Cost Report 101 FINAL - SoCal HFMA Report Training.pdf · Cost Report Preparation and Documentation...

Cost Report Preparation and Documentation 101

“A How-To Guide to Workpaper and Supporting Documentation Preparation”Documentation Preparation

Essential Consulting LLC www.esshc.com

AgendaAgenda

• Medicare Reimbursement Methodologies• Medicare Reimbursement Methodologies• What is a Cost Report and Why is it Important• Filing Guidelines• Basic Flow of a Cost Reportp• Most Common Data Used in a Cost Report• Basic Data Rules and Reconciliations• Basic Data Rules and Reconciliations


AgendaAgenda• 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 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)


AgendaAgenda• Documentation is the Key!• Documentation is the Key!• Electronic vs. Manual Data Manipulation and Analysis• Special Issues• Special Issues

– Critical Access– Home Office Cost Statement– Skilled Nursing Cost Report– Home Health Cost Report– Community Mental Health Center Cost ReportCommunity Mental Health Center Cost Report


AgendaAgenda

• Specialty Pages on the Cost Report• 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


Medicare Reimbursement MethodologiesMedicare Reimbursement MethodologiesMedicare Program Part A Medicare Program Part B

Physician Services

Medicare Program Part A

IP Services Hospital Based Outpatient Services

Medicare Program Part B

Clinic Services

IP Ancillary Services Onsite/Offsite Clinics Clinics and MD OfficesOutpatient Services

Medicare Part B CarrierMedicare Part A intermediary

Cost Report Part A (IP) Cost Report Part B (OP)

Medicare Cost Reports (UB‐92 Bills) CMS‐1500 Bills


Cost Report Part A (IP) Cost Report Part B (OP)

Medicare Reimbursement MethodologiesMedicare Reimbursement Methodologies• Reimbursement Mechanisms for Hospital Units/Entities• 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)• Home Health Agency – HHAPPS (Home Health Prospective Payment System)


Medicare Reimbursement MethodologiesMedicare Reimbursement Methodologies• Reimbursement Mechanisms for “Special Services”• Reimbursement Mechanisms for Special Services

• IME/GME (Medical Education) – FTEs• Disproportionate Share Hospitals (DSH) – Indigency PercentageDisproportionate Share Hospitals (DSH) Indigency Percentage• Medicare Bad Debs – Portion of the Un-paid Coinsurance and

Deductibles• Organ Acquisition – Cost Reimbursement


What is a Cost Report and why is it p yimportant?

• The cost report is a financial report that identifies • The cost report is a financial report that identifies the cost and charges related to healthcare treatment activitiestreatment 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.


Filing GuidelinesFiling Guidelines

• Medicare cost reports are due within 150 Days from • 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– Variations can be significant


2552 96 vs 2552 102552-96 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 laterlater.

• 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.)


g p g ( )

Basic Flow of a Cost ReportBasic Flow of a Cost Report• WS A Series – general ledger or trial balance information by functional departmentg 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• WS S Series – statistical information and wage index• WS H Series – Home Health Services• WS J, K, M Series – Clinics and Freestanding components

WS I E d St R l Di l i (ESRD)


• WS I – End Stage Renal Dialysis (ESRD)

Most Commonly Used Data in a Cost ReportMost Commonly Used Data in a Cost Report

• General Ledger (Summary Trial Balance)• General Ledger (Summary Trial Balance)• Payroll Register• Chargemaster with Volumes (Volume Report)• Chargemaster with Volumes (Volume Report)• Medicare Charges by Department and Revenue Code

(Revenue and Usage)(Revenue and Usage)• Provider Statistical Report (PSR)• Patient Census (Days and Discharges)• Patient Census (Days and Discharges)• Allocation Statistics

S ifi P D tEssential Consulting LLC www.esshc.com

• Specific Purpose Data

Basic Data RulesBasic Data Rules

Every data file has its unique issues and reasons for 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–Know Your Data!


The General LedgerThe General Ledger

The General Ledger is the most important data that is 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 datag•Mix and Match data

–How does the GL break down?A t d Li biliti•Assets and Liabilities

•Revenues•Expenses


•Other Operating and Non-Operating Revenue/Expenses

General LedgerGeneral Ledger

Show a General Ledger in Excel and reviewShow 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• Expenses• Other Operating and Non-Operating Revenue/Expenses


ReconciliationsReconciliations serve two purposes:1. Identify that all of the revenues/expenses (data) have been 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 3rd Party Revenues to Revenue & Usage


General Ledger to Income StatementGeneral Ledger to Income Statement


Cost Report to Income Statement pReconciliation


Other Operating/Non-Operating Rev/Exp p g p g pReconciliation


General Ledger vs. Volume Report g pComparison


WS A (Expenses by Department)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 lines are added for general service cost centers, add corresponding columns for cost finding.


4090 (Cont.) FORM CMS-2552-10 12-10RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES P ROVIDER NO.: P ERIOD: WORKSHEET A

FROM ____________

________________ TO _______________

RECLASSIFIED NET EXPENSESRECLASSIFIED NET EXPENSESCOST 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 12 00200 Capital Related Costs-Movable Equipment 23 00300 Other Capital Related Costs ‐0‐ 34 00400 Employee Benefits 44 00400 Employee Benefits 45 00500 Administrative and General 56 00600 Maintenance and Repairs 67 00700 Operation of Plant 78 00800 Laundry and Linen Service 89 00900 Housekeeping 910 01000 Dietary 1011 01100 Cafeteria 1112 01200 Maintenance of Personnel 1212 01200 Maintenance of Personnel 1213 01300 Nursing Administration 1314 01400 Central Services and Supply 1415 01500 Pharmacy 1516 01600 Medical Records & Medical Records Library 1617 01700 Social Service 1718 Other General Service (specify) 1819 01900 Nonphysician Anesthetists 1920 02000 Nursing School 20g21 02100 Intern & Res. Service-Salary & Fringes (Approved) 2122 02200 Intern & Res. Other Program Costs (Approved) 2223 02300 Paramedical Ed. Program (specify) 23

INPATIENT ROUTINE SERVICE COST CENTERS 30 03000 Adults and Pediatrics (General Routine Care) 3031 03100 Intensive Care Unit 3132 03200 Coronary Care Unit 3233 03300 Burn Intensive Care Unit 3334 03400 Surgical Intensive Care Unit 3435 Other Special Care (specify) 3540 04000 Subprovider - IPF 4041 04100 Subprovider - IRF 4142 04200 Subprovider (specify) 4243 04300 Nursery 4344 04400 Skilled Nursing Facility 4445 04500 Nursing Facility 45


46 04600 Other Long Term Care 46

FORM CMS-2552-10 (12/2010) (INSTRUCTIONS FOR THIS WORKSHEET ARE P UBLISHED IN CMS P UB. 15-II, SECTION 4013)

40-524 Rev. 1

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 EXPENSESCOST CENTER DESCRIPTIONS TOTAL RECLASSIFI‐ TRIAL BALANCE FOR ALLOCATION


ANCILLARY SERVICE COST CENTERS 50 05000 Operating Room 5051 05100 Recovery Room 5152 05200 Labor Room and Delivery Room 5253 05300 Anesthesiology 5354 05400 Radiology-Diagnostic 5455 05500 Radiology-Therapeutic 5556 05600 Radioisotope 5657 05700 Computed Tomography (CT) Scan 5758 05800 Magnetic Resonance Imaging (MRI) 5859 05900 Cardiac Catheterization 5960 06000 Laboratory 60y61 06100 PBP Clinical Laboratory Services-Program Only 6162 06200 Whole Blood & Packed Red Blood Cells 6263 06300 Blood Storing, Processing, & Trans. 6364 06400 Intravenous Therapy 6465 06500 Respiratory Therapy 6566 06600 Physical Therapy 6667 06700 Occupational Therapy 6768 06800 Speech Pathology 6868 06800 Speech Pathology 6869 06900 Electrocardiology 6970 07000 Electroencephalography 7071 07100 Medical Supplies Charged to Patients 7172 07200 Implantable Devices Charged to Patients 7273 07300 Drugs Charged to Patients 7374 07400 Renal Dialysis 7475 07500 ASC (Non-Distinct Part) 7576 Other Ancillary (specify) 7676 Other Ancillary (specify) 76

OUTPATIENT SERVICE COST CENTERS 88 08800 Rural Health Clinic (RHC) 8889 08900 Federally Qualified Health Center (FQHC) 8990 09000 Clinic 9091 09100 Emergency 9192 09200 Observation Beds 9293 Other Outpatient Service (specify) 93


FORM CMS-2552-10 (12/2010) (INSTRUCTIONS FOR THIS WORKSHEET ARE P UBLISHED IN CMS P UB. 15-II, SECTION 4013) 40-525Rev. 1

12-10 FORM CMS-2552-10 4090 (Cont.)RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES P ROVIDER NO.: P ERIOD: WORKSHEET A

FROM ____________

TO _______________________________ _______________

RECLASSIFIED NET EXPENSESCOST CENTER DESCRIPTIONS TOTAL RECLASSIFI‐ TRIAL BALANCE FOR ALLOCATION


OTHER REIMBURSABLE COST CENTERS 94 09400 Home Program Dialysis 9495 09500 Ambulance Services 9596 09600 Durable Medical Equipment-Rented 9697 09700 Durable Medical Equipment-Sold 9798 Other Reimbursable (specify) 9899 Outpatient Rehabilitation Provider (specify) 99100 10000 Intern-Resident Service (not appvd. tchng. prgm.) 100101 10100 Home Health Agency 101

SPECIAL PURPOSE COST CENTERS 105 10500 Kidney Acquisition 105106 10600 Heart Acquisition 106107 10700 Liver Acquisition 107108 10800 Lung Acquisition 108109 10900 Pancreas Acquisition 109110 11000 Intestinal Acquisition 110111 11100 Islet Acquisition 111112 Oth O A i iti ( if ) 112112 Other Organ Acquisition (specify) 112113 11300 Interest Expense ‐ 0 ‐ 113114 11400 Utilization Review-SNF ‐ 0 ‐ 114115 11500 Ambulatory Surgical Center (Distinct Part) 115116 11600 Hospice 116117 Other Special Purpose (specify) 117118 SUBTOTALS (sum of lines 1-117) 118

NONREIMBURSABLE COST CENTERS NONREIMBURSABLE COST CENTERS 190 19000 Gift, Flower, Coffee Shop, & Canteen 190191 19100 Research 191192 19200 Physicians' Private Offices 192193 19300 Nonpaid Workers 193194 Other Nonreimbursable (specify) 194200 TOTAL (sum of lines 118-199) ‐ 0 ‐ 200



40-526 Rev. 1

WS AWS A

Cost report line numbers should be grouped based on 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)– Non-Reimbursable Cost Centers (190-194)


– Total (200)

WS AWS 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?• Bonuses?• Stand-By/On Call?•Training/Orientation?Training/Orientation?•Non-Operating Expense (i.e. Joint Ventures, Minority Interests)


WS AWS A

Steps to process WS A Data:Steps to process WS A Data:1. Main Data is the General Ledger2 K Y D t2. Know Your Data

1. Review Accounts2 Review Sub Accounts2. Review Sub-Accounts3. New Accounts and Sub-Accounts

3 Groupings3. Groupings4. Salary vs. Other Expense Split5 Sort and Subtotal


5. Sort and Subtotal

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 FASB Accounting Rules to where Medicare requires these expenses to be.

WS A-6 Reclassifications need to separately identify Salary Expenses vs. Other Expenses.


WS A 6WS 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 tCharged to Patients2. Drugs Charged to Patients3. Equipment Depreciation Expense4 Employee Benefits Expenses4. Employee Benefits Expenses5. Cafeteria Expenses6 OB N d L&D S i EEssential Consulting LLC www.esshc.com

6. OB, Nursery and L&D Service Expenses

12-10 FORM CMS-2552-10 4090 (Cont.)RECLASSIFICATIONS PROVIDER NO.: PERIOD: WORKSHEET A-6

FROM ____________ ________________ TO _______________

INCREASES DECREASES Wk tINCREASES 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 12 23 34 45 55 56 67 78 89 9

10 1011 1112 1213 1313 1314 1415 1516 1617 1718 1819 1920 2021 2121 2122 2223 2324 2425 2526 2627 2728 2829 2929 2930 3031 3132 3233 3334 3435 35

500 Total reclassifications (sum of columns 4 and 5 500must equal sum of columns 8 and 9)


q ) (1) A le tte r (A, B , e tc .) mus t be entered o n each line to identify each rec las s ifica tio n entry.

Trans fer the amo unts in co lumns 4, 5, 8, and 9 to Wo rks hee t A, co lumn 4, lines as appro pria te .


Rev. 1 40-527

WS A 6WS A-6Steps to process WS A 6 Data:Steps to process WS A-6 Data:• Identify the data to be reclassified

– General Ledgerg– 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• Workpapers should always show the increase as well as the

decrease (No Assumptions)


decrease (No Assumptions)

WS A 6WS 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


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– Settlement Charges impact


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 MedicareAccounting 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 – Expense Adjustments are where the Expenses are treated differently between Financial Accounting and Medicare


12-10 FORM CMS-2552-10 4090 (Cont.)ADJUSTMENTS TO EXPENSES PROVIDER NO.: PERIOD: WORKSHEET A-8

FROM ____________________________ TO _______________

EXPENSE CLASSIFICATION ONDESCRIPTION (1) Wkst.

A-7BASIS/CODE (2) AMOUNT LINE # Ref.

