Medicare Form10 Instructions
User Manual: Pdf
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- R1P240_1.pdf
- NOTE: This form is not used by freestanding skilled nursing facilities.
- NOTE: Follow this sequence of numbering for subscripting lines throughout the cost report.
- 1. Round to 2 decimal places:
- 3. Round to 4 decimal places:
- 4. Round to 5 decimal places:
- Line 2, Column 2--Enter the 5 position Contractor Number.
- FROM__________
- FROM__________
- 4004.1 Part I - Hospital and Hospital Health Care Complex Identification Data.-- The information required on this worksheet is needed to properly identify the provider. The responses to all lines are Yes or No unless otherwise indicated by the type o...
- Line Descriptions
- Line 21--Indicate the type of control or auspices under which the hospital is conducted as indicated:
- Line 27--For the Standard Geographic classification (not wage), what is your status at the end of the cost reporting period. Enter “1” for urban or “2” for rural.
- Lines 28 - 34--Reserved for future use.
- Lines 39 - 44--Reserved for future use.
- Lines 48 - 54--Reserved for future use.
- Lines 63 - 69--Reserved for future use.
- covers the beginning of the fourth academic year of the first new teaching program’s existence, enter the number “4” in column 3. If the current cost reporting period covers the beginning of the fifth or subsequent academic years of the first new teac...
- Lines 72 - 74--Reserved for future use.
- Lines 77 - 79--Reserved for future use.
- Lines 81-84--Reserved for future use.
- Line 85--Is this a new hospital under 42 CFR 413.40(f)(1)(i) (TEFRA)? Enter “Y” for yes or “N” for no in column 1.
- Line 87 - 89--Reserved for future use.
- Line 95--If line 94 of the corresponding column is “Y” for yes, enter the percentage by which capital costs are reduced.
- Line 96--Does title V and/or XIX reduce operating costs? Enter “Y” for yes or “N” for no in the applicable column.
- Line 97--If line 96 of the corresponding column is “Y” for yes, enter the percentage by which operating costs are reduced.
- Lines 98 - 104--Reserved for future use.
- Lines 110 - 114--Reserved for future use.
- Line 116--Are you classified as a referral center? Enter “Y” for yes or “N” for no. See 42 CFR 412.96.
- Lines 121 - 124--Reserved for future use.
- Line 125--Does your facility operate a transplant center? Enter “Y” for yes or “N” for no in column 1. If yes, enter the certification dates below.
- Line 134--If this is an organ procurement organization (OPO), enter the OPO number in column 1 and termination date, if applicable, in column 3.
- Line 147--Was there a change in the statistical basis? Enter “Y” for yes or “N” for no.
- Line 148--Was there a change in the order of allocation? Enter “Y” for yes or “N” for no.
- Lines 150 - 154--Reserved for future use.
- Lines 162 - 164--Reserved for future use.
- Column Descriptions
- Line Descriptions
- Line 2--Enter title XVIII M+C and XIX HMO days (columns 6 and 7) and other Medicaid eligible days not included on line 1, columns 6 and 7, respectively.
- Line 3--Enter title XVIII M+C and XIX HMO days (columns 6 and 7) for IPF subproviders days not included on line 1, columns 6 and 7, respectively.
- Line 4--Enter title XVIII M+C and XIX HMO days (columns 6 and 7) for IRF subproviders days not included on line 1, columns 6 and 7, respectively.
- Line 5--Enter the Medicare covered swing bed days (which are considered synonymous with SNF swing bed days) for all Title XVIII programs where applicable. See 42 CFR 413.53(a)(2). Exclude all M+C days from column 6, include the M+C days in column 8.
- Line 6--Enter the non-Medicare covered swing bed days (which are considered synonymous with NF swing bed days) for all programs where applicable. See 42 CFR 413.53(a)(2).
- Line 7--Enter the sum of lines 1, 5 and 6.
- Lines 8 through 13--Enter the appropriate statistic applicable to each discipline for all programs.
- Line 21--If you have more than one hospital-based other long term care facility, subscript this line.
- Line 22--If you have more than one hospital-based HHA, subscript this line.
- Line 23--Enter data for an ASC. If you have more than one ASC, subscript this line.
- Line 24--Enter days applicable to hospice patients in a distinct part hospice.
