Identification, Utilization, Statistical Data

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Worksheet SectionDescriptionReference
Wkst. S, Parts II Hospital and Hospital Health Care Complex Cost Report Certification and Settlement Summary3603-3603.2
Wkst. S-2 Hospital and Hospital Health Care Complex Identification Data3604
Wkst. S-3, Part IHospital and Hospital Health Care Complex Statistical Data3605-3605.1
Wkst. S-3, Parts II-III Hospital Wage Index Information3605.2-3605.3
Wkst. S-4 Hospital-Based Home Health Agency Statistical Data3606
Wkst. S-5 Hospital Renal Dialysis Department Statistical Data3607
Wkst. S-6Hospital-Based Outpatient Rehabilitation Provider Data3608.1
Wkst. S-7NHCMQ Demonstration Statistical Data and Prospective Payment for Skilled Nursing Facilities (July 1, 1998)3609
Wkst. S-8Provider-Based Rural Health Clinic/Federally Qualified Health Center Provider Statistical Data (1/98)3608.2
Wkst. S-9, Parts I & IIHospice Identification Data-Enrollment Days Based on Level of Care3609.1-3609.3
Wkst. S-10Hospital Uncompensated Care Data3609.4

Reclassification And Adjustment Of Trial Balance Of Expenses

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Worksheet SectionDescriptionReference
Wkst. A Reclassification and Adjustment of Trial Balance of Expenses3610
Wkst. A-7, Part I & IIAnalysis of Changes in Old Capital Asset Balances and Part II Analysis of Changes in New Capital Asset Balances3612-3612.1
Wkst. A-7, Part III & IVReconciliation of Capital Cost Centers and Reconciliation of Amounts from Wkst A3612.2-3612.3
Wkst. A-8 Adjustments to Expenses3613
Wkst. A-8-1 Statement of Costs of Services From Related Organizations and Home Office Costs3614
Wkst. A-8-2 Provider-Based Physician Adjustments3615
Wkst. A-8-4, Parts I-VII Reasonable Cost Determination for Therapy Service Furnished after April 10, 1998 by Outside Suppliers3616.8-3616.15
Wkst. A-8-4, Part I General Information3616.9
Wkst. A-8-4, Part II Salary Equivalency Computation3616.1
Wkst. A-8-4, Part III Standard and Optional Travel Allowance and Travel Expense Computation3616.11
Wkst. A-8-4, Part IV Standard Travel Allowance and Standard Travel Expense - Off Site Services3616.12
Wkst. A-8-4, Part V Overtime Computation3616.13
Wkst. A-8-4, Part VI Computation of Therapy Limitation and Excess Cost Adjustment3616.14
Wkst. A-8-4, Part VII Allocation of Physical Therapy Excess Cost Over Limitation for Non-Shared Therapy Department Services3616.15

Cost and Cost Allocation

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Worksheet SectionDescriptionReference
Wkst. B, Part I Cost Allocation - General Service Cost and3617
Wkst. B, Part II Allocation of Old Capital-Related Costs3618
Wkst. B, Part III Allocation of New Capital-Related Costs3618
Wkst. B-1 Cost Allocation - Statistical Basis3617

Computation of Ratio of Costs to Charges

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Worksheet SectionDescriptionReference
Wkst. C, Part I Computation of Ratio of Cost to Charges3620
Wkst. C, Part II Calculation of Outpatient Services Cost to Charge Ratios Net of Reductions3620.2
Wkst. C, Part III Computation of Total Inpatient Ancillary Costs - Rural Primary Care Hospitals3620.3
Wkst. C, Part IV Computation of Inpatient Operating Cost - Rural Primary Care Hospitals3620.4
Wkst. C, Part V Computation of Outpatient Cost Per Visit -Rural Primary Care Hospitals3620.5

Apportionment of Inpatient Cost (Routine, Ancillary, Capital), Computation of Operating Cost

