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[" 4090 (Cont.)",null,null,null,"  FORM CMS-2552-10",{"$nulls":5},"DRAFT"]
["RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES",{"$nulls":4},"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET A"]
[{"$nulls":7},"FROM ____________"]
[{"$nulls":5},"_",null,"TO ___________"]
[{"$nulls":7},"RECLASSIFIED",null,"NET EXPENSES"]
[null,null,"COST CENTER DESCRIPTIONS",null,null,"TOTAL","RECLASSIFI-","TRIAL BALANCE",null,"FOR ALLOCATION"]
[null,null,"(omit cents)","SALARIES","OTHER","(col. 1 + col. 2)","CATIONS","(col. 3 ± col. 4)","ADJUSTMENTS","(col. 5 ± col. 6)"]
[null,null,null,"1","2","3","4","5","6","7"]
[null,null,"GENERAL SERVICE COST CENTERS"," "," "," "," "," "," "," "]
[1,"00100","Capital Related Costs-Buildings and Fixtures"," ",{"$nulls":6},1]
[2,"00200","Capital Related Costs-Movable Equipment"," ",{"$nulls":6},2]
[3,"00300","Other Capital Related Costs",{"$nulls":6},"-0-",3]
[4,"00400","Employee Benefits",{"$nulls":7},4]
[5,"00500","Administrative and General",{"$nulls":7},5]
[6,"00600","Maintenance and Repairs",{"$nulls":7},6]
[7,"00700","Operation of Plant",{"$nulls":7},7]
[8,"00800","Laundry and Linen Service",{"$nulls":7},8]
[9,"00900","Housekeeping",{"$nulls":7},9]
[10,"01000","Dietary",{"$nulls":7},10]
[11,"01100","Cafeteria",{"$nulls":7},11]
[12,"01200","Maintenance of Personnel",{"$nulls":7},12]
[13,"01300","Nursing Administration",{"$nulls":7},13]
[14,"01400","Central Services and Supply",{"$nulls":7},14]
[15,"01500","Pharmacy",{"$nulls":7},15]
[16,"01600","Medical Records  & Medical Records Library",{"$nulls":7},16]
[17,"01700","Social Service",{"$nulls":7},17]
[18,null,"Other General Service (specify)",{"$nulls":7},18]
[19,"01900","Nonphysician Anesthetists",{"$nulls":7},19]
[20,"02000","Nursing School",{"$nulls":7},20]
[21,"02100","Intern & Res. Service-Salary & Fringes (Approved)",{"$nulls":7},21]
[22,"02200","Intern & Res. Other Program Costs (Approved)",{"$nulls":7},22]
[23,"02300","Paramedical Ed. Program (specify) ",{"$nulls":7},23]
[null,null,"INPATIENT ROUTINE SERVICE COST CENTERS"," "," "," "," "," "," "," "]
[30,"03000","Adults and Pediatrics (General Routine Care)",{"$nulls":7},30]
[31,"03100","Intensive Care Unit",{"$nulls":7},31]
[32,"03200","Coronary Care Unit",{"$nulls":7},32]
[33,"03300","Burn Intensive Care Unit",{"$nulls":7},33]
[34,"03400","Surgical Intensive Care Unit",{"$nulls":7},34]
[35,null,"Other Special Care (specify)",{"$nulls":7},35]
[40,"04000","Subprovider - IPF",{"$nulls":7},40]
[41,"04100","Subprovider - IRF",{"$nulls":7},41]
[42,"04200","Subprovider (specify)",{"$nulls":7},42]
[43,"04300","Nursery",{"$nulls":7},43]
[44,"04400","Skilled Nursing Facility",{"$nulls":7},44]
[45,"04500","Nursing Facility",{"$nulls":7},45]
[46,"04600","Other Long Term Care",{"$nulls":7},46]
[]
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4013)"]
["40-524",{"$nulls":9},"Rev. 1"]
["DRAFT",null,null,null,"  FORM CMS-2552-10",{"$nulls":5}," 4090 (Cont.)"]
["RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES",{"$nulls":4},"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET A"]
[{"$nulls":7},"FROM ____________"]
[{"$nulls":5},"_",null,"TO ___________"]
[{"$nulls":7},"RECLASSIFIED",null,"NET EXPENSES"]
[null,null,"COST CENTER DESCRIPTIONS",null,null,"TOTAL","RECLASSIFI-","TRIAL BALANCE",null,"FOR ALLOCATION"]
[null,null,"(omit cents)","SALARIES","OTHER","(col. 1 + col. 2)","CATIONS","(col. 3 ± col. 4)","ADJUSTMENTS","(col. 5 ± col. 6)"]
[null,null,null,"1","2","3","4","5","6","7"]
[null,null,"ANCILLARY SERVICE COST CENTERS"," "," "," "," "," "," "," "]
[50,"05000","Operating Room",{"$nulls":7},50]
[51,"05100","Recovery Room",{"$nulls":7},51]
[52,"05200","Labor Room and Delivery Room",{"$nulls":7},52]
[53,"05300","Anesthesiology",{"$nulls":7},53]
[54,"05400","Radiology-Diagnostic",{"$nulls":7},54]
[55,"05500","Radiology-Therapeutic",{"$nulls":7},55]
[56,"05600","Radioisotope",{"$nulls":7},56]
[57,"05700","Computed Tomography (CT) Scan",{"$nulls":7},57]
[58,"05800","Magnetic Resonance Imaging (MRI)",{"$nulls":7},58]
[59,"05900","Cardiac Catheterization",{"$nulls":7},59]
[60,"06000","Laboratory",{"$nulls":7},60]
[61,"06100","PBP Clinical Laboratory Services-Program Only"," "," "," "," "," "," "," ",61]
[62,"06200","Whole Blood & Packed Red Blood Cells",{"$nulls":7},62]
[63,"06300","Blood Storing, Processing, & Trans.",{"$nulls":7},63]
[64,"06400","Intravenous Therapy",{"$nulls":7},64]
[65,"06500","Respiratory Therapy",{"$nulls":7},65]
[66,"06600","Physical Therapy",{"$nulls":7},66]
[67,"06700","Occupational Therapy",{"$nulls":7},67]
[68,"06800","Speech Pathology",{"$nulls":7},68]
[69,"06900","Electro cardiology",{"$nulls":7},69]
[70,"07000","Electroencephalography",{"$nulls":7},70]
[71,"07100","Medical Supplies Charged to Patients",{"$nulls":7},71]
[72,"07200","Implantable Devices Charged to Patients",{"$nulls":7},72]
[73,"07300","Drugs Charged to Patients",{"$nulls":7},73]
[74,"07400","Renal Dialysis",{"$nulls":7},74]
[75,"07500","ASC (Non-Distinct Part)",{"$nulls":7},75]
[76,null,"Other Ancillary (specify)",{"$nulls":7},76]
[null,null,"OUTPATIENT SERVICE COST CENTERS"," "," "," "," "," "," "," "]
[88,"08800","Rural Health Clinic (RHC)",{"$nulls":7},88]
[89,"08900","Federally Qualified Health Center (FQHC)",{"$nulls":7},89]
[90,"09000","Clinic",{"$nulls":7},90]
[91,"09100","Emergency",{"$nulls":7},91]
[92,"09200","Observation Beds"," "," "," "," "," "," "," ",92]
[93,null,"Other Outpatient Service (specify)",{"$nulls":7},93]
[]
[]
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4013)"]
[]
[]
["Rev. 1",{"$nulls":9},"                 40-525"]
["DRAFT",null,null,null,"  FORM CMS-2552-10",{"$nulls":5}," 4090 (Cont.)"]
["RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES",{"$nulls":4},"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET A"]
[{"$nulls":7},"FROM ____________"]
[{"$nulls":5},"_",null,"TO ___________"]
[{"$nulls":7},"RECLASSIFIED",null,"NET EXPENSES"]
[null,null,"COST CENTER DESCRIPTIONS",null,null,"TOTAL","RECLASSIFI-","TRIAL BALANCE",null,"FOR ALLOCATION"]
[null,null,"(omit cents)","SALARIES","OTHER","(col. 1 + col. 2)","CATIONS","(col. 3 ± col. 4)","ADJUSTMENTS","(col. 5 ± col. 6)"]
[null,null,null,"1","2","3","4","5","6","7"]
[null,null,"OTHER REIMBURSABLE COST CENTERS"," "," "," "," "," "," "," "]
[94,"09400","Home Program Dialysis",{"$nulls":7},94]
[95,"09500","Ambulance Services",{"$nulls":7},95]
[96,"09600","Durable Medical Equipment-Rented",{"$nulls":7},96]
[97,"09700","Durable Medical Equipment-Sold",{"$nulls":7},97]
[98,null,"Other Reimbursable (specify)",{"$nulls":7},98]
[99,null,"Outpatient Rehabilitation Provider (specify)",{"$nulls":7},99]
[100,"10000","Intern-Resident Service (not appvd. tchng. prgm.)",{"$nulls":7},100]
[101,"10100","Home Health Agency",{"$nulls":7},101]
[null,null,"SPECIAL PURPOSE COST CENTERS"," "," "," "," "," "," "," "]
[105,"10500","Kidney Acquisition",{"$nulls":7},105]
[106,"10600","Heart Acquisition",{"$nulls":7},106]
[107,"10700","Liver Acquisition",{"$nulls":7},107]
[108,"10800","Lung Acquisition",{"$nulls":7},108]
[109,"10900","Pancreas Acquisition",{"$nulls":7},109]
[110,"11000","Intestinal Acquisition",{"$nulls":7},110]
[111,"11100","Islet Acquisition",{"$nulls":7},111]
[112,null,"Other Organ Acquisition (specify)",{"$nulls":7},112]
[113,"11300","Interest Expense"," ",{"$nulls":5},"- 0 -",113]
[114,"11400","Utilization Review-SNF",{"$nulls":6},"- 0 -",114]
[115,"11500","Ambulatory Surgical Center (Distinct Part)",{"$nulls":7},115]
[116,"11600","Hospice",{"$nulls":7},116]
[117,null,"Other Special Purpose (specify)",{"$nulls":7},117]
[118," ","SUBTOTALS (sum of lines 1-117)",{"$nulls":7},118]
[null,null,"NONREIMBURSABLE COST CENTERS"," "," "," "," "," "," "," "]
[190,"19000","Gift, Flower, Coffee Shop, & Canteen",{"$nulls":7},190]
[191,"19100","Research",{"$nulls":7},191]
[192,"19200","Physicians' Private Offices",{"$nulls":7},192]
[193,"19300","Nonpaid Workers",{"$nulls":7},193]
[194,null,"Other Nonreimbursable (specify)",{"$nulls":7},194]
[200," ","TOTAL (sum of lines 118-199)"," "," "," ","- 0 -"," "," "," ",200]
[]
[]
[]
[]
[]
[]
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4013)"]
["40-526",{"$nulls":9},"Rev. 1"]
{"$rows_empty":363}
[""]

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["DRAFT",null,null,"FORM CMS-2552-10",{"$nulls":8},"           4090 (Cont.)"]
