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["PART  I  -  ALL PROVIDER COMPONENTS"]
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[1," Inpatient days (including private room days and swing-bed days, excluding newborn)",{"$nulls":8},1]
[2," Inpatient days (including private room days, excluding swing-bed and newborn days)",{"$nulls":8},2]
[3," Private room days (excluding swing-bed and observation bed days)",{"$nulls":8},3]
[4," Semi-private room days (excluding swing-bed and observation bed days)",{"$nulls":8},4]
[5," Total swing-bed SNF type inpatient days (including private room days) through December 31 of the cost reporting period",{"$nulls":8},5]
[6," Total swing-bed SNF type inpatient days (including private room days) after December 31 of the cost reporting period (if",{"$nulls":8},6]
[null," calendar year, enter 0 on this line)"]
[7," Total swing-bed NF type inpatient days (including private room days) through December 31 of the cost reporting period",{"$nulls":8},7]
[8," Total swing-bed NF type inpatient days (including private room days) after December 31 of the cost reporting period (if",{"$nulls":8},8]
[null," calendar year, enter 0 on this line) "]
[9," Total inpatient days including private room days applicable to the Program (excluding swing-bed and newborn days)",{"$nulls":8},9]
[10," Swing-bed SNF type inpatient days applicable to title XVIII only (including private room days) through December 31 of the",{"$nulls":8},10]
[null,"  cost reporting period (see instructions)."]
[11," Swing-bed SNF type inpatient days applicable to title XVIII only (including private room days) after  December 31 of the",{"$nulls":8},11]
[null,"  cost reporting period (if calendar year, enter 0 on this line)"]
[12," Swing-bed NF type inpatient days applicable to titles V or XIX only (including private room days) through December 31 of",{"$nulls":8},12]
[null,"  the cost reporting period."]
[13," Swing-bed NF type inpatient days applicable to titles V or XIX only (including private room days) after December 31 of the",{"$nulls":8},13]
[null," cost reporting period (if calendar year, enter 0 on this line) "]
[14," Medically necessary private room days applicable to the Program ( excluding swing-bed days)",{"$nulls":8},14]
[15," Total nursery days (title V or XIX only)",{"$nulls":8},15]
[16," Nursery days (title V or XIX only)",{"$nulls":8},16]
[{"$nulls":4},"SWING BED ADJUSTMENT"]
[17," Medicare rate for swing-bed SNF services applicable to services through December 31 of the cost reporting period",{"$nulls":8},17]
[18," Medicare rate for swing-bed SNF services applicable to services after December 31 of the cost reporting period",{"$nulls":8},18]
[19," Medicaid rate for swing-bed NF services applicable to services through December 31 of the cost reporting period",{"$nulls":8},19]
[20," Medicaid rate for swing-bed NF services applicable to services after December 31 of the cost reporting period",{"$nulls":8},20]
[21," Total general inpatient routine service cost (see instructions)",{"$nulls":8},21]
[22," Swing-bed cost applicable to SNF type services through  December 31 of the cost reporting period (line 5 x line 17)",{"$nulls":8},22]
[23," Swing-bed cost applicable to SNF type services after  December 31 of the cost reporting period (line 6 x line 18)",{"$nulls":8},23]
[24," Swing-bed cost applicable to NF type services through  December 31 of the cost reporting period (line 7 x line 19)",{"$nulls":8},24]
[25," Swing-bed cost applicable to NF type services after December 31 of the cost reporting period (line 8 x line 20)",{"$nulls":8},25]
[26," Total swing-bed cost (see instructions)",{"$nulls":8},26]
[27," General inpatient routine service cost net of swing-bed cost (line 21 minus line 26)",{"$nulls":8},27]
[{"$nulls":4},"PRIVATE ROOM DIFFERENTIAL ADJUSTMENT"]
[28," General inpatient routine service charges (excluding swing-bed charges)",{"$nulls":8},28]
[29," Private room charges (excluding swing-bed charges)",{"$nulls":8},29]
[30," Semi-private room charges (excluding swing-bed charges)",{"$nulls":8},30]
[31," General inpatient routine service cost/charge ratio (line 27 ÷ line 28)",{"$nulls":8},31]
[32," Average private room per diem charge (line 29 ÷ line 3)",{"$nulls":8},32]
[33," Average semi-private room per diem charge (line 30 ÷ line 4)",{"$nulls":8},33]
[34," Average per diem private room charge differential (line 32 minus line 33)(see instructions)",{"$nulls":8},34]
[35," Average per diem private room cost differential (line 34 x line 31)",{"$nulls":8},35]
[36," Private room cost differential adjustment (line 3 x line 35)",{"$nulls":8},36]
[37," General inpatient routine service cost net of swing-bed cost and private room cost differential (line 27 minus line 36)",{"$nulls":8},37]
{"$rows_empty":12}
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4025.1)"]
[]
[]
["Rev. 1",{"$nulls":9},"40-573"]

{"sheet":"D1II","index":6,"n_rows":69,"n_cols":33,"rows_kept":69,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4090 (Cont.)",null,null,null,"           FORM CMS-2552-10",{"$nulls":5},"DRAFT"]
["COMPUTATION OF INPATIENT",null,null,null,"PROVIDER NO.:",null,"COMPONENT NO.:",null,"PERIOD:","WORKSHEET D-1,",{"$nulls":22},"  ."]