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Worksheet SectionDescriptionReference
Wkst. D, Part I Apportionment of Inpatient Routine Service Capital Costs3621
Wkst. D, Part II Apportionment of Inpatient Ancillary Service Capital Costs3621.2
Wkst. D, Part III Apportionment of Inpatient Routine Service Other Pass Through Costs3621.3
Wkst. D, Part IV Apportionment of Inpatient Ancillary Service Other Pass Through Costs3621.4
Wkst. D, Part V Apportionment of Medical and Other Health Services Costs3621.5
Wkst. D, Part VI Vaccine Cost Apportionment3621.6
Wkst. D-1, Part I Computation of Inpatient Operating Cost: All Provider Components3622
Wkst. D-1, Part II Computation of Inpatient Operating Cost: Hospital and Subproviders Only3622.2
Wkst. D-1, Part III Computation of Inpatient Operating Cost: Skilled Nursing Facility and Other Nursing Facility Only3622.3
Wkst. D-1, Part IV Computation of Inpatient Operating Cost: Computation of Observation Bed Cost3622.4
Wkst. D-2Apportionment of Cost of Services Rendered by I&R3623
Wkst. D-2, Part I Apportionment of Cost of Services Rendered by I&R: Not in Approved Teaching Program3623.1
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 XVIII3623.3
Wkst. D-4Inpatient Ancillary Service Cost Apportionment3624
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 Charges3625.3
Wkst. D-6, Part IV Computation of Organ Acquisition Costs and Charges: Statistics3625.4

Calculation of Reimbursement Settlement

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Worksheet SectionDescriptionReference
Wkst. E, Part A Calculation of Reimbursement Settlement: Inpatient Hospital Services Under PPS3630
Wkst. E, Part B Calculation of Reimbursement Settlement: Medical and Other Health Services3630.2
Wkst. E, Part C Calculation of Reimbursement Settlement: Outpatient Ambulatory Surgical Center3630.3
Wkst. E, Part D Calculation of Reimbursement Settlement: Outpatient Radiology Services3630.4
Wkst. E, Part E Calculation of Reimbursement Settlement: Other Outpatient Diagnostic Procedures3630.5
Wkst. E-1 Analysis of Payments to Providers for Services Rendered3631
Wkst. E-2Calculation of Reimbursement Settlement - Swing Beds3632
Wkst. E-3, Part I Calculation of Medicare Reimbursement Settlement Under TEFRA3633
Wkst. E-3, Part II Calculation of Reimbursement Settlement for Medicare Part A Services - Cost Reimbursement3633.2
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 SNFs3633.3
Wkst. E-3, Part IV Direct Graduate Medical Education and ESRD Outpatient Direct Medical Education Costs3633.4
Wkst. E-3, Part V Calculation of NHCMQ Demonstration Reimbursement Settlement for Medicare Part A Services3633.5
Wkst. E-3, Part VICalculation of Reimbursement Settlement: Calculation of GME and IME PaymentsFor Redistribution of Unused Residency Slots3633.6

Financial Statements

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Worksheet SectionDescriptionReference
Wkst. GFinancial Statements: Balance Sheet3640
Wkst. G-2Financial Statements: Statement of Patient Revenues and Operating Expenses3640
Wkst. G-3Financial Statements: Statement of Revenues and Expenses3640

Provider Based Home Health Agency

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Worksheet SectionDescriptionReference
Wkst. HAnalysis of Provider-Based Home Health Agency Costs3641
Wkst. H-1Compensation Analysis - Salaries and Wages3642
Wkst. H-2Compensation Analysis - Employee Benefits (Payroll-Related)3643
Wkst. H-3Compensation Analysis - Contracted Services/Purchased Services3644
Wkst. H-4Cost Allocation HHA Statistical Basis3645
Wkst. H-5Allocation of General Service Costs to HHA Cost Centers3646
Wkst. H-5, Part I Allocation of General Service Costs to HHA Cost Centers3646.1
Wkst. H-5, Part II Allocation of General Service Costs to HHA Cost Centers-Statistical Basis3646.2
Wkst. H-6Apportionment of Patient Service Costs3647
Wkst. H-6, Part I Apportionment of Patient Service Costs3647.1
Wkst. H-6, Part II Apportionment of HHA Costs Shared Services3647.2
Wkst. H-6, Part III Outpatient Therapy Reduction Computation3647.3
Wkst. H-7Calculation of HHA Reimbursement Settlement3648
Wkst. H-7, Part I Calculation of HHA Reimbursement Settlement3648.1
Wkst. H-7, Part II Calculation of HHA Reimbursement Settlement3648.2
Wkst. H-8Analysis of Payments to Provider-Based Home Health Agencies for Services Rendered to program Beneficiaries3649

