Cost Report 101 FINAL - SoCal HFMA - South

Cost Report Preparation and Documentation 101 “A How-To Guide to Workpaper and Supporting Documentation Preparation” Preparation

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Agenda • • • • • •

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


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Agenda • Review of Cost Report Pages Pages, Their Data and the Workpapers Needed to Support Them: – – – – – – – – –

WS A ((Summaryy Trial Balance of Expenses)) WS A-6 (Reclassifications) WS A-8 (Adjustments) WS B-1 (Statistical Allocation of Overhead Expenses) WS C (Patient Treatment Revenues – Total Charges) Settlement (Charges and Data) WS S S-2 S (Provider ( Questionnaire) Q ) WS S-3 Part 1(Census Data), WS S-3 Part 2 (Wage Index) WS S-10 (Uncompensated Care)


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

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


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Agenda • Specialty Pages on the Cost Report – – – – – –

WS A-8-1 (Related Parties) WS A-8-2 A 8 2 (Ph (Physician i i C Compensation) ti ) WS H Series (Home Health Agencies) WS I Series (Renal Dialysis) WS M Series (RHC, FQHC) WS J Series (CMHC)

• Wrap Up Essential Consulting LLC

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Medicare Reimbursement Methodologies Medicare PProgramPartA Medicare rogram Part A

Medicare PProgramPartB Medicare rogram Part B

IP Services IP Ancillary Services

CostReportPartA(IP) Cost Report Part A (IP) Essential Consulting LLC

Hospital Based Outpatient Services

Clinic Services

Physician Services

Outpatient Services

Onsite/Offsite Clinics Clinics and MD Offices

Medicare Part A intermediary

Medicare Part B Carrier

Medicare Cost Reports (UB‐92 Bills)

CMS‐1500 Bills

CostReportPartB(OP) Cost Report Part B (OP) www.esshc.com

Medicare Reimbursement Methodologies • Reimbursement Mechanisms for Hospital Units/Entities IP Acute Care – DRG (Diagnostic Related Groups) Hospital Based Outpatient Services – APC (Ambulatory Payment Categories) Hospital Based Clinics – APC or Cost Reimbursement (Based on Designation) Skilled Nursing Facility/Unit – RUGS (Resource Utilization Groups) IP Rehab Services – IRFPPS (IP Rehab Facility Prospective Payment System) IP Psychiatric Services – PsychPPS (Psychiatric Prospective Payment System) • Home Health Agency – HHAPPS (Home Health Prospective Payment System) • • • • • •


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Medicare Reimbursement Methodologies • Reimbursement Mechanisms for “Special Special Services Services” • IME/GME (Medical Education) – FTEs • Disproportionate Share Hospitals (DSH) – Indigency Percentage • Medicare Bad Debs – Portion of the Un-paid Coinsurance and Deductibles • Organ Acquisition – Cost Reimbursement


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What is a Cost Report p and whyy is it important? • The cost report is a financial report that identifies the cost and charges related to healthcare treatment activities • Cost Reports Impact Reimbursement! – Today – Future Reimbursement

• Congress/CMS rate setting and policy decisions are based on data in the cost reports and MedPar. Essential Consulting LLC

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Filing Guidelines • Medicare cost reports are due within 150 Days from the FYE of the facility (Post Marked) • Electronic El t i costt reportt AND supporting ti documentation are submitted • State reports (Medicaid) vary from state to state, but generally due at same time as Medicare report – Variations can be significant


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2552 96 vs 2552-96 vs. 2552 2552-10 10 • The new hospital cost report form 2552-10 2552 10 must be used for all cost reports with FYE of 4-30-2011 and later. later • The class will focus on the use of the 2552-10 • Changes between 2552-96 and 2552-10 – Grouping of Departments on WS A is the main change – Settlement Pages (E series) were “de cluttered” – Minor Changes g on various ppages g ((S-2, S-3, etc.)) Essential Consulting LLC

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Basic Flow of a Cost Report • WS A Series – ggeneral ledger g or trial balance information byy functional department 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 Series S i – statistical t ti ti l information i f ti andd wage iindex d • WS H Series – Home Health Services • WS J, K, M Series – Clinics and Freestanding components • WS I – End E d Stage St Renal R l Dialysis Di l i (ESRD) Essential Consulting LLC

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

General Ledger (Summary Trial Balance) Payroll Register Chargemaster with Volumes (Volume Report) Medicare Charges by Department and Revenue Code (Revenue and Usage) Provider Statistical Report (PSR) Patient Census (Days and Discharges) Allocation Statistics S ifi P Specific Purpose Data D t


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Basic Data Rules Every data file has its unique issues and reasons for being used in the cost report. As a universal rule, the general ledger is the “Parent” Parent data source and all others should agree to or relate to the general ledger. –Accounts/Departments/Accounting Units/Cost Centers/etc. Centers/etc –Cost Report Line Number Groupings –Sub-Accounts/Object Codes/etc. –Raw data vs. Processed data –Know Your Data!


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The General Ledger The General Ledger is the most important data that is included in the cost report. –Structure Structure of a General Ledger –Account vs. Sub-Account •Ranges g of data •Mix and Match data

–How does the GL break down? •Assets A t andd Liabilities Li biliti •Revenues •Expenses •Other Operating and Non-Operating Revenue/Expenses Essential Consulting LLC

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General Ledger Show a General Ledger in Excel and review – Account Structure – Sub-Account S bA t St Structure t – Cut up GL to show • • • •

Assets A t andd Liabilities Li biliti Revenues Expenses Other Operating and Non-Operating Revenue/Expenses


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Reconciliations Reconciliations serve two purposes: 1.

Identify that all of the revenues/expenses (data) have been accounted for to an outside source. – – –

2.

General Ledger to Income Statement C tR Cost Reportt tto Income I Statement St t t Other Operating/Non-Operating Revenue/Expense

Validate that two different data sources generate the same data in different formats and can be used as surrogates. – – –

Generall LLedger G d R Revenues vs. Volume V l R Reportt General Ledger Salaries vs. Payroll Report General Ledger 3rd Party Revenues to Revenue & Usage


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General Ledger to Income Statement


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Cost Report p to Income Statement Reconciliation


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Other Operating/Non-Operating p g p g Rev/Expp Reconciliation


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General Ledger g vs. Volume Report p Comparison


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WS A (Expenses by Department) The purpose of WS A is to identify all Direct Expenses (Salary vs. Other) i incurred d att the th facility f ilit by b department d t t iinto t costt reportt lilines (“C (“Costt Centers”). Criteria for Independent Cost Centers – 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.


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4090 (Cont.)

FORM CMS-2552-10

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES

12-10

P R OVIDER NO.:

P ER IOD:

________________

TO _______________

WOR KS HEET A

F R OM ____________

COST CENTER DESCRIPTIONS (omit cents)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

00100 00200 00300 00400 00500 00600 00700 00800 00900 01000 01100 01200 01300 01400 01500 01600 01700

30 31 32 33 34 35 40 41 42 43 44 45 46

03000 03100 03200 03300 03400

01900 02000 02100 02200 02300

04000 04100 04200 04300 04400 04500 04600

GENERAL SERVICE COST CENTERS Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Other Capital Related Costs Employee Benefits Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services and Supply Pharmacy Medical Records & Medical Records Library Social Service Other General Service (specify) Nonphysician Anesthetists Nursing g School Intern & Res. Service-Salary & Fringes (Approved) Intern & Res. Other Program Costs (Approved) Paramedical Ed. Program (specify) INPATIENT ROUTINE SERVICE COST CENTERS Adults and Pediatrics (General Routine Care) Intensive Care Unit Coronary Care Unit Burn Intensive Care Unit Surgical Intensive Care Unit Other Special Care (specify) Subprovider - IPF Subprovider - IRF Subprovider (specify) Nursery Skilled Nursing Facility Nursing Facility Other Long Term Care

SALARIES 1

TOTAL (col. 1 + col. 2) 3

OTHER 2

RECLASSIFIED TRIAL BALANCE (col. 3 ± col. 4) 5

RECLASSIFI‐ CATIONS 4

ADJUSTMENTS 6

NET EXPENSES NET EXPENSES FOR ALLOCATION (col. 5 ± col. 6) 7

‐0‐

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

30 31 32 33 34 35 40 41 42 43 44 45 46

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

40-524


Rev. 1

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12-10

FORM CMS-2552-10


4090 (Cont.)

PROVIDER NO.: ________________

COST CENTER DESCRIPTIONS (omit cents)

50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76

05000 05100 05200 05300 05400 05500 05600 05700 05800 05900 06000 06100 06200 06300 06400 06500 06600 06700 06800 06900 07000 07100 07200 07300 07400 07500

88 89 90 91 92 93

08800 08900 09000 09100 09200

ANCILLARY SERVICE COST CENTERS Operating Room Recovery Room Labor Room and Delivery Room Anesthesiology Radiology-Diagnostic Radiology-Therapeutic Radioisotope Computed Tomography (CT) Scan Magnetic Resonance Imaging (MRI) Cardiac Catheterization y Laboratory PBP Clinical Laboratory Services-Program Only Whole Blood & Packed Red Blood Cells Blood Storing, Processing, & Trans. Intravenous Therapy Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Electroencephalography Medical Supplies Charged to Patients Implantable Devices Charged to Patients Drugs Charged to Patients Renal Dialysis ASC (Non-Distinct Part) Other Ancillary (specify) OUTPATIENT SERVICE COST CENTERS Rural Health Clinic (RHC) Federally Qualified Health Center (FQHC) Clinic Emergency Observation Beds Other Outpatient Service (specify)

SALARIES 1


OTHER 2


PERIOD: FROM ____________ TO _______________ RECLASSIFIED TRIAL BALANCE (col. 3 ± col. 4) ADJUSTMENTS 5 6

WORKSHEET A

NET EXPENSES FOR ALLOCATION (col. 5 ± col. 6) 7


50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 88 89 90 91 92 93

40-525

Rev. 1


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12-10

FORM CMS-2552-10


4090 (Cont.)

P R OVIDER NO.:

P ER IOD:

WOR KS HEET A

F R OM ____________

________________ COST CENTER DESCRIPTIONS (omit cents)

94 95 96 97 98 99 100 101

09400 09500 09600 09700

105 106 107 108 109 110 111 112 113 114 115 116 117 118

10500 10600 10700 10800 10900 11000 11100

190 191 192 193 194 200

19000 19100 19200 19300

10000 10100

11300 11400 11500 11600

OTHER REIMBURSABLE COST CENTERS Home Program Dialysis Ambulance Services Durable Medical Equipment-Rented Durable Medical Equipment-Sold Other Reimbursable (specify) Outpatient Rehabilitation Provider (specify) Intern-Resident Service (not appvd. tchng. prgm.) Home Health Agency SPECIAL PURPOSE COST CENTERS Kidney Acquisition Heart Acquisition Liver Acquisition Lung Acquisition Pancreas Acquisition Intestinal Acquisition Islet Acquisition Oth Organ Other O A Acquisition i iti (specify) ( if ) Interest Expense Utilization Review-SNF Ambulatory Surgical Center (Distinct Part) Hospice Other Special Purpose (specify) SUBTOTALS (sum of lines 1-117) NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop, & Canteen Research Physicians' Private Offices Nonpaid Workers Other Nonreimbursable (specify) TOTAL (sum of lines 118-199)

SALARIES 1


OTHER 2

TO _______________

RECLASSIFIED TRIAL BALANCE (col. 3 ± col. 4) 5


NET EXPENSES FOR ALLOCATION ADJUSTMENTS (col. 5 ± col. 6) 6 7 94 95 96 97 98 99 100 101

‐ 0 ‐ ‐ 0 ‐

105 106 107 108 109 110 111 112 113 114 115 116 117 118

‐ 0 ‐

190 191 192 193 194 200


40-526


Rev. 1

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WS A Cost report line numbers should be grouped based on the account: – – – – – – – –

Overhead Departments (1-23) (1 23) Routine Services (30-46) Ancillary Services (50 (50-76) 76) Outpatient Services (88-93) Other Reimbursable Services (94-101) Special Purpose Cost Centers (105-118) Non-Reimbursable Cost Centers (190-194) Total (200)


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WS A Salary vs vs. Other Expenses should be determined based on the Sub-Account. H should How h ld the th following f ll i be b treated? t t d? • Contract Labor? • Bonuses? • Stand-By/On Call? •Training/Orientation? Training/Orientation? •Non-Operating Expense (i.e. Joint Ventures, Minority Interests)


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WS A Steps to process WS A Data: 1. Main Data is the General Ledger 2 Know 2. K Y Your Data D t 1. 2 2. 3.

Review Accounts Review Sub-Accounts Sub Accounts New Accounts and Sub-Accounts

33. Groupings 4. Salary vs. Other Expense Split 5 Sort and Subtotal 5. Essential Consulting LLC

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WS A-6 A 6 (Reclassifications) The purpose of the WS A-6 A 6 Reclassifications is to move expenses from where they were booked per the FASB Accounting Rules to where Medicare requires these expenses to be. WS A-6 Reclassifications need to separately identify Salary Expenses vs. Other Expenses.


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WS A-6 A6 Common Examples of WS A-6 A 6 Reclassifications: 1. Medical Supplies (High Cost med Supplies) Ch Charged d to t Patients P ti t 2. Drugs Charged to Patients 3. Equipment Depreciation Expense 4 Employee Benefits Expenses 4. 5. Cafeteria Expenses 6 OB, 6. OB N Nursery andd L&D Service S i Expenses E Essential Consulting LLC

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12-10

FORM CMS-2552-10

4090 (Cont.)