- Line 30--Enter in column 8 the employee discount days if applicable. These days are used on Worksheet E, Part A, line 31 in the calculation of the DSH adjustment and Worksheet E-3, Part III, line 3 in the calculation of the LIP adjustment.
- Line 31--Enter in column 8 the employee discount days, if applicable, for IRF subproviders.
- For the purposes of reporting on this line, labor and delivery days are defined as days during which a maternity patient is in the labor/delivery room ancillary area at midnight at the time of census taking, and is not included in the census of the in...
- Line 33--See instructions for “Columns 5 through 7 of this worksheet.
- 4005.2 Part II - Hospital Wage Index Information.--This worksheet provides for the collection of hospital wage data which is needed to update the hospital wage index applied to the labor-related portion of the national average standardized amounts of ...
- NOTE: Any line reference for Worksheets A and A-6 includes all subscripts of that line.
- Column 2
- Line 1--Enter from Worksheet A, column 1, line 200, the wages and salaries paid to hospital employees increased by amounts paid for vacation, holiday, sick, other paid-time-off (PTO), severance, and bonus pay if not reported in column 1.
- Column 4--Enter on each line the result of column 2 plus or minus column 3.
- Enter the number of hours in your normal work week in the space provided.
- Report in column 2 the FTE contracted and consultant staff of the outpatient rehabilitation provider.
- Column Descriptions for Lines 3 Through 200
- Column 1--The case mix resource utilization group (RUGs) designations are already entered in this column.
- Column 3--Enter the number of days associated with the swing beds. All swingbed SNF payment data will be reported as a total amount paid under the RUG PPS payment system on Worksheet E-2, line 1 and will be generated from the PS&R or your records.
- Column 4--Enter the sum total of columns 2 and 3.
- Line 201--Enter in column 1, the CBSA code in effect at the beginning of the cost reporting period. Enter in column 2, the CBSA code in effect on or after October 1 of the current cost reporting period, if applicable.
- R1P240_2.pdf
- Lines 1 and 2--Enter the full address of the RHC/FQHC.
- Line 14--Identify provider’s name and CCN number filing the consolidated cost report.
- Lines 24 - 29--Reserved for future use.
- Lines 36 - 39--Reserved for future use.
- Lines 47-49--Reserved for future use.
- Lines 77 - 87--Reserved for future use.
- Line 91--Enter the costs of the emergency room cost center.
- Lines 96 and 97--Use these lines to report durable medical equipment rented or sold, respectively. Enter the direct expenses incurred in renting or selling durable medical equipment (DME) items to patients. Also, include all direct expenses incurred...
- Column Descriptions
- Line 7--Enter the standard travel expense rate applicable. (See CMS Pub. 15-1, chapter 14.)
- Line 9--Enter in the appropriate columns the total number of hours worked for each category.
- NOTE: There is no travel allowance for aides employed by outside suppliers.
- When you furnish therapy services from outside suppliers to health care program patients but simply arrange for such services for non health care program patients and do not pay the non health care program portion of such services, your books reflect ...
- R1P240_3.pdf
- NOTE: Do not transfer negative numbers.
- Column Descriptions
- Since capital-related cost, non-physician anesthetists, and approved education programs are not included in the operating cost per discharge, columns 19 through 23, lines 30 through 194 are shaded on Worksheet B, Part II, for all lines except 19 throu...
- Line Descriptions
- Column Descriptions
- Inpatient routine service cost centers
- Inpatient ancillary
- Other Reimbursable
- Special Purpose
- Column 3--Enter on each cost center line the sum of columns 1 and 2.
- Ratios
- Hospital, subprovider, SNF, NF, swing
- Column Descriptions
- Column 3--For each line, subtract column 2 from column 1, and enter the result.
- Column 4--Multiply column 2 by the appropriate capital reduction percentage, and enter the result.
- Column 6--Subtract columns 4 and 5 from column 1, and enter the result.
- Column 7--Enter the total charges from Worksheet C, Part I, column 8.
- Column 8--Divide column 6 by column 7, and enter the result.
- Column 5--Enter the sum of columns 1 through 3 (including subscripts) minus column 4.
