3590 (Cont.) | FORM CMS 2540-96 | 5-06 | |||||||||
SKILLED NURSING FACILITY | PROVIDER NO.: | PERIOD | WORKSHEET | ||||||||
AND SKILLED NURSING FACILITY | FROM_____________ | S - 2 | |||||||||
COMPLEX IDENTIFICATION DATA | __________ | __________ | TO_______________ | ||||||||
Skilled Nursing Facility and Skilled Nursing Facility Complex Address: | |||||||||||
1 | Street: | X | P.O Box: | X | 1 | ||||||
2 | City: | X | State: | X | Zip Code: | X | 2 | ||||
3 | County: | X | MSA Code: | CBSA Code: | X | Urban / Ru | X | 3 | |||
3.1 | Facility Specific Rate: | Transition Period - enter 1, 2, 3 or 100 | X | 3.1 | |||||||
3.2 | Wage Index Adjustment Factor: Before October 1 | X | After Sept 30 | X | 3.2 | ||||||
SNF and SNF-Based Component Identification: | |||||||||||
Payment System | |||||||||||
Component | Provider No. | NPI\ Number | Date | (P, O, or N) | |||||||
Component | Name | Certified | V | XVIII | XIX | ||||||
0 | 1 | 2 | 2.01 | 3 | 4 | 5 | 6 | ||||
4 | S N F | X | X | X | X | X | 4 | ||||
5 | 5 | ||||||||||
6 | Nursing Facility | X | X | X | 6 | ||||||
6.1 | I C F / M R | X | X | X | 6.1 | ||||||
7 | SNF-Based O.L.T.C. | 7 | |||||||||
8 | SNF-Based H.H.A. | X | X | X | X | 8 | |||||
9 | 9 | ||||||||||
10 | SNF-Based Outpatient | 10 | |||||||||
Rehabilitation Providers | X | X | X | X | |||||||
11 | SNF-Based R.H.C. | X | X | X | X | 11 | |||||
12 | SNF-Based HOSPICE | X | X | 12 | |||||||
13 | Cost Reporting Period (mm/dd/yyyy) | From: | To: | 13 | |||||||
14 | Type of Control (See Instructions) | X | 14 |
12-00 | FORM CMS 2540-96 | 3590 (Cont.) | |||||||||
PROVIDER N | PERIOD: | ||||||||||
RECLASSIFICATION AND ADJUSTMENT | FROM ___________ | WORKSHEET A | |||||||||
OF TRIAL BALANCE OF EXPENSES | ________ | TO _______ | |||||||||
RECLASSI- | RECLASSIFIED | ADJUSTMENTS | NET EXPENSES | ||||||||
FICATIONS | TRIAL | TO EXPENSES | FOR COST | ||||||||
COST CENTER | SALARIES | OTHER | TOTAL | Increase/Decrease | BALANCE | Increase/Decrease | ALLOCATION | ||||
(Omit Cents) | ( Col 1 + Col 2 ) | ( Fr Wkst A-6 ) | ( Col 3 +/- Col 4 ) | ( Fr Wkst A-8 ) | ( Col 5 +/- Col 6 ) | ||||||
A | B | C | D | 1 | 2 | 3 | 4 | 5 | 6 | 7 | |
GENERAL SERVICE COST CENTERS | |||||||||||
1 | 0100 | x | Captial-Related Costs - Building & Fixture | X | X | X | 1 | ||||
2 | 0200 | x | Capital-Related Costs - Movable Equipmen | X | X | X | 2 | ||||
3 | 0300 | x | Employee Benefits | X | X | X | X | 3 | |||
4 | 0400 | x | Administrative and General | X | X | X | X | 4 | |||
5 | 0500 | x | Plant Operation, Maintenance and Repairs | X | X | X | X | 5 | |||
6 | 0600 | x | Laundry and Linen Service | X | X | X | X | 6 | |||
7 | 0700 | x | Housekeeping | X | X | X | X | 7 | |||
8 | 0800 | x | Dietary | X | X | X | X | 8 | |||
9 | 0900 | x | Nursing Administration | X | X | X | X | 9 | |||
10 | 1000 | Central Services and Supply | X | X | X | X | 10 | ||||
11 | 1100 | Pharmacy | X | X | X | X | 11 | ||||
12 | 1200 | Medical Records and Library | X | X | X | X | 12 | ||||
13 | 1300 | Social Service | X | X | X | X | 13 | ||||
14 | 1400 | Intern & Residents (Apprvd Tchng Prog.) | X | X | X | X | 14 | ||||
15 | Other General Service Cost | X | X | X | X | 15 | |||||