RECLASSIFICATIONS

INCREASES CODE EXPLANATION OF RECLASSIFICATION(S) (1) COST CENTER LINE # SALARY 1 2 3 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 500 Total reclassifications (sum of columns 4 and 5 q sum of columns 8 and 9)) must equal

PROVIDER NO.:

PERIOD: FROM ____________ ________________ TO _______________ DECREASES OTHER 5

COST CENTER 6

LINE # 7

SALARY 8

WORKSHEET A-6

OTHER 9

Wkst. Wk t A-7 Ref. 10 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 500

(1) A le tte r (A, B , e tc .) m us t be e nte re d o n e a c h line to ide ntify e a c h re c la s s ific a tio n e ntry. Tra ns fe r the a m o unts in c o lum ns 4, 5, 8, a nd 9 to Wo rks he e t A, c o lum n 4, line s a s a ppro pria te . F OR M C M S -2552-10 (12/2010) (INS TR UC TIONS F OR THIS WOR KS HEET AR E P UB LIS HED IN C M S P UB . 15-II, S EC TION 4014)

Rev. 1


40-527

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WS A-6 A6 Steps to process WS A-6 A 6 Data: • Identify the data to be reclassified – General Ledger g – Statistics (Split and Complex Reclassifications)

• What is the basis for the reclassification? – Wh Whole l M Move (Si (Simple l Reclassification) R l ifi ti ) – Partial Move (Split Reclassification) – Allocation Move (Complex Reclassification)

• Cost Center Assignment • Workpapers should always show the increase as well as the decrease (No Assumptions) Essential Consulting LLC

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WS A-6 A6 Steps to Process WS A-6 A 6 Data: • Supporting Analytical Workpapers – Workpaper Referencing

• Sort and Subtotal • WS A A-66 R Reclassification l ifi ti Al Alpha h C Code d Assignment A i t


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WS A-6 A 6 (impact on cost report) Are we done with WS A-6 A 6 Reclassifications? – – – – – –

Matching Principle P i Reclass Prior R l i impact t on C Currentt Reclass R l WS S-3 Wage Index impact WS B-1 Statistics impact WS C Revenue impact Settlement Charges impact


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WS A-8 A 8 (Revenue/Expense Adjustments) WS A-8 A 8 adjustments allow the user to adjust the Expenses on WS A for differences between Financial Accounting and Medicare. Medicare – Revenue Adjustments are where Other Operating/NonOperating Revenue is “offset” offset against the associated Expenses – Expense Adjustments are where the Expenses are treated differently between Financial Accounting and Medicare Essential Consulting LLC

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12-10

FORM CMS-2552-10

ADJUSTMENTS TO EXPENSES

4090 (Cont.)

PROVIDER NO.:

PERIOD: FROM ____________ TO _______________

________________

DESCRIPTION (1) BASIS/CODE (2) 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

Investment income - buildings and fixtures (chapter 2) Investment income - movable equipment (chapter 2) Investment income - other (chapter 2) Trade, quantity, and time discounts (chapter 8) Refunds and rebates of expenses (chapter 8) Rental of provider space by suppliers (chapter 8) Telephone services (pay stations excluded) (chapter 21) Television and radio service (chapter 21) Parking lot (chapter 21) Provider-based physician adjustment Sale of scrap, waste, etc. (chapter 23) Related organization transactions (chapter 10) Laundry and linen service Cafeteria-employees and guests Rental of quarters to employee and others Sale of medical and surgical supplies to other than patients Sale of drugs to other than patients Sale of medical records and abstracts Nursing school (tuition, fees, books, etc.) Vending machines p of interest,, Income from imposition finance or penalty charges (chapter 21) Interest expense on Medicare overpayments and borrowings to repay Medicare overpayments Adjustment for respiratory therapy costs in excess of limitation (chapter 14) Adjustment for physical therapy costs in excess of limitation (chapter 14) Utilization review - physicians' compensation (chapter 21) Depreciation - buildings and fixtures Depreciation - movable equipment Non-physician Anesthetist Physicians' assistant Adjustment for occupational therapy costs in excess of limitation (chapter 14) Adjustment for speech pathology costs in excess of limitation (chapter 14) CAH HIT Adjustment for Depreciation and d Interest I t t

AMOUNT 2

WORKSHEET A-8

EXPENSE CLASSIFICATION ON WORKSHEET A TO/FROM WHICH Wkst. THE AMOUNT IS TO BE ADJUSTED A-7 COST CENTER LINE # Ref. 3 4 5 Buildings and Fixtures 1 Movable Equipment 2

Worksheet A-8-2 Worksheet A-8-1

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Worksheet A-8-3

Respiratory Therapy

65

Worksheet A-8-3

Physical Therapy Utilization Review - SNF Buildings and Fixtures Movable Equipment Nonphysician Anesthetist

65 114 1 2 19

Worksheet A-8-3

Occupational Therapy

65

Worksheet A-8-3

Speech Pathology

65

24 25 26 27 28 29 30 31

(3)

33 Other adjustments (specify) 50 TOTAL (sum of lines 1 thru 49) (Transfer to Worksheet A, column 6, line 200)

32 33 50



Rev. 1

40-529

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WS A-8 A8 Common Examples of WS A-8 A 8 Adjustments: 1. 2 2. 3. 4. 5.

Bad Debt Expense (Simple Adjustment) Mi Revenue Misc R (“Primarily” (“P i il ” Simple Si l Adjustment) Adj t t) Interest Income/Expense (Partial Adjustment) Grant Revenues (No Offset) Cafeteria Revenue (Move and Offset)


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WS A-8 A8 Steps to process WS A-6 A 6 Data: • Identify the data to be Adjusted – General Ledger g – Statistics (Partial Adjustments)

• What is the basis for the Adjustment? – – – –

Whole Wh l (Si (Simple) l ) Partial No Offset Matching Principle (Cost Center Assignment)

• Sort and Subtotal


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Purpose:

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

Sources:

General LedgerInterste Income and Expense Accounts Related Party transaction analysis (WP A‐8‐1_2) R l dP i l i (WP A 8 1 2)

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

Account

Description

SubAccount Description

80250 NON ALLOCABLE OVERHEAD 80250 NON ALLOCABLE OVERHEAD

Interest Income Interest Income

Net Interest Exp (A) Net Interest Exp (A)

461170 INTEREST INC PHYSICANS\' NOTES (42,379.93) 461270 INTEREST INC OTHER (4,834.15) (47,214.08) 28,348.28

Account

Description

80102 80250 80250 80250 80250 82110

SubAccount Description

ADMINISTRATION NON ALLOCABLE OVERHEAD NON ALLOCABLE OVERHEAD NON ALLOCABLE OVERHEAD NON ALLOCABLE OVERHEAD NUTRITIONAL SVCS

790480 528220 528225 790130 790150 790650

INT CONTRA CAP INT 1998 BONDS I/C EXP‐ INT L/T NOTES I/C EXP‐ INT L/T NOTES INT CAP LEASE 1 INT CAP LEASE 2 INT CONTRA CAP INT 1999 BONDS

Interest Expense

WS A‐8 Line Cost Center 39

Audit Tags

Interest Exp

Interest income Offset

Related Party Adjustment (C )

(1,270,121.20) 5,786,570.17 (4,525,798.65) 41,019.62 27,752.57 714.74 (31,788.97) 4,554,146.93

Description 6

Max Interest Rev Offset Max Interest Rev Offset

28,348.28 (B)

Net Interest Exp (1,270,121.20) 1,260,771.52 41,019.62 27,752.57 714.74 (31,788.97)

(4,525,798.65) 28,348.28 (A)

Amount 28,348.28 (B)

(A) ‐ This amount represents the Net Interest Expense (Max Offset of interest Income) (B) ‐ Interest Income exceeds the ralated expenses ‐ Net Interest Income Offset (C ) ‐ Cost of related party transaction adjustment based on WP A‐8‐1_2


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WS A-8 A8 Do WS A-8 A 8 Adjustments impact other cost report pages?


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WS B-1 B 1 (Statistical Allocations) WS B-1 B 1 is where the Overhead Cost Centers are Allocated to the rest of the Hospital Departments based on their individual Statistics. Statistics – Single Allocation Methodology CFR 413.24(d)(1) – Multiple M lti l Allocation All ti M Methodology th d l CFR413.24(d)(2)(ii) – Simplified Cost Allocation


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12-10

FORM CMS-2552-10

COST ALLOCATION ‐ STATISTICAL BASIS

4090 (Cont.)

PROVIDER NO.: ________________

CENTER DESCRIPTIONS

1 2 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 30 31 32 33 34 35 40 41 42 43 44 45 46

GENERAL SERVICE COST CENTERS Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment E l Employee Benefits B fit Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services and Supply Pharmacy Medical Records & Medical Records Library Social Service Other General Service (specify) Nonphysician Anesthetists Nursing School Intern & Res. Service-Salary y & Fringes g ((Approved) pp ) Intern & Res. Other Program Costs (Approved) Paramedical Education Program (specify) INPATIENT ROUTINE SERVICE COST CENTERS Adults and Pediatrics (General Routine Care) Intensive Care Unit Coronary Care Unit Burn Intensive Care Unit Surgical Intensive Care Unit Other Special Care Unit (specify) Subprovider IPF Subprovider IRF Subprovider (specify) Nursery Skilled Nursing Facility Nursing Facility Other Long Term Care

CAPITAL RELATED COST CAPITAL RELATED COST BLDGS. & MOVABLE FIXTURES EQUIPMENT (SQUARE (DOLLAR FEET) VALUE) 1 2

EMPLOYEE BENEFITS (GROSS SALARIES) 4

RECONCIL‐ IATION 5A

PERIOD: FROM ____________ TO _______________ ADMINIS‐ ADMINIS MAIN‐ MAIN TRATIVE & TENANCE & GENERAL REPAIRS (ACCUM. (SQUARE COST) FEET) 5 6

WORKSHEET B-1 OPERATION OF PLANT (SQUARE FEET) 7 1 2 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

30 31 32 33 34 35 40 41 42 43 44 45 46


Rev. 1


40-553

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12-10

FORM CMS-2552-10


4090 (Cont.)

PROVIDER NO.: ________________

CENTER DESCRIPTIONS

50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 88 89 90 91 92 93

ANCILLARY SERVICE COST CENTERS Operating Room Recovery y Room Labor Room and Delivery Room Anesthesiology Radiology-Diagnostic Radiology-Therapeutic Radioisotope Computed Tomography (CT) Scan Magnetic Resonance Imaging (MRI) Cardiac Catheterization Laboratory PBP Clinical Laboratory Services-Program Only Whole Blood & Packed Red Blood Cells Blood Storing, Processing, & Trans. Intravenous Therapy Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Electroencephalography Medical Supplies Charged to Patients Implantable Devices Charged to Patients Drugs Charged to Patients Renal Dialysis ASC (Non-Distinct (Non Distinct Part) Other Ancillary (specify) OUTPATIENT SERVICE COST CENTERS Rural Health Clinic (RHC) Federally Qualified Health Center (FQHC) Clinic Emergency Observation Beds Other Outpatient Service (specify)

CAPITAL RELATED COST BLDGS. & MOVABLE FIXTURES EQUIPMENT (SQUARE (DOLLAR FEET) VALUE) 1 2



PERIOD: FROM ____________ TO _______________ ADMINIS‐ MAIN‐ TRATIVE & TENANCE & GENERAL REPAIRS (ACCUM. (SQUARE COST) FEET) 5 6

WORKSHEET B-1 OPERATION OF PLANT (SQUARE FEET) 7

50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 88 89 90 91 92 93


40-554


Rev. 1

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12-10

FORM CMS-2552-10


4090 (Cont.)

PROVIDER NO.: ________________

T CENTER DESCRIPTIONS

OTHER REIMBURSABLE COST CENTERS Home Program Dialysis A b l Ambulance Services S i Durable Medical Equipment-Rented Durable Medical Equipment-Sold Other Reimbursable (specify) Outpatient Rehabilitation Provider (specify) Intern-Resident Service (not appvd. tchng. prgm.) Home Health Agency SPECIAL PURPOSE COST CENTERS Kidney Acquisition Heart Acquisition Liver Acquisition Lung Acquisition Pancreas Acquisition Intestinal Acquisition Islet Acquisition Other Organ Acquisition (specify) Ambulatory Surgical Center (Distinct Part) Hospice Other Special Purpose (specify) SUBTOTALS (sum of lines 1-117) NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop, & Canteen Research Physicians' Private Offices Nonpaid Workers Other Nonreimbursable (specify) Cross foot adjustments Negative cost centers Cost to be allocated (per Worksheet B, Part I) Unit cost multiplier (Worksheet B, Part I) Cost to be allocated (p (per Worksheet B, Part II)) Unit cost multiplier (Worksheet B, Part II)

94 95 96 97 98 99 100 101 105 106 107 108 109 110 111 112 115 116 117 118 190 191 192 193 194 200 201 202 203 204 205

CAPITAL RELATED COST CAPITAL RELATED COST BLDGS. & MOVABLE FIXTURES EQUIPMENT (SQUARE (DOLLAR FEET) VALUE) 1 2



PERIOD: FROM ____________ TO _______________ ADMINIS‐ ADMINIS MAIN‐ MAIN TRATIVE & TENANCE & GENERAL REPAIRS (ACCUM. (SQUARE COST) FEET) 5 6

WORKSHEET B-1 OPERATION OF PLANT (SQUARE FEET) 7 94 95 96 97 98 99 100 101

105 106 107 108 109 110 111 112 115 116 117 118

190 191 192 193 194 200 201 202 203 204 205


Rev. 1


40-555

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WS B-1 B1 The standard Statistics that CMS allows for each Cost Center are as Follows: – – – – – – –

Square Feet (CC# 1, 6, and 7) Dollar Value (CC# 2) Gross Salaries (CC# 4) Accumulated Cost (CC# 5) LBS of Laundry (CC# 8) Meals Served (CC # 9 and 10) Number Housed (CC# 12)


– – – –

Direct ec Nursing u s g Hours ou s (CC# 13) 3) Costed Requisitions (CC# 14 and 15) Time Spent (CC# 16 and 17) Assigned Time (CC# 19-23)

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WS B-1 B1 Steps to process WS B-1 B 1 Data: • Identify the data to be used as Statistic – General Ledger g ((Dollar Value, Gross Salaries, Costed Requisitions, q etc.)) – Statistics (Various Data Sources)

• • • • • •

Calculated Values or imputed Values C t Center Cost C t Assignment A i t Identification of Adjustments due to WS A-6 or WS A-8 Previously Allocated Cost Centers Sort and Subtotal Workpapers should always agree to the total Statistic that was used in the cost report


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WS C (Patient Treatment Revenues) WS C is used to identify the Total IP and OP Charges by Department for Patient Treatment activities. These charges are then compared to the expenses (after stepdown) in order to arrive at the Cost to Charge Ratio (CCR). (CCR) The CCRs are how Medicare and Medicaid identify the cost of services based on the bills submitted. submitted


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12-10

FORM CMS-2552-10

4090 (Cont.)

