Identification, Utilization, Statistical Data
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| Worksheet Section | Description | Reference |
|---|---|---|
| Wkst. S, Parts I, II, III | Hospital and Hospital Health Care Complex Cost Report Certification and Settlement Summary | 4003-4003.3 |
| Wkst. S-2 , Parts I, II | Hospital and Hospital Health Care Complex Identification Data & Reimbursement Questionnaire | 4004-4004.2 |
| Wkst. S-3, Part I | Hospital and Hospital Health Care Complex Statistical Data | 4005-4005.1 |
| Wkst. S-3, Parts II-III | Hospital Wage Index Information | 4005.2-4005.3 |
| Wkst. S-3, Parts IV | Hospital Wage Related Cost | 4005.4 |
| Wkst. S-3, Parts V | Hospital and Health Care Complex Contract Labor and Benefit Cost | 4005.5 |
| Wkst. S-4 | Hospital-Based Home Health Agency Statistical Data | 4006 |
| Wkst. S-5 | Hospital Renal Dialysis Department Statistical Data | 4007 |
| Wkst. S-6 | Hospital-Based Outpatient Rehabilitation Provider Data | 4008 |
| Wkst. S-7 | Statistical Data and Prospective Payment for Skilled Nursing Facilities | 4009 |
| Wkst. S-8 | Provider-Based Rural Health Clinic/Federally Qualified Health Center Provider Statistical Data | 4010 |
| Wkst. S-9, Parts I & II | Hospice Identification Data-Enrollment Days Based on Level of Care | 4011.1-4011.2 |
| Wkst. S-10 | Hospital Uncompensated Care Data | 4012 |
Reclassification And Adjustment Of Trial Balance Of Expenses
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| Worksheet Section | Description | Reference |
|---|---|---|
| Wkst. A | Reclassification and Adjustment of Trial Balance of Expenses | 4013 |
| Wkst. A-7, Part I | Analysis of Capital Assets: Analysis of Changes in Capital Asset Balances | 4015-4015.1 |
| Wkst. A-7, Part II | Analysis of Capital Assets: Reconciliation of Capital Cost Centers | 4015.2 |
| Wkst. A-7, Part III | Analysis of Capital Assets: Reconciliation of Amounts from Worksheet A, Column 2, Lines 1 thru 2 | 4015.3 |
| Wkst. A-8 | Adjustments to Expenses | 4016 |
| Wkst. A-8-1 | Statement of Costs of Services From Related Organizations and Home Office Costs | 4017 |
| Wkst. A-8-2 | Provider-Based Physician Adjustments | 4018 |
| Wkst. A-8-4, Parts I-VI | Reasonable Cost Determination for Therapy Service Furnished by Outside Suppliers | 4019-4019.6 |
Cost and Cost Allocation
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| Worksheet Section | Description | Reference |
|---|---|---|
| Wkst. B, Part I | Cost Allocation – General Service Cost and | 4020 |
| Wkst. B, Part II | Allocation of Capital-Related Costs and Worksheet B | 4021 |
| Wkst. B-1 | Cost Allocation – Statistical Basis | 4020 |
| Wkst. B-2 | Post Stepdown Adjustments | 4022 |
Computation of Ratio of Costs to Charges
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| Worksheet Section | Description | Reference |
|---|---|---|
| Wkst. C, Part I | Computation of Ratio of Cost to Charges | 4023-4023.1 |
| Wkst. C, Part II | Calculation of Outpatient Services Cost to Charge Ratios Net of Reductions | 4023.2 |
Apportionment of Inpatient Cost (Routine, Ancillary, Capital), Computation of Operating Cost
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| Worksheet Section | Description | Reference |
|---|---|---|
| Wkst. D, Part I | Apportionment of Inpatient Routine Service Capital Costs | 4024-4024.1 |
| Wkst. D, Part II | Apportionment of Inpatient Ancillary Service Capital Costs | 4024.2 |
| Wkst. D, Part III | Apportionment of Inpatient Routine Service Other Pass Through Costs | 4024.3 |
| Wkst. D, Part IV | Apportionment of Inpatient Ancillary Service Other Pass Through Costs | 4024.4 |
| Wkst. D, Part V | Apportionment of Medical and Other Health Services Costs | 4024.5 |
| Wkst. D-1, Part I | Computation of Inpatient Operating Cost: All Provider Components | 4025-4025.1 |
| Wkst. D-1, Part II | Computation of Inpatient Operating Cost: Hospital and Subproviders Only | 4025.2 |
| Wkst. D-1, Part III | Computation of Inpatient Operating Cost: Skilled Nursing Facility and Other Nursing Facility Only | 4025.3 |
