Cost Report Preparation and Documentation 101

(1)

Cost Report Preparation and

Documentation 101

“A How-To Guide to Workpaper and Supporting

Documentation Preparation”

Documentation Preparation

(2)

Agenda

• Medicare Reimbursement Methodologies

• What is a Cost Report and Why is it Important

• Filing Guidelines

• Basic Flow of a Cost Report

p

• Most Common Data Used in a Cost Report

• Basic Data Rules and Reconciliations

(3)

Agenda

• Review of Cost Report Pages Their Data and the

• Review of Cost Report Pages, Their Data and the

Workpapers Needed to Support Them:

– WS A (Summary Trial Balance of Expenses)

(

y

)

– WS A-6 (Reclassifications)

– WS A-8 (Adjustments)

– WS B-1 (Statistical Allocation of Overhead Expenses)

– WS C (Patient Treatment Revenues – Total Charges)

– Settlement (Charges and Data)

S S (

Q

)

– WS S-2 (Provider Questionnaire)

– WS S-3 Part 1(Census Data), WS S-3 Part 2 (Wage Index)

– WS S-10 (Uncompensated Care)

(4)

Agenda

• Documentation is the Key!

• Electronic vs. Manual Data Manipulation and Analysis

• Special Issues

– Critical Access

– Home Office Cost Statement

– Skilled Nursing Cost Report

– Home Health Cost Report

(5)

Agenda

• Specialty Pages on the Cost Report

– WS A-8-1 (Related Parties)

WS A 8 2 (Ph i i C

ti )

– WS A-8-2 (Physician Compensation)

– WS H Series (Home Health Agencies)

– WS I Series (Renal Dialysis)

– WS M Series (RHC, FQHC)

– WS J Series (CMHC)

• Wrap Up

(6)

Medicare Reimbursement Methodologies

Medicare ProgramPartA

Medicare ProgramPartB

Physician Services

Medicare Program Part A

IP Services

Hospital Based Outpatient Services

Medicare Program Part B

Clinic Services

IP Ancillary Services

Outpatient Services

Onsite/Offsite Clinics Clinics and MD Offices

Medicare Part B Carrier

Medicare Part A intermediary

(7)

Medicare Reimbursement Methodologies

• Reimbursement Mechanisms for Hospital Units/Entities

• IP Acute Care – DRG (Diagnostic Related Groups)

• Hospital Based Outpatient Services – APC (Ambulatory Payment Categories)

• Hospital Based Clinics – APC or Cost Reimbursement (Based on Designation)

• Skilled Nursing Facility/Unit – RUGS (Resource Utilization Groups)

• IP Rehab Services – IRFPPS (IP Rehab Facility Prospective Payment System)

IP Rehab Services IRFPPS (IP Rehab Facility Prospective Payment System)

• IP Psychiatric Services – PsychPPS (Psychiatric Prospective Payment

System)

• Home Health Agency – HHAPPS (Home Health Prospective Payment System)

(8)

Medicare Reimbursement Methodologies

• Reimbursement Mechanisms for “Special Services”

• Reimbursement Mechanisms for Special Services

• IME/GME (Medical Education) – FTEs

• Disproportionate Share Hospitals (DSH) – Indigency Percentage

Disproportionate Share Hospitals (DSH) Indigency Percentage

• Medicare Bad Debs – Portion of the Un-paid Coinsurance and

Deductibles

(9)

What is a Cost Report and why is it

p

y

important?

• The cost report is a financial report that identifies

the cost and charges related to healthcare

treatment activities

• Cost Reports Impact Reimbursement!

– Today

– Future Reimbursement

• Congress/CMS rate setting and policy decisions are

based on data in the cost reports and MedPar.

(10)

Filing Guidelines

• Medicare cost reports are due within 150 Days from

the FYE of the facility (Post Marked)

El t

i t t

AND

ti

• Electronic cost report AND supporting

documentation are submitted

• State reports (Medicaid) vary from state to state, but

generally due at same time as Medicare report

(11)

2552 96 vs 2552 10

2552-96 vs. 2552-10

• The new hospital cost report form 2552 10 must be

• The new hospital cost report form 2552-10 must be

used for all cost reports with FYE of 4-30-2011 and

later

later.

• The class will focus on the use of the 2552-10

• Changes between 2552-96 and 2552-10

– Grouping of Departments on WS A is the main change

– Settlement Pages (E series) were “de cluttered”

– Minor Changes on various pages (S-2, S-3, etc.)

