Read PPS9-12.XLS text version

Minimum Data Set IDENTIFYING INFORMATION SOURCES: FORM HCFA 2552-92, WORKSHEET S-2, AND HCFA RECORDS FIELD NAME F F F F F F F F F F F F F F F F F 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 MAN FIELD SIZE 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 36 1

08/22/96

DESCRIPTION Provider Number - Hospital Provider Number - Subprovider Provider Number - Subprovider II Provider Number - Subprovider III Provider Number - Subprovider IV Provider Number - Subprovider V Provider Number - Swing Bed SNF Provider Number - Swing Bed NF Provider Number - Hospital-Based SNF Provider Number - Hospital-Based NF Provider Number - Hospital-Based OLTC Provider Number - Hospital-Based HHA Provider Number - Hospital-Based CORF Provider Number - Hospital-Based ASC Provider Number - Hospital-Based Hospice Hospital Name Manual Cost Report Indicator (M=Manual) Hospital Title XVIII Payment System (P=PPS, T=TEFRA, O=OTHER) Subprovider I Title XVIII Payment System (P=PPS, T=TEFFA, O=OTHER) Subprovider II Title XVIII Payment System (P=PPS, T=TEFFA, O=OTHER) Subprovider III Title XVIII Payment System (P=PPS, T=TEFFA, O=OTHER) Subprovider IV Title XVIII Payment System (P=PPS, T=TEFFA, O=OTHER) Subprovider V Title XVIII Payment System (P=PPS, T=TEFFA, O=OTHER) Cost Reporting Period Begin Date (CCYYMMDD) Cost Reporting Period End Date (CCYYMMDD) Number of Months in Reporting Period (See Note 1) Type of Control (See Table I) Type of Hospital (See Table II) Medicare Certified Kidney Transplant Center? (Y/N) Medicare Certified Heart Transplant Center? (Y/N) Medicare Certified Liver Transplant Center? (Y/N) Sole Community Hospital? (Y/N) Eye and Ear Specialty Hospital? (Y/N) Rural Primary Care Hospital? (Y/N) RESERVED FOR FUTURE USE Funded Depreciation? (Y/N) Inpatient Capital Reduction Rate (See Note 2) Outpatient Capital Reduction Rate (See Note 3) File Creation Date (See Note 4) (CCYYMMDD) System Identification (See Note 4) SSA State Code (See Table III) MSA/NECMA Code Fiscal Intermediary Number Cost Report Status (See Table IV) All Inclusive Rate Provider ? (Y/N) Medicare Utilization Indicator (L, N, or F) (See Note 5) Census Division (See Table V) HCFA Region (See Table VI)

LINE(S) 2 3 3.01 3.02 3.03 3.04 4 5 6 7 8 9 10 11 12 2

COL(S) 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1

USAGE X X X X X X X X X X X X X X X X X

LOCATION 1 7 13 19 25 31 37 43 49 55 61 67 73 79 85 91 127 6 12 18 24 30 36 42 48 54 60 66 72 78 84 90 126 127

F 17

2

5

1

X

128 - 128

F 18

3

5

1

X

129 - 129

F 19

3.01

5

1

X

130 - 130

F 20

3.02

5

1

X

131 - 131

F 21

3.03

5

1

X

132 - 132

F 22

3.04 13 13

5 1 2

1 8 8

X 9 9

133 - 133 134 - 141 142 - 149

F 23 F 24 F 25

X 14 15

X 1 1

2 2 1 1 1 1 1 1 1 10 1 6 6 8 5 2 4 5 1 1 1 1 2

9 9 9 X X X X X X X X SV9(6) SV9(6) 9 X 9 X X X X X X X

150 - 151 152 154 155 156 157 158 159 160 161 171 172 178 184 192 197 199 203 208 209 210 211 212 153 154 155 156 157 158 159 160 170 171 177 183 191 196 198 202 207 208 209 210 211 213

F F F F F F F F F F F F F F F F F F F F F F

26 27 27A 27B 27C 27D 27E 27F 27G 28 29 30 31 31A 32 33 34 35 36 37 38 39

23 21 26

1 1 1

30 29

1 1

STATISTICAL AND SUMMARY UTILIZATION DATA Page 1

SOURCE: FORM HCFA Minimum WORKSHEET S-3, PART I 2552-92, Data Set

08/22/96

FIELD NAME F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81

DESCRIPTION General Service Beds Available (See Note 6) Intensive Care Unit Beds Available Coronary Care Unit Beds Available Other Special Care Unit Beds Available Total Beds Available in Hospital (Excl. Nursery) Total Beds Available in the Hospital Total Beds Available in Facility General Service Bed Days Available (See Note 7) Intensive Care Bed Days Available Coronary Care Bed Days Available Other Special Care Unit Bed Days Available Total Bed Days Available in Hospital (Excl. Nursery) Total Bed Days Available in the Hospital Total Bed Days Available in the Facility Medicare Routine Days (Excl. Swing Bed) Medicare Swing Bed SNF Days Medicare Intensive Care Unit Days Medicare Coronary Care Unit Days Medicare Other Special Care Unit Days Medicare Inpatient Days- Total Hospital Medicare Inpatient Days - Total Facility Medicaid Routine Days (Excl. Swing Bed) Medicaid Intensive Care Unit Days Medicaid Coronary Care Unit Days Medicaid Other Special Care Unit Days Medicaid Inpatient Days- Total Hospital Medicaid Inpatient Days - Total Facility Total Routine Days (Excl. Swing Bed) Total Swing Bed SNF Days Total Intensive Care Unit Days Total Coronary Care Unit Days Total Other Special Care Unit Days Inpatient Days, All Patients--Hospital Total Inpatient Days, All Patients--Facility Total Full-Time Interns & Residents - Total Hospital Full-Time Interns & Residents - Total Facility Net Full-Time Interns & Residents - Total Hospital Net Full-Time Interns & Residents - Total Facility Average Number of Employees - Total Hospital Average Number of Employees - Total Facility Average Number of Nonpaid Workers - Total Hospital Average Number of Nonpaid Workers - Total Facility Medicare Discharges - Total Hospital (Including Swing Bed SNF) Medicare Discharges-- Swing Bed SNF Medicare Discharges--Total Hospital (Excluding Swing Bed SNF) Medicare Discharges--Total Facility

LINE(S) 1.01 2 3 4-6 X 8 18 1.01 2 3 4-6 X 8 18 1.01 1.02 2 3 4-6 8 18 1.01 2 3 4-6 8 18 1.01 1.02 2 3 4-6 8 18 8 18 8 18 8 18 8 18

COL(S) 1 1 1 1 1 1 1 2 2 2 2 2 2 2 4 4 4 4 4 4 4 5 5 5 5 5 5 6 6 6 6 6 6 6 7 7 9 9 10 10 11 11

FIELD SIZE 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11

USAGE S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9(9)V9(2) S9(9)V9(2) S9(9)V9(2) S9(9)V9(2) S9(9)V9(2) S9(9)V9(2) S9(9)V9(2) S9(9)V9(2)

LOCATION 214 225 236 247 258 269 280 291 302 313 324 335 346 357 368 379 390 401 412 423 434 445 456 467 478 489 500 511 522 533 544 555 566 577 588 599 610 621 632 643 654 665 224 235 246 257 268 279 290 301 312 323 334 345 356 367 378 389 400 411 422 433 444 455 466 477 488 499 510 521 532 543 554 565 576 587 598 609 620 631 642 653 664 675

F 82

8 1.02 X 18

13 13 13 13

11 11 11 11

S9 S9 S9 S9

676 - 686 687 - 697 698 - 708 709 - 719

F 82A F 82B F 83

STATISTICAL AND SUMMARY UTILIZATION DATA SOURCE: FORM HCFA 2552-92, WORKSHEET S-3 FIELD Page 2 FIELD

NAME F F F F F F F F F 84 84A 84B 84C 85 86 86A 87 88

DESCRIPTION

Minimum Data Set COL(S) LINE(S) 8 1.03 X 18 8 1.02 18 8 1.02 1.03 14 14 14 14 16 16 16 15 15 15