COMPUTATION OF RATIO OF COSTS TO CHARGES

PROVIDER NO.:

Total Cost (from Wkst. B, Part I, col. 26) 1

COST CENTER DESCRIPTIONS

30 31 32 33 34 35 40 41 42 43 44 45 46 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68

INPATIENT ROUTINE SERVICE COST CENTERS Adults and Pediatrics (General Routine Care) I t i Care Intensive C Unit U it Coronary Care Unit Burn Intensive Care Unit Surgical Intensive Care Unit Other Special Care (specify) Subprovider IPF Subprovider IRF Subprovider (Specify) Nursery Skilled Nursing Facility Nursing Facility Other Long Term Care ANCILLARY SERVICE COST CENTERS Operating Room Recovery Room Labor Room and Delivery Room Anesthesiology Radiology-Diagnostic Radiology-Therapeutic Radioisotope Computed Tomography (CT) Scan Magnetic Resonance Imaging (MRI) Cardiac Catheterization Laboratoryy PBP Clinical Laboratory Services-Prgm. Only Whole Blood & Packed Red Blood Cells Blood Storing, Processing, & Trans. Intravenous Therapy Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology

Therapy Limit Adj. 2

Costs RCE Dis‐ allowance 4

Total Costs 3

PERIOD: FROM ____________ TO TO _______________

_____________ Charges Total Costs 5

Inpatient 6

Total (column 6 + column 7) 8

Outpatient 7

WORKSHEET C PART I

TEFRA Inpatient Ratio 10

Cost or Other Ratio 9

PPS Inpatient Ratio 11 30 31 32 33 34 35 40 41 42 43 44 45 46

50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68

F OR M CM S -2552-10 (12/2010) (INS TR UC TIONS F OR THIS WORKS HEET ARE P UB LIS HED IN C M S P UB . 15-II, S EC TIONS 4023)

Rev. 1

40-563


www.esshc.com

4090 (Cont.)

FORM CMS-2552-10

#REF!

COMPUTATION OF RATIO OF COSTS TO CHARGES

COST CENTER DESCRIPTIONS

69 70 71 72 73 74 75 76 88 89 90 91 92 93 94 95 96 97 98 99 100 101 105 106 107 108 109 110 111 112 115 116 117 200 201 202

PROVIDER NO.:

Total Cost (from Wkst. B, Part I, col. 26) 1

Therapy Limit Adj. 2

OUTPATIENT SERVICE COST CENTERS Electrocardiology Electroencephalography Medical Supplies Charged to Patients Implantable Devices Charged to Patients Drugs Charged to Patients Renal Dialysis ASC (Non-Distinct Part) Other Ancillary (specify) Rural Health Clinic (RHC) Federally Qualified Health Center (FQHC) Clinic Emergency g y Observation Beds (see instructions) Other Outpatient Service (specify) OTHER REIMBURSABLE COST CENTERS Home Program Dialysis Ambulance Services Durable Medical Equipment-Rented Durable Medical Equipment-Sold Other Reimbursable (specify) O Outpatient i R Rehabilitation h bili i Provider P id (specify) ( if ) Intern-Resident Service (not appvd. tchng. prgm.) Home Health Agency SPECIAL PURPOSE COST CENTERS Kidney Acquisition Heart Acquisition Liver Acquisition Lung Acquisition Pancreas Acquisition Intestinal Acquisition Islet Acquisition Other Organ Acquisition (specify) Ambulatory Surgical Center (Distinct Part) Hospice Other Special Purpose (specify) Subtotal (sum of lines 30 thru 199) Less Observation Beds Total (line 200 minus line 201)

Total Costs 3

Costs RCE Dis‐ allowance 4

PERIOD: FROM ____________ TO _______________

_____________ Charges Total Costs 5

Inpatient 6

Outpatient 7

Total (column 6 + column 7) 8

Cost or Other Ratio 9

WORKSHEET C PART I

TEFRA Inpatient Ratio 10

PPS Inpatient Ratio 11 69 70 71 72 73 74 75 76 88 89 90 91 92 93 94 95 96 97 98 99 100 101 105 106 107 108 109 110 111 112 115 116 117 200 201 202

F OR M C M S -2552-10 (12/2010) (INS TR UC TIONS F OR THIS WOR KS HEET AR E P UB LIS HED IN C M S P UB . 15-II, S EC TIONS 4023)

40-564

Rev. 1


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WS C Steps to process WS C Data: • Identify the data to be used: – General Ledger g – Volume Report (Revenue Reclasses and Adjustments)

• Cost Center Assignment • Revenue R R l Reclasses – – – –

Medical Supplies Drugs g Observation Etc.


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WS C Steps to process WS C Data: • Revenue Adjustments – IP/OP charges g in wrongg category g y – Epogene – Etc.

• Identify and WS A-6 A 6 Impacts on Revenues • Sort and Subtotal • Workpapers should always reconcile back to the Original GL (CR to IS Recon) as well as agree to the WS C Values.


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Settlement Charges The Settlement Charges are the Medicare/Medicaid charges that have been accumulated from the Bills submitted and are sumaraized on the Provider Statistical Report (PSR). These charges are applied to the CCR (WS C) to calculate the cost of treating the Medicare/Medicaid patients. Charges on the PSR are identified by their 3(4) digit numeric revenue code. code


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Settlement Charges Settlement Charges are obtained from the PSR. PSR The PSR contains multiple report types. Listed below are the most common IP PSR Report p Types: yp – – – – – – –

110 I/P Part A – 122 I/P Part B Vaccines 118 Inpatient - Part A Managed Care – 125 I/P Part B - Fee Reimbursed 119 I/P PPS Interim Bills – 12P I/P Part B - OPPS 11A I/P Part A (MSP) 11R I/P Rehab 11U I/P Psych 120 Inpatient - Part B


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Settlement Charges Listed below are the most common OP PSR Report Types: – – – – – – – – –

130 O/P All Other / Ambulance 132 O/P Part B Vaccines 135 O/P Fee Reimbursed 13A O/P All Other (MSP) 13P O/P OPPS 140 O/P All Other 145 O/P Other Mamography Fee Reimbursed 14A O/P Clinical Labs (MSP) 14P O/P Other OPPS


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4090 (Cont.)

FORM CMS-2552-10

INPATIENT ANCILLARY SERVICE COST APPORTIONMENT

12-10

PROVIDER NO.: ________________ C OM P ONENT NO.:

Check applicable boxes:

[ ] Title V [ ] Title XVIII, XVIII Part A [ ] Title XIX

[ ] Hospital [ ] IPF [ ] IRF

COST CENTER DESCRIPTION

30 31 32 33 34 35 40 41 42 43 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 88 89 90 91 92 93 94 95 96 97 98 200 201 202


________________ [ ] Subprovider (other) [ ] SNF [ ] NF Ratio of Cost to Charges 1

INPATIENT ROUTINE SERVICE COST CENTERS Adults and Pediatrics (General Routine Care) Intensive Care Unit Coronary Care Unit Burn Intensive Care Unit Surgical Intensive Care Unit Other Special Care (specify) Subprovider IPF Subprovider IRF Subprovider (Specify) Nursery ANCILLARY SERVICE COST CENTERS Operating Room Recovery Room Labor Room and Delivery Room Anesthesiology Radiology‐Diagnostic gy g Radiology‐Therapeutic Radioisotope Computed Tomography (CT) Scan Magnetic Resonance Imaging (MRI) Cardiac Catheterization Laboratory PBP Clinical Laboratory Services‐Prgm. Only Whole Blood & Packed Red Blood Cells Blood Storing, Processing, & Trans. Intravenous Therapy Respiratory Therapy Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Electroencephalography Medical Supplies Charged to Patients Implantable Devices Charged to Patients Drugs Charged to Patients Renal Dialysis ASC (Non‐Distinct Part) Other Ancillary (specify) ( ) OUTPATIENT SERVICE COST CENTERS Rural Health Clinic (RHC) Federally Qualified Health Center (FQHC) Clinic Emergency Observation Beds (see instructions) Other Outpatient Service (specify) OTHER REIMBURSABLE COST CENTERS Home Program Dialysis Ambulance Services Durable Medical Equipment‐Rented Durable Medical Equipment‐Sold Other Reimbursable (specify) Total (sum of lines 50‐94 and 96‐98) Less PBP Clinic Laboratory Services‐Program only charges (line 61) Net Charges (line 200 minus line 201)

PERIOD: FROM ____________ TO _______________ [ ] Swing-Bed SNF [ ] Swing Swing-Bed Bed NF [ ] ICF/MR Inpatient Program Charges 2

WOR KS HEET D-3

[ ] PPS [ ] TEFRA [ ] Other Inpatient Program Costs (col. 1 x col. 2) 3 30 31 32 33 34 35 40 41 42 43 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 88 89 90 91 92 93 94 95 96 97 98 200 201 202


40-578

Rev. 1

www.esshc.com

4090 (Cont.)

FORM CMS-2552-10

APPORTIONMENT OF MEDICAL AND OTHER HEALTH SERVICES COSTS

Check [ ] Title V - O/P applicable li bl [ ] Ti Title l XVIII XVIII, P Part B boxes: [ ] Title XIX - O/P PART V - APPORTIONMENT OF MEDICAL AND OTHER HEALTH

50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 88 89 90 91 92 93 94 95 96 97 98 200 201 202

Cost Center Description ANCILLARY SERVICE COST CENTERS ANCILLARY SERVICE COST CENTERS Operating Room Recovery Room Labor & Delivery Room Anesthesiology Radiology-Diagnostic Radiology-Therapeutic Radioisotope Computed Tomography (CT) Scan Magnetic Resonance Imaging (MRI) Cardiac Catheterization Laboratory PBP Clinic Laboratory Services-Prgm. Only Whole Blood & Packed Red Blood Cells Blood Storing, Processing, & Transfusing Intravenous Therapy Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Electroencephalography Medical Supplies Charged To Patients Implantable Devices Charged to Patients Drugs Charged to Patients Renal Dialysis ASC (Non-Distinct Part) Other Ancillary (specify) OUTPATIENT SERVICE COST CENTERS Rural Health Clinic (RHC) Federally Qualified Health Center (FQHC) Clinic Emergency Observation Bed Other Outpatient Service (specify) OTHER REIMBURSABLE COST CENTERS Home Program Dialysis Ambulance Durable Medical Equipment-Rented Durable Medical Equipment-Sold Other Reimbursable Cost Center Subtotal (see instructions) L Less PBP Cli Clinic i Lab. L b Services-Program S i P Only Charges Net Charges (line 200 ± line 201 )

12-10

PROVIDER NO.: ______________ PERIOD: FROM ____________ COMPONENT NO.: ____________ TO _______________

Cost to Charge Ratio from Worksheet C, Part I, col. 9 1

[ ] Hospital [ ] Subprovider (Other) [ ] IPF [ ] SNF [ ] IRF [ ] NF SERVICES COSTS Program Charges Cost Reimbursed Cost Reimbursed Services Services Not PPS Reimbursed Subject to Subject to Services Ded. & Coins. Ded. & Coins. (see instructions) (see instructions) (see instructions) 2 3 4

WORKSHEET D, PART V

[ ] Swing Bed SNF []S Swing i B Bed d NF [ ] ICF/MR

PPS Services (see instructions) 5

Program Cost Cost Services Subject to Ded. & Coins. (see instructions) 6

Cost Services Not Subject to Ded. & Coins. (see instructions) 7 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 88 89 90 91 92 93 94 95 96 97 98 200 201 202

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

40-572


Rev. 1

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Settlement Charges The Settlement charges are intended to be identified against the department that generated the charge as matching the revenues against the expense incurred to perform that treatment/service. There are severall ways th thatt providers id hhave undertaken d t k th the id identification tifi ti off th the PSR charges to the Cost Center: 1. 2. 3. 4.