1 2 3 4 51 Investment income - buildings and fixtures (chapter 2) Buildings and Fixtures 1 12 Investment income - movable equipment (chapter 2) Movable Equipment 2 23 Investment income - other (chapter 2) 34 Trade, quantity, and time discounts (chapter 8) 4

EXPENSE CLASSIFICATION ONWORKSHEET A TO/FROM WHICH

THE AMOUNT IS TO BE ADJUSTED COST CENTER

5 Refunds and rebates of expenses (chapter 8) 56 Rental of provider space by suppliers (chapter 8) 67 Telephone services (pay stations excluded) (chapter 21) 78 Television and radio service (chapter 21) 89 Parking lot (chapter 21) 9

10 Provider-based physician adjustment Worksheet A-8-2 1011 Sale of scrap, waste, etc. (chapter 23) 1112 Related organization transactions (chapter 10) Worksheet A-8-1 1213 Laundry and linen service 1314 Cafeteria-employees and guests 1415 Rental of quarters to employee and others 1516 Sale of medical and surgical 16

supplies to other than patients17 Sale of drugs to other than patients 1718 Sale of medical records and abstracts 1819 Nursing school (tuition, fees, books, etc.) 1920 Vending machines 2021 Income from imposition of interest, 21p ,

finance or penalty charges (chapter 21)22 Interest expense on Medicare overpayments and 22

borrowings to repay Medicare overpayments23 Adjustment for respiratory therapy 23

costs in excess of limitation (chapter 14) Worksheet A-8-3 Respiratory Therapy 6524 Adjustment for physical therapy costs 24

in excess of limitation (chapter 14) Worksheet A-8-3 Physical Therapy 6525 Utilization review - physicians' compensation (chapter 21) Utilization Review - SNF 114 2526 Depreciation - buildings and fixtures Buildings and Fixtures 1 2626 Depreciation - buildings and fixtures Buildings and Fixtures 1 2627 Depreciation - movable equipment Movable Equipment 2 2728 Non-physician Anesthetist Nonphysician Anesthetist 19 2829 Physicians' assistant 2930 Adjustment for occupational therapy costs 30

in excess of limitation (chapter 14) Worksheet A-8-3 Occupational Therapy 6531 Adjustment for speech pathology costs 31

in excess of limitation (chapter 14) Worksheet A-8-3 Speech Pathology 6532 CAH HIT Adjustment for Depreciation 32

d I t t


and Interest33 Other adjustments (specify) (3) 3350 TOTAL (sum of lines 1 thru 49) 50

(Transfer to Worksheet A, column 6, line 200)


Rev. 1 40-529

WS A 8WS 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)


WS A 8WS A-8Steps to process WS A 6 Data:Steps to process WS A-6 Data:• Identify the data to be Adjusted

– General Ledgerg– Statistics (Partial Adjustments)

• What is the basis for the Adjustment?Wh l (Si l )– Whole (Simple)

– Partial – No Offset– Matching Principle (Cost Center Assignment)

• Sort and Subtotal


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

Sources: General LedgerInterste Income and Expense AccountsR 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 OffsetAccount 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 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) (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 41,019.62 80250 NON ALLOCABLE OVERHEAD 790130 INT CAP LEASE 1 27,752.57 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) (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)


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

WS A 8WS A-8

Do WS A 8 Adjustments impact other cost report Do WS A-8 Adjustments impact other cost report pages?


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 Statisticsbased 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


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 MAINBLDGS. & MOVABLE EMPLOYEE TRATIVE & TENANCE & OPERATIONFIXTURES EQUIPMENT BENEFITS GENERAL REPAIRS OF PLANT

CENTER DESCRIPTIONS (SQUARE (DOLLAR (GROSS RECONCIL‐ (ACCUM. (SQUARE (SQUAREFEET) VALUE) SALARIES) IATION COST) FEET) FEET)1 2 4 5A 5 6 7

GENERAL SERVICE COST CENTERS 1 Capital Related Costs-Buildings and Fixtures 12 Capital Related Costs-Movable Equipment 24 E l B fit 44 Employee Benefits 45 Administrative and General 56 Maintenance and Repairs 67 Operation of Plant 78 Laundry and Linen Service 89 Housekeeping 910 Dietary 1011 Cafeteria 1112 Maintenance of Personnel 1213 Nursing Administration 1314 Central Services and Supply 1415 Pharmacy 1516 Medical Records & Medical Records Library 1617 Social Service 1718 Other General Service (specify) 1819 Nonphysician Anesthetists 1920 Nursing School 2021 Intern & Res. Service-Salary & Fringes (Approved) 21y g ( pp )22 Intern & Res. Other Program Costs (Approved) 2223 Paramedical Education Program (specify) 23

INPATIENT ROUTINE SERVICE COST CENTERS 30 Adults and Pediatrics (General Routine Care) 3031 Intensive Care Unit 3132 Coronary Care Unit 3233 Burn Intensive Care Unit 3334 Surgical Intensive Care Unit 3435 Other Special Care Unit (specify) 3535 Other Special Care Unit (specify) 3540 Subprovider IPF 4041 Subprovider IRF 4142 Subprovider (specify) 4243 Nursery 4344 Skilled Nursing Facility 4445 Nursing Facility 4546 Other Long Term Care 46



Rev. 1 40-553


FROM ____________________________ TO _______________

CAPITAL RELATED COST ADMINIS‐ MAIN‐BLDGS. & MOVABLE EMPLOYEE TRATIVE & TENANCE & OPERATIONFIXTURES EQUIPMENT BENEFITS GENERAL REPAIRS OF PLANT

CENTER DESCRIPTIONS (SQUARE (DOLLAR (GROSS RECONCIL‐ (ACCUM. (SQUARE (SQUAREFEET) VALUE) SALARIES) IATION COST) FEET) FEET)1 2 4 5A 5 6 7

ANCILLARY SERVICE COST CENTERS 50 Operating Room 5051 Recovery Room 51y52 Labor Room and Delivery Room 5253 Anesthesiology 5354 Radiology-Diagnostic 5455 Radiology-Therapeutic 5556 Radioisotope 5657 Computed Tomography (CT) Scan 5758 Magnetic Resonance Imaging (MRI) 5859 Cardiac Catheterization 5960 Laboratory 6061 PBP Clinical Laboratory Services-Program Only 6162 Whole Blood & Packed Red Blood Cells 6263 Blood Storing, Processing, & Trans. 6364 Intravenous Therapy 6465 Respiratory Therapy 6566 Physical Therapy 6667 Occupational Therapy 6767 Occupational Therapy 6768 Speech Pathology 6869 Electrocardiology 6970 Electroencephalography 7071 Medical Supplies Charged to Patients 7172 Implantable Devices Charged to Patients 7273 Drugs Charged to Patients 7374 Renal Dialysis 7475 ASC (Non-Distinct Part) 7575 ASC (Non Distinct Part) 7576 Other Ancillary (specify) 76

OUTPATIENT SERVICE COST CENTERS 88 Rural Health Clinic (RHC) 8889 Federally Qualified Health Center (FQHC) 8990 Clinic 9091 Emergency 9192 Observation Beds 9293 Other Outpatient Service (specify) 93


93 Other Outpatient Service (specify) 93


40-554 Rev. 1


FROM ____________________________ TO _______________

CAPITAL RELATED COST ADMINIS‐ MAIN‐CAPITAL RELATED COST ADMINIS MAINBLDGS. & MOVABLE EMPLOYEE TRATIVE & TENANCE & OPERATIONFIXTURES EQUIPMENT BENEFITS GENERAL REPAIRS OF PLANT

T CENTER DESCRIPTIONS (SQUARE (DOLLAR (GROSS RECONCIL‐ (ACCUM. (SQUARE (SQUAREFEET) 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 i95 Ambulance Services 9596 Durable Medical Equipment-Rented 9697 Durable Medical Equipment-Sold 9798 Other Reimbursable (specify) 9899 Outpatient Rehabilitation Provider (specify) 99100 Intern-Resident Service (not appvd. tchng. prgm.) 100101 Home Health Agency 101

SPECIAL PURPOSE COST CENTERS 105 Kidney Acquisition 105106 Heart Acquisition 106107 Liver Acquisition 107108 Lung Acquisition 108109 Pancreas Acquisition 109110 Intestinal Acquisition 110111 Islet Acquisition 111112 Other Organ Acquisition (specify) 112112 Other Organ Acquisition (specify) 112115 Ambulatory Surgical Center (Distinct Part) 115116 Hospice 116117 Other Special Purpose (specify) 117118 SUBTOTALS (sum of lines 1-117) 118

NONREIMBURSABLE COST CENTERS 190 Gift, Flower, Coffee Shop, & Canteen 190191 Research 191192 Physicians' Private Offices 192193 Nonpaid Workers 193194 Other Nonreimbursable (specify) 194200 Cross foot adjustments 200201 Negative cost centers 201202 Cost to be allocated (per Worksheet B, Part I) 202203 Unit cost multiplier (Worksheet B, Part I) 203204 Cost to be allocated (per Worksheet B, Part II) 204


(p )205 Unit cost multiplier (Worksheet B, Part II) 205


Rev. 1 40-555

WS B 1WS B-1The standard Statistics that CMS allows for each Cost Center are 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)


WS B 1WS B-1Steps 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 ValuesC 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• Previously Allocated Cost Centers• Sort and Subtotal• Workpapers should always agree to the total Statistic that was used


Workpapers should always agree to the total Statistic that was used in the cost report

WS C (Patient Treatment Revenues)WS C (Patient Treatment Revenues)

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


12-10 FORM CMS-2552-10 4090 (Cont.)COMPUTATION OF RATIO OF COSTS TO CHARGES PROVIDER NO.: PERIOD: WORKSHEET C

FROM ____________ PART ITO_____________ 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 Inpatientcol. 26) Adj. Costs allowance Costs Inpatient Outpatient + column 7) Other Ratio Ratio Ratio

1 2 3 4 5 6 7 8 9 10 11INPATIENT ROUTINE SERVICE COST CENTERS

30 Adults and Pediatrics (General Routine Care) 3031 I t i C U it 31

Costs Charges

31 Intensive Care Unit 3132 Coronary Care Unit 3233 Burn Intensive Care Unit 3334 Surgical Intensive Care Unit 3435 Other Special Care (specify) 3540 Subprovider IPF 4041 Subprovider IRF 4142 Subprovider (Specify) 4243 Nursery 4344 Skilled Nursing Facility 4445 Nursing Facility 4546 Other Long Term Care 46

ANCILLARY SERVICE COST CENTERS50 Operating Room 5051 Recovery Room 5152 Labor Room and Delivery Room 5253 Anesthesiology 5354 Radiology-Diagnostic 5455 Radiology-Therapeutic 5556 Radioisotope 5657 Computed Tomography (CT) Scan 5758 Magnetic Resonance Imaging (MRI) 5859 Cardiac Catheterization 5960 Laboratory 60y61 PBP Clinical Laboratory Services-Prgm. Only 6162 Whole Blood & Packed Red Blood Cells 6263 Blood Storing, Processing, & Trans. 6364 Intravenous Therapy 6465 Respiratory Therapy 6566 Physical Therapy 6667 Occupational Therapy 6768 Speech Pathology 68


68 Speech Pathology 68

FORM CMS-2552-10 (12/2010) (INSTRUCTIONS FOR THIS WORKSHEET ARE P UBLISHED IN CMS P UB. 15-II, SECTIONS 4023)

Rev. 1 40-563

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 Inpatientcol. 26) Adj. Costs allowance Costs Inpatient Outpatient + column 7) Other Ratio Ratio Ratio

1 2 3 4 5 6 7 8 9 10 11OUTPATIENT SERVICE COST CENTERS

69 Electrocardiology 6970 Electroencephalography 7071 Medical Supplies Charged to Patients 7172 Implantable Devices Charged to Patients 7272 Implantable Devices Charged to Patients 7273 Drugs Charged to Patients 7374 Renal Dialysis 7475 ASC (Non-Distinct Part) 7576 Other Ancillary (specify) 7688 Rural Health Clinic (RHC) 8889 Federally Qualified Health Center (FQHC) 8990 Clinic 9091 Emergency 91g y92 Observation Beds (see instructions) 9293 Other Outpatient Service (specify) 93

OTHER REIMBURSABLE COST CENTERS94 Home Program Dialysis 9495 Ambulance Services 9596 Durable Medical Equipment-Rented 9697 Durable Medical Equipment-Sold 9798 Other Reimbursable (specify) 9899 O i R h bili i P id ( if ) 9999 Outpatient Rehabilitation Provider (specify) 99100 Intern-Resident Service (not appvd. tchng. prgm.) 100101 Home Health Agency 101

SPECIAL PURPOSE COST CENTERS105 Kidney Acquisition 105106 Heart Acquisition 106107 Liver Acquisition 107108 Lung Acquisition 108109 Pancreas Acquisition 109109 Pancreas Acquisition 109110 Intestinal Acquisition 110111 Islet Acquisition 111112 Other Organ Acquisition (specify) 112115 Ambulatory Surgical Center (Distinct Part) 115116 Hospice 116117 Other Special Purpose (specify) 117200 Subtotal (sum of lines 30 thru 199) 200201 Less Observation Beds 201


202 Total (line 200 minus line 201) 202

FORM CMS-2552-10 (12/2010) (INSTRUCTIONS FOR THIS WORKSHEET ARE P UBLISHED IN CMS P UB. 15-II, SECTIONS 4023)

40-564 Rev. 1

WS CWS CSteps to process WS C Data:Steps to process WS C Data:• Identify the data to be used:

– General Ledger g– Volume Report (Revenue Reclasses and Adjustments)

• Cost Center AssignmentR R l• Revenue Reclasses– Medical Supplies– Drugsg– Observation– Etc.


WS CWS CSteps to process WS C Data:Steps to process WS C Data:• Revenue Adjustments

– IP/OP charges in wrong categoryg 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

IS Recon) as well as agree to the WS C Values.


Settlement ChargesSettlement Charges

The Settlement Charges are the Medicare/Medicaid The Settlement Charges are the Medicare/Medicaid charges that have been accumulated from the Bills submitted and are sumaraized on the Provider 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 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 codeidentified by their 3(4) digit numeric revenue code.


Settlement ChargesSettlement ChargesSettlement 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 – 11U I/P Psych

120 Inpatient Part B


– 120 Inpatient - Part B

Settlement ChargesSettlement ChargesListed below are the most common OP PSR Report Types: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


– 14P O/P Other OPPS

4090 (Cont.) FORM CMS-2552-10 12-10INPATIENT ANCILLARY SERVICE PROVIDER NO.: PERIOD: WORKSHEET D-3

COST APPORTIONMENT ________________ FROM ____________ COMP ONENT NO.: TO _______________ ________________

Check [ ] Title V [ ] Hospital [ ] Subprovider (other) [ ] Swing-Bed SNF [ ] PPSapplicable [ ] Title XVIII Part A [ ] IPF [ ] SNF [ ] Swing Bed NF [ ] TEFRAapplicable [ ] Title XVIII, Part A [ ] IPF [ ] SNF [ ] Swing-Bed NF [ ] TEFRAboxes: [ ] Title XIX [ ] IRF [ ] NF [ ] ICF/MR [ ] Other

Ratio of Cost Inpatient Inpatient Program CostsCOST CENTER DESCRIPTION to Charges Program Charges (col. 1 x col. 2)

1 2 3INPATIENT ROUTINE SERVICE COST CENTERS

30 Adults and Pediatrics (General Routine Care) 3031 Intensive Care Unit 3132 Coronary Care Unit 3233 Burn Intensive Care Unit 3334 Surgical Intensive Care Unit 3435 Other Special Care (specify) 3540 Subprovider IPF 4041 Subprovider IRF 4142 Subprovider (Specify) 4243 Nursery 43

ANCILLARY SERVICE COST CENTERS50 Operating Room 5051 Recovery Room 5152 Labor Room and Delivery Room 5253 Anesthesiology 5354 Radiology‐Diagnostic 54gy g55 Radiology‐Therapeutic 5556 Radioisotope 5657 Computed Tomography (CT) Scan 5758 Magnetic Resonance Imaging (MRI) 5859 Cardiac Catheterization 5960 Laboratory 6061 PBP Clinical Laboratory Services‐Prgm. Only 6162 Whole Blood & Packed Red Blood Cells 6263 Blood Storing, Processing, & Trans. 6364 Intravenous Therapy 6465 Respiratory Therapy 6565 Respiratory Therapy 6566 Physical Therapy 6667 Occupational Therapy 6768 Speech Pathology 6869 Electrocardiology 6970 Electroencephalography 7071 Medical Supplies Charged to Patients 7172 Implantable Devices Charged to Patients 7273 Drugs Charged to Patients 7374 Renal Dialysis 7475 ASC (Non‐Distinct Part) 75