["OPERATING COST",{"$nulls":7},"FROM __________","PART II"]
[{"$nulls":4},"______________",null,"______________",null,"TO __________"]
["Check",null,"  [  ]  Title V - I/P",null,null," [  ]  Hospital    [  ]Subprovider (other)        ",null,null,"  [  ]  PPS"]
["applicable",null,"  [  ]  Title XVIII, Part A",null,null," [  ]  IPF",null,null,"  [  ]  TEFRA"]
["boxes",null,"  [  ]  Title XIX - I/P",null,null," [  ]  IRF",null,null,"  [  ]  Other"]
["PART  II  -  HOSPITAL AND SUBPROVIDERS ONLY"]
[null,null,"PROGRAM INPATIENT OPERATING COST BEFORE"]
[null,null,"    PASS THROUGH COST ADJUSTMENTS",{"$nulls":6},"1"]
[38," Adjusted general inpatient routine service cost per diem (see instructions)",{"$nulls":8},38]
[39," Program general inpatient routine service cost (line 9 x line 38)",{"$nulls":8},39]
[40," Medically necessary private room cost applicable to the Program (line 14 x line 35)",{"$nulls":8},40]
[41," Total Program general inpatient routine service cost (line 39 + line 40)",{"$nulls":8},41]
[{"$nulls":7},"Average"]
[{"$nulls":4},"Total ","Total",null,"Per Diem","Program","Program Cost"]
[{"$nulls":4},"Inpatient Cost","Inpatient Days",null,"(col. 1 ÷ col. 2)","Days","(col. 3 x col. 4)"]
[{"$nulls":4},"1",null,"2","3","4","5"]
[42," Nursery (title V & XIX only)",{"$nulls":8},42]
[null," Intensive Care Type Inpatient"]
[null," Hospital Units"]
[43," Intensive Care Unit",{"$nulls":8},43]
[44," Coronary Care Unit",{"$nulls":8},44]
[45," Burn Intensive Care Unit",{"$nulls":8},45]
[46," Surgical Intensive Care Unit",{"$nulls":8},46]
[47," Other Special Care Unit (specify)",{"$nulls":8},47]
[{"$nulls":9},"1"]
[48," Program inpatient ancillary service cost (Wkst. D-3, col. 3, line 200)",{"$nulls":8},48]
[49," Total Program inpatient costs (sum of lines 41 through 48) (see instructions)",{"$nulls":8},49]
[]
[null,null,"PASS THROUGH COST ADJUSTMENTS"]
[50," Pass through costs applicable to Program inpatient routine services (from Wkst. D, sum of Parts I and III)",{"$nulls":8},50]
[51," Pass through costs applicable to Program inpatient ancillary services (from Wkst. D, sum of Parts II and IV)",{"$nulls":8},51]
[52," Total Program excludable cost (sum of lines 50 and 51)",{"$nulls":8},52]
[53," Total Program inpatient operating cost excluding capital related, nonphysician anesthetist, and  medical education costs",{"$nulls":8},53]
[null," (line 49 minus line 52)"]
[]
[null,null,"TARGET AMOUNT AND LIMIT COMPUTATION"]
[54," Program discharges",{"$nulls":8},54]
[55," Target amount per discharge",{"$nulls":8},55]
[56," Target amount (line 54 x line 55)",{"$nulls":8},56]
[57," Difference between adjusted inpatient operating cost and target amount (line 56 minus line 53)",{"$nulls":8},57]
[58," Bonus payment (see instructions)",{"$nulls":8},58]
[59," Lesser of lines 53/54 or 55 from the cost reporting period ending 1996, updated and compounded by the market basket.",{"$nulls":8},59]
[60," Lesser of lines 53/54 or 55 from prior year cost report, updated by the market basket.",{"$nulls":8},60]
[61," If line 53/54 is less than the lower of lines 55, 59 or 60 enter the lesser of 50% of the amount by which operating costs",{"$nulls":8},61]
[null," (line 53) are less than expected costs (lines 54 x 60), or 1 % of the target amount (line 56), otherwise enter zero."]
[null," (see instructions)"]
[62," Relief payment (see instructions)",{"$nulls":8},62]
[63,"Allowable Inpatient cost plus incentive payment (see instructions)",{"$nulls":8},63]
[]
[null,null,"PROGRAM INPATIENT ROUTINE SWING BED COST"]
[64," Medicare swing-bed SNF inpatient routine costs through December 31 of the cost reporting period (See instructions)",{"$nulls":8},64]
[null," (title XVIII only)"]
[65," Medicare swing-bed SNF inpatient routine costs after December 31 of the cost reporting period (See instructions)",{"$nulls":8},65]
[null," (title XVIII only)"]
[66," Total Medicare swing-bed SNF inpatient routine costs ( line 64 plus line 65) (title XVIII only). For CAH (see instructions)",{"$nulls":8},66]
[67," Title V or XIX swing-bed NF inpatient routine costs through December 31 of the cost reporting period (line 12 x line 19)",{"$nulls":8},67]
[68," Title V or XIX swing-bed NF inpatient routine costs after December 31 of the cost reporting period (line 13 x line 20)",{"$nulls":8},68]
[69," Total title V or XIX swing-bed NF inpatient routine costs ( line 67 + line 68)",{"$nulls":8},69]
{"$rows_empty":7}
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4025.2)"]
["40-574",{"$nulls":9},"Rev.  1"]

{"sheet":"D1III","index":7,"n_rows":68,"n_cols":31,"rows_kept":68,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["DRAFT",null,null,null,"CMS FORM-2552-10",null,null,null,"4090 (Cont.)"]
