost Multiplier (see instructions)											23	23	Unit Cost Multiplier (see instructions)													23	23	Unit Cost Multiplier (see instructions)											23
(1) Columns 0 through 26, line 22 must agree with the corresponding columns of Wkst. B, Part I, lines as appropriate. See instructions.													(1) Columns 0 through 26, line 22 must agree with the corresponding columns of Wkst. B, Part I, lines as appropriate. See instructions.															(1) Columns 0 through 26, line 22 must agree with the corresponding columns of Wkst. B, Part I, lines as appropriate. See instructions.
FORM CMS-2552-10 (10-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.1)													FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.1)															FORM CMS-2552-10 (01-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.1)
40-622												Rev. 18	Rev. 17														40-623	40-624												Rev. 17

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Sheet 84: J1II

09-13						FORM CMS-2552-10						4090 (Cont.)	4090 (Cont.)							FORM CMS-2552-10							09-13	01-22						FORM CMS-2552-10						4090 (Cont.)
ALLOCATION OF GENERAL SERVICE COSTS TO									PROVIDER CCN:	PERIOD:	WORKSHEET J-1,		ALLOCATION OF GENERAL SERVICE COSTS TO											PROVIDER CCN:	PERIOD:	WORKSHEET J-1,		ALLOCATION OF GENERAL SERVICE COSTS TO									PROVIDER CCN:	PERIOD:	WORKSHEET J-1,
COMMUNITY MENTAL HEALTH CENTERS									________________	FROM ____________	PART II		COMMUNITY MENTAL HEALTH CENTERS											________________	FROM ____________	PART II (CONT.)		COMMUNITY MENTAL HEALTH CENTERS									________________	FROM ____________	PART II (CONT.)
									COMPONENT CCN:	TO _______________														COMPONENT CCN:	TO _______________												COMPONENT CCN:	TO _______________
									________________															________________													________________
PART II - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS - STATISTICAL BASIS													PART II - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS - STATISTICAL BASIS															PART II - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS - STATISTICAL BASIS
				CAPITAL															MAIN-							NON-								PARA-
				RELATED COST		EMPLOYEE		ADMINIS-	MAIN-		LAUNDRY								TENANCE	NURSING	CENTRAL		MEDICAL			PHYSICIAN						INTERNS & RESIDENTS		MEDICAL
				BLDGS &	MOVABLE	BENEFITS		TRATIVE &	TENANCE &	OPERATION	& LINEN					HOUSE-			OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL	OTHER	ANES-					NURSING	SALARY &	PROGRAM	EDUCATION
	CMHC COST CENTER			FIXTURES	EQUIPMENT	DEPARTMENT		GENERAL	REPAIRS	OF PLANT	SERVICE			CORF COST CENTER		KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE	GENERAL	THETISTS			CORF COST CENTER		PROGRAM	FRINGES	COSTS	(SPECIFY)
	(omit cents)			(SQUARE	(SQUARE	(GROSS	RECONCIL-	(ACCUM.	(SQUARE	(SQUARE	(POUNDS OF			(omit cents)		(HOURS OF	(MEALS	(MEALS	(NUMBER	(DIRECT	(COSTED	(COSTED	(TIME	(TIME	SERVICE	(ASSIGNED			(omit cents)		(ASSIGNED	(ASSIGNED	(ASSIGNED	(ASSIGNED
				FEET)	FEET)	SALARIES)	IATION	COST)	FEET)	FEET)	LAUNDRY)					SERVICE)	SERVED)	SERVED)	HOUSED)	NURS. HRS)*	REQUIS.)	REQUIS.)	SPENT)	SPENT)	(SPECIFY)	TIME)					TIME)	TIME)	TIME)	TIME)
			0	1	2	4	4A	5	6	7	8					9	10	11	12	13	14	15	16	17	18	19					20	21	22	23	24	25	26	27	28
1	Administrative and General											1	1	Administrative and General													1	1	Administrative and General											1
2	Skilled Nursing Care											2	2	Skilled Nursing Care													2	2	Skilled Nursing Care											2
3	Physical Therapy											3	3	Physical Therapy													3	3	Physical Therapy											3
4	Occupational Therapy											4	4	Occupational Therapy													4	4	Occupational Therapy											4
5	Speech Pathology											5	5	Speech Pathology													5	5	Speech Pathology											5
6	Medical Social Services											6	6	Medical Social Services													6	6	Medical Social Services											6
7	Respiratory Therapy											7	7	Respiratory Therapy													7	7	Respiratory Therapy											7
8	Psychiatric/Psychological Services											8	8	Psychiatric/Psychological Services													8	8	Psychiatric/Psychological Services											8
9	Individual Therapy											9	9	Individual Therapy													9	9	Individual Therapy											9
10	Group Therapy											10	10	Group Therapy													10	10	Group Therapy											10
11	Individualized Activity Therapies											11	11	Individualized Activity Therapies													11	11	Individualized Activity Therapies											11
12	Family Counseling											12	12	Family Counseling													12	12	Family Counseling											12
13	Diagnostic Services											13	13	Diagnostic Services													13	13	Diagnostic Services											13
14	Approved Patient Training & Education											14	14	Approved Patient Training & Education													14	14	Approved Patient Training & Education											14
15	Prosthetic and Orthotic Devices											15	15	Prosthetic and Orthotic Devices													15	15	Prosthetic and Orthotic Devices											15
16	Drugs and Biologicals											16	16	Drugs and Biologicals													16	16	Drugs and Biologicals											16
17	Medical Supplies											17	17	Medical Supplies													17	17	Medical Supplies											17
18	Medical Appliances											18	18	Medical Appliances													18	18	Medical Appliances											18
19	Durable Medical Equipment-Rented											19	19	Durable Medical Equipment-Rented													19	19	Durable Medical Equipment-Rented											19
20	Durable Medical Equipment-Sold											20	20	Durable Medical Equipment-Sold													20	20	Durable Medical Equipment-Sold											20
21	All Others											21	21	All Others													21	21	All Others											21
22	Totals (sum of lines 1-21)											22	22	Totals (sum of lines 1-21)													22	22	Totals (sum of lines 1-21)											22
23	Total Cost to be Allocated											23	23	Total Cost to be Allocated													23	23	Total Cost to be Allocated											23
24	Unit Cost Multiplier (see instructions)											24	24	Unit Cost Multiplier (see instructions)													24	24	Unit Cost Multiplier (see instructions)											24
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.2)													FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.2)															FORM CMS-2552-10 (01-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.2)
Rev. 4												40-625	40-626														Rev. 4	Rev. 17												40-627

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Sheet 85: J2I

4090 (Cont.)						FORM CMS-2552-10						01-22
COMPUTATION OF COMMUNITY MENTAL HEALTH CENTER PROVIDER COSTS									PROVIDER CCN:	PERIOD:	WORKSHEET J-2,
									________________	FROM ____________	PART I
									COMPONENT CCN:	TO _______________
									________________
PART I - APPORTIONMENT OF CMHC COST CENTERS
			(From		Ratio of		Title V		Title XVIII		Title XIX
			Wkst. J-1,	Total	Costs to	Title V	Component	Title XVIII	Component	Title XIX	Component
			Pt. I,	Component	Charges	Component	Costs (col. 3	Component	Costs (col. 3	Component	Costs (col. 3
			col. 28)	Charges	(col. 1 ÷ col. 2)	Charges	x col. 4)	Charges	x col. 6)	Charges	x col. 8)
			1	2	3	4	5	6	7	8	9
1	Administrative and General											1
2	Skilled Nursing Care											2
3	Physical Therapy											3
4	Occupational Therapy											4
5	Speech Pathology											5
6	Medical Social Services											6
7	Respiratory Therapy											7
8	Psychiatric/Psychological Services											8
9	Individual Therapy											9
10	Group Therapy											10
11	Individualized Activity Therapy											11
12	Family Counseling											12
13	Diagnostic Services											13
14	Approved Patient Training & Education											14
15	Prosthetic and Orthotic Devices											15
16	Drugs and Biologicals											16
17	Medical Supplies											17
18	Medical Appliances											18
19	All Others (1)											19
20	Totals (sum of lines 1 through19)											20
(1)	Enter amount in column 1 from Worksheet J-1, Part I, column 28, line 21.
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4054.1)
40-628												Rev. 17

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Sheet 86: J2II

11-17

FORM CMS-2552-10

4090 (Cont.)

COMPUTATION OF COMMUNITY MENTAL HEALTH CENTER PROVIDER COSTS

PROVIDER CCN:

PERIOD:

WORKSHEET J-2,

________________

FROM ____________

PART II

COMPONENT CCN:

TO _______________

________________

PART II - APPORTIONMENT OF COST OF CMHC PROVIDER SERVICES FURNISHED BY SHARED HOSPITAL DEPARTMENTS

(From

Title V

Title XVIII

Title XIX

Wkst. J-1,

Total

Ratio of

Title V

Component

Title XVIII

Component

Title XIX

Component

Pt. I,

Component

Costs to

Component

costs (col. 3

Component

costs (col. 3

Component

costs (col. 3

col. 29)

Charges

Charges (1)

Charges (2)

x col. 4)

Charges (2)

x col. 6)

Charges (2)

x col. 8)

1

2

3

4

5

6

7

8

9

21

Respiratory Therapy

21

22

Physical Therapy

22

23

Occupational Therapy

23

24

Speech Pathology

24

25

Medical Supplies Charged to Patients

25

26

Implantable Devices Charged to Patients

26

27

Drugs Charged to Patients

27

28

Total (sum of lines 21-28)

28

29

Total component costs. Add the amount from Pt. I, line 20,

29

and the amounts from line 28, columns 5, 7, and 9. (3)

(1)

From Worksheet C, Part I, column 9, lines as appropriate

(2)

Charges for columns 4 and 8 are obtained from your records.

(3)

Transfer the amounts on line 28, columns 5, 7, and 9, as appropriate, to Worksheet J-3, line 1.