( )76 Other Ancillary (specify) 76OUTPATIENT SERVICE COST CENTERS

88 Rural Health Clinic (RHC) 8889 Federally Qualified Health Center (FQHC) 8990 Clinic 9091 Emergency 9192 Observation Beds (see instructions) 9293 Other Outpatient Service (specify) 93

OTHER REIMBURSABLE COST CENTERS94 Home Program Dialysis 9495 Ambulance Services 95


96 Durable Medical Equipment‐Rented 9697 Durable Medical Equipment‐Sold 9798 Other Reimbursable (specify) 98200 Total (sum of lines 50‐94 and 96‐98) 200201 Less PBP Clinic Laboratory Services‐Program only charges (line 61) 201202 Net Charges (line 200 minus line 201) 202


40-578 Rev. 1

4090 (Cont.) FORM CMS-2552-10 12-10APPORTIONMENT 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 SNFli bl [ ] Ti l XVIII P B [ ] IPF [ ] SNF [ ] S i B d NFapplicable [ ] Title XVIII, Part B [ ] IPF [ ] SNF [ ] Swing Bed NF

boxes: [ ] Title XIX - O/P [ ] IRF [ ] NF [ ] ICF/MRPART V - APPORTIONMENT OF MEDICAL AND OTHER HEALTH SERVICES COSTS

Cost to Cost Reimbursed Cost Reimbursed Cost CostCharge Services Services Not PPS Services Services Not

Ratio from PPS Reimbursed Subject to Subject to Services Subject to Subject toWorksheet 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 7ANCILLARY SERVICE COST CENTERS

Program Charges Program Cost

Cost Center DescriptionANCILLARY SERVICE COST CENTERS

50 Operating Room 5051 Recovery Room 5152 Labor & Delivery Room 5253 Anesthesiology 5354 Radiology-Diagnostic 5455 Radiology-Therapeutic 5556 Radioisotope 5657 Computed Tomography (CT) Scan 5758 Magnetic Resonance Imaging (MRI) 5859 Cardiac Catheterization 5960 Laboratory 6061 PBP Clinic Laboratory Services-Prgm. Only 6162 Whole Blood & Packed Red Blood Cells 6263 Blood Storing, Processing, & Transfusing 6364 Intravenous Therapy 6465 Respiratory Therapy 6566 Physical Therapy 6667 Occupational Therapy 6768 Speech Pathology 6869 Electrocardiology 6970 Electroencephalography 7070 Electroencephalography 7071 Medical Supplies Charged To Patients 7172 Implantable Devices Charged to Patients 7273 Drugs Charged to Patients 7374 Renal Dialysis 7475 ASC (Non-Distinct Part) 7576 Other Ancillary (specify) 76

OUTPATIENT SERVICE COST CENTERS88 Rural Health Clinic (RHC) 8889 Federally Qualified Health Center (FQHC) 8990 Clinic 9091 Emergency 9192 Observation Bed 9293 Other Outpatient Service (specify) 93

OTHER REIMBURSABLE COST CENTERS94 Home Program Dialysis 9495 Ambulance 9596 Durable Medical Equipment-Rented 9697 Durable Medical Equipment-Sold 9798 Other Reimbursable Cost Center 98200 Subtotal (see instructions) 200201 L PBP Cli i L b S i P 201


201 Less PBP Clinic Lab. Services-Program 201 Only Charges

202 Net Charges (line 200 ± line 201 ) 202

FORM CMS-2552-10 (12/2010) (INSTRUCTIONS FOR THIS WORKSHEET ARE P UBLISHED IN CMS P UB. 15-II, SECTIONS 4024.5)

40-572 Rev. 1

Settlement ChargesSettlement ChargesThe Settlement charges are intended to be identified against the 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 3. Allocate Total Charges to all cost centers based on the Total or Medicare total

charges by cost center (Total Allocation)4. A combination of the three methods identified above (3rd most common method)


Settlement ChargesSettlement ChargesSteps to process 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


Settlement ChargesSettlement ChargesSteps to process Settlement Charges:Steps to process Settlement Charges:• Adjustments to the PSR

– Pending Claimsg– Errors

• Grouping / Allocation of ChargesU i R d U fil– Using Revenue and Usage files

– Crosswalks to Cost Centers– Specialty Revenue Codes

• Observation• Medical Supplies• Implantable Devices

Dr gs


• Drugs

Settlement ChargesSettlement ChargesSteps to process 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


Settlement DataSettlement Data

Settlement Data is the information that is contained on Settlement Data is the information that is contained on the PSR that is not Charges (No Revenue Code). Examples of Settlement Data are:Examples of Settlement Data are:

– DeductibleC I– Co-Insurance

– PPS Payments (DRG, APC, RUGS, etc.)– Interim Payments– Capital Payments


– Etc.

4090 (Cont.) CMS FORM-2552-10 12-10CALCULATION OF REIMBURSEMENT PROVIDER NO.: PERIOD: WORKSHEET E,SETTLEMENT ________________ FROM ____________ PART A

COMPONENT NO.: TO _______________ ________________

Check [ ] Hospitalapplicable box: [ ] Subprovider (Other)

PART A - INPATIENT HOSPITAL SERVICES UNDER PPS

1 DRG amounts other than outlier payments 12 Outlier payments for discharges (see instructions) 23 Managed care simulated payments 34 Bed days available divided by number of days in the cost reporting period (see instructions) 44 Bed days available divided by number of days in the cost reporting period (see instructions) 4

Indirect Medical Education Adjustment Calculation for Hospitals5 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) 8p ( )9 Sum of lines 5 through 7 plus/minus line 8 (see instructions) 910 FTE count for allopathic and osteopathic programs in the current year from your records 1011 FTE count for residents in dental and podiatric programs 1112 Current year allowable FTE (see instructions) 1213 Total allowable FTE count for the prior year 1314 Total allowable FTE count for the penultimate year if that year ended on or after September 30, 1997, otherwise enter zero. 1415 Sum of lines 12 through 14 divided by 3 1516 Adjustment for residents in initial years of the program 1617 Adjustment for residents displaced by program or hospital closure 1718 Adjusted rolling average FTE count 1819 Current year resident to bed ratio (line 15 divided by line 4) 1920 Prior year resident to bed ratio (see instructions) 2021 Enter the lesser of lines 19 or 20 (see instructions) 2122 IME payment adjustment (see instructions) 22

Indirect Medical Education Adjustment for the Add-on23 Number of additional allopathic and osteopathic IME FTE resident cap slots under 42 Sec. 412.105 (f)(1)(iv)(C ). 2324 IME FTE resident count over cap (see instructions) 2424 IME FTE resident count over cap (see instructions) 2425 If the amount on line 24 is greater than -0-, then enter the lower of line 23 or line 24 (see instructions) 2526 Resident to bed ratio (divide line 25 by line 4) 2627 IME payments adjustment (see instructions) 2728 IME Adjustment (see instructions) 2829 Total IME payment (sum of lines 22 and 28) 29

Disproportionate Share Adjustment30 Percentage of SSI recipient patient days to Medicare Part A patient days (see instructions) 3031 Percentage of Medicaid patient days to total days reported on Worksheet S-3, Part I (see instructions) 31


g p y y p ( )32 Sum of lines 30 and 31 3233 Allowable disproportionate share percentage (see instructions) 3334 Disproportionate share adjustment (see instructions) 34

FORM CMS-2552-10 (12/2010) (INSTRUCTIONS FOR THIS WORKSHEET ARE P UBLISHED IN CMS P UB. 15-II, SECTION 4030.1)

40-584 Rev. 1

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 [ ] HospitalCheck [ ] Hospitalapplicable box: [ ] IRF

PART A - INPATIENT HOSPITAL SERVICES UNDER PPS

Additional payment for high percentage of ESRD beneficiary discharges40 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) 4142 Divide line 41 by line 40 (if less than 10%, you do not qualify for adjustment) 42y ( y q y j )43 Total Medicare ESRD inpatient days excluding MS-DRGs 652, 682, 683, 684 an 685 (see instructions) 4344 Ratio of average length of stay to one week (line 43 divided by line 41 divided by 7 days) 4445 Average weekly cost for dialysis treatments (see instructions) 4546 Total additional payment (line 45 times line 44 times line 41) 4647 Subtotal (see instructions) 4748 Hospital specific payments (to be completed by SCH and MDH, small rural hospitals only (see instructions) 4849 Total payment for inpatient operating costs SCH and MDH only (see instructions) 4950 Payment for inpatient program capital (from Worksheet L, Parts I, II, as applicable) 5051 Exception payment for inpatient program capital (Worksheet L, Part III) (see instructions) 5152 Direct graduate medical education payment (from Worksheet E-4, line 49) (see instructions). 5253 Nursing and allied health managed care payment 5354 Special add-on payments for new technologies 5455 Net organ acquisition cost (Worksheet D-4 Part III, col. 1, line 69) 5556 Cost of teaching physicians (Worksheet D-5, Part II, col. 3, line 20) 5657 Routine service other pass through costs 5758 Ancillary service other pass through costs Worksheet D, Part IV, col. 11 line 200) 5859 Total (sum of amounts on lines 49 through 58) 5960 Primary payer payments 6061 Total amount payable for program beneficiaries (line 59 minus line 60) 6161 Total amount payable for program beneficiaries (line 59 minus line 60) 6162 Deductibles billed to program beneficiaries 6263 Coinsurance billed to program beneficiaries 6364 Allowable bad debts (see instructions) 6465 Adjusted reimbursable bad debts (see instructions) 6566 Allowable bad debts for dual eligible beneficiaries (see instructions) 6667 Subtotal (line 61 plus line 65 minus lines 62 and 63) 6768 Credits received from manufacturers for replaced devices applicable to MS-DRG (see instructions) 6869 Outlier payments reconciliation 6970 Other adjustments (specify) (see instructions) 70j ( p y) ( )71 Amount due provider (line 67 minus lines 68 plus/minus lines 69 & 70) 7172 Interim payments 7273 Tentative settlement (for contractor use only) 7374 Balance due provider (Program) (sum of lines 71 minus the sum of lines 72 and 73) 7475 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-II, section 115.2 75

TO BE COMPLETED BY CONTRACTOR90 Operating outlier amount from Worksheet E, Part A line 2 9091 Capital outlier from Worksheet L, Part I, line 2 91


92 Operating outlier reconciliation adjustment amount (see instructions) 9293 Capital outlier reconciliation adjustment amount (see instructions) 9394 The rate used to calculate the Time Value of Money (see instructions) 9495 Time Value of Money for operating expenses (see instructions) 9596 Time Value of Money for capital related expenses (see instructions) 96


Rev. 1 40-585

4090 (Cont.) FORM CMS-2552-10 12-10CALCULATION OF PROVIDER NO.: PERIOD: WORKSHEET E,REIMBURSEMENT SETTLEMENT ________________ FROM ____________ PART B

COMPONENT NO.: TO _______________ ________________

Check applicable box: [ ] Hospital [ ] IPF [ ] IRF [ ] Subprovider (Other) [ ] SNFCheck applicable box: [ ] Hospital [ ] IPF [ ] IRF [ ] Subprovider (Other) [ ] SNFPART B - MEDICAL AND OTHER HEALTH SERVICES1 Medical and other services (see instructions) 12 Medical and other services reimbursed under OPPS (see instructions). 23 PPS payments 34 Outlier payment (see instructions) 45 Enter the hospital specific payment to cost ratio (see instructions) 56 Line 2 times line 5 67 Sum of lines line 3 plus line 4 divided by line 6 78 Transitional corridor payment (see instructions) 89 Enter the amount from Worksheet D, Part IV, column 13, line 200 910 Organ acquisition 1011 Total cost (sum of lines 1 and 10) (see instructions) 11

COMPUTATION OF LESSER OF COST OR CHARGESReasonable charges

12 Ancillary service charges 1213 Organ acquisition charges (from Worksheet D‐4, Part III, line 69, col. 4) 1314 Total reasonable charges (sum of lines 12 and 13) 14

Customary charges15 Aggregate amount actually collected from patients liable for payment for services on a charge basis 1516 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) 1718 Total customary charges (see instructions) 1819 Excess of customary charges over reasonable cost (complete only if line 18 exceeds line 11) (see instructions) 1920 Excess of reasonable cost over customary charges (complete only if line 11 exceeds line 18) (see instructions) 2021 Lesser of cost or charges (line 11 or line 20) (for CAH, see instructions) 2122 Interns and residents (see instructions) 2223 Cost of teaching physicians (see instructions 42 CFR 415 160 and CMS Pub 15 1 §2148) 2323 Cost of teaching physicians (see instructions, 42 CFR 415.160 and CMS Pub. 15‐1, §2148) 2324 Total prospective payment (sum of lines 3, 4, 8 and 9) 24

COMPUTATION OF REIMBURSEMENT SETTLEMENT25 Deductibles and coinsurance (see instructions) 2526 Deductibles and Coinsurance relating to amount on line 24 (see instructions) 2627 Subtotal {(lines 21 and 24 ‐ the sum of lines 25 and 26) plus the sum of lines 22 and 23} (see instructions) 2728 Direct graduate medical education payments (from Worksheet E‐4, line 50) 2829 ESRD direct medical education costs (from Worksheet E‐4, line 36) 2930 Subtotal (sum of lines 27 through 29) 3031 Primary payer payments 31y p y p y32 Subtotal (line 30 minus line 31) 32 ALLOWABLE BAD DEBTS (EXCLUDE BAD DEBTS FOR PROFESSIONAL SERVICES) 33 Composite rate ESRD (from Worksheet I‐5, line 11) 3334 Allowable bad debts (see instructions) 3435 Adjusted reimbursable bad debts (see instructions) 3536 Allowable bad debts for dual eligible beneficiaries (see instructions) 3637 Subtotal (sum of lines 32, 33, and 34 or 35) (line 35 hospital and subprovider only) 3738 MSP‐LCC reconciliation amount from PS&R 3839 Other adjustments (specify) (see instructions) 39


40 Subtotal (line 37 plus or minus lines 39 minus 38) 4041 Interim payments 4142 Tentative settlement (for contractors use only) 4243 Balance due provider/program (line 40 minus the sum of lines 41, and 42) 4344 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15‐II, section 115.2 44


40-586 Rev.1

4090 (Cont.) FORM CMS-2552-10 12-10ANALYSIS OF PAYMENTS TO PROVIDERS PROVIDER NO.: PERIOD: WORKSHEET E-1,FOR SERVICES RENDERED ________________ FROM ____________ PART I

COMPONENT NO.: TO _______________________________

Check [ ] Hospital [ ] Subprovider (Other) Inpatientapplicable [ ] IPF [ ] SNF Part A Part Bbox: [ ] IRF [ ] Swing-Bed SNF mm/dd/yyyy Amount mm/dd/yyyy Amount

Description 1 2 3 41 Total interim payments paid to provider 12 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 zerofor services rendered in the cost reporting period. If none, write NONE or enter a zero3 List separately each retroactive .01 3.01

lump sum adjustment amount based .02 3.02on subsequent revision of the Program to .03 3.03interim rate for the cost reporting period. Provider .04 3.04Also show date of each payment. .05 3.05If none, write "NONE" or enter a zero. (1) .50 3.50

.51 3.51Provider to .52 3.52Program .53 3.53

.54 3.54Subtotal (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, lineand column as appropriate)TO BE COMPLETED BY CONTRACTORTO BE COMPLETED BY CONTRACTOR

5 List separately each tentative settlement Program to .01 5.01payment after desk review. Also show Provider .02 5.02date of each payment. .03 5.03If none, write "NONE" or enter a zero. (1) .50 5.50

Provider to .51 5.51Program .52 5.52

Subtotal (sum of lines 5.01‐5.49minus sum of lines 5.50 ‐5.98) .99 5.99Subtotal (sum of lines 5.01 5.49 minus sum of lines 5.50 5.98) .99 5.996 Determined net settlement amount (balance Program to provider .01 6.01

due) based on the cost report (1) Provider to program .02 6.027 Total Medicare program liability (see instructions) 78 Name of Contractor Contractor Number 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.