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(12)

Basic Flow of a Cost Report

• WS A Series – general ledger or trial balance information by functional department

g

y

p

• WS B Series – allocation of overhead costs to patient treatment and other operating

departments

• WS C Series – revenue by patient treatment department to determine the cost/charge ratio

(for every dollar billed how much did it cost to provide the service to the patient)

• WS D Series – determine the cost of treating the Medicare/MediCaid patients by

reimbursement mechanism

• WS E Series – determine the due to/from Medicare Program based on the reimbursement

mechanism/cost/interim payments

• WS G Series – Financial Statements

WS S S i t ti ti l i f

ti

d

i d

(13)

Most Commonly Used Data in a Cost Report

• General Ledger (Summary Trial Balance)

• Payroll Register

• Chargemaster with Volumes (Volume Report)

• Medicare Charges by Department and Revenue Code

(Revenue and Usage)

• Provider Statistical Report (PSR)

• Patient Census (Days and Discharges)

• Allocation Statistics

S

ifi P

D t

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(14)

Basic Data Rules

Every data file has its unique issues and reasons for

being used in the cost report. As a universal rule, the

general ledger is the “Parent” data source and all

general ledger is the Parent data source and all

others should agree to or relate to the general ledger.

–Accounts/Departments/Accounting Units/Cost Centers/etc

–Accounts/Departments/Accounting Units/Cost Centers/etc.

–Cost Report Line Number Groupings

–Sub-Accounts/Object Codes/etc.

–Raw data vs. Processed data

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The General Ledger

The General Ledger is the most important data that is

included in the cost report.

Structure of a General Ledger

–Structure of a General Ledger

–Account vs. Sub-Account

•Ranges of data

g

•Mix and Match data

–How does the GL break down?

A

t d

Li biliti

•Assets and Liabilities

•Revenues

•Expenses

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(16)

General Ledger

Show a General Ledger in Excel and review

– Account Structure

S b A

t St t

– Sub-Account Structure

– Cut up GL to show

A

t d

Li biliti

• Assets and Liabilities

• Revenues

• Expenses

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Reconciliations

Reconciliations serve two purposes:

1. Identify that all of the revenues/expenses (data) have been

accounted for to an outside source.

–

General Ledger to Income Statement

C t R

t t I

St t

t

–

Cost Report to Income Statement

–

Other Operating/Non-Operating Revenue/Expense

2. Validate that two different data sources generate the same data in

different formats and can be used as surrogates.

G

l L d

R

V l

R

t

–

General Ledger Revenues vs. Volume Report

–

General Ledger Salaries vs. Payroll Report

–

General Ledger 3

rd

_{Party Revenues to Revenue & Usage}

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General Ledger to Income Statement

(19)

Cost Report to Income Statement

p

Reconciliation

(20)

Other Operating/Non-Operating Rev/Exp

p

g

p

g

p

Reconciliation

(21)

General Ledger vs. Volume Report

g

p

Comparison

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WS A (Expenses by Department)

The purpose of WS A is to identify all Direct Expenses (Salary vs. Other)

i

d t th f ilit b d

t

t i t

t

t li

(“C t

incurred at the facility by department into cost report lines (“Cost

Centers”).

Criteria for Independent Cost Centers

– Standard (i.e., preprinted) CMS line numbers and cost center descriptions

Standard (i.e., preprinted) CMS line numbers and cost center descriptions

cannot be changed. If you need to use additional or different cost center

descriptions, add additional lines to the cost report. Where an added cost center

description bears a logical relationship to a standard line description, the added

label must be inserted immediately after the related standard line. If additional

(23)

4090 (Cont.) FORM CMS-2552-10 12-10

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES P R OVIDER NO.: P ER IOD: WOR KS HEET A

F R OM ____________

________________ 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 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 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 Schoolg 20

21 02100 Intern & Res. Service-Salary & Fringes (Approved) 21

22 02200 Intern & Res. Other Program Costs (Approved) 22

23 02300 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 04200 Subprovider (specify) 42

43 04300 Nursery 43

44 04400 Skilled Nursing Facility 44

45 04500 Nursing Facility 45

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46 04600 Other Long Term Care 46

F OR M C M S -2552-10 (12/2010) (INS TR UC TIONS F OR THIS WOR KS HEET AR E P UB LIS HED IN C M S P UB . 15-II, S EC TION 4013)

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12-10 FORM CMS-2552-10 4090 (Cont.)

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES PROVIDER NO.: 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 Laboratoryy 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 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 76 Other Ancillary (specify) 76

(25)

12-10 FORM CMS-2552-10 4090 (Cont.)

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES

P R OVIDER NO.: P ER IOD: WOR KS HEET A

F R OM ____________ 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 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 Oth

O

A

i iti

(

if )

112

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 1-117)

118 NONREIMBURSABLE COST CENTERS

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 118-199)

‐ 0 ‐

200 Essential Consulting LLC

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(26)

WS A

Cost report line numbers should be grouped based on

the account:

Overhead Departments (1 23)

– Overhead Departments (1-23)

– Routine Services (30-46)

– Ancillary Services (50-76)

Ancillary Services (50 76)

– Outpatient Services (88-93)

– Other Reimbursable Services (94-101)

– Special Purpose Cost Centers (105-118)

(27)

WS A

Salary vs Other Expenses should be determined

Salary vs. Other Expenses should be determined

based on the Sub-Account.