["RECLASSIFICATIONS",null,null,null,"PROVIDER NO.:",null,null,"PERIOD:",null,null,"WORKSHEET A-6"]
[{"$nulls":7},"FROM ___________"]
[{"$nulls":4},"  ____________________",null,null,"TO ______________"]
[{"$nulls":4},"INCREASES",null,null,null,"DECREASES",null,null,"Wkst."]
[null,null,"CODE",{"$nulls":8},"A-7"]
[null,"EXPLANATION OF RECLASSIFICATION(S)","(1)","COST CENTER","LINE #","SALARY","OTHER","COST CENTER","LINE #","SALARY","OTHER","Ref."]
[null,null,"1","2","3","4","5","6","7","8","9","10"]
[1,{"$nulls":11},1]
[2,{"$nulls":11},2]
[3,{"$nulls":11},3]
[4,{"$nulls":11},4]
[5,{"$nulls":11},5]
[6,{"$nulls":11},6]
[7,{"$nulls":11},7]
[8,{"$nulls":11},8]
[9,{"$nulls":11},9]
[10,{"$nulls":11},10]
[11,{"$nulls":11},11]
[12,{"$nulls":11},12]
[13,{"$nulls":11},13]
[14,{"$nulls":11},14]
[15,{"$nulls":11},15]
[16,{"$nulls":11},16]
[17,{"$nulls":11},17]
[18,{"$nulls":11},18]
[19,{"$nulls":11},19]
[20,{"$nulls":11},20]
[21,{"$nulls":11},21]
[22,{"$nulls":11},22]
[23,{"$nulls":11},23]
[24,{"$nulls":11},24]
[25,{"$nulls":11},25]
[26,{"$nulls":11},26]
[27,{"$nulls":11},27]
[28,{"$nulls":11},28]
[29,{"$nulls":11},29]
[30,{"$nulls":11},30]
[31,{"$nulls":11},31]
[32,{"$nulls":11},32]
[33,{"$nulls":11},33]
[34,{"$nulls":11},34]
[35,{"$nulls":11},35]
[500,"Total reclassifications (sum of columns 4 and 5",{"$nulls":10},500]
[null,"must equal sum of columns 8 and 9)"]
[" (1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry."]
[" Transfer the amounts in columns 4, 5, 8, and 9 to Worksheet A, column 4, lines as appropriate. "]
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4014) "]
["Rev. 1",{"$nulls":11},"  40-527"]

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["4090 (Cont.)",null,null,"      FORM CMS-2552-10",{"$nulls":6},"DRAFT"]
["RECONCILIATION OF CAPITAL COSTS CENTERS",{"$nulls":4},"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET A-7,"]
[{"$nulls":7},"FROM _________",null,"PARTS I, II & III"]
[{"$nulls":5}," _____________",null,"TO __________"]
["PART I - ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCES"]
[{"$nulls":5},"Acquisitions",null,"Disposals",null,"Fully"]
[null,null,null,"Beginning",null,null,null,"and","Ending","Depreciated"]
[null,"Description",null,"Balances","Purchases","Donation","Total","Retirements","Balance","Assets"]
[null,null,null,"1","2","3","4","5","6","7"]
[1,"Land",{"$nulls":8},1]
[2,"Land Improvements",{"$nulls":8},2]
[3,"Buildings and Fixtures",{"$nulls":8},3]
[4,"Building Improvements",{"$nulls":8},4]
[5,"Fixed Equipment",{"$nulls":8},5]
[6,"Movable Equipment",{"$nulls":8},6]
[7,"HIT designated Assets",{"$nulls":8},7]
[8,"Subtotal (sum of lines 1-7)",{"$nulls":8},8]
[9,"Reconciling Items",{"$nulls":8},9]
[10,"Total (line 7 minus line 9)",{"$nulls":8},10]
["PART II - RECONCILIATION OF AMOUNTS FROM WORKSHEET A, COLUMN 2, LINES 1 and 2 "]
[{"$nulls":5},"   SUMMARY OF CAPITAL"]
[{"$nulls":8},"Other Capital-","Total (1)"]
[{"$nulls":6},"Insurance","Taxes","Related Costs","(sum of "]
[null,"Description",null,"Depreciation","Lease","Interest","(see instru.)","(see instru.)","(see instru.)","cols. 9-14)"]
["*",null,null,"9","10","11","12","13","14","15"]
[1,"Capital Related Costs-Buildings and Fixtures",{"$nulls":8},1]
[2,"Capital Related Costs-Movable Equipment",{"$nulls":8},2]
[3,"Total (sum of lines 1-2)",{"$nulls":8},3]
["(1)","The  amount in columns 9 thru 14 must equal the amount on Worksheet A, column 2, lines 1 and 2.  Enter in each column the appropriate amounts including any directly assigned cost "]
[null,"which may have been included in Worksheet A, column 2, lines 1 and 2."]