FORM CMS-2552-10 (03-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4054.2)

Rev. 12

40-629

---

Sheet 87: J3

4090 (Cont.)					FORM CMS-2552-10				11-17
CALCULATION OF REIMBURSEMENT SETTLEMENT COMMUNITY						PROVIDER CCN:	PERIOD:	WORKSHEET J-3
MENTAL HEALTH CENTER PROVIDER SERVICES						________________	FROM ____________
						COMPONENT CCN:	TO _______________
						________________
Check		[ ] Title V
applicable		[ ] Title VIII
box:		[ ] Title XIX
								PROGRAM
								COST
1	Cost of component services (from Wkst. J-2, Pt. II, line 29)								1
2	PPS payments received excluding outliers								2
3	Outlier payments								3
4	Primary payer payments								4
5	Total reasonable cost (see instructions)								5
6	Total charges for program services								6
	CUSTOMARY CHARGES
7	Aggregate amount actually collected from patients liable for services on a charge basis								7
8	Amount that would have been realized from patients liable for payment for services on a charge								8
	basis had such payment been made in accordance with 42 CFR 413.13(e)								8
9	Ratio of line 7 to line 8 (not to exceed 1.000000) (see instructions)								9
10	Total customary charges (see instructions)								10
11	Excess of customary charges over reasonable cost (see instructions)								11
12	Excess of reasonable cost over customary charges (see instructions)								12
	COMPUTATION OF REIMBURSEMENT SETTLEMENT
13	Total reasonable cost (from line 5)								13
14	Part B deductible billed to program patients								14
15	Net cost (line 13 minus line 14)								15
16	Excess of reasonable cost over customary charges (from line 12)								16
17	Subtotal (line 15 minus line 16)								17
18	80 percent of costs (80% of line 17) (see instructions)								18
19	Actual coinsurance billed to program patients (from provider records)								19
20	Net cost less actual billed coinsurance (line 17 minus line 19)								20
21	Allowable bad debts (from provider records) (see instructions)								21
22	Adjusted reimbursable bad debts (see instructions)								22
23	Allowable bad debts for dual eligible beneficiaries (see instructions)								23
24	Net reimbursable amount (see instructions)								24
25	Other adjustments (see instructions) (specify)								25
25.50	Pioneer ACO demonstration payment adjustment (see instructions)								25.50
25.99	Demonstration payment adjustment amount before sequestration								25.99
26	Total cost (see instructions)								26
26.01	Sequestration adjustment (see instructions)								26.01
26.02	Demonstration payment adjustment amount after sequestration								26.02
27	Interim payments (see instructions)								27
28	Tentative settlement (for contractor use only)								28
29	Balance due component/program (line 26 minus lines 26.01, 26.02, 27, and 28)								29
30	Protested amounts (nonallowable cost report items in accordance with CMS Pub. 15-2, chapter 1, §115.2)								30
FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4055)
40-630									Rev. 12

---

Sheet 88: J4

11-16				FORM CMS-2552-10					4090 (Cont.)
ANALYSIS OF PAYMENTS TO HOSPITAL-BASED COMMUNITY MENTAL HEALTH					PROVIDER CCN:		PERIOD:	WORKSHEET J-4
CENTER FOR SERVICES RENDERED TO PROGRAM BENEFICIARIES					________________		FROM ____________
					COMPONENT CCN:		TO _______________
					________________
Check
applicable		[ ] Title XVIII
boxes:
							Part B
	DESCRIPTION						1	2
							mm/dd/yyyy	Amount
1	Total interim payments paid to providers								1
2	Interim payments payable on individual bills, either								2
	submitted or to be submitted to the intermediary, for
	services rendered in the cost reporting periods. If
	none, write "NONE", or enter zero.
3	List separately each retroactive					.01			3.01
	lump sum adjustment amount				Program	.02			3.02
	based on subsequent revision of				to	.03			3.03
	the interim rate for the				Provider	.04			3.04
	cost reporting period. Also show					.05			3.05
	date of each payment.					.50			3.50
	If none, write "NONE",				Provider	.51			3.51
	or enter zero (1).				to	.52			3.52
					Program	.53			3.53
						.54			3.54
	Subtotal (sum of lines 3.01-3.49
	minus sum of lines 3.50-3.98)					.99			3.99
4	Total interim payments (sum of lines 1, 2, and 3.99)								4
	(transfer to Worksheet J-3, line 27)
	TO BE COMPLETED BY INTERMEDIARY
5	List separately each tentative				Program	.01			5.01
	settlement payment after desk review.				to	.02			5.02
	Also show date of each payment.				Provider	.03			5.03
	If none, write "NONE,"				Provider	.50			5.50
	or enter zero (1).				to	.51			5.51
					Program	.52			5.52
	Subtotal (sum of lines 5.01-5.49 minus
	sum of lines 5.50-5.98)					.99			5.99
6	Determine net settlement amount				Program
	(balance due) based on the cost				to
	report (see instructions). (1)				Provider	.01			6.01
					Provider
					to
					Program	.02			6.02
7	Total Medicare liability								7
	(see instructions)
8	Name of Contractor			Contractor Number		NPR Date (Month, Day, Year)			8
(1)	On lines 3, 5, and 6, where an amount is due provider to program, show the amount and date on which you agree to the amount of
	repayment, even though the total repayment is not accomplished until a later date.
FORM CMS-2552-10 (03-2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4056)
Rev. 10									40-631

---

Sheet 89: K

4090 (Cont.)						FORM CMS-2552-10							11-16
ANALYSIS OF HOSPITAL-BASED										PROVIDER CCN:	PERIOD:	WORKSHEET K
HOSPICE COSTS										________________	FROM ____________
										COMPONENT CCN:	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 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4057)
40-632													Rev. 10

---

Sheet 90: K1

11-16						FORM CMS-2552-10						4090 (Cont.)
HOSPICE COMPENSATION ANALYSIS									PROVIDER CCN:	PERIOD:	WORKSHEET K-1
SALARIES AND WAGES									________________	FROM ____________
									COMPONENT CCN:	TO _______________
									________________
					MEDICAL
	COST CENTER DESCRIPTIONS		ADMINIS-		SOCIAL	SUPER-		TOTAL
	(omit cents)		TRATOR	DIRECTOR	WORKERS	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 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4058)
Rev. 10												40-633

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Sheet 91: K2

4090 (Cont.)						FORM CMS-2552-10						11-16
HOSPICE COMPENSATION ANALYSIS EMPLOYEE									PROVIDER CCN:	PERIOD:	WORKSHEET K-2
BENEFITS (PAYROLL RELATED)									________________	FROM ____________
									COMPONENT CCN:	TO _______________
									________________
					MEDICAL
	COST CENTER DESCRIPTIONS		ADMINIS-		SOCIAL	SUPER-		TOTAL
	(omit cents)		TRATOR	DIRECTOR	WORKERS	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 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4059)
40-634												Rev. 10

---

Sheet 92: K3

09-13						FORM CMS-2552-10						4090 (Cont.)
HOSPICE COMPENSATION ANALYSIS									PROVIDER CCN:	PERIOD:	WORKSHEET K-3
CONTRACTED SERVICES/PURCHASED SERVICES									________________	FROM ____________
									COMPONENT CCN:	TO _______________
									________________
					MEDICAL
	COST CENTER DESCRIPTIONS		ADMINIS-		SOCIAL	SUPER-		TOTAL
	(omit cents)		TRATOR	DIRECTOR	WORKERS	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 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4060)
Rev. 4												40-635

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Sheet 93: K4I

4090 (Cont.)						FORM CMS-2552-10						09-13
COST ALLOCATION - HOSPICE GENERAL SERVICE COST									PROVIDER CCN:	PERIOD:	WORKSHEET K-4,
									________________	FROM ____________	PART I
									COMPONENT CCN:	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											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
FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4061)
40-636												Rev. 4

---

Sheet 94: K4II

09-13					FORM CMS-2552-10						4090 (Cont.)
COST ALLOCATION - HOSPICE STATISTICAL BASIS								PROVIDER CCN:	PERIOD:	WORKSHEET K-4,
								________________	FROM ____________	PART II
								COMPONENT CCN:	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-Bldg and Fixt.										1
2	Capital Related Costs-Movable Equip.										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										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	Cost To be Allocated (per Wkst. K-4, Part I)										39
40	Unit Cost Multiplier										40
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4061)
Rev. 4											40-637

---

Sheet 95: K5I

4090 (Cont.)						FORM CMS-2552-10						09-13	10-12					FORM CMS-2552-10							4090 (Cont.)	4090 (Cont.)					FORM CMS-2552-10								10-12
ALLOCATION OF GENERAL SERVICE									PROVIDER CCN:	PERIOD:	WORKSHEET K-5,		ALLOCATION OF GENERAL SERVICE									PROVIDER CCN:	PERIOD:	WORKSHEET K-5,		ALLOCATION OF GENERAL SERVICE										PROVIDER CCN:	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.)
									COMPONENT CCN:	TO _______________												COMPONENT CCN:	TO _______________													COMPONENT CCN:	TO _______________
									________________													________________														________________
PART I - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS													PART I - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS													PART I - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS
																																			INTERN &
			From	HOSPICE	CAPITAL																								NON-				PARA-		RESIDENT		ALLOCATED	TOTAL
	HOSPICE COST CENTER		Wkst. K-4	TRIAL	RELATED COSTS		EMPLOYEE		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	BENEFITS	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	DEPARTMENT	(cols. 0-4)	GENERAL	REPAIRS	OF PLANT				SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE				SERVICE	THETISTS	SCHOOL	FRINGES	COSTS	(SPECIFY)	(cols. 4a-23)	ADJUST.	(cols. 24 ± 25)	Part II)	(cols. 26 ± 27)
			line	0	1	2	4	4A	5	6	7				8	9	10	11	12	13	14	15	16	17				`8	19	20	21	22	23	24	25	26	27	28
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		15									10	10	Medical Social Services											10	10	Medical Social Services												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 Homemaker		19									14	14	Home Health Aide and Homemaker											14	14	Home Health Aide and Homemaker												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, Biological and Infusion Therapy		22									17	17	Drugs, Biological and Infusion Therapy											17	17	Drugs, Biological and Infusion Therapy												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 1-33) (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 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.1)													FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.1)													FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.1)
40-638												Rev. 4	Rev. 3												40-639	40-640													Rev. 3

---

Sheet 96: K5II

09-13						FORM CMS-2552-10						4090 (Cont.)	4090 (Cont.)						FORM CMS-2552-10						09-13	10-12						FORM CMS-2552-10							4090 (Cont.)
ALLOCATION OF GENERAL SERVICE COSTS TO									PROVIDER CCN:	PERIOD:	WORKSHEET K-5,		ALLOCATION OF GENERAL SERVICE COSTS TO									PROVIDER CCN:	PERIOD:	WORKSHEET K-5,		ALLOCATION OF GENERAL SERVICE COSTS TO										PROVIDER CCN:	PERIOD:	WORKSHEET K-5,
HOSPICE COST CENTERS STATISTICAL BASIS									________________	FROM ____________	PART II		HOSPICE COST CENTERS STATISTICAL BASIS									________________	FROM ____________	PART II		HOSPICE COST CENTERS STATISTICAL BASIS										________________	FROM ____________	PART II
									COMPONENT CCN:	TO _______________												COMPONENT CCN:	TO _______________													COMPONENT CCN:	TO _______________
									________________													________________														________________
PART II - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS - STATISTICAL BASIS													PART II - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS - STATISTICAL BASIS													PART II - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS - STATISTICAL BASIS
					CAPITAL																													NON-				PARA-
					RELATED COST		EMPLOYEE		ADMINIS-	MAIN-						LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL										PHYSICIAN		INTERNS & RESIDENTS		MEDICAL
					BLDGS. &	MOVABLE	BENEFITS		TRATIVE &	TENANCE &	OPERATION					& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &								SOCIAL	OTHER	ANES-	NURSING	SALARY &	PROGRAM	EDUCATION
	HOSPICE COST CENTER				FIXTURES	EQUIPMENT	DEPARTMENT		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	5A	5	6	7					8	9	10	11	12	13	14	15	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											10	10	Medical Social Services											10	10	Medical Social Services												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 Homemaker											14	14	Home Health Aide and Homemaker											14	14	Home Health Aide and Homemaker												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, Biological and Infusion Therapy											17	17	Drugs, Biological and Infusion Therapy											17	17	Drugs, Biological and Infusion Therapy												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 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.2)													FORM CMS-2552-10 (09-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.2)													FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.2)
Rev. 4												40-641	40-642												Rev. 4	Rev. 3													40-643