- Exclude charges for which costs were excluded on Worksheet A-8. For example, CRNA costs reimbursed on a fee schedule are excluded from total cost on Worksheet A-8. For titles V and XIX, enter the appropriate outpatient service charges.
- For title XVIII, complete a separate Worksheet D, Part V, for each provider component as applicable. Enter the applicable component number in addition to the hospital provider number. Make no entries in columns 5 through 7 of this worksheet for any c...
- Column 4--Cost Reimbursed Services Not Subject to Deductibles and Coinsurance--Vaccine Cost Apportionment--This column provides for the apportionment of costs which are not subject to deductible and coinsurance i.e., Pneumococcal, Influenza, Hepatitis...
- Line Descriptions
- Line 200--Enter the sum of lines 50 through 98.
- Transfer References
- Definitions
- The following definitions apply to days used on this worksheet.
- Lines 1 through 16--Inpatient days reported, unless specifically stated, exclude days applicable to newborn and intensive care type patient stays. Report separately the required statistics for the hospital, each subprovider, hospital-based SNF, hospi...
- Column 5--Multiply the average cost per diem in column 3 by the program days in column 4.
- Line 52--Enter the sum of lines 50 and 51.
- 4025.3 Part III - Skilled Nursing Facility, Other Nursing Facility, and Intermediate Care Facility/Mental Retardation Only--This part provides for the apportionment of inpatient operating costs to titles V, XVIII, and XIX. Hospital-based SNFs comple...
- Line Descriptions
- Line 70--Enter the hospital-based SNF or other nursing facility routine service cost from Part I, line 37.
- Line 78--Calculate the inpatient routine service cost by subtracting line 77 from line 74.
- Line 79--Enter the aggregate charges to beneficiaries for excess costs obtained from your records.
- Line 84-- Enter the program ancillary service amount from Worksheet D-3, column 3, line 200.
- Line 88--Calculate the result of general inpatient routine cost on line 27 divided by line 2.
- Line 74--Enter the sum of lines 70 through 73.
- Line 83--Enter in columns 1 and 2 the applicable number of unusable organs.
- NOTE: CAHs do not complete this worksheet.
- Line Descriptions
- R1P240_4.pdf
- Part A - Inpatient Hospital Services Under PPS
- 4030.1 Part A - Inpatient Hospital Services Under IPPS--
- Line Descriptions
- NOTE: Reduce the bed days available by swing bed days (Worksheet S-3, Part I, column 8, sum of lines 5 and 6), and the number of observation days (Worksheet S-3, Part I, column 8, line 28).
- Calculation of the adjusted cap in accordance with 42 CFR 412.105(f):
- Calculation of the allowable current year FTEs:
- from the rolling average has expired (see 42 CFR 412.105(f)(1)(v)), enter on this line the allowable FTE count from line 12 plus the count of previously new FTE residents in that specific program that were added to line 15 of the prior year’s cost rep...
- Line 19--Enter the current year resident to bed ratio. Line 15 divided by line 4.
- Disproportionate Share Adjustment--Section 1886(d)(5)(F) of the Act, as implemented by 42 CFR 412.106, requires additional Medicare payments to hospitals with a disproportionate share of low income patients. Calculate the amount of the Medicare dispr...
- Line 30--Enter the percentage of SSI recipient patient days to Medicare Part A patient days. (Obtain the percentage from your contractor.)
- Line 32--Add lines 30 and 31 to equal the hospital’s DSH patient percentage.
- Lines 35-39--Reserved for future use.
- Line 46--Enter the ESRD payment adjustment (line 44, column 1 times line 45, column 1 times line 41, column 1 plus, if applicable, line 44, column 1 times line 45, column 2 times line 41, column 2).
- Line 55--Enter the net organ acquisition cost from Worksheet(s) D-4, Part III, column 1, line 69.
- Line 56--Enter the cost of teaching physicians from Worksheet D-5, Part II, column 3, line 20.
- Line 58--Enter the ancillary service other pass through costs from Worksheet D, Part IV, column 11, line 200.
- deductible and coinsurance obligation.
- Line 61--Enter the result of line 59 minus line 60.
- Line 62--Enter from the PS&R or your records the deductibles billed to program patients.
- Line 63--Enter from the PS&R or your records the coinsurance billed to program patients.