40-588 Rev. 1

12-10 FORM CMS-2552-10 4090 (Cont.)CALCULATION OF REIMBURSEMENT SETTLEMENT PROVIDER NO.: PERIOD: WORKSHEET E‐3,

________________ FROM ____________ PART ICOMPONENT NO.: TO _______________ ________________

Check [ ] Hospitalapplicable [ ] Subprovider (Other) box:

PART I CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER TEFRAPART I - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER - TEFRA

1 Inpatient hospital services (see instructions) 12 Organ acquisition 23 Cost of teaching physicians (from Worksheet D‐5, Part II, column 3, line 20) (see instructions) 34 Subtotal (sum of lines 1 thru 3) 45 Primary payer payments 55 Primary payer payments 56 Subtotal (line 4 less line 5). 67 Deductibles 78 Subtotal (line 6 minus line 7) 89 Coinsurance 910 Subtotal (line 8 minus line 9) 1011 Allowable bad debts (exclude bad debts for professional services) (see instructions) 11( p ) ( )12 Adjusted reimbursable bad debts (see instructions) 1213 Allowable bad debts for dual eligible beneficiaries (see instructions) 1314 Subtotal (sum of lines 10 and 12) 1415 Direct graduate medical education payments (from Worksheet E‐4, line 49) 1516 Other pass through costs (see instructions) 1617 Other adjustments (specify) (see instructions) 1718 Total amount payable to the provider (see instructions) 1819 Interim payments 1920 Tentative settlement (for contractor use only) 2021 Balance due provider/program (line 18 minus the sum lines 19 and 20) 2122 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2 22



Rev. 1 40-591

4090 (Cont.) FORM CMS-2552-10 12-10CALCULATION OF REIMBURSEMENT SETTLEMENT PROVIDER NO.: PERIOD: WORKSHEET E‐3,

________________ FROM ____________ PART II COMPONENT NO.: TO _______________________________


PART II - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER IPF PPS

1 Net Federal IPF PPS payment (excluding outlier, ECT, and medical education payments) 12 Net IPF PPS Outlier payment 2p y3 Net IPF PPS ECT payment 34 Unweighted intern and resident FTE count in the most recent cost report filed on or before November 15, 2004 (see instructions) 45 New teaching program adjustment (see instructions) 56 Current year unweighted FTE count of I&R other than FTEs in the first 3 years of a "new teaching program" (see instructions) 67 Current year unweighted I&R FTE count for residents within the first 3 years of a "new teaching program" (see instructions) 78 Intern and resident count for IPF PPS medical education adjustment (see instructions) 89 Average daily census (see instructions) 9

10 Medical Education Adjustment Factor {((1 + (line 8/line 9)) raised to the power of .5150 -1}. 10j {(( ( )) p }11 Medical Education Adjustment (line 1 multiplied by line 10). 1112 Adjusted Net IPF PPS Payments (sum of lines 1, 2, 3 and 11) 1213 Nursing and allied health managed care payment (see instruction) 1314 Organ acquisition 1415 Cost of teaching physicians (from Worksheet D‐5, Part II, column 3, line 20) (see instructions) 1516 Subtotal (see instructions) 1617 Primary payer payments 1718 Subtotal (line 16 less line 17). 1818 Subtotal (line 6 less line 7). 1819 Deductibles 1920 Subtotal (line 18 minus line 19) 2021 Coinsurance 2122 Subtotal (line 20 minus line 21) 2223 Allowable bad debts (exclude bad debts for professional services) (see instructions) 2324 Adjusted reimbursable bad debts (see instructions) 2425 Allowable bad debts for dual eligible beneficiaries (see instructions) 2526 Subtotal (sum of lines 22 and 24) 2626 Subtotal (sum of lines 22 and 24) 2627 Direct graduate medical education payments (from Worksheet E‐4, line 49) 2728 Other pass through costs (see instructions) 2829 Outlier payments reconciliation 2930 Other adjustments (specify) (see instructions) 3031 Total amount payable to the provider (see instructions) 3132 Interim payments 3233 Tentative settlement (for contractor use only) 3334 Balance due provider/program (line 31minus the sum lines 32 and 33) 34


34 Balance due provider/program (line 31 minus the sum lines 32 and 33) 3435 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2 35


40-592 Rev. 1

12-10 FORM CMS-2552-10 4090 (Cont.)CALCULATION OF REIMBURSEMENT SETTLEMENT PROVIDER NO.: PERIOD: WORKSHEET E‐3,

________________ FROM ____________ PART III COMPONENT NO.: TO _______________________________


PART III - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER IRF PPS

1 Net Federal PPS payment (see instructions) 12 Medicare SSI ratio (IRF PPS only) (see instructions) 23 Inpatient Rehabilitation LIP payments (see instructions) 34 Outlier payments 45 Unweighted intern and resident FTE count in the most recent cost reporting period ending 5

on or prior to November 15, 2004 (see instructions)6 New teaching program adjustment (see instructions) 67 Current year unweighted FTE count of I&R other than FTEs in the first 3 years of a "new teaching program" (see instructions) 78 Current year unweighted I&R FTE count for residents within the first 3 years of a "new teaching program" (see instructions) 89 Intern and resident count for IRF PPS medical education adjustment (see instructions) 910 A d il ( i t ti ) 1010 Average daily census (see instructions) 1011 Medical Education Adjustment Factor {((1 + (line 9/line 10)) raised to the power of .6876 -1}. 1112 Medical Education Adjustment (line 1 multiplied by line 11). 1213 Total PPS Payment (sum of lines 1, 3, 4 and 12) 1314 Nursing and Allied Health Managed Care payment (see instructions) 1415 Organ acquisition 1516 Cost of teaching physicians (from Worksheet D‐5, Part II, column 3, line 20) (see instructions) 1617 Subtotal (see instructions) 1718 Primary payer payments 1818 Primary payer payments 1819 Subtotal (line 17 less line 18). 1920 Deductibles 2021 Subtotal (line 19 minus line 20) 2122 Coinsurance 2223 Subtotal (line 21 minus line 22) 2324 Allowable bad debts (exclude bad debts for professional services) (see instructions) 2425 Adjusted reimbursable bad debts (see instructions) 2526 Allowable bad debts for dual eligible beneficiaries (see instructions) 266 Allowable bad debts for dual eligible beneficiaries (see instructions) 627 Subtotal (sum of lines 23 and 25) 2728 Direct graduate medical education payments (from Worksheet E‐4, line 49) 2829 Other pass through costs (see instructions) 2930 Outlier payments reconciliation 3031 Other adjustments (specify) (see instructions) 3132 Total amount payable to the provider (see instructions) 3233 Interim payments 3334 Tentative settlement (for contractor use only) 34


35 Balance due provider/program (line 32 minus the sum lines 33 and 34) 3536 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2 36


Rev. 1 40-593

4090 (Cont.) FORM CMS-2552-10 12-10CALCULATION OF CAPITAL PAYMENT PROVIDER NO.: PERIOD: WORKSHEET L

____________ FROM ____________ COMPONENT NO.: TO ___________________________

Check [ ] Title V [ ] Hospital [ ] PPSapplicable [ ] Title XVIII, Part A [ ] Subprovider (other) [ ] Cost Methodboxes: [ ] Title XIXPART I ‐ FULLY PROSPECTIVE METHOD

CAPITAL FEDERAL AMOUNT1 Capital DRG other than outlier 12 Capital DRG outlier payments 23 Total inpatient days divided by number of days in the cost reporting period (see instructions) 34 Number of interns & residents (see instructions) 44 Number of interns & residents (see instructions) 45 Indirect medical education percentage (see instructions) 56 Indirect medical education adjustment (sum of lines 1 & 2 times line 5) 67 Percentage of SSI recipient patient days to Medicare Part A patient days (Worksheet E, part A line 30) (see instructions) 78 Percentage of Medicaid patient days to total days reported on Worksheet S‐3, Part I (see instructions) 89 Sum of lines 3 and 4 910 Allowable disproportionate share percentage (see instructions) 1011 Disproportionate share adjustment (line 6 times the sum of lines 1 and 2) 1112 Total prospective capital payments (sum of lines 1‐2, 6 and 11) 12p p p p y ( , )PART II ‐ PAYMENT UNDER REASONABLE COST1 Program inpatient routine capital cost (see instructions) 12 Program inpatient ancillary capital cost (see instructions) 23 Total inpatient program capital cost (line 1 plus line 2) 34 Capital cost payment factor (see instructions) 45 Total inpatient program capital cost (line 3 x line 4) 5

PART III ‐ COMPUTATION OF EXCEPTION PAYMENTS1 Program inpatient capital costs (see instructions) 12 Program inpatient capital costs for extraordinary circumstances (see instructions) 23 Net program inpatient capital costs (line 1 minus line 2) 34 Applicable exception percentage (see instructions) 45 Capital cost for comparison to payments (line 3 x line 4) 56 Percentage adjustment for extraordinary circumstances (see instructions) 67 Adjustment to capital minimum payment level for extraordinary circumstances (line 2 x line 6) 78 Capital minimum payment level (line 5 plus line 7) 89 Current year capital payments (from Part I, line 12 as applicable) 910 Current year comparison of capital minimum payment level to capital payments (line 8 less line 9) 1010 Current year comparison of capital minimum payment level to capital payments (line 8 less line 9) 1011 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) 1213 Current year exception payment (if line 12 is positive, enter the amount on this line) 1314 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) 1516 Current year operating and capital costs (see instructions) 16


y p g p ( )17 Current year exception offset amount (see instructions) 17

FORM CMS-2552-10 (12/2010) (INSTRUCTIONS FOR THIS WORKSHEET ARE P UBLISHED IN CMS P UB. 15-II, SECTIONS 4064.1 - 4064.3)

40-646 Rev. 1

Settlement DataSettlement DataSteps to process Settlement Data:Steps to process Settlement Data:• Identify the data to be used:

– Provider Statistical Report (PSR) p ( )– Medicare logs– Settlement Crosswalk

• Start with PSR• Start with PSR• Adjustments to the PSR

– Pending Claimsg– Errors

• Grouping Settlement DataTi S iti D t


– Time Sensitive Data

Settlement DataSettlement Data• The following is the basic IP Grouping of Settlement Data:• The following is the basic IP Grouping of Settlement Data:

– Federal Specific Payments– OutliersOutliers– Co-Insurance– Deductible– Medicare Secondary Payor Payments (MSP)– Etc.


WS S 2 (Provider Questionnaire)WS S-2 (Provider Questionnaire)

WS S 2 is designed to provide CMS with basic WS S-2 is designed to provide CMS with basic demographic information about the hospital to identify various reimbursement mechanisms as well as various reimbursement mechanisms as well as specialty programs and services.

M tl Y /N A– Mostly Yes/No Answers– Misc Data


4090 (Cont.) FORM CMS-2552-10 12-10HOSPITAL AND HOSPITAL HEALTH CARE PROVIDER NO.: PERIOD WORKSHEET S‐2COMPLEX IDENTIFICATION DATA FROM __________ PART I

______________ TO _____________Hospital and Hospital Health Care Complex Address:Hospital and Hospital Health Care Complex Address:1 Street: P.O. Box: 12 City: State: Zip Code: County: 2Hospital 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 83 Hospital 34 Subprovider‐ IPF 45 S b id IRF 55 Subprovider‐ IRF 56 Subprovider‐ (Other) 67 Swing Beds‐SNF 78 Swing Beds‐NF 89 Hospital‐Based SNF 910 Hospital‐Based NF 1011 Hospital‐Based OLTC 1112 Hospital‐Based HHA 1213 Separately Certified ASC 1314 Hospital‐Based Hospice 1415 Hospital‐Based Health Clinic‐RHC 1516 Hospital‐Based Health Clinic‐FQHC 1617 Hospital‐Based (CMHC) 1718 Renal Dialysis 1819 Other 19

20 Cost Reporting Period (mm/dd/yyyy) From:_______________ To: ______________ 2021 Type of control (see instructions) 21yp ( )Inpatient PPS Information 1 222 Does this facility qualify for and receive disproportionate share hospital payment in accordance with 42 CFR §412.106, or low income payment in accordance with 42 CFR §412.624 (e)(2)? 22

In column 1, enter "Y" for yes and "N" for no. Is this facility subject to 42 CFR §412.06 (c )(2) (Pickle amendment hospital)? In column 2, enter "Y" for yes or "N" for no. 23 Which method is used to determine Medicaid days on Worksheet S‐3, Part I, line 32, column 7? 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 OtherMedicaid Medicaid Medicaid Medicaid HMO Medicaidpaid days eligible days paid days eligible days days dayspaid days eligible days paid days eligible days days days

1 2 3 4 5 624 If line 22 is "yes", and this provider is an IPPS hospital enter the in‐state Medicaid paid days in col. 1, in‐state 24

Medicaid eligible days in col. 2 out‐of‐state Medicaid paid days in col. 3, out‐of‐state Medicaid eligible daysin col. 4, Medicaid HMO days in col. 5, and other Medicaid days in col. 6.

25 If line 22 is "yes", and this provider is an IRF then, enter the in‐state Medicaid paid days in col. 1, in‐state 25Medicaid eligible days in col. 2, out‐of‐state Medicaid days in col. 3, out‐of state Medicaid eligible daysin col. 4 Medicaid HMO days in col. 5 and other Medicaid days in col. 6.

