Medicare Form10 Instructions

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Medicare
Department of Health and
Human Services (DHHS)
Provider Reimbursement Manual
Part 2, Provider Cost Reporting Forms and
Instructions, Chapter 40, Form CMS 2552-10
Centers for Medicare and
Medicaid Services (CMS)
Transmittal 1
Date: December 2010
HEADER SECTION NUMBERS
PAGES TO INSERT
PAGES TO DELETE
Table of Contents
Chapter 40
40-1 - 40-6 (6 pp.) -----
4000 - 4070
40-7 - 40-287 (281 pp.)
-----
4090
40-501 - 40-663 (163 pp.)
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4095
40-701 - 40-811 (111 pp.)
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NEW/REVISED MATERIAL--EFFECTIVE DATE: Cost Reporting Periods Beginning on
or After May 1, 2010.
This transmittal introduces Chapter 40, Hospital and Hospital Health Care Complex Cost Report,
Form CMS-2552-10, which contains instructions for the completion of the new cost report forms
to be filed by hospitals and hospital health care complexes.
The following is a summary of the major revisions to the cost reporting forms:
Form CMS Form CMS
2552-96 Wkst. 2552-10 Wkst. Summary of Changes
S S, Parts I, II &III Added Part I for cost report status, Part II is
now the certification and Part III is now the
settlement summary.
S-2 S-2, Part I Expanded the questions that will generate
other worksheets on the cost report.
S-2, Part II Included the Hospital Cost Report
Questionnaire CMS Form 339 into
CMS-2552-10.
S-3, Part I S-3, Part I Re-designated the subscripted lines and
columns into whole number lines and
columns.
S-3, Part II & III S-3, Part II & III Re-designated the subscripted lines and
columns into whole number lines and
columns.
S-3, Part IV New worksheet to capture wage related cost
that was formerly on the hospital cost
report questionnaire CMS Form 339.
S-3, Part V New worksheet to capture contract
labor and benefit cost.
Pub. 15-2-40
Form CMS Form CMS
2552-96 Wkst. 2552-10 Wkst. Summary of Changes
S-4 S-4 Re-designated the subscripted lines and
columns into whole number lines and
columns.
S-5 S-5 Re-designated the subscripted lines and
into whole number lines.
S-6 S-6 Minor changes.
S-7 S-7 This redesigned worksheet captures all
of the statistics for hospital based skilled
nursing facility (SNFs).
S-8 S-8 Minor changes.
S-9 S-9 No change.
S-10 S-10 Redesigned the entire worksheet.
A A Eliminated “Old Capital,” “New
Capital” designation. Re-designated
the subscripted lines and columns
into whole number lines and columns.
A-6 A-6 No change.
A-7 A-7 Minor changes to conform to
Worksheet A.
A-8 A-8 Minor changes to conform to
Worksheet A.
A-8-1 A-8-1 Minor changes to conform to
Worksheet A.
A-8-2 A-8-2 No change.
A-8-3 A-8-3 Designated the worksheet for cost
reimbursed providers.
A-8-4 Eliminated.
Form CMS Form CMS
2552-96 Wkst. 2552-10 Wkst. Summary of Changes
B, Part I B, Part I Eliminated “Old Capital” and “New Capital”
designation. Re-designated the subscripted
lines and columns into whole number lines
and columns.
B, Part II Eliminated since Old Capital no longer applies.
B, Part III B, Part II Re-designated New Capital to Capital Related
Costs. Re-designated the subscripted lines and
columns into whole number lines and columns.
B-1 B-1 Changes to conform to Worksheet A and B.
C, Parts I - II C, Parts I - II Changes to conform to Worksheet A and B.
C, Parts III - IV Eliminated.
D, Parts I - V D, Parts I - V Minor changes.
D, Part VI Eliminated.
D-1 D-1 Minor changes.
D-2 D-2 Minor changes.
D-4 D-3 Renamed D-4 to D-3 and made minor
changes.
D-6 D-4 Renamed D-6 to D-4 and made minor
changes.
D-9 D-5 Renamed D-9 to D-5 and made minor
changes.
E, Part A E, Part A Re-designated the worksheet to eliminate
obsolete lines and convert subscripted
lines into whole number lines.
E, Part B E, Part B Re-designated the worksheet to eliminate
obsolete lines and convert subscripted lines
into whole number lines.
E, Part C Eliminated.
E, Part D Eliminated.
E, Part E Eliminated.
E-1 E-1, Part I Renamed worksheet with minor changes.
E-1, Part II New section to accommodate the collection of
data necessary to calculate the Health
Information Technology (HIT) payment.
Form CMS Form CMS
2552-96 Wkst. 2552-10 Wkst. Summary of Changes
E-2 Minor changes.
E-3, Part I E-3, Part I Redesigned the worksheet to be used
exclusively by TEFRA reimbursed providers.
E-3, Part II New worksheet to be used exclusively by
Inpatient Psychiatric providers.
E-3, Part III New worksheet to be used exclusively by
Inpatient Rehabilitation providers.
E-3, Part IV New worksheet to be used exclusively by
Long Term Care providers.
E-3, Part II E-3, Part V Redesigned the worksheet to be used
exclusively by cost reimbursed providers.
E-3, Part III E-3, Part VI Redesigned the worksheet now to be used
exclusively for title XVIII SNF
reimbursement.
E-3, Part VII New worksheet for titles V & XIX SNF
reimbursement.
E-3, Part IV E-4 New worksheet to calculate Direct Graduate
Medical Education and ESRD Direct
Graduate Medical Education.
G, G-1, G-2, and G-3 G, G-1, G-2, and G-3 Minor changes. Re-designated the subscripted
lines and into whole number lines.
H H No Change.
H-1 Eliminated data included on Worksheet H.
H-2 Eliminated data included on Worksheet H.
H-3 Eliminated data included on Worksheet H.
H-4, Parts I & II H-1, Parts I & II Renamed the worksheet and eliminated
“Old Capital” and New Capital” designations.
Re-designated the subscripted lines and
columns into whole number lines and
columns.
H-5, Parts I & II H-2, Parts I & II Renamed the worksheet and eliminated
“Old Capital” and New Capital” designations.
Re-designated the subscripted lines and
columns into whole number lines and
columns.
Form CMS Form CMS
2552-96 Wkst. 2552-10 Wkst. Summary of Changes
H-6 H-3 Renamed and redesigned the worksheet
to eliminate obsolete data requirements.
H-7 H-4 Eliminated obsolete lines and re-designated
subscripted lines to whole number lines.
H-8 H-5 Renamed the worksheet with some minor
changes.
I-1, I-2, I-3, I-4, & I-5 I-1, I-2, I-3, I-4, & I-5 Eliminated “Old Capital” and “New Capital”
designations. Re-designated the subscripted
lines and columns into whole number
lines and columns.
J-1, J-2, J-3, & J-4 J-1, J-2, J-3, & J-4 Eliminated “Old Capital” and “New Capital”
designations. Re-designated the subscripted
lines and columns into whole number
lines and columns. These worksheets
are now to be used exclusively by CMHC.
K, K-1, K-2, K-3, K, K-1, K-2, K-3,
K-4, Parts I&II K-4, Parts I&II
K-5, Parts I-III, K-5, Parts I-III,
& K-6 & K-6 Eliminated “Old Capital” and “New Capital”
designations. Re-designated the subscripted
lines and columns into whole number
lines and columns.
L L Re-designated the subscripted lines to whole
lines and eliminated the hold harmless
section.
L-1, Parts I-III L-2, Part I-III Eliminated “Old Capital” “New
Capital” designations. Re-designated
the subscripted lines and columns
into whole number lines and
columns.
Paper Reduction Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-0050. The time required to complete this
information collection is estimated 673 hours per response, including the time to review
instructions, search existing resources, gather the data needed, and complete and review the
information collection. If you have any comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Report Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.
CHAPTER 40
HOSPITAL AND HOSPITAL
HEALTH CARE COMPLEX COST REPORT
FORM CMS-2552-10
Section
General ............................................................................................................................... 4000
Rounding Standards for Fractional Computations...................... .............................. 4000.1
Acronyms and Abbreviations................................................................ .................... 4000.2
Recommended Sequence for Completing Form CMS-2552-10..................................... ... 4001
Sequence of Assembly...................................................................................................... . 4002
Sequence of Assembly for Non-Proprietary Hospital Participating in Medicare
and Subject to Prospective Payment System ........................................................ 4002.1
Sequence of Assembly for Proprietary Health Care Complex Participating
in Titles V, XVIII, and XIX .................................................................................... 4002.2
Worksheet S - Hospital and Hospital Health Care Complex Cost Report Certification
and Settlement Summary....................................................... ......................................... 4003
Part I - Cost Report Status ........................................................................................ 4003.1
Part II - Certification by Officer or Administrator of Provider(s) ............................. 4003.2
Part III - Settlement Summary...................................................................................4003.3
Worksheet S-2 .................................................................................................................... 4004
Part I - Hospital and Hospital Health Care Complex Identification Data ................. 4004.1
Part II - Hospital and Hospital Heath Care Complex Questionnaire ........................ 4004.2
Worksheet S-3 - Hospital and Hospital Health Care Complex Statistical Data and
Hospital Wage Index Information ................................................................................... 4005
Part I - Hospital and Hospital Health Care Complex Statistical Data ...................... 4005.1
Part II - Hospital Wage Index Information.......................................... ..................... 4005.2
Part III - Hospital Wage Index Summary......................................... ......................... 4005.3
Part IV - Hospital Wage Related Cost ...................................................................... 4005.4
Part V - Hospital and Health Care Complex Contract Labor and Benefit Cost ........ 4005.5
Worksheet S-4 - Hospital-Based Home Health Agency Statistical Data ........................... 4006
Worksheet S-5 - Hospital Renal Dialysis Department Statistical Data ............................. 4007
Worksheet S-6 - Hospital-Based Outpatient Rehabilitation Provider Data......... .............. 4008
Worksheet S-7 - Statistical Data and Prospective Payment for Skilled Nursing
Facilities .................................................... ................................................................... 4009
Worksheet S-8 - Provider-Based Rural Health Clinic/Federally Qualified
Health Center Provider Statistical Data ....................................... ............................... 4010
Worksheet S-9 - Hospice Identification Data .................................................................... 4011
Part I - Enrollment Days Based on Level of Care ..................................................... 4011.1
Part II - Census Data ................................................................................................. 4011.2
Worksheet S-10 - Hospital Uncompensated Care Data ..................................................... 4012
Rev. 1 40-1
CHAPTER 40
Section
Worksheet A - Reclassification and Adjustment of Trial Balance of Expenses ................ 4013
Worksheet A-6 - Reclassifications................................................................................... .. 4014
Worksheet A-7 - Analysis of Capital Assets..................................................................... 4015
Part I - Analysis of Changes in Capital Asset Balances ........................................... 4015.1
Part II - Reconciliation of Capital Cost Centers........................................................ 4015.2
Part III - Reconciliation of Amounts from Worksheet A, Column 2,
Lines 1 thru 2........................................................................................ ................. 4015.3
Worksheet A-8 - Adjustments to Expenses....................................................................... 4016
Worksheet A-8-1 - Statement of Costs of Services from Related Organizations and
Home Office Costs..................................................... ..................................................... 4017
Worksheet A-8-2 - Provider-Based Physician Adjustments.................................. ............ 4018
Worksheet A-8-3 - Reasonable Cost Determination for Therapy Services
Furnished by Outside Suppliers for Cost Based Providers ............................................. 4019
Part I - General Information................................................ ...................................... 4019.1
Part II - Salary Equivalency Computation......................................... ....................... 4019.2
Part III - Standard Travel Allowance and Standard Travel Expense Computation
Provider Site.......................................................................................................... 4019.3
Part IV - Standard Travel Allowance and Standard Travel Expense -
Off Site Services...................................................... .............................................. 4019.4
Part V - Overtime Computation........................................................... ..................... 4019.5
Part VI - Computation of Therapy Limitation and Excess Cost Adjustment ........... 4019.6
Worksheet B, Part I - Cost Allocation - General Service Cost and
Worksheet B-1 - Cost Allocation - Statistical Basis........................................... ............... 4020
Worksheet B, Part II - Allocation of Capital-Related Costs and Worksheet B ................. 4021
Worksheet B-2 - Post Stepdown Adjustments............................................ ....................... 4022
Worksheet C - Computation of Ratio of Cost to Charges and Outpatient
Capital Reduction............................................................................................................ 4023
Part I - Computation of Ratio of Costs to Charges ................................................... 4023.1
Part II - Computation of Ratio of Outpatient Service
Cost to Charge Ratios Net of reductions ................................................................ 4023.2
Worksheet D - Cost Apportionment................................................................................. . 4024
Part I - Apportionment of Inpatient Routine Service Capital Costs........................... 4024.1
Part II - Apportionment of Inpatient Ancillary Service Capital Costs ....................... 4024.2
Part III - Apportionment of Inpatient Routine Service Other Pass
Through Costs........................................................................... .............................. 4024.3
Part IV - Apportionment of Inpatient Ancillary Service Other Pass Through
Costs........................................................................... ............................................. 4024.4
Part V - Apportionment of Medical and Other Health Services Costs ...................... 4024.5
40-2 Rev. 1
CHAPTER 40
Section
Worksheet D-1 - Computation of Inpatient Operating Cost .............................................. 4025
Part I - All Provider Components ................................................................................ 4025.1
Part II - Hospital and Subproviders Only ..................................................................... 4025.2
Part III - Skilled Nursing Facility and Other Nursing Facility Only ............................ 4025.3
Part IV - Computation of Observation Bed Cost ......................................................... 4025.4
Worksheet D-2 - Apportionment of Cost of Services Rendered by Interns and Residents 4026
Part I - Not in Approved Teaching Program ................................................................ 4026.1
Part II - In Approved Teaching Program (Title XVIII, Part B Inpatient Routine
Costs Only) ............................................................................................................... 4026.2
Part III - Summary for Title XVIII ............................................................................... 4026.3
Worksheet D-3 - Inpatient Ancillary Service Cost Apportionment ................................... 4027
Worksheet D-4 - Computation of Organ Acquisition Costs and Charges for Hospitals
Which Are Certified Transplant Centers ........................................................................ 4028
Part I - Computation of Organ Acquisition Costs (Inpatient Routine and
Ancillary Services) .................................................................................................... 4028.1
Part II - Computation of Organ Acquisition Costs (Other Than Inpatients Routine
and Ancillary Service Costs) ..................................................................................... 4028.2
Part III - Summary of Costs and Charges ..................................................................... 4028.3
Part IV - Statistics ........................................................................................................ 4028.4
Worksheet D-5 - Apportionment of Cost for Services of Teaching Physicians ................ 4029
Part I - Reasonable Compensation Equivalent Computation ....................................... 4029.1
Part II - Apportionment of Cost for Services of Teaching Physicians ......................... 4029.2
Worksheet E - Calculation of Reimbursement Settlement ................................................ 4030
Part A - Inpatient Hospital Services Under PPS .......................................................... 4030.1
Part B - Medical and Other Health Services ................................................................ 4030.2
Worksheet E-1 - Analysis of Payments to Providers for Services Rendered ..................... 4031
Part I - Analysis of Payments to Providers for Services Rendered .............................. 4031.1
Part II - Calculation of reimbursement Settlement for Health
Information Technology ............................................................................................ 4031.2
Worksheet E-2 - Calculation of Reimbursement Settlement - Swing Beds ...................... 4032
Worksheet E-3 - Calculation of Reimbursement Settlement ............................................. 4033
Part I - Calculation of Medicare Reimbursement Settlement Under TEFRA .............. 4033.1
Part II - Calculation of Reimbursement Settlement for Medicare Part A Services
- IPF PPS ................................................................................................................... 4033.2
Part III - Calculation of Reimbursement Settlement All Other Health Services
- IRF PPS .................................................................................................................. 4033.3
Part IV - Calculation of Reimbursement Settlement All Other Health Services
- LTCH PPS ............................................................................................................. 4033.4
Part V - Calculation of Reimbursement Settlement for Cost Providers ...................... 4033.5
Part VI - Calculation of Reimbursement Settlement for SNF PPS .............................. 4033.6
Part VII - Calculation of Reimbursement Settlement for Title V & XIX .................... 4033.7
Worksheet E-4 - Direct Graduate Medical Education and ESRD
Outpatient Direct Medical Education Costs ......................................................... 4034
Rev. 1 40-3
CHAPTER 40
Section
Financial Statements Worksheets ...................................................................................... 4040
