Identification, Utilization, Statistical Data
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Worksheet Section | Description | Reference |
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Wkst. S, Parts II | Hospital and Hospital Health Care Complex Cost Report Certification and Settlement Summary | 3603-3603.2 |
Wkst. S-2 | Hospital and Hospital Health Care Complex Identification Data | 3604 |
Wkst. S-3, Part I | Hospital and Hospital Health Care Complex Statistical Data | 3605-3605.1 |
Wkst. S-3, Parts II-III | Hospital Wage Index Information | 3605.2-3605.3 |
Wkst. S-4 | Hospital-Based Home Health Agency Statistical Data | 3606 |
Wkst. S-5 | Hospital Renal Dialysis Department Statistical Data | 3607 |
Wkst. S-6 | Hospital-Based Outpatient Rehabilitation Provider Data | 3608.1 |
Wkst. S-7 | NHCMQ Demonstration Statistical Data and Prospective Payment for Skilled Nursing Facilities (July 1, 1998) | 3609 |
Wkst. S-8 | Provider-Based Rural Health Clinic/Federally Qualified Health Center Provider Statistical Data (1/98) | 3608.2 |
Wkst. S-9, Parts I & II | Hospice Identification Data-Enrollment Days Based on Level of Care | 3609.1-3609.3 |
Wkst. S-10 | Hospital Uncompensated Care Data | 3609.4 |
Reclassification And Adjustment Of Trial Balance Of Expenses
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Worksheet Section | Description | Reference |
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Wkst. A | Reclassification and Adjustment of Trial Balance of Expenses | 3610 |
Wkst. A-7, Part I & II | Analysis of Changes in Old Capital Asset Balances and Part II Analysis of Changes in New Capital Asset Balances | 3612-3612.1 |
Wkst. A-7, Part III & IV | Reconciliation of Capital Cost Centers and Reconciliation of Amounts from Wkst A | 3612.2-3612.3 |
Wkst. A-8 | Adjustments to Expenses | 3613 |
Wkst. A-8-1 | Statement of Costs of Services From Related Organizations and Home Office Costs | 3614 |
Wkst. A-8-2 | Provider-Based Physician Adjustments | 3615 |
Wkst. A-8-4, Parts I-VII | Reasonable Cost Determination for Therapy Service Furnished after April 10, 1998 by Outside Suppliers | 3616.8-3616.15 |
Wkst. A-8-4, Part I | General Information | 3616.9 |
Wkst. A-8-4, Part II | Salary Equivalency Computation | 3616.1 |
Wkst. A-8-4, Part III | Standard and Optional Travel Allowance and Travel Expense Computation | 3616.11 |
Wkst. A-8-4, Part IV | Standard Travel Allowance and Standard Travel Expense - Off Site Services | 3616.12 |
Wkst. A-8-4, Part V | Overtime Computation | 3616.13 |
Wkst. A-8-4, Part VI | Computation of Therapy Limitation and Excess Cost Adjustment | 3616.14 |
Wkst. A-8-4, Part VII | Allocation of Physical Therapy Excess Cost Over Limitation for Non-Shared Therapy Department Services | 3616.15 |
Cost and Cost Allocation
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Worksheet Section | Description | Reference |
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Wkst. B, Part I | Cost Allocation - General Service Cost and | 3617 |
Wkst. B, Part II | Allocation of Old Capital-Related Costs | 3618 |
Wkst. B, Part III | Allocation of New Capital-Related Costs | 3618 |
Wkst. B-1 | Cost Allocation - Statistical Basis | 3617 |
Computation of Ratio of Costs to Charges
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Worksheet Section | Description | Reference |
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Wkst. C, Part I | Computation of Ratio of Cost to Charges | 3620 |
Wkst. C, Part II | Calculation of Outpatient Services Cost to Charge Ratios Net of Reductions | 3620.2 |
Wkst. C, Part III | Computation of Total Inpatient Ancillary Costs - Rural Primary Care Hospitals | 3620.3 |
Wkst. C, Part IV | Computation of Inpatient Operating Cost - Rural Primary Care Hospitals | 3620.4 |
Wkst. C, Part V | Computation of Outpatient Cost Per Visit -Rural Primary Care Hospitals | 3620.5 |
Apportionment of Inpatient Cost (Routine, Ancillary, Capital), Computation of Operating Cost
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Worksheet Section | Description | Reference |
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Wkst. D, Part I | Apportionment of Inpatient Routine Service Capital Costs | 3621 |
Wkst. D, Part II | Apportionment of Inpatient Ancillary Service Capital Costs | 3621.2 |
Wkst. D, Part III | Apportionment of Inpatient Routine Service Other Pass Through Costs | 3621.3 |
Wkst. D, Part IV | Apportionment of Inpatient Ancillary Service Other Pass Through Costs | 3621.4 |