INPATIENT ROUTINE SERVICE COST CENTERS | |||||||||||
16 | 1600 | x | Skilled Nursing Facility | X | X | X | X | 16 | |||
17 | 17 | ||||||||||
18 | 1800 | x | Nursing Facility | X | X | X | X | 18 | |||
18.1 | 1810 | Intermediate Care Facility - Mentally Retard | X | X | X | X | 18.1 | ||||
19 | 1900 | x | Other Long Term Care | X | X | X | X | 19 | |||
20 | Other Inpatient Routine Cost | 20 | |||||||||
ANCILLARY SERVICE COST CENTERS | |||||||||||
21 | 2100 | x | Radiology | X | X | X | X | 21 | |||
22 | 2200 | x | Laboratory | X | X | X | X | 22 | |||
23 | 2300 | x | Intravenous Therapy | X | X | X | X | 23 | |||
24 | 2400 | x | Oxygen (Inhalation) Therapy | X | X | X | X | 24 | |||
25 | 2500 | x | Physical Therapy | X | X | X | X | 25 | |||
26 | 2600 | x | Occupational Therapy | X | X | X | X | 26 | |||
27 | 2700 | x | Speech Pathology | X | X | X | X | 27 | |||
28 | 2800 | x | Electrocardiology | X | X | X | X | 28 | |||
29 | 2900 | x | Medical Supplies Charged to Patients | X | X | X | X | 29 | |||
30 | 3000 | x | Drugs Charged to Patients | X | X | X | X | 30 | |||
31 | 3100 | x | Dental Care - Title XIX only | X | X | X | X | 31 | |||
32 | 3200 | x | Support Surfaces | X | X | X | X | 32 | |||
33 | x | Other Ancillary Service Cost Center | X | X | X | 33 | |||||
x | Indicates the lines to be used under the Simplified Method | ||||||||||
OUTPATIENT SERVICE COST CENTERS | |||||||||||
34 | 3400 | Clinic | X | X | X | X | 34 | ||||
35 | 3500 | Rural Health Clinic (RHC) | X | X | X | X | 35 | ||||
36 | Other Outpatient Service Cost | X | X | X | X | 36 | |||||
OTHER REIMBURSABLE COST CENTERS | |||||||||||
37 | 3700 | Administrative and General - HHA | X | X | X | X | 37 | ||||
38 | 3800 | Skilled Nursing Care - HHA | X | X | X | X | 38 | ||||
39 | 3900 | Physical Therapy - HHA | X | X | X | X | 39 | ||||
40 | 4000 | Occupational Therapy - HHA | X | X | X | X | 40 | ||||
41 | 4100 | Speech Pathology - HHA | X | X | X | X | 41 | ||||
42 | 4200 | Medical Social Services - HHA | X | X | X | X | 42 | ||||
43 | 4300 | Home Health Aide - HHA | X | X | X | X | 43 | ||||
44 | 4400 | Durable Medical Equipment - Rented - HHA | X | X | X | X | 44 | ||||
45 | 4500 | Durable Medical Equipment - Sold - HHA | X | X | X | X | 45 | ||||
46 | 4600 | Home Delivered Meals - HHA | X | X | X | X | 46 | ||||
47 | 4700 | Other Home Health Services - HHA | X | X | X | X | 47 | ||||
48 | 4800 | Ambulance | X | X | X | X | 48 | ||||
49 | 4900 | Intern and Resident (Not Apprvd Tchng Pro | X | X | X | X | 49 | ||||
50 | 5000 | Outpatient Rehabilitation Provider | X | X | X | X | 50 | ||||
51 | Other Reimbursable Cost | X | X | X | X | 51 | |||||
SPECIAL PURPOSE COST CENTERS | |||||||||||
52 | 5200 | Malpractice Premiums & Paid Losses | X | X | X | X | 52 | ||||
53 | 5300 | Interest Expense | X | X | X | - 0 - | 53 | ||||
54 | 5400 | x | Utilization Review -- SNF | X | X | X | X | - 0 - | 54 | ||
55 | 5500 | Hospice | X | X | X | X | - 0 - | 55 | |||
56 | x | Other Special Purpose Cost | X | X | X | X | 56 | ||||
57 | 5700 | Subtotals | X | X | X | X | 57 | ||||
NON REIMBURSABLE COST CENTERS | |||||||||||
58 | 5800 | Gift, Flower, Coffee Shops and Canteen | X | X | X | X | 58 | ||||