SIZE 11 11 11 11 11 11 11 11 11 11 11

USAGE S9 S9 S9 S9 S9 S9 S9 S9 S9 S9

LOCATION 720 731 742 753 764 775 786 797 730 741 752 763 774 785 796 807

08/22/96

F 88A F 88B F 88C

Medicaid Discharges--Hospital Total (Including Swing Bed NF) Medicaid Discharges--Swing Bed NF RESERVED FOR FUTURE USE Medicaid Discharges--Hospital Total (Excluding Swing Bed SNF) Medicaid Discharges--Total Facility Medicare Discharges (Medicaid Elig.) Total Hospital Medicare Discharges (Medicaid Elig.) Swing Bed SNF Medicare Discharges (Medicaid Elig.) Total Facility Total Discharges--Hospital Total (Including Swing Bed SNF and Swing Bed NF Total Discharges, All Patients, Swing Bed SNF Total Discharges, All Patients, Swing Bed NF Total Discharges--Hospital total (Excluding Swing Bed SNF and Swing Bed NF) Total Discharges, All Patients--Facility Total

808 - 818 819 - 829 830 - 840

X 18

15 15

11 11

S9 S9

841 - 851 852 - 862

F 89

TOTAL FACILITY COSTS SOURCE: FORM HCFA 2552-92, WORKSHEET A FIELD NAME F 90 FIELD SIZE

DESCRIPTION Old and New Capital Related Costs-Buildings and Fixtures, Before Reclassification or Adjustment Old and New Capital Related Costs-Movable Equipment, Before Reclassification or Adjustment Direct Salaries--All General Service Cost Centers Direct Salaries and Fringe Benefits of the Intern & Resident Service (in Approved Programs) Direct Salaries--All Hospital Inpatient Cost Centers Direct Salaries--All Other Inpatient Cost Centers Direct Salaries--All Ancillary Service Cost Centers Direct Salaries--All Outpatient Service Cost Centers Direct Salaries--All Other Reimbursable Cost Centers

LINE(S)

COL(S)

USAGE

LOCATION

1+3

2

11

S9

863 - 873

F 91

2+4 3-24

2 1

11 11

S9 S9

874 - 884 885 - 895

F 92 F 93

22 25-30 31, 33-36 37-59 60-63 64-68, 70-82 83-94 96-100 101 1-24

1 1 1 1 1 1

11 11 11 11 11 11

S9 S9 S9 S9 S9 S9

896 - 906 907 918 929 940 917 928 939 950

F F F F

94 95 96 97

F 98

951 - 961

F F F F

99 100 101 102

Direct Salaries--All Special Purpose Cost Centers Direct Salaries--All NonReimbursable Cost Centers Direct Salaries--Total Other Direct Cost--All General Service Cost Centers Other Direct Cost of the Intern and Resident Service (in Approved Program) Other Direct Cost--All Hospital Inpatient Cost Centers Other Direct Cost--All Other Inpatient Cost Centers Other Direct Cost--All Ancillary Service Cost Centers Other Direct Cost--All Outpatient Service Cost Centers Other Direct Cost--All Other Reimbursable Cost Centers

1 1 1 1

11 11 11 11

S9 S9 S9 S9

962 973 984 995

-

972 983 994 1005

F 103

22 22-30 31, 33-36 37-59 60-63 64-68 70-82 83-94 96-100 101

2 2 2 2 2 2

11 11 11 11 11 11

S9 S9 S9 S9 S9 S9

1006 - 1016 1017 1028 1039 1050 1027 1038 1049 1060

F F F F

104 105 106 107

F 108

1061 - 1071

F 109 F 110 F 111

Other Direct Cost--All Special Purpose Cost Centers Other Direct Cost--All NonReimbursable Cost Centers Other Direct Cost--Total

2 2 2

11 11 11

S9 S9 S9

1072 - 1082 1083 - 1093 1094 - 1104

PROVIDER BASED PHYSICIAN REIMBURSEMENT DATA SOURCE: FORM HCFA 2552-92, SUPPLEMENTAL WORKSHEET A-8-2 FIELD NAME F 112 FIELD SIZE 11

DESCRIPTION Physicians' Remuneration--Total

LINE(S) 101 Page 3

COL(S) 3

USAGE S9

LOCATION 1105 - 1115

F F F F F F

113 114 115 116 117 118

Physicians' Remuneration--Professional Component Physicians' Remuneration--Provider Component Number of Physicians' Hours-Provider Component Physician Cost of Malpractice Insurance--Total Physician Cost of Malpractice Insurance--Provider's Share RCE Disallowance--Total Adjustment for Physicians' Professional Services and Cost in Excess of RCE Limits

Minimum Data Set 101 101 101 101 101 101

4 5 7 14 15 17

11 11 11 11 11 11

S9 S9 S9 S9 S9 S9

1116 1127 1138 1149 1160 1171

-

1126 1137 1148 1159 1170 1181

08/22/96

F 119

101

18

11

S9

1182 - 1192

REIMBURSABLE COSTS, BEFORE COST ALLOCATION SOURCE: FORM HCFA 2552-92, WORKSHEET B, PART FIELD NAME F 120 FIELD SIZE

DESCRIPTION Old and New Capital Related Costs--Buildings and Fixtures After Reclassification and Adjustment--Inpatient Old and New Capital Related Costs--Buildings and Fixtures After Reclassification and Adjustment--Total Old and New Capital Related Costs-Movable Equipment After Reclassification and Adjustment--Inpatient Old and New Capital Related Costs-Movable Equipment After Reclassification and Adjustment--Total Nursing School Costs Interns- Resident Service (Appvd Programs) Combined Intern-Resident Service (Appvd Programs) Salary and Salary Related Fringe Benefits Intern-Resident Service (Approved Programs) Other Paramedical Education Costs All General Service Cost Centers All Hospital Inpatient Cost Centers All Other Inpatient Cost Centers

LINE(S) 5-33, 37-59

COL(S)

USAGE

LOCATION

1+3

11

S9

1193 - 1203

F 121

103 5-33, 37-59

1+3

11

S9

1204 - 1214

F 122

2+4

11

S9

1215 - 1225

F 123

103 21 22 + 23

2+ 4 0 0

11 11 11

S9 S9 S9

1226 - 1236 1237 - 1247 1248 - 1258

F 124 F 125 F 126

22 23 24 1-24 25-30 31, 33-36 37-59 60-63 64-68, 70-82 83-94 96-100 102 103

0 0 0 0 0

11 11 11 11 11

S9 S9 S9 S9 S9

1259 - 1269 1270 1281 1292 1303 1280 1291 1302 1313

F F F F

127 128 129 130

F 131

0 0 0

11 11 11

S9 S9 S9

1314 - 1324 1325 - 1335 1336 - 1346

F 132 F 133 F 134

All Ancillary Service Cost Centers All Outpatient Service Cost Centers All Other Reimbursable Cost Centers

0 0 0 0 0

11 11 11 11 11

S9 S9 S9 S9 S9

1347 - 1357 1358 1369 1380 1391 1368 1379 1390 1401

F F F F

135 136 137 138

All Special Purpose Cost Centers All NonReimbursable Cost Centers Negative Cost Center Total Reimbursable Costs

MEDICAL EDUCATION COSTS, INCLUDING ALLOCATED OVERHEAD - FACILITY SOURCE: HCFA FORM 2552-92, WORKSHEET B, PART I FIELD NAME F 139 F 140 F 141 FIELD SIZE 11 11 11

DESCRIPTION Total Nonphysician Anesthetist Cost Total Nursing School Costs Total Paramedical Education Cost

LINE(S) 103 103 103 Page 4

COL(S) 20 21 24

USAGE S9 S9 S9

LOCATION 1402 - 1412 1413 - 1423 1424 - 1434

Minimum Data Set COST OF INTERNS & RESIDENTS IN APPROVED PROGRAMS, INCLUDING ALLOCATED OVERHEAD SOURCE: FORM HCFA 2552-92, WORKSHEET B, PART FIELD NAME F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 FIELD SIZE 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11

08/22/96

DESCRIPTION Adults & Pediatrics - (General Routine Care) Intensive Care Unit Coronary Care Unit Other Special Care Units Subprovider -Total Nursery Skilled Nursing Facility Nursing Facility Other Long Term Care Facility Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic Radiology - Therapeutic Radioisotope Laboratory Whole Blood & Packed Red Blood Cells Blood Storing, Processing, & Trans. Intravenous Therapy Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis All Other Inpatient Ancillary Cost Centers Outpatient Clinic Emergency All Other Outpatient Service Cost Centers (Including Observation Beds) (See Note 8) Other Reimbursable Cost Centers