---

Sheet 97: K5III

4090 (Cont.)				FORM CMS-2552-10				10-12
APPORTIONMENT OF HOSPICE SHARED SERVICES					PROVIDER CCN:	PERIOD:	WORKSHEET K-5,
					________________	FROM ____________	PART III
					COMPONENT CCN:	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			66				1
2	Occupational Therapy			67				2
3	Speech/ Language Pathology			68				3
4	Drugs, Biological and Infusion Therapy			73				4
5	Durable Medical Equipment/Oxygen			96				5
6	Labs and Diagnostics			60				6
7	Medical Supplies			71				7
8	Outpatient Services (including E/R Dept.)			93				8
9	Radiation Therapy			55				9
10	Other			76				10
11	Totals (sum of lines 1-10)							11
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4062.3)
40-644								Rev. 3

---

Sheet 98: K6

07-23				FORM CMS-2552-10				4090 (Cont.)
CALCULATION OF HOSPICE PER DIEM COST					PROVIDER CCN:	PERIOD:	WORKSHEET K-6
					________________	FROM ____________
					COMPONENT CCN:	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 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4063)
Rev. 21								40-645

---

Sheet 99: L

4090 (Cont.)				FORM CMS-2552-10				07-23
CALCULATION OF CAPITAL PAYMENT					PROVIDER CCN:	PERIOD:	WORKSHEET L
					________________	FROM ____________
					COMPONENT CCN:	TO _______________
					________________
Check		[ ] Title V	[ ] Hospital	[ ] PPS
applicable		[ ] Title XVIII, Part A	[ ] PARHM Demonstration	[ ] Cost Method
boxes:		[ ] Title XIX
PART I - FULLY PROSPECTIVE METHOD
	CAPITAL FEDERAL AMOUNT
1	Capital DRG other than outlier							1
1.01	Model 4 BPCI Capital DRG other than outlier							1.01
2	Capital DRG outlier payments							2
2.01	Model 4 BPCI Capital DRG outlier payments							2.01
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 (see instructions)							6
7	Percentage of SSI recipient patient days to Medicare Part A patient days (Worksheet E, Part A line 30) (see instructions)							7
8	Percentage of Medicaid patient days to total days (see instructions)							8
9	Sum of lines 7 and 8							9
10	Allowable disproportionate share percentage (see instructions)							10
11	Disproportionate share adjustment (see instructions)							11
12	Total prospective capital payments (see instructions)							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 12 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 (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4064.1 - 4064.3)
40-646								Rev. 21

---

Sheet 100: L1I

02-24						FORM CMS-2552-10						4090 (Cont.)	4090 (Cont.)						FORM CMS-2552-10							12-22	02-24						FORM CMS-2552-10						4090 (Cont.)
ALLOCATION OF ALLOWABLE COSTS FOR									PROVIDER CCN:	PERIOD:	WORKSHEET L-1,		ALLOCATION OF ALLOWABLE COSTS FOR										PROVIDER CCN:	PERIOD:	WORKSHEET L-1,		ALLOCATION OF ALLOWABLE COSTS FOR									PROVIDER CCN:	PERIOD:	WORKSHEET L-1,
EXTRAORDINARY CIRCUMSTANCES									________________	FROM ____________	PART I		EXTRAORDINARY CIRCUMSTANCES											FROM ____________	PART I (Cont.)		EXTRAORDINARY CIRCUMSTANCES										FROM ____________	PART I (Cont.)
										TO _______________													________________	TO _______________												________________	TO _______________
				EXTRA-	CAPITAL																																INTERN &
				ORDINARY	RELATED COSTS																										NON-		INTERNS &	INTERNS &	PARA-		RESIDENT
				CAPITAL			SUBTOTAL	EMPLOYEE	ADMINIS-	MAIN-						LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL						OTHER	PHYSICIAN		RESIDENTS	RESIDENTS	MEDICAL		COST & POST
	Cost Center Descriptions			RELATED	BLDGS. &	MOVABLE	(sum of	BENEFITS	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)	DEPARTMENT	GENERAL	REPAIRS	OF PLANT					SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE					SERVICE	THETISTS	PROGRAM	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													GENERAL SERVICE COST CENTERS														GENERAL SERVICE COST CENTERS
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 Department											4	4	Employee Benefits Department												4	4	Employee Benefits Department											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 Program											20	20	Nursing Program												20	20	Nursing Program											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													INPATIENT ROUTINE SERVICE COST CENTERS														INPATIENT ROUTINE SERVICE COST CENTERS
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 (01-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)													FORM CMS-2552-10 (01-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)														FORM CMS-2552-10 (01-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)
Rev. 22												40-647	40-650													Rev. 18	Rev. 22												40-653
4690 (Cont.)						FORM CMS-2552-10						02-24	02-24						FORM CMS-2552-10							4090 (Cont.)	4690 (Cont.)						FORM CMS-2552-10						02-24
ALLOCATION OF ALLOWABLE COSTS FOR									PROVIDER CCN:	PERIOD:	WORKSHEET L-1,		ALLOCATION OF ALLOWABLE COSTS FOR										PROVIDER CCN:	PERIOD:	WORKSHEET L-1,		ALLOCATION OF ALLOWABLE COSTS FOR									PROVIDER CCN:	PERIOD:	WORKSHEET L-1,
EXTRAORDINARY CIRCUMSTANCES									________________	FROM ____________	PART I		EXTRAORDINARY CIRCUMSTANCES											FROM ____________	PART I (Cont.)		EXTRAORDINARY CIRCUMSTANCES										FROM ____________	PART I (Cont.)
										TO _______________													________________	TO _______________												________________	TO _______________
				EXTRA-	CAPITAL																																INTERN &
				ORDINARY	RELATED COSTS																												INTERNS &	INTERNS &	PARA-		RESIDENT
				CAPITAL			SUBTOTAL	EMPLOYEE	ADMINIS-	MAIN-						LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL						OTHER			RESIDENTS	RESIDENTS	MEDICAL		COST & POST
	Cost Center Descriptions			RELATED	BLDGS. &	MOVABLE	(sum of	BENEFITS	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)	DEPARTMENT	GENERAL	REPAIRS	OF PLANT					SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE					SERVICE	ANESTHETISTS	PROGRAM	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													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 Catheterization											59	59	Cardiac Catheterization												59	59	Cardiac Catheterization											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
77	Allogeneic HSCT Acquisition											77	77	Allogeneic HSCT Acquisition												77	77	Allogeneic HSCT Acquisition											77
78	CAR T-Cell Immunotherapy											78	78	CAR T-Cell Immunotherapy												78	78	CAR T-Cell Immunotherapy											78
	OUTPATIENT SERVICE COST CENTERS													OUTPATIENT SERVICE COST CENTERS														OUTPATIENT SERVICE COST CENTERS
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
93.99	Partial Hospitalization Program											93.99	93.99	Partial Hospitalization Program												93.99	93.99	Partial Hospitalization Program											93.99
FORM CMS-2552-10 (01-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)													FORM CMS-2552-10 (01-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)														FORM CMS-2552-10 (01-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)
40-648												Rev. 22	Rev. 22													40-651	40-654												Rev. 22
12-22						FORM CMS-2552-10						4090 (Cont.)	4090 (Cont.)						FORM CMS-2552-10							02-24	01-22						FORM CMS-2552-10						4090 (Cont.)
ALLOCATION OF ALLOWABLE COSTS FOR									PROVIDER CCN:	PERIOD:	WORKSHEET L-1,		ALLOCATION OF ALLOWABLE COSTS FOR										PROVIDER CCN:	PERIOD:	WORKSHEET L-1,		ALLOCATION OF ALLOWABLE COSTS FOR									PROVIDER CCN:	PERIOD:	WORKSHEET L-1,
EXTRAORDINARY CIRCUMSTANCES									________________	FROM ____________	PART I		EXTRAORDINARY CIRCUMSTANCES											FROM ____________	PART I (Cont.)		EXTRAORDINARY CIRCUMSTANCES										FROM ____________	PART I (Cont.)
										TO _______________													________________	TO _______________												________________	TO _______________
				EXTRA-	CAPITAL																																INTERN &
				ORDINARY	RELATED COSTS																												INTERNS &	INTERNS &	PARA-		RESIDENT
				CAPITAL			SUBTOTAL	EMPLOYEE	ADMINIS-	MAIN-						LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL						OTHER			RESIDENTS	RESIDENTS	MEDICAL		COST & POST
	Cost Center Descriptions			RELATED	BLDGS. &	MOVABLE	(sum of	BENEFITS	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)	DEPARTMENT	GENERAL	REPAIRS	OF PLANT					SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE					SERVICE	ANESTHETISTS	PROGRAM	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													OTHER REIMBURSABLE COST CENTERS														OTHER REIMBURSABLE COST CENTERS
94	Home Program Dialysis											94	94	Home Program Dialysis												94	94	Home Program Dialysis											94
95	Ambulance Services											95	95	Ambulance Services												95	95	Ambulance Services											95
96	Durable Medical Equipment-Rented											96	96	Durable Medical Equipment-Rented												96	96	Durable Medical Equipment-Rented											96
97	Durable Medical Equipment-Sold											97	97	Durable Medical Equipment-Sold												97	97	Durable Medical Equipment-Sold											97
98	Other Reimbursable (specify)											98	98	Other Reimbursable (specify)												98	98	Other Reimbursable (specify)											98
99	Outpatient Rehabilitation Provider (specify)											99	99	Outpatient Rehabilitation Provider (specify)												99	99	Outpatient Rehabilitation Provider (specify)											99
100	Intern-Resident Service (not appvd. tchng. prgm.)											100	100	Intern-Resident Service (not appvd. tchng. prgm.)												100	100	Intern-Resident Service (not appvd. tchng. prgm.)											100
101	Home Health Agency											101	101	Home Health Agency												101	101	Home Health Agency											101
102	Opioid Treatment Program											102	102	Opioid Treatment Program												102	102	Opioid Treatment Program											102
	SPECIAL PURPOSE COST CENTERS													SPECIAL PURPOSE COST CENTERS														SPECIAL PURPOSE COST CENTERS
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 through 117)											118	118	SUBTOTALS (sum of lines 1 through 117)												118	118	SUBTOTALS (sum of lines 1 through 117)											118
	NONREIMBURSABLE COST CENTERS													NONREIMBURSABLE COST CENTERS														NONREIMBURSABLE COST CENTERS
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
200	Cross Foot Adjustments											200	200	Cross Foot Adjustments												200	200	Cross Foot Adjustments											200
201	Negative Cost Centers											201	201	Negative Cost Centers												201	201	Negative Cost Centers											201
202	Total (sum of line 118 and lines 190 through 201)											202	202	Total (sum of line 118 and lines 190 through 201)												202	202	Total (sum of line 118 and lines 190 through 201)											202
203	Total Statistical Basis											203	203	Total Statistical Basis												203	203	Total Statistical Basis											203
204	Unit Cost Multiplier											204	204	Unit Cost Multiplier												204	204	Unit Cost Multiplier											204
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)													FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)														FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)
Rev. 18												40-649	40-652													Rev. 22	Rev. 18												40-655

---

Sheet 101: L1II

4090 (Cont.)