["COMPUTATION OF INPATIENT",null,null,null," PROVIDER NO.:","COMPONENT NO.:","PERIOD:","WORKSHEET D-1,",{"$nulls":22},"  ."]
["OPERATING COST",{"$nulls":5},"FROM ________","PARTS III & IV"]
[{"$nulls":4}," _______________"," _________________","TO ___________"]
["Check",null,"  [  ]  Title V - I/P",null,"  [  ]  Hospital            [  ]  Subprovider (other)      [  ]  ICF/MR",null,null,"  [  ]  PPS"]
["applicable",null,"  [  ]  Title XVIII, Part A",null,"  [  ]  IPF                      [  ]  SNF",null,null,"  [  ]  TEFRA"]
["boxes",null,"  [  ]  Title XIX - I/P",null,"  [  ]  IRF                      [  ]  NF",null,null,"  [  ]  Other"]
["PART  III  -  SKILLED NURSING FACILITY, OTHER NURSING FACILITY,  AND ICF/MR ONLY"]
[]
[70," Skilled nursing facility/other nursing facility/ICF/MR routine service cost (line 37)",{"$nulls":6},70]
[]
[71," Adjusted general inpatient routine service cost per diem (line 70 ÷ line 2)",{"$nulls":6},71]
[]
[72," Program routine service cost (line 9 x line 71)",{"$nulls":6},72]
[]
[73," Medically necessary private room cost applicable to Program (line 14 x line 35)",{"$nulls":6},73]
[]
[74," Total Program general inpatient routine service costs (line 72 + line 73)",{"$nulls":6},74]
[null," Capital-related cost allocated to inpatient routine service costs"]
[75," (from Worksheet B, sum of Parts II, column 26)",{"$nulls":6},75]
[]
[76," Per diem capital-related costs (line 75 ÷ line 2)",{"$nulls":6},76]
[]
[77," Program capital-related costs (line 9 x line 76)",{"$nulls":6},77]
[]
[78," Inpatient routine service cost (line 70 minus line 73)",{"$nulls":6},78]
[]
[79," Aggregate charges to beneficiaries for excess costs (from provider records)",{"$nulls":6},79]
[]
[80," Total Program routine service costs for comparison to the cost limitation (line 78 minus line 79)",{"$nulls":6},80]
[]
[81," Inpatient routine service cost per diem limitation",{"$nulls":6},81]
[]
[82," Inpatient routine service cost limitation (line 9 x line 81)",{"$nulls":6},82]
[]
[83," Reasonable inpatient routine service costs (see instructions)",{"$nulls":6},83]
[]
[84," Program inpatient ancillary services (see instructions)",{"$nulls":6},84]
[]
[85," Utilization review - physician compensation (see instructions)",{"$nulls":6},85]
[]
[86," Total Program inpatient operating costs (sum of lines 74 through 85)",{"$nulls":6},86]
[]
["PART  IV  - COMPUTATION OF OBSERVATION BED PASS THROUGH COST"]
[]
[87," Total observation bed days (see instructions)",{"$nulls":6},87]
[]
[88," Adjusted general inpatient routine cost per diem (line 27 ÷ line 2)",{"$nulls":6},88]
[]
[89," Observation bed cost (line 87 x line 88)  (see instructions)",{"$nulls":6},89]
[]
[null,null,"COMPUTATION  OF  OBSERVATION  BED  PASS THROUGH  COST"]
[{"$nulls":6},"Total","Observation Bed"]
[{"$nulls":4},"Routine",null,"Observation","Pass Through Cost"]
[{"$nulls":4},"Cost",null,"Bed Cost","(col. 3 x col. 4)"]
[null,null,null,"Cost","(from line 27)","col. 1 ÷ col. 2","(from line 89)","(see instructions)"]
[null,null,null,"1","2","3","4","5"]
[]
[90," Capital-related cost",{"$nulls":6},90]
[]
[91,"Nursing School cost",{"$nulls":6},91]
[]
[92,"Allied  Health cost",{"$nulls":6},92]
[]
[93,"All other Medical Education",{"$nulls":6},93]
[]
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4025.3 - 4025.4)"]
["Rev. 1",{"$nulls":7},"40-575"]

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["APPORTIONMENT OF COST OF",{"$nulls":4},"PROVIDER NO.:","PERIOD:","WORKSHEET  D-2,",null,"APPORTIONMENT OF COST OF",null,null,"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET D-2,"]
["SERVICES RENDERED BY",{"$nulls":5},"FROM ___________","PARTS I-III",null,"SERVICES RENDERED BY",{"$nulls":4},"FROM ____________",null,"PARTS I-III (Cont.)"]