LINE(S) 25 26 27 28-30 31 33 34 35 36 37 38 39 40 41 42 43 44 46 47 48 49 50 51 52 53 54 55 56 57 58-59 60 61

COL(S) 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23 22 + 23

USAGE S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9

LOCATION 1435 1446 1457 1468 1479 1490 1501 1512 1523 1534 1545 1556 1567 1578 1589 1600 1611 1622 1633 1644 1655 1666 1677 1688 1699 1710 1721 1732 1743 1754 1765 1776 1445 1456 1467 1478 1489 1500 1511 1522 1533 1544 1555 1566 1577 1588 1599 1610 1621 1632 1643 1654 1665 1676 1687 1698 1709 1720 1731 1742 1753 1764 1775 1786

F 174

62 + 63 64-68, 70-82 83-86, 92-94 96-100 101 102 103

22 + 23

11

S9

1787 - 1797

F 175

22 + 23

11

S9

1798 - 1808

F 176

Special Purpose Cost Centers

22 + 23 22 + 23 22 + 23 22 + 23 22 + 23

11 11 11 11 11

S9 S9 S9 S9 S9

1809 - 1819 1820 1831 1842 1853 1830 1841 1852 1863

F F F F

177 178 179 180

NonReimbursable Cost Centers Cross Foot Adjustment Negative Cost Center Total Interns & Residents Costs (Approved Programs)

CAPITAL RELATED COSTS SOURCE: FORM HCFA 2552-92, WORKSHEET B, PARTS II AND III FIELD NAME F 181 FIELD SIZE

DESCRIPTION Directly Assigned Old and New Capital Related Costs - Inpatient Directly Assigned Old and New Capital Related Costs - Total Adults & Pediatrics - (General Routine Care) Intensive Care Unit

LINE(S) 5-33, 37-59

COL(S)

USAGE

LOCATION

27

11

S9

1864 - 1874

F 182

103 25 Page26 5

27 27 27

11 11 11

S9 S9 S9

1875 - 1885 1886 - 1896 1897 - 1907

F 183 F 184

F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F

185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214

Coronary Care Unit Other Special Care Units Subprovider -Total Nursery Skilled Nursing Facility Nursing Facility Other Long Term Care Facility Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic Radiology - Therapeutic Radioisotope Laboratory Whole Blood & Packed Red Blood Cells Blood Storing, Processing, & Trans. Intravenous Therapy Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis All Other Inpatient Ancillary Cost Centers Outpatient Clinic Emergency All Other Outpatient Service Cost Centers (Including Observation Beds) Other Reimbursable Cost Centers

Minimum Data Set 27 28-30 31 33 34 35 36 37 38 39 40 41 42 43 44 46 47 48 49 50 51 52 53 54 55 56 57 58-59 60 61

27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27

11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11

S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9

1908 1919 1930 1941 1952 1963 1974 1985 1996 2007 2018 2029 2040 2051 2062 2073 2084 2095 2106 2117 2128 2139 2150 2161 2172 2183 2194 2205 2216 2227

-

1918 1929 1940 1951 1962 1973 1984 1995 2006 2017 2028 2039 2050 2061 2072 2083 2094 2105 2116 2127 2138 2149 2160 2171 2182 2193 2204 2215 2226 2237

08/22/96

F 215

62-63 64-68, 70-82 83-96, 92-94 96-100 101 102 103

27

11

S9

2238 - 2248

F 216

27

11

S9

2249 - 2259

F 217

Special Purpose Cost Centers

27 27 27 27 27

11 11 11 11 11

S9 S9 S9 S9 S9

2260 - 2270 2271 2282 2293 2304 2281 2292 2303 2314

F F F F

218 219 220 221

NonReimbursable Cost Centers Cross Foot Adjustment Negative Cost Center Total Capital Related Costs

TOTAL COSTS, AFTER COST ALLOCATION (See Note 9) SOURCES: FORM HCFA 2552-92, WORKSHEET B, PART I, COLUMN 27 AND WORKSHEET C, PART I, COLUMN 2 FIELD NAME F F F F F F F F F F F 222 223 224 225 226 227 228 229 230 231 232 FIELD SIZE 11 11 11 11 11 11 11 11 11 11 11

DESCRIPTION Adults & Pediatrics (General Routine Care) Intensive Care Unit Cororonary Care Unit All Other Special Care Units Subprovider--Total Nursery Skilled Nursing Facility Nursing Facility Other Long Term Care Facility Operating Room Recovery Room

LINE(S) 25 26 27 28-30 31 33 34 35 36 37 38 Page 6

COL(S) 27 27 27 27 27 27 27 27 27 27 27

USAGE S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9

LOCATION 2315 2326 2337 2348 2359 2370 2381 2392 2403 2414 2425 2325 2336 2347 2358 2369 2380 2391 2402 2413 2424 2435

F F F F F F F F F F F F F F F F F F F F F F F F

233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256

Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic Radiology - Therapeutic Radioisotope Laboratory PBP Clinic Lab Services--Program Only Whole Blood & Packed Red Blood Cells Blood Storing, Processing, & Trans. Intravenous Therapy Respiratory Therapy Respiratory Therapy Limit Adjustment (Worksheet C) Physical Therapy Physical Therapy Limit Adjustment (Worksheet C) Occupational Therapy Speech Pathology Electrocardiology Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis All Other Inpatient Ancillary Cost Centers Outpatient Clinic Emergency All Other Outpatient Service Cost Centers (Including Observation Beds) All Other Reimbursable Cost Centers

Minimum Data Set 39 40 41 42 43 44 45 46 47 48 49 49 50 50 51 52 53 54 55 56 57 58-59 60 61

27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27

11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11

S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9

2436 2447 2458 2469 2480 2491 2502 2513 2524 2535 2546 2557 2568 2579 2590 2601 2612 2623 2634 2645 2656 2667 2678 2689

-

2446 2457 2468 2479 2490 2501 2512 2523 2534 2545 2556 2567 2578 2589 2600 2611 2622 2633 2644 2655 2666 2677 2688 2699

08/22/96

F 257

62 + 63 64-68, 70-82 25-68 83-96, 92-94 96-100 102 103

27

11

S9

2700 - 2710

F 258

27 27

11 11

S9 S9

2711 - 2721 2722 - 2732

F 259 F 260

Total Facility Reimbursable Costs After Step Down All Special Purpose Cost Centers

27 27 27 27

11 11 11 11

S9 S9 S9 S9

2733 - 2743 2744 - 2754 2755 - 2765 2766 - 2776

F 260 F 262 F 263

All NonReimbursable Cost Centers Negative Cost Center Total Facility Costs

TOTAL FACILITY ANCILLARY CHARGES SOURCE: FORM HCFA 2552-92, WORKSHEET C, PART I FIELD NAME F F F F F F F F F F F F F F 263A 263B 263C 263D 263E 263F 263G 263H 263I 264 265 266 267 268 FIELD SIZE 11 11 11 11 11 11 11 11 11 11 11 11 11 11

DESCRIPTION Adults & Pediatrics (General Routine Care) Intensive Care Unit Cororonary Care Unit All Other Special Care Units Subprovider--Total Nursery Skilled Nursing Facility Nursing Facility Other Long Term Care Facility Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic

LINE(S) 25 26 27 28-30 31 33 34 35 36 37 38 39 40 41 Page 7

COL(S) 6 6 6 6 6 6 6 6 6 6 6 6 6 6

USAGE S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9

LOCATION 2777 2788 2799 2810 2821 2832 2843 2854 2865 2876 2887 2898 2909 2920 2787 2798 2809 2820 2831 2842 2853 2864 2875 2886 2897 2908 2919 2930

F F F F F F F F F F F F F F F F F F F

269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287

Radiology - Therapeutic Radioisotope Laboratory PBP Clinic Lab Services--Program Only Whole Blood & Packed Red Blood Cells Blood Storing, Processing, & Trans. Intravenous Therapy Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis All Other Inpatient Ancillary Cost Centers Outpatient Clinic Emergency All Other Outpatient Service Cos Centers (Including Observation Beds) All Other Reimbursable Cost Centers Total Charges - All Cost Centers