59 | 5900 | x | Barber and Beauty Shop | X | X | X | X | 59 | |||
60 | 6000 | Physicians' Private Offices | X | X | X | X | 60 | ||||
61 | 6100 | Nonpaid Workers | X | X | X | X | 61 | ||||
62 | 6200 | Patients Laundry | X | X | X | X | 62 | ||||
63 | x | Other Non Reimbursable Cost | X | X | X | X | 63 | ||||
75 | x | TOTAL | X | X | X | 75 | |||||
04-06 | FORM CMS 2540-96 | 3590 ( Cont.) | ||||
PROVIDER NO.: | PERIOD: | |||||
CALCULATION OF | FROM __________ | WORKSHEET E | ||||
REIMBURSEMENT SETTLEMENT | _____________ | TO ___________ | PART III | |||
PART III - SNF REIMBURSEMENT UNDER PPS | ||||||
Check one: | [ ] Title V | [ ] Title XVIII | [ ] Title XIX | |||
PART A - INPATIENT SERVICE PPS PROVIDER COMPUTATION OF REIMBURSEMENT LESSER OF COST OR CHARGES | ||||||
1 | Inpatient ancillary services - Part A - ( See Instructions ) | X | 1 | |||
2 | Interns & Residents and Medical Education cost for Title XVIII ( See Instructions ) | X | 2 | |||
3 | Total cost ( Sum of lines 1 and 2) | X | 3 | |||
4 | Medicare inpatient ancillary charges (see instructions) | X | 4 | |||
5 | Intern and Resident Charges ( From Provider Records) | X | 5 | |||
6 | Cost of covered services (lesser of line 3, or the sum of lines 4 and 5) | X | 6 | |||
7 | Inpatient PPS amount (see instructions) | X | 7 |
3590 ( Cont.) | FORM CMS 2540-96 | 07-99 | ||||
PROVIDER NO.: | PERIOD: | |||||
BALANCE SHEET | FROM ______ | WORKSHEET G | ||||
(If you are nonproprietary and do not maintain fund-type | _______ | TO _______ | ||||
accounting records, complete the "General Fund" column only) | ||||||
Specific | ||||||
Assets | General | Purpose | Endowment | Plant | ||
(Omit cents) | Fund | Fund | Fund | Fund | ||
1 | 2 | 3 | 4 | |||
CURRENT ASSETS | ||||||
1 | Cash on hand and in banks | X | X | X | X | 1 |
2 | Temporary investments | X | X | X | X | 2 |
3 | Notes receivable | X | X | X | X | 3 |
4 | Accounts receivable | X | X | X | X | 4 |
5 | Other receivables | X | X | X | X | 5 |
6 | Less: allowances for uncollectible notes | ( X ) | ( X ) | ( X ) | ( X ) | 6 |
and accounts receivable | ||||||
7 | Inventory | X | X | X | X | 7 |
8 | Prepaid expenses | X | X | X | X | 8 |
9 | Other current assets | X | X | X | X | 9 |
10 | Due from other funds | X | X | X | X | 10 |
11 | TOTAL CURRENT ASSETS | 11 | ||||
(Sum of lines 1 - 10) | X | X | X | X | ||
FIXED ASSETS | ||||||
12 | Land | X | X | X | X | 12 |
13 | Land improvements | X | X | X | X | 13 |
14 | Less: Accumulated depreciation | ( X ) | ( X ) | ( X ) | ( X ) | 14 |
15 | Buildings | X | X | X | X | 15 |
16 | Less Accumulated depreciation | ( X ) | ( X ) | ( X ) | ( X ) | 16 |
17 | Leasehold improvements | X | X | X | X | 17 |
18 | Less: Accumulated Amortization | ( X ) | ( X ) | ( X ) | ( X ) | 18 |
19 | Fixed equipment | X | X | X | X | 19 |
20 | Less: Accumulated depreciation | ( X ) | ( X ) | ( X ) | ( X ) | 20 |
21 | Automobiles and trucks | X | X | X | X | 21 |
22 | Less: Accumulated depreciation | ( X ) | ( X ) | ( X ) | ( X ) | 22 |
23 | Major movable equipment | X | X | X | X | 23 |
24 | Less: Accumulated depreciation | ( X ) | ( X ) | ( X ) | ( X ) | 24 |
25 | Minor equipment nondepreciable | X | X | X | X | 25 |
26 | Other fixed assets | X | X | X | X | 26 |