H h ld th f ll i b t t d?

How should the following be treated?

• Contract Labor?

• Bonuses?

• Stand-By/On Call?

•Training/Orientation?

Training/Orientation?

•Non-Operating Expense (i.e. Joint Ventures, Minority Interests)

(28)

WS A

Steps to process WS A Data:

1. Main Data is the General Ledger

2 K

Y

D t

2. Know Your Data

1. Review Accounts

2 Review Sub Accounts

2. Review Sub-Accounts

3. New Accounts and Sub-Accounts

3 Groupings

3. Groupings

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WS A 6 (Reclassifications)

WS A-6 (Reclassifications)

The purpose of the WS A 6 Reclassifications is to

The purpose of the WS A-6 Reclassifications is to

move expenses from where they were booked per the

FASB Accounting Rules to where Medicare requires

these expenses to be.

WS A-6 Reclassifications need to separately identify

Salary Expenses vs. Other Expenses.

(34)

WS A 6

WS A-6

Common Examples of WS A 6 Reclassifications:

Common Examples of WS A-6 Reclassifications:

1. Medical Supplies (High Cost med Supplies)

Ch

d t P ti t

Charged to Patients

2. Drugs Charged to Patients

3. Equipment Depreciation Expense

4 Employee Benefits Expenses

(35)

12-10 FORM CMS-2552-10 4090 (Cont.)

RECLASSIFICATIONS PROVIDER NO.: PERIOD: WORKSHEET A-6 FROM ____________

________________ TO _______________

INCREASES DECREASES Wk t INCREASES DECREASES Wkst.

CODE 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 5 5 6 6 7 7 8 8 9 9 10 10 11 11 12 12 13 13 13 13 14 14 15 15 16 16 17 17 18 18 19 19 20 20 21 21 21 21 22 22 23 23 24 24 25 25 26 26 27 27 28 28 29 29 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)

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q )

(1) A le tte r (A, B , e tc .) m us t be e nte re d o n e a c h line to ide ntify e a c h re c la s s ific a tio n e ntry. Tra ns fe r the a m o unts in c o lum ns 4, 5, 8, a nd 9 to Wo rks he e t A, c o lum n 4, line s a s a ppro pria te .

(36)

WS A 6

WS A-6

Steps to process WS A 6 Data:

Steps to process WS A-6 Data:

• Identify the data to be reclassified

– General Ledger

g

– Statistics (Split and Complex Reclassifications)

• What is the basis for the reclassification?

Wh l M

(Si l R l

ifi ti )

– Whole Move (Simple Reclassification)

– Partial Move (Split Reclassification)

– Allocation Move (Complex Reclassification)

• Cost Center Assignment

(37)

WS A 6

WS A-6

Steps to Process WS A 6 Data:

Steps to Process WS A-6 Data:

• Supporting Analytical Workpapers

Workpaper Referencing

– Workpaper Referencing

• Sort and Subtotal

WS A 6 R l

ifi ti Al h C d A i

t

• WS A-6 Reclassification Alpha Code Assignment

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WS A 6 (impact on cost report)

WS A-6 (impact on cost report)

Are we done with WS A 6 Reclassifications?

Are we done with WS A-6 Reclassifications?

– Matching Principle

P i R l

i

t C

t R l

– Prior Reclass impact on Current Reclass

– WS S-3 Wage Index impact

– WS B-1 Statistics impact

– WS C Revenue impact

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WS A 8 (Revenue/Expense Adjustments)

WS A-8 (Revenue/Expense Adjustments)

WS A 8 adjustments allow the user to adjust the

WS A-8 adjustments allow the user to adjust the

Expenses on WS A for differences between Financial

Accounting and Medicare

Accounting and Medicare.

– Revenue Adjustments are where Other

Operating/Non-Operating Revenue is “offset” against the associated

Operating Revenue is offset against the associated

Expenses

– Expense Adjustments are where the Expenses are

treated differently between Financial Accounting and

Medicare

(52)

12-10 FORM CMS-2552-10 4090 (Cont.)

ADJUSTMENTS TO EXPENSES PROVIDER NO.: PERIOD: WORKSHEET A-8

FROM ____________ ________________ TO _______________

EXPENSE CLASSIFICATION ON

DESCRIPTION (1) Wkst.