["INTERNS AND RESIDENTS",{"$nulls":4},"__________________","TO  _____________",null,null,"INTERNS AND RESIDENTS",null,null,"_____________",null,"TO _______________"]
[" PART I - NOT IN APPROVED TEACHING PROGRAM",{"$nulls":8}," PART I - NOT IN APPROVED TEACHING PROGRAM"]
[{"$nulls":5},"Percent of","Expense","Total Inpatient Days",null,null,"Average Cost",null,"Health  Care  Program  Inpatient  Days",null,"Title V","Title XVIII","Title XIX"]
[null,null,"Cost Centers",null,null,"Assigned Time","Allocation"," All Patients",null,null,"Per Day","Title V","Title XVIII, Part B","Title XIX","(col. 4 x col. 5)","(col. 4 x col. 6)","(col. 4 x col. 7)"]
[{"$nulls":5},"1","2","3",null,null,"4","5","6","7","8","9","10"]
[1," Total cost of services rendered",null,null,null,"100.00",null,null,1,1,{"$nulls":7},1]
[null," Hospital Inpatient Routine Services:"]
[2," ","Adults & pediatrics (general routine care)",{"$nulls":5},2,2,{"$nulls":7},2]
[3,null,"Intensive care unit",{"$nulls":5},3,3,{"$nulls":7},3]
[4,null,"Coronary care unit",{"$nulls":5},4,4,{"$nulls":7},4]
[5,null,"Burn Intensive Care Unit",{"$nulls":5},5,5,{"$nulls":7},5]
[6,null,"Surgical Intensive Care Unit",{"$nulls":5},6,6,{"$nulls":7},6]
[7,null,"Other Special Care (specify)",{"$nulls":5},7,7,{"$nulls":7},7]
[8,null,"Nursery",{"$nulls":5},8,8,{"$nulls":7},8]
[9," Subtotal (sum of lines 2 through 8)",{"$nulls":6},9,9,{"$nulls":7},9]
[10," IPF - Inpatient routine service",{"$nulls":6},10,10,{"$nulls":7},10]
[11," IRF - Inpatient routine service",{"$nulls":6},11,11,{"$nulls":7},11]
[12," Subprovider (Other) - Inpatient routine service",{"$nulls":6},12,12,{"$nulls":7},12]
[13," Skilled Nursing Facility",{"$nulls":6},13,13,{"$nulls":7},13]
[14," Nursing Facility",{"$nulls":6},14,14,{"$nulls":7},14]
[15," Other Long Term Care",{"$nulls":6},15,15,{"$nulls":7},15]
[16," Home Health Agency",{"$nulls":6},16,16,{"$nulls":7},16]
[17," Outpatient Rehabilitation Providers",{"$nulls":6},17,17,{"$nulls":7},17]
[18," Ambulatory Surgical Center",{"$nulls":6},18,18,{"$nulls":7},18]
[19," Hospice",{"$nulls":6},19,19,{"$nulls":7},19]
[20," Subtotal (sum of lines 9 through 19)",{"$nulls":6},20,20,{"$nulls":7},20]
[{"$nulls":7},"Total Charges",null,null,"Ratio of Cost",null,"Titles V and XIX Outpatient and ",null,null,"Titles V and XIX Outpatient and "]
[{"$nulls":7},"(from Wkst. C.",null,null,"to Charges",null,"Title XVIII Part B Charges",null,null,"Title XVIII Part B Cost"]
[{"$nulls":7},"Part I, col. 8,",null,null,"(col. 2 ÷","Title","Title XVIII","Title","  Title","Title XVIII","Title"]
[null,"Hospital Outpatient Services:",{"$nulls":5},"lines 88 thru 93)",null,null,"col. 3)","V","Part B","XIX","V","Part B","XIX"]
[21,null,"Rural Health Clinic (RHC)",{"$nulls":5},21,21,{"$nulls":7},21]
[22,null,"Federally Qualified Health Center (FQHC)",{"$nulls":5},22,22,{"$nulls":7},22]
[23,null,"Clinic",{"$nulls":5},23,23,{"$nulls":7},23]
[24,null,"Emergency",{"$nulls":5},24,24,{"$nulls":7},24]
[25,null,"Observation beds",{"$nulls":5},25,25,{"$nulls":7},25]
[26,null,"Other Outpatient Service (specify)",{"$nulls":5},26,26,{"$nulls":7},26]
[27," Subtotal (sum of lines 21 through 26)",{"$nulls":6},27,27,{"$nulls":7},27]
[28," Total (sum of lines 20 and 27)",null,null,null,"100.00",null,null,28,28,{"$nulls":7},28]
["PART II - IN AN APPROVED TEACHING PROGRAM (TITLE XVIII, PART B INPATIENT ROUTINE COSTS ONLY)",{"$nulls":8},"PART II - IN AN APPROVED TEACHING PROGRAM (TITLE XVIII, PART B INPATIENT ROUTINE COSTS ONLY) "]
[{"$nulls":5},"Expenses Allocated",{"$nulls":7},"Expenses"]
[{"$nulls":5},"To cost centers",null,"Net cost",null,null,"Total","Average Cost","Title XVIII"," Applicable"]
[{"$nulls":5},"on Wkst B, Part I","Swing bed","(col. 1 plus",null,null," Inpatient Days -","Per Day"," Part B","to Title XVIII"]
[{"$nulls":5}," cols. 21 & 22","Amount","col. 2 )",null,null," All Patients","(col. 3 ÷ col. 4)"," Inpatient Days","(col. 5 x col. 6)"]
[null,"Hospital Inpatient Routine Services:",null,null,null,"1","2","3",null,null,4,5,6,7]
[29,null,"Adults & Pediatrics (general routine care)",{"$nulls":5},29,29,{"$nulls":7},29]
[30,null,"Swing Bed - SNF",{"$nulls":5},30,30,{"$nulls":7},30]
[31,null,"Swing Bed - NF",{"$nulls":5},31,31,{"$nulls":7},31]
[32,null,"Intensive care unit",{"$nulls":5},32,32,{"$nulls":7},32]