Worksheet G ................................................................................................................ 4040.1
Worksheet G-1 ............................................................................................................. 4040.2
Worksheet G-2 ............................................................................................................. 4040.3
Worksheet G-3 ............................................................................................................. 4040.4
Worksheet H - Analysis of Provider-Based Home Health Agency Costs ......................... 4041
Worksheet H-1 - Cost Allocation HHA Statistical Basis .................................................. 4042
Worksheet H-2 - Allocation of General Service Costs to HHA Cost Centers ................... 4043
Part I - Allocation of General Service Costs to HHA Cost Centers............................. 4043.1
Part II - Allocation of General Service Cost to HHA Cost Centers - Statistical Basis 4043.2
Worksheet H-3 - Apportionment of Patient Service Costs ................................................ 4044
Part I - Computation of Lesser of Aggregate Medicare Cost Aggregate Medicare
Limitation Cost, or Per Beneficiary Cost Limitation ............................................... 4044.1
Part II - Apportionment of Cost of HHA Services Furnished by Shared Hospital
Departments .............................................................................................................. 4044.2
Worksheet H-4 - Calculation of HHA Reimbursement Settlement ................................... 4045
Part I - Computation of Lesser of Reasonable Cost or Customary Charges ................ 4045.1
Part II - Computation of HHA Reimbursement Settlement ......................................... 4045.2
Worksheet H-5 - Analysis of Payments to Provider-Based HHAs
for Services Rendered to Program Beneficiaries ............................................................ 4046
Worksheet I - Analysis of Renal Dialysis Department Costs ............................................ 4047
Worksheet I-1 - Analysis of Renal Cost ............................................................................ 4048
Worksheet I-2 - Allocation of Renal Department Costs to Treatment Modalities ............ 4049
Worksheet I-3 - Direct and Indirect Renal Dialysis Cost Allocation - Statistical Basis .... 4050
Worksheet I-4 - Computation of Average Cost Per Treatment for Outpatient
Renal Dialysis ................................................................................................................. 4051
Worksheet I-5 - Calculation of Reimbursable Bad Debts - Title XVIII, Part B ................ 4052
40-4 Rev. 1
CHAPTER 40
Section
Worksheet J-1 - Allocation of General Service Costs to CMHC Cost Centers ................ 4053
Part I - Allocation of General Service Costs to CMHC Cost Centers ......................... 4053.1
Part II - Allocation of General Service Costs to CMHC
Cost Centers -Statistical Basis ............................................................................... 4053.2
Worksheet J-2 - Computation of CMHC Provider Costs .................................................. 4054
Part I - Apportionment of CMHC Cost Centers ....................................................... 4054.1
Part II - Apportionment of Cost of CMHC Provider Services Furnished
by Shared Hospital Departments.................... ...................................................... 4054.2
Worksheet J-3 - Calculation of Reimbursement Settlement -
CMHC Provider Services .................................................................................... 4055
Worksheet J-4 - Analysis of Payments to Hospital-Based CMHC
for Services Rendered to Program Beneficiaries ................................................ 4056
Worksheet K - Analysis of Provider-Based Hospice Costs ............................................... 4057
Worksheet K-1 - Compensation Analysis - Salaries and Wage ......................................... 4058
Worksheet K-2 - Compensation Analysis - Employee Benefits (Payroll Related) ............ 4059
Worksheet K-3 - Compensation Analysis - Contracted Services/Purchased Services ...... 4060
Worksheet K-4 - Part I - Cost Allocation - General Service Costs and
Part II - Cost Allocation - Statistical Basis .......................................................... 4061
Worksheet K-5 - Allocation of General Service Costs to Hospice Cost Centers .............. 4062
Part I - Allocation of General Service Costs to Hospice Cost Centers ..................... 4062.1
Part II - Allocation of General Service Costs to Hospice
Cost Centers - Statistical Basis ............................................................................ 4062.2
Part III - Computation of the Total Hospice Shared Costs ....................................... 4062.3
Worksheet K-6 - Calculation of Per Diem Cost ................................................................ 4063
Rev. 1 40-5
CHAPTER 40
Section
Worksheet L - Calculation of Capital Payment.................................................................. 4064
Part I - Fully Prospective Method............................................................................... 4064.1
Part II Payment Under Reasonable Cost ................................................................. 4064.2
Part III - Computation of Exception Payments........................................................... 4064.3
Worksheet L-1.................................................................................................................... 4065
Part I - Allocation of Allowable Capital Costs for Extraordinary Circumstances ..... 4065.1
Part II - Computation of Program Inpatient Ancillary Service Capital Costs for
Extraordinary Circumstances ................................................................................... 4065.2
Part II - Computation of Program Inpatient Routine Service Capital Costs for
Extraordinary Circumstances..................................................................... ............. 4065.3
Worksheet M-1 - Analysis of Provider Based Rural Health Clinic Federally
Qualified Health Center Costs.................................................................... .................... 4066
Worksheet M-2 - Allocation of Overhead to RHC/FQHC Services....................................4067
Worksheet M-3 - Calculation of Reimbursement Settlement for RHC/FQHC Services ... 4068
Worksheet M-4 - Computation of Pneumococcal and Influenza Vaccine Cost ................ 4069
Worksheet M-5 - Analysis of Payments to Hospital-Based RHC/FQHC
Services Rendered to Program Beneficiaries ........................................................... 4070
Exhibit 1 - Form CMS-2552-10 Worksheets...................................................... ............... 4090
Exhibit 2 - Electronic Reporting Specifications for Form CMS-2552-10 ......................... 4095
40-6 Rev. 1
12-10 FORM CMS-2552-10 4000
4000. GENERAL
The Paperwork Reduction Act of 1995 requires that you be informed why information is collected
and what the information is used for by the government. Section 1886(f)(1) of the Social Security
Act (the Act) requires the Secretary to maintain a system of cost reporting for Prospective Payment
System (PPS) hospitals, which includes a standardized electronic format. In accordance with
§§1815(a), 1833(e), and 1861(v)(1)(A) of the Act, providers of service participating in the Medicare
program are required to submit annual information to achieve settlement of costs for health care
services rendered to Medicare beneficiaries. Also, 42 CFR 413.20(b) requires cost reports on an
annual basis. In accordance with these provisions, all hospital and health care complexes to
determine program payment must complete Form-CMS-2552-10 with a valid Office of Management
and Budget (OMB) control number. In addition to determining program payment, the data submitted
on the cost report support management of the Federal programs, e.g., data extraction in developing
cost limits, data extraction in developing and updating various prospective payment systems. The
information reported on Form CMS-2552-10 must conform to the requirements and principles set
forth in 42 CFR, Part 412, 42 CFR, Part 413, and in the Provider Reimbursement Manual, Part I.
The filing of the cost report is mandatory, and failure to do so results in all payments to be deemed
overpayment and a withhold up to 100 percent until the cost report is received. (See Pub. 15-2,
§100.) Except for the compensation information, the cost report information is considered public
record under the freedom of information act 45 CFR Part 5. The instructions contained in this
chapter are effective for hospitals and hospital health care complexes with cost reporting periods
beginning on or after May 1, 2010.
NOTE: This form is not used by freestanding skilled nursing facilities.
Worksheets are provided on an as needed basis dependent on the needs of the hospital. Not all
worksheets are needed by all hospitals. The following are a few examples of conditions for which
worksheets are needed:
Reimbursement is claimed for hospital swing beds;
Reimbursement is claimed for a hospital-based inpatient rehabilitation facility (IRF) or
inpatient psychiatric facility (IPF);
Reimbursement is claimed for a hospital-based community mental health center (CMHC);
The hospital has physical therapy services furnished by outside suppliers (applicable for
cost reimbursement and Tax Equity and Fiscal responsibility Act of 1982 (PL97248)
(TEFRA providers, not PPS); or
The hospital is a certified transplant center (CTC).
NOTE: Public reporting burden for this collection of information is estimated to average 108
hours per response, and record keeping burden is estimated to average 565 hours per
response. This includes time for reviewing instructions, searching existing data sources,
gathering and maintaining data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing the burden, to:
o Center for Medicare and Medicaid Services
7500 Security Boulevard
Mail Stop C5-03-03
Baltimore, MD 21244-1855
o The Office of Information and Regulatory Affairs
Office of Management and Budget
Washington, DC 20503
Rev. 1 40-7
4000 (Cont.) FORM CMS-2552-10 12-10
Section 4007(b) of the omnibus reconciliation Act (OBRA 1987) states that effective with cost
reporting periods beginning on or after October 1, 1989, you are required to submit your cost report
electronically unless you receive an exemption from CMS. The legislation allows CMS to delay or
waiver implementation if the electronic submission results in financial hardship (in particular for
providers with only a small percentage of Medicare volume). Exemptions are granted on a case-by-
case basis. (See Pub. 15-2, §130.3 for electronically prepared cost reports and requirements.)
In addition to Medicare reimbursement, these forms also provide for the computation of
reimbursement applicable to titles V and XIX to the extent required by individual State programs.
Generally, the worksheets and portions of worksheets applicable to titles V and XIX are completed
only to the extent these forms are required by the State program. However, Worksheets S-3 and D-1
must always be completed with title XIX data.
Each electronic system provides for the step down method of cost finding. This method provides for
allocating the cost of services rendered by each general service cost center to other cost centers,
which utilize the services. Once the costs of a general service cost center have been allocated, that
cost center is considered closed. Once closed, it does not receive any of the costs subsequently
allocated from the remaining general service cost centers. After all costs of the general service cost
centers have been allocated to the remaining cost centers, the total costs of these remaining cost
centers are further distributed to the departmental classification to which they pertain, e.g., hospital
general inpatient routine, subprovider.
The cost report is designed to accommodate a health care complex with multiple entities. If a health
care complex has more than one entity reporting (except skilled nursing facilities and nursing
facilities which cannot exceed more than one hospital-based facility), add additional lines for each
entity by subscripting the line designation. For example, subprovider, line 4, Worksheet S, Part III is
subscripted 4.00 for subprovider I and 4.01 for subprovider II.
NOTE: Follow this sequence of numbering for subscripting lines throughout the cost report.
Similarly, add lines 42.00 and 42.01 to Worksheets A; B, Parts I and II; B-1; C; D, Parts I and III;
and Worksheet L-1, Parts I and II. For multiple use worksheets such as Worksheet D-1, add
subprovider II to the existing designations in the headings and the corresponding component number.
In completing the worksheets, show reductions in expenses in parentheses ( ) unless otherwise
indicated.
4000.1 Rounding Standards for Fractional Computations.--Throughout the Medicare cost report,
required computations result in fractions. The following rounding standards must be employed for
such computations. When performing multiple calculations, round after each calculation. However,
1. Round to 2 decimal places:
a. Percentages
b. Averages, standard work week, payment rates, and cost limits
c. Full time equivalent employees
d. Per diems, hourly rates
2. Round to 3 decimal places:
a. Payment to cost ratio
40-8 Rev. 1
12-10 FORM CMS-2552-10 4000.2
3. Round to 4 decimal places:
a. Wage adjustment factor
b. Medicare SSI ratio
4. Round to 5 decimal places:
a. Payment reduction (e.g., capital reduction, outpatient cost reduction)
5. Round to 6 decimal places:
a. Ratios (e.g., unit cost multipliers, cost/charge ratios, days to days)
Where a difference exists within a column as a result of computing costs using a fraction or decimal,
and therefore the sum of the parts do not equal the whole, the highest amount in that column must
either be increased or decreased by the difference. If it happens that there are two high numbers
equaling the same amount, adjust the first high number from the top of the worksheet for which it
applies.
4000.2 Acronyms and Abbreviations.--Throughout the Medicare cost report and instructions, a
number of acronyms and abbreviations are used. For your convenience, commonly used acronyms
and abbreviations are summarized below.
ACA - Patient Protection and Affordable Care Act
A&G - Administrative and General
AHSEA - Adjusted Hourly Salary Equivalency Amount
ARRA - American Recovery and Reinvestment Act of 2009
ASC - Ambulatory Surgical Center
BBA - Balanced Budget Act
BBRA - Balanced Budget Reform Act
BIPA - Benefits Improvement and Protection Act
CAH - Critical Access Hospitals
CAPD - Continuous Ambulatory Peritoneal Dialysis
CAP-REL - Capital-Related
CBSA - Core Based Statistical Areas
CCN - CMS Certification Number (formerly known as a provider number)
CCPD - Continuous Cycling Peritoneal Dialysis
CCU - Coronary Care Unit
CFR - Code of Federal Regulations
CMHC - Community Mental Health Center
CMS - Center for Medicare and Medicaid Services
COL - Column
CORF - Comprehensive Outpatient Rehabilitation Facility
CRNA - Certified Registered Nurse Anesthetist
CT - Computer Tomography
CTC - Certified Transplant Center
DEFRA - Deficit Reduction Act of 1984
DPP - Disproportionate Patient Percentage
DRA - Deficit Reduction Act of 2005
DRG - Diagnostic Related Group
DSH - Disproportionate Share
EACH - Essential Access Community Hospital
ECR - Electronic Cost Report
EHR - Electronic Health Records
ESRD - End Stage Renal Disease
FQHC - Federally Qualified Health Center
Rev. 1 40-9
4000.3 FORM CMS-2552-10 12-10
FR - Federal Register
FTE - Full Time Equivalent
HCERA - Health Care and Education Reconciliation Act of 2010
HCRIS - Healthcare Cost Report Information System
GME - Graduate Medical Education
HHA - Home Health Agency
HIT - Health Information Technology
HMO - Health Maintenance Organization
HSR - Hospital Specific Rate
I & Rs - Interns and Residents
ICF/MR - Intermediate Care Facility for the Mentally Retarded
ICU - Intensive Care Unit
IME - Indirect Medical Education
INPT - Inpatient
IOM - Internet Only Manual
IPF - Inpatient Psychiatric Facility
IPPS - Inpatient Prospective Payment System
IRF - Inpatient Rehabilitation Facility
LDP - Labor, Delivery and Postpartum
LIP - Low Income Patient
LOS - Length of Stay
LCC - Lesser of Reasonable Cost or Customary Charges
LTCH - Long Term Care Hospital
MA - Medicare Advantage (previously known as M+C)
M+C - Medicare + Choice (also known as Medicare Part C, Medicare Advantage
and Medicare HMO)
MCP - Monthly Capitation Payment
MDH - Medicare Dependent Hospital
MED-ED - Medical Education
MIPPA - Medicare Improvements for Patients and Providers Act of 2008
MMA - Medicare Prescription Drug Improvement and Modernization Act of 2003
MRI - Magnetic Resonance Imaging
MS-DRG - Medicare Severity Diagnosis-Related Group
MSP - Medicare Secondary Payer
NF - Nursing Facility
NPI - National Provider Identifier
NPR - Notice of Program Reimbursement
OBRA - Omnibus Budget Reconciliation Act
OLTC - Other Long Term Care
OOT - Outpatient Occupational Therapy
OPD - Outpatient Department
OPO - Organ Procurement Organization
OPPS - Outpatient Prospective Payment System
OPT - Outpatient Physical Therapy
OSP - Outpatient Speech Pathology
ORF - Outpatient Rehabilitation Facility
PBP - Provider-Based Physician
PPS - Prospective Payment System
PRM - Provider Reimbursement Manual
PRO - Professional Review Organization
PRA - Per Resident Amount
PS&R - Provider Statistical and Reimbursement Report (or System)
PT - Physical Therapy
PTO - Paid Time Off
RCE - Reasonable Compensation Equivalent
RHC - Rural Health Clinic
40-14 Rev. 1
12-10 FORM CMS-2552-10 4001
RPCH - Rural Primary Care Hospitals
RT - Respiratory Therapy
RUG - Resource Utilization Group
SCH - Sole Community Hospitals
SCHIP - State Children’s Health Insurance Program
SNF - Skilled Nursing Facility
SSI - Supplemental Security Income
TEFRA - Tax Equity and Fiscal Responsibility Act of 1982
TOPPS - Transitional Corridor Payment for Outpatient Prospective Payment System
UPIN - Unique Physician Identification Number
WKST - Worksheet
NOTE: In this chapter, TEFRA refers to §1886(b) of the Act and not to the entire Tax Equity
and Fiscal Responsibility Act.
4000.3 Instructional, Regulatory and Statutory Effective Dates.--Throughout the Medicare cost
report instructions, various effective dates implementing instructions, regulations and/or statutes are
utilized.
Where applicable, at the end of select paragraphs and/or sentences the effective date (s) is indicated
in parentheses ( ) for cost reporting periods ending on or after that date, i.e., (12/31/2010). Dates
followed by a “b” are effective for cost reporting periods beginning on or after the specified date, i.e.,
(9/30/2010b). Dates followed by an “s” are effective for services rendered on or after the specified
date, i.e., (4/1/2010s). Instructions not followed by an effective date are effective retroactive back to
cost reporting periods beginning on or after 5/1/2010 (transmittal 1).
Rev. 1 40-11
4001 (Cont.) FORM CMS-2552-10 12-10
4001. RECOMMENDED SEQUENCE FOR COMPLETING FORM CMS-2552-10
Part I - Statistics, Departmental Cost Adjustments and Cost Allocations
Step Worksheet Instructions
1 S-2, Parts I & II Read §4004.1 - 4004.2. Complete entire
worksheet.
2 S-3, Parts I - V Read §4005 - 4005.5. Complete entire
worksheets.
3 S-4 Read §4006. Complete entire worksheet, if
applicable.
4 S-5 Read §4007. Complete entire worksheet, if
applicable.
5 S-6 Read §4008. Complete entire worksheet, if
applicable.
6 S-7 Read §4009. Complete entire worksheet, if
applicable.
7 S-8 Read §4010. Complete entire worksheet, if
applicable.