FORM CMS-2552-10

12-22

COMPUTATION OF PROGRAM INPATIENT ROUTINE SERVICE

PROVIDER CCN:

PERIOD:

WORKSHEET L-1,

CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES

________________

FROM ____________

PART II

TO _______________

Check

[ ] Title V

applicable

[ ] Title XVIII, Part A

box:

[ ] Title XIX

Capital Cost

Reduced

for Extraordinary

Capital Cost

Circumstances

for Extraordinary

Inpatient Program

(from Wkst. L-1,

Swing Bed

Circumstances

Total

Per Diem

Inpatient

Capital Cost

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)

(A)

1

2

3

4

5

6

7

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 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.2)

40-656

Rev. 18

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Sheet 102: L1III

02-24					FORM CMS-2552-10						4090 (Cont.)
COMPUTATION OF PROGRAM INPATIENT ANCILLARY SERVICE								PROVIDER CCN:	PERIOD:	WORKSHEET L-1,
CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES								________________	FROM ____________	PART III
								COMPONENT CCN:	TO _______________
								________________
Check		[ ] Hospital		[ ] Title V
applicable				[ ] 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)
(A)						1	2	3	4	5
	ANCILLARY SERVICE COST CENTERS
50	Operating Room										50
51	Recovery Room										51
52	Labor Room and Delivery Room										52
53	Anesthesiology										53
54	Radiology-Diagnostic										54
55	Radiology-Therapeutic										55
56	Radioisotope										56
57	Computed Tomography (CT) Scan										57
58	Magnetic Resonance Imaging (MRI)										58
59	Cardiac Catheterization										59
60	Laboratory										60
61	PBP Clinical Laboratory 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
77	Allogeneic Stem Cell Acquisition										77
	(A) Worksheet A line numbers
FORM CMS-2552-10 (01-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4065.3)
Rev. 22											40-657
4090 (Cont.)					FORM CMS-2552-10						02-24
COMPUTATION OF PROGRAM INPATIENT ANCILLARY SERVICE								PROVIDER CCN:	PERIOD:	WORKSHEET L-1,
CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES								________________	FROM ____________	PART III (CONT.)
								COMPONENT CCN:	TO _______________
								________________
Check		[ ] Hospital	[ ] Title V
applicable			[ ] 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)
(A)						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
93.99	Partial Hospitalization Program										93.99
	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 (04-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4065.3)
40-658											Rev. 22

---

Sheet 103: M1

02-24						FORM CMS-2552-10						4090 (Cont.)
ANALYSIS OF HOSPITAL-BASED RHC/FQHC COSTS									PROVIDER CCN:	PERIOD:	WORKSHEET M-1
									________________	FROM __________
									COMPONENT CCN:	TO ____________
									________________
Check applicable box:		[ ] Hospital-based RHC [ ] Hospital-based FQHC
									RECLASSIFIED		NET EXPENSES
									TRIAL		FOR
					COMPEN-		TOTAL	RECLASS-	BALANCE		ALLOCATION
					SATION	OTHER COSTS	(col. 1 + col. 2)	IFICATIONS	(col. 3 + col. 4)	ADJUSTMENTS	(col. 5 + col. 6)
					1	2	3	4	5	6	7
	FACILITY HEALTH CARE STAFF COSTS
1	Physician											1
2	Physician Assistant											2
3	Nurse Practitioner											3
4	Visiting Nurse											4
5	Other Nurse											5
6	Clinical Psychologist											6
7	Clinical Social Worker											7
7.10	Marriage and Family Therapist											7.10
7.11	Mental Health Counselor											7.11
8	Laboratory Technician											8
9	Other Facility Health Care Staff Costs											9
10	Subtotal (sum of lines 1-9)											10
	COSTS UNDER AGREEMENT
11	Physician Services Under Agreement											11
12	Physician Supervision Under Agreement											12
13	Other Costs Under Agreement											13
14	Subtotal (sum of lines 11-13)											14
	OTHER HEALTH CARE COSTS
15	Medical Supplies											15
16	Transportation (Health Care Staff)											16
17	Depreciation-Medical Equipment											17
18	Professional Liability Insurance											18
19	Other Health Care Costs											19
20	Allowable GME Costs											20
21	Subtotal (sum of lines 15-20)											21
22	Total Cost of Health Care Services											22
	(sum of lines 10, 14, and 21)
	COSTS OTHER THAN RHC/FQHC SERVICES
23	Pharmacy											23
24	Dental											24
25	Optometry											25
25.01	Telehealth											25.01
25.02	Chronic Care Management											25.02
26	All other nonreimbursable costs											26
27	Nonallowable GME costs											27
28	Total Nonreimbursable Costs (sum of lines 23-27)											28
	FACILITY OVERHEAD
29	Facility Costs											29
30	Administrative Costs											30
31	Total Facility Overhead (sum of lines 29 and 30)											31
32	Total facility costs (sum of lines 22, 28 and 31)											32
The net expenses for cost allocation on Worksheet A for the hospital-based RHC/FQHC cost center line must equal the total facility costs in column 7, line 32, of this worksheet.
FORM CMS-2552-10 (02-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4066)
Rev. 22												40-659

---

Sheet 104: M2

4090 (Cont.)				FORM CMS-2552-10				02-24
ALLOCATION OF OVERHEAD					PROVIDER CCN:	PERIOD:	WORKSHEET M-2
TO HOSPTIAL-BASED RHC/FQHC SERVICES					________________	FROM __________
					COMPONENT CCN:	TO ___________
					________________
Check applicable box:		[ ] Hospital-based RHC [ ] Hospital-based FQHC
VISITS AND PRODUCTIVITY
			Number			Minimum	Greater of
			of FTE	Total	Productivity	Visits (col. 1	col. 2 or
			Personnel	Visits	Standard (1)	x col. 3)	col. 4
	Positions		1	2	3	4	5
1	Physicians							1
2	Physician Assistants							2
3	Nurse Practitioners							3
4	Subtotal (sum of lines 1 through 3)							4
5	Visiting Nurse							5
6	Clinical Psychologist							6
7	Clinical Social Worker							7
7.01	Medical Nutrition Therapist (FQHC only)							7.01
7.02	Diabetes Self Management Training (FQHC only)							7.02
7.03	Marriage and Family Therapist							7.03
7.04	Mental Health Counselor							7.04
8	Total FTEs and Visits (sum of lines 4 through 7)							8
9	Physician Services Under Agreements							9
DETERMINATION OF ALLOWABLE COST APPLICABLE TO HOSPITAL-BASED RHC/FQHC SERVICES
10	Total costs of health care services (from Worksheet M-1, column 7, line 22)							10
11	Total nonreimbursable costs (from Worksheet M-1, column 7, line 28)							11
12	Cost of all services (excluding overhead) (sum of lines 10 and 11)							12
13	Ratio of hospital-based RHC/FQHC services (line 10 divided by line 12)							13
14	Total hospital-based RHC/FQHC overhead (from Worksheet M-1, column 7, line 31)							14
15	Parent provider overhead allocated to facility (see instructions)							15
16	Total overhead (sum of lines 14 and 15)							16
17	Allowable Direct GME overhead (see instructions)							17
18	Enter the amount from line 16							18
19	Overhead applicable to hospital-based RHC/FQHC services (line 13 x line 18)							19
20	Total allowable cost of hospital-based RHC/FQHC services (sum of lines 10 and 19)							20
(1)	The productivity standard for physicians is 4,200 and 2,100 for physician assistants and nurse practitioners. If an exception
	to the standard has been granted (Worksheet S-8, line 12 equals "Y"), column 3, lines 1thru 3 of this worksheet should contain,
	at a minimum, one element that is different than the standard.
FORM CMS-2552-10 (02-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4067)
40-660								Rev. 22

---

Sheet 105: M3

12-24				FORM CMS-2552-10				4090(Cont.)
CALCULATION OF REIMBURSEMENT					PROVIDER CCN:	PERIOD:	WORKSHEET M-3
SETTLEMENT FOR HOSPITAL-BASED RHC/FQHC SERVICES					________________	FROM ___________
					COMPONENT CCN:	TO ___________
					________________
Check		[ ] Hospital-based RHC	[ ] Title V
applicable		[ ] Hospital-based FQHC	[ ] Title XVIII
boxes:			[ ] Title XIX
DETERMINATION OF RATE FOR HOSPITAL-BASED RHC/FQHC SERVICES
1	Total allowable cost of hospital-based RHC/FQHC services (from Worksheet M-2, line 20)							1
2	Cost of injections/infusions and their administration (from Worksheet M-4, line 15)							2
3	Total allowable cost excluding injections/infusions (line 1 minus line 2)							3
4	Total visits (from Worksheet M-2, column 5, line 8)							4
5	Physicians visits under agreement (from Worksheet M-2, column 5, line 9)							5
6	Total adjusted visits (line 4 plus line 5)							6
7	Adjusted cost per visit (line 3 divided by line 6)							7
					Calculation of Limit (1)
					Payment Limit	Payment Limit	Payment Limit
					Period 1	Period 2	Period 3
					1	2	3
8	Per visit payment limit (from CMS Pub. 100-04, chapter 9, §20.6, or your contractor)							8
9	Rate for Program covered visits (see instructions)							9
CALCULATION OF SETTLEMENT
10	Program covered visits excluding mental health services (from contractor records)							10
11	Program cost excluding costs for mental health services (line 9 x line 10)							11
12	Program covered visits for mental health services (from contractor records)							12
13	Program covered cost from mental health services (line 9 x line 12)							13
14	Limit adjustment for mental health services (see instructions)							14
15	Graduate Medical Education pass-through cost (see instructions)							15
16	Total program cost (sum of lines 11, 14, and 15, columns 1, 2 and 3)							16
16.01	Total program charges (see instructions)(from contractor's records)							16.01
16.02	Total program preventive charges (see instructions)(from provider's records)							16.02
16.03	Total program preventive costs (see instructions)							16.03
16.04	Total program non-preventive costs (see instructions)							16.04
16.05	Total program cost (see instructions)							16.05
17	Primary payer amounts							17
18	Less: Beneficiary deductible for RHC only (see instructions) (from contractor records)							18
19	Less: Beneficiary coinsurance for RHC/FQHC services (see instructions) (from contractor records)							19
20	Net program cost excluding injections/infusions (see instructions)							20
21	Program cost of injections/infusions and their administration (from Worksheet M-4, line 16)							21
21.50	Total program IOP OPPS payments (see instructions)							21.50
					Program IOP Visits	Program IOP Costs
					1	2
21.55	Total program IOP visits and costs (see instructions)							21.55
21.60	Program IOP deductible and coinsurance (see instructions)							21.60
22	Total reimbursable program cost (sum of lines 20, 21, 21.50, minus line 21.60)							22
23	Allowable bad debts (see instructions)							23
23.01	Adjusted reimbursable bad debts (see instructions)							23.01
24	Allowable bad debts for dual eligible beneficiaries (see instructions)							24
25	Other adjustments (specify) (see instructions)							25
25.50	Pioneer ACO demonstration payment adjustment (see instructions)							25.50
25.99	Demonstration payment adjustment amount before sequestration							25.99
26	Net reimbursable amount (see instructions)							26
26.01	Sequestration adjustment (see instructions)							26.01
26.02	Demonstration payment adjustment amount after sequestration							26.02
27	Interim payments							27
28	Tentative settlement (for contractor use only)							28
29	Balance due component/program line 26 minus lines 26.01, 26.02, 27, and 28							29
30	Protested amounts (nonallowable cost report items) in accordance with CMS							30
	Pub. 15-2, chapter 1, section 115.2
(1)	Lines 8 through 14: Fiscal year providers use columns 1 and 2 (and column 3, if applicable). Calendar year
	providers with one rate in effect for the entire cost reporting period use column 2 only.
FORM CMS-2552-10 (12-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4068)
Rev. 23								40-661