A-7

BASIS/CODE (2) AMOUNT 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

EXPENSE CLASSIFICATION ON WORKSHEET A TO/FROM WHICH THE AMOUNT IS TO BE ADJUSTED

COST CENTER

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 school (tuition, fees, books, etc.) 19

20 Vending machines 20

21 Income from imposition of interest,p , 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 65

25 Utilization review - physicians' compensation (chapter 21) Utilization Review - SNF 114 25 26 Depreciation - buildings and fixtures Buildings and Fixtures 1 26 26 Depreciation - buildings and fixtures Buildings and Fixtures 1 26

27 Depreciation - movable equipment Movable Equipment 2 27

(53)

WS A 8

WS A-8

Common Examples of WS A 8 Adjustments:

Common Examples of WS A-8 Adjustments:

1. Bad Debt Expense (Simple Adjustment)

2 Mi R

(“P i

il ” Si l Adj t

t)

2. Misc Revenue (“Primarily” Simple Adjustment)

3. Interest Income/Expense (Partial Adjustment)

4. Grant Revenues (No Offset)

5. Cafeteria Revenue (Move and Offset)

(54)

WS A 8

WS A-8

Steps to process WS A 6 Data:

Steps to process WS A-6 Data:

• Identify the data to be Adjusted

– General Ledger

g

– Statistics (Partial Adjustments)

• What is the basis for the Adjustment?

Wh l (Si l )

– Whole (Simple)

– Partial

– No Offset

(55)

(56)

(57)

Purpose:

To identify and offset the Interest Income against the associated expenses on the Medicare cost report

Sources:

General LedgerInterste Income and Expense Accounts

R l

d P

i

l i (WP A 8 1 2)

Related Party transaction analysis (WP A‐8‐1_2)

Comments: Interest Income is to offset to the extent of the Related Expenses.

Account

Description

SubAccount Description

Interest Income

Net Interest Exp (A)

Max Interest Rev Offset

Account

Description

SubAccount Description

Interest Income

Net Interest Exp (A)

Max Interest Rev Offset

80250 NON ALLOCABLE OVERHEAD

461170 INTEREST INC PHYSICANS\' NOTES

(42,379.93)

80250 NON ALLOCABLE OVERHEAD

461270 INTEREST INC OTHER

(4,834.15)

(47,214.08)

28,348.28

(B)

Account

Description

SubAccount Description

Interest Exp

Related Party Adjustment (C )

Net Interest Exp

80102 ADMINISTRATION

790480 INT CONTRA CAP INT 1998 BONDS

(1,270,121.20)

80250 NON ALLOCABLE OVERHEAD

528220 I/C EXP‐ INT L/T NOTES

5,786,570.17

(4,525,798.65)

1,260,771.52

80250 NON ALLOCABLE OVERHEAD

528225 I/C EXP‐ INT L/T NOTES

41,019.62

80250 NON ALLOCABLE OVERHEAD

790130 INT CAP LEASE 1

27,752.57

80250 NON ALLOCABLE OVERHEAD

790150 INT CAP LEASE 2

714.74

714.74 82110 NUTRITIONAL SVCS

790650 INT CONTRA CAP INT 1999 BONDS

(31,788.97)

Interest Expense

4,554,146.93

(4,525,798.65)

28,348.28

(A)

WS A‐8 Line Cost Center

Description

Amount

39

6 Interest income Offset

28,348.28

(B)

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Audit Tags

(A) ‐ This amount represents the Net Interest Expense (Max Offset of interest Income)

(B) ‐ Interest Income exceeds the ralated expenses ‐ Net Interest Income Offset

(C ) ‐ Cost of related party transaction adjustment based on WP A‐8‐1_2

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(59)

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WS A 8

WS A-8

Do WS A 8 Adjustments impact other cost report

Do WS A-8 Adjustments impact other cost report

pages?

(61)

WS B 1 (Statistical Allocations)

WS B-1 (Statistical Allocations)

WS B 1 is where the Overhead Cost Centers are

WS B-1 is where the Overhead Cost Centers are

Allocated to the rest of the Hospital Departments

based on their individual Statistics

based on their individual Statistics.

– Single Allocation Methodology

CFR 413.24(d)(1)

M lti l All

ti M th d l

– Multiple Allocation Methodology

CFR413.24(d)(2)(ii)

– Simplified Cost Allocation

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12-10 FORM CMS-2552-10 4090 (Cont.)

COST ALLOCATION ‐ STATISTICAL BASIS PROVIDER NO.: PERIOD: WORKSHEET B-1

FROM ____________

________________ TO _______________

CAPITAL RELATED COST ADMINIS‐ MAIN‐

CAPITAL RELATED COST ADMINIS MAIN

BLDGS. & MOVABLE EMPLOYEE TRATIVE & TENANCE & OPERATION

FIXTURES EQUIPMENT BENEFITS GENERAL REPAIRS OF PLANT

CENTER DESCRIPTIONS (SQUARE (DOLLAR (GROSS RECONCIL‐ (ACCUM. (SQUARE (SQUARE

FEET) VALUE) SALARIES) IATION COST) FEET) FEET)

1 2 4 5A 5 6 7

GENERAL SERVICE COST CENTERS

1 Capital Related Costs-Buildings and Fixtures 1

2 Capital Related Costs-Movable Equipment 2

4 E l B fit 4

4 Employee Benefits 4

5 Administrative and General 5

6 Maintenance and Repairs 6

7 Operation of Plant 7

8 Laundry and Linen Service 8

9 Housekeeping 9

10 Dietary 10

11 Cafeteria 11

12 Maintenance of Personnel 12

13 Nursing Administration 13

14 Central Services and Supply 14

15 Pharmacy 15

16 Medical Records & Medical Records Library 16

17 Social Service 17

18 Other General Service (specify) 18

19 Nonphysician Anesthetists 19

20 Nursing School 20

21 Intern & Res. Service-Salary & Fringes (Approved)y g ( pp ) 21

22 Intern & Res. Other Program Costs (Approved) 22

23 Paramedical Education Program (specify) 23

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 Unit (specify) 35

40 Subprovider IPF 40

(63)

12-10 FORM CMS-2552-10 4090 (Cont.)