["*","All lines numbers are to be consistent with Worksheet A line numbers for capital cost centers."]
["PART III - RECONCILIATION OF CAPITAL COSTS CENTERS"]
[null,null,null,"    COMPUTATION OF RATIOS",null,null,null,"ALLOCATION OF OTHER CAPITAL"]
[{"$nulls":4},"Gross Assets",{"$nulls":4},"Total"]
[null,null,null,"Capitalized","for Ratio","Ratio",null,null,"Other Capital-","(sum of"]
[null,"Description","Gross Assets","Leases","(col. 1 - col. 2)","(see instru.)","Insurance","Taxes","Related Costs","cols. 5-7)"]
["*",null,"1","2","3","4","5","6","7","8"]
[1,"Capital Related Costs-Buildings and Fixtures",{"$nulls":8},1]
[2,"Capital Related Costs-Movable Equipment",{"$nulls":8},2]
[3,"Total (sum of lines 1-2)",null,null,null,"1.000000",{"$nulls":4},3]
[]
[{"$nulls":5},"   SUMMARY  OF CAPITAL"]
[{"$nulls":8},"Other Capital-","Total (1)"]
[{"$nulls":6},"Insurance","Taxes","Related Costs","(sum of "]
[null,"Description",null,"Depreciation","Lease","Interest","(see instru.)","(see instru.)","(see instru.)","cols. 9-14)"]
["*",null,null,"9","10","11","12","13","14","15"]
[1,"Capital Related Costs-Buildings and Fixtures",{"$nulls":8},1]
[2,"Capital Related Costs-Movable Equipment",{"$nulls":8},2]
[3,"Total (sum of lines 1-2)",{"$nulls":8},3]
[" (1)  The amounts on lines 1 and 2 must equal the corresponding amounts on Worksheet A, column 7, lines 1 and 2.  Columns 9 through 14 should include related"]
[null,"Worksheet A-6 reclassifications, Worksheet A-8 adjustments, and Worksheet A-8-1  related organizations and home office costs. (See instructions.)"]
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4015)"]
["40-528",{"$nulls":9},"Rev. 1"]

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["DRAFT",null,"     FORM CMS-2552-10",{"$nulls":6},"4090 (Cont.)"]
["ADJUSTMENTS TO EXPENSES",null,null,"PROVIDER NO.",null,"PERIOD:",null,"WORKSHEET A-8"]
[{"$nulls":5},"FROM ____________"]
[null,null,null,"________________",null,"TO _______________"]
[{"$nulls":5},"  EXPENSE CLASSIFICATION ON"]
[{"$nulls":5},"  WORKSHEET A TO/FROM WHICH",null,null,"Wkst."]
[null,"DESCRIPTION (1)",null,"(2)",null,"  THE AMOUNT IS TO BE ADJUSTED",null,null,"A-7"]
[null,null,null,"BASIS/CODE","AMOUNT","        COST CENTER",null,"LINE #","Ref."]