27 | TOTAL FIXED ASSETS | 27 | ||||
(Sum of lines 12 - 26) | X | X | X | X | ||
OTHER ASSETS | ||||||
28 | Investments | X | X | X | X | 28 |
29 | Deposits on leases | X | X | X | X | 29 |
30 | Due from owners/officers | X | X | X | X | 30 |
31 | Other assets | X | X | X | X | 31 |
32 | TOTAL OTHER ASSETS | 32 | ||||
(Sum of lines 28 - 31) | X | X | X | X | ||
33 | TOTAL ASSETS | 33 | ||||
(Sum of lines 11, 27 and 32) | X | X | X | X | ||
( ) = contra amount |
11-98 | FORM CMS 2540-96 | 3590 ( Cont.) | ||||
PROVIDER NO.: | PERIOD: | |||||
BALANCE SHEET | FROM _______ | WORKSHEET G | ||||
(If you are nonproprietary and do not maintain fund-type | TO __________ | (Cont.) | ||||
accounting records, complete the "General Fund" column only) | ||||||
Liabilities and Fund | Specific | |||||
Balances | General | Purpose | Endowment | Plant | ||
(Omit cents) | Fund | Fund | Fund | Fund | ||
1 | 2 | 3 | 4 | |||
CURRENT LIABILITIES | ||||||
34 | Accounts payable | X | X | X | X | 34 |
35 | Salaries, wages & fees payable | X | X | X | X | 35 |
36 | Payroll taxes payable | X | X | X | X | 36 |
37 | Notes & loans payable (Short term) | X | X | X | X | 37 |
38 | Deferred income | X | X | X | X | 38 |
39 | Accelerated payments | X | 39 | |||
40 | Due to other funds | X | X | X | X | 40 |
41 | Other current liabilities | X | X | X | X | 41 |
42 | TOTAL CURRENT LIABILITIES | 42 | ||||
(Sum of lines 34 - 41) | X | X | X | X | ||
LONG TERM LIABILITIES | ||||||
43 | Mortgage payable | X | X | X | X | 43 |
44 | Notes payable | X | X | X | X | 44 |
45 | Unsecured loans | X | X | X | X | 45 |
46 | Loans from owners: a. Prior to 7/1/66 | 46 | ||||
b. On or after 7/1/66 | X | X | X | X | ||
47 | Other long term liabilities | X | X | X | X | 47 |
48 | 48 | |||||
49 | TOTAL LONG TERM LIABILITIES | 49 | ||||
(Sum of lines 43 - 48) | X | X | X | X | ||
50 | TOTAL LIABILITIES | 50 | ||||
(Sum of lines 42 and 49) | X | X | X | X | ||
CAPITAL ACCOUNTS | ||||||
51 | General fund balance | X | 51 | |||
52 | Specific purpose fund | X | 52 | |||
53 | Donor created - endowment fund | 53 | ||||
balance - restricted | X | |||||
54 | Donor created - endowment fund | 54 | ||||
balance - unrestricted | X | |||||
55 | Governing body created - endowment | 55 | ||||
fund balance | X | |||||
56 | Plant fund balance - invested in plant | X | 56 | |||
57 | Plant fund balance - reserve for | 57 | ||||
plant improvement, replacement and | ||||||
expansion | X | |||||
58 | TOTAL FUND BALANCES | 58 | ||||
(Sum of lines 51 thru 57) | X | X | X | X | ||
59 | TOTAL LIABILITIES AND | 59 | ||||
FUND BALANCES | ||||||
(Sum of lines 50 and 58) | X | X | X | X | ||
( ) = contra amount |
11-98 | FORM CMS 2540-96 | 3590 ( Cont.) | |||
PROVIDER NO: | PERIOD: | ||||
STATEMENT OF PATIENT REVENUES | ______________ | FROM _________ | WORKSHEET G - 2 | ||
AND OPERATING EXPENSES | TO ___________ | PARTS I & II | |||
PART I - PATIENT REVENUES | |||||
Revenue Center | INPATIENT | OUTPATIENT | TOTAL | ||
1 | 2 | 3 | |||
GENERAL INPATIENT ROUTINE CARE SERVICES | |||||
1 | Skilled Nursing Facility | X | 1 | ||
2 | 2 | ||||
3 | Nursing facility | X | 3 | ||
4 | Other long term care | X | 4 | ||