Allocate the Revenues from the PSR by revenue code to the cost centers based on internal data (Revenue and Usage) Directly assigning the Revenues by revenue codes to cost centers (Crosswalk) Allocate Total Charges to all cost centers based on the Total or Medicare total charges by cost center (Total Allocation) A combination of the three methods identified above (3rd most common method)


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Settlement Charges Steps to process Settlement Charges: • Identify the data to be used: – – – –

Provider Statistical Report p ((PSR)) Revenue and Usage (Medicare Patients) Settlement Crosswalk (should be consistent between years) Medicare logs

• Determine the Methodology – Should be consistent with prior year

• Start with PSR


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Settlement Charges Steps to process Settlement Charges: • Adjustments to the PSR – Pendingg Claims – Errors

• Grouping / Allocation of Charges – Using U i Revenue R andd Usage U files fil – Crosswalks to Cost Centers – Specialty Revenue Codes • • • •

Observation Medical Supplies Implantable Devices Dr gs Drugs


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Settlement Charges Steps to process Settlement Charges: • Workpapers should show the Settlement Charges “Both Directions Directions” – What was done with each Revenue Code (Revcode to Cost Center Crosswalk) – What makes up each number in the Cost Report


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

Deductible C I Co-Insurance PPS Payments (DRG, APC, RUGS, etc.) Interim Payments Capital Payments Etc.


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4090 (Cont.)

CMS FORM-2552-10

CALCULATION OF REIMBURSEMENT SETTLEMENT

Check applicable box:

12-10

PROVIDER NO.: ________________ COMPONENT NO.: ________________

PERIOD: FROM ____________ TO _______________

WORKSHEET E, PART A

[ ] Hospital [ ] Subprovider (Other)

PART A - INPATIENT HOSPITAL SERVICES UNDER PPS 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34


DRG amounts other than outlier payments Outlier payments for discharges (see instructions) Managed care simulated payments Bed days available divided by number of days in the cost reporting period (see instructions) Bed days available divided by number of days in the cost reporting period (see instructions) Indirect Medical Education Adjustme nt Calculation for Hospitals FTE count for allopathic and osteopathic programs for the most recent cost reporting period ending on or before 12/31/1996 (see instructions) FTE count for allopathic and osteopathic programs which meet the criteria for an add-on to the cap for new programs in accordance with section 1886(d)(5)(B)(viii) Adjusted FTE count for allopathic and osteopathic programs for affiliated programs in accordance with section 1886(d)(5)(B)(viii) Reduced Direct GME FTE Cap p ((see instructions)) Sum of lines 5 through 7 plus/minus line 8 (see instructions) FTE count for allopathic and osteopathic programs in the current year from your records FTE count for residents in dental and podiatric programs Current year allowable FTE (see instructions) Total allowable FTE count for the prior year Total allowable FTE count for the penultimate year if that year ended on or after September 30, 1997, otherwise enter zero. Sum of lines 12 through 14 divided by 3 Adjustment for residents in initial years of the program Adjustment for residents displaced by program or hospital closure Adjusted rolling average FTE count Current year resident to bed ratio (line 15 divided by line 4) Prior year resident to bed ratio (see instructions) Enter the lesser of lines 19 or 20 (see instructions) IME payment adjustment (see instructions) Indirect Medical Education Adjustme nt for the Add-on Number of additional allopathic and osteopathic IME FTE resident cap slots under 42 Sec. 412.105 (f)(1)(iv)(C ). IME FTE resident count over cap (see instructions) If the amount on line 24 is greater than -0-, then enter the lower of line 23 or line 24 (see instructions) Resident to bed ratio (divide line 25 by line 4) IME payments adjustment (see instructions) IME Adjustment (see instructions) Total IME payment (sum of lines 22 and 28) Disproportionate Share Adjustment Percentage of SSI recipient patient days to Medicare Part A patient days (see instructions) Percentage g of Medicaid patient p days y to total days y reported p on Worksheet S-3, Part I (see ( instructions)) Sum of lines 30 and 31 Allowable disproportionate share percentage (see instructions) Disproportionate share adjustment (see instructions)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34

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

40-584

Rev. 1

www.esshc.com

12-10

CMS FORM-2552-10




4090 (Cont.)

PERIOD: FROM ____________ TO _______________

WORKSHEET E, PART A (Cont.)

[ ] Hospital [ ] Hospital [ ] IRF

PART A - INPATIENT HOSPITAL SERVICES UNDER PPS

41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75

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

41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75

90 91 92 93 94 95 96

TO BE COMPLETED BY CONTRACTOR Operating outlier amount from Worksheet E, Part A line 2 Capital outlier from Worksheet L, Part I, line 2 Operating outlier reconciliation adjustment amount (see instructions) Capital outlier reconciliation adjustment amount (see instructions) The rate used to calculate the Time Value of Money (see instructions) Time Value of Money for operating expenses (see instructions) Time Value of Money for capital related expenses (see instructions)

90 91 92 93 94 95 96

40


40


Rev. 1

40-585

www.esshc.com

4090 (Cont.)

FORM CMS-2552-10


PROVIDER NO.: PERIOD: ________________ FROM ____________ COMPONENT NO.: TO _______________ ________________ Check applicable box: Check applicable box: [ ] Hospital [ ] IPF [ ] IRF [ ] Subprovider (Other) [ ] SNF [ ] Hospital [ ] IPF [ ] IRF [ ] Subprovider (Other) [ ] SNF PART B - MEDICAL AND OTHER HEALTH SERVICES 1 Medical and other services (see instructions) 2 Medical and other services reimbursed under OPPS (see instructions). 3 PPS payments 4 Outlier payment (see instructions) 5 Enter the hospital specific payment to cost ratio (see instructions) 6 Line 2 times line 5 7 Sum of lines line 3 plus line 4 divided by line 6 8 Transitional corridor payment (see instructions) 9 Enter the amount from Worksheet D, Part IV, column 13, line 200 10 Organ acquisition 11 Total cost (sum of lines 1 and 10) (see instructions) COMPUTATION OF LESSER OF COST OR CHARGES Reasonable charges 12 Ancillary service charges 13 Organ acquisition charges (from Worksheet D‐4, Part III, line 69, col. 4) 14 Total reasonable charges (sum of lines 12 and 13) Customary charges 15 Aggregate amount actually collected from patients liable for payment for services on a charge basis 16 Amounts that would have been realized from patients liable for payment for services on a charge 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) 18 Total customary charges (see instructions) 19 Excess of customary charges over reasonable cost (complete only if line 18 exceeds line 11) (see instructions) 20 Excess of reasonable cost over customary charges (complete only if line 11 exceeds line 18) (see instructions) 21 Lesser of cost or charges (line 11 or line 20) (for CAH, see instructions) 22 Interns and residents (see instructions) 23 Cost of teaching physicians (see instructions, 42 CFR 415.160 and CMS Pub. 15‐1, §2148) Cost of teaching physicians (see instructions 42 CFR 415 160 and CMS Pub 15 1 §2148) 24 Total prospective payment (sum of lines 3, 4, 8 and 9) COMPUTATION OF REIMBURSEMENT SETTLEMENT 25 Deductibles and coinsurance (see instructions) 26 Deductibles and Coinsurance relating to amount on line 24 (see instructions) 27 Subtotal {(lines 21 and 24 ‐ the sum of lines 25 and 26) plus the sum of lines 22 and 23} (see instructions) 28 Direct graduate medical education payments (from Worksheet E‐4, line 50) 29 ESRD direct medical education costs (from Worksheet E‐4, line 36) 30 Subtotal (sum of lines 27 through 29) 31 Primary payer payments yp y p y 32 Subtotal (line 30 minus line 31) ALLOWABLE BAD DEBTS (EXCLUDE BAD DEBTS FOR PROFESSIONAL SERVICES) 33 Composite rate ESRD (from Worksheet I‐5, line 11) 34 Allowable bad debts (see instructions) 35 Adjusted reimbursable bad debts (see instructions) 36 Allowable bad debts for dual eligible beneficiaries (see instructions) 37 Subtotal (sum of lines 32, 33, and 34 or 35) (line 35 hospital and subprovider only) 38 MSP‐LCC reconciliation amount from PS&R 39 Other adjustments (specify) (see instructions) 40 Subtotal (line 37 plus or minus lines 39 minus 38) 41 Interim payments 42 Tentative settlement (for contractors use only) 43 Balance due provider/program (line 40 minus the sum of lines 41, and 42) 44 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15‐II, section 115.2


12-10

WORKSHEET E, PART B

1 2 3 4 5 6 7 8 9 10 11

12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44


40-586

Rev.1

www.esshc.com

4090 (Cont.)

FORM CMS-2552-10

ANALYSIS OF PAYMENTS TO PROVIDERS FOR SERVICES RENDERED


12-10

PROVIDER NO.: ________________ COMPONENT NO.: ________________ [ ] Hospital [ ] IPF [ ] IRF

PERIOD: FROM ____________ TO _______________ Inpatient Part A mm/dd/yyyy Amount 1 2

[ ] Subprovider (Other) [ ] SNF [ ] Swing-Bed SNF

Description 1 Total interim payments paid to provider 2 Interim payments payable on individual bills, either submitted or to be submitted to the intermediary for services rendered in the cost reporting period. If none, write "NONE" for services rendered in the cost reporting period. If none, write NONE or enter a zero or enter a zero 3 List separately each retroactive lump sum adjustment amount based on subsequent revision of the Program to interim rate for the cost reporting period. Provider Also show date of each payment. If none, write "NONE" or enter a zero. (1) Provider to Program Subtotal (sum of lines 3.01‐ 3.49 minus sum of lines 3.50‐3.98) 4 Total interim payments (sum of lines 1, 2, and 3.99) (transfer to Wkst. E or Wkst. E‐3, line and column as appropriate) TO BE COMPLETED BY CONTRACTOR TO BE COMPLETED BY CONTRACTOR 5 List separately each tentative settlement payment after desk review. Also show date of each payment. If none, write "NONE" or enter a zero. (1)

Program to Provider

Provider to Program Subtotal (sum of lines 5.01‐5.49 Subtotal (sum of lines 5.01 5.49 minus sum of lines 5.50 minus sum of lines 5.50 ‐5.98) 5.98) 6 Determined net settlement amount (balance due) based on the cost report (1) 7 Total Medicare program liability (see instructions) 8 Name of Contractor

Program to provider Provider to program

WORKSHEET E-1, PART I

Part B mm/dd/yyyy Amount 3 4 1 2

.01 .02 .03 .04 .05 .50 .51 .52 .53 .54 .99

3.01 3.02 3.03 3.04 3.05 3.50 3.51 3.52 3.53 3.54 3.99 4

.01 .02 .03 .50 .51 .52 .99 .01 .02

5.01 5.02 5.03 5.50 5.51 5.52 5.99 6.01 6.02 7 8

Contractor Number

Date (Month/Day/Year)

(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. F OR M C M S -2552-10 (12/2010) (INS TR UC TIONS F OR THIS WOR KS HEET AR E P UB LIS HED IN C M S P UB . 15-II, S EC TION 4031)

40-588


Rev. 1

www.esshc.com

12-10

FORM CMS-2552-10



4090 (Cont.)


PERIOD: FROM ____________ TO _______________

WORKSHEET E‐3, PART I


PART I - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER - TEFRA 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

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

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22


Rev. 1


40-591

www.esshc.com

4090 (Cont.)

FORM CMS-2552-10



12-10


PERIOD: FROM ____________ TO _______________

WORKSHEET E‐3, PART II


PART II - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER IPF PPS 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

Net Federal IPF PPS payment (excluding outlier, ECT, and medical education payments) Net IPF PPS Outlier p payment y Net IPF PPS ECT payment Unweighted intern and resident FTE count in the most recent cost report filed on or before November 15, 2004 (see instructions) New teaching program adjustment (see instructions) Current year unweighted FTE count of I&R other than FTEs in the first 3 years of a "new teaching program" (see instructions) Current year unweighted I&R FTE count for residents within the first 3 years of a "new teaching program" (see instructions) Intern and resident count for IPF PPS medical education adjustment (see instructions) Average daily census (see instructions) Medical Education Adjustment j Factor {((1 {(( + (line ( 8/line 9)) )) raised to the power p of .5150 -1}. } Medical Education Adjustment (line 1 multiplied by line 10). Adjusted Net IPF PPS Payments (sum of lines 1, 2, 3 and 11) Nursing and allied health managed care payment (see instruction) Organ acquisition Cost of teaching physicians (from Worksheet D‐5, Part II, column 3, line 20) (see instructions) Subtotal (see instructions) Primary payer payments Subtotal (line 16 less line 17). Subtotal (line 6 less line 7). Deductibles Subtotal (line 18 minus line 19) Coinsurance Subtotal (line 20 minus line 21) Allowable bad debts (exclude bad debts for professional services) (see instructions) Adjusted reimbursable bad debts (see instructions) Allowable bad debts for dual eligible beneficiaries (see instructions) Subtotal (sum of lines 22 and 24) Subtotal (sum of lines 22 and 24) Direct graduate medical education payments (from Worksheet E‐4, line 49) Other pass through costs (see instructions) Outlier payments reconciliation Other adjustments (specify) (see instructions) Total amount payable to the provider (see instructions) Interim payments Tentative settlement (for contractor use only) Balance due provider/program (line 31 minus the sum lines 32 and 33) Balance due provider/program (line 31 minus the sum lines 32 and 33) Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35


40-592


Rev. 1

www.esshc.com

12-10

FORM CMS-2552-10



4090 (Cont.)