| Wkst. D-1, Part IV | Computation of Inpatient Operating Cost: Computation of Observation Bed Cost | 4025.4 |
| Wkst. D-2 | Apportionment of Cost of Services Rendered by I&R | 4026 |
| Wkst. D-2, Part I | Apportionment of Cost of Services Rendered by I&R: Not in Approved Teaching Program | 4026.1 |
| 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) | 4026.2 |
| Wkst. D-2, Part III | Apportionment of Cost of Services Rendered by I&R: Summary for Title XVIII | 4026.3 |
| Wkst. D-3 | Inpatient Ancillary Service Cost Apportionment | 4027 |
| Wkst. D-4, Part I | Computation of Organ Acquisition Costs (Inpatient Routine and Ancillary Services) | 4028-4028.1 |
| Wkst. D-4, Part II | Computation of Organ Acquisition Costs (Other Than Inpatients Routine and Ancillary Service Costs) | 4028.2 |
| Wkst. D-4, Part III | Computation of Organ Acquisition Costs and Charges: Summary of Costs and Charges | 4028.3 |
| Wkst. D-4, Part IV | Computation of Organ Acquisition Costs and Charges: Statistics | 4028.4 |
| Wkst. D-5, Part I | “Apportionment of Cost for Services of Teaching Physicians-Reasonable Compensation Equivalent Computation | 4029-4029.1 |
| Wkst. D-5, Part II | Apportionment of Cost for Services of Teaching Physicians | 4029.2 |
Calculation of Reimbursement Settlement
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| Worksheet Section | Description | Reference |
|---|---|---|
| Wkst. E, Part A | Calculation of Reimbursement Settlement: Inpatient Hospital Services Under PPS | 4030-4030.1 |
| Wkst. E, Part B | Calculation of Reimbursement Settlement: Medical and Other Health Services | 4030.2 |
| Wkst. E-1, Part I | Analysis of Payments to Providers for Services Rendered | 4031.1 |
| Wkst. E-1, Part II | Calculation of reimbursement Settlement for Health Information Technology | 4031.2 |
| Wkst. E-2 | Calculation of Reimbursement Settlement – Swing Beds | 4032 |
| Wkst. E-3, Part I | Calculation of Medicare Reimbursement Settlement Under TEFRA | 4033.1 |
| Wkst. E-3, Part II | Calculation of Reimbursement Settlement for Medicare Part A Services – IPF PPS | 4033.2 |
| Wkst. E-3, Part III | Calculation of Reimbursement Settlement All Other Health Services – IRF PPS | 4033.3 |
| Wkst. E-3, Part IV | Calculation of Reimbursement Settlement All Other Health Services – LTCH PPS | 4033.4 |
| Wkst. E-3, Part V | Calculation of Reimbursement Settlement for Cost Providers | 4033.5 |
| Wkst. E-3, Part VI | Calculation of Reimbursement Settlement for SNF PPS | 4033.6 |
| Wkst. E-3, Part VII | Calculation of Reimbursement Settlement for Title V & XIX | 4033.7 |
Financial Statements
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| Worksheet Section | Description | Reference |
|---|---|---|
| Wkst. G | Financial Statements: Balance Sheet | 4040.1 |
| Wkst. G-1 | Financial Statements: Statement of Changes in Fund Balances | 4040.2 |
| Wkst. G-2 | Financial Statements: Statement of Patient Revenues and Operating Expenses | 4040.3 |
| Wkst. G-3 | Financial Statements: Statement of Revenues and Expenses | 4040.4 |
Provider Based Home Health Agency
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| Worksheet Section | Description | Reference |
|---|---|---|
| Wkst. H | Analysis of Provider-Based Home Health Agency Costs | 4041 |
| Wkst. H-1 | Cost Allocation – Statistical Basis | 4042 |
| Wkst. H-2, Part I | Apportionment of Patient Service Costs | 4043-4043.1 |
| Wkst. H-2, Part II | Allocation of General Service Cost to HHA Cost Centers – Statistical Basis | 4043.2 |
| Wkst. H-3 | Compensation Analysis – Contracted Services/Purchased Services | 4044 |
| Wkst. H-3, Part I | “Computation of Lesser of Aggr. Medicare Cost Aggr. Medicare Limitation Cost or Per Beneficiary Cost Limitation | 4044.1 |
| Wkst. H-3, Part II | Apportionment of Cost of HHA Services Furnished by Shared Hospital Departments | 4044.2 |
| Wkst. H-4 | Calculation of HHA Reimbursement Settlement | 4045 |