COST ALLOCATION ‐ STATISTICAL BASIS PROVIDER NO.: PERIOD: WORKSHEET B-1

FROM ____________

________________ TO _______________

CAPITAL RELATED COST ADMINIS‐ MAIN‐

BLDGS. & MOVABLE EMPLOYEE TRATIVE & TENANCE & OPERATION

FIXTURES EQUIPMENT BENEFITS GENERAL REPAIRS OF PLANT

CENTER DESCRIPTIONS (SQUARE (DOLLAR (GROSS RECONCIL‐ (ACCUM. (SQUARE (SQUARE

FEET) VALUE) SALARIES) IATION COST) FEET) FEET)

1 2 4 5A 5 6 7

50 Operating Room 50

51 Recovery Roomy 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-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 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

75 ASC (Non Distinct Part) 75

76 Other Ancillary (specify) 76

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

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12-10 FORM CMS-2552-10 4090 (Cont.)

COST ALLOCATION ‐ STATISTICAL BASIS PROVIDER NO.: PERIOD: WORKSHEET B-1 FROM ____________

________________ TO _______________ CAPITAL RELATED COST ADMINIS‐ MAIN‐ CAPITAL RELATED COST ADMINIS MAIN

BLDGS. & MOVABLE EMPLOYEE TRATIVE & TENANCE & OPERATION FIXTURES EQUIPMENT BENEFITS GENERAL REPAIRS OF PLANT T CENTER DESCRIPTIONS (SQUARE (DOLLAR (GROSS RECONCIL‐ (ACCUM. (SQUARE (SQUARE FEET) VALUE) SALARIES) IATION COST) FEET) FEET)

1 2 4 5A 5 6 7

OTHER REIMBURSABLE COST CENTERS

94 Home Program Dialysis 94 A b l S i

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

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) 112 112 Other Organ Acquisition (specify) 112 115 Ambulatory Surgical Center (Distinct Part) 115

116 Hospice 116

117 Other Special Purpose (specify) 117 118 SUBTOTALS (sum of lines 1-117) 118

NONREIMBURSABLE COST CENTERS

190 Gift, Flower, Coffee Shop, & Canteen 190

191 Research 191

192 Physicians' Private Offices 192

(65)

WS B 1

WS B-1

The standard Statistics that CMS allows for each Cost Center are

as Follows:

– Square Feet (CC# 1, 6, and 7) – Direct Nursing Hours (CC# 13)

Square Feet (CC# 1, 6, and 7)

– Dollar Value (CC# 2)

– Gross Salaries (CC# 4)

ec u s g ou s (CC# 3)

–

Costed Requisitions (CC# 14 and 15)

–

Time Spent (CC# 16 and 17)

– Accumulated Cost (CC# 5)

– LBS of Laundry (CC# 8)

–

Assigned Time (CC# 19-23)

– Meals Served (CC # 9 and 10)

– Number Housed (CC# 12)

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WS B 1

WS B-1

Steps to process WS B 1 Data:

Steps to process WS B-1 Data:

• Identify the data to be used as Statistic

– General Ledger (Dollar Value, Gross Salaries, Costed Requisitions, etc.)

g (

q

)

– Statistics (Various Data Sources)

• Calculated Values or imputed Values

C t C t A i

t

• Cost Center Assignment

• Identification of Adjustments due to WS A-6 or WS A-8

• Previously Allocated Cost Centers

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(75)

(76)

(77)

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WS C (Patient Treatment Revenues)

WS C is used to identify the Total IP and OP Charges

by Department for Patient Treatment activities. These

charges are then compared to the expenses (after

stepdown) in order to arrive at the Cost to Charge

Ratio (CCR) The CCRs are how Medicare and

Ratio (CCR). The CCRs are how Medicare and

Medicaid identify the cost of services based on the

bills submitted

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12-10 FORM CMS-2552-10 4090 (Cont.)