PERIOD: FROM ____________ TO _______________

WORKSHEET E‐3, PART III


PART III - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER IRF PPS 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 6 26 27 28 29 30 31 32 33 34 35 36

Net Federal PPS payment (see instructions) Medicare SSI ratio (IRF PPS only) (see instructions) Inpatient Rehabilitation LIP payments (see instructions) Outlier payments Unweighted intern and resident FTE count in the most recent cost reporting period ending on or prior to November 15, 2004 (see instructions) New teaching program adjustment (see instructions) Current year unweighted FTE count of I&R other than FTEs in the first 3 years of a "new teaching program" (see instructions) Current year unweighted I&R FTE count for residents within the first 3 years of a "new teaching program" (see instructions) Intern and resident count for IRF PPS medical education adjustment (see instructions) A Average d daily il census (see ( instructions) i t ti ) Medical Education Adjustment Factor {((1 + (line 9/line 10)) raised to the power of .6876 -1}. Medical Education Adjustment (line 1 multiplied by line 11). Total PPS Payment (sum of lines 1, 3, 4 and 12) Nursing and Allied Health Managed Care payment (see instructions) Organ acquisition Cost of teaching physicians (from Worksheet D‐5, Part II, column 3, line 20) (see instructions) Subtotal (see instructions) Primary payer payments Primary payer payments Subtotal (line 17 less line 18). Deductibles Subtotal (line 19 minus line 20) Coinsurance Subtotal (line 21 minus line 22) Allowable bad debts (exclude bad debts for professional services) (see instructions) Adjusted reimbursable bad debts (see instructions) Allowable bad debts for dual eligible beneficiaries (see instructions) Allowable bad debts for dual eligible beneficiaries (see instructions) Subtotal (sum of lines 23 and 25) Direct graduate medical education payments (from Worksheet E‐4, line 49) Other pass through costs (see instructions) Outlier payments reconciliation Other adjustments (specify) (see instructions) Total amount payable to the provider (see instructions) Interim payments Tentative settlement (for contractor use only) Balance due provider/program (line 32 minus the sum lines 33 and 34) Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 6 27 28 29 30 31 32 33 34 35 36


Rev. 1


40-593

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4090 (Cont.)

FORM CMS-2552-10

CALCULATION OF CAPITAL PAYMENT

PROVIDER NO.: PERIOD: WORKSHEET L ____________ FROM ____________ COMPONENT NO.: TO _______________ ____________ [ ] Hospital [ ] PPS [ ] Subprovider (other) [ ] Cost Method

Check [ ] Title V applicable [ ] Title XVIII, Part A boxes: [ ] Title XIX PART I ‐ FULLY PROSPECTIVE METHOD CAPITAL FEDERAL AMOUNT 1 Capital DRG other than outlier 2 Capital DRG outlier payments 3 Total inpatient days divided by number of days in the cost reporting period (see instructions) 4 Number of interns & residents (see instructions) Number of interns & residents (see instructions) 5 Indirect medical education percentage (see instructions) 6 Indirect medical education adjustment (sum of lines 1 & 2 times line 5) 7 Percentage of SSI recipient patient days to Medicare Part A patient days (Worksheet E, part A line 30) (see instructions) 8 Percentage of Medicaid patient days to total days reported on Worksheet S‐3, Part I (see instructions) 9 Sum of lines 3 and 4 10 Allowable disproportionate share percentage (see instructions) 11 Disproportionate share adjustment (line 6 times the sum of lines 1 and 2) 12 Total prospective capital payments (sum of lines 1‐2, 6 and 11) p p p p y ( , ) PART II ‐ PAYMENT UNDER REASONABLE COST 1 Program inpatient routine capital cost (see instructions) 2 Program inpatient ancillary capital cost (see instructions) 3 Total inpatient program capital cost (line 1 plus line 2) 4 Capital cost payment factor (see instructions) 5 Total inpatient program capital cost (line 3 x line 4) PART III ‐ COMPUTATION OF EXCEPTION PAYMENTS 1 Program inpatient capital costs (see instructions) 2 Program inpatient capital costs for extraordinary circumstances (see instructions) 3 Net program inpatient capital costs (line 1 minus line 2) 4 Applicable exception percentage (see instructions) 5 Capital cost for comparison to payments (line 3 x line 4) 6 Percentage adjustment for extraordinary circumstances (see instructions) 7 Adjustment to capital minimum payment level for extraordinary circumstances (line 2 x line 6) 8 Capital minimum payment level (line 5 plus line 7) 9 Current year capital payments (from Part I, line 12 as applicable) 10 Current year comparison of capital minimum payment level to capital payments (line 8 less line 9) Current year comparison of capital minimum payment level to capital payments (line 8 less line 9) 11 Carryover of accumulated capital minimum payment level over capital payment (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) 13 Current year exception payment (if line 12 is positive, enter the amount on this line) 14 Carryover of accumulated capital minimum payment level over capital payment 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) 16 Current year operating and capital costs (see instructions) y p g p ( ) 17 Current year exception offset amount (see instructions)

12-10

1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

F OR M C M S -2552-10 (12/2010) (INS TR UC TIONS F OR THIS WOR KS HEET AR E P UB LIS HED IN C M S P UB . 15-II, S EC TIONS 4064.1 - 4064.3)

40-646


Rev. 1

www.esshc.com

Settlement Data Steps to process Settlement Data: • Identify the data to be used: – Provider Statistical Report p ((PSR)) – Medicare logs – Settlement Crosswalk

• Start with PSR • Adjustments to the PSR – Pendingg Claims – Errors

• Grouping Settlement Data – Time Ti S Sensitive iti D Data t Essential Consulting LLC

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

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


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WS S-2 S 2 (Provider Questionnaire) WS S-2 S 2 is designed to provide CMS with basic demographic information about the hospital to identify various reimbursement mechanisms as well as specialty programs and services. – Mostly M tl Yes/No Y /N Answers A – Misc Data


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4090 (Cont.)

FORM CMS-2552-10

12-10

HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX IDENTIFICATION DATA

PROVIDER NO.: ______________

Hospital and Hospital Health Care Complex Address: Hospital and Hospital Health Care Complex Address: 1 Street: P.O. Box: 2 City: State: Hospital and Hospital‐Based Component Identification: Component Component Name 0 1 3 Hospital 4 Subprovider‐ IPF 5 Subprovider‐ IRF S b id IRF 6 Subprovider‐ (Other) 7 Swing Beds‐SNF 8 Swing Beds‐NF 9 Hospital‐Based SNF 10 Hospital‐Based NF 11 Hospital‐Based OLTC 12 Hospital‐Based HHA 13 Separately Certified ASC 14 Hospital‐Based Hospice 15 Hospital‐Based Health Clinic‐RHC 16 Hospital‐Based Health Clinic‐FQHC 17 Hospital‐Based (CMHC) 18 Renal Dialysis 19 Other

Zip Code:

PERIOD FROM __________ TO _____________

WORKSHEET S‐2 PART I

1 2

County: CCN Number 2

CBSA Number 3

Provider Type 4

Date Certified 5

V 6

Payment System (P, T, O, or N) XVIII 7

XIX 8 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

20 Cost Reporting Period (mm/dd/yyyy) From:_______________ To: ______________ 21 Type of control (see instructions) yp ( ) Inpatient PPS Information 22 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)? 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. 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 Medicaid paid days paid days 1

In‐State Medicaid eligible days eligible days 2

Out‐of State Medicaid paid days paid days 3

Out‐of State Medicaid eligible days eligible days 4

20 21 1

2 22 23

Medicaid HMO days 5

Other Medicaid days 6

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

24

25

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. E d d hi l ifi i ( ) h b i i f h i i d E "1" f b d "2" f l 27 Enter your standard geographic classification (not wage) status at the end of the cost reporting period. Enter "1" for urban and "2" for rural.

26 27

F OR M C MS -2552-10 (12/2010) (INS TR UC TIONS F OR THIS WOR KS HEET AR E P UB LIS HED IN C M S P UB . 15-II, S EC TION 4004.1)

40-504

Rev. 1


www.esshc.com

12-10

FORM CMS-2552-10

HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX IDENTIFICATION DATA 35 36 37 38

4090 (Cont.)

PROVIDER NO.:

______________ If this is a sole community hospital (SCH), enter the number of periods SCH status in effect in the cost reporting period. y p ( ), p p gp Enter applicable beginning and ending dates of SCH status. Subscript line 36 for number of periods in excess of one and enter subsequent dates. If this is a Medicare dependent hospital (MDH), enter the number of periods MDH status in effect in the cost reporting period. Enter applicable beginning and ending dates of MDH status. Subscript line 38 for number of periods in excess of one and enter subsequent dates.

PERIOD FROM __________ TO _____________

WORKSHEET S‐2 PART I (CONT.) 35 36 37 38

Beginning:_______________ Ending: ______________ Beginning:_______________ Ending: ______________

Prospective Payment System (PPS)‐Capital 45 Does this facility qualify and receive capital payment for disproportionate share in accordance with 42 CFR §412.320? (see instructions) 46 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. y g p p p y p § (g) y , p , , g 47 Is this a new hospital under 42 CFR §412.300 PPS capital? Enter "Y for yes and "N" for no in column 1. Is the facility electing full federal payment? Enter "Y" for yes and "N" for no in column 2.

Teaching Hospitals 55 Is this a teaching hospital? Enter "Y" for yes or "N" for no. 56 If line 55 is yes, is this teaching program approved in accordance with CMS Pub. 15‐1, chapter 4? 57 If line 56 is yes, was Medicare participation and approved teaching program status in effect during the first month of the cost reporting period? y , p p pp gp g g p gp 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? If yes, complete Worksheet D‐5. 59 Are costs claimed on line 100 of Worksheet A? If yes, complete Worksheet D‐2, Part I. 60 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)? 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)? 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)

V 1

XVIII 2

V 1

XVIII 2

XIX 3

45 46 47

XIX 3 55 56 57 58 59 60 61 62

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

70 71

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

75 76


40-504

Rev. 1


www.esshc.com

12-10

4090 (Cont.)

FORM CMS-2552-10


PROVIDER NO.: ______________

PERIOD FROM __________ TO _____________

WORKSHEET S‐2 PART I (CONT.)

Long Term Care Hospital PPS 80 Is this a Long Term Care Hospital (LTCH)? Enter "Y" for yes or "N" for no. TEFRA Providers 85 Is this a new hospital under 42 CFR §413.40(f)(1)(i) TEFRA? Enter "Y" for yes, and "N" for no. 86 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. Title V and XIX Inpatient Services 90 Does this facility have title V and/or XIX inpatient hospital services? Enter "Y" for yes, and "N" for no in applicable column. 91 Is this hospital reimbursed for title V and/or XIX through the cost report either in full or in part? Enter "Y" for yes, and "N" for no in the applicable column. 92 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. 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 93 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. 94 Does title V or title XIX reduce capital cost? Enter "Y" for yes or "N" for no in the applicable column. 95 If line 94 is "Y", enter the reduction percentage in the applicable column. 96 Does title V or title XIX reduce operating cost? Enter "Y" for yes or "N" for no in the applicable column. 97 If line 96 is "Y", enter the reduction percentage in the applicable column. Rural Providers 105 Does this hospital qualify as a Critical Access Hospital (CAH)? 106 If this facility qualifies as a CAH, has it elected the all If this facility qualifies as a CAH has it elected the all‐inclusive inclusive method of payment for outpatient services? (see instructions) method of payment for outpatient services? (see instructions) 107 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 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). Physical Occupational 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. Miscellaneous Cost Reporting Information 115 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. 116 Is this facility classified as a referral center? 117 Is this facility legally‐required to carry malpractice insurance? 118 Is the malpractice insurance a claims‐made or occurrence policy? Enter 1 if the policy is claim‐ made. Enter 2 if the policy is occurrence. 119 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. 120 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. 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. / / 126 If this is a Medicare certified kidney transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 127 If this is a Medicare certified heart transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 128 If this is a Medicare certified liver transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 129 If this is a Medicare certified lung transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 130 If this is a Medicare certified pancreas transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 131 If this is a Medicare certified intestinal transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 132 If this is a Medicare certified islet transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 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. If this is a Medicare certified other transplant center enter the certification date in column 1 and termination date if applicable in column 2 ## If this is an organ procurement organization (OPO), enter the OPO number in column 1 and termination date, if applicable, in column 2.

80 85 86 V 1

XIX 2 90 91 92 93 94 95 96 97 105 106 107

108 Speech

Respiratory 109 115 116 117 118 119 120

125 126 127 128 129 130 131 132 133 134


Rev. 1

40-506


www.esshc.com

4090 (Cont.)

FORM CMS-2552-10


12-10

PROVIDER NO.:

PERIOD FROM __________ ______________ TO _____________

WORKSHEET S‐2 PART I (CONT.)

All Providers 1

2

140 Are there any related organization or home office costs as defined in CMS Pub. 15‐1, chapter 10? Enter "Y" for yes and "N" for no in column 1. If yes, and home office costs are claimed, enter in column 2 the home office chain number. (see instructions)

140

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: ___________________ 142 Street: S P O B P. O. Box: 143 City: State: Zip Code: 144 Are provider based physicians' costs included in Worksheet A? 145 If costs for renal services are claimed on Worksheet A, are they costs for inpatient services only? 146 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) If yes, enter the approval date (mm/dd/yyyy) in column 2. 147 Was there a change in the statistical basis? 148 Was there a change in the order of allocation? 149 Was the change to the simplified cost finding method? Was the change to the simplified cost finding method?

Contractor's Number: __________

147 148 149

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. (See 42 CFR §413.13) 155 Hospital 156 Subprovider ‐ IPF 157 Subprovider ‐ IRF 158 Subprovider ‐ Other 159 SNF 160 HHA 161 CMHC

Part A 1

Part B 2 155 156 157 158 159 160 161

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.