Minimum Data Set 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58-59 60 61

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11

S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9

2931 2942 2953 2964 2975 2986 2997 3008 3019 3030 3041 3052 3063 3074 3085 3096 3107 3118 3129

-

2941 2952 2963 2974 2985 2996 3007 3018 3029 3040 3051 3062 3073 3084 3095 3106 3117 3128 3139

08/22/96

F 288

62-63 64-68 101

6 6 6

11 11 11

S9 S9 S9

3140 - 3150 3151 - 3161 3162 - 3172

F 289 F 290

MEDICARE PART A HOSPITAL INPATIENT ANCILLARY CHARGES SOURCE: HCFA FORM 2552-92, WORKSHEET D-4 FIELD NAME F F F F F F F F F F F F F F F 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 FIELD SIZE 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11

DESCRIPTION Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic Radiology - Therapeutic Radioisotope Laboratory PBP Clinic Lab Services--Program Only Whole Blood & Packed Red Blood Cells Blood Storing, Processing, & Trans. Intravenous Therapy Respiratory Therapy Physical Therapy Occupational Therapy

LINE(S) 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51

COL(S) 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

USAGE S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9

LOCATION 3173 3184 3195 3206 3217 3228 3239 3250 3261 3272 3283 3294 3305 3316 3327 3183 3194 3205 3216 3227 3238 3249 3260 3271 3282 3293 3304 3315 3326 3337

MEDICARE PART A HOSPITAL INPATIENT ANCILLARY CHARGES (CONTINUED) SOURCE: FORM HCFA 2552-92, WORKSHEET D-4 FIELD NAME F F F F F F F F F 306 307 308 309 310 311 312 313 314 FIELD SIZE 11 11 11 11 11 11 11 11 11

DESCRIPTION Speech Pathology Electrocardiology Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis All Other Inpatient Ancillary Cost Centers Outpatient Clinic Emergency All Other Outpatient Service Cost Centers (Including Observation Beds) All Other Reimbursable Cost Centers Total Medicare Inpatient Hospital Charges

LINE(S) 52 53 54 55 56 57 58-59 60 61

COL(S) 2 2 2 2 2 2 2 2 2

USAGE S9 S9 S9 S9 S9 S9 S9 S9 S9

LOCATION 3338 3349 3360 3371 3382 3393 3404 3415 3426 3348 3359 3370 3381 3392 3403 3414 3425 3436

F 315

62-63 64-68 101 Page 8

2 2 2

11 11 11

S9 S9 S9

3437 - 3447 3448 - 3458 3459 - 3469

F 316 F 317

Minimum Data Set MEDICARE PART A HOSPITAL INPATIENT ANCILLARY COSTS (See Note 9) SOURCE: FORM HCFA 2552-92, WORKSHEET D-4 FIELD NAME F F F F F F F F F F F F F F F F F F F F F F F F 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 FIELD SIZE 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11

08/22/96

DESCRIPTION Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic Radiology - Therapeutic Radioisotope Laboratory PBP Clinic Lab Services--Program Only Whole Blood & Packed Red Blood Cells Blood Storing, Processing, & Trans. Intravenous Therapy Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis All Other Inpatient Ancillary Cost Centers Outpatient Clinic Emergency All Other Outpatient Service Cost Centers (Including Observation Beds) All Other Reimbursable Cost Centers Total Medicare Inpatient Hospital Ancillary Charges

LINE(S) 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58-59 60 61

COL(S) 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

USAGE S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9

LOCATION 3470 3481 3492 3503 3514 3525 3536 3547 3558 3569 3580 3591 3602 3613 3624 3635 3646 3657 3668 3679 3690 3701 3712 3723 3480 3491 3502 3513 3524 3535 3546 3557 3568 3579 3590 3601 3612 3623 3634 3645 3656 3667 3678 3689 3700 3711 3722 3733

F 342

62-63 64-68 101

3 3 3

11 11 11

S9 S9 S9

3734 - 3744 3745 - 3755 3756 - 3766

F 343 F 344

MEDICARE PART A HOSPITAL INPATIENT CAPITAL-RELATED COSTS (See Note 10) SOURCES: FORM HCFA 2552-92, WORKSHEET D, PARTS I AND II FIELD NAME F F F F F F F F F F F F F F F F F F F F 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 FIELD SIZE 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11

DESCRIPTION Adults & Pediatrics (General Routine Care) Intensive Care Unit Cororonary Care Unit All Other Special Care Units Subprovider--Total Nursery Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic Radiology - Therapeutic Radioisotope Laboratory Whole Blood & Packed Red Blood Cells Blood Storing, Processing, & Trans. Intravenous Therapy Respiratory Therapy Physical Therapy Occupational Therapy

LINE(S) 25 26 27 28-30 31 33 37 38 39 40 41 42 43 44 46 47 48 49 50 51 Page 9

COL(S) 10 + 12 10+ 12 10 + 12 10+ 12 10 + 12 10+ 12 6+8 6+8 6+8 6+8 6+8 6+8 6+8 6+8 6+8 6+8 6+8 6+8 6+8 6+8

USAGE S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9

LOCATION 3767 3778 3789 3800 3811 3822 3833 3844 3855 3866 3877 3888 3899 3910 3921 3932 3943 3954 3965 3976 3777 3788 3799 3810 3821 3832 3843 3854 3865 3876 3887 3898 3909 3920 3931 3942 3953 3964 3975 3986

F F F F F F F F F

365 366 367 368 369 370 371 372 373

Speech Pathology Electrocardiology Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis All Other Inpatient Ancillary Cost Centers Outpatient Clinic Emergency All Other Outpatient Service Cost Centers (Including Observation Beds) All Other Reimbursable Cost Centers Total Medicare Capital Pass-Through Costs

Minimum Data Set 52 53 54 55 56 57 58-59 60 61

6+8 6+8 6+8 6+8 6+8 6+8 6+8 6+8 6+8

11 11 11 11 11 11 11 11 11

S9 S9 S9 S9 S9 S9 S9 S9 S9

3987 3998 4009 4020 4031 4042 4053 4064 4075

-

3997 4008 4019 4030 4041 4052 4063 4074 4085

08/22/96

F 374

62-63 64-68 X

6+8 6+8 6+8

11 11 11

S9 S9 S9

4086 - 4096 4097 - 4107 4108 - 4118

F 375 F 376

OTHER COSTS AVAILABLE FOR HOSPITAL INPATIENT PASS-THROUGH (See Note 9) SOURCES: FORM HCFA 2552-92, WORKSHEET D, PARTS III AND IV FIELD NAME F F F F F F F F F F 377 378 379 380 381 382 383 384 385 386 FIELD SIZE 11 11 11 11 11 11 11 11 11 11

DESCRIPTION Adults & Pediatrics (General Routine Care) Intensive Care Unit Cororonary Care Unit All Other Special Care Units Subprovider--Total Nursery Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology

LINE(S) 25 26 27 28-30 31 33 37 38 39 40

COL(S) 1+2 1+2 1+2 1+2 1+2 1+2 1+2 1+2 1+2 1+2

USAGE S9 S9 S9 S9 S9 S9 S9 S9 S9 S9

LOCATION 4119 4130 4141 4152 4163 4174 4185 4196 4207 4218 4129 4140 4151 4162 4173 4184 4195 4206 4217 4228

OTHER COSTS AVAILABLE FOR HOSPITAL INPATIENT PASS-THROUGH (CONTINUED) SOURCES: FORM HCFA 2552-92, WORKSHEET D, PARTS III AND IV FIELD NAME F F F F F F F F F F F F F F F F F F F 387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 FIELD SIZE 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11

DESCRIPTION Radiology - Diagnostic Radiology - Therapeutic Radioisotope Laboratory Whole Blood & Packed Red Blood Cells Blood Storing, Processing, & Trans. Intravenous Therapy Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis All Other Inpatient Ancillary Cost Centers Outpatient Clinic Emergency All Other Outpatient Service Cost Centers All Other Reimbursable Cost Centers

LINE(S) 41 42 43 44 46 47 48 49 50 51 52 53 54 55 56 57 58-59 60 61 62 + 63 64-68 Page 10