8 S-9, Parts I & II Read §4011. Complete entire worksheet, if
applicable.
9 A Read §4013. Complete columns 1-3, lines
1-200.
10 A-6 Read §4014. Complete, if applicable.
11 A Read §4013. Complete columns 4 and 5,
lines 1-200.
12 A-7, Parts I - III Read §4015. Complete entire worksheet.
13 A-8-1 Read §4017. Complete Parts A and B.
14 A-8-2 Read §4018. Complete, if applicable.
15 A-8-3, Parts I - VI Read §§4019 - 4019.6. Complete, if
applicable.
40-12 Rev. 1
12-10 FORM CMS-2552-10 4001 (Cont.)
Step Worksheet Instructions
16 A-8 Read §4016. Complete entire worksheet.
17 A Read §4013. Complete columns 6 and 7,
lines 1-200.
18 B, Part I & B-1 Read §4020. Complete all columns through
column 26.
19 B, Part II Read §4021. Complete entire worksheet.
20 B-2 Read §4022. Complete, if applicable.
21 L-1, Part I Read §§4065 and 4065.1. Complete, if
applicable.
Rev. 1 40-13
4001 (Cont.) FORM CMS-2552-10 12-10
Part II - Departmental Cost Distribution and Cost Apportionment
Step Worksheet Instructions
1 C Read §4023 - 4023.1. Complete entire
worksheet.
2 D, Part I Read §§4024 and 4024.1. Complete entire
worksheet.
3 D, Part III Read §§4024 and 4021.3. Complete entire
worksheet.
4 L-1, Part II Read §4065.2. Complete, if applicable.
5 D-1, Parts I & IV Read §§4025, 4025.1 and 4025.4.
Complete both parts.
6 D, Part II Read §§4024 and 4024.2. Complete entire
worksheet. A separate worksheet must be
completed for each applicable healthcare
program for each hospital and subprovider
subject to PPS or TEFRA provisions.
7 D, Part IV Read §§4024 and 4024.4. Complete entire
worksheet. A separate worksheet must be
completed for each applicable health care
program for each hospital and subprovider
subject to PPS or TEFRA provisions.
8 L-1, Part III Read §4065.3. Complete, if applicable.
9 D, Part V Read §§4024 and 4024.5. Complete entire
worksheet. A separate worksheet must be
completed for each applicable health care
program for each applicable provider
component.
10 D-3 Read §4027. Complete entire worksheet.
A separate copy of this worksheet must be
completed for each applicable health care
program for each applicable provider
component.
11 D-1, Parts I & II Read §§4025, 4025.1 and 4025.2. All
providers must complete Part I. The
hospital and subprovider(s) must complete
Part II, lines 38-39 and lines 64-69.
40-14 Rev. 1
12-10
FORM CMS-2552-10
4001 (Cont.)
Step Worksheet Instructions
12 D-1, Parts III & IV Read §§4025, 4025.3 and 4025.4. Only the
hospital-based SNF and hospital-based NF
must complete Part III, lines 70-86. All
providers must complete Part IV.
13 D-2, Parts I - III Read §§4026 - 4026.3. Complete only
those parts that are applicable. Do not
complete Part III unless both Parts I and II
are completed.
14 L, Parts I - III Read §4064. Complete applicable parts.
15 D-5, Parts I & II Read §§4029 - 4029.2. Complete entire
worksheet, if applicable.
16 D-4, Parts I - IV Read §§4028 - 4028.4. Complete only if
hospital is a certified transplant center.
17 E-4 Read §§4034. Complete entire worksheet,
if applicable.
Rev. 1
40-15
4001 (Cont.) FORM CMS-2552-10 12-10
Part III - Calculation and Apportionment of Hospital-Based Facilities
A. Title XVIII - For SNF Only Reimbursed Under PPS.--
Step Worksheet Instructions
1 E-3, Part VI Read §4033.6. If applicable, complete lines
1-15 for title XVIII SNF PPS services.
2 E-1, Part I Read §4031.1. Complete this worksheet for
title XVIII services corresponding to
Worksheet E-3, Part VI.
3 E-3, Part VI Complete the remainder of this worksheet,
lines 16-19.
B. Titles V and XIX - For Hospital, Subprovider(s), NF and ICF/MRs.--
Step Worksheet Instructions
4 E-3, Part VII Read §4033.7. If applicable, complete
entire worksheet for titles V and XIX
services. Use a separate worksheet for
each title.
C. Title XVIII - For Swing Bed-SNF and Titles V and XIX - For Swing Bed-NF.--
Step Worksheet Instructions
5 E-2 Read §4032. Complete a separate copy of
this worksheet (lines 1-19) for each
applicable health care program for each
applicable provider component. Only
entries applicable to title XVIII are made
in column 2. Complete lines 9, 13, and 17
of column 1 for titles V and XIX and
columns 1 and 2 for title XVIII.
6 E-1, Part I Read §4031.1. Complete this worksheet
for title XVIII services corresponding to
Worksheet E-2 title XVIII swing bed-SNF
only.
7 E-2 Complete the remainder of this worksheet,
lines 20-23.
40-16
Rev. 1
12-10 FORM CMS-2552-10 4001 (Cont.)
D. Title XVIII Only - For Home Health Agency.--
Step Worksheet Instructions
8 H Read §4041. Complete entire worksheet,
if applicable.
9 H-1, Parts I and II Read §4042. Complete entire worksheet, if
applicable.
10 H-2, Parts I and II Read §§4043 - 4043.2. Complete entire
worksheet, if applicable.
11 H-3, Parts I and II Read §§4044 - 4044.2. Complete entire
worksheet, if applicable.
12 H-4, Parts I and II Read §§4045 - 4045.2. Complete entire
worksheet, if applicable.
13 H-5 Read §4046. Complete entire worksheet, if
applicable.
E. Title XVIII- For ESRD.--
14 I-1 Read §§4047 - 4048. Complete a separate
worksheet for renal dialysis department(s)
and a separate worksheet for home program
dialysis department(s), if applicable.
15 I-2 Read §4049. Complete a separate
worksheet for renal dialysis department(s)
and a separate worksheet for home program
dialysis department(s), if applicable.
16 I-3 Read §4050. Complete a separate
worksheet for renal dialysis department(s)
and a separate worksheet for home program
dialysis department(s), if applicable.
17 I-4 Read §4051. Complete a separate
worksheet for renal dialysis department(s)
and a separate worksheet for home program
dialysis department(s), if applicable.
18 I-5 Read §4052. Complete only one worksheet
combining all renal dialysis departments
and home program dialysis departments, if
applicable.
Rev. 1
40-17
40-17
4001(Cont.) FORM CMS-2552-10 12-10
F. Title XVIII - For CMHC.--
Step Worksheet Instructions
19 J-1, Parts I and II Read §§4053 - 4053.2. Complete entire
worksheet, if applicable.
20 J-2, Part I Read §§4054 - 4054.1. Complete entire
worksheet, if applicable.
21 J-2, Part II Read §4054.2. Complete entire worksheet,
if applicable.
22 J-3 Read §4055. Complete entire worksheet,
if applicable.
23 J-4 Read §4056. Complete lines 1-4 for title
XVIII only.
G. Titles XVIII and XIX - For Provider Based-Hospice.--
24 K-1 Read §4058. Complete entire worksheet,
if applicable.
25 K-2 Read §4059. Complete entire worksheet,
if applicable.
26 K-3 Read §4060. Complete entire worksheet,
if applicable.
27 K Read §4057. Complete entire worksheet,
if applicable.
28 K-4, Parts I and II Read §4061. Complete both worksheets,
if applicable.
29 K-5, Parts I, II & III Read §§4062 - 4062.3. Complete all
worksheets, if applicable.
30 K-6 Read §4063. Complete entire worksheet,
if applicable.
40-18 Rev. 1
12-10 FORM CMS-2552-10 4001 (Cont.)
H. Titles V, XVIII, and XIX - For Rural Health Clinics/Federally Qualified Health
Clinics.--
Step Worksheet Instructions
31 M-1 Read §4066. Complete entire worksheet,
if applicable.
32 M-2 Read §4067. Complete entire worksheet,
if applicable.
33 M-3 Read §4068. Complete entire worksheet,
if applicable.
34 M-4 Read §4069. Complete entire worksheet,
if applicable.
35 M-5 Read §4070. Complete entire worksheet,
if applicable, for title XVIII only.
Rev. 1
40-19
4001(Cont.) FORM CMS-2552-10 12-10
Part IV - Calculation of Reimbursement Settlement
Step Worksheet Instructions
1 E, Part A Read §§4030 and 4030.1. Complete lines
1-71 of this worksheet for title XVIII for
each applicable provider component subject
to IPPS.
2 E-1, Part I Read §4031.1. Complete this worksheet for
title XVIII services corresponding to
Worksheet E, Part A.
3 E, Part A Complete the remainder of this worksheet,
lines 72-75.
4 E, Part B Read §4030.2. Complete lines 1-40 for title
XVIII for each applicable provider
component.
5 E-1, Part I Read §4031.1. Complete this worksheet for
title XVIII services corresponding to
Worksheet E, Part B.
6 E, Part B Complete the remainder of this worksheet,
lines 41-44.
7 E-3, Part I Read §§4033 and 4033.1. If applicable,
complete lines 1-18 for title XVIII for each
applicable provider component subject to
TEFRA.
8 E-1, Part I Read §4031.1. Complete this worksheet for
title XVIII services corresponding to
Worksheet E-3, Part I.
9 E-3, Part I Complete the remainder of this worksheet,
lines 19-22.
10 E-3, Part II Read §4033.2. If applicable, complete lines
1-31 for title XVIII IPF PPS.
11 E-1, Part I Read §4031.1. Complete this worksheet for
title XVIII services corresponding to
Worksheet E-3, Part II.
12 E-3, Part II Complete the remainder of this worksheet,
lines 32-35.
40-20 Rev. 1
12-10 FORM CMS-2552-10 4001 (Cont.)
Step Worksheet Instructions
13 E-3, Part III Read §4033.3. If applicable, complete lines
1-32 for title XVIII IRF PPS.
14 E-1, Part I Read §4031.1. Complete this worksheet for
title XVIII services corresponding to
Worksheet E-3, Part III.
15 E-3, Part III Complete the remainder of this worksheet,
lines 33-36.
16 E-3, Part IV Read §4033.4. If applicable, complete lines
1-22 for title XVIII LTCH PPS.
17 E-1, Part I Read §4031.1. Complete this worksheet for
title XVIII services corresponding to
Worksheet E-3, Part IV.
18 E-3, Part IV Complete the remainder of this worksheet,
lines 23-26.
19 E-3, Part V Read §4033.5. If applicable, complete lines
1-30 for title XVIII reasonable cost
reimbursed providers.
20 E-1, Part I Read §4031.1. Complete this worksheet for
title XVIII services corresponding to
Worksheet E-3, Part V.
21 E-3, Part V Complete the remainder of this worksheet,
lines 31-34.
19 E-3, Part VI Read §4033.6. If applicable, complete lines
1-15 for title XVIII reasonable cost
reimbursed providers.
20 E-1, Part I Read §4031.1. Complete this worksheet for
title XVIII services corresponding to
Worksheet E-3, Part VI.
21 E-3, Part VI Complete the remainder of this worksheet,
lines 16-19.
22 E-3, Part VII Read §4033.7. If applicable, complete the
entire worksheet for titles V and XIX
providers.
Rev. 1
40-21
4001(Cont.) FORM CMS-2552-10 12-10
Part V - Additional Data
Step Worksheet Instructions
1 G Read §4040. All providers maintaining
fund type accounting records must
complete this worksheet. Nonproprietary
providers which do not maintain fund type
records complete the General Fund column
only.
2 G-1 Read §4040.1. Complete entire worksheet.
3 G-2, Parts I & II Read §4040.2. Complete entire worksheet.
4 G-3 Read §4040.3. Complete entire worksheet.
5 S-10 Read §4012. Acute care hospitals and
CAHs complete this worksheet.
6 E-1, Part II Read §4031.2 Acute care hospitals and
CAHs complete this worksheet.
7 S, Parts I - III Read §§4003.1 - 4003.3. Complete Part III,
then complete Parts I and II.
40-22 Rev. 1
12-10 FORM CMS-2552-10 4002
4002. SEQUENCE OF ASSEMBLY
The following examples of assembly of worksheets are provided so all providers are consistent in the
order of submission of their annual cost report. All providers using Form CMS-2552-10 must adhere
to this sequence. If worksheets are not completed because they are not applicable, do not include
blank worksheets in the assembly of the cost report.
4002.1 Sequence of Assembly for Hospital Health Care Complex Participating in Medicare.--
Cost report worksheets are assembled in alpha-numeric sequence starting with the "S" series,
followed by A, B, C, etc.
Work- Health Care
Form CMS sheet Part Program (Title) Component
2552-10 S I - III
2552-10 S-2 I & II
2552-10 S-3 I - V
2552-10 S-4 XVIII Hospital-Based HHA
2552-10 S-5 XVIII Renal Dialysis Dept
2552-10 S-6 XVIII Hospital-Based CMHC
2552-10 S-7 XVIII Hospital-Based SNF
2552-10 S-8 XVIII Hospital-Based RHC/FQHC
2552-10 S-9 XVIII Hospital-Based Hospice
2552-10 S-10 XVIII Hospital & CAH
2552-10 A
2552-10 A-6
2552-10 A-7 I - III
2552-10 A-8
2552-10 A-8-1
2552-10 A-8-2
2552-10 A-8-3 I - VI
2552-10 B I
2552-10 B II
2552-10 B-1
2552-10 B-2
2552-10 C I Hospital
2552-10 C II V Hospital
2552-10 C II XIX Hospital
2552-10 D I V Hospital
2552-10 D II V Hospital
2552-10 D III V Hospital
2552-10 D IV V Hospital
2552-10 D V V Hospital
2552-10 D II V Subprovider
2552-10 D V V Subprovider
2552-10 D I XVIII Hospital
2552-10 D II XVIII Hospital
2552-10 D III XVIII Hospital
2552-10 D IV XVIII Hospital
2552-10 D V XVIII Hospital
2552-10 D II XVIII Subprovider
2552-10 D III XVIII Subprovider
Rev. 1 40-23
4002 (Cont.) FORM CMS-2552-10 12-10
Work- Health Care
Form CMS sheet Part Program (Title) Component
2552-10 D V XVIII Subprovider
2552-10 D III XVIII Swing Bed SNF
2552-10 D III XVIII SNF
2552-10 D I XIX Hospital
2552-10 D II XIX Hospital
2552-10 D III XIX Hospital
2552-10 D IV XIX Hospital
2552-10 D V XIX Hospital
2552-10 D VI XIX Hospital
2552-10 D II XIX Subprovider
2552-10 D V XIX Subprovider
2552-10 D-1 I, II, & IV V Hospital
2552-10 D-1 I, II, & IV V Subprovider
2552-10 D-1 I & III V SNF
2552-10 D-1 I & III V NF, ICF/MR
2552-10 D-1 I, II, & IV XVIII Hospital
2552-10 D-1 I, II, & IV XVIII Subprovider
2552-10 D-1 I & III XVIII SNF
2552-10 D-1 I, II, & IV XIX Hospital
2552-10 D-1 I, II, & IV XIX Subprovider
2552-10 D-1 I & III XIX SNF
2552-10 D-1 I & III XIX NF, ICF/MR
2552-10 D-2 I V, XVIII, & XIX
2552-10 D-2 II XVIII
2552-10 D-2 III XVIII
2552-10 D-3 V Hospital
2552-10 D-3 V Subprovider
2552-10 D-3 V Swing Bed SNF
2552-10 D-3 V Swing Bed NF
2552-10 D-3 V SNF
2552-10 D-3 V NF, ICF/MR
2552-10 D-3 XVIII Hospital
2552-10 D-3 XVIII Subprovider
2552-10 D-3 XVIII Swing Bed SNF
2552-10 D-3 XIX Hospital
2552-10 D-3 XIX Subprovider
2552-10 D-3 XIX Swing Bed SNF
2552-10 D-3 XIX Swing Bed NF
2552-10 D-3 XIX SNF
2552-10 D-3 XIX NF, ICF/MR
2552-10 D-4 I - IV XVIII
2552-10 D-5 I V, XVIII, & XIX
2552-10 D-5 II V, XVIII, & XIX Hospital
2552-10 D-5 II V, XVIII, & XIX Subprovider
2552-10 E A XVIII Hospital
2552-10 E B XVIII Hospital
2552-10 E-1 Part I XVIII Hospital
2552-10 E-1 Part I XVIII IPF-Subprovider
2552-10 E-1 Part I XVIII IRF-Subprovider
2552-10 E-1 Part I XVIII Subprovider
2552-10 E-1 Part I XVIII Swing Bed SNF
2552-10 E-1 Part I XVIII SNF
40-24 Rev. 1
12-10 FORM CMS-2552-10 4002.2 (Cont.)