26 E d d hi l ifi i ( ) h b i i f h i i d E "1" f b d "2" f l 26


26 Enter your standard geographic classification (not wage) status at the beginning of the cost reporting period. Enter "1" for urban and "2" for rural. 2627 Enter your standard geographic classification (not wage) status at the end of the cost reporting period. Enter "1" for urban and "2" for rural. 27


40-504 Rev. 1

12-10 FORM CMS-2552-10 4090 (Cont.)HOSPITAL AND HOSPITAL HEALTH CARE PROVIDER NO.: PERIOD WORKSHEET S‐2COMPLEX IDENTIFICATION DATA FROM __________ PART I (CONT.)

______________ TO _____________35 If this is a sole community hospital (SCH), enter the number of periods SCH status in effect in the cost reporting period. 35y p ( ), p p g p36 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: ______________ 3637 If this is a Medicare dependent hospital (MDH), enter the number of periods MDH status in effect in the cost reporting period. 3738 Enter applicable beginning and ending dates of MDH status. Subscript line 38 for number of periods in excess of one and enter subsequent dates. Beginning:_______________ Ending: ______________ 38

V XVIII XIX Prospective Payment System (PPS)‐Capital 1 2 345 Does this facility qualify and receive capital payment for disproportionate share in accordance with 42 CFR §412.320? (see instructions) 4546 Is this facility eligible for the special exceptions payment pursuant to 42 CFR §412.348(g)? If yes, complete Worksheet L, Part III and L‐1, Parts I through III. 46y g p p p y p § (g) y , p , , g47 Is this a new hospital under 42 CFR §412.300 PPS capital? Enter "Y for yes and "N" for no in column 1. 47

Is the facility electing full federal payment? Enter "Y" for yes and "N" for no in column 2.

V XVIII XIXTeaching Hospitals 1 2 355 Is this a teaching hospital? Enter "Y" for yes or "N" for no. 5556 If line 55 is yes, is this teaching program approved in accordance with CMS Pub. 15‐1, chapter 4? 5657 If line 56 is yes, was Medicare participation and approved teaching program status in effect during the first month of the cost reporting period? 57y , p p pp g p g g p g p

If yes, complete Worksheet E‐4. If no, complete Worksheet D, Part III & IV and D‐2, Part II, if applicable.58 If line 55 is yes, did this facility elect cost reimbursement for physicians' services as defined in CMS Pub. 15‐1, section 2148? 58

If yes, complete Worksheet D‐5.59 Are costs claimed on line 100 of Worksheet A? If yes, complete Worksheet D‐2, Part I. 5960 Has this facility's direct GME FTE cap (column 1) or IME FTE cap (column 2) been reduced under 42 CFR §413.79(c)(3) or 42 CFR §412.105(f)(1)(iv)(B)? 60

Enter "Y" for yes and "N" for no in the applicable columns. (see instructions)61 Has this facility received additional direct GME FTE resident cap slots or IME FTE residents cap slots under 42 CFR §413.79(c)(4) or 42 CFR §412.105(f)(1)(iv)(C)? 61

Enter "Y" for yes and "N" for no in the applicable columns. (see instructions)nter Y for yes and N for no in the applicable columns. (see instructions)62 Are costs claimed for nursing and allied health costs? (see instructions) 62

Inpatient Psychiatric Facility PPS70 Is this facility an Inpatient Psychiatric Facility (IPF), or does it contain an IPF subprovider? Enter "Y" for yes and "N" for no. 7071 If line 70 yes: 71

Column 1: Did the facility have a teaching program in the most recent cost report filed on or before November 15, 2004? Enter "Y" for yes or "N" for no. Column 2: Did this facility training residents in a new teaching program in accordance with 42 CFR §412.424 (d)(1)(iii)(D)? Enter "Y" for yes and "N" for no.Column 3: If column 2 is Y, enter 1, 2 or 3 respectively in column 3. (see instructions) If this cost reporting period covers the beginning of the fourth year, enter 4 Column 3: If column 2 is Y, enter 1, 2 or 3 respectively in column 3. (see instructions) If this cost reporting period covers the beginning of the fourth year, enter 4 in column 3, or if the subsequent academic years of the new teaching program in existence, enter 5. (see instructions)

Inpatient Rehabilitation Facility PPS75 Is this facility an Inpatient Rehabilitation Facility (IRF), or does it contain an IRF subprovider? Enter "Y" for yes and "N" for no. 7576 If line 75 yes: 76

Column 1: Did the facility have a 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 training residents in a new teaching program in accordance with 42 CFR §412.424 (d)(1)(iii)(D)? Enter "Y" for yes and "N" for no.Column 3: If column 2 is Y, enter 1, 2 or 3 respectively in column 3. (see instructions) If this cost reporting period covers the beginning of the fourth year, enter 4


Column 3: If column 2 is Y, enter 1, 2 or 3 respectively in column 3. (see instructions) If this cost reporting period covers the beginning of the fourth year, enter 4 in column 3, or if the subsequent academic years of the new teaching program in existence, enter 5. (see instructions)


40-504 Rev. 1

12-10 FORM CMS-2552-10 4090 (Cont.)HOSPITAL AND HOSPITAL HEALTH CARE PROVIDER NO.: PERIOD WORKSHEET S‐2COMPLEX IDENTIFICATION DATA FROM __________ PART I (CONT.)

______________ TO _____________Long Term Care Hospital PPS80 Is this a Long Term Care Hospital (LTCH)? Enter "Y" for yes or "N" for no. 80

TEFRA Providers85 Is this a new hospital under 42 CFR §413.40(f)(1)(i) TEFRA? Enter "Y" for yes, and "N" for no. 8586 Did this facility establish a new Other subprovider (excluded unit) under 42 CFR §413.40(f)(1)(ii)? Enter "Y" for yes, and "N" for no. 86

V XIX Title V and XIX Inpatient Services 1 290 Does this facility have title V and/or XIX inpatient hospital services? Enter "Y" for yes, and "N" for no in applicable column. 9091 Is this hospital reimbursed for title V and/or XIX through the cost report either in full or in part? Enter "Y" for yes, and "N" for no in the applicable column. 9192 A i l XIX NF i i i l XVIII SNF b d (d l ifi i )? ( i i ) E "Y" f d "N" f i h li bl l 9292 Are title XIX NF patients occupying title XVIII SNF beds (dual certification)? (see instructions) Enter "Y" for yes, and "N" for no in the applicable column. 9293 Does this facility operate an ICF\MR facility for purposes of title V and XIX? Enter "Y" for yes, and "N" for no in the applicable column. 9394 Does title V or title XIX reduce capital cost? Enter "Y" for yes or "N" for no in the applicable column. 9495 If line 94 is "Y", enter the reduction percentage in the applicable column. 9596 Does title V or title XIX reduce operating cost? Enter "Y" for yes or "N" for no in the applicable column. 9697 If line 96 is "Y", enter the reduction percentage in the applicable column. 97

Rural Providers105 Does this hospital qualify as a Critical Access Hospital (CAH)? 105106 If this facility qualifies as a CAH has it elected the all‐inclusive method of payment for outpatient services? (see instructions) 106106 If this facility qualifies as a CAH, has it elected the all inclusive method of payment for outpatient services? (see instructions) 106107 Column 1: If this facility qualifies as a CAH, is it eligible for cost reimbursement for I &R training programs? Enter "Y" for yes and "N" for no in column 1. (see 107

instructions) If yes, the GME elimination would not be on Worksheet B, Part I, column 26 and the program would be cost reimbursed. If yes complete Worksheet D‐2, Part II. Column 2: If this facility is a CAH, do I&Rs in an approved medical education program train in the CAH's excluded IPF and/or IRF unit? Enter "Y" for yes or "N" for no in column 2. (see instructions)

108 Is this a rural hospital qualifying for an exception to the CRNA fee schedule? See 42 CFR §412.113(c). 108Physical Occupational Speech Respiratory

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 each therapy. 109Miscellaneous Cost Reporting Information115 Is this an all‐inclusive rate provider? Enter "Y" for yes and "N" for no in column 1. If yes, enter the method used (A, B, or E only) in column 2. 115116 Is this facility classified as a referral center? 116117 Is this facility legally‐required to carry malpractice insurance? 117118 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. 118119 What is the liability limit for the malpractice insurance policy? Enter in coumn 1 the monetary limit per lawsuit. Enter in column 2 the monetary limit per policy year. 119120 Is this a SCH or EACH that qualifies for the Outpatient Hold Harmless provision in ACA §3121? Enter in column 1 "Y" for yes or "N" for no. 120

Is this a rural hospital with <100 beds that qualifies for the Outpatient Hold Harmless provision in ACA §3121? Enter in column 2 "Y" for yes or "N" for no.Transplant Center Information

/ /125 Does this facility operate a transplant center? Enter "Y" for yes and "N" for no. If yes, enter certification date(s) (mm/dd/yyyy) below. 125126 If this is a Medicare certified kidney transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 126127 If this is a Medicare certified heart transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 127128 If this is a Medicare certified liver transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 128129 If this is a Medicare certified lung transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 129130 If this is a Medicare certified pancreas transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 130131 If this is a Medicare certified intestinal transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 131132 If this is a Medicare certified islet transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 132133 If this is aMedicare certified other transplant center enter the certification date in column 1 and termination date if applicable in column 2 133


133 If this is a Medicare certified other transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 133## If this is an organ procurement organization (OPO), enter the OPO number in column 1 and termination date, if applicable, in column 2. 134


40-506 Rev. 1

4090 (Cont.) FORM CMS-2552-10 12-10HOSPITAL AND HOSPITAL HEALTH CARE PROVIDER NO.: PERIOD WORKSHEET S‐2COMPLEX IDENTIFICATION DATA FROM __________ PART I (CONT.)

______________ TO _____________

All Providers1 2

140 Are there any related organization or home office costs as defined in CMS Pub. 15‐1, chapter 10? Enter "Y" for yes and "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: __________ 141142 S P O B 142142 Street: P. O. Box: 142143 City: State: Zip Code: 143144 Are provider based physicians' costs included in Worksheet A? 144145 If costs for renal services are claimed on Worksheet A, are they costs for inpatient services only? 145146 Has the cost allocation methodology changed from the previously filed cost report? Enter "Y" for yes and "N" for no in column 1. (See CMS Pub. 15‐2, section 4020) 146

If yes, enter the approval date (mm/dd/yyyy) in column 2.147 Was there a change in the statistical basis? 147148 Was there a change in the order of allocation? 148149 Was the change to the simplified cost finding method? 149149 Was the change to the simplified cost finding method? 149

Does this facility contains a provider that qualifies for an exemption from the application of the lower of costs or charges? Enter "Y" for yes or "N" for no for each component for Part A and Part B. Part A Part B (See 42 CFR §413.13) 1 2155 Hospital 155156 Subprovider ‐ IPF 156157 Subprovider ‐ IRF 157158 Subprovider ‐ Other 158159 SNF 159160 HHA 160161 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 and "N" for no. 165

/166 If line 165 is yes, 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. 166 Name County State Zip Code CBSA FTE/Campus

1 2 3 4 5

Health Information Technology incentive in the American Recovery and Reinvestment Act (HIT)167 Is this provider a meaningful user under §1886 (n)? Enter "Y" for yes or "N" for no. 167168 If this provider is a CAH (line 105 is "Y") and is ameaningful user (line 167 is "Y") enter the reasonable cost incurred for the HIT assets (see instructions) 168


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) 168169 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


Rev. 1 40-507

WS S 2WS S-2

Data Sources used on WS S 2:Data Sources used on WS S-2:– Prior Year Cost Report

G l L d– General Ledger– Statistics


WS S 3 Part 1 (Census Data)WS S-3 Part 1 (Census Data)

WS S 3 Part 1 is designed to provide CMS with the WS S-3 Part 1 is designed to provide CMS with the Volume of Services (Patient Days/Discharges) as well as Visits for specific Services as Visits for specific Services.

– MedicareM di id– Medicaid

– Total


12-10 FORM CMS-2552-10 4090 (Cont.)HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX PROVIDER NO.: PERIOD WORKSHEET S‐3STATISTICAL DATA FROM __________ PART I

TO______________ TO _____________

WorksheetA Total Total Employees Total

Line No. of Bed Days CAH Title Title All Interns & On Nonpaid Title Title AllComponent 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 14 151 Hospital Adults & Peds. (columns 5, 1

6, 7 and 8 exclude Swing Bed,

Inpatient Days / Outpatient Visits / Trips Full Time Equivalents Discharges

Observation Bed and Hospice days)2 HMO 23 HMO IPF 34 HMO IRF 45 Hospital Adults & Peds. Swing Bed SNF 56 Hospital Adults & Peds.Swing Bed NF 67 Total Adults and Peds. (exclude 7

observation beds) (see instructions)8 I t i C U it 88 Intensive Care Unit 89 Coronary Care Unit 910 Burn Intensive Care Unit 1011 Surgical Intensive Care Unit 1112 Other Special Care 1213 Nursery 1314 Total (see instructions) 1415 CAH visits 1516 Subprovider ‐ IPF 1616 Subprovider IPF 1617 Subprovider ‐ IRF 1718 Subprovider ‐ Other 1819 Skilled Nursing Facility 1920 Nursing Facility 2021 Other Long Term Care 2122 Home Health Agency 2223 ASC (Distinct Part) 2324 Hospice (Distinct Part) 2425 CMHC 2526 RHC/FQHC (specify) 2627 Total (sum of lines 14‐26) 2728 Observation Bed Days 2829 Ambulance Trips 2930 Employee discount days (see instructions) 3031 Employee discount days ‐IRF 3132 Labor & delivery days (see instructions) 32

d d


33 LTCH non‐covered days 33


Rev. 1 40-511

WS S 3 Part 1WS S-3 Part 1Steps to process WS S 3 Part 1 Data:Steps to process WS S-3 Part 1 Data:• Identify the data to be used:

– Midnight Censusg– Patient Accounting System Statistics– Provider Summary Report (PSR)

Medicare logs– Medicare logs– CDM with Volumes– Observation Logs– Payroll Register– Statistics

• Grouping WS S-3 Part 1


Grouping WS S 3 Part 1

WS S 3 Part 1WS S-3 Part 1Steps to process WS S 3 Part 1 Data:Steps to process WS S-3 Part 1 Data:• Sort and Subtotal• Workpapers should show the WS A Cost Center Grouping as well as Workpapers should show the WS A Cost Center Grouping as well as

the WS S-3 Part 1 Line Grouping


WS S 3 Part 2 (Wage Index)WS S-3 Part 2 (Wage Index)

WS S 2 is designed to identify the Average Hourly WS S-2 is designed to identify the Average Hourly Wage of Staff and Contract Employees at the Hospital by Department or Categoryby Department or Category.