5 | Total general inpatient care services | 5 | |||
(Sum of lines 1 - 4) | X | ||||
All Other Care Service | |||||
6 | Ancillary services | X | X | 6 | |
7 | Clinic | X | X | 7 | |
8 | Home health agency | X | 8 | ||
9 | 9 | ||||
10 | Ambulance | X | X | 10 | |
11 | Hospice | X | X | 11 | |
12 | Outpatient Rehabilitation Provider | X | X | 12 | |
13 | X | X | 13 | ||
14 | Total Patient Revenues ( Sum of lines 5 - 13 ) | 14 | |||
( Transfer column 3 to Worksheet G-3, Line 1 ) | X | X | X | ||
PART II - OPERATING EXPENSES | |||||
1 | Operating Expenses ( Per Worksheet A, Col. 3, Line 75 ) | 1 | |||
X | |||||
2 | Add ( Specify ) | 2 | |||
3 | 3 | ||||
4 | 4 | ||||
5 | 5 | ||||
6 | 6 | ||||
7 | 7 | ||||
8 | Total Additions ( Sum of lines 2 - 7 ) | 8 | |||
X | |||||
9 | Deduct ( Specify ) | 9 | |||
10 | 10 | ||||
11 | 11 | ||||
12 | 12 | ||||
13 | 13 | ||||
14 | Total Deductions ( Sum of lines 9 - 13 ) | 14 | |||
X | |||||
15 | Total Operating Expenses ( Sum of lines 1 and 8, minus line 14 ) | 15 | |||
( Transfer to Worksheet G-3, Line 4 ) | X |
3590 ( Cont.) | FORM CMS 2540-96 | 11-98 | |||
STATEMENT OF REVENUES | PROVIDER NO: | PERIOD: | |||
AND EXPENSES | ______________ | FROM _________ | WORKSHEET G - 3 | ||
TO ___________ | |||||
1 | Total patient revenues (From Wkst. G - 2, Part I, col. 3, line 14) | 1 | |||
2 | Less: contractual allowances and discounts on patients accounts | 2 | |||
3 | Net patient revenues (Line 1 minus line 2) | X | 3 | ||
4 | Less: total operating expenses (From Worksheet G-2, Part II, line 15) | 4 | |||
5 | Net income from service to patients (Line 3 minus 4) | X | 5 | ||
6 | Other income: | 6 | |||
7 | Contributions, donations, bequests, etc | X | 7 | ||
8 | Income from investments | X | 8 | ||
9 | Revenues from telephone and telegraph service | 9 | |||
10 | Revenue from television and radio service | 10 | |||
11 | Purchase discounts | 11 | |||
12 | Rebates and refunds of expenses | 12 | |||
13 | Parking lot receipts | 13 | |||
14 | Revenue from laundry and linen service | 14 | |||
15 | Revenue from meals sold to employees and guests | 15 | |||
16 | Revenue from rental of living quarters | 16 | |||
17 | Revenue from sale of medical and surgical supplies to other than patients | 17 | |||
18 | Revenue from sale of drugs to other than patients | 18 | |||
19 | Revenue from sale of medical records and abstracts | 19 | |||
20 | Tuition (fees, sale of textbooks, uniforms, etc.) | 20 | |||
21 | Revenue from gifts, flower, coffee shops, canteen | 21 | |||
22 | Rental of vending machines | 22 | |||
23 | Rental of skilled nursing space | 23 | |||
24 | Governmental appropriations | X | 24 | ||
25 | Other (specify) | 25 | |||
26 | Total other income (Sum of lines 7 - 25) | X | 26 | ||
27 | Total (Line 5 plus line 26) | 27 | |||
28 | Other expenses (specify) | 28 | |||
29 | 29 | ||||
30 | 30 | ||||
31 | Total other expenses (Sum of lines 28 - 30) | X | 31 | ||
32 | Net income (or loss) for the period (Line 27 minus line 31) | X | 32 |
3590 (Cont.) | FORM HCFA 2540-96 | 10-03 | ||||||||||||
SKILLED NURSING FACILITY AND | PROVIDER NO.: | PERIOD | WORKSHEET S-3 | |||||||||||
SKILLED NURSING FACILITY HEALTH CARE COMPLEX | FROM____________________ | PART I | ||||||||||||