Work- Health Care
Form CMS sheet Part Program (Title) Component
2552-10 E-1 II HIT Hospital and CAH
2552-10 E-2 V Swing Bed SNF
2552-10 E-2 V Swing Bed NF
2552-10 E-2 XVIII Swing Bed SNF
2552-10 E-2 XIX Swing Bed SNF
2552-10 E-2 XIX Swing Bed NF
2552-10 E-3 I - V XVIII Hospital
2552-10 E-3 I - III or V XVIII Subprovider
2552-10 E-3 IV XVIII LTCH
2552-10 E-3 VI XVIII SNF
2552-10 E-3 VII V & XIX Hospital
2552-10 E-3 VII V & XIX NF, ICF/MR
2552-10 E-3 VII V & XIX SNF
2552-10 G
2552-10 G-1
2552-10 G-2
2552-10 G-3
2552-10 H Hospital-based HHA
2552-10 H-1 I & II Hospital-based HHA
2552-10 H-2 I & II Hospital-based HHA
2552-10 H-3 I & II V, XVIII, & XIX Hospital-based HHA
2552-10 H-4 I & II V, XVIII, & XIX Hospital-based HHA
2552-10 H-5 XVIII Hospital-based HHA
2552-10 I-1 - I-5 Renal Dialysis
2552-10 I-1 - I-5 Home Program Dialysis
2552-10 J-1 - J-2 I & II CMHC
2552-10 J-3 V, XVIII, & XIX CMHC
2552-10 J-4 XVIII CMHC
2552-10 K Hospital-based Hospice
2552-10 K-1 Hospital-based Hospice
2552-10 K-2 Hospital-based Hospice
2552-10 K-3 Hospital-based Hospice
2552-10 K-4 I & II Hospital-based Hospice
2552-10 K-5 I - III Hospital-based Hospice
2552-10 K-6 XVIII, XIX Hospital-based Hospice
2552-10 L I - III V, XVIII, & XIX Hospital
2552-10 L I - III V, XVIII, & XIX Subprovider
2552-10 L-1 I Hospital
2552-10 L-1 II V, XVIII, & XIX Hospital
2552-10 L-1 III V, XVIII, & XIX Hospital
2552-10 L-1 III V, XVIII, & XIX Subprovider
2552-10 M-1 V, XVIII, &XIX Hospital-based RHC/FQHC
2552-10 M-2 V, XVIII, &XIX Hospital-based RHC/FQHC
2552-10 M-3 V, XVIII, &XIX Hospital-based RHC/FQHC
2552-10 M-4 V, XVIII, &XIX Hospital-based RHC/FQHC
2552-10 M-5 V, XVIII, &XIX Hospital-based RHC/FQHC
Rev. 1 40-25
4003 FORM CMS-2552-10 12-10
4003. WORKSHEET S - HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX
COST REPORT CERTIFICATION AND SETTLEMENT SUMMARY
4003.1 Part I - Cost Report Status.--This section is to be completed by the provider and fiscal
intermediary (FI)/Medicare administrative contractor (MAC) (hereafter referred to as contactor) as
indicated on the worksheet.
The provider must check the appropriate box to indicate whether this cost report is being filed
electronically or manually. For electronic filing, indicate on the appropriate line the date and time
corresponding to the creation of the electronic file. This date and time remains as an identifier for
the file by the contractor and is archived accordingly. This file is your original submission and is not
to be modified.
The contractor must indicate in the appropriate box whether this is the initial cost report (first cost
report for the provider number, for this contractor), final report due to termination, or if this is a
reopening. If it is a reopening, indicate the number of times the cost report has been reopened. The
contractor should also indicate in Healthcare Cost Report Information System (HCRIS) on line 1,
column 1 of worksheet S the following codes that correspond to the filing status of the cost report:
1=As submitted; 2=Amended; 3=Settled; and 4=Reopened.
The contractor indicates general information about this cost report. This data is submitted as alpha-
numeric data in the HCRIS file as follows (this does not appear on the cost report):
Line 1, Column 1--Enter the cost report status code of 1 for as submitted, 2 for amended, 3 for
settled, and 4 for reopened. (Refer to section 10.3 of Chapter 8 of Office of Financial Management
settled Manual Pub. 100-06.)
Line 1, Column 2--If this is a reopened cost report, enter the number of times the cost report has been
reopened. This field should only be completed if the cost report status code in line 1, column 1 is 4.
Line 2, Column 1--Enter the date (mm/dd/yyyy) an accepted cost report was received from the
provider.
Line 2, Column 2--Enter the 5 position Contractor Number.
Line 2, Column 3--Enter I for initial, enter F for final, or enter N for neither. An initial report is the
very first cost report the contractor submits for a particular provider number. It may not be the first
cost report ever for this provider number which may have been handled by a previous contractor, but
it would be the initial cost report for the new contractor.
A final report is the terminating cost report for a particular provider number. If, for example, the
provider terminated in 2004, but the 1998 cost report was reopened and submitted after the
submission of the 2004 report, the 2004 report is still considered the final report for the provider.
If a provider does have a cost report that is both an initial and final report for a particular year then
this field should contain an I if the cost report is an as submitted report, and an F if the cost report is
a settled report.
Line 2, Column 4--Enter the Notice of Program Reimbursement (NPR) date (mm/dd/yyyy). The
NPR date must be present if the cost report status code is 3 or 4.
4003.2 Part II - Certification.--This certification is read, prepared, and signed by the an officer or
administrator of the provider after the cost report has been completed in its entirety.
4003.3 Part III - Settlement Summary.--Enter the balance due to or due from the applicable
program for each applicable component of the complex. Transfer settlement amounts as follows:
40-26 Rev. 1
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FROM__________
Hospital/ Title XVIII Title XVIII
Hospital Component Title V Part A Part B HIT Title XIX
Hospital Wkst. E-3, Wkst. E, Wkst. E, Wkst. E-1, Wkst. E-3,
Part VII, Part A, Part B, Part II, Part VII,
line 35 line 74 line 43 line 32 line 35
or
Wkst. E-3,
Part I,
line 21
or
Wkst. E-3,
Part IV,
line 25
or
Wkst. E-3,
Part V,
line 33
Subprovider-IPF Wkst. E-3, Wkst. E-3, Wkst. E Wkst. E-3,
Part VII, Part II, Part B, Part VII,
line 35 line 34 line 43 line 35
Subprovider-IRF Wkst. E-3 Wkst. E-3, Wkst. E Wkst E-3,
Part VII, Part III, Part B, Part VII
line 35 line 35 line 43 line 35
Subprovider-Other Wkst. E series as applicable.
Swing Bed - SNF Wkst. E-2, Wkst. E-2, Wkst. E-2, Wkst. E-2,
col. 1, col. 1, col. 2, col. 1,
line 22 line 22 line 22 line 22
Swing Bed - NF Wkst. E-2, N/A N/A Wkst. E-2
col. 1, col. 1,
line 22 line 22
SNF Wkst. E-3, Wkst. E-3, Wkst. E, Wkst. E-3,
Part VII, Part VI, Part B, Part VII,
Line 35 line 18 line 43 line 35
NF, ICF/MR Wkst. E-3, N/A N/A Wkst. E-3,
Part VII, Part VII
Line 35 line 35
Rev. 1 40-27
12-10 FORM CMS-2552-10 4003.2 (Cont.)
FROM__________
Hospital/ Title XVIII Title XVIII
Hospital Component Title V Part A Part B Title XIX
Home Health Wkst. H-4, Wkst. H-4, Wkst. H-4, Wkst. H-4,
Agency Part II, Part II, Part II, Part I,
sum of cols. col. 1, col. 2, sum of cols.
1&2, line 34 line 34 line 34 1 & 2, line 34
Outpatient Wkst. N/A Wkst. Wkst.
Rehabilitation J-3, J-3, J-3,
Providers line 29 line 29 line 29
Rural Health Clinic/ Wkst. N/A Wkst. Wkst.
Federally Qualified M-3 M-3 M-3
Health Clinic line 29 line 29 line 29
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FORM CMS-2552-10
4004
4004. WORKSHEET S-2 - HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX
IDENTIFICATION DATA
This worksheet consists of two parts:
Part I - Hospital and Hospital Health Care Complex Identification Data
Part II - Hospital and Hospital Health Care Complex Reimbursement Questionnaire
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 of question.
Line Descriptions
Lines 1 and 2--Enter the street address, post office box (if applicable), the city, State, zip code, and
county of the hospital.
Lines 3 through 17--Enter on the appropriate lines and columns indicated the component names,
CMS certification numbers (CCN), core based statistical area (CBSA) number, provider type, and
certification dates of the hospital and its various components, if any. Indicate for each health care
program (titles V, XVIII, or XIX) the payment system applicable to the hospital and its various
components by entering P, T, O, or N in the appropriate column to designate PPS, TEFRA, OTHER
(CAHs or cost reimbursement), or NOT APPLICABLE, respectively.
Column 4--Indicate, as applicable, the number listed below which best corresponds with the type of
services provided.
1 = General Short Term 6 = Religious Non-Medical Health Care Institution
2 = General Long Term 7 = Children
3 = Cancer 8 = Alcohol and Drug
4 = Psychiatric 9 = Other
5 = Rehabilitation
If your hospital services various types of patients, indicate "General - Short Term" or "General -
Long Term," as appropriate.
NOTE: Long term care hospitals are hospitals organized to provide long term treatment programs
with lengths of stay greater than 25 days. Some hospitals may be certified as other than long term
care hospitals, but also have lengths of stay greater than 25 days.
If your hospital cares for only a special type of patient (such as cancer patients), indicate the special
group served. If you are not one of the hospital types described in items 1 through 8 above, indicate
9 for "Other".
Line 3--This is an institution which meets the requirements of §1861(e) or §1861(mm)(1) of the Act
and participates in the Medicare program or is a Federally controlled institution approved by CMS.
Line 4--The distinct part inpatient psychiatric facility (IPF) is a portion of a general hospital which
has been issued a subprovider CCN because it offers a clearly different type of service from the
remainder of the hospital with such services reimbursed under inpatient psychiatric PPS. See CMS
Pub. 15-1, chapter 23, for a complete explanation of separate cost entities in multiple facility
hospitals. While an excluded unit (excluded from IPPS) in a hospital subject to IPPS may not meet
the definition of a subprovider, treat it as a subprovider for cost reporting purposes.
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Line 5--The distinct part inpatient rehabilitation facility (IRF) is a portion of a general hospital which
has been issued a subprovider CCN because it offers a clearly different type of service from the
remainder of the hospital with such services reimbursed under inpatient rehabilitation PPS. See
CMS Pub. 15-1, chapter 23, for a complete explanation of separate cost entities in multiple facility
hospitals. While an excluded unit (excluded from IPPS) in a hospital subject to IPPS may not meet
the definition of a subprovider, treat it as a subprovider for cost reporting purposes.
Line 6--This is a portion of a general hospital which has been issued a subprovider CCN because it
offers a clearly different type of service from the remainder of the hospital. See CMS Pub. 15-1,
chapter 23, for a complete explanation of separate cost entities in multiple facility hospitals. While
an excluded unit (excluded from IPPS)in a hospital subject to IPPS may not meet the definition of a
subprovider, treat it as a subprovider for cost reporting purposes. If you have more than one
subprovider, subscript this line.
Line 7--Medicare swing-bed services are paid under the SNF PPS system (indicate payment system
as “P”). CAHs are reimbursed on a cost basis for swing-bed services and should indicate “O” as the
payment system. Rural hospitals with fewer than 100 beds may be approved by CMS to use these
beds interchangeably as hospital and skilled nursing facility beds with payment based on the specific
care provided. This is authorized by §1883 of the Act. (See CMS Pub. 15-1, §§2230-2230.6.)
Line 8--Swing bed-NF services are not payable under the Medicare program but are payable under
State Medicaid programs if included in the Medicaid State plan. This is a rural hospital with fewer
than 100 beds that has a Medicare swing bed agreement approved by CMS and that is approved by
the State Medicaid agency to use these beds interchangeably as hospital and other nursing facility
beds, with payment based on the specific level of care provided. This is authorized by §1913 of the
Act.
Line 9--This is a distinct part skilled nursing facility that has been issued an SNF identification
number and which meets the requirements of §1819 of the Act. For cost reporting periods beginning
on or after October 1, 1996, a complex cannot contain more than one hospital-based SNF or hospital-
based NF.
Line 10--This is a distinct part nursing facility which has been issued a separate identification
number and which meets the requirements of §1905 of the Act. (See 42 CFR 442.300 and 42 CFR
442.400 for standards for other nursing facilities, for other than facilities for the mentally retarded,
and for facilities for the mentally retarded.) If your State recognizes only one level of care, i.e.,
skilled, do not complete any lines designated as NF and report all activity on the SNF line for all
programs. The NF line is used by facilities having two levels of care, i.e., either 100 bed facility all
certified for NF and partially certified for SNF or 50 beds certified for SNF only and 50 beds
certified for NF only. The contractor will reject a cost report attempting to report more than one
nursing facility.
If the facility operates an Intermediate Care Facility/Mental Retarded (ICF/MR) subscript line 10 to
10.01 and enter the data on that line. Note: Subscripting is allowed only for the purpose of
reporting an ICF/MR.
Line 11--This is any other hospital-based facility not listed above. The beds in this unit are not
certified for titles V, XVIII, or XIX.
Line 12--This is a distinct part HHA that has been issued an HHA identification number and which
meets the requirements of §§1861(o) and 1891 of the Act. If you have more than one hospital-based
HHA, subscript this line, and report the required information for each HHA.
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Line 13--This is a distinct entity that operates exclusively for the purpose of providing surgical
services to patients not requiring hospitalization and which meets the conditions for coverage in 42
CFR 416, Subpart B. The ASC operated by a hospital must be a separately identifiable entity which
is physically, administratively, and financially independent and distinct from other operations of the
hospital. (See 42 CFR 416.30(f).) Under this restriction, hospital outpatient departments providing
ambulatory surgery (among other services) are not eligible. (See 42 CFR 416.120(a).)
Line 14--This is a distinct part hospice and separately certified component of a hospital which meets
the requirements of §1861(dd) of the Act. No payment designation is required in columns 6, 7, and
8.
Lines 15 and 16--Enter the applicable information for rural health clinics (RHCs) on line 15 and for
federally qualified health clinics (FQHCs) on line 16. These lines are used by RHCs and/or FQHCs
which have been issued a provider number and meet the requirements of §1861(aa) of the Act. If
you have more than one RHC, report them on subscripts of line 15. If you have more than one
FQHC, report them on subscripts of line 16. Report the required information in the appropriate
column for each. (See Exhibit 2, Table 4) RHCs and FQHCs may elect to file a consolidated cost
report pursuant to CMS Pub. 100-4, chapter 9, §30.8. Do not subscript this line if you elect to file
under the consolidated cost reporting method. See section 4008.2 for further instructions.
Line 17--This line is used by hospital-based community mental health centers (CMHCs). Subscript
this line as necessary to accommodate multiple CMHCs. (See Exhibit 2, Table 4, Part III)
Line 18--If this facility operates a renal dialysis facility (CCN 2300-2499), a renal dialysis satellite
(CCN 3500-3699), and/or a special purpose renal dialysis facility (CCN 3700-3799), enter in column
2 the applicable CCN. Subscript this line as applicable.
Line 19--For any component type not identified on lines 3 through 19, enter the required information
in the appropriate column. This includes, but is not limited to comprehensive outpatient
rehabilitation facilities (CORFs), outpatient physical therapy (OPT) providers , outpatient occupation
therapy (OOT) providers, and/or outpatient speech pathology (OSP) clinics.
Line 20--Enter the inclusive dates covered by this cost report. In accordance with 42 CFR 413.24(f),
you are required to submit periodic reports of your operations which generally cover a consecutive
12 month period of your operations. (See CMS Pub. 15-2, §§102.1-102.3 for situations where you
may file a short period cost report.)
Line 21--Indicate the type of control or auspices under which the hospital is conducted as indicated:
1 = Voluntary Nonprofit, Church 8 = Governmental, City-County
2 = Voluntary Nonprofit, Other 9 = Governmental, County
3 = Proprietary, Individual 10 = Governmental, State
4 = Proprietary, Corporation 11 = Governmental, Hospital District
5 = Proprietary, Partnership 12 = Governmental, City
6 = Proprietary, Other 13 = Governmental, Other
7 = Governmental, Federal
Line 22--Does your facility qualify and is it currently receiving payments for disproportionate share
hospital adjustment, in accordance with 42 CFR 412.106? Enter “Y” for yes or “N” for no. Is this
facility subject to the provisions of 42 CFR 412.106(c)(2) (Pickle Amendment hospitals)? Enter in
column 2 “Y” for yes or “N” for no.
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Line 23--Indicate in column 1 the method used to capture Medicaid (title XIX) days reported on
Worksheet S-3, Part I, line 32, column 7 during the cost reporting period by entering a “1” if days are
based on the date of admission, “2” if days are based on census days (also referred to as the day
count), or “3” if the days are based on the date of discharge. Is the method of identifying the days in
the current cost reporting period different from the method used in the prior cost reporting period?
Enter in column 2 “Y” for yes or “N” for no.