– Identify Duplication of HoursShift Differential• Shift Differential

• Overtime


4090 (Cont.) FORM CMS-2552-10 12-10HOSPITAL WAGE INDEX INFORMATION PROVIDER NO.: PERIOD WORKSHEET S‐3

FROM __________ PART IITO______________ TO _____________

Part II ‐ Wage DataWorksheet Reclassification Adjusted Paid Hours Average

A of Salaries Salaries Related Hourly WageLine 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

SALARIES SALARIES1 Total salaries (see instructions) 12 Non‐physician anesthetist Part A 23 Non‐physician anesthetist Part B 34 Physician‐Part A 45 Physician‐Part B 56 Non‐physician‐Part B 67 Interns & residents (in an approved program) 78 Home office personnel 89 SNF 910 Excluded area salaries (see instructions) 10

OTHER WAGES AND RELATED COSTS11 Contract labor (see instructions) 1112 Management and administrative services 12g13 Contract labor: physician‐Part A 1314 Home office salaries & wage‐related costs 1415 Home office: physician Part A 1516 Teaching physician salaries (see instructions) 16

WAGE‐RELATED COSTS 17 Wage‐related costs (core) Worksheet S‐3, Part IV line 24 1718 Wage‐related costs (other) Worksheet S‐3 Part IV line 25 1818 Wage related costs (other) Worksheet S 3, Part IV line 25 1819 Excluded areas 1920 Non‐physician anesthetist Part A 2021 Non‐physician anesthetist Part B 2122 Physician Part A 2223 Physician Part B 2324 Wage‐related costs (RHC/FQHC) 2425 I t & id t (i d ) 25


25 Interns & residents (in an approved program) 25

FORM CMS-2552-10 (12/2010) (INSTRUCTIONS FOR THIS WORKSHEET ARE P UBLISHED IN CMS P UB. 15-II, SECTION 4005.2 - 4005.3)

46-512 Rev. 1

12-10 FORM CMS-2552-10 4090 (Cont.)HOSPITAL WAGE INDEX INFORMATION PROVIDER NO.: PERIOD WORKSHEET S‐3

FROM __________ PART II & IIITO______________ TO _____________

Part II ‐ Wage DataWorksheet Reclassification Adjusted Paid Hours Average

A of Salaries Salaries Related Hourly WageLine 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 OVERHEAD COSTS ‐ DIRECT SALARIES26 Employee Benefits 2627 Administrative & General 2728 Administrative & General under contract (see instructions) 2829 Maintenance & Repairs 2930 Operation of Plant 3031 Laundry & Linen Service 3132 Housekeeping 3233 Housekeeping under contract (see instructions) 3334 Dietary 3435 Dietary under contract (see instructions) 3536 Cafeteria 3637 Maintenance of Personnel 3738 Nursing Administration 38g39 Central Services and Supply 3940 Pharmacy 4041 Medical Records & Medical Records Library 4142 Social Service 4243 Other General Service 43

Part III ‐ Hospital Wage Index SummaryPart III Hospital Wage Index Summary1 Net salaries (see instructions) 12 Excluded area salaries (see instructions) 23 Subtotal salaries (line 1 minus line 2) 34 Subtotal other wages and related costs (see instructions) 45 Subtotal wage‐related costs (see instructions) 56 Total (sum of lines 3 through 5) 67 T t l h d t ( i t ti ) 7


7 Total overhead cost (see instructions) 7

FORM CMS-2552-10 (12/2010) (INSTRUCTIONS FOR THIS WORKSHEET ARE P UBLISHED IN CMS P UB. 15-II, SECTION 4005.2 - 4005.3)

Rev. 1 40-513

WS S 3 Part 2WS S-3 Part 2Steps to process WS S 3 Part 2 Data:Steps to process WS S-3 Part 2 Data:• Identify the data to be used:

– General Ledgerg– Payroll Register– Contract Labor Files

Home office Documentation– Home office Documentation• Start with GL or Reconcile to the GL• Processing Payroll Hoursg y

– Identify duplicate Hours– Identify Non-Payroll items

Incorporate WS A 6 Reclasses of Salary Exp


– Incorporate WS A-6 Reclasses of Salary Exp.

WS S 3 Part 2WS S-3 Part 2Steps to process WS S 3 Part 2 Data:Steps to process WS S-3 Part 2 Data:• Grouping by Category on WS S-3 Part 2• Sort and SubtotalSort and Subtotal• Workpapers should contain the WS A Grouping as well as the WS S-

3 part 2 Grouping


WS S 10 (Uncompensated Care)WS S-10 (Uncompensated Care)

WS S 10 is designed to identify what portion of the WS S-10 is designed to identify what portion of the Hospitals Business and Profitability is provided to Uncompensated and Indigent care PatientsUncompensated and Indigent care Patients.

– This worksheet WILL become the new calculation for DSH why?DSH….why?• State Specific variances in Medicaid Eligibility• State Specific variations in coverage of servicesState Specific variations in coverage of services• CMS is just making sure that the data they collect is accurate

for the DSH calc


12-10 FORM CMS-2552-10 4090 (Cont.)HOSPITAL UNCOMPENSATED AND INDIGENT PROVIDER NO.: PERIOD: WORKSHEET S‐10CARE DATA FROM ___________

________________ TO ______________

U t d d i di t t t tiUncompensated and indigent care cost computation1 Cost to charge ratio (Worksheet C, Part I line 200 column 3 divided by line 200 column 8) 1

Medicaid (see instructions for each line)2 Net revenue from Medicaid 23 Did you receive DSH or supplemental payments from Medicaid? 34 If line 3 is yes, does line 2 include all DSH or supplemental payments from Medicaid? 45 If line 4 is no, enter DSH or supplemental payments from Medicaid 56 Medicaid charges 67 Medicaid cost (line 1 times line 6) 78 Difference between net revenue and costs for Medicaid program (line 2 plus line 5 minus line 7) 8

State Children's Health Insurance Program (SCHIP) (see instructions for each line)9 Net revenue from stand‐alone SCHIP 910 Stand‐alone SCHIP charges 1011 Stand‐alone SCHIP cost (line 1 times line 10) 1112 Difference between net revenue and costs for stand‐alone SCHIP (line 9 minus line 11) 12

Other state or local government indigent care program (see instructions for each line)13 Net revenue from state or local indigent care program (not included on lines 2, 5 or 9) 1314 Charges for patients covered under state or local indigent care program (not included in lines 6 or 10) 1415 State or local indigent care program cost (line 1 times line 14) 1516 Difference between net revenue and costs for state or local indigent care program (line 13 minus line 15) 16

Uncompensated care (see instructions for each line)17 Private grants, donations, or endowment income restricted to funding charity care 1718 Government grants, appropriations or transfers for support of hospital operations 18g pp p pp p p19 Total unreimbursed cost for Medicaid, SCHIP and state and local indigent care programs (sum of lines 8, 12 and 16) 19

Uninsured Insured Totalpatients patients (col. 1 + col. 2)

1 2 320 Total initial obligation of patients approved for charity care (at full charges excluding 20

non‐reimbursable cost centers) for the entire facility21 Cost of initial obligation of patients approved for charity care (line 1 times line 20) 2122 Partial payment by patients approved for charity care 2222 Partial payment by patients approved for charity care 2223 Cost of charity care (line 21 minus line 22) 23

24 Does the amount in line 20, column 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 charges for patient days beyond an indigent care program's length of stay limit (see instructions) 2526 Total bad debt expense for the entire facility (see instructions) 2627 Medicare bad debts for §1886(d) hospitals from Worksheets E, Part A and E, Part B, or for CAHs from Worksheet E‐3, Part V 2728 Non‐Medicare and non‐reimbursable bad debt expense (line 26 minus line 27) 2829 Cost of non‐Medicare bad debt expense (line 1 times line 28) 29


29 Cost of non‐Medicare bad debt expense (line 1 times line 28) 2930 Cost of non‐Medicare uncompensated care (line 23 column 3 plus line 29) 3031 Total unreimbursed and uncompensated care cost (line 19 plus line 30) 31


Rev. 1 40-523

WS S 10WS S-10Steps to process WS S 10 Data:Steps to process WS S-10 Data:• Identify the data to be used:

– General Ledgerg– Patient Accounting System Analysis– AR outstanding Reports

Decision Support Queries– Decision Support Queries• Group, Sort and Subtotal• Workpapers should clearly identify Where the data was obtained and p p y y

what the basis of the information is


Documentation is the Key!Documentation is the Key!

Why have we stressed documentation?Why have we stressed documentation?– Increasing Complexity

Ti L b t P ti d A dit– Time Lag between Preparation and Audit– Staff Turnover– Accuracy, Efficiency and Consistency


Electronic vs Manual data ProcessingElectronic vs. Manual data ProcessingWith voluminous data that needs to be processed and re-processed many time over to With voluminous data that needs to be processed and re processed many time over to achieve all of the analysis that are required for the cost report it is important to gain efficiency. It is always important to make sure that accuracy is never compromised for efficiency, but manual processing should only be used when the data/analysis changes y g y y gfrom year to year. Where the data/analysis remains consistent electronic processing should be used. Some ways to use electronic processing are:• Excel• Access• KPMG GL Download Import• HFS AAI Import • Other products that can help

Monarch• Easy WP


• Decision Support Systems

Special IssuesSpecial Issues

• Critical Access Hospitals• Critical Access Hospitals• Home Office Cost Statements• Skilled Nursing Cost Reports• Home Health Cost Reportsp• Community Mental Health Centers Cost Reports


WS A 8 1 (Related Parties)WS A-8-1 (Related Parties)

Related party transactions are transactions where a Related party transactions are transactions where a facility is doing business with a company or organization that has an owner or a controlling organization that has an owner or a controlling “Manager” that is also an owner or controlling “Manager” at the facility This definition also includes Manager at the facility. This definition also includes instances where one organization has “directorship” over anotherover another.

– Arms Length TransactionsA t l C t f th i / l


– Actual Cost of the service/supply

4090 (Cont.) FORM CMS-2552-10 12-10STATEMENT OF COSTS OF SERVICES PROVIDER NO.: PERIOD: WORKSHEET A‐8‐1FROM RELATED ORGANIZATIONS AND FROM ____________HOME OFFICE COSTS ________________ TO _______________

A. COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS ORCLAIMED HOME OFFICE COSTS:

Amount NetAmount of included in Adjustments Wkst.Allowable Wkst. A (col. 4 minus A‐7

Line No. Cost Center Expense Items Cost column 5 col. 5) * Ref.1 2 3 4 5 6 7

1 12 23 34 45 TOTALS (sum of lines 1‐4) Transfer column 6, line 5 to Worksheet 5

A‐8, column 2, line 12.

* The amo unts o n lines 1 thro ugh 4 (and s ubs cripts as appro pria te ) a re trans fe rred in de ta il to Wo rks hee t A, co lumn 6, lines as appro pria te .g ( p pp p ) pp p

P o s itive amo unts increas e co s t and negative amo unts decreas e co s t. Fo r re la ted o rganiza tio n o r ho me o ffice co s t which have no t

been po s ted to Wo rks hee t A, co lumns 1 and/o r 2, the amo unt a llo wable s ho uld be indicated in co lumn 4 o f this part.

B. INTERRELATIONSHIP TO RELATED ORGANIZATION(S) AND/OR HOME OFFICE:The Secre ta ry, by virtue o f the autho rity granted under s ec tio n 1814(b)(1) o f the So cia l Security Act, requires that yo u furnis h

the info rmatio n reques ted under P art B o f this wo rks hee t.

Related Organization(s) and/or Home OfficeRelated Organization(s) and/or Home OfficePercentage Percentage

Symbol of of Type of(1) Name Ownership Name Ownership Business1 2 3 4 5 6

6 67 78 89 99 910 10

(1) Us e the fo llo wing s ymbo ls to indica te inte rre la tio ns hip to re la ted o rganiza tio ns :

A. Individua l has financ ia l inte res t (s to ckho lder, pa rtner, e tc .) in bo th re la ted E. Individual is direc to r, o ffice r, adminis tra to r, o r key pers o n o f pro vider and

o rganiza tio n and in pro vider. re la ted o rganiza tio n.

B. Co rpo ra tio n, partners hip, o r o ther o rganizatio n has financ ia l inte res t in pro vider. F . Direc to r, o ffice r, adminis tra to r, o r key pers o n o f re la ted o rganiza tio n o r re la tive

C. P ro vider has financ ia l inte res t in co rpo ra tio n, partners hip, o r o ther o rganiza tio n. o f s uch pers o n has financ ia l inte res t in pro vider.


D. Direc to r, o ffice r, adminis tra to r, o r key pers o n o f pro vider o r re la tive o f s uch G. Other (financ ia l o r no n-financ ia l) s pec ify __________________________

pe rs o n has financ ia l interes t in re la ted o rganizatio n.


40-530 Rev. 1

WS A 8 1WS A-8-1Steps to process WS A 8 1 Data:Steps to process WS A-8-1 Data:• Identify the data to be used:

– General Ledgerg– Home Office cost statement– Related Party expenses (GL, TB, AFS, etc.)

• Identify the expenses on facility GL• Identify the expenses on facility GL• Identify the Related Party Expense that corresponds to the expense

incurred at the facilityy• Group, Sort and Subtotal• Workpapers should clearly identify Where the data was obtained and


what the basis of the information is

WS A 8 2 (Physician Compensation)WS A-8-2 (Physician Compensation)

CMS believes that MDs go to many years of school to CMS believes that MDs go to many years of school to learn to treat patients, therefore unless otherwise documented ALL Physician activities are Patient documented ALL Physician activities are Patient Treatment. WS A-8-2 is where the Facility can document the component of MD payments that are for document the component of MD payments that are for Administrative Duties.


WS A 8 2WS A-8-2

Physician Patient Treatment Time (Part B):Physician Patient Treatment Time (Part B):– Any time or activity where an MD is working on/for an

individual Patientindividual Patient• Chart Review• InterventionIntervention• Progress Notes• Research


WS A 8 2WS A-8-2

Physician Administrative Time (Part A):Physician Administrative Time (Part A):– Activities that are designed to help the facility manage

the treatment of all of its patientsthe treatment of all of its patients• Medical Directors• Utilization/Quality Review Utilization/Quality Review • Department Directorship• Do NOT include activities that are meant to Manage the MDs g

Practice!– Part A Activies MUST be Documented!


WS A 8 2WS A-8-2

How to document Part A vs Part BHow to document Part A vs. Part B– Part A

Time Studies (2 two week time Studies in non consecutive • Time Studies (2 two week time Studies in non-consecutive Quarters)

• Timely signatures y g• Contracts

– Part B• Unless noted as Part A time, ALL time is assumed to be for

Part B activities


12-10 FORM CMS-2552-10 4090 (Cont.)PROVIDER-BASED PHYSICIANS ADJUSTMENTS PROVIDER NO.: PERIOD: WORKSHEET A-8-2

FROM _________________________ TO _______________

Cost Center/ Physician/ 5 Percent ofWkst. A Physician Total Professional Provider RCE Provider Unadjusted UnadjustedLine # Identifier Remuneration Component Component Amount Component Hours RCE Limit RCE Limit

1 2 3 4 5 6 7 8 91 12 23 34 45 56 67 78 89 9

10 1010 1011 11

200 TOTAL 200

Cost of Provider Physician ProviderCost Center/ Memberships Component Cost of Component

Wkst. A Physician & Continuing Share of Malpractice Share of Adjusted RCELi # Id tifi Ed ti l 12 I l 14 RCE Li it Di ll Adj t tLine # Identifier Education col. 12 Insurance col. 14 RCE Limit Disallowance Adjustment

10 11 12 13 14 15 16 17 181 12 23 34 45 56 67 78 89 9

10 1011 11

200 TOTAL 200



Rev. 1 40-531

WS A 8 2WS A-8-2Steps to process WS A 8 2 Data:Steps to process WS A-8-2 Data:• Identify the data to be used:

– General Ledgerg– Payroll Register– Physician Contracts, and Invoices

Physician Time Studies– Physician Time Studies• Organize Data by MD or by Cost Center

– MD specific data is better documentation– Cost Center is for Summary


WS A 8 2WS A-8-2Steps to process WS A 8 2 Data:Steps to process WS A-8-2 Data:• Identify total compensation paid to ALL MDs

– Salary y– Benefits– Malpractice Insurance

Dues and Fees– Dues and Fees– Housing Allowance– Etc.