| Wkst. H-4, Part I | Computation of Lesser of Reasonable Cost or Customary Charges | 4045.1 |
| Wkst. H-4, Part II | Computation of HHA Reimbursement Settlement | 4045.2 |
| Wkst. H-5 | Analysis of Payments to Provider-Based HHAs for Services Rendered to Program Beneficiaries | 4046 |
Provider Based Renal Dialysis
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| Worksheet Section | Description | Reference |
|---|---|---|
| Wkst. I | Analysis of Renal Dialysis Department Costs | 4047 |
| Wkst. I-1 | Analysis of Renal Dialysis Department Costs | 4048 |
| Wkst. I-2 | Allocation of Renal Department Costs to Treatment Modalities | 4049 |
| Wkst. I-3 | Direct and Indirect Renal Dialysis Cost Allocation – Statistical Basis | 4050 |
| Wkst. I-4 | Computation of Average Cost Per Treatment for Outpatient Renal Dialysis | 4051 |
| Wkst. I-5 | Calculation of Reimbursable Bad Debts – Title XVIII, Part B | 4052 |
Provider Based CORF
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| Worksheet Section | Description | Reference |
|---|---|---|
| Wkst. J-1 | Allocation of General Service Costs to CMHC Cost Centers | 4053 |
| Wkst. J-1, Part I | Allocation of General Service Costs to CMHC Cost Centers | 4053.1 |
| Wkst. J-1, Part II | Allocation of General Service Costs to CMHC Cost Centers -Statistical Basis | 4053.2 |
| Wkst. J-2 | Computation of CMHC Provider Costs | 4054 |
| Wkst. J-2, Part I | Apportionment of CMHC Cost Centers | 4054.1 |
| Wkst. J-2, Part II | Apportionment of Cost of CMHC Provider Services Furnished by Shared Hospital Departments | 4054.2 |
| Wkst. J-3 | Calculation of Reimbursement Settlement – CMHC Provider Services | 4055 |
| Wkst. J-4 | Analysis of Payments to Hospital-Based CMHC for Services Rendered to Program Beneficiaries | 4056 |
Provider Based Hospice
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| Worksheet Section | Description | Reference |
|---|---|---|
| Wkst. K | Analysis of Provider-Based Hospice Costs | 4057 |
| Wkst. K-1 | Compensation Analysis – Salaries and Wage | 4058 |
| Wkst. K-2 | Compensation Analysis – Employee Benefits (Payroll Related) | 4059 |
| Wkst. K-3 | Compensation Analysis – Contracted Services/Purchased Services | 4060 |
| Wkst. K-4, Part I | Cost Allocation – General Service Costs | 4061 |
| Wkst. K-4, Part II | Cost Allocation – Statistical Basis | 4061 |
| Wkst. K-5, Part I | Allocation of General Service Costs to Hospice Cost Centers | 4062-4062.1 |
| Wkst. K-5, Part II | Allocation of General Service Costs to Hospice Cost Centers – Statistical Basis | 4062.2 |
| Wkst. K-5, Part III | Computation of the Total Hospice Shared Costs | 4062.3 |
| Wkst. K-6 | Calculation of Per Diem Cost | 4063 |
Computation of Medicare Capital Payment
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| Worksheet Section | Description | Reference |
|---|---|---|
| Wkst. L | Calculation of Capital Payment | 4064 |
| Wkst. L, Part I | Fully Prospective Method | 3660.1 |
| Wkst. L, Part II | Payment Under Reasonable Cost | 3660.2 |
| Wkst. L, Part III | Computation of Exception Payments | 4065 |
| Wkst. L-1, Part I | Allocation of Allowable Capital Costs for Extraordinary Circumstances | 4065.1 |
| Wkst. L-1, Part II | Computation of Program Inpatient Ancillary Service Capital Costs for Extraordinary Circumstances | 4065.2 |
| Wkst. L-1, Part III | Computation of Program Inpatient Routine Service Capital Costs for Extraordinary Circumstances | 4065.3 |
Computation of Medicare RHC/FQHC Medicare Payment
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| Worksheet Section | Description | Reference |
|---|---|---|
| Wkst. M-1 | Analysis of Provider Based Rural Health Clinic Federally Qualified Health Center Costs | 4066 |
| Wkst. M-2 | Allocation of Overhead to RHC/FQHC Services | 4067 |
| Wkst. M-3 | Calculation of Reimbursement Settlement for RHC/FQHC Services | 4068 |
| Wkst. M-4 | Computation of Pneumococcal and Influenza Vaccine Cost | 4069 |
| Wkst. M-5 | Analysis of Payments to Hospital-Based RHC/FQHC Services Rendered to Program Beneficiaries | 4070 |