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. / Name

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. 168 If this provider is a CAH (line 105 is If this provider is a CAH (line 105 is "Y") Y ) and is a meaningful user (line 167 is and is a meaningful user (line 167 is "Y") Y ), enter the reasonable cost incurred for the HIT assets. (see instructions) enter the reasonable cost incurred for the HIT assets (see instructions) 169 If this provider is a meaningful user (line 167 is "Y") and is not a CAH (line 105 is "N"), enter the transition factor. (see instructions)

141 142 143 144 145 146

165

166 County 1

State 2

Zip Code 3

CBSA 4

FTE/Campus 5

167 168 169

F OR M C M S -2552-10 (12/2010) (INS TR UC TIONS F OR THIS WOR KS HEET AR E P UB LIS HED IN C M S P UB . 15-II, S ECTION 4004.1)

Rev. 1

40-507


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WS S-2 S2 Data Sources used on WS S-2: S 2: – Prior Year Cost Report – General G l LLedger d – Statistics


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WS S-3 S 3 Part 1 (Census Data) WS S-3 S 3 Part 1 is designed to provide CMS with the Volume of Services (Patient Days/Discharges) as well as Visits for specific Services. Services – Medicare – Medicaid M di id – Total


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12-10

FORM CMS-2552-10

4090 (Cont.)

HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX STATISTICAL DATA

PROVIDER NO.:

Inpatient Days / Outpatient Visits / Trips

Component

Worksheet A Line No. 1

No. of Beds 2

Bed Days Available 3

CAH Hours 4

Title V 5

Title XVIII 6

Title XIX 7

Total All Patients 8

______________ Full Time Equivalents Total Interns & Residents 9

Employees On Payroll 10

Nonpaid Workers 11

PERIOD FROM __________ TO TO _____________

WORKSHEET S‐3 PART I Discharges

Title V 12

Title XVIII 13

Title XIX 14

Total All Patients 15

1 Hospital Adults & Peds. (columns 5, 6, 7 and 8 exclude Swing Bed, Observation Bed and Hospice days) 2 HMO 3 HMO IPF 4 HMO IRF 5 Hospital Adults & Peds. Swing Bed SNF 6 Hospital Adults & Peds.Swing Bed NF 7 Total Adults and Peds. (exclude observation beds) (see instructions) 8 Intensive Care Unit I t i C U it 9 Coronary Care Unit 10 Burn Intensive Care Unit 11 Surgical Intensive Care Unit 12 Other Special Care 13 Nursery 14 Total (see instructions) 15 CAH visits 16 Subprovider Subprovider ‐ IPF IPF 17 Subprovider ‐ IRF 18 Subprovider ‐ Other 19 Skilled Nursing Facility 20 Nursing Facility 21 Other Long Term Care 22 Home Health Agency 23 ASC (Distinct Part) 24 Hospice (Distinct Part) 25 CMHC 26 RHC/FQHC (specify) 27 Total (sum of lines 14‐26) 28 Observation Bed Days 29 Ambulance Trips 30 Employee discount days (see instructions) 31 Employee discount days ‐IRF 32 Labor & delivery days (see instructions) 33 LTCH non‐covered days dd

1

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33


Rev. 1

40-511


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

Midnight g Census Patient Accounting System Statistics Provider Summary Report (PSR) Medicare logs CDM with Volumes Observation Logs Payroll Register Statistics

• Grouping WS S S-33 Part 1 Essential Consulting LLC

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


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WS S-3 S 3 Part 2 (Wage Index) WS S-2 S 2 is designed to identify the Average Hourly Wage of Staff and Contract Employees at the Hospital by Department or Category. Category – Identify Duplication of Hours • Shift Differential • Overtime


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4090 (Cont.)

FORM CMS-2552-10

HOSPITAL WAGE INDEX INFORMATION

PROVIDER NO.:

12-10

PERIOD FROM __________ TO TO _____________

______________

WORKSHEET S‐3 PART II

Part II ‐ Wage Data Worksheet A Line Number 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Amount Reported 2

SALARIES SALARIES Total salaries (see instructions) Non‐physician anesthetist Part A Non‐physician anesthetist Part B Physician‐Part A Physician‐Part B Non‐physician‐Part B Interns & residents (in an approved program) Home office personnel SNF Excluded area salaries (see instructions) OTHER WAGES AND RELATED COSTS Contract labor (see instructions) Management and administrative services g Contract labor: physician‐Part A Home office salaries & wage‐related costs Home office: physician Part A Teaching physician salaries (see instructions) WAGE‐RELATED COSTS Wage‐related costs (core) Worksheet S‐3, Part IV line 24 Wage Wage‐related related costs (other) Worksheet S costs (other) Worksheet S‐3 3, Part IV line 25 Part IV line 25 Excluded areas Non‐physician anesthetist Part A Non‐physician anesthetist Part B Physician Part A Physician Part B Wage‐related costs (RHC/FQHC) Interns & residents (in an approved program) I t & id t (i d )

Reclassification of Salaries (from Worksheet A‐6) 3

Adjusted Salaries (column 2 ± column 3) 4

Paid Hours Related to Salaries in column 4 5

Average Hourly Wage (column 4 ÷ column 5) 6 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

F OR M C M S -2552-10 (12/2010) (INS TR UC TIONS F OR THIS WOR KS HEET AR E P UB LIS HED IN C M S P UB . 15-II, S EC TION 4005.2 - 4005.3)

46-512


Rev. 1

www.esshc.com

12-10

FORM CMS-2552-10

HOSPITAL WAGE INDEX INFORMATION

PROVIDER NO.:

4090 (Cont.)

PERIOD FROM __________ TO TO _____________

______________

WORKSHEET S‐3 PART II & III

Part II ‐ Wage Data Worksheet A Line Number 1

Amount Reported 2

OVERHEAD COSTS ‐ DIRECT SALARIES OVERHEAD COSTS DIRECT SALARIES Employee Benefits Administrative & General Administrative & General under contract (see instructions) Maintenance & Repairs Operation of Plant Laundry & Linen Service Housekeeping Housekeeping under contract (see instructions) Dietary Dietary under contract (see instructions) Cafeteria Maintenance of Personnel Nursing Administration g Central Services and Supply Pharmacy Medical Records & Medical Records Library Social Service Other General Service

26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43

Reclassification of Salaries (from Worksheet A‐6) 3

Adjusted Salaries (column 2 ± column 3) 4

Paid Hours Related to Salaries in column 4 5

Average Hourly Wage (column 4 ÷ column 5) 6 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43

Part III Part III ‐ Hospital Wage Index Summary Hospital Wage Index Summary 1 Net salaries (see instructions) 2 Excluded area salaries (see instructions) 3 Subtotal salaries (line 1 minus line 2) 4 Subtotal other wages and related costs (see instructions) 5 Subtotal wage‐related costs (see instructions) 6 Total (sum of lines 3 through 5) 7 Total overhead cost (see instructions) T t l h d t( i t ti )

1 2 3 4 5 6 7

F OR M C M S -2552-10 (12/2010) (INS TR UC TIONS F OR THIS WOR KS HEET AR E P UB LIS HED IN C M S P UB . 15-II, S EC TION 4005.2 - 4005.3)

Rev. 1


40-513

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

General Ledger g Payroll Register Contract Labor Files Home office Documentation

• Start with GL or Reconcile to the GL • Processingg Payroll y Hours – Identify duplicate Hours – Identify Non-Payroll items – Incorporate WS A-6 A 6 Reclasses of Salary Exp Exp. Essential Consulting LLC

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WS S-3 S 3 Part 2 Steps to process WS S-3 S 3 Part 2 Data: • Grouping by Category on WS S-3 Part 2 • Sort and Subtotal • Workpapers should contain the WS A Grouping as well as the WS S3 part 2 Grouping


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WS S-10 S 10 (Uncompensated Care) WS S-10 S 10 is designed to identify what portion of the Hospitals Business and Profitability is provided to Uncompensated and Indigent care Patients. 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 services • CMS is just making sure that the data they collect is accurate for the DSH calc Essential Consulting LLC

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12-10

FORM CMS-2552-10

HOSPITAL UNCOMPENSATED AND INDIGENT CARE DATA

4090 (Cont.)

PROVIDER NO.: ________________

PERIOD: FROM ___________ TO ______________

WORKSHEET S‐10

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

1

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

2 3 4 5 6 7 8

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

9 10 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) 14 Charges for patients covered under state or local indigent care program (not included in lines 6 or 10) 15 State or local indigent care program cost (line 1 times line 14) 16 Difference between net revenue and costs for state or local indigent care program (line 13 minus line 15)

13 14 15 16

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

17 18 19

Uninsured patients 1

Insured patients 2

Total (col. 1 + col. 2) 3

20 Total initial obligation of patients approved for charity care (at full charges excluding non‐reimbursable cost centers) for the entire facility 21 Cost of initial obligation of patients approved for charity care (line 1 times line 20) 22 Partial payment by patients approved for charity care Partial payment by patients approved for charity care 23 Cost of charity care (line 21 minus line 22)

20

24 Does the amount in line 20, column 2 include charges for patient days beyond a length of stay limit imposed on patients covered 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) 26 Total bad debt expense for the entire facility (see instructions) 27 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 28 Non‐Medicare and non‐reimbursable bad debt expense (line 26 minus line 27) 29 Cost of non‐Medicare bad debt expense (line 1 times line 28) Cost of non‐Medicare bad debt expense (line 1 times line 28) 30 Cost of non‐Medicare uncompensated care (line 23 column 3 plus line 29) 31 Total unreimbursed and uncompensated care cost (line 19 plus line 30)

24

21 22 23

25 26 27 28 29 30 31


Rev. 1


40-523

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

General Ledger g Patient Accounting System Analysis AR outstanding Reports Decision Support Queries

• Group, Sort and Subtotal • Workpapers p p should clearlyy identifyy Where the data was obtained and what the basis of the information is


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Documentation is the Key! Why have we stressed documentation? – – – –

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


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Electronic vs vs. Manual data Processing With voluminous data that needs to be processed and re re-processed 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, y but manual processingg should onlyy be used when the data/analysis y changes g from 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


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Special Issues • • • • •

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


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WS A-8-1 A 8 1 (Related Parties) Related party transactions are transactions where a facility is doing business with a company or organization that has an owner or a controlling “Manager” that is also an owner or controlling Manager at the facility. facility This definition also includes “Manager” instances where one organization has “directorship” over another. another – Arms Length Transactions – Actual A t lC Costt off th the service/supply i / l Essential Consulting LLC

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4090 (Cont.)

FORM CMS-2552-10

STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS AND HOME OFFICE COSTS

12-10

PROVIDER NO.:

PERIOD: WORKSHEET A‐8‐1 FROM ____________ ________________ TO _______________

A. COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS OR CLAIMED HOME OFFICE COSTS: Amount Net Amount of included in Adjustments Allowable Wkst. A (col. 4 minus Line No. Cost Center Expense Items Cost column 5 col. 5) * 4 5 6 1 2 3 1 2 3 4 5 TOTALS (sum of lines 1‐4) Transfer column 6, line 5 to Worksheet A‐8, column 2, line 12.

Wkst. A‐7 Ref. 7 1 2 3 4 5

* The a m o unts o n line s 1 thro ugh g 4 ((a nd s ubs c ripts p a s a pp ppro p pria te ) a re tra ns fe rre d in de ta il to Wo rks he e t A, c o lum n 6, line s a s a ppro pp pria p te . P o s itive a m o unts inc re a s e c o s t a nd ne ga tive a m o unts de c re a s e c o s t. F o r re la te d o rga niza tio n o r ho m e o ffic e c o s t whic h ha ve no t be e n po s te d to Wo rks he e t A, c o lum ns 1 a nd/o r 2, the a m o unt a llo wa ble s ho uld be indic a te d in c o lum n 4 o f this pa rt.

B. INTERRELATIONSHIP TO RELATED ORGANIZATION(S) AND/OR HOME OFFICE: The S e c re ta ry, by virtue o f the a utho rity gra nte d unde r s e c tio n 1814(b)(1) o f the S o c ia l S e c urity Ac t, re quire s tha t yo u furnis h the info rm a tio n re que s te d unde r P a rt B o f this wo rks he e t.

Symbol (1) 1

Name 2

Percentage of Ownership 3

Name 4

Related Organization(s) and/or Home Office Related Organization(s) and/or Home Office Percentage of Type of Ownership Business 5 6

6 7 8 9 10

6 7 8 9 10 (1) Us e the fo llo wing s ym bo ls to indic a te inte rre la tio ns hip to re la te d o rga niza tio ns : A. Individua l ha s fina nc ia l inte re s t (s to c kho lde r, pa rtne r, e tc .) in bo th re la te d o rga niza tio n a nd in pro vide r. B . C o rpo ra tio n, pa rtne rs hip, o r o the r o rga niza tio n ha s fina nc ia l inte re s t in pro vide r. C . P ro vide r ha s fina nc ia l inte re s t in c o rpo ra tio n, pa rtne rs hip, o r o the r o rga niza tio n. D. Dire c to r, o ffic e r, a dm inis tra to r, o r ke y pe rs o n o f pro vide r o r re la tive o f s uc h

E. Individua l is dire c to r, o ffic e r, a dm inis tra to r, o r ke y pe rs o n o f pro vide r a nd re la te d o rga niza tio n. F . Dire c to r, o ffic e r, a dm inis tra to r, o r ke y pe rs o n o f re la te d o rga niza tio n o r re la tive o f s uc h pe rs o n ha s fina nc ia l inte re s t in pro vide r. G. Othe r (fina nc ia l o r no n-fina nc ia l) s pe c ify __________________________

pe rs o n ha s fina nc ia l inte re s t in re la te d o rga niza tio n.


40-530


Rev. 1

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WS A-8-1 A81 Steps to process WS A-8-1 A 8 1 Data: • Identify the data to be used: – General Ledger g – Home Office cost statement – Related Party expenses (GL, TB, AFS, etc.)

• 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 Essential Consulting LLC

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WS A-8-2 A 8 2 (Physician Compensation) CMS believes that MDs go to many years of school to learn to treat patients, therefore unless otherwise 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 Administrative Duties.