[null,null,null,"1","2","3",null,"4","5"]
[1,"Investment income - buildings and fixtures (chapter 2)",null,null,null,"Buildings and Fixtures",null,1,null,1]
[2,"Investment income - movable equipment (chapter 2)",null,null,null,"Movable Equipment",null,2,null,2]
[3,"Investment income - other (chapter 2)",{"$nulls":7},3]
[4,"Trade, quantity, and time discounts (chapter 8)",{"$nulls":7},4]
[5,"Refunds and rebates of expenses (chapter 8)",{"$nulls":7},5]
[6,"Rental of provider space by suppliers (chapter 8)",{"$nulls":7},6]
[7,"Telephone services (pay stations excluded) (chapter 21)",{"$nulls":7},7]
[8,"Television and radio service (chapter 21)",{"$nulls":7},8]
[9,"Parking lot (chapter 21)",{"$nulls":7},9]
[10,"Provider-based physician adjustment",null,"Wkst A-8-2",{"$nulls":5},10]
[11,"Sale of scrap, waste, etc. (chapter 23)",{"$nulls":7},11]
[12,"Related organization transactions (chapter 10)",null,"Wkst A-8-1",{"$nulls":5},12]
[13,"Laundry and linen service",{"$nulls":7},13]
[14,"Cafeteria-employees and guests",{"$nulls":7},14]
[15,"Rental of quarters to employee and others",{"$nulls":7},15]
[16,"Sale of medical and surgical ",{"$nulls":7},16]
[null,"supplies to other than patients"]
[17,"Sale of drugs to other than patients",{"$nulls":7},17]
[18,"Sale of medical records and abstracts",{"$nulls":7},18]
[19,"Nursing school (tuition, fees, books, etc.)",{"$nulls":7},19]
[20,"Vending machines",{"$nulls":7},20]
[21,"Income from imposition of interest,",{"$nulls":7},21]
[null,"finance or penalty charges (chapter 21)"]
[22,"Interest expense on Medicare overpayments and",{"$nulls":7},22]
[null,"borrowings to repay Medicare overpayments"]
[23,"Adjustment for respiratory therapy",{"$nulls":7},23]
[null,"costs in excess of limitation (chapter 14)",null,"Wkst A-8-3",null,"Respiratory Therapy",null,62]
[24,"Adjustment for physical therapy costs",{"$nulls":7},24]
[null,"in excess of limitation (chapter 14)",null,"Wkst A-8-3",null,"Physical Therapy",null,63]
[25,"Utilization review - physicians' compensation (chapter 21)",null,null,null,"Utilization Review - SNF",null,114,null,25]
[26,"Depreciation - buildings and fixtures",null,null,null,"Buildings and Fixtures",null,1,null,26]
[27,"Depreciation - movable equipment",null,null,null,"Movable Equipment",null,2,null,27]
[28,"Non-physician Anesthetist",null,null,null,"Nonphysician Anesthetist",null,19,null,28]
[29,"Physicians' assistant",{"$nulls":7},29]
[30,"Adjustment for occupational therapy costs",{"$nulls":7},30]
[null,"in excess of limitation (chapter 14)",null,"Wkst A-8-3",null,"Occupational Therapy",null,64]
[31,"Adjustment for speech pathology costs",{"$nulls":7},31]
[null,"in excess of limitation (chapter 14)",null,"Wkst A-8-3",null,"Speech Pathology",null,65]
[null,"CAH HIT Adjustment for Depreciation"]
[32,"and Interest",{"$nulls":7},32]
[33,"Other adjustments (specify) (3)",{"$nulls":7},33]
[50,"TOTAL (sum of lines 1 thru 49)",{"$nulls":7},50]
[null,"(Transfer to Worksheet A, column 6, line 200.)"]
{"$rows_empty":8}
["(1) Description - all chapter references in this column pertain to CMS Pub. 15-1."]
["(2) Basis for adjustment (see instructions)."]
["    A. Costs - if cost, including applicable overhead, can be determined."]
["    B. Amount Received - if cost cannot be determined."]
["(3) Additional adjustments may be made on lines 32 thru 49 and subscripts thereof."]
["Note:  See instructions for column 5 referencing to Worksheet A-7."]
[]
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4016)"]
["Rev. 1",{"$nulls":8},"40-529"]

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["4090 (Cont.)",null,null," FORM CMS-2552-10",{"$nulls":4},"DRAFT"]
["STATEMENT OF COSTS OF SERVICES",null,null,"PROVIDER NO:","PERIOD:",null,"WORKSHEET A-8-1"]
["FROM RELATED ORGANIZATIONS AND",null,null,null,"FROM____________"]
["HOME OFFICE COSTS",null,null,"_______________","TO_______________"]
[]
["A. Costs incurred and adjustments required as a result of transactions with related organizations or the claiming of home office costs:"]
[{"$nulls":5},"Amount","Net"]
[{"$nulls":4},"Amount of","included in","Adjustments","Wkst."]
[{"$nulls":4},"Allowable","Wkst. A,","(col. 4 minus","A-7"]
[null,"Line No.","Cost Center","Expense Items","Cost","column 5","col. 5) *","Ref."]
[null,"1","2","3","4","5","6","7"]
[1,{"$nulls":7},1]
[2,{"$nulls":7},2]
[3,{"$nulls":7},3]
[4,{"$nulls":7},4]
[5,"TOTALS (sum of lines 1-4) Transfer column 6, line 5 to Worksheet",{"$nulls":6},5]
[null,"A-8, column 2, line 12. "]
[]
[" *  The amounts on lines 1-4 and subscripts as appropriate are transferred in detail to Worksheet A, column 6, lines as appropriate."]
["  Positive amounts increase cost and negative amounts decrease cost.  For related organizational or home office cost which has not "]
["  been posted to Worksheet A, columns 1 and/or 2, the amount allowable should be indicated in column 4 of this part."]
[]
["B. Interrelationship to related organization(s) and/or home office:"]
["The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires that you furnish"]
["the information requested under Part B of this worksheet."]