Wkst. D, Part V | Apportionment of Medical and Other Health Services Costs | 3621.5 |
Wkst. D, Part VI | Vaccine Cost Apportionment | 3621.6 |
Wkst. D-1, Part I | Computation of Inpatient Operating Cost: All Provider Components | 3622 |
Wkst. D-1, Part II | Computation of Inpatient Operating Cost: Hospital and Subproviders Only | 3622.2 |
Wkst. D-1, Part III | Computation of Inpatient Operating Cost: Skilled Nursing Facility and Other Nursing Facility Only | 3622.3 |
Wkst. D-1, Part IV | Computation of Inpatient Operating Cost: Computation of Observation Bed Cost | 3622.4 |
Wkst. D-2 | Apportionment of Cost of Services Rendered by I&R | 3623 |
Wkst. D-2, Part I | Apportionment of Cost of Services Rendered by I&R: Not in Approved Teaching Program | 3623.1 |
Wkst. D-2, Part II | Apportionment of Cost of Services Rendered by I&R: In Approved Teaching Program (Title XVIII, Part B Inpatient Routine Costs Only) | 3623.2 |
Wkst. D-2, Part III | Apportionment of Cost of Services Rendered by I&R: Summary for Title XVIII | 3623.3 |
Wkst. D-4 | Inpatient Ancillary Service Cost Apportionment | 3624 |
Wkst. D-6, Part I | Computation of Organ Acquisition Costs (Inpatient Routine and Ancillary Services) | 3625 |
Wkst. D-6, Part II | Computation of Organ Acquisition Costs (Other Than Inpatients Routine and Ancillary Service Costs) | 3625.2 |
Wkst. D-6, Part III | Computation of Organ Acquisition Costs and Charges: Summary of Costs and Charges | 3625.3 |
Wkst. D-6, Part IV | Computation of Organ Acquisition Costs and Charges: Statistics | 3625.4 |
Calculation of Reimbursement Settlement
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Worksheet Section | Description | Reference |
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Wkst. E, Part A | Calculation of Reimbursement Settlement: Inpatient Hospital Services Under PPS | 3630 |
Wkst. E, Part B | Calculation of Reimbursement Settlement: Medical and Other Health Services | 3630.2 |
Wkst. E, Part C | Calculation of Reimbursement Settlement: Outpatient Ambulatory Surgical Center | 3630.3 |
Wkst. E, Part D | Calculation of Reimbursement Settlement: Outpatient Radiology Services | 3630.4 |
Wkst. E, Part E | Calculation of Reimbursement Settlement: Other Outpatient Diagnostic Procedures | 3630.5 |
Wkst. E-1 | Analysis of Payments to Providers for Services Rendered | 3631 |
Wkst. E-2 | Calculation of Reimbursement Settlement - Swing Beds | 3632 |
Wkst. E-3, Part I | Calculation of Medicare Reimbursement Settlement Under TEFRA | 3633 |
Wkst. E-3, Part II | Calculation of Reimbursement Settlement for Medicare Part A Services - Cost Reimbursement | 3633.2 |
Wkst. E-3, Part III | Calculation of Reimbursement Settlement All Other Health Services for Titles V or XIX Services and Part A Services for Title XVIII PPS and SNFs | 3633.3 |
Wkst. E-3, Part IV | Direct Graduate Medical Education and ESRD Outpatient Direct Medical Education Costs | 3633.4 |
Wkst. E-3, Part V | Calculation of NHCMQ Demonstration Reimbursement Settlement for Medicare Part A Services | 3633.5 |
Wkst. E-3, Part VI | Calculation of Reimbursement Settlement: Calculation of GME and IME PaymentsFor Redistribution of Unused Residency Slots | 3633.6 |
Financial Statements
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Worksheet Section | Description | Reference |
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Wkst. G | Financial Statements: Balance Sheet | 3640 |
Wkst. G-2 | Financial Statements: Statement of Patient Revenues and Operating Expenses | 3640 |
Wkst. G-3 | Financial Statements: Statement of Revenues and Expenses | 3640 |
Provider Based Home Health Agency
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Worksheet Section | Description | Reference |
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Wkst. H | Analysis of Provider-Based Home Health Agency Costs | 3641 |
Wkst. H-1 | Compensation Analysis - Salaries and Wages | 3642 |
Wkst. H-2 | Compensation Analysis - Employee Benefits (Payroll-Related) | 3643 |
Wkst. H-3 | Compensation Analysis - Contracted Services/Purchased Services | 3644 |
Wkst. H-4 | Cost Allocation HHA Statistical Basis | 3645 |
Wkst. H-5 | Allocation of General Service Costs to HHA Cost Centers | 3646 |
Wkst. H-5, Part I | Allocation of General Service Costs to HHA Cost Centers | 3646.1 |
Wkst. H-5, Part II | Allocation of General Service Costs to HHA Cost Centers-Statistical Basis | 3646.2 |
Wkst. H-6 | Apportionment of Patient Service Costs | 3647 |