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WS A-8-2 A82 Physician Patient Treatment Time (Part B): – Any time or activity where an MD is working on/for an individual Patient • • • •

Chart Review Intervention Progress Notes Research


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WS A-8-2 A82 Physician Administrative Time (Part A): – Activities that are designed to help the facility manage the treatment of all of its patients • • • •

Medical Directors Utilization/Quality Review Department Directorship Do NOT include activities that are meant to Manage g the MDs Practice!

– Part A Activies MUST be Documented! Essential Consulting LLC

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WS A-8-2 A82 How to document Part A vs vs. Part B – Part A • Time Studies (2 two week time Studies in non-consecutive non consecutive Quarters) g • Timelyy signatures • Contracts

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


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12-10

FORM CMS-2552-10

PROVIDER-BASED PHYSICIANS ADJUSTMENTS

4090 (Cont.)

PROVIDER NO.: _____________

Wkst. A Line # 1

Cost Center/ Physician Identifier 2

Total Remuneration 3

Professional Component 4

Provider Component 5

RCE Amount 6

PERIOD: FROM ____________ TO _______________ Physician/ Provider Unadjusted Component Hours RCE Limit 7 8

WORKSHEET A-8-2

5 Percent of Unadjusted RCE Limit 9

1 2 3 4 5 6 7 8 9 10 11 200 TOTAL

Wkst. A Li # Line 10

1 2 3 4 5 6 7 8 9 10 11 200

Cost Center/ Physician Id tifi Identifier 11

Cost of Memberships & Continuing Ed Education ti 12

Provider Component Share of col. l 12 13

Physician Cost of Malpractice I Insurance 14

Provider Component Share of col. l 14 15

1 2 3 4 5 6 7 8 9 10 11 200 TOTAL

Adjusted RCE Limit Li it 16

RCE Disallowance Di ll 17

Adjustment Adj t t 18 1 2 3 4 5 6 7 8 9 10 11 200


Rev. 1


40-531

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WS A-8-2 A82 Steps to process WS A-8-2 A 8 2 Data: • Identify the data to be used: – – – –

General Ledger g Payroll Register Physician Contracts, and Invoices Physician Time Studies

• Organize Data by MD or by Cost Center – MD specific data is better documentation – Cost Center is for Summary


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WS A-8-2 A82 Steps to process WS A-8-2 A 8 2 Data: • Identify total compensation paid to ALL MDs – – – – – –

Salaryy Benefits Malpractice Insurance Dues and Fees Housing Allowance Etc.

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

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WS A-8-2 A82 Steps to process WS A-8-2 A 8 2 Data: • Calculate Part A vs. Part B – Total Paid Hrs – Total Compensation

• Sort and Subtotal • These Th workpapers k should h ld make k sure tto be b able bl to t trace t th theiri information to the source documentation as well as allow the auditors to easyy follow the flow of the calculations and data


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WS H Series (Home Health Agency) Home Health services are paid on the HH Prospective P Payment t System S t (HH PPS) PPS). •Home Health Agencies (HHA) must bill for all of the following provided during the 60-day HH episode: – Skilled nursing services; – Physical therapy (PT), occupational therapy (OT), and speech-language pathology th l (SLP) services; i – 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. disciplines Essential Consulting LLC

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WS H Series The 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 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. Essential Consulting LLC

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WS 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 Allocation ti off generall services i costs t (Overhead (O h d C Costs) t ) ffrom WS B B, Part P t I,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 p byy HHA costs. • Calculates Medicare Due To/From . Essential Consulting LLC

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


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WS I Series The WS I Series consists of the following Worksheets: – WS S-5 (Renal Dialysis Treatment stats) – WS II-11 (Id (Identification tifi ti off R Renall Di Dialysis l i E Expenses by b type of Expense) • Must Reconcile to WS A line 74 (Renal Dialysis)

– WS I-2 (Allocation of Expenses to the Treatment Modalities) • No input Required


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

Hemodialysis 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) Essential Consulting LLC

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12-10

FORM CMS-2552-10

HOSPITAL RENAL DIALYSIS DEPARTMENT STATISTICAL DATA

4090 (Cont.)

PROVIDER NO.: ________________

PERIOD: FROM ___________ TO ______________

WORKSHEET S‐5

RENAL DIALYSIS STATISTICS Outpatient DESCRIPTION

Regular 1

High Flux 2

Training Hemo‐ dialysis 3

Home CAPD CCPD 4

Hemo‐ dialysis 5

CAPD CCPD 6

1 Number of patients in program at end of cost reporting period 2 Number of times per week patient receives dialysis 3 Average patient dialysis time including setup 4 CAPD exchanges per day 5 Number of days in year dialysis furnished 6 Number of stations 7 Treatment capacity per day per station 8 Utilization (see instructions) Utili ti ( i t ti ) 9 Average times dialyzers re‐used 10 Percentage of patients re‐using dialyzers

1

3 4 5 6 7 8 9 10

TRANSPLANT INFORMATION 11 Number of patients on transplant list 12 Number of patients transplanted during the cost reporting period

11 12

2

13 14 15 16

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

13 14 15 16

17 18 19 20

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

17 18 19 20

PHYSICIAN PAYMENT METHOD (Enter "X" for applicable method(s)) 21 MCP_________ INITIAL METHOD__________

21


Rev. 1


40-517

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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 Check applicable box: [ ] Renal Dialysis Department [ ] Home Program Dialysis [ ] Renal Dialysis Department [ ] Home Program Dialysis TOTAL FTEs per COSTS BASIS STATISTICS 2080 Hours 1 2 3 4 1 Registered Nurses Hours of Service 2 Licensed Practical Nurses Hours of Service 3 Nurses Aides Hours of Service 4 Technicians Technicians Hours of Service Hours of Service 5 Social Workers Hours of Service 6 Dieticians Hours of Service 7 Physicians Accumulated Cost 8 Non‐patient Care Salary Accumulated Cost 9 Subtotal (sum of lines 1‐8) 10 Employee Benefits Salary 11 Capital Related Costs‐Bldgs. & Fixtures Square Feet 12 Capital Related Costs‐Mov. Equip. Percentage of Time 13 Machine Costs & Repairs Percentage of Time 14 Supplies Requisitions 15 Drugs Requisitions 16 Other Accumulated Cost 17 Subtotal (sum of lines 9‐16)* 18 Capital Related Costs‐Bldgs. & Fixtures Square Feet 19 Capital Related Costs‐Mov. Equip. Capital Related Costs Mov Equip Percentage of Time Percentage of Time 20 Employee Benefits Salary 21 Administrative and General Accumulated Cost 22 Maint./Repairs‐Operation‐Housekeeping Square Feet 23 Medical Education Program Costs 24 Central Services & Supplies Requisitions 25 Pharmacy Requisitions 26 Other Allocated Costs Other Allocated Costs Accumulated Cost Accumulated Cost 27 Subtotal (sum of lines 17‐26)* 28 Laboratory (see instructions) Charges 29 Respiratory Therapy (see instructions) Charges 30 Other (see instructions) Charges 31 Total costs (sum of lines 27‐30)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

* Line 17, c o lum n 1 s ho uld a gre e with Wo rks he e t A, c o lum n 7 fo r line 74 o r line 94 a s a ppro pria te , a nd line 27, c o lum n 1 s ho uld a gre e with Wo rks he e t B , P a rt I, c o lum n 26 fo r line 74 o r line 94 a s a ppro pria te .


Rev. 1


40-617

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12-10

FORM CMS-2552-10

DIRECT AND INDIRECT RENAL DIALYSIS COST ALLOCATION ‐ STATISTICAL BASIS

PERIOD: FROM ____________ TO _______________

WORKSHEET I‐3


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

[ ] Renal Dialysis Department [ ] Home Program Dialysis CAPITAL AND RELATED COSTS DIRECT PATIENT BUILDING EQUIPMENT CARE SALARY COMPOSITE PAYMENT SERVICES ((SQUARE ((% OF RNs OTHERS FEET) TIME) (HOURS) (HOURS) 1 2 3 4 Total Renal Department Costs MAINTENANCE Hemodialysis Intermittent Peritoneal TRAINING Hemodialysis Intermittent Peritoneal CAPD CCDP HOME Hemodialysis Intermittent Peritoneal CAPD CCDP OTHER BILLABLE SERVICES Inpatient Dialysis Treatments __________ Method II Home Patient EPO ARENESP Other Total Statistical Basis Unit Cost Multiplier (line 1 ÷ line 17)

4090 (Cont.)

PROVIDER NO.: ___________

ROUTINE EMPLOYEE MEDICAL ANCILLARY BENEFITS DRUGS SUPPLIES SERVICES (SALARY) (REQUIST.) (REQUIST.) (CHARGES) 5 6 7 8

SUB‐ TOTAL 9

OVERHEAD ((ACCUM. COST) 10 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

F ORM C M S -2552-10 (12/2010) (INS TRUC TIONS F OR THIS WOR KS HEET AR E P UB LIS HED IN CM S P UB . 15-II, S EC TION 4050)

Rev. 1


40-619

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4090 (Cont.)

FORM CMS-2552-10

COMPUTATION OF AVERAGE COST PER TREATMENT FOR OUTPATIENT RENAL DIALYSIS Ch k Check applicable box: li bl b

PERIOD: FROM ____________ TO _______________

WORKSHEET I‐4

[ ] Renal Dialysis Department [ ] Home Program Dialysis [ ] R l Di l i D t t []H P Di l i

Number of Total Treatments 1 1 2 3 4 5 6 7 8

12-10

PROVIDER NO.: ______________

Total Cost (from Wkst. I‐2, col. 11) 2

Average Cost of Program Treatments (col. 2 ÷ col. 1) 3

Number of Program Treatments 4

Total Program Expenses (col. 4 x col. 3) 5

Total Program Payment 6

Average Payment Rate (col. 6 ÷ col. 4) 7

Maintenance ‐ Hemodialysis Maintenance ‐ Peritoneal Dialysis Training ‐ Hemodialysis Training ‐ Peritoneal Dialysis Training ‐ Continuous Ambulatory Peritoneal Dialysis Training ‐ Continuous Cycling Peritoneal Dialysis Training Continuous Cycling Peritoneal Dialysis Home Program ‐ Hemodialysis Home Program ‐ Peritoneal Dialysis

1 2 3 4 5 6 7 8 Patient Weeks

9 Home Program ‐ Continuous Ambulatory Peritoneal Dialysis 10 Home Program ‐ Continuous Cycling Peritoneal Dialysis 11 Totals (sum of lines 1‐8, columns 1 and 4) Totals (sum of lines 1‐8 columns 1 and 4) (sum of lines 1‐10, columns 2, 5, and 7)

Patient Weeks 9 10 11

F ORM C M S -2552-10 (12/2010) (INS TRUC TIONS F OR THIS WOR KS HEET AR E P UB LIS HED IN CM S P UB . 15-II, S EC TION 4051)

40-620


Rev. 1

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4090 (Cont (Cont.))

FORM CMS CMS-2552-10 2552 10

CALCULATION OF REIMBURSABLE BAD DEBTS ‐ TITLE XVIII ‐ PART B

12 10 12-10

PROVIDER NO.: ________________

PERIOD: WORKSHEET I‐5 FROM ____________ TO _______________

Description 1 2 3 4 5 6 7 8 9 10

Total expenses related to care of program beneficiaries (see instructions) Total payment (from Worksheet I Total payment (from Worksheet I‐4, 4, column 6, line 11) column 6, line 11) Deductibles billed to Medicare (Part B) patients Coinsurance billed to Medicare (Part B) patients Bad debts for deductibles and coinsurance, net of bad debt recoveries

Reimbursable bad debts for dual eligible beneficiaries (see instructions) Net deductibles and coinsurance billed to Medicare (Part B) patients (sum of lines 3 and 4 less line 5) Program payment (line 2 less line 3, times 80 percent) Unrecovered from Medicare (Part B) patients (lesser of line 1 or line 2 minus the sum of lines 7 and 8) (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)

1 2 3 4 5 6 7 8 9 10 11

FORM CMS-2552-10 (12/2010) (INSTRUCTIONS FOR THIS WORKSHEET ARE P UBLISHED IN CMS P UB. 15-II, SECTION 4052)

Rev. 1


40-621

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

General Ledger g Payroll Register Statistics 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 Essential Consulting LLC

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WS J Series (CMHC) 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 CHMC services by Modality, determine the program cost and final settlement cost, settlement.


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WS J Series The WS J Series consists of the following worksheets: – WS S-6 (CMHC Treatment Staff Statistics) – WS JJ-11 Part P t 1 (A (Apportionment ti t off Costs C t to t the th mental t l Health Modalities) • Column 0 must reconcile to WS A (CMHC Cost Center)

– WS J-1 Part 2 (Allocation Statistics for Cost Apportionment) • Each columns statistics should agree to WS B-1 Stats fro the CMHC Cost Center) Essential Consulting LLC

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WS J Series – WS J-2 J 2 (Determination of Program Costs) – WS J-3 (Determination of Settlement) – WS J-4 J 4 (Identification of Interim Payments and Lump Sum Payments)


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4090 (Cont.)