[33,null,"Coronary care unit",{"$nulls":5},33,33,{"$nulls":7},33]
[34,null,"Burn Intensive Care Unit",{"$nulls":5},34,34,{"$nulls":7},34]
[35,null,"Surgical Intensive Care Unit",{"$nulls":5},35,35,{"$nulls":7},35]
[36,null,"Other Special Care (specify)",{"$nulls":5},36,36,{"$nulls":7},36]
[37," Subtotal (sum of lines 28, and 29 through 36)",{"$nulls":6},37,37,{"$nulls":7},37]
[38," IPF - Inpatient routine service",{"$nulls":6},38,38,{"$nulls":7},38]
[39," IRF - Inpatient routine service",{"$nulls":6},39,39,{"$nulls":7},39]
[40," Subprovider (Other)- Inpatient routine service",{"$nulls":6},40,40,{"$nulls":7},40]
[41," Skilled Nursing Facility",{"$nulls":6},41,41,{"$nulls":7},41]
[42," Total (sum of lines 37 through 41)",{"$nulls":6},42,42,{"$nulls":7},42]
["PART III - SUMMARY FOR TITLE XVIII (TO BE COMPLETED ONLY IF BOTH PARTS I AND II ARE USED)",{"$nulls":8},"PART III - SUMMARY FOR TITLE XVIII (TO BE COMPLETED ONLY IF BOTH PARTS I AND II ARE USED)"]
[{"$nulls":6}," Not In Approved Teaching Program",null,null,null,"In Approved Teaching Program",null,"Total Title XVIII Costs"]
[{"$nulls":6},"(from Part I:)","Amount",null,null,"(from Part II, col. 7, - )","Amount","(to Wkst. E, Part B - )","(col. 2 + col. 4)"]
[null," Hospital",{"$nulls":4},"1","2",null,null,3,4,5,6]
[43," Inpatient",{"$nulls":4}," col. 9, lines 9",null,43,43,"line 37",{"$nulls":6},43]
[44," Outpatient",{"$nulls":4}," col. 9, line 26",null,44,44,{"$nulls":7},44]
[45," Total Hospital (sum of lines 41 and 42)",{"$nulls":6},45,45,null,null,"line 2",{"$nulls":4},45]
[46," IPF - Inpatient routine service",{"$nulls":4}," col. 9, line 10 ",null,46,46,"line 38",null,"line 2",{"$nulls":4},46]
[47," IRF - Inpatient routine service",{"$nulls":4}," col. 9, line 11",null,47,47,"line 39",null,"line 2",{"$nulls":4},47]
[48," Subprovider (Other)- Inpatient routine service",{"$nulls":4}," col. 9, line 12",null,48,48,"line 40",null,"line 2",{"$nulls":4},48]
[49," Skilled Nursing Facility",{"$nulls":4}," col. 9, line 13",null,49,49,"line 41",null,"line 2",{"$nulls":4},49]
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4026)",{"$nulls":8},"FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4026)"]
["40-576",{"$nulls":7},"Rev. 1","Rev. 1",{"$nulls":7},"40-577"]

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["4090 (Cont.)",null,null,"     FORM CMS-2552-10",null,null,null,"DRAFT"]
["INPATIENT ANCILLARY SERVICE",null,null,null,"PROVIDER NO.:","PERIOD:","WORKSHEET D-3",{"$nulls":22},"  ."]
["COST APPORTIONMENT",null,null,null,"_______________","FROM_________"]
[{"$nulls":4},"COMPONENT NO.:","TO____________"]
[{"$nulls":4},"_______________"]
["Check",null,"[ ]  Title V","[ ]  Hospital","[ ]  Subprovider (other)","[ ] Swing-Bed SNF","  [  ]  PPS"]
["Applicable",null,"[ ]  Title XVIII, Part A","[ ]  IPF","[ ]  SNF","[ ]  Swing-Bed NF","  [  ]  TEFRA"]
["Boxes",null,"[ ]  Title XIX","[ ]  IRF","[ ]  NF","[ ]  ICF/MR","  [  ]  Other"]
[{"$nulls":4},"Ratio of Cost","Inpatient","  Inpatient Program Costs"]
[null,"COST  CENTER  DESCRIPTION",null,null,"To Charges","Program Charges","(col. 1 x col. 2)"]
[{"$nulls":4},"1","2","3"]
[null,"INPATIENT ROUTINE SERVICE COST CENTERS"]
[30,"Adults and Pediatrics (General Routine Care)",{"$nulls":5},30]
[31,"Intensive Care Unit",{"$nulls":5},31]
[32,"Coronary Care Unit",{"$nulls":5},32]
[33,"Burn Intensive Care Unit",{"$nulls":5},33]
[34,"Surgical Intensive Care Unit",{"$nulls":5},34]
[35,"Other Special Care (specify)",{"$nulls":5},35]
[40,"Subprovider IPF",{"$nulls":5},40]
[41,"Subprovider IRF",{"$nulls":5},41]
[42,"Subprovider (Specify)",{"$nulls":5},42]
[43,"Nursery",{"$nulls":5},43]
[null,"ANCILLARY SERVICE COST CENTERS"]
[50,"Operating Room",{"$nulls":5},50]
[51,"Recovery Room",{"$nulls":5},51]
[52,"Labor Room and Delivery Room",{"$nulls":5},52]
[53,"Anesthesiology",{"$nulls":5},53]
[54,"Radiology-Diagnostic",{"$nulls":5},54]
[55,"Radiology-Therapeutic",{"$nulls":5},55]
[56,"Radioisotope",{"$nulls":5},56]
[57,"Computed Tomography (CT) Scan",{"$nulls":5},57]
[58,"Magnetic Resonance Imaging (MRI)",{"$nulls":5},58]
[59,"Cardiac Catheterization",{"$nulls":5},59]
[60,"Laboratory",{"$nulls":5},60]
[61,"PBP Clinical Laboratory Services-Prgm. Only",{"$nulls":5},61]
[62,"Whole Blood & Packed Red Blood Cells",{"$nulls":5},62]
[63,"Blood Storing, Processing, & Trans.",{"$nulls":5},63]