STATISTICAL DATA | ||||||||||||||
Number | Bed | I n p a t i e n t D a y s | D i s c h a r g e s | |||||||||||
of | Days | Title | Title | Title | Total | Title | Title | Title | Total | |||||
Component | Beds | Available | V | XVIII | XIX | Other | V | XVIII | XIX | Other | ||||
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | |||
1 | Skilled Nursing Facility | X | X | X | X | X | X | X | X | X | X | X | X | 1 |
2 | 2 | |||||||||||||
3 | Nursing Facility | X | X | X | X | X | X | X | X | X | X | 3 | ||
3.1 | ICF/MR | X | X | X | X | X | X | X | X | 3.1 | ||||
4 | Other Long Term Care | X | X | X | X | X | X | 4 | ||||||
5 | Home Health Agency | 5 | ||||||||||||
6 | 6 | |||||||||||||
7 | SNF-Based Outpatient | 7 | ||||||||||||
Rehabilitation Providers | ||||||||||||||
8 | Hospice | X | X | X | X | X | X | X | X | X | X | X | X | 8 |
9 | Total (Sum of lines 1-8) | X | X | X | X | X | X | X | X | X | X | X | X | 9 |
10 | Ambulance Trips | X | 10 | |||||||||||
Full Time | ||||||||||||||
Average Length of Stay | A d m i s s i o n s | Equivalent | ||||||||||||
Title | Title | Title | Total | Title | Title | Title | Total | Employees | Nonpaid | |||||
V | XVIII | XIX | V | XVIII | XIX | Other | on Payroll | Workers | ||||||
13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | ||||
1 | Skilled Nursing Facility | X | X | X | X | X | X | X | X | X | X | 1 | ||
2 | 2 | |||||||||||||
3 | Nursing Facility | X | X | X | X | X | X | X | X | X | 3 | |||
3.1 | ICF/MR | X | X | X | X | X | X | X | 3.1 | |||||
4 | Other Long Term Care Facility | X | X | X | X | X | 4 | |||||||
5 | Home Health Agency | X | X | 5 | ||||||||||
6 | 6 | |||||||||||||
7 | SNF-Based Outpatient | 7 | ||||||||||||
Rehabilitation Providers | X | X | ||||||||||||
8 | Hospice | X | X | X | X | X | X | X | X | X | X | X | 8 | |
9 | Total (Sum of lines 1-8) | X | X | X | X | X | X | X | X | X | X | X | 9 | |
10 | Ambulance trips | 10 |
08-01 | FORM CMS 2540-96 | 3590(Cont.) | ||||||
PROVIDER NO.: | PERIOD: | WORKSHEET S-3 | ||||||
SNF WAGE INDEX INFORMATION | FROM __________ | PARTS II & III | ||||||
______________ | TO _____________ | |||||||
Reclass. | Adjusted | Paid Hours | Average | |||||
of Salaries | Salaries | Related | Hourly Wage | |||||
PART II DIRECT SALARIES | Amount | from Wkst. | (col. 1 ± | to Salary | (col. 3 ÷ | Data | ||
Reported | A-6 | col. 2) | in col. 3 | col. 4) | Source | |||
1 | 2 | 3 | 4 | 5 | 6 | |||
1 | Total salary (See Instructions) | X | X | X | X | 1 | ||
2 | Physician salaries-Part A | X | X | X | X | X | 2 | |
3 | Physician salaries-Part B | X | X | X | X | X | 3 | |
4 | Interns & Residents (approved) | X | X | X | X | X | 4 | |
5 | Home office personnel | X | X | X | X | X | 5 | |
6 | Sum of lines 2 thru 5 | X | X | X | X | X | 6 | |
7 | Revised wages (line 1 minus line 6) | X | X | X | X | 7 | ||
8 | Other Long Term Care | X | X | X | X | X | 8 | |
9 | Other Inpatient Routine Service | 9 | ||||||
10 | Interns & Residents | 10 | ||||||
(Not In Approved Program) | X | X | X | X | X | |||
11 | HHA | X | X | X | X | X | 11 | |
12 | Outpatient Rehabilitation Providers | X | X | X | X | X | 12 | |
13 | Hospice | X | X | X | X | X | 13 | |