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Sheet 106: M4

4090 (Cont.)				FORM CMS-2552-10				12-24
COMPUTATION OF HOSPITAL-BASED RHC/FQHC VACCINE COST					PROVIDER CCN:	PERIOD:	WORKSHEET M-4
					________________	FROM __________
					COMPONENT CCN:	TO ___________
					________________
Check		[ ] Hospital-based RHC	[ ] Title V
applicable		[ ] Hospital-based FQHC	[ ] Title XVIII
boxes:			[ ] Title XIX
							MONOCLONAL
				PNEUMOCOCCAL	INFLUENZA	COVID-19	ANTIBODY
				VACCINES	VACCINES	VACCINES	PRODUCTS
				1	2	2.01	2.02
1	Health care staff cost (from Worksheet M-1, column 7, line 10)							1
2	Ratio of injection/infusion staff time to total							2
	health care staff time
3	Injection/infusion health care staff cost (line 1 x line 2)							3
4	Injections/infusions and related medical supplies costs							4
	(from your records)
5	Direct cost of injections/infusions (line 3 plus line 4)							5
6	Total direct cost of the hospital-based RHC/FQHC (from							6
	Worksheet M-1, column 7, line 22)
7	Total overhead (from Worksheet M-2, line 19)							7
8	Ratio of injection/infusion direct cost to total direct							8
	cost (line 5 divided by line 6)
9	Overhead cost - injection/infusion (line 7 x line 8)							9
10	Total injection/infusion costs and their							10
	administration costs (sum of lines 5 and 9)
11	Total number of injections/infusions							11
	(from your records)
12	Cost per injection/infusion (line 10/line 11)							12
13	Number of injection/infusion administered							13
	to Program beneficiaries
13.01	Number of COVID-19 vaccine injections/infusions							13.01
	administered to MA enrollees
14	Program cost of injections/infusions and their administration							14
	costs (line 12 times the sum of lines 13 and 13.01, as applicable)
					COST OF
					INJECTIONS /
					INFUSIONS AND
					ADMINISTRATION
				1	2
15	Total cost of injections/infusions and their							15
	administration costs (sum of columns 1, 2, 2.01, and 2.02, line 10)
	(transfer this amount to Worksheet M-3, line 2)
16	Total Program cost of injections/infusions and their							16
	administration costs (sum of columns 1, 2, 2.01, and 2.02, line 14)
	(transfer this amount to Worksheet M-3, line 21)
FORM CMS 2552-10 (03-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4069)
40-662								Rev. 23

---

Sheet 107: M5

02-24				FORM CMS-2552-10					4090 (Cont.)
ANALYSIS OF PAYMENTS TO HOSPITAL-BASED					PROVIDER CCN:		PERIOD:	WORKSHEET M-5
RHC/FQHC FOR SERVICES RENDERED					________________		FROM ___________
TO PROGRAM BENEFICIARIES					COMPONENT CCN:		TO ___________
					________________
Check applicable box:		[ ] Hospital-based RHC [ ] Hospital-based FQHC
							Part B
	DESCRIPTION						1	2
							mm/did/ivy	Amount
1	Total interim payments paid to hospital-based RHC/FQHC								1
2	Interim payments payable on individual bills, either								2
	submitted or to be submitted to the intermediary, for
	services rendered in the cost reporting periods. If
	none, write "NONE", or enter zero.
3	List separately each retroactive					.01			3.01
	lump sum adjustment amount				Program	.02			3.02
	based on subsequent revision of				to	.03			3.03
	the interim rate for the				Provider	.04			3.04
	cost reporting period. Also show					.05			3.05
	date of each payment.					.50			3.50
	If none, write "NONE",				Provider	.51			3.51
	or enter zero (1).				to	.52			3.52
					Program	.53			3.53
						.54			3.54
	Subtotal (sum of lines 3.01-3.49 minus sum of lines 3.50-3.98)					.99			3.99
4	Total interim payments (sum of lines 1, 2, and 3.99)								4
	(transfer to Worksheet M-3, line 27)
	TO BE COMPLETED BY CONTRACTOR
5	List separately each tentative				Program	.01			5.01
	settlement payment after desk review.				to	.02			5.02
	Also show date of each payment.				Provider	.03			5.03
	If none, write "NONE,"				Provider	.50			5.50
	or enter zero (1).				to	.51			5.51
					Program	.52			5.52
	Subtotal (sum of lines 5.01-5.49 minus sum of lines 5.50-5.98)					.99			5.99
6	Determine net settlement amount				Program
	(balance due) based on the cost				to
	report (see instructions). (1)				Provider	.01			6.01
					Provider
					to
					Program	.02			6.02
7	Total Medicare liability (see instructions)								7
8	Name of Contractor					Contractor Number		NPR Date	8
								(Month/Day/Year)
(1)	On lines 3, 5, and 6, where an amount is due component to program,
	show the amount and date on which you agree to the amount of repayment,
	even though the total repayment is not accomplished until a later date.
FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4070)
Rev. 22									40-663

---

Sheet 108: N1

4090 (Cont.)						FORM CMS-2552-10						02-24
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES									PROVIDER CCN:	PERIOD:	WORKSHEET N-1
FOR HOSPITAL-BASED FQHC									_________________	FROM: ___________
									COMPONENT CCN:	TO: ___________
									_________________
											NET
									RECLASSIFIED		EXPENSES FOR
	COST CENTER DESCRIPTIONS						TOTAL	RECLASSIFI-	TRIAL BALANCE		ALLOCATION
	(omit cents)				SALARIES	OTHER	(col. 1 + col. 2)	CATIONS	(col. 3 ± col. 4)	ADJUSTMENTS	(col. 5 ± col. 6)
					1	2	3	4	5	6	7
GENERAL SERVICE COST CENTERS
1	Cap Rel Costs-Bldg and Fix											1
2	Cap Rel Costs-Mvble Equip											2
3	Employee Benefits											3
4	Administrative and General											4
5	Plant Operation and Maintenance											5
6	Janitorial											6
7	Medical Records											7
8	Subtotal - Administrative Overhead											8
9	Pharmacy											9
10	Medical Supplies											10
11	Transportation											11
12	Other General Service											12
13	Subtotal - Total Overhead											13
DIRECT CARE COST CENTERS
23	Physician											23
24	Physician Services Under Agreement											24
25	Physician Assistant											25
26	Nurse Practitioner											26
27	Visiting Registered Nurse											27
28	Visiting Licensed Practical Nurse											28
29	Certified Nurse Midwife											29
30	Clinical Psychologist											30
31	Clinical Social Worker											31
31.10	Marriage and Family Therapist											31.10
31.11	Mental Health Counselor											31.11
32	Laboratory Technician											32
33	Reg Dietician/Cert DSMT/MNT Educator											33
34	Physical Therapist											34
35	Occupational Therapist											35
36	Other Allied Health Personnel											36
37	Subtotal - Direct Patient Care Services											37
FORM CMS-2552-10 (02-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4071)
40-664												Rev. 22
02-24						FORM CMS-2552-10						4090 (Cont.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES									PROVIDER CCN:	PERIOD:	WORKSHEET N-1
FOR HOSPITAL-BASED FQHC									_________________	FROM: ___________
									COMPONENT CCN:	TO: ___________
									_________________
											NET
									RECLASSIFIED		EXPENSES FOR
	COST CENTER DESCRIPTIONS						TOTAL	RECLASSIFI-	TRIAL BALANCE		ALLOCATION
	(omit cents)				SALARIES	OTHER	(col. 1 + col. 2)	CATIONS	(col. 3 ± col. 4)	ADJUSTMENTS	(col. 5 ± col. 6)
					1	2	3	4	5	6	7
REIMBURSABLE PASS THROUGH COSTS
47	Pneumococcal Vaccines & Med Supplies											47
48	Influenza Vaccines & Med Supplies											48
48.10	COVID-19 Vaccine & Med Supplies											48.10
48.11	Monoclonal Antibody Products											48.11
49	Subtotal - Reimbursable Pass through Costs											49
OTHER FQHC SERVICES
60	Medicare Excluded Services											60
61	Diagnostic & Screening Lab Tests											61
62	Radiology - Diagnostic											62
63	Prosthetic Devices											63
64	Durable Medical Equipment											64
65	Ambulance Services											65
66	Telehealth											66
67	Drugs Charged to Patients											67
68	Chronic Care Management											68
69	Other											69
70	Subtotal - Other FQHC Services											70
NONREIMBURSABLE COST CENTERS
77	Retail Pharmacy											77
78	Other Nonreimbursable											78
79	Subtotal - Non-Reimbursable Costs											79
100	TOTAL (sum of lines 13, 37, 49, 70, and 79)											100
FORM CMS-2552-10 (01-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4071)
Rev. 22												40-665

---

Sheet 109: N2

4090 (Cont.)																																																								02-24
CALCULATION OF HOSPITAL-BASED FQHC COST PER VISIT																																							PROVIDER CCN:						PERIOD:						WORKSHEET N-2
																																							______________							FROM				______________
																																							COMPONENT CCN:							TO				______________
																																							______________
											Wkst. N-1, col. 7, line:			Direct Cost by Practitioner from Wkst. N-1					Total Medical, Mental Health, & IOP Visits by Practitioner					Other Direct Care Costs & Pharmacy Costs (see instructions)					General Service Cost (see instructions)					Total Costs by Practitioner					Average Cost Per Visit by Practitioner
			Positions											1					2					3					4					5					6
1	Physician										23																																													1
2	Physician Services Under Agreement										24																																													2
3	Physician Assistant										25																																													3
4	Nurse Practitioner										26																																													4
5	Visiting Registered Nurse										27																																													5
6	Visiting Licensed Practical Nurse										28																																													6
7	Certified Nurse Midwife										29																																													7
8	Clinical Psychologist										30																																													8
9	Clinical Social Worker										31																																													9
9.10	Marriage and Family Therapist										31.10																																													9.10
9.11	Mental Health Counselor										31.11																																													9.11
10	Reg Dietician/Cert DSMT/MNT Educator										33																																													10
11	Totals																																																							11
12	Unit Cost Multiplier																																																							12
13	Total Cost Per Visit																																																							13
											Total Visits															Title XVIII Visits															Title XVIII Costs
											Medical Visits by Practitioner					Mental Health (Non IOP) Visits by Practitioner					IOP Visits by Practitioner					Medical Visits by Practitioner					Mental Health (Non IOP) Visits by Practitioner					IOP Visits by Practitioner					Medical Visits by Practitioner					Mental Health (Non IOP) Visits by Practitioner					IOP Visits by Practitioner
			Positions								7					8					8.01					9					10					10.01					11					12					12.01
1	Physician																																																							1
2	Physician Services Under Agreement																																																							2
3	Physician Assistant																																																							3
4	Nurse Practitioner																																																							4
5	Visiting Registered Nurse																																																							5
6	Visiting Licensed Practical Nurse																																																							6
7	Certified Nurse Midwife																																																							7
8	Clinical Psychologist																																																							8
9	Clinical Social Worker																																																							9
9.10	Marriage and Family Therapist																																																							9.10
9.11	Mental Health Counselor																																																							9.11
10	Reg Dietician/Cert DSMT/MNT Educator																																																							10
11	Totals																																																							11
12	Unit Cost Multiplier																																																							12
13	Total Cost Per Visit																																																							13
FORM CMS-2552-10 (02-2024) INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4071.1)
40-666																																																								Rev. 22