COL(S) 1+2 1+2 1+2 1+2 1+2 1+2 1+2 1+2 1+2 1+2 1+2 1+2 1+2 1+2 1+2 1+2 1+2 1+2 1+2 1+2 1+2

USAGE S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9

LOCATION 4229 4240 4251 4262 4273 4284 4295 4306 4317 4328 4339 4350 4361 4372 4383 4394 4405 4416 4427 4239 4250 4261 4272 4283 4294 4305 4316 4327 4338 4349 4360 4371 4382 4393 4404 4415 4426 4437

F 406 F 407

4438 - 4448 4449 - 4459

Minimum Data Set F 408 Total Other Costs Available for Hospital Inpatient Pass-Through X 1+2 11 S9 4460 - 4470

08/22/96

MEDICARE PART A HOSPITAL INPATIENT OTHER PASS THROUGH COSTS (See Note 9) SOURCES: FORM HCFA 2552-92, WORKSHEET D, PARTS III AND IV FIELD NAME F F F F F F F F F F F F F F F F F F F F F F 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 FIELD SIZE 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11

DESCRIPTION Adults & Pediatrics (General Routine Care) Intensive Care Unit Cororonary Care Unit All Other Special Care Units Subprovider--Total Nursery Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic Radiology - Therapeutic Radioisotope Laboratory Whole Blood & Packed Red Blood Cells Blood Storing, Processing, & Trans. Intravenous Therapy Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology

LINE(S) 25 26 27 28-30 31 33 37 38 39 40 41 42 43 44 46 47 48 49 50 51 52 53

COL(S) 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8

USAGE S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9

LOCATION 4471 4482 4493 4504 4515 4526 4537 4548 4559 4570 4581 4592 4603 4614 4625 4636 4647 4658 4669 4680 4691 4702 4481 4492 4503 4514 4525 4536 4547 4558 4569 4580 4591 4602 4613 4624 4635 4646 4657 4668 4679 4690 4701 4712

MEDICARE PART A HOSPITAL INPATIENT OTHER PASS THROUGH COSTS (Continued) SOURCES: FORM HCFA 2552-92, WORKSHEET D, PARTS III AND IV FIELD NAME F F F F F F F 431 432 433 434 435 436 437 FIELD SIZE 11 11 11 11 11 11 11 11 11

DESCRIPTION Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis All Other Inpatient Ancillary Cost Centers Outpatient Clinic Emergency All Other Outpatient Service Cost Centers All Other Reimbursable Cost Centers Total Medicare Part A Hospital Inpatient Other Pass Through Costs (See Note 12)

LINE(S) 54 55 56 57 58-59 60 61 62 + 63 64-68

COL(S) 7 7 7 7 7 7 7 7 7

USAGE S9 S9 S9 S9 S9 S9 S9 S9 S9

LOCATION 4713 4724 4735 4746 4757 4768 4779 4723 4734 4745 4756 4767 4778 4789

F 438 F 439 F 440

4790 - 4800 4801 - 4811

X

X

11

S9

4812 - 4822

MEDICARE PART B HOSPITAL ANCILLARY CHARGES AND COSTS SOURCE: FORM HCFA 2552-92, WORKSHEET D, PART V FIELD NAME F F F F 441 442 443 444 FIELD SIZE 11 11 11 11

DESCRIPTION Outpatient Clinic Charges Emergency Room Charges All Other Outpatient Department Charges Total Outpatient Charges

LINE(S) 60 61 62 + 63 101 Page 11

COL(S) 2-5 2-5 2-5 2-5

USAGE S9 S9 S9 S9

LOCATION 4823 4834 4845 4856 4833 4844 4855 4866

F 445 F 445A

Outpatient Clinic Costs (See Note 9) Outpatient Clinic Capital Reduction Amount (See Note 3) Outpatient Clinic Non-Capital Reduction Amount (See Note 11) Emergency Room Costs Emergency Room Capital Reduction Amount Emergency Room Non-Capital Reduction Amount All Other Outpatient Department Costs All Other Outpatient Department Capital Reduction Amount

Minimum Data Set 60

6-9

11

S9

4867 - 4877

08/22/96

X

X

11

S9

4878 - 4888

F 445B

X 61 X X 62 + 63 X X 101 X X

X 6-9 X X 6-9 X X 6-9 X X

11 11 11 11 11 11 11 11 11 11

S9 S9 S9 S9 S9 S9 S9 S9 S9 S9

4889 - 4899 4900 4911 4922 4933 4944 4955 4966 4977 4988 4910 4921 4932 4943 4954 4965 4976 4987 4998

F F F F F F F F F

446 446A 446B 447 447A 447B 448 448A 448B

All Other Outpatient Department Non-Capital Reduction Amount Total Outpatient Costs Total Outpatient Capital Reduction Amount Total Outpatient Non-Capital Reduction Amount

SUMMARY OF INPATIENT OPERATING COSTS IN TOTAL AND FOR MEDICARE (See Note 9) SOURCES: FORM HCFA 2552-92, WORKSHEET D-1, PARTS I AND II FIELD NAME F 449 F 450 FIELD SIZE 11

DESCRIPTION Total Swing Bed Cost General Inpatient Routine Service Cost Net of Swing Bed Cost General Inpatient Routine Service Cost, Net of Swing Bed Cost and Private Room Differential General Inpatient Routine Service Cost Total Medicare Cost Intensive Care Unit - Total Medicare Cost Coronary Care Unit - Total Medicare Cost All Other Special Care Units--Total Medicare Cost Medicare Inpatient Ancillary Cost, Before Limitation RESERVED FOR FUTURE USE Total Medicare Inpatient Operating Costs, Including Pass Through Costs (See Note 12) TEFRA Target Amount per Discharge Incentive/Penalty Payment

LINE(S) 26

COL(S) 1

USAGE S9

LOCATION 4999 - 5009

27

1

11

S9

5010 - 5020

F 451

37

1

11

S9

5021 - 5031

F 452

41 43 44 45-47 48

1 5 5 5 1

11 11 11 11 11 11

S9 S9 S9 S9 S9 S9 S9 S9(9)V9(2) S9

5032 - 5042 5043 5054 5065 5076 5053 5064 5075 5086

F F F F F

453 454 455 456 457

5087 - 5097 5098 - 5108 5109 - 5119 5120 - 5130

F 458

49 55 58

1 1 1

11 11 11

F 459 F 460

KIDNEY ACQUISITION COSTS SOURCE: FORM HCFA 2552-92, SUPPLEMENTAL WORKSHEET D-6, PART III FIELD NAME FIELD SIZE

DESCRIPTION

LINE(S) Page 12

COL(S)

USAGE

LOCATION

Minimum Data Set F 461 F 462 F 463 FIELD NAME F F F F F F 464 465 466 467 468 469 RESERVED FOR FUTURE USE Direct Kidney Acquisition Costs Revenue for Kidneys Sold 51 58 1 1 11 11 11 FIELD SIZE 11 11 11 11 11 11 S9 S9 S9 5131 - 5141 5142 - 5152 5153 - 5163

08/22/96

DESCRIPTION RESERVED FOR FUTURE USE RESERVED FOR FUTURE USE RESERVED FOR FUTURE USE RESERVED FOR FUTURE USE RESERVED FOR FUTURE USE RESERVED FOR FUTURE USE

LINE(S)

COL(S)

USAGE S9 S9 S9 S9 S9 S9

LOCATION 5164 5175 5186 5197 5208 5219 5174 5185 5196 5207 5218 5229

MEDICARE PART A SETTLEMENT SUMMARY (See Note 12) SOURCES: FORM HCFA 2552-92, WORKSHEET E, PART A AND SUPPLEMENTAL WORKSHEET E-3, PARTS I, II, AND IV, COLUMN 1 FIELD NAME F F F F F 470 471 472 473 473A E PART A 1 2 * 14 E PART I * * 1 * E-3 PART II * * 1 * FIELD SIZE 11 11 11 11 11 11

DESCRIPTION DRG Payments - Other Than Outliers DRG Outlier Payments Inpatient Hospital Services Routine Service Pass Through Cost RESERVED FOR FUTURE USE Routine Medical Education Pass Through Costs (Included in F473)

USAGE S9 S9 S9 S9 S9 S9

LOCATION 5230 5241 5252 5263 5274 5240 5251 5262 5273 5284

F 473B

X

*

*

5285 - 5295

F 473C Routine Nonphysician Anesthetist Pass Through Costs (Included in F473) F 474 F 474A F 474B Ancillary Service Pass Through Costs RESERVED FOR FUTURE USE Ancillary Medical Education Pass Through Costs (Included in F474)