Line 24--If the response to line 22 is “yes”, and this provider is an IPPS, enter the in-State Medicaid
paid days in column 1, the in State Medicaid eligible but unpaid days in column 2, the out of State
Medicaid paid days in column 3, the out of State Medicaid eligible but unpaid days in column 4,
Medicaid HMO days in column 5, and other Medicaid days in column 6.
Line 25--If the response to line 22 is “yes”, and this provider is an IRF, enter the in-State Medicaid
paid days in column 1, the in State Medicaid eligible days in column 2, the out of State Medicaid
paid days in column 3, the out of State Medicaid eligible days in column 4, Medicaid HMO days in
column 5, and other Medicaid days in column 6.
Line 26--For the Standard Geographic classification (not wage), what is your status at the beginning
of the cost reporting period. Enter “1” for urban or “2” for rural.
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.
Line 35--If this is a sole community hospital (SCH), enter the number of periods (0, 1 or 2) within
this cost reporting period that SCH status was in effect. Enter the beginning and ending dates of
SCH status on line 36. Subscript line 36 if more than 1 period is identified for this cost reporting
period and enter multiple dates. Multiple dates are created where there is a break in the date between
SCH status, i.e., for calendar year provider SCH status dates are 1/1/2010-6/30/2010 and 9/1/2010-
12/31/2010.
Line 37--If this is a Medicare dependent hospital (MDH), enter the number of periods within this
cost reporting period that MDH status was in effect. Enter the beginning and ending dates of MDH
status on line 38. Subscript line 38 if more than 1 period is identified for this cost reporting period
and enter multiple dates.
Lines 39 - 44--Reserved for future use.
Line 45--Does your facility qualify and receive capital payments for disproportionate share in
accordance with 42 CFR 412.320? Enter "Y" for yes and "N" for no. If you are eligible as a result of
the Pickle amendment, enter "P" instead of "Y." Only new providers certified prior to October 1,
2001 shall complete this line.
Line 46--Are you eligible for the special exception payment pursuant to 42 CFR 412.348(g)? Enter
“Y” for yes or “N” for. If yes, complete Worksheets L, Part III and L-1.
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Line 47--Is this a new hospital under 42 CFR 412.300 (PPS capital)? Enter “Y” for yes or “N” for
no in column 1. If yes, do you elect full federal capital payments. Enter “Y” for yes or “N” for no in
column 2.
Lines 48 - 54--Reserved for future use.
NOTE: CAHs complete question 107 in lieu of questions 55, 56, and 57.
Line 55--Is this a teaching hospital? Enter “Y” for yes or “N” for no.
Line 56--If line 55 is yes, is the teaching program approved in accordance with CMS Pub. 15-1,
chapter 4? Enter “Y” for yes or “N” for no.
Line 57--If line 56 is yes and this is the first cost reporting period in which you are training residents
in approved programs and the residents were on duty during the first month of the cost reporting
period, enter “Y” for yes and complete Worksheet E-4 or “N” for no and complete Worksheets D,
Parts III and IV and D-2, Part II, if applicable.
Line 58--As a teaching hospital, did you elect cost reimbursement for teaching physicians as defined
in CMS Pub. 15-1, §2148? Enter “Y” for yes or “N” for no. If yes, complete Worksheet D-5.
Line 59--Are you claiming costs of intern & resident in unapproved programs on line 100, column 7,
of Worksheet A? Enter “Y” for yes or “N” for no. If yes, complete worksheet D-2, Part I.
Line 60--Has your 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 or “N” for
no in the applicable column. (Impacts Worksheet E, Part A; and E-4.)
Line 61--Has your facility received additional direct GME (column 1) resident cap slots or IME
(column 2) resident cap slots under 42 CFR 413.79(c)(4) or 42 CFR 412.105(f)(1)(iv)(C)? Enter
“Y” for yes or “N” for no in the applicable column. (Impacts Worksheet E-4.)
Line 62--Are you claiming nursing school and allied health costs for a program that meets the
provider-operated criteria under 42 CFR 413.85? Enter “Y” for yes or “N” for no. If yes, you must
identify such costs in the applicable column(s) of Worksheet D, Parts III and IV to separately identify
nursing and allied health (paramedical education) from all other medical education costs.
Lines 63 - 69--Reserved for future use.
Line 70--Are you an IPF or do you contain an IPF subprovider? Enter in column 1 “Y” for yes or
“N” for no.
Line 71--If this facility is an IPF or contains an IPF subprovider (response to line 70, column 1 is
“Y” for yes), were residents training in this facility in the most recent cost report filed on or
before November 15, 2004? Enter in column 1 “Y” for yes or “N” for no. Is the facility training
residents in new teaching programs in accordance with §412.424(d)(1)(iii)(D)? Enter in column 2
“Y” for yes or “N” for no. (Note: questions 1 and 2 must have opposite answers, i.e., if column 1 is
“Y”, then column 2 must be “N” and vice versa; columns 1 and 2 cannot be “Y” simultaneously,
columns 1
and 2 can be “N” simultaneously.) If yes, enter a “1”, “2”, or “3”, respectively, in column 3 to
correspond to the I&R academic year in the first 3 program years of the first new program’s
existence that begins during the current cost reporting period. If the current cost reporting period
Rev. 1
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FORM CMS-2552-10
12-10
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 teaching program’s existence, enter the number “5” in
column 3.
Lines 72 - 74--Reserved for future use.
Line 75--Are you an IRF or do you contain an IRF subprovider? Enter in column 1 “Y” for yes and
“N” for no.
Line 76--If this facility is an IRF or contains an IRF subprovider (response to line 75, column 1 is
“Y” for yes), did the facility train residents in teaching programs in the most recent cost reporting
period ending on or before November 15, 2004? Enter in column 1 “Y” for yes or “N” for no. Is
the facility training residents in new teaching programs in accordance with FR, Vol. 70, No. 156,
page 47929 dated August 15, 2005? Enter in column 2 “Y” for yes or “N” for no. (Note: questions 1
and 2 must have opposite answers, i.e., if column 1 is “Y”, then column 2 must be “N” and vice
versa; columns 1 and 2 cannot be “Y” simultaneously, columns 1 and 2 can be “N” simultaneously.)
If yes, enter a “1”, “2”, or “3”, respectively, in column 3 to correspond to the I&R academic year in
the first 3 program years of the first new program’s existence that begins during the current cost
reporting period. If the current cost reporting period 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
teaching program’s existence, enter the number “5” in column 3.
Lines 77 - 79--Reserved for future use.
Line 80--Are you a Long Term Care Hospital (LTCH)? Enter in column 1 “Y” for yes and “N” for
no. LTCHs can only exist as independent /freestanding facilities.
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 86--Have you established a new “Other” subprovider (excluded unit) under 42 CFR 413.40
(f)(1)(i)? Enter “Y” for yes or "N" for no in column 1. If there is more than one subprovider,
subscript this line.
Line 87 - 89--Reserved for future use.
Lines 90--Do you provide title V and/or XIX inpatient hospital services? Enter "Y" for yes or "N"
for no in the applicable column.
Line 91--Is this hospital reimbursed for title V and/or XIX through the cost report in full or in part?
Enter “Y” for yes or “N’ for no in the applicable column.
Line 92--If all of the nursing facility beds are certified for title XIX, and there are also title XVIII
certified beds (dual certified), are any of the title XVIII beds occupied by title XIX patients? Enter
“Y” for yes or “Nfor no in the applicable column. You must complete a separate Worksheet D-1
for title XIX for each level of care.
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Line 93--Do you operate an ICF/MR facility for purposes of title XIX? Enter “Y” for yes or “N” for
no.
Line 94--Does title V and/or XIX reduce capital costs? Enter “Y” for yes or “N” for no in the
applicable column.
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.
Line 105--If this hospital qualifies as a critical access hospital (CAH), enter “Y” for yes in column 1.
Otherwise, enter “N” for no, and skip to line 108. (See 42 CFR 485.606ff.)
Line 106--If this facility qualifies as a CAH, has it elected the all-inclusive method of payment for
outpatient services? Enter “Y” for yes or “N” for no. If yes, an adjustment for the professional
component is still required on Worksheet A-8-2.
NOTE: If the facility elected the all-inclusive method for outpatient services, professional
component amounts should be excluded from deductible and coinsurance amounts and should not be
included on E-1.
Line 107--If this facility qualifies as a CAH, is it eligible for 101 percent reasonable cost
reimbursement for I&R in approved training programs? Enter a “Y” for yes or an “N” for no in
column 1. If yes, the GME elimination is not made on Worksheet B, Part I, column 25 and the
program would be cost reimbursed. If yes, complete Worksheet D-2, Part II.
If this facility qualifies as a CAH, do I&R in approved medical education programs train in the
CAH’s excluded IPF and/or IRF unit? Enter a “Y” for yes or an “N” for no in column 2. If yes,
complete Worksheet E-4. CAHs are reimbursed for GME in subproviders on worksheet E-4; and are
reimbursed for GME in the rest of the CAH at 101 percent of reasonable cost. The CAH must
maintain adequate documentation to support the FTE count and time spent for the excluded IPF
and/or IRF units.
Line 108--Is this a rural hospital qualifying for an exception to the certified registered nurse
anesthetist (CRNA) fee schedule? (See CFR 412.113(c).) Enter “Y” for yes in column 1. Otherwise,
enter “N” for no.
Line 109--If this hospital qualifies as a critical access hospital (CAH) (response to line 105 is yes) or
is a cost reimbursed provider, are therapy services provided by outside suppliers? Enter “Y” for yes
or “N” for no under the corresponding physical, occupational, speech and/or respiratory therapy
services as applicable in columns 1 through 4.
Lines 110 - 114--Reserved for future use.
Line 115--If this is an all inclusive rate provider (see instructions in CMS Pub. 15-1, §2208), enter
the applicable method (A, B, or E only) in column 2.
Line 116--Are you classified as a referral center? Enter “Y” for yes or “N” for no. See 42 CFR
412.96.
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Line 117--Are you legally required to carry malpractice insurance? Enter “Y” for yes or “N” for no.
Malpractice insurance, sometimes referred to as professional liability insurance, is insurance
purchased by physicians and hospitals to cover the cost of being sued for malpractice.
Line 118--Is the malpractice insurance a claims-made or occurrence policy? A claims-made
insurance policy covers claims first made (reported or filed) during the year the policy is in force for
any incidents that occur that year or during any previous period during which the insured was
covered under a "claims-made" contract. The occurrence policy covers an incident occurring while
the policy is in force regardless of when the claim arising out of that incident is filed. If the policy is
claims-made, enter 1. If the policy is occurrence, enter 2.
Line 119--What is the liability limit for the malpractice insurance policy? Enter in column 1 the
monetary limit per lawsuit or enter in column 2 the monetary limit per policy year. A liability limit
refers to the maximum sum of money an insurance company will pay per lawsuit and per policy
year. For example, a standard liability limit for physician professional liability is $1 million in
damages per lawsuit and a total of $3 million for all lawsuits during the policy year (often referred to
as $1 million/$3 million).
Line 120--If this is an SCH (or EACH), regardless of bed size, that qualifies for the outpatient hold
harmless provision in ACA, section 3121, enter “Y” for yes or “N” for no in column 1. If this is
rural hospital with 100 or fewer beds that qualifies for the outpatient hold harmless provision in
ACA, section 3121, enter “Y” for yes or “N” for no in column 2. These responses impact the TOPs
calculation on Worksheet E. Part B, line 8.
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 126--If this is a Medicare certified kidney transplant center, enter the certification date in
column 1 and termination date in column 2. Also complete Worksheet D-4.
Line 127--If this is a Medicare certified heart transplant center, enter the certification date in column
1 and termination date in column 2. Also complete Worksheet D-4.
Line 128--If this is a Medicare certified liver transplant center, enter the certification date in column
1 and termination date in column 2. Also complete Worksheet D-4.
Line 129--If this is a Medicare certified lung transplant center, enter the certification date in column
1 and termination date in column 2. Also, complete Worksheet D-4.
Line 130--If Medicare pancreas transplants are performed, enter the more recent date of July 1, 1999
(coverage of pancreas transplants) or the certification date in column 1 for kidney transplants and
termination date in column 2. Also, complete Worksheet D-4.
Line 131--If this is a Medicare certified intestinal transplant center enter the certification date in
column 1 and termination date in column 2. Also, complete Worksheet D-4.
Line 132--If this is a Medicare certified islet transplant center enter the certification date in column 1
and termination date in column 2. Also, complete Worksheet D-4.
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Line 133--Use this line if your facility contains a Medicare certified transplant center not specifically
identified on lines 126 through 132. Enter the certification date in column 1 and termination date in
column 2. Subscript this line as applicable and complete a separate Worksheet D-4 for each
Medicare certified transplant center type.
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.
Lines 135 - 139--Reserved for future use.
Line 140--Are there any related organization or home office costs claimed as defined in CMS Pub.
15-1, chapter 10? Enter “Y” for yes or “N” for no in column 1. If yes, complete Worksheet A-8-1.
If this facility is part of a chain and you are claiming home office costs, enter in column 2 the home
office chain number; and enter the chain name, home office number, contractor number, street
address, post office box (if applicable), the city, State, zip code of the home office on lines 141
through 143. Also, enter on line 141, column 2, the contractor name, who receives the Home Office
Cost Statement and in column 3, the contractor number. See CMS Pub. 15-1, §2150 for a definition
of a chain organization.
Line 141--Enter the name of the Home Office.
Line 142--Enter the street address and P. O. Box (if applicable) of the Home Office.
Line 143--Enter the city, State and zip code of the Home Office.
Line 144--Are provider based physicians' costs included in Worksheet A? Enter “Y” for yes or “N”
for no. If yes, complete Worksheet A-8-2.
Line 145--If you are claiming costs for renal services on Worksheet A, are they inpatient services
only? Enter “Y” for yes or “N” for no. If yes, do not complete Worksheet S-5 and the Worksheet I
series.
Line 146--Have you changed your cost allocation methodology from the previously filed cost report?
Enter “Y” for yes or “N” for no. If yes, enter the approval date in column 2.
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.
Line 149--Was there a change to the simplified cost finding method? Enter “Y” for yes or “N”
for no.
Lines 150 - 154--Reserved for future use.
Lines 155 - 161--If you are a provider (public or non public) that qualifies for an exemption from the
application of the lower of cost or charges as provided in 42 CFR 413.13, indicate the component
and/or services that qualify for the exemption by entering in the corresponding box a “Y” for yes, if
you qualify for the exemption or an “N” for no if you do not qualify for the exemption. Subscript as
needed for additional components.
Lines 162 - 164--Reserved for future use.
Line 165--Is the hospital part of a multi-campus hospital that has one or more campuses in different
CBSAs? Enter “Y” for yes or “N” for no.
Rev. 1
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4004.1 (Cont.)
FORM CMS-2552-10
12-10
Line 166--If you responded “Y” for yes to question 165, enter information for each campus
(including the main campus) as follows: name in column 0, county in column 1, State in column 2,
zip code in column 3, CBSA in column 4, and the FTE count for this campus in column 5. If
additional campuses exist, subscript this line as necessary.
Line 167--Is this hospital/campus a meaningful user of electronic health record (EHR) technology in
accordance section 1886(n) of the Social Security Act as amended by the section 4102 of the
American Recovery and Reinvestment Act (ARRA) of 2009? Enter “Y” for yes or “N” for no.
Line 168--If this provider is a CAH (line 105 is “Y” for yes) and is also a meaningful EHR
technology user (line 167 is “N” for yes) enter, if applicable, the reasonable acquisition cost incurred
in the current cost reporting period for depreciable assets such as computers and associated hardware
and software necessary to administer certified EHR technology. See Federal Register, Vol. 75,
number 144, dated July 28, 2010, pages 44573.
Line 169--If this is a §1886(d) provider that responded “N” for no to question 105 and “Yfor yes to
question 167, enter the transition factor to be used in the calculation of your HIT incentive payment.
See Federal Register, Vol. 75, number 144, dated July 28, 2010, pages 44458-60. The Transition
Factor equals:
If a hospital first becomes a meaningful EHR user in fiscal year 2011, 2012 or 2013
The first year transition factor is 1.00
The second year transition factor is 0.75
The third year transition factor is 0.50
The fourth year transition factor is 0.25
Any succeeding transition year is 0
If a hospital first becomes a meaningful EHR user in fiscal year 2014
The first year transition factor is 0.75
The second year transition factor is 0.50
The third year transition factor is 0.25
Any succeeding transition year is 0
If a hospital first becomes a meaningful EHR user in fiscal year 2015
The first year transition factor is 0.50
The second year transition factor is 0.25
Any succeeding transition year is 0
40-38
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12-10 FORM CMS-2552-10 4002.2
4004.2 Part II - Hospital and Hospital Health Care Complex Reimbursement Questionnaire.--
The information required on Part II of this worksheet (formerly Form CMS-339) must be completed
by all hospitals submitting cost reports to the Medicare contractor under Title XVIII of the Social
Security Act (hereafter referred to as “The Act”). Its purpose is to assist you in preparing an
acceptable cost report, to minimize the need for direct contact between you and your contractor, and
to expedite review and settlement of cost reports. It is designed to answer pertinent questions about
key reimbursement concepts displayed in the cost reports and to gather information necessary to
support certain financial and statistical entries on the cost report. The questionnaire is a tool used in
arriving at a prompt and equitable settlement of your cost report.