---

Sheet 110: N3

02-24				FORM CMS-2552-10				4090 (Cont.)
COMPUTATION OF HOSPITAL-BASED FQHC VACCINE COST					PROVIDER CCN:	PERIOD:	WORKSHEET N-3
					________________	FROM: __________
					COMPONENT CCN:	TO: __________
					________________
							MONOCLONAL
				PNEUMOCOCCAL	INFLUENZA	COVID-19	ANTIBODY
				VACCINES	VACCINES	VACCINES	PRODUCTS
				1	2	2.01	2.02
1	Health care staff cost (from Worksheet N-1, column 7, sum of							1
	lines 23, and 25 through 36)
2	Ratio of injection/infusion staff time to total							2
	health care staff time
3	Injection/infusion health care staff cost (line 1 x line 2)							3
4	Injections/infusions and related medical supplies cost (from Worksheet N-1,							4
	column 7, lines 47, 48, 48.10, and 48.11, respectively)
5	Direct cost of injections/infusions (line 3 + line 4)							5
6	Total direct cost of the hospital-based FQHC (from Worksheet N-1,							6
	column 7, line 100, minus Worksheet N-1, column 7, line 8)
7	Total administrative overhead (from Worksheet N-1, column 7, line 8)							7
8	Ratio of injection/infusion direct cost to total direct							8
	cost (line 5 / line 6)
9	Overhead cost - injections/infusions (line 7 x line 8)							9
10	Total cost of injections/infusions and their							10
	administration (sum of lines 5 and 9)
11	Total number of injections/infusions (from your records)							11
12	Cost per injection/infusion (line 10 / line 11)							12
13	Number of injections/infusions administered							13
	to Medicare beneficiaries
13.01	Number of COVID-19 vaccine injections/infusions							13.01
	administered to MA enrollees
14	Cost of injections/infusions and their administration							14
	costs furnished to Medicare/MA beneficiaries
	(line 12 times the sum of lines 13 and 13.01, as applicable)
15	Total cost of injections/infusions and their administration costs							15
	(sum of columns 1, 2, 2.01, and 2.02, line 10)
16	Total Medicare cost of injections/infusions and their							16
	administration costs (sum of columns 1, 2, 2.01, and 2.02, line 14)
	(transfer this amount to Worksheet N-4, line 2)
FORM CMS-2552-10 (01-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4071.2)
Rev. 22								40-667

---

Sheet 111: N4

4090 (Cont.)				FORM CMS-2552-10				02-24
CALCULATION OF HOSPITAL-BASED FQHC REIMBURSEMENT SETTLEMENT					PROVIDER CCN:	PERIOD:	WORKSHEET N-4
					________________	FROM: ___________
					COMPONENT CCN:	TO: ___________
					________________
1	FQHC PPS amount (see instructions)							1
2	Medicare cost of injections/infusions and administration (From Worksheet N-3, line 16)							2
3	Medicare advantage supplemental payments (for information only)							3
4	Total (sum of lines 1 and 2)							4
5	Primary payer payments							5
6	Total amount payable for program beneficiaries (line 4 minus line 5)							6
7	Coinsurance billed to program beneficiaries							7
8	Net Medicare reimbursement excluding bad debts (line 6 minus line 7)							8
9	Allowable bad debts (see instructions)							9
10	Adjusted reimbursable bad debts (see instructions)							10
11	Allowable bad debts for dual eligible beneficiaries (see instructions)							11
12	Subtotal (line 8 plus line 10)							12
13	Other adjustments (specify) (see instructions)							13
13.99	Demonstration payment adjustment amount before sequestration							13.99
14	Amount due hospital-based FQHC prior to the sequestration adjustment (see instructions)							14
15	Sequestration adjustment (see instructions)							15
15.25	Sequestration for non-claims based amounts (see instructions)							15.25
16	Amount due hospital-based FQHC after sequestration adjustment (see instructions)							16
16.01	Demonstration payment adjustment amount after sequestration							16.01
17	Interim payments (from Worksheet N-5, col. 2, line 4)							17
18	Tentative settlement (for contractor use only)							18
19	Balance due hospital-based FQHC/program (line 16 minus lines 16.01, 17 and 18)							19
20	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2							20
FORM CMS-2552-10 (02-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4071.3)
40-668								Rev. 22

---

Sheet 112: N5

10-18					FORM CMS-2552-10						4090 (Cont.)
ANALYSIS OF PAYMENTS TO HOSPITAL-BASED FQHC FOR SERVICES RENDERED							PROVIDER CCN:		PERIOD:	WORKSHEET N-5
							________________		FROM: ____________
							COMPONENT CCN:		TO: ___________
							________________
									Part B
									mm/dd/yyyy	Amount
	Description								1	2
1	Total interim payments paid to hospital-based FQHC										1
2	Interim payments payable on individual bills, either submitted or to be submitted to the contractor										2
	for services rendered in the cost reporting period. If none, write "NONE" or enter a zero
3	List separately each retroactive							.01			3.01
	lump sum adjustment amount based							.02			3.02
	on subsequent revision of the					Program to		.03			3.03
	interim rate for the cost reporting period.					Provider		.04			3.04
	Also show date of each payment.							.05			3.05
	If none, write "NONE" or enter a zero. (1)							.50			3.5
								.51			3.51
						Provider to		.52			3.52
						Program		.53			3.53
								.54			3.54
	Subtotal (sum of lines 3.01 through 3.49 minus sum of lines 3.50 through 3.98)							.99			3.99
4	Total interim payments (sum of lines 1, 2, and 3.99)										4
	(transfer to Wkst. N-4, line 17)
	TO BE COMPLETED BY CONTRACTOR
5	List separately each tentative settlement					Program to		.01			5.01
	payment after desk review. Also show					Provider		.02			5.02
	date of each payment.							.03			5.03
	If none, write "NONE" or enter a zero. (1)							.50			5.5
						Provider to		.51			5.51
						Program		.52			5.52
	Subtotal (sum of lines 5.01 through 5.49 minus sum of lines 5.50 through 5.98)							.99			5.99
6	Determine net settlement amount (balance					Program to provider		.01			6.01
	due) based on the cost report (1)					Provider to program		.02			6.02
7	Total Medicare program liability (see instructions)										7
(1)	On lines 3, 5, and 6, where an amount is due hospital-based FQHC to program, show the amount and date on which the hospital-based FQHC agrees to the amount of repayment
	even though total repayment is not accomplished until a later date.
FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4071.4)
Rev. 15											40-669

---

Sheet 113: O

4090 (Cont.)					FORM CMS-2552-10						10-18
ANALYSIS OF HOSPITAL-BASED HOSPICE COSTS								PROVIDER CCN:	PERIOD:	WORKSHEET O
								________________	FROM ___________
								HOSPICE CCN:	TO ___________
								________________
						SUBTOTAL
						( col. 1 plus	RECLASSI-		ADJUST-	TOTAL
				SALARIES	OTHER	col. 2 )	FICATIONS	SUBTOTAL	MENTS	( col. 5 ± col. 6 )
				1	2	3	4	5	6	7
GENERAL SERVICE COST CENTERS
1	Cap Rel Costs-Bldg & Fixt*										1
2	Cap Rel Costs-Mvble Equip*										2
3	Employee Benefits Department*										3
4	Administrative & General *										4
5	Plant Operation and Maintenance*										5
6	Laundry & Linen Service*										6
7	Housekeeping*										7
8	Dietary*										8
9	Nursing Administration*										9
10	Routine Medical Supplies*										10
11	Medical Records*										11
12	Staff Transportation*										12
13	Volunteer Service Coordination*										13
14	Pharmacy*										14
15	Physician Administrative Services*										15
16	Other General Service*										16
17	Patient/Residential Care Services										17
DIRECT PATIENT CARE SERVICE COST CENTERS
25	Inpatient Care-Contracted**										25
26	Physician Services**										26
27	Nurse Practitioner**										27
28	Registered Nurse**										28
29	LPN/LVN**										29
30	Physical Therapy**										30
31	Occupational Therapy**										31
32	Speech/ Language Pathology**										32
33	Medical Social Services**										33
34	Spiritual Counseling**										34
35	Dietary Counseling**										35
36	Counseling - Other**										36
37	Hospice Aide and Homemaker Services**										37
38	Durable Medical Equipment/Oxygen**										38
39	Patient Transportation**										39
*	Transfer the amounts in column 7 to Wkst. O-5, col. 1, line as appropriate.
**	See instructions. Do not transfer the amounts in col. 7 to Wkst. O-5.
FORM CMS-2552-10 (10-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072)
40-670											Rev. 15
03-18					FORM CMS-2552-10						4090 (Cont.)
ANALYSIS OF HOSPITAL-BASED HOSPICE COSTS								PROVIDER CCN:	PERIOD:	WORKSHEET O
								________________	FROM ___________
								HOSPICE CCN:	TO ___________
								________________
						SUBTOTAL
						( col. 1 plus	RECLASSI-		ADJUST-	TOTAL
				SALARIES	OTHER	col. 2 )	FICATIONS	SUBTOTAL	MENTS	( col. 5 ± col. 6 )
				1	2	3	4	5	6	7
DIRECT PATIENT CARE SERVICE COST CENTERS (Cont.)
40	Imaging Services**										40
41	Labs and Diagnostics**										41
42	Medical Supplies-Non-routine**										42
42.50	Drugs Charged to Patients**										42.50
43	Outpatient Services**										43
44	Palliative Radiation Therapy**										44
45	Palliative Chemotherapy**										45
46	Other Patient Care Services**										46
NONREIMBURSABLE COST CENTERS
60	Bereavement Program *										60
61	Volunteer Program *										61
62	Fundraising*										62
63	Hospice/Palliative Medicine Fellows*										63
64	Palliative Care Program*										64
65	Other Physician Services*										65
66	Residential Care *										66
67	Advertising*										67
68	Telehealth/Telemonitoring*										68
69	Thrift Store*										69
70	Nursing Facility Room & Board*										70
71	Other Nonreimbursable*										71
100	Total										100
*	Transfer the amounts in column 7 to Wkst. O-5, col. 1, line as appropriate.
**	See instructions. Do not transfer the amounts in col. 7 to Wkst. O-5.
FORM CMS-2552-10 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072)
Rev. 14											40-671