- Line 64--Enter the program allowable bad debts, reduced by the bad debt recoveries. If recoveries exceed the current year’s bad debts, line 64 and 65 will be negative.
- Line 66--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is reported for statistical purposes only. These amounts must also be reported on line 64.
- Line 70--Enter any other adjustments. For example, enter an adjustment resulting from changing the recording of vacation pay from cash basis to accrual basis. (See Pub. 15-1, §2146.4.) Specify the adjustment in the space provided.
- Effective for discharges occurring during Federal fiscal years 2011 and 2012, enter on lines 70.97 through 70.99 the additional payment in accordance with ACA of 2010, §§3125 and 10314 which amends §1886(d)(12) of the Act (as implemented by 42 CFR 4...
- Line 74--Enter line 71 minus the sum of lines 72 and 73. Transfer to Worksheet S, Part III.
- NOTE: If a cost report is reopened more than one time, subscript lines 90 through 96, respectively, one time for each time the cost report is reopened.
- 4030.2 Part B - Medical and Other Health Services--Use Worksheet E, Part B, to calculate reimbursement settlement for hospitals, subproviders, and SNFs.
- Line Descriptions
- Line 3--Enter the gross PPS payments received including payment for drugs and device pass through payments.
- Line 5--Enter the hospital specific payment to cost ratio provided by your contractor. If a new provider does not file a full cost report for a cost reporting period that ends prior to January 1, 2001, the provider is not eligible for transitional co...
- Line 6--Enter the result of line 2 times line 5.
- If the sum of lines 3 and 4 is < line 6 complete lines 7 and 8, otherwise do not complete lines 7 and 8.
- Line 7--Enter the result of the sum of lines 3 and 4 divided by line 6.
- Line Descriptions
- Line 21--Enter the amount from line 11, less any amount on reported on line 20 for hospital/services subject to LCC.
- For hospital/services that are not subject to LCC in accordance with 42 CFR 413.13 (e.g., CAHs or nominal charge public or private hospitals identified on Worksheet S-2, lines 155-161), enter the reasonable costs from line 11.
- For CAHs enter on this line 101 percent of line 11.
- Line 22--Enter the cost of services rendered by interns and residents as follows from Worksheet D-2.
- Line 23--For hospitals or subproviders that have elected to be reimbursed for the services of teaching physicians on the basis of cost (see 42 CFR 415.160 and CMS Pub. 15-1, §2148), enter the amount from Worksheet D-5, Part II, column 3, line 21.
- 4030.2 (Cont.) FORM CMS-2552-10 12-10
- Line 27--Subtract lines 25 and 26 from lines 21 and 24 respectively. Add to that result the sum of lines 22 and 23.
- For critical access hospitals (CAHs), enter the lesser of (line 21 minus the sum of lines 25 and 26) or 80 percent times the result of (line 21 minus line 25 minus 101% of lab cost (Worksheet D, Part V, column 6, lines 60, 61, and subscripts) minus 10...
- Line 32--Enter line 30 minus line 31.
- Line 36--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is reported for statistical purposes only. This amount must also be reported on line 34.
- Line 37--Enter the sum of lines 32, 33 and 34 or 35 (hospitals and subproviders only).
- 4030.2 (Cont.) FORM CMS-2552-10 12-10
- 4031.1 Part I - Analysis of Payments to Providers for Services Rendered--
- Columns 1 and 2 - Inpatient Part A
- Line Descriptions
- 4031.2 Part II - Calculation of Reimbursement Settlement for Health Information Technology--
- Line Descriptions
- Line 4--Enter the sum of lines 1, 2 and 3.
- Line 6--Enter line 4 minus line 5.
- Line 7--Enter the Part A deductibles.
- Line 8--Enter line 6 less line 7.
- Line 10--Enter the result of subtracting line 9 from line 8.
- Line 13--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is reported for statistical purposes only. This amount must also be reported on line 11.
- Line 15--Enter the amount from Worksheet E-4, line 49 for the hospital component only.
- Line 16--Enter the routine service other pass through costs from Worksheet D, Part III, column 9, line 30 for a freestanding facility or lines 40 through 42, as applicable, for the corresponding subproviders. Add to this amount the ancillary service ...
- Line Descriptions
- Line 16--Enter the sum of lines 12, 13, 14 and 15.