[64,"Intravenous Therapy",{"$nulls":5},64]
[65,"Respiratory Therapy",{"$nulls":5},65]
[66,"Physical Therapy",{"$nulls":5},66]
[67,"Occupational Therapy",{"$nulls":5},67]
[68,"Speech Pathology",{"$nulls":5},68]
[69,"Electrocardiology",{"$nulls":5},69]
[70,"Electroencephalography",{"$nulls":5},70]
[71,"Medical Supplies Charged to Patients",{"$nulls":5},71]
[72,"Implantable Devices Charged to Patients",{"$nulls":5},72]
[73,"Drugs Charged to Patients",{"$nulls":5},73]
[74,"Renal Dialysis",{"$nulls":5},74]
[75,"ASC (Non-Distinct Part)",{"$nulls":5},75]
[76,"Other Ancillary (specify)",{"$nulls":5},76]
[null,"OUTPATIENT SERVICE COST CENTERS"]
[88,"Rural Health Clinic (RHC)",{"$nulls":5},88]
[89,"Federally Qualified Health Center (FQHC)",{"$nulls":5},89]
[90,"Clinic",{"$nulls":5},90]
[91,"Emergency",{"$nulls":5},91]
[92,"Observation Beds (see instructions)",{"$nulls":5},92]
[93,"Other Outpatient Service (specify)",{"$nulls":5},93]
[null,"OTHER REIMBURSABLE COST CENTERS"]
[94,"Home Program Dialysis",{"$nulls":5},94]
[95,"Ambulance Services",{"$nulls":5},95]
[96,"Durable Medical Equipment-Rented",{"$nulls":5},96]
[97,"Durable Medical Equipment-Sold",{"$nulls":5},97]
[98,"Other Reimbursable (specify)",{"$nulls":5},98]
[200," Total (sum of lines 30-94 and 96-98)",{"$nulls":5},200]
[201," Less PBP Clinic Laboratory Services-Program only charges (line 58)",{"$nulls":5},201]
[202," Net Charges (line 200 minus line 201)",{"$nulls":5},202]
[]
[null,"(A) Worksheet A line numbers"]
[]
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4027)"]
["40-578",{"$nulls":6},"Rev. 1"]

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["DRAFT",null,null,"                    FORM CMS-2552-10",{"$nulls":4},"4090 (Cont.)"]
["COMPUTATION OF ORGAN ACQUISITION",null,null,null,"PROVIDER NO.:",null,"PERIOD:","WORKSHEET D-4,"]
["COSTS AND CHARGES",null,null,null,"_______________",null,"FROM ___________","PART I"]
[{"$nulls":4},"OPO NO.: ",null,"TO ______________"]
[{"$nulls":4},"_______________"]
["Check",null,"  [ ] HEART","  [ ] LIVER"," [  ] PANCREAS",null," [  ] ISLET"]
["Applicable Box",null,"  [ ] KIDNEY","  [ ] LUNG"," [  ] INTESTINE",null," [  ] OTHER (specify)"]
["PART I - COMPUTATION OF ORGAN ACQUISITION COSTS (INPATIENT ROUTINE AND ANCILLARY SERVICES)"]
["     Computation of Inpatient",null,null,"Inpatient",null,null,"Organ"]
["      Routine Service  Costs ",null,null,"Routine Organ",null,"Per Diem Costs","Acquisition","Cost"]
["      Applicable to Organ Acquisition",null,null,"Charges",null,"(from Wkst. D-1,Part II)","Days","(col. 2 x col. 3)"]
[null,null,null,"1","D","2","3","4"]
[1," Adults and Pediatrics",null,null,38,null,null,null,1]
[2," Intensive Care",null,null,43,null,null,null,2]
[3," Coronary Care",null,null,44,null,null,null,3]
[4," Burn Intensive Care Unit",null,null,45,null,null,null,4]
[5," Surgical Intensive Care Unit",null,null,46,null,null,null,5]
[6," Other Special Care (specify)",null,null,47,null,null,null,6]
[7,"TOTAL (sum of lines 1-6)",{"$nulls":6},7]
["    Computation of Ancillary",{"$nulls":4},"Ratio of Cost/","Organ","Organ"]
["     Service Cost Applicable",{"$nulls":4},"Charges","Acquisition","Acquisition"]
["      to Organ Acquisition",{"$nulls":4},"(from","Ancillary","Ancillary"]
[{"$nulls":5},"Wkst. C)","Charges","Costs"]
[{"$nulls":4},"C","1","2","3"]
[8," Operating Room",null,null,50,null,null,null,8]
[9," Recovery Room",null,null,51,null,null,null,9]
[10," Labor Room & Delivery Room ",null,null,52,null,null,null,10]
[11," Anesthesiology",null,null,53,null,null,null,11]
[12," Radiology-Diagnostic",null,null,54,null,null,null,12]
[13," Radiology-Therapeutic",null,null,55,null,null,null,13]
[14," Radioisotope",null,null,56,null,null,null,14]
[15,"Computed Tomography (CT) Scan",null,null,57,null,null,null,15]
[16,"Magnetic Resonance Imaging (MRI)",null,null,58,null,null,null,16]
[17,"Cardiac Catheterization",null,null,59,null,null,null,17]
[18," Laboratory",null,null,60,null,null,null,18]
[19," PBP Clinical Laboratory Services-Program Only",null,null,61,null,null,null,19]
[20," Whole Blood & Packed Red Blood Cells",null,null,62,null,null,null,20]
[21," Blood Storage, Processing, & Transfusing",null,null,63,null,null,null,21]
[22," IV Therapy",null,null,64,null,null,null,22]
[23," Respiratory Therapy",null,null,65,null,null,null,23]