COMPUTATION OF RATIO OF COSTS TO CHARGES PROVIDER NO.: PERIOD: WORKSHEET C

FROM ____________ PART I TO

_____________ TO _______________ Total Cost

(from Wkst. Therapy RCE Total TEFRA PPS

COST CENTER DESCRIPTIONS B, Part I, Limit Total Dis‐ Total (column 6 Cost or Inpatient Inpatient 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

30 Adults and Pediatrics (General Routine Care) 30

31 I t i C U it 31

Costs Charges

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

51 Recovery Room 51

52 Labor Room and Delivery Room 52

56 Radioisotope 56

60 Laboratoryy 60

61 PBP Clinical Laboratory Services-Prgm. Only 61

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

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68 Speech Pathology 68

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4090 (Cont.) FORM CMS-2552-10 #REF!

COMPUTATION OF RATIO OF COSTS TO CHARGES PROVIDER NO.: PERIOD: WORKSHEET C

FROM ____________ PART I _____________ TO _______________

Total Cost Costs Charges

(from Wkst. Therapy RCE Total TEFRA PPS

COST CENTER DESCRIPTIONS B, Part I, Limit Total Dis‐ Total (column 6 Cost or Inpatient Inpatient 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

90 Clinic 90

91 Emergencyg y 91

92 Observation Beds (see instructions) 92

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 O i R h bili i P id ( if ) 99

99 Outpatient Rehabilitation Provider (specify) 99

100 Intern-Resident Service (not appvd. tchng. prgm.) 100

101 Home Health Agency 101

SPECIAL PURPOSE COST CENTERS

105 Kidney Acquisition 105 106 Heart Acquisition 106 107 Liver Acquisition 107 108 Lung Acquisition 108 109 Pancreas Acquisition 109 109 Pancreas Acquisition 109 110 Intestinal Acquisition 110 111 Islet Acquisition 111

(81)

WS C

Steps to process WS C Data:

• Identify the data to be used:

– General Ledger

g

– Volume Report (Revenue Reclasses and Adjustments)

• Cost Center Assignment

R

R l

• Revenue Reclasses

– Medical Supplies

– Drugs

g

– Observation

– Etc.

(82)

WS C

Steps to process WS C Data:

• Revenue Adjustments

– IP/OP charges in wrong category

g

g y

– Epogene

– Etc.

• Identify and WS A 6 Impacts on Revenues

• Identify and WS A-6 Impacts on Revenues

• Sort and Subtotal

• Workpapers should always reconcile back to the Original GL (CR to

Workpapers should always reconcile back to the Original GL (CR to

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(85)

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Settlement Charges

The Settlement Charges are the Medicare/Medicaid

charges that have been accumulated from the Bills

submitted and are sumaraized on the Provider

Statistical Report (PSR). These charges are applied

to the CCR (WS C) to calculate the cost of treating the

Medicare/Medicaid patients. Charges on the PSR are

identified by their 3(4) digit numeric revenue code

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Settlement Charges

Settlement Charges are obtained from the PSR The PSR

Settlement Charges are obtained from the PSR. The PSR

contains multiple report types. Listed below are the most

common IP PSR Report Types:

p

yp

– 110 I/P Part A

– 118 Inpatient - Part A Managed Care

– 122 I/P Part B Vaccines

– 125 I/P Part B - Fee Reimbursed

– 119 I/P PPS Interim Bills

– 11A I/P Part A (MSP)

– 12P I/P Part B - OPPS

– 11R I/P Rehab

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Settlement Charges

Listed below are the most common OP PSR Report Types:

– 130 O/P All Other / Ambulance

– 132 O/P Part B Vaccines

132 O/P Part B Vaccines

– 135 O/P Fee Reimbursed

– 13A O/P All Other (MSP)

– 13P O/P OPPS

– 140 O/P All Other

– 145 O/P Other Mamography Fee Reimbursed

– 14A O/P Clinical Labs (MSP)

14P O/P Other OPPS

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4090 (Cont.) FORM CMS-2552-10 12-10

INPATIENT ANCILLARY SERVICE PROVIDER NO.: PERIOD: WOR KS HEET D-3

COST APPORTIONMENT ________________ FROM ____________

C OM P ONENT NO.: TO _______________ ________________

Check [ ] Title V [ ] Hospital [ ] Subprovider (other) [ ] Swing-Bed SNF [ ] PPS

applicable [ ] Title XVIII Part A [ ] IPF [ ] SNF [ ] Swing Bed NF [ ] TEFRA

applicable [ ] Title XVIII, Part A [ ] IPF [ ] SNF [ ] Swing-Bed NF [ ] TEFRA

boxes: [ ] Title XIX [ ] IRF [ ] NF [ ] ICF/MR [ ] Other

Ratio of Cost Inpatient Inpatient Program Costs

COST CENTER DESCRIPTION to Charges Program Charges (col. 1 x col. 2)

1 2 3

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‐Diagnosticgy g 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 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 OUTPATIENT SERVICE COST CENTERS 88 Rural Health Clinic (RHC) 88

(93)