- Line 18--Enter line 16 minus line 17.
- Line 19--Enter the Part A deductibles.
- Line 20--Enter line 18 minus line 19.
- Line 22--Enter the result of subtracting line 21 from line 20.
- Line 25--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is reported for statistical purposes only. This amount must also be reported on line 23.
- Line 27--Enter the amount from Worksheet E-4, line 49 for the hospital component only.
- Line 28--Enter the routine service other pass through costs from Worksheet D, Part III, column 9, line 30 for a freestanding facility or line 40 for the IPF subprovider. Add to this amount the ancillary service other pass through costs from Worksheet...
- Line Descriptions
- Line 17--Enter the sum of lines 13, 14, 15 and 16.
- Line 19--Enter line 17 minus line 18.
- Line 20--Enter the Part A deductibles.
- Line 21--Enter line 19 less line 20.
- Line 23--Enter the result of subtracting line 22 from line 21.
- Line 26--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is reported for statistical purposes only. This amount must also be reported on line 24.
- Line 28--Enter the amount from Worksheet E-4, line 49 for the hospital component only.
- Line 29--Enter the routine service other pass through costs from Worksheet D, Part III, column 9, line 30 for a freestanding facility or line 41 for IRF the subproviders. Add to this amount the ancillary service other pass through costs from Workshee...
- Line Descriptions
- Line 7--Enter the sum of lines 3, 4, 5 and 6.
- Line 9--Enter line 7 minus line 8.
- Line 10--Enter the Part A deductibles.
- Line 11--Enter line 9 less line 10.
- Line 13--Enter the result of subtracting line 12 from line 11.
- Line 16--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is reported for statistical purposes only. This amount must also be reported on line 14.
- Line 18--Enter the amount from Worksheet E-4, line 49 for the hospital component only.
- Line 19--Enter the routine service other pass through costs from Worksheet D, Part III, column 9, line 30 for a freestanding facility. Add to this amount the ancillary service other pass through costs from Worksheet D, Part IV, column 11, line 200.
- Line 10--Enter the sum of lines 7 through 9.
- Line 15--Enter the excess of the customary charges on line 14 over the reasonable cost on line 6.
- Computation of Reimbursement Settlement
- Line 19--Enter the sum of lines 6, 17 and 18.
- Line 20--Enter the Part A deductibles billed to Medicare beneficiaries.
- Line 22--Enter line 19 less the sum of lines 20 and 21.
- Line 23--Enter from PS&R or your records the coinsurance billed to Medicare beneficiaries.
- Line 24--Enter line 22 minus line 23.
- Line 27--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is reported for statistical purposes only. This amount must also be reported on line 25.
- Line 30--Enter line 28, plus or minus line 29.
- Line Descriptions
- Prospective Payment Amount
- Line 6--Enter any deductible amounts imposed.
- Line 9--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is reported for statistical purposes only. This amount must also be reported on line 8.
- Line 10--DRA 2005 SNF Bad Debt--Calculate this line as follows: [((line 8 - line 9) *.7) + line 9]. This is the adjusted SNF reimbursable bad debt in accordance with DRA 2005, section 5004.
- Line Descriptions
- Line 1--Enter the appropriate inpatient operating costs.
- Line 12--Enter the sum of the amounts recorded on lines 8 through 11.
- Prospective Payment Amount
- Line 25--Enter the result of Worksheet L, Part III, line 13 less Worksheet L, Part III, line 17. If this amount is negative, enter zero on this line.
- Line 27--Enter the sum of lines 22 through 26.
- Line 28--For titles V and XIX only, enter the customary charges for PPS.
- Computation of Reimbursement Settlement
- Line 33--Enter any coinsurance amounts imposed.
- Line 38--Enter the result of line 36 plus or minus line 37.
- Line 40--Enter the sum of lines 38 and 39.
- Line 5--Enter the sum of lines 1, 3, and 4, less line 2, to determine the FTE adjusted cap. However, if the resulting cap is less than zero, enter zero on this line.
- Line 7--Enter the lesser of lines 5 or 6.
- Line 10--Enter in column 2 the weighted dental and podiatric resident FTE count for the current year.
- Line 11--Enter in column 1, the amount from column 1, line 9. Enter in column 2, the sum of the amounts in column 2, lines 9 and 10.