---

Sheet 114: O1

4090 (Cont.)					FORM CMS-2552-10						03-18
ANALYSIS OF HOSPITAL-BASED HOSPICE COSTS								PROVIDER CCN:	PERIOD:	WORKSHEET O-1
HOSPICE CONTINUOUS HOME CARE								________________	FROM ___________
								HOSPICE CCN:	TO ____________
								________________
						SUBTOTAL
						( col. 1 plus	RECLASSI-		ADJUST-	TOTAL
				SALARIES	OTHER	col. 2 )	FICATIONS	SUBTOTAL	MENTS	( col. 5 ± col. 6 )
				1	2	3	4	5	6	7
DIRECT PATIENT CARE SERVICE COST CENTERS
25	Inpatient Care - Contracted										25
26	Physician Services										26
27	Nurse Practitioner										27
28	Registered Nurse										28
29	LPN/LVN										29
30	Physical Therapy										30
31	Occupational Therapy										31
32	Speech/ Language Pathology										32
33	Medical Social Services										33
34	Spiritual Counseling										34
35	Dietary Counseling										35
36	Counseling - Other										36
37	Hospice Aide and Homemaker Services										37
38	Durable Medical Equipment/Oxygen										38
39	Patient Transportation										39
40	Imaging Services										40
41	Labs and Diagnostics										41
42	Medical Supplies-Non-routine										42
42.50	Drugs Charged to Patients										42.50
43	Outpatient Services										43
44	Palliative Radiation Therapy										44
45	Palliative Chemotherapy										45
46	Other Patient Care Svc										46
100	Total *										100
*	Transfer the amount in column 7 to Wkst. O-5, column 1, line 50
FORM CMS-2552-10 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.1)
40-672											Rev. 14

---

Sheet 115: O2

10-18					FORM CMS-2552-10						4090 (Cont.)
ANALYSIS OF HOSPITAL-BASED HOSPICE COSTS								PROVIDER CCN:	PERIOD:	WORKSHEET O-2
HOSPICE ROUTINE HOME CARE								________________	FROM ___________
								HOSPICE CCN:	TO ____________
								________________
						SUBTOTAL
						( col. 1 plus	RECLASSI-		ADJUST-	TOTAL
				SALARIES	OTHER	col. 2 )	FICATIONS	SUBTOTAL	MENTS	( col. 5 ± col. 6 )
				1	2	3	4	5	6	7
DIRECT PATIENT CARE SERVICE COST CENTERS
25	Inpatient Care - Contracted										25
26	Physician Services										26
27	Nurse Practitioner										27
28	Registered Nurse										28
29	LPN/LVN										29
30	Physical Therapy										30
31	Occupational Therapy										31
32	Speech/ Language Pathology										32
33	Medical Social Services										33
34	Spiritual Counseling										34
35	Dietary Counseling										35
36	Counseling - Other										36
37	Hospice Aide and Homemaker Services										37
38	Durable Medical Equipment/Oxygen										38
39	Patient Transportation										39
40	Imaging Services										40
41	Labs and Diagnostics										41
42	Medical Supplies-Non-routine										42
42.50	Drugs Charged to Patients										42.50
43	Outpatient Services										43
44	Palliative Radiation Therapy										44
45	Palliative Chemotherapy										45
46	Other Patient Care Svc										46
100	Total *										100
*	Transfer the amount in column 7 to Wkst. O-5, column 1, line 51
FORM CMS-2552-10 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.1)
Rev. 15											40-673

---

Sheet 116: O3

4090 (Cont.)					FORM CMS-2552-10						10-18
ANALYSIS OF HOSPITAL-BASED HOSPICE COSTS								PROVIDER CCN:	PERIOD:	WORKSHEET O-3
HOSPICE INPATIENT RESPITE CARE								________________	FROM ___________
								HOSPICE CCN:	TO ____________
								________________
						SUBTOTAL
						( col. 1 plus	RECLASSI-		ADJUST-	TOTAL
				SALARIES	OTHER	col. 2 )	FICATIONS	SUBTOTAL	MENTS	( col. 5 ± col. 6 )
				1	2	3	4	5	6	7
DIRECT PATIENT CARE SERVICE COST CENTERS
25	Inpatient Care - Contracted										25
26	Physician Services										26
27	Nurse Practitioner										27
28	Registered Nurse										28
29	LPN/LVN										29
30	Physical Therapy										30
31	Occupational Therapy										31
32	Speech/ Language Pathology										32
33	Medical Social Services										33
34	Spiritual Counseling										34
35	Dietary Counseling										35
36	Counseling - Other										36
37	Hospice Aide and Homemaker Services										37
38	Durable Medical Equipment/Oxygen										38
39	Patient Transportation										39
40	Imaging Services										40
41	Labs and Diagnostics										41
42	Medical Supplies-Non-routine										42
42.50	Drugs Charged to Patients										42.50
43	Outpatient Services										43
44	Palliative Radiation Therapy										44
45	Palliative Chemotherapy										45
46	Other Patient Care Svc										46
100	Total *										100
*	Transfer the amount in column 7 to Wkst. O-5, column 1, line 52
FORM CMS-2552-10 (10-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.1)
40-674											Rev. 15

---

Sheet 117: O4

10-18					FORM CMS-2552-10						4090 (Cont.)
ANALYSIS OF HOSPITAL-BASED HOSPICE COSTS								PROVIDER CCN:	PERIOD:	WORKSHEET O-4
HOSPICE GENERAL INPATIENT CARE								________________	FROM ___________
								HOSPICE CCN:	TO ____________
								________________
						SUBTOTAL
						( col. 1 plus	RECLASSI-		ADJUST-	TOTAL
				SALARIES	OTHER	col. 2 )	FICATIONS	SUBTOTAL	MENTS	( col. 5 ± col. 6 )
				1	2	3	4	5	6	7
DIRECT PATIENT CARE SERVICE COST CENTERS
25	Inpatient Care - Contracted										25
26	Physician Services										26
27	Nurse Practitioner										27
28	Registered Nurse										28
29	LPN/LVN										29
30	Physical Therapy										30
31	Occupational Therapy										31
32	Speech/ Language Pathology										32
33	Medical Social Services										33
34	Spiritual Counseling										34
35	Dietary Counseling										35
36	Counseling - Other										36
37	Hospice Aide and Homemaker Services										37
38	Durable Medical Equipment/Oxygen										38
39	Patient Transportation										39
40	Imaging Services										40
41	Labs and Diagnostics										41
42	Medical Supplies-Non-routine										42
42.50	Drugs Charged to Patients										42.50
43	Outpatient Services										43
44	Palliative Radiation Therapy										44
45	Palliative Chemotherapy										45
46	Other Patient Care Svc										46
100	Total *										100
*	Transfer the amount in column 7 to Wkst. O-5, column 1, line 53
FORM CMS-2552-10 (10-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.1)
Rev. 15											40-675

---

Sheet 118: O5

4090 (Cont.)			FORM CMS-2552-10				10-18
COST ALLOCATION - DETERMINATION OF HOSPITAL-BASED HOSPICE				PROVIDER CCN:	PERIOD:	WORKSHEET O-5
NET EXPENSES FOR ALLOCATION				________________	FROM ___________
				HOSPICE CCN:	TO ____________
				________________
					GENERAL
				HOSPICE	SERVICE
				DIRECT	EXPENSES	TOTAL
				EXPENSES	FROM WKST B, PART I	EXPENSES
				( see instructions )	( see instructions )	( sum of cols. 1 + 2 )
	Descriptions			1	2	3
GENERAL SERVICE COST CENTERS
1	Cap Rel Costs-Bldg & Fixt						1
2	Cap Rel Costs-Mvble Equip						2
3	Employee Benefits						3
4	Administrative & General						4
5	Plant Operation and Maintenance						5
6	Laundry & Linen Service						6
7	Housekeeping						7
8	Dietary						8
9	Nursing Administration						9
10	Routine Medical Supplies						10
11	Medical Records						11
12	Staff Transportation						12
13	Volunteer Service Coordination						13
14	Pharmacy						14
15	Physician Administrative Services						15
16	Other General Service						16
17	Patient/Residential Care Services						17
LEVEL OF CARE
50	Hospice Continuous Home Care						50
51	Hospice Routine Home Care						51
52	Hospice Inpatient Respite Care						52
53	Hospice General Inpatient Care						53
NONREIMBURSABLE COST CENTERS
60	Bereavement Program						60
61	Volunteer Program						61
62	Fundraising						62
63	Hospice/Palliative Medicine Fellows						63
64	Palliative Care Program						64
65	Other Physician Services						65
66	Residential Care						66
67	Advertising						67
68	Telehealth/Telemonitoring						68
69	Thrift Store						69
70	Nursing Facility Room & Board						70
71	Other Nonreimbursable						71
99	Negative Cost Center						99
100	Total						100
FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4072.2)
40-676							Rev. 15