Where the instructions for this worksheet direct you to submit documentation/information, mail or
otherwise transmit to the contractor immediately, after submission of the ECR. The contractor has
the right under §§1815(a) and 1883(e) of the Act to request any missing documentation required to
complete the desk review.
To the degree that the information in the questionnaire constitutes commercial or financial
information which is confidential and/or is of a highly sensitive personal nature, the information will
be protected from release under the Freedom of Information Act. If there is any question about
releasing information, the contractor should consult with the CMS Regional Office.
NOTE: The responses on all lines are Yes or No unless otherwise indicated. If in accordance with
the following instructions, you are requested to submit documentation, indicate the line
number for each set of documents you submit.
Line Descriptions
Lines 1 through 21 are required to be completed by all hospitals.
Line 1--Indicate whether the hospital has changed ownership immediately prior to the beginning of
the cost reporting period. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, enter the
date the change of ownership occurred in column 2. Also, submit the name and address of the new
owner and a copy of the sales agreement with the cost report.
Line 2--Indicate whether the hospital has terminated participation in the Medicare program. Enter
“Y” for yes or “N” for no in column 1. If column 1 is “Y”, enter the date of termination in column 2,
and “V” for voluntary or “I” for involuntary in column 3.
Line 3--Indicate whether the hospital is involved in business transactions, including management
contracts, with individuals or entities (e.g., chain home offices, drug or medical supply companies)
that are related to the provider or its officers, medical staff, management personnel, or members of
the board of directors through ownership, control, or family and other similar relationships. Enter
“Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a list of the individuals, the
organizations involved, and a description of the transactions with the cost report.
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4004.2 (Cont.) FORM CMS-2552-10 12-10
Note: A related party transaction occurs when services, facilities, or supplies are furnished to the
provider by organizations related to the provider through common ownership or control. (See Pub.
15-1, Chapter 10 and 42 CFR §413.17.)
Line 4--Indicate whether the financial statements were prepared by a Certified Public Accountant.
Enter “Y” for yes or “N” for no in column 1. If you answer “Y” in column 1, enter “A” for audited,
“C” for compiled, or “R” for reviewed in column 2. Submit a complete copy of the financial
statements (i.e., the independent public accountant’s opinion, the statements themselves, and the
footnotes) with the cost report. If the financial statements are not available for submission with the
cost report enter the date they will be available in column 3.
If you answer no in column 1, submit a copy of the financial statements you prepared, and written
statements of significant accounting policy and procedure changes affecting Medicare reimbursement
which occurred during the cost reporting period. You may submit the changed accounting or
administrative procedures manual in lieu of written statements.
Line 5--Indicate whether the total expenses and total revenues reported on the cost report differ from
those on the filed financial statements. Enter “Y” for yes or “N” for no in column 1. If you answer
“Y” in column 1, submit a reconciliation with the cost report.
Line 6--Indicate whether costs were claimed for Nursing School. Enter “Y” for yes or “N” for no in
column 1. If you answer “Y” in column 1, enter “Y” for yes or “N” for no in column 2 to indicate
whether the provider is the legal operator of the program .
Line 7--Indicate whether costs were claimed for Allied Health Programs. Enter “Y” for yes or “N”
for no in column 1. If you answer “Y” in column 1, submit a list of the program(s) with the cost
report and annotate for each whether the provider is the legal operator of the program.
Note: For purposes of lines 6 and 7, the provider is the legal operator of a nursing school and/or
allied health programs if it meets the criteria in 42 CFR §413.85(f)(1) or (f)(2).
Line 8--Indicate whether approvals and/or renewals were obtained during the cost reporting period
for Nursing School and/or Allied Health programs. Enter “Y” for yes or “N” for no in column 1. If
you answer “Y” in column 1, submit a list of the program(s), and copies of the approvals and/or
renewals with the cost report.
Line 9--Indicate whether Intern-Resident costs were claimed on the current cost report. Enter “Y”
for yes or “N” for no in column 1. If you answer “Y” in column 1, submit the current year Intern-
Resident Information System (IRIS) on diskette with the cost report.
Line 10--Indicate whether Intern-Resident program(s) have been initiated or renewed during the cost
reporting period. Enter “Y” for yes or “N” for no in column 1. If you answer “Y” in column 1,
submit copies of the certification(s)/program approval(s) with the cost report. (See 42 CFR
§413.79(l) for the definition of a new program.)
Line 11--Indicate whether Graduate Medical Education costs were directly assigned to cost centers
other than the Intern-Resident Services in an Approved Teaching Program on Worksheet A of form
CMS-2552-10. Enter “Y” for yes or “N” for no in column 1. If you answer “Y” in column 1, submit
a listing of the cost centers and amounts with the cost report.
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12-10 FORM CMS-2552-10 4004.2 (Cont.)
Line 12--Indicate whether you are seeking reimbursement for bad debts resulting from Medicare
deductible and coinsurance amounts which are uncollectible from Medicare beneficiaries. (See 42
CFR §413.89ff and Pub. 15-1, §§306 -324 for the criteria for an allowable bad debt.) Enter “Y” for
yes or “N” for no in column 1. If you answer “Y” in column 1, submit a completed Exhibit 2 or
internal schedules duplicating the documentation requested on Exhibit 2 to support the bad debts
claimed. If you are claiming bad debts for inpatient and outpatient services, complete a separate
Exhibit 2 or internal schedule for each category.
Exhibit 2 requires the following documentation:
Columns 1, 2, 3 - Patient Names, Health Insurance Claim (HIC) Number, Dates of Service (From -
To)--The documentation required for these columns is derived from the beneficiary’s bill. Furnish
the patient’s name, health insurance claim number and dates of service that correlate to the filed bad
debt. (See Pub. 15-1, §314 and 42 CFR §413.89.)
Column 4--Indigency/Welfare Recipient--If the patient included in column 1 has been deemed
indigent, place a check in this column. If the patient in column 1 has a valid Medicaid number, also
include this number in this column. See the criteria in Pub. 15-1, §§312 and 322 and 42 CFR
§413.89 for guidance on the billing requirements for indigent and welfare recipients.
Columns 5 & 6--Date First Bill Sent to Beneficiary & Date Collection Efforts Ceased--This
information should be obtained from the provider’s files and should correlate with the beneficiary
name, HIC number, and dates of service shown in columns 1, 2 and 3 of this exhibit. The dates in
column 6 represents the date that the unpaid account is deemed worthless, whereby all collection
efforts, both internal and by an outside entity, ceased and there is no likelihood of recovery of the
unpaid account. (See CFR 413.89(f), and Pub. 15-1, §§308, 310, and 314.)
Column 7--Remittance Advice Dates--Enter in this column the remittance advice dates that correlate
with the beneficiary name, HIC No., and dates of service shown in columns 1, 2, and 3 of this
exhibit.
Columns 8 & 9--Deductibles & Coinsurance--Record in these columns the beneficiary’s unpaid
deductible and coinsurance amounts that relate to covered services.
Column 10--Total Medicare Bad Debts--Enter on each line of this column, the sum of the amounts in
columns 8 and 9. Calculate the total bad debts by summing up the amounts on all lines of Column
10. This “total” must agree with the bad debts claimed on the cost report. Attach additional
supporting schedules, if necessary, for bad debt recoveries.
Line 13--Indicate whether your bad debt collection policy changed during the cost reporting period.
Enter “Y” for yes or “N” for no in column 1. If you answer “Y” in column 1, submit a copy of the
policy with the cost report.
Line 14--Indicate whether patient deductibles and/or copayments are waived. Enter “Y” for yes or
“N” for no in column 1. If you answer “Y” in column 1, ensure that they are not included on the bad
debt listings (i.e., Exhibit 2 or your internal schedules) submitted with the cost report.
Rev. 1
40-41
4004.2 (Cont.) FORM CMS-2552-10 12-10
Line 15--Indicate whether total available beds have changed from the prior cost reporting period.
Enter “Y” for yes or “N” for no in column 1. If you answer “Y” in column 1, provide an analysis of
available beds and explain any changes that occurred during the cost reporting period.
NOTE: For purposes of line 14, available beds are provider beds that are permanently maintained
for lodging inpatients. They must be available for use and housed in patient rooms or
wards (i.e., do not include beds in corridors or temporary beds). (See Pub. 15-1,
§2200.2.C., Pub. 15-2, §4005.1, and CFR §412.105(b).)
Line 16--Indicate whether the cost report was prepared using the Provider Statistical &
Reimbursement Report (PS&R) only. Use columns 1 and 2 for Part A and columns 3 and 4 for Part
B. Enter “Y” for yes or “N” for no in columns 1 and 3. If either column 1 or 3 is “Y” enter the paid
through date of the PS&R in columns 2 and/or 4. Also, submit a crosswalk between revenue codes
and charges found on the PS&R to the cost center groupings on the cost report. This crosswalk will
reflect a cost center to revenue code match only.
Line 17--Indicate whether the cost report was prepared using the PS&R for totals and provider
records for allocation. Use columns 1 and 2 for Part A and columns 3 and 4 for Part B. Enter “Y”
for yes or “N” for no in columns 1 and 3. If either column 1 or 3 is “Y” enter the paid through date
of the PS&R used to prepare this cost report in columns 2 and/or 4. Also, submit a detailed
crosswalk between revenue codes, departments and charges on the PS&R to the cost center
groupings on the cost report. This crosswalk must show dollars by cost center and include which
revenue codes were allocated to each cost center. The total revenue on the cost report must match
the total charges on the PS&R (as appropriately adjusted for unpaid claims, etc.) to use this method.
Supporting workpapers must accompany this crosswalk to provide sufficient documentation as to the
accuracy of the provider records. If the contractor does not find the documentation sufficient, the
PS&R will be used in its entirety.
Line 18--If you entered “Y” on either line 16 or 17, columns 1 and/or 3, indicate whether
adjustments were made to the PS&R data for additional claims that have been billed but not included
on the PS&R used to file this cost report. Enter “Y” for yes or “N” for no in columns 1 and 3. If
either column 1 or 3 is “Y”, include a schedule which supports any claims not included on the
PS&R. This schedule should include totals consistent with the breakdowns on the PS&R, and
should reflect claims that are unprocessed or unpaid as of the cut-off date of the PS&R used to file
the cost report.
Line 19--If you entered “Y” on either line 16 or 17, columns 1 and/or 3, indicate whether
adjustments were made to the PS&R data for corrections of other PS&R information. Enter “Y” for
yes or “N” for no in columns 1 and 3. If either column 1 or 3 is “Y”, submit a detailed explanation
and documentation which provides an audit trail from the PS&R to the cost report.
Line 20--If you entered “Y” on either line 16 or 17, columns 1 and/or 3, indicate whether other
adjustments were made to the PS&R data. Enter “Y” for yes or “N” for no in columns 1 and 3. If
either column 1 or 3 is “Y”, include a description of the other adjustments and documentation which
provides an audit trail from the PS&R to the cost report.
Line 21--Indicate whether the cost report was prepared using provider records only. Enter “Y” for
yes or “N” for no in columns 1 and 3. If either column 1 or 3 is “Y”, submit detailed documentation
of the system used to support the data reported on the cost report. If detail documentation was
previously supplied, submit only necessary updated documentation with the cost report.
40-42
Rev. 1
12-10 FORM CMS-2552-10 4004.2 (Cont.)
The minimum requirements are:
Copies of input tables, calculations, or charts supporting data elements for PPS operating rate
components, capital PPS rate components and other PRICER information covering the cost
reporting period.
Internal records supporting program utilization statistics, charges, prevailing rates and
payment information broken into each Medicare bill type in a manner consistent with the
PS&R.
Reconciliation of remittance totals to the provider’s internal records.
Include the name of the system used and indicate how the system was maintained (vendor or
provider). If the provider maintained the system, include date of last software update.
Note: Additional information may be supplied such as narrative documentation, internal flow charts,
or outside vendor informational material to further describe and validate the reliability of your
system.
Lines 22 through 40 are required to be completed by cost-reimbursed and TEFRA hospitals only.
Line 22--Indicate whether assets have been relifed for Medicare purposes. Enter “Y” for yes or “N”
for no in column 1. If column 1 is “Y”, submit a detailed listing of these specific assets, by class, as
shown in the Fixed Asset Register with the cost report.
Note: Class” means those depreciable asset groupings you use (e.g., land improvements, moveable
equipment, buildings, fixed equipment).
Line 23--Indicate whether changes occurred in the Medicare depreciation expense due to appraisals
made during the cost reporting period. Enter “Y” for yes or “N” for no in column 1. If column 1 is
“Y”, submit a copy of the Appraisal Report and Appraisal Summary by class of asset with the cost
report.
Line 24--Indicate whether new leases and/or amendments to existing leases were entered into during
the cost reporting period. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a
listing of the new leases and/or amendments to existing leases if the annual rental cost of each of
these leases is $50,000 or greater with the cost report. The listing should include the following
information:
Identify if the lease is new or a renewal.
Parties to the lease.
Period covered by the lease.
Description of the asset being leased.
Annual charge by the lessor.
NOTE: Providers are required to submit copies of the lease, or significant extracts, upon
request from the contractor.
Rev. 1
40-43
4004.2 (Cont.) FORM CMS-2552-10 12-10
Line 25--Indicate whether new capitalized leases were entered into during the cost reporting period.
Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a list of the individual
assets by class, the department assigned to, and respective dollar amounts if the annual rental cost of
these leases is $50,000 or greater with the cost report.
Line 26--Indicate whether assets subject to §2314 of DEFRA were acquired during the cost reporting
period. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a computation of
the basis with the cost report.
Line 27--Indicate whether your capitalization policy changed during the cost reporting period. Enter
“Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a copy with the cost report.
Line 28--Indicate whether new loans, mortgage agreements, or letters of credit were entered into
during the cost reporting period. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”,
submit copies of the debt documents and amortization schedules with the cost report. Also, state the
purpose of the borrowing.
Line 29--Indicate whether you have a funded depreciation account and/or bond funds (Debt Service
Reserve Fund) treated as a funded depreciation account. Enter “Y” for yes or “N” for no in column
1. If column 1 is “Y”, submit a detailed analysis of the funded depreciation account for the cost
reporting period with the cost report. (See Pub. 15-1, §226 and 42 CFR §413.153.)
Line 30--Indicate whether existing debt has been replaced prior to its scheduled maturity with new
debt. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a copy of the new
debt document and a schedule calculating the allowable cost. (See Pub. 15-1, §233.3 for description
of allowable cost.)
Line 31--Indicate whether debt has been recalled before its scheduled maturity without the issuance
of new debt. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a detailed
analysis supporting the debt cancellation costs and treatment of these expenses on the cost report.
(See Pub. 15-1, §215 for description and treatment of debt cancellation costs.)
Line 32--Indicate whether you have entered into new agreements or if changes occurred in patient
care services furnished through contractual arrangements with suppliers of service. Enter “Y” for
yes or “N” for no in column 1. If column 1 is “Y”, submit copies of the contracts in those instances
where the cost of the individual’s services exceeds $25,000 per year with the cost report.
Where you do not have written agreements for purchased services, submit a description listing the
following information:
Duration of the arrangement.
Description of services.
Financial arrangement.
Name(s) of parties to the agreement furnishing the services.
Line 33--If you answered “Y” on line 32, were the requirements of Pub. 15-1, §2135.2 pertaining to
competitive bidding applied? Enter “Y” for yes or “N” for no in column 1. If column 1 is “N”,
submit an explanation with the cost report.
40-44
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12-10 FORM CMS-2552-10 4004.2 (Cont.)
Line 34--Indicate whether services are furnished at your facility under an arrangement with provider-
based physicians. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit Exhibit
1, where applicable.
You may submit computer generated substitutes for these schedules provided they contain, at a
minimum, the same information as in Exhibit 1. (This includes the signature on a substitute Exhibit
2.)
Allocation agreements (Exhibit 1) are required if physician compensation is attributable to both
direct patient care and provider services. Allocation agreements are also required if all of the
provider-based physician’s compensation is attributable to provider services (i.e., departmental
supervision and administration, quality control activities, teaching and supervision of Interns-
Residents and/or Allied Health Students, and in the case of teaching hospitals electing cost
reimbursement for teaching physicians’ services, for compensation attributable to direct medical and
surgical services furnished to individual patients, and the supervision of intern and residents
furnishing direct medical and surgical services to individual patients. However, Exhibit 1 is not
required if all of the provider-based physician’s compensation is attributable to direct medical and
surgical services to individual patients.
Physicians’ compensation information is considered to be confidential, and therefore, qualifies for
exemption from disclosure under the Freedom of Information Act, and specifically under 5 U.S.C.
552(b)(4). The compensation information also qualifies for exemption from disclosure under 5
U.S.C. 552(b)(6) which covers “personnel and medical files, the disclosure of which would
constitute a clearly unwarranted invasion of personal privacy.” An individual’s compensation is a
personal matter and its release would be an invasion of privacy. Accordingly, CMS will not release,
or make available to the public, compensation information collected.