14 | Non-reimbursable | X | X | X | X | X | 14 | |
15 | Total Excluded salary | 15 | ||||||
(Sum of lines 8 through 14) | X | X | X | X | X | |||
16 | Subtotal (line 7 minus line 15) | X | X | X | X | X | 16 | |
17 | Contract Labor: Patient Related & Mgmt | X | X | X | X | X | CMS 339 | 17 |
18 | Home office salaries & wage related costs | X | X | X | X | X | 18 | |
19 | Wage related costs (core) | X | X | X | CMS 339 | 19 | ||
20 | Wage related costs (other) | X | X | X | CMS 339 | 20 | ||
21 | Wage related costs (excluded units) | X | X | X | CMS 339 | 21 | ||
22 | Subtotal (see instructions) | X | X | X | 22 | |||
23 | Total (see instructions) | X | X | X | X | 23 | ||
24 | Contract Labor: Physician services-Part A | X | X | X | X | X | 24 | |
PART III - OVERHEAD COST - DIRECT SALARIES | ||||||||
Reclass. | Adjusted | Paid Hours | Average | |||||
of Salaries | Salaries | Related | Hourly Wage | |||||
Amount | from | (col. 1 ± | to Salary | (col. 3 ÷ | ||||
Reported | Wkst. A-6 | col. 2) | in col. 3 | col. 4) | ||||
1 | 2 | 3 | 4 | 5 | ||||
1 | Employee Benefits | X | X | X | X | X | 1 | |
2 | Administrative & General | X | X | X | X | X | 2 | |
3 | Plant Operation, Maintenance & Repairs | X | X | X | X | X | 3 | |
4 | Laundry & Linen Service | X | X | X | X | X | 4 | |
5 | Housekeeping | X | X | X | X | X | 5 | |
6 | Dietary | X | X | X | X | X | 6 | |
7 | Nursing Administration | X | X | X | X | X | 7 | |
8 | Central Services and Supply | X | X | X | X | X | 8 | |
9 | Pharmacy | X | X | X | X | X | 9 | |
10 | Medical Records & | 10 | ||||||
Medical Records Library | X | X | X | X | X | |||
11 | Social Service | X | X | X | X | X | 11 | |
12 | Interns & Records (Apprvd Tching Prog) | X | X | X | X | X | 12 | |
13 | Other General Service (specify) | X | X | X | X | X | 13 | |
14 | Total (sum lines 1 thru 13) | X | X | X | X | X | 14 |
04-06 | FORM CMS 2540-96 | 3590 (Cont.) | |||||||
PROSPECTIVE PAYMENT FOR SNF | PROVIDER NO.: | PERIOD: | WORKSHEET S-7 | ||||||
STATISTICAL DATA | FROM: | PART IV | |||||||
TO: | |||||||||
M3PI | SERVICES PRIOR TO | SERVICES ON OR AFTER | HIGH COST | TOTAL | |||||
REVENUE | October 1 | October 1 | RUGs (2) | (see | |||||
GROUP (1) | CODE | RATE | DAYS | RATE | DAYS | DAYS | instructions) | ||
1 | 2 | 3 | 3.01 | 4 | 4.01 | 4.05 | 5 | ||
1 | RUC | X | X | X | X | X | 1 | ||
2 | RUB | X | X | X | X | X | 2 | ||
3 | RUA | X | X | X | X | X | 3 | ||
3.01 | RUX | X | X | X | X | X | 3.01 | ||
3.02 | RUL | X | X | X | X | X | 3.02 | ||
4 | RVC | X | X | X | X | X | 4 | ||
5 | RVB | X | X | X | X | X | 5 | ||
6 | RVA | X | X | X | X | X | 6 | ||
6.01 | RVX | X | X | X | X | X | 6.01 | ||
6.02 | RVL | X | X | X | X | X | 6.02 | ||
7 | RHC | X | X | X | X | X | X | 7 | |
8 | RHB | X | X | X | X | X | 8 | ||
9 | RHA | X | X | X | X | X | 9 | ||
9.01 | RHX | X | X | X | X | X | 9.01 | ||
9.02 | RHL | X | X | X | X | X | 9.02 | ||
10 | RMC | X | X | X | X | X | X | 10 | |
11 | RMB | X | X | X | X | X | X | 11 | |
12 | RMA | X | X | X | X | X | 12 | ||
12.01 | RMX | X | X | X | X | X | 12.01 | ||
12.02 | RML | X | X | X | X | X | 12.02 | ||
13 | RLB | X | X | X | X | X | 13 | ||
14 | RLA | X | X | X | X | X | 14 | ||
14.01 | RLX | X | X | X | X | X | 14.01 | ||