4090 (Cont.) FORM CMS-2552-10 12-10

APPORTIONMENT OF MEDICAL AND OTHER PROVIDER NO.: ______________ PERIOD: WORKSHEET D,

HEALTH SERVICES COSTS FROM ____________ PART V

COMPONENT NO.: ____________ TO _______________

Check [ ] Title V - O/P [ ] Hospital [ ] Subprovider (Other) [ ] Swing Bed SNF

li bl [ ] Ti l XVIII P B [ ] IPF [ ] SNF [ ] S i B d NF

applicable [ ] Title XVIII, Part B [ ] IPF [ ] SNF [ ] Swing Bed NF

boxes: [ ] Title XIX - O/P [ ] IRF [ ] NF [ ] ICF/MR

PART V - APPORTIONMENT OF MEDICAL AND OTHER HEALTH SERVICES COSTS

Cost to Cost Reimbursed Cost Reimbursed Cost Cost

Charge Services Services Not PPS Services Services Not

Ratio from PPS Reimbursed Subject to Subject to Services Subject to Subject to

Worksheet C, Services Ded. & Coins. Ded. & Coins. (see Ded. & Coins. Ded. & Coins.

Part I, col. 9 (see instructions) (see instructions) (see instructions) instructions) (see instructions) (see instructions)

1 2 3 4 5 6 7

Program Charges Program Cost

Cost Center Description ANCILLARY SERVICE COST CENTERS

51 Recovery Room 51

52 Labor & Delivery Room 52

56 Radioisotope 56

60 Laboratory 60

61 PBP Clinic Laboratory Services-Prgm. Only 61

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 70 Electroencephalography 70

71 Medical Supplies Charged To Patients 71

90 Clinic 90

91 Emergency 91

92 Observation Bed 92

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 L PBP Cli i L b S i P 201

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201 Less PBP Clinic Lab. Services-Program 201

Only Charges

202 Net Charges (line 200 ± line 201 ) 202

F OR M C M S -2552-10 (12/2010) (INS TR UC TIONS F OR THIS WOR KS HEET AR E P UB LIS HED IN C M S P UB . 15-II, S EC TIONS 4024.5)

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Settlement Charges

The Settlement charges are intended to be identified against the

department that generated the charge as matching the revenues against

the expense incurred to perform that treatment/service. There are

l

th t

id h

d t k th id tifi ti f th

several ways that providers have undertaken the identification of the

PSR charges to the Cost Center:

1. Allocate the Revenues from the PSR by revenue code to the cost centers based

on internal data (Revenue and Usage)

2. Directly assigning the Revenues by revenue codes to cost centers (Crosswalk)

3. Allocate Total Charges to all cost centers based on the Total or Medicare total

(95)

Settlement Charges

Steps to process Settlement Charges:

• Identify the data to be used:

– Provider Statistical Report (PSR)

p

(

)

– Revenue and Usage (Medicare Patients)

– Settlement Crosswalk (should be consistent between years)

Medicare logs

– Medicare logs

• Determine the Methodology

– Should be consistent with prior year

• Start with PSR

(96)

Settlement Charges

Steps to process Settlement Charges:

• Adjustments to the PSR

– Pending Claims

g

– Errors

• Grouping / Allocation of Charges

U i R

d U

fil

– Using Revenue and Usage files

– Crosswalks to Cost Centers

– Specialty Revenue Codes

(97)

Settlement Charges

Steps to process Settlement Charges:

• Workpapers should show the Settlement Charges “Both

Directions”

Directions

– What was done with each Revenue Code (Revcode to Cost

Center Crosswalk)

– What makes up each number in the Cost Report

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(99)

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(101)

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Settlement Data

Settlement Data is the information that is contained on

the PSR that is not Charges (No Revenue Code).

Examples of Settlement Data are:

– Deductible

C I

– Co-Insurance

– PPS Payments (DRG, APC, RUGS, etc.)

– Interim Payments

– Capital Payments

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4090 (Cont.) CMS FORM-2552-10 12-10

CALCULATION OF REIMBURSEMENT PROVIDER NO.: PERIOD: WORKSHEET E,

SETTLEMENT ________________ FROM ____________ PART A

COMPONENT NO.: TO _______________ ________________

Check [ ] Hospital

applicable box: [ ] Subprovider (Other)

PART A - INPATIENT HOSPITAL SERVICES UNDER PPS

1 DRG amounts other than outlier payments 1

2 Outlier payments for discharges (see instructions) 2

3 Managed care simulated payments 3

4 Bed days available divided by number of days in the cost reporting period (see instructions) 4 4 Bed days available divided by number of days in the cost reporting period (see instructions) 4

Indire ct Me dical Education Adjustme nt Calculation for Hospitals

5 FTE count for allopathic and osteopathic programs for the most recent cost reporting period ending on or 5 before 12/31/1996 (see instructions)

6 FTE count for allopathic and osteopathic programs which meet the criteria for an add-on to the cap for new programs in 6 accordance with section 1886(d)(5)(B)(viii)

7 Adjusted FTE count for allopathic and osteopathic programs for affiliated programs in accordance with 7 section 1886(d)(5)(B)(viii)

8 Reduced Direct GME FTE Cap (see instructions)p ( ) 8

9 Sum of lines 5 through 7 plus/minus line 8 (see instructions) 9

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 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 15 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

Indire ct Me dical Education Adjustme nt for the Add-on

23 Number of additional allopathic and osteopathic IME FTE resident cap slots under 42 Sec. 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

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12-10 CMS FORM-2552-10 4090 (Cont.)