Instructions for completing Exhibit 1:
Exhibit 1, Allocation of Physician Compensation Hours:
Complete this exhibit in accordance with Pub. 15-1, §2182.3. The data elements shown are
physicians’ hours of service providing a breakdown between the professional and provider
component.
Prepare a physician time allocation for each physician by department, who receives payment
directly from you or a related organization for services rendered. This includes physicians
paid through affiliated agreements. A weighted average for the entire department may be
used where all physicians in the department are in the same specialty. Where a weighted
average is submitted, individual time allocations need not be submitted. The physician or
department head supplying this information must sign the schedule.
Rev. 1
40-45
4004.2 (Cont.) FORM CMS-2552-10 12-10
Line 35--If you answered “Y” on line 34, indicate whether new agreements or amendments to
existing agreements were entered into during the cost reporting period. Enter “Y” for yes or “N” for
no in column 1. If column 1 is “Y”, submit copies of the new agreements or the amendments to
existing agreements with the cost report.
Line 36--Indicate whether home office costs are claimed on the cost report. Enter “Y” for yes or “N
for no in column 1.
Line 37--If you answered “Y” on line 36, indicate whether a home office cost statement was prepared
by the home office. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a
schedule displaying the entire chain’s direct, functional, and pooled costs as provided to the
designated home office contractor as part of the home office cost statement.
Line 38--If you answered “Y” on line 36, indicate whether the fiscal year end of the home office is
different from that of the provider. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”,
enter the fiscal year end of the home office in column 2.
Line 39--If you answered “Y” on line 36, indicate whether the provider renders services to other
components of the chain. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a
schedule listing the names of the entities, the services provided, and cost incurred to provide these
services with the cost report.
Line 40--If you answered “Y” on line 36, indicate whether the provider renders services to the home
office. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a schedule listing
the services provided, and cost incurred to provide these services with the cost report.
NOTE: Exhibits 1 and 2 must be completed either manually (in hard copy) or via separate
electronic/digital media as this information is not captured in the ECR file.
40-46
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12-10 FORM CMS-2552-10 4004.2 (Cont.)
EXHIBIT 1
Allocation of Physician Provider Name: ________________________________________
Compensation: Hours
Provider Number:____________________
Department: ___________________________
Physician Name: _______________________________________
______________________________________________________________________________________________________
Cost Reporting Year: Beginning___________________ Ending ___________________
___ ___ ___ ___
Basis of Allocation: Time Study /__/; Other /__/; Describe:______________________________
______________________________________________________________________________________________________
Services Total
Hours
______________________________________________________________________________________________________
1. Provider Services - Teaching and Supervision of I/R's and other GME Related Functions. _________
1A. Provider Services - Teaching and Supervision of Allied Health Students _________
1B. Provider Services - Non Teaching Reimbursable Activities such as Departmental Administration,
Supervision of Nursing, and Technical Staff, Utilization Review, etc. _________
1C. Provider Services - Emergency Room Physician Availability _________
(Do not include minimum guarantee arrangements for Emergency Room Physicians.)
1D. Sub-Total - Provider Administrative Services (Lines 1, 1A, 1B, 1C). _________
2. Physician Services: Medical and Surgical Services to Individual Patients _________
3. Non-Reimbursable Activities: Research, Teaching of I/R's in Non-Approved Programs, Teaching
and Supervision of Medical Students, Writing for Medical Journals, etc. _________
4. Total Hours: (Lines 1D, 2, and 3) _________
5. Professional Component Percentage (Line 2 / Line 4) _________
6. Provider Component Percentage - (Line 1D / Line 4) _________
_________________________________________ ______________
Signature: Physician or Physician Department Head Date
Rev. 1
40-47
4004.2 (Cont.) FORM CMS-2552-10 12-10
EXHIBIT 2
LISTING OF MEDICARE BAD DEBTS AND APPROPRIATE SUPPORTING DATA
PROVIDER ____________________ PREPARED BY __________________________________
NUMBER ______________________ DATE PREPARED ________________________________
FYE _________________________ INPATIENT __________ OUTPATIENT ______________
(1)
Patient
Name
(2)
HIC. NO.
(3)
DATES OF
SERVICE
(4)
INDIGENCY &
WEL. RECIP.
(CK IF APPL)
(5)
DATE FIRST
BILL SENT TO
BENEFICIARY
(6)
DATE
COLLECTION
EFFORTS
CEASED
(7)
MEDICARE
REMITTANCE
ADVICE
DATES
(8)*
DEDUCT
(9)*
CO-INS
(10)
TOTAL
FROM
TO
YES
MEDICAID
NUMBER
* THESE AMOUNTS MUST NOT BE CLAIMED UNLESS THE PROVIDER BILLS FOR THESE SERVICES WITH THE INTENTION OF PAYMENT.
SEE INSTRUCTIONS FOR COLUMN 4 - INDIGENCY/WELFARE RECIPIENT, FOR POSSIBLE EXCEPTION
40-48 Rev. 1
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Page 49 reserved for future use.
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Pages 50 through 54 are reserved for future use.
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12-10 FORM CMS-2552-10 4005
4005. WORKSHEET S-3 - HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX
STATISTICAL DATA AND HOSPITAL WAGE INDEX INFORMATION
This worksheet consists of three parts:
Part I - Hospital and Hospital Health Care Complex Statistical Data
Part II - Hospital Wage Index Information
Part III - Hospital Wage Index Summary
Part IV - Hospital Wage Related Costs
Part V - Hospital Contract Labor and Benefit Costs
4005.1 Part I - Hospital and Hospital Health Care Complex Statistical Data.--This part collects
statistical data regarding beds, days, FTEs, and discharges.
Column Descriptions
Column 1--Enter the Worksheet A line number that corresponds to the Worksheet S-3 component
line description.
Column 2--Refer to 42 CFR 412.105(b) and Vol. 69 of the Federal Register 154, dated August 11,
2004, page 49093 to determine the facility bed count. Indicate the number of beds available for use
by patients at the end of the cost reporting period. A bed means an adult bed, pediatric bed, birthing
room, or newborn ICU bed (excluding newborn bassinets) maintained in a patient care area for
lodging patients in acute, long term, or domiciliary areas of the hospital. Beds in labor room,
birthing room, postanesthesia, postoperative recovery rooms, outpatient areas, emergency rooms,
ancillary departments, nurses' and other staff residences, and other such areas which are regularly
maintained and utilized for only a portion of the stay of patients (primarily for special procedures or
not for inpatient lodging) are not termed a bed for these purposes. (See CMS Pub. 15-1, §§2200.2 C
and 2205.)
Column 3--Enter the total bed days available. Bed days are computed by multiplying the number of
beds available throughout the period in column 2 by the number of days in the reporting period. If
there is an increase or decrease in the number of beds available during the period, multiply the
number of beds available for each part of the cost reporting period by the number of days for which
that number of beds was available.
Column 4--CAHs accumulate the aggregate number of hours all CAH patients spend in each
category on lines 1 and 8 through 12. This data is for informational purposes only.
Columns 5 through 7--Enter the number of inpatient days or visits, where applicable, for each
component by program. Do not include HMO days except where required (lines 2 through 4,
columns 6 and 7), organ acquisition, or observation bed days in these columns. Observation bed
days are reported in columns 7 (title XIX) and 8 (total), line 28. For LTCH, enter in column 6 on the
applicable line the number of covered Medicare days (from the PS&R) and enter in column 6, line 33
the number of noncovered days (from provider’s books and records) for Medicare patients.
Report the program days for PPS providers (acute care hospital, IPF, IRF, and LTCH) in the cost
reporting period in which the discharge is reported. This also applies to providers under the
TEFRA/PPS blend. TEFRA providers should report their program days in the reporting period in
which they occur.
NOTE: Section 1886(d)(5)(F) of the Act provides for an additional Medicare payment for
hospitals serving a disproportionate share of low income patients. A hospital's eligibility
for these additional payments is partially based on its Medicaid utilization. The count of
Medicaid days used in the Medicare disproportionate share adjustment computation
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4005.1 (Cont.) FORM CMS-2552-10 12-10
includes days for Medicaid recipients who are members of an HMO as well as out of State
days, Medicaid secondary payer patient days, Medicaid eligible days for which no payment
was received, and baby days after mother's discharge. Medicaid HMO days are reported
on lines 2 through 4 in accordance with CFR 412.106(b)(4)(ii). Therefore, Medicaid
patient days reported on line 1, column 7 do not include days for Medicaid patients who
are also members of an HMO.
Column 8--Enter the number of inpatient days for all classes of patients for each component. Include
organ acquisition and HMO days in this column. This amount will not equal the sum of columns 5
through 7 when the provider renders services to other than titles V, XVIII, or XIX patients.
Column 9--Enter the number of intern and resident full time equivalents (FTEs) in an approved
program determined in accordance with 42 CFR 412.105(f) for the indirect medical education
adjustment. The FTE residents reported by an IPF PPS facility or an IRF PPS facility (whether
freestanding or a unit reported on line 16 or 17, respectively, of an IPPS hospital’s cost report) shall
be determined in accordance with 42 CFR 412.424(d)(1)(iii) for IPFs and in accordance with the
Federal Register, Vol. 70, number 156, dated August 15, 2005, pages 47929-30 for IRFs.
Columns 10 and 11--The average number of FTE employees for the period may be determined either
on a quarterly or semiannual basis. When quarterly data are used, add the total number of hours
worked by all employees on the first week of the first payroll period at the beginning of each quarter,
and divide the sum by 160 (4 times 40). When semiannual data are used, add the total number of
paid hours on the first week of the first payroll period of the first and seventh months of the period.
Divide this sum by 80 (2 times 40). Enter the average number of paid employees in column 10 and
the average number of nonpaid workers in column 11 for each component, as applicable.
Columns 12 through 14--Enter the number of discharges including deaths (excluding newborn and
DOAs) for each component by program. A patient discharge, including death, is a formal release of
a patient. (See 42 CFR 412.4.) Enter the XVIII M+C HMO discharges in column 13, line 2.
Column 15--Enter the number of discharges including deaths (excluding newborn and DOAs) for all
classes of patients for each component.
Line Descriptions
Line 1--In columns 5, 6, 7 and 8, enter the number of adult and pediatric hospital days excluding the
SNF and NF swing bed, observation bed, and hospice days. In columns 6 and 7 also exclude HMO
days. Do not include in column 6 Medicare Secondary Payer/Lesser of Reasonable Cost
(MSP/LCC) days. Include these days only in column 8. However, do not include employee
discount days in column 8.
Labor and delivery days (as defined in the instructions for line 32 of Worksheet S-3, Part I) must not
be included on this line.
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.
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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 14--Enter the sum of lines 7 - 13 for columns 2 - 8, and for columns 12 - 15, enter the amount
from line 1. For columns 9 - 11, enter the total for each from your records.
Labor and delivery days (as defined in the instructions for line 32 of Worksheet S-3, Part I) must not
be included on this line.
Line 15--Enter the number of outpatient visits for CAHs by program and total. An outpatient CAH
visit is defined in 42 CFR 413.70(b)(3)(iii).
Line 16--Enter the applicable data for the IPF subprovider.
Line 17--Enter the applicable data for the IRF subprovider.
Line 18--Enter the applicable data for other than IPF or IRF subproviders. If you have more than one
subprovider, subscript this line.
Line 19--If your State recognizes one level of care, complete this line for titles V, XVIII, and XIX,
however, do not complete line 20. If you answered yes to line 92 of Worksheet S-2, complete all
columns.
Line 20--Enter nursing facility days if you have a separately certified nursing facility for Title XIX or
you answered yes to line 92 of Worksheet S-2. Make no entry if your State recognizes only SNF
level of care. If you operate an ICF/MR, subscript this line to 20.01 and enter the ICF/MR days. Do
not report any nursing facility data on line 20.01.
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 25--CMHCs enter the number of partial hospitalization days as applicable. For reporting of
multiple facilities follow the same format used on Worksheet S-2, line 17.
Line 26--Enter the number of outpatient visits for FQHC and RHC. If you have both or multiples of
one, subscript the line.
Line 28--Enter the total observation bed days in column 8. Divide the total number of observation
bed hours by 24 and round up to the nearest whole day. These total hours should include the hours
for observation of patients who are subsequently admitted as inpatients but only the hours up to the
time of admission as well as the hours for observation of patients who are not subsequently admitted
as inpatients but only the hours up to the time of discharge from the facility. Observation bed days
only need to be computed if the observation bed patients are placed in a routine patient care area.
The bed days are needed to calculate the cost of observation beds since it cannot be separately costed
when the routine patient care area is used. If, however, you have a distinct observation bed area, it
must be separately costed (as are all other outpatient cost centers), and this computation is not
needed.
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4005.2 FORM CMS-2552-10 12-10
Line 29--Enter in column 6 the total number of ambulance trips, as defined by section 4531(a)(1) of
The BBA. Do not subscript this line.
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.
Line 32--Indicate in column 7 the count of labor/delivery days for Title XIX and in column 8 the
total count of labor/delivery days for the entire facility.
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 inpatient routine care area because the patient has not
occupied an inpatient routine bed at some time before admission (see Pub. 15-1, section 2205.2). In
the case where the maternity patient is in a single multipurpose labor, delivery and postpartum (LDP)
room, hospitals must determine the proportion of each inpatient stay that is associated with ancillary
services (labor and delivery) versus routine adult and pediatric services (post partum) and report the
days associated with the labor and delivery portion of the stay on this line. An example of this would
be for a hospital to determine the percentage of each stay associated with labor/delivery services and
apply that percentage to the stay to determine the number of labor and delivery days of the stay.
Alternatively, a hospital could calculate an average percentage of time maternity patients receive
ancillary services in an LDP room during a typical month, and apply that percentage through the rest
of the year to determine the number of labor and delivery days to report on line 32. Maternity
patients must be admitted to the hospital as an inpatient for their labor and delivery days to be
included on line 32. These days must not be reported on Worksheet S-3, Part I, line 1 or line 14.
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 the prospective payment system. It is
important for hospitals to ensure that the data reported on Worksheet S-3, Parts II, III and IV are
accurate. Beginning October 1, 1993, the wage index must be updated annually. (See
§1886(d)(3)(E) of the Act.) Congress also indicated that any revised wage index must exclude data
for wages incurred in furnishing SNF services. Complete this worksheet for IPPS hospitals (see
§1886(d)), any hospital with an IPPS subprovider, or any hospital that would be subject to IPPS if
not granted a waiver.
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.
NOTE: Bonus pay includes award pay and vacation, holiday, and sick pay conversion (pay in lieu of
time off).
NOTE: Capital related salaries, hours, and wage-related costs associated with lines 1 and 2 of
Worksheet A must not be included on Worksheet S-3, Parts II and III.
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12-10 FORM CMS-2552-10 4005.2 (Cont.)
NOTE: Methodology for including vacation/sick/other PTO accruals in the wage index:
PTO salary cost--The required source for costs on Worksheet A is the General Ledger (see
Provider Reimbursement Manual, Part II, section 4013 and 42 CFR 413.24(e)). Worksheet
S-3, Part II (wage index) data are derived from Worksheet A; therefore, the proper source for
costs for the wage index is also the General Ledger. A hospital’s current year General
Ledger includes both costs that are paid during the current year and costs that are expensed in
the current year but paid in the subsequent year (current year accruals). Hospitals and
contractors are to include on Worksheet S-3, Part II the current year PTO cost incurred as
reflected on the General Ledger; that is, both the current year PTO cost paid and the current
year PTO accrual. (Costs that are expensed in the prior year but paid in the current year
(prior year accruals) are not included on a hospital’s current year General Ledger and should
not be included on the hospital's current year Worksheet S-3, Part II.)
PTO hours--The source for PTO paid hours on Worksheet S-3, Part II is the Payroll Report.
Hours are included on the Payroll Report in the period in which the associated PTO expense
is paid. Hospitals and contractors are to include on Worksheet S-3, Part II the PTO hours
that are reflected on the current year Payroll Report, which includes hours associated with
PTO cost that was expensed in the prior year but paid in the current year. The time period
must cover the weeks that best matches the provider’s cost reporting period. (Hours
associated with PTO cost expensed in the current year but not paid until the subsequent year
(current year PTO accrual) are not included on the current year Payroll Report and should not
be included on the hospital’s current year Worksheet S-3, Part II.)
Although this methodology does not provide a perfect match between paid PTO cost and
paid PTO hours for a given year, it should approximate an actual match between cost and
hours. Over time, any variances should be minimum.
Lines 2 through 10--The amounts to be reported must be adjusted for vacation, holiday, sick, other
paid time off, severance, and bonus pay if not already included. Do not include in lines 2 through 7
the salaries for employees associated with excluded areas lines 9 and 10.
Line 2--Enter the salaries for directly-employed Part A non-physician anesthetist salaries (for rural
hospitals that have been granted CRNA pass through) to the extent these salaries are included in line
1. Add to this amount the costs for CRNA Part A services furnished under contract to the extent
hours can be accurately determined. Report only the personnel costs associated with these contracts.