15 | SE3 | X | X | X | X | X | X | 15 | |
16 | SE2 | X | X | X | X | X | X | 16 | |
17 | SE1 | X | X | X | X | X | X | 17 | |
18 | SSC | X | X | X | X | X | X | 18 | |
19 | SSB | X | X | X | X | X | X | 19 | |
20 | SSA | X | X | X | X | X | X | 20 | |
21 | CC2 | X | X | X | X | X | X | 21 | |
22 | CC1 | X | X | X | X | X | X | 22 | |
23 | CB2 | X | X | X | X | X | X | 23 | |
24 | CB1 | X | X | X | X | X | X | 24 | |
25 | CA2 | X | X | X | X | X | X | 25 | |
26 | CA1 | X | X | X | X | X | X | 26 | |
27 | IB2 | X | X | X | X | X | 27 | ||
28 | IB1 | X | X | X | X | X | 28 | ||
29 | IA2 | X | X | X | X | X | 29 | ||
30 | IA1 | X | X | X | X | X | 30 | ||
31 | BB2 | X | X | X | X | X | 31 | ||
32 | BB1 | X | X | X | X | X | 32 | ||
33 | BA2 | X | X | X | X | X | 33 | ||
34 | BA1 | X | X | X | X | X | 34 | ||
35 | PE2 | X | X | X | X | X | 35 | ||
36 | PE1 | X | X | X | X | X | 36 | ||
37 | PD2 | X | X | X | X | X | 37 | ||
38 | PD1 | X | X | X | X | X | 38 | ||
39 | PC2 | X | X | X | X | X | 39 | ||
40 | PC1 | X | X | X | X | X | 40 | ||
41 | PB2 | X | X | X | X | X | 41 | ||
42 | PB1 | X | X | X | X | X | 42 | ||
43 | PA2 | X | X | X | X | X | 43 | ||
44 | PA1 | X | X | X | X | X | 44 | ||
45 | Default rate | X | X | X | X | X | 45 | ||
46 | TOTAL | X | X | X | X | 46 |
08-10 | FORM CMS 2540-96 | 3590 (Cont.) | |||||||
PROSPECTIVE PAYMENT FOR SNF | PROVIDER NO.: | PERIOD: | WORKSHEET S-7 | ||||||
STATISTICAL DATA | FROM: | PART IV | |||||||
TO: | CONTINUED | ||||||||
Line | M3PI | SERVICES PRIOR TO | SERVICES ON OR AFTER | HIGH COST | TOTAL | ||||
45 | REVENUE | October 1 | October 1 | RUGs (2) | (see | ||||
Sub- | GROUP (1) | CODE | RATE | DAYS | RATE | DAYS | DAYS | instructions) | |
script | 1 | 2 | 3 | 3.01 | 4 | 4.01 | 4.05 | 5 | |
45.01 | ES3 | 45.01 | |||||||
45.02 | ES2 | 45.02 | |||||||
45.03 | ES1 | 45.03 | |||||||
45.04 | HE2 | 45.04 | |||||||
45.05 | HE1 | 45.05 | |||||||
45.06 | HD2 | 45.06 | |||||||
45.07 | HD1 | 45.07 | |||||||
45.08 | HC2 | 45.08 | |||||||
45.09 | HC1 | 45.09 | |||||||
45.10' | HB2 | 45.10' | |||||||
45.11 | HB1 | 45.11 | |||||||
45.12 | LE2 | 45.12 | |||||||
45.13 | LE1 | 45.13 | |||||||
45.14 | LD2 | 45.14 | |||||||
45.15 | LD1 | 45.15 | |||||||
45.16 | LC2 | 45.16 | |||||||
45.17 | LC1 | 45.17 | |||||||
45.18 | LB2 | 45.18 | |||||||
45.19 | LB1 | 45.19 | |||||||
45.20' | CE2 | 45.20' | |||||||
45.21 | CE1 | 45.21 | |||||||
45.22 | CD2 | 45.22 | |||||||
45.23 | CD1 | 45.23 | |||||||
46 | TOTAL | 46 | |||||||
RUG-IV groups were puiblished in the "Federal Register", Vol. 74.No. 153/August 11, 2009, | |||||||||
page 40288- FY 2010 SNF Final Rule. These RUGs are effective for services on and after 10/01/2010. | |||||||||
RUG-IV groups are added for reimbursement on Worksheet S-7, Part IV, and are displayed above. | |||||||||
Subscript line 45 as shown above to accommodate this addition. | |||||||||
NOTE: The default line code designation has been changed to "AAA". |
|
The data in all VIGsnfcomps.com reports comes from the SNF Medicare Cost Report worksheets.
Click on any data cell in the sample report on the left in order to see how the data is derived.
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|