[]
["This information is used by the Centers for Medicare and Medicaid Services and its intermediaries/contractors in determining that the costs applicable to"]
["services, facilities, and supplies furnished by organizations related to you by common ownership or control represent reasonable costs"]
["as determined under section 1861 of the Social Security Act.  If you do not provide all or any part of the requested information, the cost "]
["report is considered incomplete and not acceptable for purposes of claiming reimbursement under title XVIII."]
[]
[{"$nulls":4},"Related Organization(s) and/or Home Office"]
[null,null,null,"Percentage",null,"Percentage"]
[null," Symbol",null,"of",null,"of","Type of"]
[null,"(1)","Name","Ownership","Name","Ownership","Business"]
[null,"1","2","3","4","5","6"]
[6,{"$nulls":7},6]
[7,{"$nulls":7},7]
[8,{"$nulls":7},8]
[9,{"$nulls":7},9]
[10,{"$nulls":7},10]
[]
[null,"(1) Use the following symbols to indicate interrelationship to related organizations:"]
[]
[null,null,"A. Individual has financial interest (stockholder, partner, etc.) in both related"]
[null,null,"      organization and in provider."]
[null,null,"B. Corporation, partnership, or other organization has financial interest in provider."]
[null,null,"C. Provider has financial interest in corporation, partnership, or other organization."]
[null,null,"D. Director, officer, administrator, or key person of provider or relative of such"]
[null,null,"      person has financial interest in related organization."]
[null,null,"E. Individual is director, officer, administrator, or key person of provider and"]
[null,null,"      related organization."]
[null,null,"F. Director, officer, administrator, or key person of related organization or relative"]
[null,null,"      of such person has financial interest in provider."]
[null,null,"G. Other (financial or non-financial) specify __________________________________________________"]
{"$rows_empty":10}
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4017)"]
[]
[]
["40-530",{"$nulls":7},"Rev. 1"]

{"sheet":"A82","index":5,"n_rows":43,"n_cols":11,"rows_kept":43,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["DRAFT",null,null,null,"FORM CMS-2552-10",{"$nulls":5},"         4090 (Cont.)"]
["PROVIDER-BASED PHYSICIANS ADJUSTMENTS",{"$nulls":4},"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET A-8-2"]
[{"$nulls":7},"FROM _________"]
[{"$nulls":5},"_____________",null,"TO ___________"]
[null,null,"Cost Center/",{"$nulls":4},"Physician/",null,"5 Percent of"]
[null,"Wkst. A","Physician","Total","Professional","Provider","RCE","Provider","Unadjusted","Unadjusted"]
[null,"Line #","Identifier","Remuneration","Component","Component","Amount","Component Hours","RCE Limit","RCE Limit"]
[null,"1","2","3","4","5","6","7","8","9"]
[1,{"$nulls":9},1]
[2,{"$nulls":9},2]
[3,{"$nulls":9},3]
[4,{"$nulls":9},4]
[5,{"$nulls":9},5]
[6,{"$nulls":9},6]
[7,{"$nulls":9},7]
[8,{"$nulls":9},8]
[9,{"$nulls":9},9]
[10,{"$nulls":9},10]
[11,{"$nulls":9},11]
[200,"TOTAL",{"$nulls":8},101]
[null,null,null,"Cost of","Provider","Physician","Provider"]
[null,null,"Cost Center/","Memberships","Component","Cost of","Component"]
[null,"Wkst. A","Physician","& Continuing","Share of","Malpractice","Share of","Adjusted","RCE"]
[null,"Line #","Identifier","Education","col. 12","Insurance","col. 14","RCE Limit","Disallowance","Adjustment"]
[null,"10","11","12","13","14","15","16","17","18"]
[1,{"$nulls":9},1]
[2,{"$nulls":9},2]
[3,{"$nulls":9},3]
[4,{"$nulls":9},4]
[5,{"$nulls":9},5]
[6,{"$nulls":9},6]
[7,{"$nulls":9},7]
[8,{"$nulls":9},8]
[9,{"$nulls":9},9]
[10,{"$nulls":9},10]
[11,{"$nulls":9},11]
[200,"TOTAL",{"$nulls":8},200]
[]
[]
[]
[]
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4018)"]
["Rev. 1",{"$nulls":9},"                40-531"]

{"sheet":"A83","index":6,"n_rows":145,"n_cols":9,"rows_kept":145,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4090 (Cont.)",null,null,"FORM CMS-2552-10",{"$nulls":4},"DRAFT"]
["REASONABLE COST DETERMINATION FOR THERAPY SERVICES",{"$nulls":4},"PROVIDER NO.:","PERIOD:","WORKSHEET A-8-3,"]
["FURNISHED BY OUTSIDE SUPPLIERS",{"$nulls":5},"FROM __________","PARTS I & II"]
[{"$nulls":5},"__________","TO ___________"]
["Check applicable box:",null," [ ] Occupational   [ ] Physical    [ ] Respiratory    [ ] Speech Pathology"]
["PART I - GENERAL INFORMATION"]
[1," Total number of weeks worked (excluding aides) (see instructions)",{"$nulls":6},1]
[2," Line 1 multiplied by 15 hours per week",{"$nulls":6},2]
[3," Number of unduplicated days in which supervisor or therapist was on provider site (see instructions)",{"$nulls":6},3]
[4," Number of unduplicated days in which therapy assistant was on provider site but neither supervisor nor therapist was on provider site (see instructions)",{"$nulls":6},4]
[5," Number of unduplicated offsite visits - supervisors or therapists (see instructions)",{"$nulls":6},5]
[6," Number of unduplicated offsite visits - therapy assistants (include only visits made by therapy assistant and on which",{"$nulls":6},6]