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Sheet 119: O6I

11-17							FORM CMS-2552-10							4090 (Cont.)
COST ALLOCATION - HOSPITAL-BASED HOSPICE GENERAL SERVICE COSTS									PROVIDER CCN:		PERIOD:		WORKSHEET O-6
									________________		FROM ___________		PART I
									HOSPICE CCN:		TO ____________
									________________
					CAP REL	CAP REL	EMPLOYEE		ADMINIS-	PLANT	LAUNDRY	HOUSE-	DIETARY
				TOTAL	BLDG	MVBLE	BENEFITS		TRATIVE &	OP &	& LINEN	KEEPING
				EXPENSES	& FIX	EQUIP	DEPARTMENT	SUBTOTAL	GENERAL	MAINT
	Descriptions			0	1	2	3	3A	4	5	6	7	8
GENERAL SERVICE COST CENTERS
1	Cap Rel Costs-Bldg & Fixt													1
2	Cap Rel Costs-Mvble Equip													2
3	Employee Benefits													3
4	Administrative & General													4
5	Plant Operation and Maintenance													5
6	Laundry & Linen Service													6
7	Housekeeping													7
8	Dietary													8
9	Nursing Administration													9
10	Routine Medical Supplies													10
11	Medical Records													11
12	Staff Transportation													12
13	Volunteer Service Coordination													13
14	Pharmacy													14
15	Physician Administrative Services													15
16	Other General Service													16
17	Patient/Residential Care Services													17
LEVEL OF CARE
50	Hospice Continuous Home Care													50
51	Hospice Routine Home Care													51
52	Hospice Inpatient Respite Care													52
53	Hospice General Inpatient Care													53
NONREIMBURSABLE COST CENTERS
60	Bereavement Program													60
61	Volunteer Program													61
62	Fundraising													62
63	Hospice/Palliative Medicine Fellows													63
64	Palliative Care Program													64
65	Other Physician Services													65
66	Residential Care													66
67	Advertising													67
68	Telehealth/Telemonitoring													68
69	Thrift Store													69
70	Nursing Facility Room & Board													70
71	Other Nonreimbursable													71
99	Negative Cost Center													99
100	Total													100
FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.3)
Rev. 12														40-677
4090 (Cont.)							FORM CMS-2552-10							11-17
COST ALLOCATION - HOSPITAL-BASED HOSPICE GENERAL SERVICE COSTS									PROVIDER CCN:		PERIOD:		WORKSHEET O-6
									________________		FROM ___________		PART I
									HOSPICE CCN:		TO ____________
									________________
				NURSING	ROUTINE	MEDICAL	STAFF	VOLUNTEER	PHARMACY	PHYSICIAN	OTHER	PATIENT /	TOTAL
				ADMINIS-	MEDICAL	RECORDS	TRANS-	SVC COOR-		ADMIN	GENERAL	RESIDENT
				TRATION	SUPPLIES		PORTATION	DINATION		SERVICES	SERVICE	CARE SVCS
	Descriptions			9	10	11	12	13	14	15	16	17	18
GENERAL SERVICE COST CENTERS
1	Cap Rel Costs-Bldg & Fixt													1
2	Cap Rel Costs-Mvble Equip													2
3	Employee Benefits													3
4	Administrative & General													4
5	Plant Operation and Maintenance													5
6	Laundry & Linen Service													6
7	Housekeeping													7
8	Dietary													8
9	Nursing Administration													9
10	Routine Medical Supplies													10
11	Medical Records													11
12	Staff Transportation													12
13	Volunteer Service Coordination													13
14	Pharmacy													14
15	Physician Administrative Services													15
16	Other General Service (specify)													16
17	Patient/Residential Care Services													17
LEVEL OF CARE
50	Continuous Home Care													50
51	Routine Home Care													51
52	Inpatient Respite Care													52
53	General Inpatient Care													53
NONREIMBURSABLE COST CENTERS
60	Bereavement Program													60
61	Volunteer Program													61
62	Fundraising													62
63	Hospice/Palliative Medicine Fellows													63
64	Palliative Care Program													64
65	Other Physician Services													65
66	Residential Care													66
67	Advertising													67
68	Telehealth/Telemonitoring													68
69	Thrift Store													69
70	Nursing Facility Room & Board													70
71	Other Nonreimbursable (specify)													71
99	Negative Cost Center													99
100	Total													100
FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.3)
40-678														Rev. 12

---

Sheet 120: O6II

11-17							FORM CMS-2552-10							4090 (Cont.)
COST ALLOCATION - HOSPITAL-BASED HOSPICE GENERAL SERVICE COSTS STATISTICAL BASIS									PROVIDER CCN:		PERIOD:		WORKSHEET O-6
									________________		FROM ___________		PART II
									HOSPICE CCN:		TO ____________
									________________
					CAP REL	CAP REL	EMPLOYEE		ADMINIS-	PLANT	LAUNDRY	HOUSE-	DIETARY
					BLDG	MVBLE	BENEFITS		TRATIVE &	OP &	& LINEN	KEEPING
					& FIX	EQUIP	DEPARTMENT		GENERAL	MAINT
					( Square	( Dollar	( Gross	RECONCIL-	( Accum.	( Square	( In-Facil-	( Square	( In-Facil-
					Feet )	Value )	Salaries )	IATION	Cost )	Feet )	ity Days )	Feet )	ity Days )
	Cost Center Descriptions				1	2	3	4A	4	5	6	7	8
GENERAL SERVICE COST CENTERS
1	Cap Rel Costs-Bldg & Fixt													1
2	Cap Rel Costs-Mvble Equip													2
3	Employee Benefits													3
4	Administrative & General													4
5	Plant Operation and Maintenance													5
6	Laundry & Linen Service													6
7	Housekeeping													7
8	Dietary													8
9	Nursing Administration													9
10	Routine Medical Supplies													10
11	Medical Records													11
12	Staff Transportation													12
13	Volunteer Service Coordination													13
14	Pharmacy													14
15	Physician Administrative Services													15
16	Other General Service													16
17	Patient/Residential Care Services													17
LEVEL OF CARE
50	Hospice Continuous Home Care													50
51	Hospice Routine Home Care													51
52	Hospice Inpatient Respite Care													52
53	Hospice General Inpatient Care													53
NONREIMBURSABLE COST CENTERS
60	Bereavement Program													60
61	Volunteer Program													61
62	Fundraising													62
63	Hospice/Palliative Medicine Fellows													63
64	Palliative Care Program													64
65	Other Physician Services													65
66	Residential Care													66
67	Advertising													67
68	Telehealth/Telemonitoring													68
69	Thrift Store													69
70	Nursing Facility Room & Board													70
71	Other Nonreimbursable													71
99	Negative Cost Center													99
100	Cost to be allocated (per Wkst. O-6, Part I)													100
101	Unit cost multiplier													101
FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.3)
Rev. 12														40-679
4090 (Cont.)							FORM CMS-2552-10							11-17
COST ALLOCATION - HOSPITAL-BASED HOSPICE GENERAL SERVICE COSTS STATISTICAL BASIS									PROVIDER CCN:		PERIOD:		WORKSHEET O-6
									________________		FROM ___________		PART II
									HOSPICE CCN:		TO ____________
									________________
				NURSING	ROUTINE	MEDICAL	STAFF	VOLUNTEER	PHARMACY	PHYSICIAN	OTHER	PATIENT /
				ADMINIS-	MEDICAL	RECORDS	TRANS-	SVC COOR-		ADMIN	GENERAL	RESIDENT
				TRATION	SUPPLIES		PORTATION	DINATION		SERVICES	SERVICE	CARE SVCS
				( Direct	( Patient	( Patient		( Hours of		( Patient	( Specify	( In-Facil-
				Nurs. Hrs. )	Days )	Days )	( Mileage )	Service )	( Charges )	Days )	Basis )	ity Days )	TOTAL
	Cost Center Descriptions			9	10	11	12	13	14	15	16	17	18
GENERAL SERVICE COST CENTERS
1	Cap Rel Costs-Bldg & Fixt													1
2	Cap Rel Costs-Mvble Equip													2
3	Employee Benefits													3
4	Administrative & General													4
5	Plant Operation and Maintenance													5
6	Laundry & Linen Service													6
7	Housekeeping													7
8	Dietary													8
9	Nursing Administration													9
10	Routine Medical Supplies													10
11	Medical Records													11
12	Staff Transportation													12
13	Volunteer Service Coordination													13
14	Pharmacy													14
15	Physician Administrative Services													15
16	Other General Service													16
17	Patient/Residential Care Services													17
LEVEL OF CARE
50	Continuous Home Care													50
51	Routine Home Care													51
52	Inpatient Respite Care													52
53	General Inpatient Care													53
NONREIMBURSABLE COST CENTERS
60	Bereavement Program													60
61	Volunteer Program													61
62	Fundraising													62
63	Hospice/Palliative Medicine Fellows													63
64	Palliative Care Program													64
65	Other Physician Services													65
66	Residential Care													66
67	Advertising													67
68	Telehealth/Telemonitoring													68
69	Thrift Store													69
70	Nursing Facility Room & Board													70
71	Other Nonreimbursable													71
99	Negative Cost Center													99
100	Cost to be allocated (per Wkst. O-6, Part I)													100
101	Unit cost multiplier													101
FORM CMS-2552-10 (11-2017) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.3)
40-680														Rev. 12

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Sheet 121: O7

11-16						FORM CMS-2552-10							4090 (Cont.)
APPORTIONMENT OF HOSPITAL-BASED HOSPICE SHARED SERVICE COSTS BY LEVEL OF CARE										PROVIDER CCN:	PERIOD:	WORKSHEET O-7
										________________	FROM ___________
										HOSPICE CCN:	TO ____________
										________________
			Wkst. C,	Cost to	Charges by LOC (from Provider Records)				Shared Service Costs by LOC
			Pt. I, col. 9,	Charge					HCHC	HRHC	HIRC	HGIP
			line	Ratio	HCHC	HRHC	HIRC	HGIP	( col. 1 x col. 2 )	( col. 1 x col. 3 )	( col. 1 x col. 4 )	( col. 1 x col. 5 )
	Cost Center Descriptions		0	1	2	3	4	5	6	7	8	9
	ANCILLARY SERVICE COST CENTERS
1	Physical Therapy		66										1
2	Occupational Therapy		67										2
3	Speech/ Language Pathology		68										3
4	Drugs, Biological and Infusion Therapy		73										4
5	Durable Medical Equipment/Oxygen		96										5
6	Labs and Diagnostics		60										6
7	Medical Supplies		71										7
8	Outpatient Services (including E/R Dept.)		93										8
9	Radiation Therapy		55										9
10	Other		76										10
11	Totals (sum of lines 1 through 10)												11
FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4072.4)
Rev. 10													40-681

---

Sheet 122: O8

4090 (Cont.)				FORM CMS-2552-10				11-16
CALCULATION OF HOSPITAL-BASED HOSPICE PER DIEM COST					PROVIDER CCN:	PERIOD:	WORKSHEET O-8
					________________	FROM ___________
					HOSPICE CCN:	TO ___________
					________________
					TITLE XVIII	TITLE XIX
					MEDICARE	MEDICAID	TOTAL
					1	2	3
HOSPICE CONTINUOUS HOME CARE
1	Total cost (Wkst. O-6, Part I, col 18, line 50 plus Wkst. O-7, col. 6, line 11)							1
2	Total unduplicated days (Wkst. S-9, col. 4, line 10)							2
3	Total average cost per diem (line 1 divided by line 2)							3
4	Unduplicated program days (Wkst. S-9, col. as appropriate, line 10)							4
5	Program cost (line 3 times line 4)							5
HOSPICE ROUTINE HOME CARE
6	Total cost (Wkst. O-6, Part I, col. 18, line 51 plus Wkst. O-7, col. 7, line 11)							6
7	Total unduplicated days (Wkst. S-9, col. 4, line 11)							7
8	Total average cost per diem (line 6 divided by line 7)							8
9	Unduplicated program days (Wkst. S-9, col. as appropriate, line 11)							9
10	Program cost (line 8 times line 9)							10
HOSPICE INPATIENT RESPITE CARE
11	Total cost (Wkst. O-6, Part I, col. 18, line 52 plus Wkst. O-7, col. 8, line 11)							11
12	Total unduplicated days (Wkst. S-9, col. 4, line 12)							12
13	Total average cost per diem (line 11 divided by line 12)							13
14	Unduplicated program days (Wkst. S-9, col. as appropriate, line 12)							14
15	Program cost (line 13 times line 14)							15
HOSPICE GENERAL INPATIENT CARE
16	Total cost (Wkst. O-6, Part I, col. 18, line 53 plus Wkst. O-7, col. 9, line 11)							16
17	Total unduplicated days (Wkst. S-9, col. 4, line 13)							17
18	Total average cost per diem (line 16 divided by line 17)							18
19	Unduplicated program days (Wkst. S-9, col. as appropriate, line 13)							19
20	Program cost (line 18 times line 19)							20
TOTAL HOSPICE CARE
21	Total cost (sum of line 1 + line 6 + line 11 + line 16)							21
22	Total unduplicated days (Wkst. S-9, col. 4, line 14)							22
23	Average cost per diem (line 21 divided by line 22)							23
FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4072.5)
40-682								Rev. 10