X

*

*

11

S9

5296 - 5306

15

*

*

11 11

S9 S9

5307 - 5317 5318 - 5328

X

*

*

11

S9

5329 - 5339

F 474C Ancillary Nonphysician Anesthetist Pass Through Costs (Included in F474) F 475 Net Organ Acquisition Costs - Certified Transplant Centers Only Cost of Teaching Physicians Indirect Medical Education Adjustment Direct Graduate Medical Payment (See Note 12) Number of FTE Residents - OB/GYN and

X

*

*

11

S9

5340 - 5350

12 13 3 11

2 3 * 14 Page 13

2 3 * 22

11 11 11 11

S9 S9 S9 S9

5351 - 5361 5362 - 5372 5373 - 5383 5384 - 5394

F 476 F 477 *F 478A *F 478B

Primary Care (From Supplemental Wksht E-3, Part ISV) *F 478C Number of FTE Residents - All Other (From Supplemental Wksht. E-3, Part IV) *F 478D Updated per Resident Amount - OB/GYN and Primary Care (From Supplemental Worksheet E-3, Part IV) *F 478E Updated per Resident Amount - All Other Primary Care (From Supplemental Worksheet E-3, Part IV) F 479 F 480 F 481 Disproportionate Share Adjustment Additional Payment for High ESRD Use Hospital Specific Payments (For Sole Community Hospitals and Medicare Dependent Hospitals only) Payment for Inpatient Capital Exception Payment for Inpatient Capital Primary Payor Payments Total Amount Payable for Medicare Beneficiaries Deductibles Coinsurance Reimbursable Bad Debts, Net of Recoveries Other Adjustments Amount Due Provider, Before Sequestration (See Note 9) Sequestration Adjustment (See Note 13) Interim Payments Protested Amounts

Minimum Data Set 1 *

08/22/96 * 11 S9(9)V9(2) 5395 - 5405

1.01

*

*

11

S9(9)V9(2)

5406 - 5416

2

*

*

11

S9(9)V9(2)

5417 - 5427

2.01 4 5

* * *

* * *

11 11 11

S9(9)V9(2) S9 S9

5428 - 5438 5439 - 5449 5450 - 5460

F F F F F F F F F F F F

482A 482B 483 484 485 486 487 487A 488 489 490 491

7 9 10 17 18 19 20 21 25 27 28 30 32

* * * 5 7 8 10 12 17 19 20 22 24

* * * 5 7 24 27 29 34 36 37 39 41

11 11 11 11 11 11 11 11 11 11 11 11 11

S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9

5461 5472 5483 5494 5505 5516 5527 5538 5549 5560 5571 5582 5593

-

5471 5482 5493 5504 5515 5526 5537 5548 5559 5570 5581 5592 5603

MEDICARE PART B SETTLEMENT SUMMARY SOURCES: FORM HCFA 2552-92, WORKSHEET E, PARTS B THROUGH E AND SUPPLEMENTAL WORKSHEET I-4 FIELD NAME F 492 F 493 F 494 F 495 F 496 F 497 FIELD SIZE 11 11 11 11 11 11 11

DESCRIPTION Medical and Other Services Interns and Residents Costs Organ Acquisition Costs Certified Transplant Centers Only RESERVED FOR FUTURE USE Cost of Teaching Physicians Total Part B Reimbursable Costs Before Deductibles and Coinsurance RESERVED FOR FUTURE USE Total Reasonable Cost for Services not Subject to Reimbursement on a Fee Schedule Outpatient Ambulatory Surgery Reimbursement, Net of Deductibles and Coinsurance From E, Part C (Included in F504, below) Outpatient Radiology Services Reimbursement, Net of Deductibles and Coinsurance From E, Part D (Included in F504, below)

LINE(S) 1 2 3 4 5

COL(S) 1 1 1 1 1

USAGE S9 S9 S9 S9 S9 S9 S9

LOCATION 5604 - 5614 5615 - 5625 5626 - 5636 5637 - 5647 5648 - 5658 5659 - 5669 5670 - 5680

F 498 F 499

7

1

11

S9

5681 - 5691

F 499A

21

1

11

S9

5692 - 5702

F 499B

21

1

11

S9

5703 - 5713

F 499C Outpatient Diagnostic Services Reimbursement, Net of Deductibles and Coinsurance From E, Part E (Included in F504, below)

21

1

11

S9

5714 - 5724

F 499D Outpatient Renal Dialysis Reimbursement, Net of Deductibles and Coinsurance from Supplemental Worksheet I-4 (Excluded from F504, below) F F F F 500 501 501A 501B Deductibles and Coinsurance, From E, Parts B - E Primary Payor Payments Direct Graduate Medical Payment (See Note 9) ESRD Direct Medial Education Costs (See Note 9)

7 X 26 23 24 Page 14

1 1 1 1 1

11 11 11 11 11

S9 S9 S9 S9 S9

5725 - 5735 5736 5747 5758 5769 5746 5757 5768 5779

F 502 F 503 F 503A F 504

Bad Debts for Composite Rate ESRD Services All Other Bad Debts, Net of Recoveries Other Adjustments Amount Due Provider, Before Sequestration (See Note 9) (Excludes F499D) Sequestration Adjustment or Payment Reduction (See Note 13) Interim Payments Protested Amounts

Minimum Data Set 28 29 35

1 1 1

11 11 11

S9 S9 S9

5780 - 5790 5791 - 5801 5802 - 5812

08/22/96

37

1

11

S9

5813 - 5823

F 505

38 40 42

1 1 1

11 11 11

S9 S9 S9

5824 - 5834 5835 - 5845 5846 - 5856

F 506 F 507

FINANCIAL DATA - FACILITY SOURCE: HCFA FORM 2552-92, WORKSHEEET G FIELD NAME F F F F F F F F 508 509 510 511 512 513 514 515 FIELD SIZE 11 11 11 11 11 11 11 11

DESCRIPTION Total Current Assets Total Fixed Assets Total Other Assets Total Assets Total Current Liabilities Total Long Term Liabilities Total Liabilities Total Fund Balances

LINE(S) 11 28 33 34 43 49 50 58

COL(S) 1-4 1-4 1-4 1-4 1-4 1-4 1-4 1-4

USAGE S9 S9 S9 S9 S9 S9 S9 S9

LOCATION 5857 5868 5879 5890 5901 5912 5923 5934 5867 5878 5889 5900 5911 5922 5933 5944

PATIENT REVENUES SOURCE: FORM HCFA 2552-92, WORKSHEET G-2, PART I FIELD NAME F F F F 516 517 518 519 FIELD SIZE 11 11 11 11

DESCRIPTION Hospital Inpatient Routine Service Revenue Total Facility Inpatient Care Service Revenue Total Intensive Care Service Revenue Inpatient Ancillary Revenue Revenue from Outpatient Services Rendered in an Inpatient Setting Revenue from Inpatient Services Rendered in an Outpatient Setting Outpatient Services Revenue Total Facility Inpatient Revenue Total Facility Outpatient Revenue

LINE(S) 1 11 15 17

COL(S) 1 1 1 1

USAGE S9 S9 S9 S9

LOCATION 5945 5956 5967 5978 5955 5966 5977 5988

F 520

18

1

11

S9

5989 - 5999

F 521

17 18 25 25

2 2 1 2

11 11 11 11

S9 S9 S9 S9

6000 - 6010 6011 - 6021 6022 - 6032 6033 - 6043

F 522 F 523 F 524

FACILITY REVENUES AND EXPENSES SOURCE: FORM HCFA 2552-92, WORKSHEET G-3 FIELD NAME F F F F F F F 525 526 527 528 529 530 530A FIELD SIZE 11 11 11 11 11 11 11

DESCRIPTION Total Patient Revenues Contractual Allowances and Discounts on Patients' Accounts Net Patient Revenues Total Operating Expenses Other Income - Contributions, Donations, Bequests, etc. Income from Investments Governmental Appropriations Total Nonpatient Revenue, Including Fields F529, F530, and F530A, above Total Other Expenses Net Income or (Loss)