[null,"  supervisor and/or therapist was not present during the visit(s)) (see instructions)"]
[7," Standard travel expense rate",{"$nulls":6},7]
[8," Optional travel expense rate per mile",{"$nulls":6},8]
[null,null,null,"Supervisors","Therapists","Assistants","Aides","Trainees"]
[null,null,null,"1","2","3","4","5"]
[9," Total hours worked",{"$nulls":6},9]
[10," AHSEA (see instructions)",{"$nulls":6},10]
[11," Standard travel allowance (columns 1 and 2, one-half of column 2,",{"$nulls":6},11]
[null,"  line 10; column 3, one-half of column 3, line 10)"]
[12," Number of travel hours (see instructions)",{"$nulls":6},12]
[13," Number of miles driven (see instructions)",{"$nulls":6},13]
["PART II - SALARY EQUIVALENCY COMPUTATION"]
[14," Supervisors (column 1, line 9 times column 1, line 10)",{"$nulls":6},14]
[15," Therapists (column 2, line 9 times column 2, line 10)",{"$nulls":6},15]
[16," Assistants (column 3, line 9 times column 3, line10)",{"$nulls":6},16]
[17," Subtotal allowance amount (sum of lines 14 and 15 for respiratory therapy or lines 14-16 for all others)",{"$nulls":6},17]
[18," Aides (column 4, line 9 times column 4, line 10)",{"$nulls":6},18]
[19," Trainees (column 5, line 9 times column 9, line 10)",{"$nulls":6},19]
[20," Total allowance amount (sum of lines 17-19 for respiratory therapy or lines 17 and 18 for all others)",{"$nulls":6},20]
[null,"  If the sum of columns 1 and 2 for respiratory therapy or columns 1-3 for physical therapy, speech pathology or occupational therapy, line 9, is greater than line 2, "]
[null,"  make no entries on lines 21 and 22 and enter on line 23 the amount from line 20.  Otherwise complete lines 21-23."]
[21," Weighted average rate excluding aides and trainees (line 17 divided by sum of columns 1 and 2, line 9 for respiratory therapy or columns 1 thru 3, line 9 for all others)",{"$nulls":6},21]
[22," Weighted allowance excluding aides and trainees (line 2 times line 21)",{"$nulls":6},22]
[23," Total salary equivalency (see instructions)",{"$nulls":6},23]
{"$rows_empty":11}
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4019)"]
["40-532",{"$nulls":7},"Rev. 1"]
["DRAFT",null,null,"FORM CMS-2552-10",{"$nulls":4}," 4090 (Cont.)"]
["REASONABLE COST DETERMINATION FOR THERAPY SERVICES",{"$nulls":4},"PROVIDER NO.:","PERIOD:","WORKSHEET A-8-3,"]
["FURNISHED BY OUTSIDE SUPPLIERS",{"$nulls":5},"FROM _________","PARTS III & IV"]
[{"$nulls":5},"_____________","TO ___________"]
["Check applicable box:",null," [ ] Occupational   [ ] Physical    [ ] Respiratory    [ ] Speech Pathology"]
["PART III - STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - PROVIDER SITE"]
["   Standard Travel Allowance"]
[24," Therapists (line 3 times column 2, line 11)",{"$nulls":6},24]
[25," Assistants (line 4 times column 3, line 11)",{"$nulls":6},25]
[26," Subtotal (line 24 for respiratory therapy or sum of lines 24 and 25 for all others)",{"$nulls":6},26]
[27," Standard travel expense (line 7 times line 3 for respiratory therapy or sum of lines 3 and 4 for all others)",{"$nulls":6},27]
[28," Total standard travel allowance and standard travel expense at the provider site (sum of lines 26 and 27)",{"$nulls":6},28]
["   Optional Travel Allowance and Optional Travel Expense"]
[29," Therapists (column 2, line 10 times the sum of columns 1 and 2, line 12 )",{"$nulls":6},29]
[30," Assistants (column 3, line 10 times column 3, line 12)",{"$nulls":6},30]
[31," Subtotal (line 29 for respiratory therapy or sum of lines 29 and 30 for all others)",{"$nulls":6},31]
[32," Optional travel expense (line 8 times columns 1 and 2, line 13 for respiratory therapy or sum of columns 1-3, line 13 for all others)",{"$nulls":6},32]
[33," Standard travel allowance and standard travel expense (line 28)",{"$nulls":6},33]
[34," Optional travel allowance and standard travel expense (sum of lines 27 and 31)",{"$nulls":6},34]
[35," Optional travel allowance and optional travel expense (sum of lines 31 and 32)",{"$nulls":6},35]
["PART IV - STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - SERVICES OUTSIDE PROVIDER SITE"]
["   Standard Travel Expense"]
[36," Therapists (line 5 times column 2, line 11)",{"$nulls":6},36]
[37," Assistants (line 6 times column 3, line 11)",{"$nulls":6},37]
[38," Subtotal (sum of lines 36 and 37)",{"$nulls":6},38]
[39," Standard travel expense (line 7 times the sum of lines 5 and 6)",{"$nulls":6},39]
["   Optional Travel Allowance and Optional Travel Expense"]
[40," Therapists (sum of columns 1 and 2, line 12 .01 times column 2, line 10)",{"$nulls":6},40]
[41," Assistants (column 3, line 12.01 times column 3, line 10)",{"$nulls":6},41]
[42," Subtotal (sum of lines 40 and 41)",{"$nulls":6},42]
[43," Optional travel expense (line 8 times the sum of columns 1-3, line 13.01)",{"$nulls":6},43]
["   Total Travel Allowance and Travel Expense - Offsite Services; Complete one of the following"]
["   three lines 44, 45, or 46, as appropriate."]