DO NOT include cost for equipment, supplies, travel expenses, and other miscellaneous or overhead
items. DO NOT include costs applicable to excluded areas reported on lines 9 and 10. Additionally,
contract CRNA cost must be included on line 11. Report in column 5 the hours that are associated
with the costs in column 4 for directly employed and contract Part A CRNAs.
Do not include physician assistants, clinical nurse specialists, nurse practitioners, and nurse
midwives.
Line 3--Enter the non-physician anesthetist salaries included in line 1, subject to the fee schedule and
paid under Part B by the contractor. Do not include salary costs for physician assistants, clinical
nurse specialists, nurse practitioners, and nurse midwives.
Line 4--Enter the physician Part A salaries, (excluding teaching physician salaries), which are
included in line 1. Also do not include intern and resident (I & R) salary on this line. Report I & R
salary on line 7.
Rev. 1 40-59
4005.2 (Cont.) FORM CMS-2552-10 12-10
Lines 5 and 6--Enter the total physician, physician assistant, nurse practitioner and clinical nurse
specialist salaries billed under Part B that are included in line 1. Under Medicare, these services are
related to patient care and billed separately under Part B. Also include physician salaries for patient
care services reported for rural health clinics and Federally qualified health clinics included on
Worksheet A, column 1, lines 88 and/or 89 as applicable. Report on line 6 the non-physician salaries
reported for Hospital-based RHC and FQHC services included on Worksheet A, column 1, lines 88
and/or 89 as applicable.
Line 7--Enter from Worksheet A the salaries reported in column 1 of line 21 for interns and
residents. Add to this amount the costs for intern and resident services furnished under contract.
Report only the personnel costs associated with these contracts. DO NOT include cost for
equipment, supplies, travel expenses, and other miscellaneous or overhead items. DO NOT include
costs applicable to excluded areas reported on lines 9 and 10. Additionally, contract intern and
resident costs must be included on line 11. DO NOT include contract intern and residents costs on
line 13. Report in column 5 the hours that are associated with the costs in column 4 for directly
employed and contract interns and residents.
Line 8--If you are a member of a chain or other related organization as defined in CMS Pub 15-1,
§2150, enter, from your records, the wages and salaries for home office related organization
personnel that are included in line 1.
Lines 9 and 10--Enter on line 9 the amount reported on Worksheet A, column 1 for line 44 for the
SNF. On line 10, enter from Worksheet A, column 1, the sum of lines 20, 23, 40 through 42, 45,
45.01, 46, 94, 95, 98 through 101, 105 through 112, 114, 115 through 117, and 190 through 194.
DO NOT include on lines 9 and 10 any salaries for general service personnel (e.g., housekeeping)
which, on Worksheet A, Column 1, may have been included directly in the SNF and the other cost
centers detailed in the instructions for Line 10.
Line 11--Enter the amount paid for services furnished under contract, rather than by employees, for
direct patient care, and top level management services as defined below. DO NOT include cost for
equipment, supplies, travel expenses, and other miscellaneous or overhead items (non-labor costs).
Do not include costs applicable to excluded areas reported on line 9 and 10. Include costs for
contract CRNA and intern and resident services (these costs are also to be reported on lines 2 and 7
respectively). Include on this line contract pharmacy and laboratory wage costs as defined below.
In general, for contract labor, the minimum requirement for supporting documentation is the contract
itself. If the wage costs, hours, and non-labor costs are not clearly specified in the contract, then
other documentation are necessary, such as a representative sample of invoices which specify the
wage costs, hours, and non-labor costs or a signed declaration from the vendor in conjunction with a
sample of invoices. Hospitals must be able to provide such documentation when requested by the
contractor or Medicare administrative contractor. A hospital’s failure to provide adequate supporting
documentation may result in the cost being disallowed for the wage index.
Direct patient care services include nursing, diagnostic, therapeutic, and rehabilitative services.
Report only personnel costs associated with these contracts. DO NOT apply the guidelines for
contracted therapy services under §1861(v)(5) of the Act and 42 CFR 413.106. Eliminate all
supplies, travel expenses, and other miscellaneous items. Direct patient care contracted labor, for
purposes of this worksheet, DOES NOT include the following: services paid under Part B: (e.g.,
physician clinical services, physician assistant services), management and consultant contracts,
billing services, legal and accounting services, clinical psychologist and clinical social worker
services, housekeeping services, security personnel, planning contracts, independent financial audits,
or any other service not directly related to patient care.
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12-10 FORM CMS-2552-10 4005.2 (Cont.)
Include the amount paid for top level management services, as defined below, furnished under
contract rather than by employees. Report only those personnel costs associated with the contract.
Eliminate all supplies, travel expenses, and other miscellaneous items. Contract management is
limited to the personnel costs for those individuals who are working at the hospital facility in the
capacity of chief executive officer, chief operating officer, chief financial officer, or nursing
administrator. The titles given to these individuals may vary from the titles indicated above.
However, the individual should be performing those duties customarily given these positions.
For purposes of this worksheet, contract top level management services DO NOT include the
following: other management or administrative services (to be included on lines 12 or 28; see
instructions), physician Part A services, consultative services, clerical and billing services, legal and
accounting services, unmet physician guarantees, physician services, planning contracts, independent
financial audits, or any services other than the top level management contracts listed above. Per
instructions on Worksheet S-2, Part II, for direct patient care, pharmacy and laboratory contracts,
submit to your Medicare contractor the types of services, wages, and associated hours; for top level
management contracts, submit the aggregate wages and hours.
If you have no contracts for direct patient care or management services as defined above, enter a zero
in column 1. If you are unable to accurately determine the number of hours associated with
contracted labor, enter a zero in column 1.
Contract pharmacy services are furnished under contract, rather than by employees. DO NOT
include the following services paid under Part B (e.g., physician clinical services, physician assistant
services), management and consultant contracts, clerical and billing services, legal and accounting
services, housekeeping services, security personnel, planning contracts, independent financial audits,
or any other service not directly related to patient care. Report only personnel costs associated with
the contracts. DO NOT include costs for equipment, supplies, travel expenses, or other
miscellaneous items. Per instructions on Worksheet S-2, Part II, submit to your contractor the
following for direct patient care pharmacy contracts: the types of services, wages, and associated
hours.
Contract laboratory services are furnished under contract, rather than by employees. DO NOT
include the following services paid under Part B (e.g., physician clinical services, physician assistant
services), management and consultant contracts, clerical and billing services, legal and accounting
services, housekeeping services, security personnel, planning contracts, independent financial audits,
or any other service not directly related to patient care. Report only personnel costs associated with
the contracts. DO NOT include costs for equipment, supplies, travel expenses, or other
miscellaneous items. Per instructions on Worksheet S-2, Part II, submit to your contractor the
following for direct patient care laboratory contracts: the types of services, wages, and associated
hours.
Line 12--Enter the amount paid for management and administrative services furnished under
contract, rather than by employees. Include on this line contract management and administrative
services associated with cost centers other than those listed on lines 26 through 43 (and their
subscripts) of this worksheet that are included in the wage index.
Examples of contract management and administrative services that would be reported on line 12
include department directors, administrators, managers, ward clerks, and medical secretaries. Report
only those personnel costs associated with the contract. DO NOT include on line 12 any contract
labor costs associated with lines 26 through 43 and subscripts for these lines. DO NOT include the
costs for contract top level management: chief executive officer, chief operating officer, and nurse
administrator; these services are included on line 11. DO NOT include costs for equipment,
supplies, travel expenses, or other miscellaneous items.
Rev. 1 40-61
4005.2 (Cont.) FORM CMS-2552-10 12-10
Line 13--Enter from your records the amount paid under contract (as defined on line 11) for Part A
physician services, excluding teaching physician services. Also include Part A teaching physicians
under contract on this line. DO NOT include contract I & R services (to be included on line 7). DO
NOT include the costs for Part A physician services from the home office allocation and/or from
related organizations (to be reported on line 15). Also, DO NOT include Part A physician contracts
for any of the management positions reported on line 11.
Line 14--Enter the salaries and wage-related costs (as defined on lines 17 and 18) paid to personnel
who are affiliated with a home office and/or related organization, who provide services to the
hospital, and whose salaries are not included on Worksheet A, column 1. In addition, add the home
office/related organization salaries included on line 8 and the associated wage-related costs. This
figure must be based on recognized methods of allocating an individual's home office/related
organization salary to the hospital. If no home office/related organization exists or if you cannot
accurately determine the hours associated with the home office/related organization salaries that are
allocated to the hospital, then enter a zero in column 1. All costs for any related organization must
be shown as the cost to the related organization.
NOTE: Do not include any costs for Part A physician services from the home office allocation
and/or related organizations. These amounts are reported on line 15.
If a wage related cost associated with the home office is not “core” (as described in the
Worksheet S-3, Part IV) and is not a category included in “other” wage related costs on
line 18 (see Worksheet S-3, Part IV and line 18 instructions below), the cost cannot be
included on line 14. For example, if a hospital’s employee parking cost does not meet the
criteria for inclusion as a wage-related cost on line 18, any parking cost associated with
home office staff cannot be included on line 14.
Line 15--Enter from your records the salaries and wage-related costs for Part A physician services,
excluding teaching physician Part A services from the home office allocation and/or related
organizations. Subscript this line and report separately on line 16 the salaries and wage-related costs
for Part A teaching physicians from the home office allocation and/or related organizations.
Lines 17 through 25--In general, the amount reported for wage-related costs must meet the
reasonable cost” provisions of Medicare. For example, in developing pension and deferred
compensation costs, hospitals must comply with the requirements in 42 CFR 413.100 and the Pub.
15-1, §§ 2140, 2141 and 2142 (see discussion in 73 FR, page 48581, dated August 19, 2008).
For those wage-related costs that are not covered by Medicare reasonable cost principles, a hospital
shall use generally accepted accounting principles (GAAP). For example, for purposes of the wage
index, disability insurance cost should be developed using GAAP. Hospital are required to complete
Worksheet S-3, Part IV, a reconciliation worksheet to aid hospital and contractors in implementing
GAAP when developing wage-related costs. Upon request by the contractor or CMS, hospitals must
provide a copy of the GAAP pronouncement, or other documentation, showing that the reporting
practice is widely accepted in the hospital industry and/or related field as support for the
methodology used to develop the wage-related costs. If a hospital does not complete Worksheet S-3,
Part IV, or, the hospital is unable, when requested, to provide a copy of the standard used in
developing the wage-related costs, the contractor may remove the cost from the hospital’s Worksheet
S-3 due to insufficient documentation to substantiate the wage-related cost relevant to GAAP.
NOTE: All costs for any related organization must be shown as the cost to the related
organization. (For Medicare cost reporting principles, see Pub. 15 15-1, §1000. For
GAAP, see FASB 57.) If a hospital’s consolidation methodology is not in accordance
with GAAP or if there are any amounts in the methodology that cannot be verified by the
contractor, the contractor may apply the hospitals cost to charge ratio to reduce the related
party expenses to cost.
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12-10 FORM CMS-2552-10 4005.2 (Cont.)
NOTE: All wage-related costs, including FICA, workers compensation, and unemployment
compensation taxes, associated with physician services are to be allocated according to the
services provided; that is, those taxes and other wage-related costs attributable to Part A
administrative services must be placed on line 22, along with Part A teaching services,
and Part B (patient care services) on line 23. Line 17 must not include wage-related costs
that are associated with physician services.
Line 17--Enter the core wage-related costs from. (See note below for costs that are not to be
included on line 17). Only the wage-related costs reported on Worksheet S-3, Part IV, line 24 are
reported on this line. (Wage-related costs are reported in column 2, not column 1, of Worksheet A.)
NOTE: Do not include wage-related costs applicable to the excluded areas reported on lines 9 and
10. Instead, these costs are reported on line 19. Also, do not include the wage-related costs for
physicians Parts A and B, non-physician anesthetists Parts A and B, interns and residents in approved
programs, and home office personnel. (See lines 14, 15, and 20 through 25.)
Health Insurance and Health-Related Wage Related Costs:
Hospitals and contractors are not required to remove from domestic claims costs the personnel costs
associated with hospital staff who deliver services to employees. Additionally, health related costs,
that is, costs for employee physicals and inpatient and outpatient services that are not covered by
health insurance but provided to employees at no cost or at a discount, are to be included as a core
wage related cost.
Line 18--Enter the wage-related costs that are considered an exception to the core list. (See note
below for costs that are not to be included on line 18.) In order for a wage-related cost to be
considered an exception, it must meet all of the following tests:
a. The cost is not listed on Worksheet S-3, Part IV,
b. The wage-related cost has not been furnished for the convenience of the provider,
c. The wage-related cost is a fringe benefit as defined by the Internal Revenue Service and,
where required, has been reported as wages to IRS (e.g., the unrecovered cost of employee
meals, education costs, auto allowances), and
d. The total cost of the particular wage-related cost for employees whose services are paid
under IPPS exceeds 1 percent of total salaries after the direct excluded salaries are
removed (Worksheet S-3, Part III, column 4, line 3). Wage-related cost exceptions to the
core list are not to include those wage-related costs that are required to be reported to the
Internal Revenue Service as salary or wages (i.e., loan forgiveness, sick pay accruals).
Include these costs in total salaries reported on line 1 of this worksheet.
NOTE: Do not include wage-related costs applicable to the excluded areas reported on lines 9 and
10. Instead, these costs are reported on line 19. Also, do not include the wage-related
costs for physician Parts A and B, non-physician anesthetists Parts A and B, interns and
residents in approved programs, and home office personnel.
Line 19--Enter the total (core and other) wage-related costs applicable to the excluded areas reported
on lines 9 and 10.
Lines 20 through 25--Enter from your records the wage-related costs for each category of employee
listed. The costs are the core wage related costs plus the other wage-related costs. Do not include
wage-related costs for excluded areas reported on line 19. Include the wage related costs for Part A
teaching physicians on line 22. On line 23, do not include wage-related costs related to non-
physician salaries reported for Hospital-based RHCs and FQHCs services included on Worksheet A,
Rev. 1 40-63
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column 1, lines 88 and/or 89, as applicable. These wage-related costs are reported separately on line
24.
Lines 26 through 43--Enter the direct wages and salaries from Worksheet A column 1 for the
appropriate cost center identified on lines 26 through 43, respectively, increased by the amounts paid
for vacation, holiday, sick, and PTO if not reported in column 1 of these lines. These lines provide
for the collection of hospital wage data for overhead costs to properly allocate the salary portion of
the overhead costs to the appropriate service areas for excluded units. These lines are completed by
all hospitals if the ratio of Part II, column 5, sum of lines 9 and 10 divided by the result of column 5,
line 1 minus the sum of lines 2, 3, 5, 6, 7, and 8 equals or exceeds a threshold of 15 percent.
However, all hospitals with a ratio greater than 5 percent must complete line 7 of Part III for all
columns. Calculate the percent to two decimal places for purposes of rounding.
Lines 28, 33, and 35--Enter the amount paid for services performed under contract, rather than by
employees, for administrative and general, housekeeping, and dietary services, respectively. DO
NOT include costs for equipment, supplies, travel expenses, and other miscellaneous or overhead
items. Report only personnel costs associated with these contracts. Continue to report on the
standard lines (line 27, 32, and 34), the amounts paid for services rendered by employees not under
contract.
Line 28--A&G costs are expenses a hospital incurs in carrying out its administrative and/or general
management functions. Include on line 28 the contract services that are included on Worksheet A,
line 5 and subscripts, column 2 (“Administrative and General”). Contract information and data
processing services, legal, tax preparation, cost report preparation, and purchasing services are
examples of contract labor costs that would be included on Worksheet S-3, Part II, line 28. Do not
include on line 28 the costs for top level management contracts (these costs are reported on line 11).
NOTE: Do not include overhead costs on lines 11 and 12.
Column 3--Enter on each line, as appropriate, the salary portion of any reclassifications made on
Worksheet A-6.
Column 4--Enter on each line the result of column 2 plus or minus column 3.
Column 5--Enter on each line the number of paid hours corresponding to the amounts reported in
column 4. Paid hours include regular hours (including paid lunch hours), overtime hours, paid
holiday, vacation and sick leave hours, paid time-off hours, and hours associated with severance pay.
For Part II, lines 1 through 15 (including subscripts), lines 26 through 43 (including subscripts), and
Part III, line 7, if the hours cannot be determined, then the associated salaries must not be included in
columns 2 through 4.
NOTE: The hours must reflect any change reported in column 3; For employees who work a
regular work schedule, on call hours are not to be included in the total paid hours (on call
hours should only relate to hours associated to a regular work schedule; overtime hours are
calculated as one hour when an employee is paid time and a half. No hours are required
for bonus pay. The intern and resident hours associated with the salaries reported on line 6
must be based on 2080 hours per year for each full time intern and resident employee. The
hours reported for salaried employees who are paid a fixed rate are recorded as 40 hours
per week or the number of hours in your standard work week.
NOTE: For workers who are contracted solely for the purpose of providing services on-call, the
wages and associated hours must be included on the appropriate contract labor line on
Worksheet S-3.
Column 6--Enter on all lines (except lines 17 through 25) the average hourly wage resulting from
dividing column 4 by column 5.
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Rev. 1