FORM CMS-2552-10

12-10

HOSPITAL‐BASED COMMUNITY MENTAL HEALTH CENTER AN PROVIDER NO.: OTHER OUTPATIENT REHABILITATION _______________ PROVIDER STATISTICAL DATA COMPONENT NO.: _______________

PERIOD: FROM ___________ TO ______________

WORKSHEET S‐6

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

[ ] CMHC [ ] CORF [ ] CORF [ ] OPT

[ ] OOT [[ ] OSP ] OSP

Enter the number of hours in your normal workweek ____________________

Staff 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Administrator and Assistant Administrator(s) Director(s) and Assistant Director(s) Other Administrative Personnel Direct Nursing Service g p Nursing Supervisor Physical Therapy Service Physical Therapy Supervisor Occupational Therapy Service Occupational Therapy Supervisor Speech Pathology Service Speech Pathology Supervisor Medical Social Service Medical Social Service Supervisor Respiratory Therapy Service Respiratory Therapy Supervisor Psychiatric/Psychological Service Psychiatric/Psychological Service Supervisor Other (specify)

Contract 2

Total (column 1 + column 2) (column 1 + column 2) 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18


40-518


Rev. 1

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4090 (Cont.)

FORM CMS-2552-10

ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTERS

PROVIDER NO.: ______________

12-10

PERIOD: FROM ____________ TO TO _______________

COMPONENT NO : COMPONENT NO.: ____________ Check applicable [ ] Title V [ ] Title XVIII [ ] Title XIX box: PART I ‐ ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS NET EXPENSES CAPITAL COMPONENT COST CENTER COMPONENT COST CENTER FOR COST FOR COST RELATED COSTS RELATED COSTS ADMINIS‐ (omit cents) ALLOCATION BLDGS. & MOVABLE EMPLOYEE SUBTOTAL TRATIVE & (see instru.) FIXTURES EQUIPMENT BENEFITS (cols. 0‐4) GENERAL 0 1 2 4 4A 5 1 Administrative and General 2 Skilled Nursing Care 3 Physical Therapy 4 Occupational Therapy Occupational Therapy 5 Speech Pathology 6 Medical Social Services 7 Respiratory Therapy 8 Psychiatric/Psychological Services 9 Individual Therapy 10 Group Therapy 11 Individualized Activity Therapies Individualized Activity Therapies 12 Family Counseling 13 Diagnostic Services 14 Approved Patient Training & Education 15 Prosthetic and Orthotic Devices 16 Drugs and Biologicals 17 Medical Supplies 18 Medical Appliances M di l A li 19 Durable Medical Equipment‐Rented 20 Durable Medical Equipment‐Sold 21 All Others 22 Totals (sum of lines 1‐21)(1) 23 Unit Cost Multiplier (see instructions)

WORKSHEET J‐1, PART I

MAIN‐ TENANCE & REPAIRS 6

OPERATION OF PLANT 7

LAUNDRY & LINEN SERVICE 8 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

( ) l (1) Columns 0 through 26, line 22 must agree with the corresponding columns of Wkst. B, Part I, lines as appropriate. See instructions. 0 h h 26 li 22 ih h di l f k li i S i i F OR M C M S -2552-10 (12/2010) (INS TR UC TIONS F OR THIS WOR KS HEET AR E P UB LIS HED IN C M S P UB . 15-II, S EC TION 4053.1)

40-622


Rev. 1

www.esshc.com

12-10

FORM CMS-2552-10

ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTERS

PROVIDER NO.: ______________

COMPONENT NO : COMPONENT NO.: ____________ Check applicable [ ] Title V [ ] Title XVIII [ ] Title XIX boxes: PART II ‐ ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS ‐ STATISTICAL BASIS CAPITAL RELATED COST BLDGS & BLDGS & MOVABLE EMPLOYEE CMHC COST CENTER FIXTURES EQUIPMENT BENEFITS (omit cents) (SQUARE (SQUARE (GROSS RECONCIL‐ FEET) FEET) SALARIES) IATION 0 1 2 4 4A 1 Administrative and General 2 Skilled Nursing Care 3 Physical Therapy Physical Therapy 4 Occupational Therapy 5 Speech Pathology 6 Medical Social Services 7 Respiratory Therapy 8 Psychiatric/Psychological Services 9 Individual Therapy 10 Group Therapy Group Therapy 11 Individualized Activity Therapies 12 Family Counseling 13 Diagnostic Services 14 Approved Patient Training & Education 15 Prosthetic and Orthotic Devices 16 Drugs and Biologicals 17 Medical Supplies M di l S li 18 Medical Appliances 19 Durable Medical Equipment‐Rented 20 Durable Medical Equipment‐Sold 21 All Others 22 Totals (sum of lines 1‐21) 23 Total Cost to be Allocated 2 Unit Cost Multiplier (see instructions) 24 i l i li ( i i )

4090 (Cont.)

PERIOD: FROM ____________ TO TO _______________

WORKSHEET J‐1, PART II

ADMINIS‐ TRATIVE & TRATIVE & GENERAL (ACCUM. COST) 5

MAIN‐ TENANCE & TENANCE & REPAIRS (SQUARE FEET) 6

OPERATION OF PLANT (SQUARE FEET) 7

LAUNDRY & LINEN & LINEN SERVICE (POUNDS OF LAUNDRY) 8 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 2 24


Rev. 1


40-625

www.esshc.com

4090 (Cont.)

FORM CMS-2552-10

COMPUTATION OF COMMUNITY MENTAL HEALTH CENTER PROVIDER COSTS

12-10

PROVIDER NO.: ______________

PERIOD: FROM ____________ TO _______________

COMPONENT NO.: ____________ Check applicable [ ] Title V boxes: PART I ‐ APPORTIONMENT OF CMHC COST CENTERS (From Wk t J 1 Wkst. J‐1, Part I, col. 28) 1 1 Administrative and General 2 Skilled Nursing Care 3 Physical Therapy Physical Therapy 4 Occupational Therapy 5 Speech Pathology 6 Medical Social Services 7 Respiratory Therapy 8 Psychiatric/Psychological Services 9 Individual Therapy 10 Group Therapy 11 Individualized Activity Therapy 12 Family Counseling 13 Diagnostic Services 14 Approved Patient Training & Education 15 Prosthetic and Orthotic Devices 16 Drugs and Biologicals Drugs and Biologicals 17 Medical Supplies 18 Medical Appliances 19 All Others (1) 20 Totals (sum of lines 1‐19)

[ ] Title XVIII

TTotal t l Component Charges 2

WORKSHEET J‐2, PART I

[ ] Title XIX

Ratio of Costs to C t t Charges (col. 1 ÷ col. 2) 3

Title V Titl V Component Charges 4

Title V Componentt C Costs (col. 3 x col. 4) 5

Title XVIII Titl XVIII Component Charges 6

Title XVIII Componentt C Costs (col. 3 x col. 6) 7

Title XIX Titl XIX Component Charges 8

Title XIX Componentt C Costs (col. 3 x col. 8) 9 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

(1) Enter amount in column 1 from Worksheet J‐1, Part I, column 28, line 21. F OR M C M S-2552-10(12/2010) (INS TR UC TIONS F OR THIS WOR KS HEET AR E P UB LIS HED IN C M S P UB . 15-II, S EC TION 4054.1)

40-628


Rev. 1

www.esshc.com

12-10

FORM CMS-2552-10

COMPUTATION OF COMMUNITY MENTAL HEALTH CENTER PROVIDER COSTS

4090 (Cont.)

PROVIDER NO.: ______________ COMPONENT NO.: ____________


[ ] Title V

[ ] Title XVIII

PERIOD: FROM ____________ TO _______________

WORKSHEET J‐2, PART II

[ ] Title XIX

PART II ‐ APPORTIONMENT OF COST OF CMHC PROVIDER SERVICES FURNISHED BY SHARED HOSPITAL DEPARTMENTS (From Wkst. J‐1, Total Ratio of Title V Part I, Component Costs to Component col. 29) Charges Charges (1) Charges (2) 1 2 3 4 21 Respiratory Therapy 22 Physical Therapy 23 Occupational Therapy 24 Speech Pathology 25 Medical Supplies Charged to Patients 26 Implantable Devices Charged to Patients 27 Drugs Charged to Patients 28 Total (sum of lines 21‐28) 29 Total component costs. Add the amount from Part I, line 20 and the amounts from line 28, columns 5, 7, and 9. (3)

Title V Component costs (col. 3 x col. 4) 5

Title XVIII Component Charges (2) 6

Title XVIII Component costs (col. 3 x col. 6) 7

Title XIX Component Charges (2) 8

Title XIX Component costs (col. 3 x col. 8) 9 21 22 23 24 25 26 27 28 29

(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. F OR M C M S -2552-10 (12/2010) (INS TRUC TIONS F OR THIS WOR KS HEET AR E P UBLIS HED IN CM S P UB . 15-II, SEC TION 4054.2)

Rev. 1


40-629

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4090 (Cont.)

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT SETTLEMENT COMMUNITY MENTAL HEALTH CENTER PROVIDER SERVICES


[ ] Title V

[ ] Title XVIII

12-10


PERIOD: FROM ____________ TO _______________

WORKSHEET J‐3

[ ] Title XIX PROGRAM COST

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Cost of component services (from Worksheet J‐2, Part II, line 29) PPS payments received excluding outliers PPS payments received excluding outliers Outlier payments Primary payer payments Total reasonable cost (see instructions) Total charges for program services CUSTOMARY CHARGES Aggregate amount actually collected from patients liable for services on a charge basis Amount that would have been realized from patients liable for payment for services on a charge basis had such payment been made in accordance with 42 CFR 413.13(e) Ratio of line 7 to line 8 (not to exceed 1.000000) (see instructions) Total customary charges (see instructions) Excess of customary charges over reasonable cost (see instructions) Excess of reasonable cost over customary charges (see instructions) COMPUTATION OF REIMBURSEMENT SETTLEMENT Total reasonable cost (from line 5) Part B deductible billed to program patients Part B deductible billed to program patients Net cost (line 13 minus line 14) Excess of reasonable cost over customary charges (from line 12) Subtotal (line 15 minus line 16) 80 percent of costs (80% of line 17) (see instructions) Actual coinsurance billed to program patients (from provider records) Net cost less actual billed coinsurance (line 17 minus line 19) Reimbursable bad debts (from provider records) (see instructions) Reimbursable bad debts for dual eligible beneficiaries (see instructions) Net reimbursable amount (see instructions) Other adjustments (see instructions) (specify) Total cost (line 24 plus or minus line 25) Interim payments (see instructions) Tentative settlement (for contractor use only) Balance due component/program (line 26 minus lines 27 and 28) Protested amounts (nonallowable cost report items in accordance with CMS Pub. 15‐II, section 115.2)

1 2 3 4 5 6 7 8 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30


40-630


Rev. 1

www.esshc.com

12-10

FORM CMS-2552-10

4090 (Cont.)

ANALYSIS OF PAYMENTS TO HOSPITAL‐BASED COMMUNITY MENTAL HEALTH CENTER FOR SERVICES RENDERED TO PROGRAM BENEFICIARIES


[ ] Title V

[ ] Title XVIII


PERIOD: WORKSHEET J‐4 FROM ____________ TO _______________

[ ] Title XIX Part B 1 mm/dd/yyyy

DESCRIPTION 1 2

3

4

Total interim payments paid to providers Interim payments payable on individual bills, either submitted or to be submitted to the intermediary, for services rendered in the cost reporting periods. If i d d i th t ti i d If none, write "NONE", or enter zero. List separately each retroactive lump sum adjustment amount based on subsequent revision of the interim rate for the cost reporting period. Also show date of each payment. If none, write "NONE", or enter zero (1). or enter zero (1).

6

7 8

1 2

Program to Provider

Provider to Program

Subtotal (sum of lines 3.01‐3.49 minus sum of lines 3.50‐3.98) Total interim payments (sum of lines 1, 2, and 3.99) (transfer to Worksheet J‐3, line 27)

O BE COMPLETED BY INTERMEDIARY 5 List separately each tentative settlement payment after desk review. Also show date of each payment. If none, write "NONE," or enter zero (1). Subtotal (sum of lines 5.01‐5.49 minus sum of lines 5.50‐5.98) Determine net settlement amount (balance due) based on the cost report (see instructions). (1) report (see instructions) (1)

Total Medicare liability (see instructions) Name of Contractor Contractor Number

2 Amount

Program to Provider Provider to Program

Program to Provider Provider to Program

.01 .02 .03 .04 .05 .50 .51 .52 .53 .54

3.01 3.02 3.03 3.04 3.05 3.50 3.51 3.52 3.53 3.54

.99

3.99 4

.01 .02 .03 .50 .51 .52

5.01 5.02 5.03 5.50 5.51 5.52

.99

5.99

.01 01

6 01 6.01

.02

6.02

(Month, Day, Year)

7 8

(1) On lines 3, 5, and 6, where an amount is due provider to program, show the amount and date on which you agree to the amount of repayment, even though the total repayment is not accomplished until a later date. F OR M C M S -2552-10 (12/2010) (INS TR UC TIONS F OR THIS WOR KS HEET AR E P UB LIS HED IN C M S P UB . 15-II, S EC TION 4056)

Rev. 1


40-631

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

General Ledger g Payroll Register Statistics 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 Essential Consulting LLC

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WS M Series (Rural Health Clinic) Rural Health Clinics Payment is based on an allinclusive 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 cost based reimbursement for a defined set of core physician and certain non-physician outpatient services. •The pper-visit limit does not apply pp y to hospital p based RHCs that are an integral and subordinate part of a hospital with fewer than 50 beds. •Laboratory tests are paid separately.


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WS M Series

The 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 M 1 must reconcile to WS A line 88.XX 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) 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 Essential Consulting LLC

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WS M Series The WS M Series consists of the following Worksheets: – WS M-2 (Allocation of Overhead to RHC Services) • Line 11-99 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 10-20 20 No input required as this is the cost report flow of the Determination of Allowable Costs Applicable to RHC/FQHC Services


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WS M Series – WS M-3 (Calculation of RHC Reimbursement 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 recordingg of PSR data and bad debts.

– 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 Essential Consulting LLC

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Cost Report 101 FINAL - SoCal HFMA - South

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