CALCULATION OF REIMBURSEMENT PROVIDER NO.: PERIOD: WORKSHEET E,

SETTLEMENT ________________ FROM ____________ PART A (Cont.)

COMPONENT NO.: TO _______________

________________

Check [ ] Hospital

applicable box: [ ] IRF

PART A - INPATIENT HOSPITAL SERVICES UNDER PPS

Additional payme nt for high pe rce ntage of ESRD be ne ficiary dis charge s

40 Total Medicare discharges on Worksheet S-3, Part I excluding discharges for MS-DRGs 652, 682, 683, 40

684 and 685 (see instructions)

41 Total ESRD Medicare discharges excluding MS-DRGs 652, 682, 683, 684 an 685 (see instructions) 41

42 Divide line 41 by line 40 (if less than 10%, you do not qualify for adjustment)y ( y q y j ) 42

43 Total Medicare ESRD inpatient days excluding MS-DRGs 652, 682, 683, 684 an 685 (see instructions) 43

44 Ratio of average length of stay to one week (line 43 divided by line 41 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) 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 SCH and MDH only (see instructions) 49

50 Payment for inpatient program capital (from Worksheet L, Parts I, II, as applicable) 50

51 Exception payment for inpatient program capital (Worksheet L, Part III) (see instructions) 51

52 Direct graduate medical education payment (from Worksheet 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

55 Net organ acquisition cost (Worksheet D-4 Part III, col. 1, line 69) 55

56 Cost of teaching physicians (Worksheet D-5, Part II, col. 3, line 20) 56

57 Routine service other pass through costs 57

58 Ancillary service other pass through costs Worksheet D, Part 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 applicable to MS-DRG (see instructions) 68

69 Outlier payments reconciliation 69

70 Other adjustments (specify) (see instructions)j ( p y) ( ) 70

71 Amount due provider (line 67 minus lines 68 plus/minus lines 69 & 70) 71

72 Interim payments 72

73 Tentative settlement (for contractor use only) 73

74 Balance due provider (Program) (sum of lines 71 minus the sum of lines 72 and 73) 74

75 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-II, section 115.2 75

TO B E COMPLETED BY CONTRACTOR

90 Operating outlier amount from Worksheet E, Part A line 2 90

91 Capital outlier from Worksheet L, Part I, line 2 91

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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

F OR M C M S -2552-10 (12/2010) (INS TR UC TIONS F OR THIS WOR KS HEET AR E P UB LIS HED IN C M S P UB . 15-II, S EC TION 4030.1)

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4090 (Cont.) FORM CMS-2552-10 12-10

CALCULATION OF PROVIDER NO.: PERIOD: WORKSHEET E,

REIMBURSEMENT SETTLEMENT ________________ FROM ____________ PART B

COMPONENT NO.: TO _______________

________________

Check applicable box: [ ] Hospital [ ] IPF [ ] IRF [ ] Subprovider (Other) [ ] SNF

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 PPS payments 3 4 Outlier payment (see instructions) 4 5 Enter the hospital specific payment to cost ratio (see instructions) 5 6 Line 2 times line 5 6 7 Sum of lines line 3 plus line 4 divided by line 6 7 8 Transitional corridor payment (see instructions) 8 9 Enter the amount from Worksheet D, Part IV, column 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 Worksheet D‐4, Part III, line 69, col. 4) 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 (line 11 or line 20) (for CAH, see instructions) 21 22 Interns and residents (see instructions) 22

23 Cost of teaching physicians (see instructions 42 CFR 415 160 and CMS Pub 15 1 §2148) 23

23 Cost of teaching physicians (see instructions, 42 CFR 415.160 and CMS Pub. 15‐1, §2148) 23 24 Total prospective payment (sum of lines 3, 4, 8 and 9) 24 COMPUTATION OF REIMBURSEMENT SETTLEMENT 25 Deductibles and coinsurance (see instructions) 25 26 Deductibles and Coinsurance relating to amount on line 24 (see instructions) 26 27 Subtotal {(lines 21 and 24 ‐ 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 Worksheet E‐4, line 50) 28 29 ESRD direct medical education costs (from Worksheet E‐4, line 36) 29 30 Subtotal (sum of lines 27 through 29) 30 31 Primary payer paymentsy p y p y 31 32 Subtotal (line 30 minus line 31) 32 ALLOWABLE BAD DEBTS (EXCLUDE BAD DEBTS FOR PROFESSIONAL SERVICES)