Hospitals and Health Care Complex Cost Report (CMS-2552-96)

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Overview

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Sheet 1: I1

DRAFT			FORM CMS-2552-10				4090 (Cont.)
ANALYSIS OF RENAL DIALYSIS DEPARTMENT COSTS				PROVIDER NO.	PERIOD:	WORKSHEET I-1
				______________	FROM__________
					TO____________
Check applicable box:		[ ] Renal Dialysis Department [ ] Home Program Dialysis
			TOTAL			FTEs per
			COSTS	BASIS	STATISTICS	2080 Hours
			1	2	3	4
1	Registered Nurses			Hours of Service			1
2	Licensed Practical Nurses			Hours of Service			2
3	Nurses Aides			Hours of Service			3
4	Technicians			Hours of Service			4
5	Social Workers			Hours of Service			5
6	Dieticians			Hours of Service			6
7	Physicians			Accumulated Cost			7
8	Non-patient Care Salary			Accumulated Cost			8
9	Subtotal (sum of lines 1-8)						9
10	Employee Benefits			Salary			10
11	Capital Related Costs-Bldgs. & Fixtures			Square Feet			11
12	Capital Related Costs-Mov. Equip.			Percentage of Time			12
13	Machine Costs & Repairs			Percentage of Time			13
14	Supplies			Requisitions			14
15	Drugs			Requisitions			15
16	Other			Accumulated Cost			16
17	Subtotal (sum of lines 9-16)*						17
18	Capital Related Costs-Bldgs. & Fixtures			Square Feet			18
19	Capital Related Costs-Mov. Equip.			Percentage of Time			19
20	Employee Benefits			Salary			20
21	Administrative and General			Accumulated Cost			21
22	Maint./Repairs-Operation-Housekeeping			Square Feet			22
23	Medical Education Program Costs						23
24	Central Services & Supplies			Requisitions			24
25	Pharmacy			Requisitions			25
26	Other Allocated Costs			Accumulated Cost			26
27	Subtotal (sum of lines 17-26)*						27
28	Laboratory (see instructions)			Charges			28
29	Respiratory Therapy (see instructions)			Charges			29
30	Other (see instructions)			Charges			30
31	Total costs (sum of lines 27-30)						31
	* Line 17, column 1 should agree with Worksheet A, column 7 for line 71 or line 94 as appropriate,
	and line 27, column 1 should agree with Worksheet B, Part I, column 26 for line 71 or line 94 as appropriate.
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4048)
Rev. 1							40-617
ALLOCATION METHOD
Statistics	Exception Requests
Charges	No S/W I-2 Part II
Weighted Treatments	I/P = 2
	O/P & Home = 1
	Training = 3

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Sheet 2: I2

4090 (Cont.)				FORM CMS-2552-10									DRAFT
ALLOCATION OF RENAL DEPARTMENT COSTS TO TREATMENT MODALITIES							PROVIDER NO.:		PERIOD:		WORKSHEET I-2
							________________		FROM __________
									TO _____________
Check applicable box:		[ ] Renal Dialysis Department [ ] Home Program Dialysis
OUTPATIENT SERVICES
COMPOSITE PAYMENT RATE		CAPITAL AND		DIRECT PATIENT					ROUTINE	SUBTOTAL		TOTAL
		RELATED COSTS		CARE SALARY		EMPLOYEE		MEDICAL	ANCILLARY	(sum of		(col. 9 +
		BUILDING	EQUIPMENT	RNs	OTHER	BENEFITS	DRUGS	SUPPLIES	SERVICES	cols. 1-8)	OVERHEAD	col. 10)
		1	2	3	4	5	6	7	8	9	10	11
1	Total Renal Department Costs												1
	MAINTENANCE
2	Hemodialysis												2
3	Intermittent Peritoneal												3
	TRAINING
4	Hemodialysis												4
5	Intermittent Peritoneal												5
6	CAPD												6
7	CCDP												7
	HOME
8	Hemodialysis												8
9	Intermittent Peritoneal												9
10	CAPD												10
11	CCDP												11
	OTHER BILLABLE SERVICES
12	Inpatient Dialysis												12
13	Method II Home Patient												13
14	EPO (included in Renal Department)												14
15	ARENESP (included in Renal Department)												15
16	Other												16
17	Total (sum of lines 2-16)												17
18	Medical Educational Program Costs												18
19	Total Renal Costs (line 17 + line 18)												19
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4049)
40-618													Rev. 1