• Identify the Part A vs. Part B– Time Studies– Contracts


Contracts

WS A 8 2WS A-8-2Steps to process WS A 8 2 Data:Steps to process WS A-8-2 Data:• Calculate Part A vs. Part B

– Total Paid Hrs– Total Compensation

• Sort and SubtotalTh k h ld k t b bl t t th i • These workpapers should make sure to be able to trace their information to the source documentation as well as allow the auditors to easy follow the flow of the calculations and datay


WS H Series (Home Health Agency)WS H Series (Home Health Agency)Home Health services are paid on the HH Prospective P t S t (HH PPS)Payment System (HH PPS).•Home Health Agencies (HHA) must bill for all of the following provided during the 60-day HH episode:during the 60-day HH episode:

– Skilled nursing services;– Physical therapy (PT), occupational therapy (OT), and speech-language

th l (SLP) ipathology (SLP) services;– Routine and non-routine medical supplies; – HH aide services; and– Medical social services.

The WS H series is designed to identify the cost of HH services by the various disciplines


various disciplines.

WS H SeriesWS H SeriesThe WS H Series consists of the following

Worksheets:– WS S-4 Hospital-based Home Health Agency Statistical

Data• Line 1-20 obtain mostly from internal data (FTEs, Unduplicated Census, etc.)• Line 21-38 is the accumulation of PPS data obtain from the Medicare PSR.Line 21 38 is the accumulation of PPS data obtain from the Medicare PSR.

– WS H Analysis of Hospital-based Home Health Agency Costs

• Summarization of HHA costs by type (salary, benefit, etc.) and by HHA discipline (Skilled Nursing, PT, OT, Etc) from the general ledger.

• WS H, Line 24, Col. 10 Net Expenses for Allocation must equal the amount


reported on WS A, Line 101, Col. 7.

WS H SeriesWS H Series– WS H-1 Part I Cost Allocation – HHA Statistical Basis

• Serves the purpose of using statistical data on Part II of worksheet to allocate HHA specific Capital, Overhead and A&G costs to the HHA patient disciplines.

– WS H-2 Part I Allocation of General Service Costs to HHA

All ti f l i t (O h d C t ) f WS B P t I • Allocation of general services costs (Overhead Costs) from WS B, Part I, Line 101, overhead columns to HHA patient disciplines by means of statistical bases on WS H-2 Part II.

– WS H-3 – H-5 HHA Cost Apportionment and Settlement• Serves the purpose of calculating the Medicare portion of HHA costs by

ratio of Medicare visits to total visits multiplied by HHA costs.


p y• Calculates Medicare Due To/From .

WS I Series (Renal Dialysis)WS I Series (Renal Dialysis)

Renal Dialysis services are paid on the Composite Renal Dialysis services are paid on the Composite Rate (PPS), while the Epogene (Drug) is reimbursed on a $0 10 per unit flat rate The WS I series is on a $0.10 per unit flat rate. The WS I series is designed to identify the cost of Renal Dialysis treatments by the Treatment Modalities treatments by the Treatment Modalities.


WS I SeriesWS I Series

The WS I Series consists of the following Worksheets:The WS I Series consists of the following Worksheets:– WS S-5 (Renal Dialysis Treatment stats)

WS I 1 (Id tifi ti f R l Di l i E b – WS I-1 (Identification of Renal Dialysis Expenses by type of Expense)

• Must Reconcile to WS A line 74 (Renal Dialysis)• Must Reconcile to WS A line 74 (Renal Dialysis)– WS I-2 (Allocation of Expenses to the Treatment

Modalities)Modalities)• No input Required


WS I SeriesWS I SeriesWS I 3 (Statistics for each expense type for each – WS I-3 (Statistics for each expense type for each Modality)

• HemodialysisHemodialysis• Peritoneal Dialysis• Training• Maintenance• Home Program

– WS I-4 (Calculation of the Average Cost of treatment by Modality)


– WS I-5 (Calculation of Reimbursable Bad Debts)

12-10 FORM CMS-2552-10 4090 (Cont.)HOSPITAL RENAL DIALYSIS DEPARTMENT PROVIDER NO.: PERIOD: WORKSHEET S‐5STATISTICAL DATA ________________ FROM ___________

TO ______________RENAL DIALYSIS STATISTICS

Hemo‐ CAPD Hemo‐ CAPDDESCRIPTION Regular High Flux dialysis CCPD dialysis CCPD

1 2 3 4 5 61 Number of patients in program at 1

end of cost reporting period

Outpatient Training Home

2 Number of times per week patient 2 receives dialysis

3 Average patient dialysis time including setup 34 CAPD exchanges per day 45 Number of days in year dialysis furnished 56 Number of stations 67 Treatment capacity per day per station 78 Utili ti ( i t ti ) 88 Utilization (see instructions) 89 Average times dialyzers re‐used 910 Percentage of patients re‐using dialyzers 10

TRANSPLANT INFORMATION11 Number of patients on transplant list 1112 Number of patients transplanted during the cost reporting period 12

EPOETIN13 Net costs of Epoetin furnished to all maintenance dialysis patients by the provider 1314 Epoetin amount from Worksheet A for home dialysis program 1415 Number of EPO units furnished relating to the renal dialysis department 1516 Number of EPO units furnished relating to the home dialysis department 16

ARANESP17 Net costs of ARANESP furnished to all maintenance dialysis patients by the provider 1718 ARANESP amount from Worksheet A for home dialysis program 1819 Number of ARANESP units furnished relating to the renal dialysis department 1920 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


Rev. 1 40-517

12-10 FORM CMS-2552-10 4090 (Cont.)ANALYSIS OF RENAL DIALYSIS DEPARTMENT COSTS PROVIDER NO.: PERIOD: WORKSHEET I‐1

________________ FROM ____________ TO _______________

Check applicable box [ ] Renal Dialysis Department [ ] Home Program DialysisCheck applicable box: [ ] Renal Dialysis Department [ ] Home Program DialysisTOTAL FTEs perCOSTS BASIS STATISTICS 2080 Hours

1 2 3 41 Registered Nurses Hours of Service 12 Licensed Practical Nurses Hours of Service 23 Nurses Aides Hours of Service 34 Technicians Hours of Service 44 Technicians Hours of Service 45 Social Workers Hours of Service 56 Dieticians Hours of Service 67 Physicians Accumulated Cost 78 Non‐patient Care Salary Accumulated Cost 89 Subtotal (sum of lines 1‐8) 910 Employee Benefits Salary 1011 Capital Related Costs‐Bldgs. & Fixtures Square Feet 1112 Capital Related Costs‐Mov. Equip. Percentage of Time 1213 Machine Costs & Repairs Percentage of Time 1314 Supplies Requisitions 1415 Drugs Requisitions 1516 Other Accumulated Cost 1617 Subtotal (sum of lines 9‐16)* 1718 Capital Related Costs‐Bldgs. & Fixtures Square Feet 1819 Capital Related Costs Mov Equip Percentage of Time 1919 Capital Related Costs‐Mov. Equip. Percentage of Time 1920 Employee Benefits Salary 2021 Administrative and General Accumulated Cost 2122 Maint./Repairs‐Operation‐Housekeeping Square Feet 2223 Medical Education Program Costs 2324 Central Services & Supplies Requisitions 2425 Pharmacy Requisitions 2526 Other Allocated Costs Accumulated Cost 2626 Other Allocated Costs Accumulated Cost 2627 Subtotal (sum of lines 17‐26)* 2728 Laboratory (see instructions) Charges 2829 Respiratory Therapy (see instructions) Charges 2930 Other (see instructions) Charges 3031 Total costs (sum of lines 27‐30) 31

* Line 17, co lumn 1 s ho uld agree with Wo rks heet A, co lumn 7 fo r line 74 o r line 94 as appro pria te ,


and line 27, co lumn 1 s ho uld agree with Wo rks hee t B, P a rt I, co lumn 26 fo r line 74 o r line 94 as appro pria te .


Rev. 1 40-617

12-10 FORM CMS-2552-10 4090 (Cont.)DIRECT AND INDIRECT RENAL DIALYSIS COST ALLOCATION ‐ PROVIDER NO.: PERIOD: WORKSHEET I‐3STATISTICAL BASIS FROM ___________ ____________

TO _______________Check applicable box: [ ] Renal Dialysis Department [ ] Home Program Dialysis

CAPITAL ANDRELATED COSTS DIRECT PATIENT ROUTINE

BUILDING EQUIPMENT CARE SALARY EMPLOYEE MEDICAL ANCILLARY OVERHEADCOMPOSITE PAYMENT SERVICES (SQUARE (% OF RNs OTHERS BENEFITS DRUGS SUPPLIES SERVICES SUB‐ (ACCUM.( ( (

FEET) TIME) (HOURS) (HOURS) (SALARY) (REQUIST.) (REQUIST.) (CHARGES) TOTAL COST)1 2 3 4 5 6 7 8 9 10

1 Total Renal Department Costs 1MAINTENANCE

2 Hemodialysis 23 Intermittent Peritoneal 3

TRAINING4 Hemodialysis 45 Intermittent Peritoneal 56 CAPD 67 CCDP 7

HOME8 Hemodialysis 89 Intermittent Peritoneal 910 CAPD 1011 CCDP 11

OTHER BILLABLE SERVICES12 Inpatient Dialysis Treatments __________ 1213 Method II Home Patient 1314 EPO 1415 ARENESP 1516 Other 1617 Total Statistical Basis 1718 Unit Cost Multiplier (line 1 ÷ line 17) 18



Rev. 1 40-619

4090 (Cont.) FORM CMS-2552-10 12-10COMPUTATION OF AVERAGE COST PER TREATMENT PROVIDER NO.: PERIOD: WORKSHEET I‐4FOR OUTPATIENT RENAL DIALYSIS ______________ FROM ____________

TO _______________Ch k li bl b [ ] R l Di l i D t t [ ] H P Di l iCheck applicable box: [ ] Renal Dialysis Department [ ] Home Program Dialysis

Average Cost TotalNumber Total Cost of Program Number Program Total Averageof Total (from Wkst. Treatments of Program Expenses Program Payment Rate

Treatments I‐2, col. 11) (col. 2 ÷ col. 1) Treatments (col. 4 x col. 3) Payment (col. 6 ÷ col. 4)1 2 3 4 5 6 71 2 3 4 5 6 7

1 Maintenance ‐ Hemodialysis 12 Maintenance ‐ Peritoneal Dialysis 23 Training ‐ Hemodialysis 34 Training ‐ Peritoneal Dialysis 45 Training ‐ Continuous Ambulatory Peritoneal Dialysis 56 Training Continuous Cycling Peritoneal Dialysis 66 Training ‐ Continuous Cycling Peritoneal Dialysis 67 Home Program ‐ Hemodialysis 78 Home Program ‐ Peritoneal Dialysis 8

Patient Weeks Patient Weeks9 Home Program ‐ Continuous Ambulatory Peritoneal Dialysis 910 Home Program ‐ Continuous Cycling Peritoneal Dialysis 1011 Totals (sum of lines 1‐8 columns 1 and 4) 1111 Totals (sum of lines 1‐8, columns 1 and 4) 11

(sum of lines 1‐10, columns 2, 5, and 7)


40-620 Rev. 1


4090 (Cont ) FORM CMS 2552 10 12 104090 (Cont.) FORM CMS-2552-10 12-10CALCULATION OF REIMBURSABLE PROVIDER NO.: PERIOD: WORKSHEET I‐5BAD DEBTS ‐ TITLE XVIII ‐ PART B ________________ FROM ____________

TO _______________

Description

1 Total expenses related to care of program beneficiaries (see instructions) 12 Total payment (fromWorksheet I‐4, column 6, line 11) 22 Total payment (from Worksheet I 4, column 6, line 11) 23 Deductibles billed to Medicare (Part B) patients 34 Coinsurance billed to Medicare (Part B) patients 45 Bad debts for deductibles and coinsurance, net of bad debt recoveries 56 67 Reimbursable bad debts for dual eligible beneficiaries (see instructions) 78 Net deductibles and coinsurance billed to Medicare (Part B) patients (sum of lines 3 and 4 less line 5) 89 Program payment (line 2 less line 3, times 80 percent) 910 Unrecovered from Medicare (Part B) patients (lesser of line 1 or line 2 minus the sum of lines 7 and 8) 10

(if negative, enter zero and do not complete line 11)11 Reimbursable bad debts (lesser of line 10 or line 5) (transfer to Worksheet E, Part B, line 33) 11



Rev. 1 40-621

WS I SeriesWS I SeriesSteps to process WS S I Series Data:Steps to process WS S-I Series Data:• Identify the data to be used:

– General Ledgerg– Payroll Register– Statistics

Renal Dialysis Treatment Stats by Modality– Renal Dialysis Treatment Stats by Modality– PSR

• Split Expenses by type of Expense– Must reconcile to WS A line 74

• Identify the Statistics by Modality• Sort and Subtotal



WS J Series (CMHC)WS J Series (CMHC)

Community Mental Health Center (CMHC) services Community Mental Health Center (CMHC) services are paid on Cost Reimbursement (for the moment). The WS I Series is designed to identify the cost of The WS I Series is designed to identify the cost of CHMC services by Modality, determine the program cost and final settlementcost, and final settlement.