Provider Based Renal Dialysis

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Worksheet SectionDescriptionReference
Wkst. IAnalysis of Renal Dialysis Department Costs3650
Wkst. I-1Analysis of Renal Cost3651
Wkst. I-2Allocation of Renal Department Costs to Treatment Modalities3652
Wkst. I-3Direct and Indirect Renal Dialysis Cost Allocation - Statistical Basis3653
Wkst. I-4Computation of Average Cost Per Treatment for Outpatient Renal Dialysis3654
Wkst. I-5Calculation of Reimbursable Bad Debts - Title XVIII, Part B3655

Provider Based CORF

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Worksheet SectionDescriptionReference
Wkst. J-1Allocation of General Service Costs to Outpatient Rehabilitation Provider Cost Centers3656
Wkst. J-1, Part ICost Allocation - General Service Costs and Statistical Basis3656.1
Wkst. J-1, Part II Cost Allocation - General Service Costs and Statistical Basis3656.2
Wkst. J-2Computation of Outpatient Rehabilitation Provider Costs3657
Wkst. J-2, Part I Apportionment of Outpatient Rehabilitation Provider Costs3657.1
Wkst. J-2, Part II Apportionment of Costs of Outpatient Rehabilitation Provider Services Furnished by Shared Hospital Departments3657.2
Wkst. J-3Calculation of Reimbursement Settlement - Outpatient Rehabilitation Provider Services3658
Wkst. J-4Analysis of Payments to Hospital-Based Outpatient Rehabilitation Provider for Services Rendered to Program Beneficiaries3659

Provider Based Hospice

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Worksheet SectionDescriptionReference
Wkst. KAnalysis of Provider-Based Hospice Costs3634
Wkst. K-1Compensation Analysis - Salaries and Wage3634.1
Wkst. K-2Compensation Analysis - Employee Benefits (Payroll Related)3634.2
Wkst. K-3Compensation Analysis - Contracted Services/Purchased Services3634.3
Wkst. K-4, Part ICost Allocation - General Service Costs3634.4
Wkst. K-4, Part II Cost Allocation - General Service Costs and Statistical Basis3634.4
Wkst. K-5, Part I Allocation of General Service Costs to Hospice Cost Centers3634.5
Wkst. K-5, Part II Allocation of General Service Costs to Hospice Cost Centers-Statistical Basis3634.7
Wkst. K-5, Part III Apportionment of Hospice Shared Services3634.8
Wkst. K-6Calculation of Per Diem Cost3634.9

Computation of Medicare Capital Payment

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Worksheet SectionDescriptionReference
Wkst. LCalculation of Capital Payment3660
Wkst. L, Part I Fully Prospective Method3660.1
Wkst. L, Part II Hold Harmless Method3660.2
Wkst. L, Part III Payment Under Reasonable Cost3660.3
Wkst. L, Part IV Computation of Exception Payments3660.4
Wkst. L-1Allocation of Allowable Costs for Extraordinary Circumstances3661
Wkst. L-1, Part I Allocation of Allowable Costs for Extraordinary Circumstances3661.1
Wkst. L-1, Part II Allocation of Program Inpatient Routine Capital Costs for Extraordinary Circumstances3661.2
Wkst. L-1, Part III Allocation of Program Inpatient Ancillary Capital Costs for Extraordinary Circumstances3661.3

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Worksheet SectionDescriptionReference
Wkst. M-1Analysis of Provider Based Rural Health Clinic Federally Qualified Health Center Costs3662
Wkst. M-2Allocation of Overhead to RHC/FQHC Services3663
Wkst. M-3Calculation of Reimbursement Settlement for RHC/FQHC Services3664
Wkst. M-4Computation of Pneumococcal and Influenza Vaccine Cost3665
Wkst. M-5 Analysis of Payments to Hospital-Based RHC/FQHC Services Rendered to Program Beneficiaries3666