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Sheet 3: I3

DRAFT				FORM CMS-2552-10								4090 (Cont.)
DIRECT AND INDIRECT RENAL DIALYSIS COST ALLOCATION -					PROVIDER NO.:			PERIOD:		WORKSHEET I-3
STATISTICAL BASIS					_			FROM __________
								TO _____________
Check applicable box:		[ ] Renal Dialysis Department [ ] Home Program Dialysis
		CAPITAL AND
		RELATED COSTS		DIRECT PATIENT					ROUTINE
		BUILDING	EQUIPMENT	CARE SALARY		EMPLOYEE		MEDICAL	ANCILLARY		OVERHEAD
	COMPOSITE PAYMENT SERVICES	(SQUARE	(% OF	RNs	OTHERS	BENEFITS	DRUGS	SUPPLIES	SERVICES	SUB-	(ACCUM.
		FEET)	TIME)	(HOURS)	(HOURS)	(SALARY)	(REQUIST.)	(REQUIST.)	(CHARGES)	TOTAL	COST)
		1	2	3	4	5	6	7	8	9	10
1	Total Renal Department Costs											1
	MAINTENANCE
2	Hemodialysis											2
3	Intermittent Peritoneal											3
	TRAINING
4	Hemodialysis											4
5	Intermittent Peritoneal											5
6	CAPD											6
7	CCDP											7
	HOME
8	Hemodialysis											8
9	Intermittent Peritoneal											9
10	CAPD											10
11	CCDP											11
	OTHER BILLABLE SERVICES
12	Inpatient Dialysis Treatments __________											12
13	Method II Home Patient											13
14	EPO											14
15	ARENESP											15
16	Other											16
17	Total Statistical Basis											17
18	Unit Cost Multiplier (line 1 ÷ line 17)											18
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4050)
Rev. 1												40-619

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Sheet 4: I4

4090 (Cont.)			FORM CMS-2552-10							DRAFT
COMPUTATION OF AVERAGE COST PER TREATMENT					PROVIDER NO.:		PERIOD:		WORKSHEET I-4
FOR OUTPATIENT RENAL DIALYSIS					___________________		FROM ____________
							TO ________________
Check applicable box:		[ ] Renal Dialysis Department	[ ] Home Program Dialysis
					Average Cost		Total
			Number	Total Cost	of Program	Number	Program	Total	Average
			of Total	(from Wkst.	Treatments	of Program	Expenses	Program	Payment Rate
			Treatments	I-2, col. 11)	(col. 2 ÷ col. 1)	Treatments	(col. 4 x col. 3)	Payment	(col. 6 ÷ col. 4)
			1	2	3	4	5	6	7
1	Maintenance - Hemodialysis									1
2	Maintenance - Peritoneal Dialysis									2
3	Training - Hemodialysis									3
4	Training - Peritoneal Dialysis									4
5	Training - Continuous Ambulatory Peritoneal Dialysis									5
6	Training - Continuous Cycling Peritoneal Dialysis									6
7	Home Program - Hemodialysis									7
8	Home Program - Peritoneal Dialysis									8
			Patient Weeks			Patient Weeks
9	Home Program - Continuous Ambulatory Peritoneal Dialysis									9
10	Home Program - Continuous Cycling Peritoneal Dialysis									10
11	Totals (sum of lines 1-8, columns 1 and 4)									11
	(sum of lines 1-10, columns 2, 5, and 7)
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4051)
40-620										Rev. 1

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Sheet 5: I5

4090 (Cont.)		FORM CMS-2552-10				DRAFT
CALCULATION OF REIMBURSABLE			PROVIDER NO.:	PERIOD:	WORKSHEET I-5
BAD DEBTS - TITLE XVIII - PART B			________________	FROM ___________
				TO ______________
	Description
1	Total expenses related to care of program beneficiaries (see instructions)					1
2	Total payment (from Worksheet I-4, column 6, line 11)					2
3	Deductibles billed to Medicare (Part B) patients					3
4	Coinsurance billed to Medicare (Part B) patients					4
5	Bad debts for deductibles and coinsurance, net of bad debt recoveries					5
6						6
7	Reimbursable bad debts for dual eligible beneficiaries (see instructions)					7
8	Net deductibles and coinsurance billed to Medicare (Part B) patients (sum of lines 3 and 4 less line 5)					8
9	Program payment (line 2 less line 3, times 80 percent)					9
10	Unrecovered from Medicare (Part B) patients (Lesser of line 1 or line 2 minus the sum of lines 7 and 8.					10
	If negative, enter zero and do not complete line 11.)
11	Reimbursable bad debts (lesser of line 10 or line 5) (transfer to Worksheet E, Part B, line 33)					11
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4052)
Rev. 1						40-621