WS J SeriesWS J Series

The WS J Series consists of the following worksheets:The WS J Series consists of the following worksheets:– WS S-6 (CMHC Treatment Staff Statistics)

WS J 1 P t 1 (A ti t f C t t th t l – WS J-1 Part 1 (Apportionment of Costs to the mental Health Modalities)

• Column 0 must reconcile to WS A (CMHC Cost Center)• Column 0 must reconcile to WS A (CMHC Cost Center)– WS J-1 Part 2 (Allocation Statistics for Cost

Apportionment)Apportionment)• Each columns statistics should agree to WS B-1 Stats fro the

CMHC Cost Center)


WS J SeriesWS J SeriesWS J 2 (Determination of Program Costs)– WS J-2 (Determination of Program Costs)

– WS J-3 (Determination of Settlement)WS J 4 (Identification of Interim Payments and Lump – WS J-4 (Identification of Interim Payments and Lump Sum Payments)


4090 (Cont.) FORM CMS-2552-10 12-10HOSPITAL‐BASED COMMUNITY MENTAL HEALTH CENTER AN PROVIDER NO.: PERIOD: WORKSHEET S‐6OTHER OUTPATIENT REHABILITATION _______________ FROM ___________PROVIDER STATISTICAL DATA COMPONENT NO.: TO ______________

_______________

COMMUNITY MENTAL HEALTH & OTHER OUTPATIENT REHABILITATION PROVIDER‐ NUMBER OF EMPLOYEES (FULL TIME EQUIVALENT)

Check [ ] CMHC [ ] OOTapplicable [ ] CORF [ ] OSP applicable [ ] CORF [ ] OSP box: [ ] OPT

Enter the number of hours in your normal workweek ____________________

TotalStaff Contract (column 1 + column 2)Staff Contract (column 1 + column 2)1 2 3

1 Administrator and Assistant Administrator(s) 12 Director(s) and Assistant Director(s) 23 Other Administrative Personnel 34 Direct Nursing Service 45 Nursing Supervisor 5g p6 Physical Therapy Service 67 Physical Therapy Supervisor 78 Occupational Therapy Service 89 Occupational Therapy Supervisor 910 Speech Pathology Service 1011 Speech Pathology Supervisor 1112 Medical Social Service 1213 Medical Social Service Supervisor 1314 Respiratory Therapy Service 1415 Respiratory Therapy Supervisor 1516 Psychiatric/Psychological Service 1617 Psychiatric/Psychological Service Supervisor 17


18 Other (specify) 18


40-518 Rev. 1

4090 (Cont.) FORM CMS-2552-10 12-10ALLOCATION OF GENERAL SERVICE COSTS TO PROVIDER NO.: ______________ PERIOD: WORKSHEET J‐1,COMMUNITY MENTAL HEALTH CENTERS FROM ____________ PART I

COMPONENTNO : TOCOMPONENT NO.: ____________ TO _______________Checkapplicable [ ] Title V [ ] Title XVIII [ ] Title XIXbox:PART I ‐ ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS

NET EXPENSES CAPITAL

COMPONENT COST CENTER FOR COST RELATED COSTS ADMINIS‐ MAIN‐ LAUNDRYCOMPONENT COST CENTER FOR COST RELATED COSTS ADMINIS‐ MAIN‐ LAUNDRY(omit cents) ALLOCATION BLDGS. & MOVABLE EMPLOYEE SUBTOTAL TRATIVE & TENANCE OPERATION & LINEN

(see instru.) FIXTURES EQUIPMENT BENEFITS (cols. 0‐4) GENERAL & REPAIRS OF PLANT SERVICE0 1 2 4 4A 5 6 7 8

1 Administrative and General 12 Skilled Nursing Care 23 Physical Therapy 34 Occupational Therapy 44 Occupational Therapy 45 Speech Pathology 56 Medical Social Services 67 Respiratory Therapy 78 Psychiatric/Psychological Services 89 Individual Therapy 910 Group Therapy 1011 Individualized Activity Therapies 1111 Individualized Activity Therapies 1112 Family Counseling 1213 Diagnostic Services 1314 Approved Patient Training & Education 1415 Prosthetic and Orthotic Devices 1516 Drugs and Biologicals 1617 Medical Supplies 1718 M di l A li 1818 Medical Appliances 1819 Durable Medical Equipment‐Rented 1920 Durable Medical Equipment‐Sold 2021 All Others 2122 Totals (sum of lines 1‐21)(1) 2223 Unit Cost Multiplier (see instructions) 23

( ) l 0 h h 26 li 22 i h h di l f k li i S i i


(1) Columns 0 through 26, line 22 must agree with the corresponding columns of Wkst. B, Part I, lines as appropriate. See instructions.


40-622 Rev. 1

12-10 FORM CMS-2552-10 4090 (Cont.)ALLOCATION OF GENERAL SERVICE COSTS TO PROVIDER NO.: ______________ PERIOD: WORKSHEET J‐1,COMMUNITY MENTAL HEALTH CENTERS FROM ____________ PART II

COMPONENTNO : TOCOMPONENT NO.: ____________ TO _______________Checkapplicable [ ] Title V [ ] Title XVIII [ ] Title XIXboxes:PART II ‐ ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS ‐ STATISTICAL BASIS

CAPITAL RELATED COST ADMINIS‐ MAIN‐ LAUNDRY

BLDGS & MOVABLE EMPLOYEE TRATIVE & TENANCE& OPERATION & LINENBLDGS & MOVABLE EMPLOYEE TRATIVE & TENANCE & OPERATION & LINENCMHC COST CENTER FIXTURES EQUIPMENT BENEFITS GENERAL REPAIRS OF PLANT SERVICE

(omit cents) (SQUARE (SQUARE (GROSS RECONCIL‐ (ACCUM. (SQUARE (SQUARE (POUNDS OFFEET) FEET) SALARIES) IATION COST) FEET) FEET) LAUNDRY)

0 1 2 4 4A 5 6 7 81 Administrative and General 12 Skilled Nursing Care 23 Physical Therapy 33 Physical Therapy 34 Occupational Therapy 45 Speech Pathology 56 Medical Social Services 67 Respiratory Therapy 78 Psychiatric/Psychological Services 89 Individual Therapy 910 Group Therapy 1010 Group Therapy 1011 Individualized Activity Therapies 1112 Family Counseling 1213 Diagnostic Services 1314 Approved Patient Training & Education 1415 Prosthetic and Orthotic Devices 1516 Drugs and Biologicals 1617 M di l S li 1717 Medical Supplies 1718 Medical Appliances 1819 Durable Medical Equipment‐Rented 1920 Durable Medical Equipment‐Sold 2021 All Others 2122 Totals (sum of lines 1‐21) 2223 Total Cost to be Allocated 232 i l i li ( i i ) 2


24 Unit Cost Multiplier (see instructions) 24


Rev. 1 40-625

4090 (Cont.) FORM CMS-2552-10 12-10COMPUTATION OF COMMUNITY MENTAL HEALTH CENTER PROVIDER COSTS PROVIDER NO.: ______________ PERIOD: WORKSHEET J‐2,

FROM ____________ PART I COMPONENT NO.: ____________ TO _______________

Checkapplicable [ ] Title V [ ] Title XVIII [ ] Title XIXboxes:PART I ‐ APPORTIONMENT OF CMHC COST CENTERS

(From Ratio of Title V Title XVIII Title XIXWk t J 1 T t l C t t Titl V C t Titl XVIII C t Titl XIX C tWkst. J‐1, Total Costs to Title V Component Title XVIII Component Title XIX ComponentPart I, Component Charges Component Costs (col. 3 Component Costs (col. 3 Component Costs (col. 3col. 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 91 Administrative and General 12 Skilled Nursing Care 23 Physical Therapy 33 Physical Therapy 34 Occupational Therapy 45 Speech Pathology 56 Medical Social Services 67 Respiratory Therapy 78 Psychiatric/Psychological Services 89 Individual Therapy 910 Group Therapy 1011 Individualized Activity Therapy 1112 Family Counseling 1213 Diagnostic Services 1314 Approved Patient Training & Education 1415 Prosthetic and Orthotic Devices 1516 Drugs and Biologicals 1616 Drugs and Biologicals 1617 Medical Supplies 1718 Medical Appliances 1819 All Others (1) 1920 Totals (sum of lines 1‐19) 20

(1) Enter amount in column 1 from Worksheet J‐1, Part I, column 28, line 21.


FORM CMS-2552-10(12/2010) (INSTRUCTIONS FOR THIS WORKSHEET ARE P UBLISHED IN CMS P UB. 15-II, SECTION 4054.1)

40-628 Rev. 1

12-10 FORM CMS-2552-10 4090 (Cont.)COMPUTATION OF COMMUNITY MENTAL HEALTH CENTER PROVIDER COSTS PROVIDER NO.: ______________ PERIOD: WORKSHEET J‐2,

FROM ____________ PART II COMPONENT NO.: ____________ TO _______________

Checkapplicable [ ] Title V [ ] Title XVIII [ ] Title XIXboxes:

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 ComponentPart I, Component Costs to Component costs (col. 3 Component costs (col. 3 Component costs (col. 3col. 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 8 921 Respiratory Therapy 2122 Physical Therapy 2223 Occupational Therapy 2324 Speech Pathology 2425 Medical Supplies Charged to Patients 2526 Implantable Devices Charged to Patients 2627 Drugs Charged to Patients 2728 Total (sum of lines 21‐28) 2829 Total component costs. Add the amount from Part 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, 6, 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.


Rev. 1 40-629


4090 (Cont.) FORM CMS-2552-10 12-10CALCULATION OF REIMBURSEMENT SETTLEMENT COMMUNITY PROVIDER NO.: PERIOD: WORKSHEET J‐3MENTAL HEALTH CENTER PROVIDER SERVICES ________________ FROM ____________

COMPONENT NO.: TO _______________ ________________


PROGRAMCOST

1 Cost of component services (from Worksheet J‐2, Part II, line 29) 12 PPS payments received excluding outliers 22 PPS payments received excluding outliers 23 Outlier payments 34 Primary payer payments 45 Total reasonable cost (see instructions) 56 Total charges for program services 6

CUSTOMARY CHARGES7 Aggregate amount actually collected from patients liable for services on a charge basis 78 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) 89 Ratio of line 7 to line 8 (not to exceed 1.000000) (see instructions) 910 Total customary charges (see instructions) 1011 Excess of customary charges over reasonable cost (see instructions) 1112 Excess of reasonable cost over customary charges (see instructions) 12

COMPUTATION OF REIMBURSEMENT SETTLEMENT13 Total reasonable cost (from line 5) 1314 Part B deductible billed to program patients 1414 Part B deductible billed to program patients 1415 Net cost (line 13 minus line 14) 1516 Excess of reasonable cost over customary charges (from line 12) 1617 Subtotal (line 15 minus line 16) 1718 80 percent of costs (80% of line 17) (see instructions) 1819 Actual coinsurance billed to program patients (from provider records) 1920 Net cost less actual billed coinsurance (line 17 minus line 19) 2021 Reimbursable bad debts (from provider records) (see instructions) 2122 2222 2223 Reimbursable bad debts for dual eligible beneficiaries (see instructions) 2324 Net reimbursable amount (see instructions) 2425 Other adjustments (see instructions) (specify) 2526 Total cost (line 24 plus or minus line 25) 2627 Interim payments (see instructions) 2728 Tentative settlement (for contractor use only) 2829 Balance due component/program (line 26 minus lines 27 and 28) 29


30 Protested amounts (nonallowable cost report items in accordance with CMS Pub. 15‐II, section 115.2) 30


40-630 Rev. 1

12-10 FORM CMS-2552-10 4090 (Cont.)ANALYSIS OF PAYMENTS TO HOSPITAL‐BASED COMMUNITY MENTAL HEALTH PROVIDER NO.: PERIOD: WORKSHEET J‐4CENTER FOR SERVICES RENDERED TO PROGRAM BENEFICIARIES ________________ FROM ____________

COMPONENT NO.: TO _______________________________


Part BDESCRIPTION 1 2

mm/dd/yyyy Amount1 Total interim payments paid to providers 12 Interim payments payable on individual bills, either 2

submitted or to be submitted to the intermediary, fori d d i th t ti i d If 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 3.51or enter zero (1). to .52 3.52 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)

O BE COMPLETED BY INTERMEDIARY5 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 toreport (see instructions) (1) Provider 01 6 01 report (see instructions). (1) Provider .01 6.01

ProvidertoProgram .02 6.02

7 Total Medicare liability (see instructions) 78 Name of Contractor Contractor Number (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 ofrepayment, even though the total repayment is not accomplished until a later date.


Rev. 1 40-631

WS J SeriesWS J SeriesSteps to process WS S J Series Data:Steps to process WS S-J Series Data:• Identify the data to be used:

– General Ledgerg– Payroll Register– Statistics

CHMC Treatment Stats by Modality– CHMC Treatment Stats by Modality– PSR

• Split Expenses by type of Expense– Must reconcile to WS A (CMHC Cost Center)

• Identify the Statistics by Modality• Sort and Subtotal



WS M Series (Rural Health Clinic)WS M Series (Rural Health Clinic)Rural Health Clinics Payment is based on an all-inclusive payment methodology, subject to a maximum payment per visit and annual reconciliation•The per-visit limit is established by Congress and update annually based on percentage change in the MEI (Medicare Economic Index)•RHCs also receive cost based reimbursement for a defined set of core •RHCs also receive cost-based reimbursement for a defined set of core physician and certain non-physician outpatient services.•The per-visit limit does not apply to hospital based RHCs that are an p pp y pintegral and subordinate part of a hospital with fewer than 50 beds.•Laboratory tests are paid separately.


WS M SeriesThe WS M Series consists of the following

Worksheets:– WS S-8 Statistical and Operational Factors

• Includes such data as clinic name and address, sources of federal funding, hours of operation, other general questions and list of medical providers and numbers.

– WS M-1 Analysis of Hospital-based RHC Costs• Total Expenses on M 1 must reconcile to WS A line 88 XX (Individual • Total Expenses on M-1 must reconcile to WS A line 88.XX (Individual

Specific RHC) including A-6 Reclassifications and A-8 Adjustments.• Categories of WS M-1 Expenses

Facility Health Care Staff Costs (Lines 1 10) Staff Expense by Type of Position– Facility Health Care Staff Costs (Lines 1-10) Staff Expense by Type of Position– Costs Under Agreement (Lines 11-14) Contract Labor by Type of Position/Arrangement– Other Health Care Costs (Lines 15-22) Med Supplies, Transportation, Malpractice,

Depreciation , Other, etc.


– Costs other than RHC /FQHC Services (Lines 23-28) Services other than RHC/FQHC– Facility Overhead (Line 29-31) Facility and Administrative Costs

WS M SeriesWS M SeriesThe WS M Series consists of the following

Worksheets:Worksheets:– WS M-2 (Allocation of Overhead to RHC Services)

• Line 1-9 From Hospital records need to input FTEs in RHC by and total Line 1 9 From Hospital records need to input FTEs in RHC by and total number of visits by position. From regulations require the input of productivity standards

• Line 10-20 No input required as this is the cost report flow of the Line 10 20 No input required as this is the cost report flow of the Determination of Allowable Costs Applicable to RHC/FQHC Services


WS M SeriesWS M Series– WS M-3 (Calculation of RHC Reimbursement

Settlement)Settlement)• Line 1-7 No input required• Line 8-9 Input Per Visit Payment Limit and Rate for Program Covered

Vistits– If applicable input the per visit payment limit as provided by your FI

• Line 10-30 Medicare Settlement and recording of PSR data and bad debts.g

– WS M-4 (Computation of Pneumococcal and Influenza Vaccine Costs))

– WS M-5 (Analysis of Payments to RHC for Services Rendered)


• Net Reimbursement and Lump Sum from the PSR or your FI

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