- Line 20--Section 422 Direct GME FTE Cap--Enter the number of unweighted allopathic and osteopathic direct GME FTE resident cap slots the hospital received under 42 CFR §413.79(c)(4).
- Line Descriptions
- Line 28--In each column, divide line 26 by line 27 and enter the result (expressed as a decimal).
- Line 42--Enter the Part B Medicare reasonable cost. Enter the sum of the amounts on each title XVIII Worksheet E, Part B, columns 1 and 1.01, sum of lines 1, 2, 9,10, 22, and 23; Worksheet E-2, column 2, line 8; Worksheet H-4, Part I, sum of columns ...
- R1P240_5.pdf
- Line Descriptions
- Line 28--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is reported for statistical purposes only. This amount must also be reported on line 27.
- Line 29--Enter the result of line 26 plus 27.
- Column Descriptions
- Column 2--This column lists the statistical bases for allocating costs on Worksheet I-3.
- Column 3--Enter paid hours per type of staff listed on lines 1 through 6.
- Column 4--Enter full time equivalents by dividing column 3 by 2080 hours.
- Line Descriptions
- R1P240_6.pdf
- Column 2--Enter the charges for each cost center. Obtain the charges from your records.
- Line 20--Enter the totals of lines 1 through 19 in columns 1, 2, and 4 through 9.
- Line 28--Enter the totals for columns 4 through 9.
- Line 5--Title XVIII CMHCs enter the result obtained by subtracting line 4 from the sum of lines 2 and 3. Titles V and XIX providers not reimbursed under PPS enter the total reasonable costs by subtracting line 4 from line 1.
- Line 18--CMHCs enter 0 (zero) as these services are reimbursed under PPS. For titles V and XIX, enter 100 percent less the applicable coinsurance.
- Line 19--Enter the actual coinsurance billed to program patients (from your records).
- Line 20--For title XVIII, enter the difference of line 17 minus line 19. For titles V and XIX, enter the difference of line 18 minus line 19.
- Line 28--For contractor final settlement, report on this line the amount from Worksheet J-4, line 5.99.
- Line Descriptions
- Line 3--Enter the amount of each retroactive lump sum adjustment and the applicable date.
- Line 4--Transfer the total interim payments to the title XVIII Worksheet J-3, line 27.
- COMPLETE ONLY PART I, II, OR III.
- Line Descriptions
- Lines 3 - 6
- Line 6--Multiply line 5 by the sum of lines 1 and 2.
- Lines 7 - 11
- Enter the amount of the Federal rate portion of the additional capital payment amounts relating to the disproportionate share adjustment. Complete these lines if you answered yes to line 45 on Worksheet S-2. (See 42 CFR 412.312(b)(3).) For hospital...
- Line 9--Add lines 7 and 8, and enter the result.
- Column descriptions
- On lines 5 through 7 and 9, enter the actual number of visits for each type of position.
- Line descriptions
- Line 8--Enter the total of lines 4 through 7.
- Line 10--Enter the cost of health care services from Worksheet M-1, column 7, line 22.
- Line 11--Enter the total nonreimbursable costs from Worksheet M-1, column 7, line 28.
- Line 12--Enter the sum of lines 10 and 11 for the cost of all services (excluding overhead).
- Line 14--Enter the total facility overhead costs incurred from Worksheet M-1, column 7, line 31.
- Line 18--Subtract the amount on line 17 from line 16 and enter the result.
- Line descriptions
- Line 1--Enter the total allowable cost from Worksheet M-2, line 20.
- Line 2--Report vaccine costs on this line from Worksheet M-4.
- Line 3--Subtract the amount on line 2 from the amount on line 1 and enter the result.
- Line 6--Enter the total adjusted visits (sum of lines 4 and 5).
- Line descriptions
- Line 17--Enter the primary payer amounts from your records.
- Line 20--For title XVIII, enter 80 percent of the amount on line 19.
- Line 21--Enter the amount from Worksheet M-4, line 16.
- Line 5--Enter the sum of lines 3 and 4.
- Line Descriptions
- Line 3--Enter the amount of each retroactive lump sum adjustment and the applicable date.
- Line 4--Transfer the total interim payments to the title XVIII Worksheet M-3, line 27.