[24," Physical Therapy",null,null,66,null,null,null,24]
[25," Occupational Therapy",null,null,67,null,null,null,25]
[26," Speech Pathology",null,null,68,null,null,null,26]
[27," Electrocardiology",null,null,69,null,null,null,27]
[28," Electroencephalography",null,null,70,null,null,null,28]
[29," Medical Supplies Charged to Patients",null,null,71,null,null,null,29]
[30,"Implantable Devices Charged to Patients",null,null,72,null,null,null,30]
[31,"Drugs Charged to Patients",null,null,73,null,null,null,31]
[32," Renal Dialysis",null,null,74,null,null,null,32]
[33," ASC (non-distinct part)",null,null,75,null,null,null,33]
[34," Other Ancillary (specify)",null,null,76,null,null,null,34]
[35,"Rural Health Clinic (RHC)",null,null,88,null,null,null,35]
[36,"Federally Qualified Health Center (FQHC)",null,null,89,null,null,null,36]
[37," Clinic",null,null,90,null,null,null,37]
[38," Emergency Room",null,null,91,null,null,null,38]
[39," Observation Beds",null,null,92,null,null,null,39]
[40," Other Outpatient Service (specify)",null,null,93,null,null,null,40]
[41," TOTAL (sum of lines 8-40)",{"$nulls":6},41]
[]
[null,"C = Worksheet C line numbers",null,"D = Worksheet D-1 line numbers"]
[]
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4028.1)"]
["Rev. 1",{"$nulls":7},"40-579"]

{"sheet":"D4II","index":11,"n_rows":62,"n_cols":39,"rows_kept":62,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4090 (Cont.)",null,null,"FORM CMS-2552-10",{"$nulls":4},"DRAFT"]
["COMPUTATION OF ORGAN ACQUISITION",null,null,"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET D-4,"]
["COSTS AND CHARGES",null,null,"_________________",null,"FROM ___________",null,"PART II"]
[null,null,null,"OPO NO.: ",null,"TO ______________"]
[null,null,null,"_________________"]
["Check",null,"  [ ] HEART","  [ ] LIVER",null," [  ] PANCREAS",null," [  ] ISLET"]
["Applicable Box",null,"  [ ] KIDNEY","  [ ] LUNG",null," [  ] INTESTINE",null," [  ] OTHER (specify)",{"$nulls":17},"[  ] LIVER",{"$nulls":10},"[  ] HEART"]
["PART II - COMPUTATION OF ORGAN ACQUISITION COSTS (OTHER THAN INPATIENT ROUTINE AND"]
["                ANCILLARY SERVICES COSTS)"]
[{"$nulls":4},"Average Cost",null,null,"Organ"]
[null,"    Computation of the Cost of Inpatient",null,null,"Per Day",null,null,"Acquisition"]
[null,"   Services of Interns and Residents Not",null,null,"(from Wkst. D-2,","Organ",null,"Costs"]
[null,"        In Approved Teaching Program",null,null,"Part I, col. 4)","Acquisition Days",null,"(col. 1 x col. 2)"]
[null,null,null," D","1",2,null,"3",{"$nulls":12}," 1",{"$nulls":8}," 2",{"$nulls":8},"   3"]
[42," Adults & Pediatrics (General routine care)",null,2,{"$nulls":4},42]
[43," Intensive Care Unit",null,3,{"$nulls":4},43]
[44," Coronary Care Unit",null,4,{"$nulls":4},44]
[45," Burn Intensive Care Unit",null,5,{"$nulls":4},45]
[46," Surgical Intensive Care Unit",null,6,{"$nulls":4},46]
[47," Other Special Care (specify)",null,7,{"$nulls":4},47]
[48," TOTAL (sum of lines 42 through 47)",{"$nulls":6},48]
[]
[]
[]
[]
[null,"    Computation of the Cost of",{"$nulls":4},"Ratio of Cost","Organ"]
[null,"Outpatient Services of Interns",null,"Organ",null,null,"To Charges","Acquisition"]
[null,"    and Residents Not In Approved",null,"Charges",null,null," from Wkst. D-2,","Costs"]
[null,"           Teaching Program",null,"(see instructions)",null,null,"Part I, col. 4)","(col. 1 x col. 2)",{"$nulls":19}," Ratio of Cost"]
[null,null,null,1,null,"D","2","3"]
[49,"Rural Health Clinic (RHC)",null,null,null,21,null,null,49,{"$nulls":17}," Supp. Wkst. D-2,"]
[50,"Federally Qualified Health Center (FQHC)",null,null,null,22,null,null,50,{"$nulls":11}," 1",{"$nulls":7},"    2",{"$nulls":9},"   3"]
[51," Clinic",null,null,null,23,null,null,51]
[52," Emergency",null,null,null,24,null,null,52]
[53," Observation Beds",null,null,null,25,null,null,53]
[54," Other Outpatient Service (specify)",null,null,null,26,null,null,54]
[55," TOTAL (sum of lines 49 through 52)",{"$nulls":6},55]
[]
[]
["D = Worksheet D-2, Part I, line numbers"]
{"$rows_empty":19}
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4028.2)"]
[]
["40-580",{"$nulls":7},"Rev. 1"]

{"sheet":"D4III","index":12,"n_rows":74,"n_cols":27,"rows_kept":74,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["DRAFT",null,null,"    FORM CMS-2552-10",null,null,null,"4090 (Cont.)"]
