CHAPTER 28 HOSPITAL AND HOSPITAL HEALTH CARE
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CHAPTER 28 HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX COST REPORT FORM HCFA-2552-92 Section General. ....................................................................................................................... Rounding Standards for Fractional Computations. ............................................... Acronyms and Abbreviations................................................................................ Recommended Sequence for Completing Form HCFA-2552-92. ............................... Sequence of Assembly. ............................................................................................... Sequence of Assembly for Non-Proprietary Hospital Participating in Medicare and Subject to Prospective Payment System. ............................................................................ Sequence of Assembly for Proprietary Health Care Complex Participating in Titles V, XVIII and XIX Worksheet S - Hospital and Hospital Health Care Complex Cost Report Certification and Settlement Summary. ............................................ Part I - Certification by Officer or Administrator of Provider(s). .................................................................................................... Part II - Settlement Summary. ........................................................................... Worksheet S-2 - Hospital and Hospital Health Care Complex Identification Data . .............................................................................................. Worksheet S-3 - Hospital and Hospital Health Care Complex Statistical Data and Hospital Wage Index Information. ........................................ Part I - Hospital and Hospital Health Care Complex Statistical Data. .................................................................................................. Part II - Hospital Wage Index Information............................................................ Part III - Hospital Wage Index Information for Cost Reporting Periods Beginning on or After October 1, 1994. ................................................................................................ Part IV - Overhead Cost - Direct Salaries. ............................................................ Worksheet A - Reclassification and Adjustment of Trial Balance of Expenses . ........................................................................................... Worksheet A-6 - Reclassifications . ............................................................................ Worksheet A-7 - Analysis of Capital Assets. .............................................................. Part I - Analysis of Changes in Old Capital Asset Balances and Part II - Analysis of Changes in New Capital Asset Balances. ............................................................................. Part III - Reconciliation of Capital Cost Centers. .................................................. Worksheet A-8 - Adjustments to Expenses. ................................................................ Worksheet B, Part I - Cost Allocation - General Service Costs and Worksheet B-1 - Cost Allocation Statistical Basis. .................................................................................................... Worksheet B, Part II - Allocation of Old Capital-Related Costs and Worksheet B, Part III - Allocation of New Capital-Related Costs. .......................................................................................... Worksheet C - Computation of Ratio of Cost to Charges and Outpatient Capital Reduction. ........................................................................ Part I - Computation of Ratio of Cost to Charges. ................................................ Part II - Calculation of Outpatient Services Cost to Charge Ratios Net of Reductions. ................................................................. Part III - Computation of Total Inpatient Ancillary Costs - Rural Primary Care Hospital.................................................................. Part IV - Computation of Inpatient Operating CostsRural Primary Care Hospitals. ........................................................................... Part V - Computation of Outpatient Cost Per Visit Rural Primary Care Hospital.............................................................................. Worksheet D - Cost Apportionment . .......................................................................... Rev. 7 2800 2800.1 2800.2 2801 2802 2802.1 2802.2 2803 2803.1 2803.2 2805 2806 2806.1 2806.2 2806.3 2806.4 2807 2808 2809 2809.1 2809.2 2810 2811 2812 2813 2813.1 2813.2 2813.3 2813.4 2813.5 2814 28-1 CHAPTER 28 Section Part I - Apportionment of Inpatient Routine Service Capital Costs. ................................................................................................. Part II - Apportionment of Inpatient Ancillary Service Capital Costs. .................................................................................... Part III - Apportionment of Inpatient Routine Service Other Pass Through Costs. ................................................................ Part IV - Apportionment of Inpatient Ancillary Service Other Pass Through Costs . ............................................................... Part V - Apportionment of Medical and Other Health Services Costs . .............................................................................................. Part VI - Vaccine Cost Apportionment. ................................................................ Worksheet D-1 - Computation of Inpatient Operating Cost. ....................................... Part I - All Provider Components. ........................................................................ Part II - Hospital and Subproviders Only. ............................................................. Part III - Skilled Nursing Facility and Other Nursing Facility Only. .................................................................................... Part IV - Computation of Observation Bed Cost. ................................................. Worksheet D-4 - Inpatient Ancillary Service Cost Apportionment. ..................................................................................................... Worksheet E - Calculation of Reimbursement Settlement. ......................................... Part A - Inpatient Hospital Services Under PPS. .................................................. Part B - Medical and Other Health Services. ........................................................ Part C - Outpatient Ambulatory Surgery . ............................................................. Part D - Outpatient Radiology Services. ............................................................... Part E - Other Outpatient Diagnostic Procedures.................................................. Worksheet E-1 - Analysis of Payments to Providers for Services Rendered. ............................................................................................... Financial Statements - Worksheets G, G-1, G-2, and G-3. .......................................... Worksheet L - Calculation of Capital Payment. .......................................................... Part I - Fully Prospective Method. ........................................................................ Part II - Hold Harmless Method. ........................................................................... Part III - Payment Under Reasonable Cost............................................................ Part IV - Computation of Exception Payments. .................................................... Supplemental Worksheet A-8-1 - Statement of Costs of Services from Related Organizations and Home Office Costs . ................................................................................................................... Supplemental Worksheet A-8-2 - Provider-Based Physician Adjustments. ......................................................................................... Supplemental Worksheet A-8-3 - Reasonable Cost Determination for Physical Therapy Services Furnished by Outside Suppliers. ............................................................................................ Part I - General Information . ................................................................................ Part II - Salary Equivalency Computation ............................................................ Part III - Standard Travel Allowance and Standard Travel Expense Computation - Provider Site . ............................................... Part IV - Standard Travel Allowance and Standard Travel Expense - HHA Services..................................................................... Part V - Overtime Computation . .......................................................................... Part VI - Computation of Physical Therapy Limitation and Excess Cost Adjustment. ....................................................... Part VII - Allocation of Physical Therapy Excess Cost Over Limitation for Non-Shared Physical Therapy Department Services. ....................................................................... Supplemental Worksheet A-8-4 - Reasonable Cost Determination for Respiratory Therapy Services Furnished by Outside Suppliers. ........................................................................... 28-2 2814.1 2814.2 2814.3 2814.4 2814.5 2814.6 2815 2815.1 2815.2 2815.3 2815.4 2816 2817 2817.1 2817.2 2817.3 2817.4 2817.5 2818 2819 2820 2820.1 2820.2 2820.3 2820.4 2821 2822 2823 2823.1 2823.2 2823.3 2823.4 2823.5 2823.6 2823.7 2824 Rev. 7 CHAPTER 28 Section Part I - General Information . ................................................................................ Part II - Salary Equivalency Computation ............................................................ Part III - Standard Travel Allowance and Standard Travel Expense Computation. ........................................................................ Part IV - Overtime Computation . ......................................................................... Part V - Computation of Respiratory Therapy Limitation and Excess Cost Adjustment. ....................................................... Supplemental Worksheet B-2 - Post Step Down Adjustments. ................................... Supplemental Worksheet D-2 - Apportionment of Cost of Services Rendered by Interns and Residents......................................................... Part I - Not in Approved Teaching Program . ....................................................... Part II - In Approved Teaching Program (Title XVIII, Part B Inpatient Routine Costs Only). ............................................................ Part III - Summary for Title XVIII . ...................................................................... Supplemental Worksheet D-3 - Apportionment of Hospital Based Physician Remuneration for Professional Services Rendered in All Inclusive Rate or No Charge Structure Hospitals Using Combined Billing . ..................................................................... Supplemental Worksheet D-6 - Computation of Organ Acquisition Costs and Charges for Hospitals Which Are Certified Transplant Centers . ............................................................................... Part I - Computation of Organ Acquisition Costs (Inpatient Routine and Ancillary Services). ................................................... Part II - Computation of Organ Acquisition Costs (Other Than Inpatient Routine and Ancillary Service Costs)................................................................................................. Part III - Summary of Costs and Charges . ............................................................ Part IV - Statistics . ............................................................................................... Supplemental Worksheet D-9 - Apportionment of Cost for Services of Teaching Physicians . ......................................................................... Part I - Reasonable Compensation Equivalent Computation Part II - Apportionment of Cost for Services of Teaching Physicians . ..................................................................................... Supplemental Worksheet E-2 - Calculation of Reimbursement Settlement - Swing Beds . ..................................................................................... Supplemental Worksheet E-3 - Calculation of Reimbursement Settlement. ............................................................................................................ Part I - Calculation of Medicare Reimbursement Settlement Under TEFRA. ............................................................................. Part II - Medicare Part A Services - Cost Reimbursement. ............................................................................................. Part III - Title V, Title XVIII (SNF Only) or Title XIX - All Other Health Services. ................................................................... Part IV - Direct Graduate Medical Education and ESRD Outpatient Direct Medical Education Costs. ....................................... Supplemental Worksheet E-4 - Recovery of Unreimbursed Cost. ...................................................................................................................... Part I - Computation of Net Cost of Part A Covered Services. ......................................................................................................... Part II - Computation of Lesser of Reasonable Cost or Customary Charges. ................................................................................... Part III - Computation of Recovery of Unreimbursed Cost. ............................................................................................................... Part IV - Computation of Carryover of Unreimbursed Cost Under Lesser of Cost or Charges . ......................................................... Rev. 7 2824.1 2824.2 2824.3 2824.4 2824.5 2825 2826 2826.1 2826.2 2826.3 2827 2828 2828.1 2828.2 2828.3 2828.4 2829 2829.1 2829.2 2831 2832 2832.1 2832.2 2832.3 2832.4 2833 2833.1 2833.2 2833.3 2833.4 28-3 CHAPTER 28 Section Supplemental Worksheet F-1 - Balance Sheet for Computation of Return on Equity Capital of Proprietary Providers. .......................................... 2834 Supplemental Worksheet F-2 - Computation of Difference Between Total Interim Payments and Net Cost of Covered Services . ................................................................................................ 2835 Part I - Title XVIII . .............................................................................................. 2835.1 Part II - Title V . ................................................................................................... 2835.2 Part III - Title XIX . .............................................................................................. 2835.3 Part IV - Swing Bed-SNF/NF . ............................................................................. 2835.4 Part V - HHA . ...................................................................................................... 2835.5 Part VI - CORF . ................................................................................................... 2835.6 Part VII - Summary . ............................................................................................. 2835.7 Supplemental Worksheet F-3 - Computation of Return on Equity Capital of Proprietary Providers . .............................................................. 2836 Supplemental Worksheet F-4 - Computation of Total Allowable Costs . .................................................................................................. 2837 Supplemental Worksheet F-5 - Apportionment of Allowable Return on Equity Capital of Proprietary Providers . ............................................. 2838 Part I - Computation of Ratio of Allowable Return on Equity Capital to Total Allowable Cost. .................................................... 2838.1 Part II - Apportionment of Allowable Return on Equity Capital................................................................................................. 2838.2 General Instructions for Preparation of Provider-Based Home Health Agency Supplemental Worksheets . ............................................... 2839 Supplemental Worksheet S-4 - Hospital-Based Home Health Agency Statistical Data . ....................................................................................... 2840 Supplemental Worksheet H - Analysis of Provider-Based Home Health Agency Costs . ................................................................................ 2841 Supplemental Worksheet H-1 - Compensation Analysis Salaries and Wages . ............................................................................................. 2842 Supplemental Worksheet H-2 - Compensation Analysis Employee Benefits (Payroll-Related) . .................................................................. 2843 Supplemental Worksheet H-3 - Compensation Analysis Contracted Services/Purchased Services . ............................................................. 2844 Supplemental Worksheet H-4 - Allocation of HHA Administrative and General Costs . ...................................................................... 2845 Part I - Allocation of HHA Administrative and General Costs . ............................................................................................... 2845.1 Part II - Apportionment of Cost of HHA Services Furnished by Shared Hospital Departments . ................................................. 2845.2 Supplemental Worksheet H-5 - Apportionment of Patient Service Costs . ...................................................................................................... 2846 Supplemental Worksheet H-6 - Calculation of HHA Reimbursement Settlement - Part A and Part B Services...................................... 2847 Part I - Computation of Lesser of Reasonable Cost or Customary Charges . .................................................................................. 