LINE(S) 1 2 3 4 6 7 23

COL(S) 1 1 1 1 1 1 1

USAGE S9 S9 S9 S9 S9 S9 S9

LOCATION 6044 6055 6066 6077 6088 6099 6110 6054 6065 6076 6087 6098 6109 6120

F 531

25 30 31

1 1 1

11 11 11

S9 S9 S9

6121 - 6131 6132 - 6142 6143 - 6153

F 532 F 533

Page 15

Minimum Data Set

08/22/96

HOSPITAL FINANCIAL WAGE INDEX INFORMATION (See Note 14) SOURCE: FORM HCFA 2552-92, WORKSHEET S-3, PART II FISCAL YEARS BEGINNING PRIOR TO OCTOBER 1, 1994 FIELD NAME W W W W W W W W W W W W W W W W 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 FIELD SIZE 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11

DESCRIPTION Total Salaries On-call Wages or Stand by Fees Unmet Physician Guarantees Home Office Personnel Sum of Lines 1.02 - 1.04 (W2 - W4) Revised Wages - Line 1.01 minus Line 1.05 (W1 minus W5) SNF, NF, and OLTC Salaries Home Program Dialysis Salaries Ambulance Service Salaries Interns and Residents Salaries (not in Approved Programs) HHA Salaries CORF Salaries ASC Salaries Hospice Salaries Non-reimbursable Salaries Other Excluded Salaries Total Excluded Salaries-Sum of Lines 2.01 - 2.10 (sum of W7 - W16) Net Hospital Salaries-Line 1.06 minus Line 2.11 (W6 minus W17) Contract Labor Costs Home Office Salaries Fringe Benefits and Deferred Compensation Total Adjusted Salary - Sum of Lines 3 - 6 (sum of W18 - W21) Total Paid Hours Unadjusted Average Hourly Wage- Line 1.06 Divided by Line 8 (W6 divided by W23) Excluded Hours Adjusted Hours - Line 8 minus Line 10 (W23 minus W25) Contract Labor Hours Home Office Salary Hours

LINE(S) 1.01 1.02 1.03 1.04 1.05 1.06 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10

COL(S) 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

USAGE S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9

LOCATION 6154 6165 6176 6187 6198 6209 6220 6231 6242 6253 6264 6275 6286 6297 6308 6319 6164 6175 6186 6197 6208 6219 6230 6241 6252 6263 6274 6285 6296 6307 6318 6329

W 17

2.11

1

11

S9

6330 - 6340

W 18

3 4 5 6

1 1 1 1

11 11 11 11

S9 S9 S9 S9

6341 - 6351 6352 - 6362 6363 - 6373 6374 - 6384

W 19 W 20 W 21 W 22

7 8

1 1

11 11

S9 S9

6385 - 6395 6396 - 6406

W 23 W 24

11 10 11 12 13 Page 16

1 1 1 1 1

11 11 11 11 11

S9(9)V9(2) S9 S9 S9 S9

6407 - 6417 6418 6429 6440 6451 6428 6439 6450 6461

W W W W

25 26 27 28

W 29

Total Adjusted Hours - Sum of Lines 11, 12, and 13 (sum of W26, W27, and W28) Adjusted Average Hourly Wage - Line 7 Divided by Line 14 (W22 divided by W29) Total Hours in General Services

Minimum Data Set 14

08/22/96 1 11 S9 6462 - 6472

W 30

15 16

1 1

11 11

S9(9)V9(2) S9

6473 - 6483 6484 - 6494

W 31

* SEE PAGES 18A, 18B, AND 18C FOR WAGE INDEX INFORMATION FOR FISCAL YEARS BEGINNING ON OR AFTER 10/01/94.

CALCULATION OF CAPITAL PAYMENT UNDER PPS (See Note 10) SOURCE: SUPPLEMENTAL WORKSHEET L, PARTS I-IV FIELD NAME FIELD SIZE

DESCRIPTION

LINE(S)

COL(S)

USAGE

LOCATION

Fully Prospective Method: L L L L L L 1 2 3 4 5 6 Capital Hospital Specific Rate Payments Capital DRG Other Than Capital Outlier Payments Capital Outlier Payments Capital Indirect Medical Education Adjustment Payments Capital Disproportionate Share Adjustment Payments Total Prospective Capital Payments 1 2 3 4 5 6 1 1 1 1 1 1 11 11 11 11 11 11 S9 S9 S9 S9 S9 S9 6495 6506 6517 6528 6539 6550 6505 6516 6527 6538 6549 6560

Hold Harmless Method: L L L L L L L L L L 7 8 9 10 11 12 13 14 15 16 New Capital Old Capital Total Capital Ratio of New Capital to Old Capital Total Capital Payments Under 100% Federal Rate Reduction Factor for Hold Harmless Payment Reduced Old Capital Amount Hold Harmless Payment for New Capital Subtotal Payment Under Hold Harmless Method 1 2 3 4 5 6 7 8 9 10 1 1 1 1 1 1 1 1 1 1 11 11 11 11 11 11 11 11 11 11 S9 S9 S9 S9(5)V9(6) S9 S9(7)V9(4) S9 S9 S9 S9 6561 6572 6583 6594 6605 6616 6627 6638 6649 6660 6571 6582 6593 6604 6615 6626 6637 6648 6659 6670

Reasonable Cost Method: L L L L L 17 18 19 20 21 Medicare Inpatient Routine Capital Cost Medicare Inpatient Ancillary Cost Total Medicare Inpatient Capital Cost Capital Cost Payment Factor Total Inpatient Program Capital Cost 1 2 3 4 5 1 1 1 1 1 11 11 11 11 11 S9 S9 S9 S9(7)V9(4) S9 6671 6682 6693 6704 6715 6681 6692 6703 6714 6725

Computation of Exception Payments: L 22 L 23 Medicare Inpatient Capital Costs Medicare Inpatient Capital Costs for Extraordinary Circumstances Net Medicare Inpatient Capital Costs Applicable Exception Percentage Capital Cost for Comparison to Payments Percentage Adjustment for Extraordinary Circumstances Adjustment to Capital Minimum Payment Level for Extraordinary Circumstances 1 1 11 S9 6726 - 6736

2 3 4 5 6

1 1 1 1 1

11 11 11 11 11

S9 S9 S9 S9(5)V9(6) S9

6737 - 6747 6748 6759 6770 6781 6758 6769 6780 6791

L L L L

24 25 26 27

L 28

7 Page 17

1

11

S9(7)V9(4)

6792 - 6802

L 29 L 30 L 31

Capital Minimum Payment Level Current Year Capital Payments Current Year Comparison of Capital Minimum Payment Level to Capital Payments Carryover of Accumulated Capital Minimum Payment Level to Capital Payments Net Comparison of Capital Minimum Payments Level to Capital Payments Current Year Exception Payment Carryover of Accumulated Capital Minimum Payment Level Over Capital Payment for following period

Minimum Data Set 8 9

08/22/96 1 1 11 11 S9 S9 6803 - 6813 6814 - 6824

11

1

11

S9

6825 - 6835

L 32

12

1

11

S9

6836 - 6846

L 33

13 14

1 1

11 11

S9 S9

6847 - 6857 6858 - 6868

L 34 L 35

15

1

11

S9

6869 - 6879

HOSPITAL FINANCIAL WAGE INDEX INFORMATION SOURCE: FORM HCFA 2552-92, WORKSHEET S-3, PART III EFFECTIVE FOR COST REPORTING PERIODS BEGINNING ON OR AFTER 10/01/94 FIELD NAME W W W W W W W W W W W W W W 32 33 34 35 36 37 38 39 40 41 42 43 44 45 FIELD SIZE 11 11 11 11 11 11 11 11 11 11 11 11 11 11