Wkst. H-6, Part I | Apportionment of Patient Service Costs | 3647.1 |
Wkst. H-6, Part II | Apportionment of HHA Costs Shared Services | 3647.2 |
Wkst. H-6, Part III | Outpatient Therapy Reduction Computation | 3647.3 |
Wkst. H-7 | Calculation of HHA Reimbursement Settlement | 3648 |
Wkst. H-7, Part I | Calculation of HHA Reimbursement Settlement | 3648.1 |
Wkst. H-7, Part II | Calculation of HHA Reimbursement Settlement | 3648.2 |
Wkst. H-8 | Analysis of Payments to Provider-Based Home Health Agencies for Services Rendered to program Beneficiaries | 3649 |
Provider Based Renal Dialysis
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Worksheet Section | Description | Reference |
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Wkst. I | Analysis of Renal Dialysis Department Costs | 3650 |
Wkst. I-1 | Analysis of Renal Cost | 3651 |
Wkst. I-2 | Allocation of Renal Department Costs to Treatment Modalities | 3652 |
Wkst. I-3 | Direct and Indirect Renal Dialysis Cost Allocation - Statistical Basis | 3653 |
Wkst. I-4 | Computation of Average Cost Per Treatment for Outpatient Renal Dialysis | 3654 |
Wkst. I-5 | Calculation of Reimbursable Bad Debts - Title XVIII, Part B | 3655 |
Provider Based CORF
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Worksheet Section | Description | Reference |
---|---|---|
Wkst. J-1 | Allocation of General Service Costs to Outpatient Rehabilitation Provider Cost Centers | 3656 |
Wkst. J-1, Part I | Cost Allocation - General Service Costs and Statistical Basis | 3656.1 |
Wkst. J-1, Part II | Cost Allocation - General Service Costs and Statistical Basis | 3656.2 |
Wkst. J-2 | Computation of Outpatient Rehabilitation Provider Costs | 3657 |
Wkst. J-2, Part I | Apportionment of Outpatient Rehabilitation Provider Costs | 3657.1 |
Wkst. J-2, Part II | Apportionment of Costs of Outpatient Rehabilitation Provider Services Furnished by Shared Hospital Departments | 3657.2 |
Wkst. J-3 | Calculation of Reimbursement Settlement - Outpatient Rehabilitation Provider Services | 3658 |
Wkst. J-4 | Analysis of Payments to Hospital-Based Outpatient Rehabilitation Provider for Services Rendered to Program Beneficiaries | 3659 |
Provider Based Hospice
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Worksheet Section | Description | Reference |
---|---|---|
Wkst. K | Analysis of Provider-Based Hospice Costs | 3634 |
Wkst. K-1 | Compensation Analysis - Salaries and Wage | 3634.1 |
Wkst. K-2 | Compensation Analysis - Employee Benefits (Payroll Related) | 3634.2 |
Wkst. K-3 | Compensation Analysis - Contracted Services/Purchased Services | 3634.3 |
Wkst. K-4, Part I | Cost Allocation - General Service Costs | 3634.4 |
Wkst. K-4, Part II | Cost Allocation - General Service Costs and Statistical Basis | 3634.4 |
Wkst. K-5, Part I | Allocation of General Service Costs to Hospice Cost Centers | 3634.5 |
Wkst. K-5, Part II | Allocation of General Service Costs to Hospice Cost Centers-Statistical Basis | 3634.7 |
Wkst. K-5, Part III | Apportionment of Hospice Shared Services | 3634.8 |
Wkst. K-6 | Calculation of Per Diem Cost | 3634.9 |
Computation of Medicare Capital Payment
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Worksheet Section | Description | Reference |
---|---|---|
Wkst. L | Calculation of Capital Payment | 3660 |
Wkst. L, Part I | Fully Prospective Method | 3660.1 |
Wkst. L, Part II | Hold Harmless Method | 3660.2 |
Wkst. L, Part III | Payment Under Reasonable Cost | 3660.3 |
Wkst. L, Part IV | Computation of Exception Payments | 3660.4 |
Wkst. L-1 | Allocation of Allowable Costs for Extraordinary Circumstances | 3661 |
Wkst. L-1, Part I | Allocation of Allowable Costs for Extraordinary Circumstances | 3661.1 |
Wkst. L-1, Part II | Allocation of Program Inpatient Routine Capital Costs for Extraordinary Circumstances | 3661.2 |
Wkst. L-1, Part III | Allocation of Program Inpatient Ancillary Capital Costs for Extraordinary Circumstances | 3661.3 |
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Worksheet Section | Description | Reference |
---|---|---|
Wkst. M-1 | Analysis of Provider Based Rural Health Clinic Federally Qualified Health Center Costs | 3662 |
Wkst. M-2 | Allocation of Overhead to RHC/FQHC Services | 3663 |
Wkst. M-3 | Calculation of Reimbursement Settlement for RHC/FQHC Services | 3664 |
Wkst. M-4 | Computation of Pneumococcal and Influenza Vaccine Cost | 3665 |
Wkst. M-5 | Analysis of Payments to Hospital-Based RHC/FQHC Services Rendered to Program Beneficiaries | 3666 |