2847.1 Part II - Computation of HHA Reimbursement Settlement ...................................................................................................... 2847.2 Supplemental Worksheet H-7 - Analysis of Payments to Provider-Based Home Health Agencies for Services Rendered to Program Beneficiaries . .................................................................... 2848 Supplemental Worksheet H-8 - Recovery of Unreimbursed Cost for Provider-Based Home Health Agencies - New Provider Only........................................................................................................ 2849 Part I - Computation of Recovery of Unreimbursed Cost Under Lesser of Reasonable Cost or Customary Charges. ....................................................................................... 2849.1 28-4 Rev. 7 CHAPTER 28 Section Part II - Computation of Carryover of Unreimbursed Cost Under Lesser of Cost or Charges . ......................................................... Supplemental Worksheet S-5 - Hospital Renal Dialysis Department Statistical Data . ................................................................................ Supplemental Worksheet I-2 - Cost Analysis - Renal Dialysis Department Costs. ................................................................................... Part I - Renal Dialysis Cost Analysis . .................................................................. Part II - Direct and Indirect Renal Dialysis Cost Allocation - Statistical Basis. ................................................................. Supplemental Worksheet I-3 - Computation of Average Cost Per Treatment for Outpatient Renal Dialysis . ...................................................... Supplemental Worksheet I-4 - Calculation of Reimbursable Bad Debts - Title XVIII, Part B . .......................................................................... Supplemental Worksheet S-6 - Hospital-Based CORF Statistical Data . .................................................................................................... Supplemental Worksheet J-1 - Allocation of General Service Costs to CORF Cost Centers. ................................................................... Part I - Allocation of General Service Costs to CORF Cost Centers. ....................................................................................... Part II - Computation of Unit Cost Multiplier for Allocation of CORF Administrative and General Costs. .............................................................................................................. Part III - Allocation of General Service Costs to CORF Cost Centers - Statistical Basis. .......................................................... Supplemental Worksheet J-2 - Computation of CORF Costs...................................... Part I - Apportionment of CORF Cost Centers . ................................................... Part II - Apportionment of Cost of CORF Services Furnished by Shared Hospital Departments. .................................................. Part III - Total CORF Costs . ................................................................................ Supplemental Worksheet J-3 - Calculation of Reimbursement Settlement - CORF Services . ............................................................................... Supplemental Worksheet J-4 - Analysis of Payments to Provider-Based CORF for Services Rendered to Program Beneficiaries . ....................................................................................................... Supplemental Worksheet L-1 . .................................................................................... Part I - Allocation of Allowable Capital Costs for Extraordinary Circumstances . ....................................................................... Part II - Computation of Program Inpatient Routine Service Capital Costs for Extraordinary Circumstances . .............................................................................................. Part III - Computation of Program Inpatient Ancillary Service Capital Costs for Extraordinary Circumstances. ........................................................................ Supplemental Worksheet M-1 - Allocation of General Service Costs to CMHC Cost Centers. ................................................................. Part I - Allocation of General Service Costs to CMHC Cost Centers. ..................................................................................... Part II - Computation of Unit Cost Multiplier for Allocation of CMHC Administrative and General Costs. .............................................................................................................. Part III - Allocation of General Service Costs to CMHC Cost Centers - Statistical Basis. ......................................................... Supplemental Worksheet M-2 - Computation of CMHC Costs. ................................. Part I - Apportionment of CMHC Cost Centers. ................................................... Part II - Apportionment of Cost of CMHC Services Furnished by Shared Hospital Departments. .................................................. Rev. 7 2849.2 2850 2851 2851.1 2851.2 2852 2853 2854 2855 2855.1 2855.2 2855.3 2856 2856.1 2856.2 2856.3 2857 2858 2859 2859.1 2859.2 2859.3 2860 2860.1 2860.2 2860.3 2861 2861.1 2861.2 28-5 CHAPTER 28 Section Part III - Total CMHC Costs.............................................................................. Supplemental Worksheet M-3 - Calculation of Reimbursement Settlement - CMHC Services. ............................................................................... Supplemental Worksheet M-4 - Analysis of Payments to Provider-Based CMHC for Services Rendered to Program Beneficiaries. ........................................................................................................ Exhibit 1 - Form HCFA-2552-92 Worksheets. ........................................................... Exhibit 2 - Electronic Reporting Specifications for Form HCFA-2552-92. .......................................................................................... 28-6 2861.3 2862 2863 2890 2895 Rev. 7