DESCRIPTION Total Salary Total Paid Hours Non-Physician Anesthetist Part A Salaries Non-Physician Anesthetist Part A Paid Hours Non-Physician Anesthetist Part B Salaries Non-Physician Anesthetist Part B Paid Hours Physician Salaries - Part A Paid Hours Related to Physician Salaries- Part A Physician Salaries - Part B Paid Hours Related to Physician Salaries- Part B Interns and Residents (in approved program) Salaries Interns and Residents (in approved Program) Paid Hours Home Office Personnel Salaries Home Office Personnel Paid Hours Sum of Column 3, Lines 2-7 (Sum of W34, W36, W38, W40, W42, and W44) - Salaries Sum of Column 4, Lines 2-7 (Sum of W35, W37, W39, W41, W43, and W45) - Paid Hours Revised Wages (Salaries) Column 3, Line 1 minus Column 3, Line 8 (W32 minus W46) Paid Hours Related to Revised Wages (Column 4, Line 1 minus Column 4, Line 8 (W33 minus W47) SNF, NF, and OLTC Salaries SNF, NF, and OLTC Paid Hours Home Program Dialysis Salaries Home Program Dialysis Paid Hours Ambulance Services Salaries Ambulance Services Paid Hours Interns and Residents - Salaries (Not in Approved Program) Interns and Residents - Paid Hours (Not in Approved Program) HHA Salaries HHA Paid Hours

LINE(S) 1 1 2 2 3 3 4 4 5 5 6 6 7 7

COL(S) 3 4 3 4 3 4 3 4 3 4 3 4 3 4

USAGE S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9

LOCATION 6880 6891 6902 6913 6924 6935 6946 6957 6968 6979 6990 7001 7012 7023 6890 6901 6912 6923 6934 6945 6956 6967 6978 6989 7000 7011 7022 7033

W 46

8

3

11

S9

7034 - 7044

W 47

8

4

11

S9

7045 - 7055

W 48

9

3

11

S9

7056 - 7066

W 49

9 10 10 11 11 12 12

4 3 4 3 4 3 4

11 11 11 11 11 11 11

S9 S9 S9 S9 S9 S9 S9

7067 - 7077 7078 7089 7100 7111 7122 7133 7088 7099 7110 7121 7132 7143

W W W W W W

50 51 52 53 54 55

W 56

13

3

11

S9

7144 - 7154

W 57

13 14 14 Page 18

4 3 4

11 11 11

S9 S9 S9

7155 - 7165 7166 - 7176 7177 - 7187

W 58 W 59

W W W W W W W W W W W W

60 61 62 63 64 65 66 67 68 69 70 71

Outpatient Rehab. Provider Salaries Outpatient Rehab. Provider Paid Hours ASC Salaries ASC Paid Hours Hospice Salaries Hospice Paid Hours Non-Reimbursable Salaries Non-Reimbursable Paid Hours Subprovider: Psych Unit Salaries Subprovider: Psych Unit Paid Hours Subprovider: Rehab Unit Salaries Subprovider: Rehab Unit Paid Hours

Minimum Data Set 15 15 16 16 17 17 18 18 19 19 20 20

3 4 3 4 3 4 3 4 3 4 3 4

11 11 11 11 11 11 11 11 11 11 11 11

S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9

7188 7199 7210 7221 7232 7243 7254 7265 7276 7287 7298 7309

-

7198 7209 7220 7231 7242 7253 7264 7275 7286 7297 7308 7319

08/22/96

HOSPITAL FINANCIAL WAGE INDEX INFORMATION SOURCE: FORM HCFA 2552-92, WORKSHEET S-3, PART III EFFECTIVE FOR COST REPORTING PERIODS BEGINNING ON OR AFTER 10/01/94 FIELD NAME W W W W W W 72 73 74 75 76 77 FIELD SIZE 11 11 11 11 11 11

DESCRIPTION Nursing School Salaries Nursing School Paid Hours Paramedical Education Salaries Paramedical Education Paid Hours Other Salaries Other Paid Hours Total Excluded Salary Sum of Column 3, Lines 10-23 (Sum of W50, W52, W54, W56, W58, W60, W62, W64, W66, W68 W70, W72, W74, and W76) Total Excluded Paid Hours Sum of Column 4, Lines 10-23 (Sum of W51, W53, W55, W57, W59, W61, W63, W65, W67, W69, W71, W73, W75, and W77) Salaries Subtotal - Column 3, Line 9 minus Column 3, Line 24 (W48 minus W78) Paid Hours Subtotal - Column 4, Line 9 minus Column 4, Line 24 (W49 minus W79) Contract Labor: Patient Related and Management Salaries Contract Labor: Patient Related and Management Paid Hours Home Office Salaries and Wage Related Costs - Salaries Paid Hours Related to Home Office Salaries and Wage Related Costs Wage Related Costs (Core) Wage Related Costs (other) Wage Related Costs (excluded units) Total Adjusted Wage Related Costs Sum of (Column 3, Line 28 plus Column 3, Line 29) minus (Column 3, Line 30) (Sum of (W86 plus W87) minus W88) Total Adjusted Salaries - Sum of Column 3, Lines 25, 26, 27, & 31 (Sum of W80, W82, W84, & W89) Total Adjusted Paid Hours - Sum of Column 4, Lines 25, 26, & 27 (Sum of W81, W83, and W85)

LINE(S) 21 21 22 22 23 23

COL(S) 3 4 3 4 3 4

USAGE S9 S9 S9 S9 S9 S9

LOCATION 7320 7331 7342 7353 7364 7375 7330 7341 7352 7363 7374 7385

W 78

24

3

11

S9

7386 - 7396

W 79

24

4

11

S9

7397 - 7407

W 80

25

3

11

S9

7408 - 7418

W 81

25 26 26 27

4 3 4 3

11 11 11 11

S9 S9 S9 S9

7419 - 7429 7430 - 7440 7441 - 7451 7452 - 7462

W 82 W 83 W 84 W 85

27 28 29 30

4 3 4 3

11 11 11 11

S9 S9 S9 S9

7463 - 7473 7474 - 7484 7485 - 7495 7496 - 7506

W 86 W 87 W 88 W 89

31

4

11

S9

7507 - 7517

W 90

32

3

11

S9

7518 - 7528

W 91

32 Page 19

4

11

S9

7529 - 7539

W 92 W 93

Contract Labor: Physician Services - Part A Salaries Contract Labor: Physician Services - Part A Paid Hours

Minimum Data Set 33 33

3 4

11 11

S9 S9

7540 - 7550 7551 - 7561

08/22/96

OVERHEAD COST - DIRECT SALARIES/PAID HOURS RELATED TO SALARY SOURCE: FORM HCFA 2552-92, WORKSHEET S-3, PART IV EFFECTIVE FOR COST REPORTING PERIODS BEGINNING ON OR AFTER 10/01/94 FIELD NAME W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 FIELD SIZE 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11

DESCRIPTION Employee Benefits Salaries Employee Benefits Paid Hours Administrative and General Salaries Administrative and General Paid Hours Maintenance and Repairs Salaries Maintenance and Repairs Paid Hours Operation of Plant Salaries Operation of Plant Paid Hours Laundry & Linen Salaries Laundry & Linen Paid Hours Housekeeping Salaries Housekeeping Paid Hours Dietary Salaries Dietary Paid Hours Cafeteria Salaries Cafeteria Paid Hours Maintenance of Personnel Salaries Maintenance of Personnel Paid Hours Nursing Administration Salaries Nursing Administration Paid Hours Central Services and Supply Salaries Central Services and Supply Paid Hours Pharmacy Salaries Pharmacy Paid Hours Medical Records and Medical Records Library Salaries Medical Records and Medical Records Library Paid Hours Social Service Salaries Social Service Paid Hours Other General Service Salaries Other General Service Paid Hours Total General Service Cost Centers' Adjusted Salaries - Sum of Column 3, Lines 1-15 (Sum of W94, 96, W98, W100, W102, W104, W106, W108, W110, W112, W114, W116, W118, W120, and W122) Total General Service Cost Centers' Paid Hours Sum of Column 4, Lines 1-15 (Sum of W95, W97, W99, W101, W103, W105, W107, W109, W111, W113, W115, W117, W119, W121, and W123)

LINE(S) 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 11 11 12 12 13 13 14 14 15 15

COL(S) 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4

USAGE S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9 S9

LOCATION 7562 7573 7584 7595 7606 7617 7628 7639 7650 7661 7672 7683 7694 7705 7716 7727 7738 7749 7760 7771 7782 7793 7804 7815 7826 7837 7848 7859 7870 7881 7572 7583 7594 7605 7616 7627 7638 7649 7660 7671 7682 7693 7704 7715 7726 7737 7748 7759 7770 7781 7792 7803 7814 7825 7836 7847 7858 7869 7880 7891

W 124

16

3

11

S9

7892 - 7902

W 125

16

4

11

S9

7903 - 7913

Page 20

Information

PPS9-12.XLS

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