[44," Standard travel allowance and standard travel expense (sum of lines 38 and 39 - see instructions)",{"$nulls":6},44]
[45," Optional travel allowance and standard travel expense (sum of lines 39 and 42 - see instructions)",{"$nulls":6},45]
[46," Optional travel allowance and optional travel expense (sum of lines 42 and 43 - see instructions)",{"$nulls":6},46]
{"$rows_empty":9}
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4019)"]
["Rev. 1",{"$nulls":7},"40-533"]
["4090 (Cont.)",null,null,"FORM CMS-2552-10",{"$nulls":4},"DRAFT"]
["REASONABLE COST DETERMINATION FOR THERAPY SERVICES",{"$nulls":4},"PROVIDER NO.:","PERIOD:","WORKSHEET A-8-3,"]
["FURNISHED BY OUTSIDE SUPPLIERS",{"$nulls":5},"FROM _________","PARTS V-VII"]
[{"$nulls":5}," ____________","TO ___________"]
["Check applicable box:",null," [ ] Occupational   [ ] Physical    [ ] Respiratory    [ ] Speech Pathology"]
["PART V - OVERTIME COMPUTATION"]
[null,null,null,"Therapists","Assistants","Aides","Trainees","Total"]
[null,null,null,"1","2","3","4","5"]
[47," Overtime hours worked during reporting period (if column 5, ",{"$nulls":6},47]
[null," line 47, is zero or equal to or greater than 2,080, do not complete "]
[null," lines 48-55 and enter zero in each column of line 56)"]
[48," Overtime rate (see instructions)",{"$nulls":6},48]
[49," Total overtime (including base and overtime allowance) (multiply",{"$nulls":6},49]
[null," line 47 times line 48)"]
["      CALCULATION OF LIMIT"]
[50," Percentage of overtime hours by category (divide the hours in each",{"$nulls":6},50]
[null," column on line 47 by the total overtime worked - column 4, line 47)"]
[51," Allocation of provider's standard work year for one full-time ",{"$nulls":6},51]
[null," employee times the percentages on line 50) (see instructions)"]
["      DETERMINATION OF OVERTIME ALLOWANCE"]
[52," Adjusted hourly salary equivalency amount (see instructions)",{"$nulls":6},52]
[53," Overtime cost limitation (line 51 times line 52)",{"$nulls":6},53]
[54," Maximum overtime cost (enter the lesser of line 49 or line 53)",{"$nulls":6},54]
[55," Portion of overtime already included in hourly computation at the AHSEA (multiply ",{"$nulls":6},55]
[null," line 47 times line 52)"]
[56," Overtime allowance (line 54 minus line 55 - if negative enter zero) ( Enter in column 5  the",{"$nulls":6},56]
[null," sum of columns 1, 3, and 4 for respiratory therapy and columns 1 through 3 for all others.)"]
["PART VI - COMPUTATION OF THERAPY LIMITATION AND EXCESS COST ADJUSTMENT"]
[57," Salary equivalency amount (from line 23)",{"$nulls":6},57]
[58," Travel allowance and expense - provider site (from lines 33, 34, or 35))",{"$nulls":6},58]
[59," Travel allowance and expense - Offsite services (from lines 44, 45, or 46)",{"$nulls":6},59]
[60," Overtime allowance (from column 5, line 56)",{"$nulls":6},60]
[61," Equipment cost (see instructions)",{"$nulls":6},61]
[62," Supplies (see instructions)",{"$nulls":6},62]
[63," Total allowance (sum of lines 57-62)",{"$nulls":6},63]
[64," Total cost of outside supplier services (from your records)",{"$nulls":6},64]
[65," Excess over limitation (line 64 minus line 63 - if negative, enter zero)",{"$nulls":6},65]
{"$rows_empty":10}
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4019)"]
["40-534",{"$nulls":7},"Rev. 1"]