["COMPUTATION OF ORGAN ACQUISITION",null,null,null,"PROVIDER NO.:","PERIOD:","WORKSHEET D-4,"]
["COSTS AND CHARGES",null,null,null,"_____________","FROM ________","PARTS III & IV"]
[{"$nulls":4},"OPO NO.: ","TO __________"]
[{"$nulls":4},"_____________"]
["Check",null,"  [  ]  HEART","  [  ]  LIVER"," [  ] PANCREAS"," [  ] ISLET"]
["Applicable Box",null,"  [  ]  KIDNEY","  [  ]  LUNG"," [  ] INTESTINE"," [  ] OTHER (specify)"]
["PART III - SUMMARY OF COSTS AND CHARGES"]
[null,null,null,"                        Cost",null,"                      Charges"]
[null,null,null,"Part A","Part B","Part A"," Part B"]
[null,null," ","  1","2","3","4"]
[56,"Routine and Ancillary from Part I ",{"$nulls":5},56]
[57,"Interns and Residents (inpatient)",{"$nulls":5},57]
[58,"Interns and Residents (outpatient)",{"$nulls":5},58]
[59,"Direct Organ Acquisition (see instructions)",{"$nulls":5},59]
[60,"Cost of Services of Teaching Physicians (Wkst. D-5, Part II)",{"$nulls":5},60]
[61,"Total (sum of lines 56 thru 60)",{"$nulls":5},61]
[62,"Total Usable Organs (see instructions)",{"$nulls":5},62]
[63,"Medicare Usable Organs (see instructions)",{"$nulls":5},63]
[64,"Ratio of Medicare Usable Organs to Total Usable ",{"$nulls":5},64]
[null,"Organs (line 63 ÷ line 62)"]
[65,"Medicare Cost/Charges (see instructions)",{"$nulls":5},65]
[66,"Revenue for Organs Sold",{"$nulls":5},66]
[67,"Subtotal (line 65 minus line 66)",{"$nulls":5},67]
[68,"Organs Furnished Part B",{"$nulls":5},68]
[69,"Net Organ Acquisition Cost and Charges (see instructions)",{"$nulls":5},69]
[]
["PART IV - STATISTICS"]
[]
[{"$nulls":4},"Living Related","Cadaveric","Revenue"]
[{"$nulls":4},"1","2","3"]
[70,"Organs Excised in Provider (1)",{"$nulls":5},70]
[71,"Organs Purchased from Other Transplant Hospitals (2)",{"$nulls":5},71]
[72,"Organs Purchased from Non-Transplant Hospitals",{"$nulls":5},72]
[74,"Organs Purchased from OPOs",{"$nulls":5},74]
[75,"Total (sum of lines 70 thru 74)",{"$nulls":5},75]
[76,"Organs Transplanted",{"$nulls":5},76]
[77,"Organs Sold to Other Hospitals",{"$nulls":5},77]
[78,"Organs Sold to OPOs",{"$nulls":5},78]
[79,"Organs Sold to Transplant Hospitals",{"$nulls":5},79]
[80,"Organs Sold to Military or VA Hospitals",{"$nulls":5},80]
[81,"Organs Sold Outside the U.S.",{"$nulls":5},81]
[82,"Organs Sent Outside the U.S. (no revenue received)",{"$nulls":5},82]
[83,"Organs Used for Research",{"$nulls":5},83]
[84,"Unusable/Discarded Organs",{"$nulls":5},84]
[85,"Total (sum of lines 76 thru 84 should equal line 75)",{"$nulls":5},85]
[]
[null,"(1)  Organs procured outside your center by a procurement team from your center are not to be included in the count."]
[null,"(2)  Organs procured outside your center by a procurement team are included in the count."]
{"$rows_empty":10}
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4028.3)"]
[]
["Rev. 1",{"$nulls":6},"40-581"]
{"$rows_empty":11}
[{"$nulls":26},"{EDIT}{HOME}{R}{DEL}{D}"]

{"sheet":"D5I","index":13,"n_rows":41,"n_cols":11,"rows_kept":41,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4090 (Cont.)",null,null,"               FORM CMS-2552-10",{"$nulls":6},"DRAFT"]
["APPORTIONMENT OF COST FOR THE SERVICES OF TEACHING PHYSICIANS",{"$nulls":4},"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET D-5,"]
["REASONABLE COMPENSATION EQUIVALENT COMPUTATION",{"$nulls":6},"FROM ________________",null,"PART I"]
[{"$nulls":5},"__________________",null,"TO ____________________"]
["Check applicable box:",null," [ ] Hospital Staff          [ ] Medical Staff"]
[{"$nulls":7},"Physician/",null,"5 Percent"]
["Line","Specialty",null,null,"Total","Professional","RCE","Professional","Unadjusted","of Unadjusted"]
[" No.","Description/Physician Identifier",null,null,"Remuneration","Component","Amount","Component Hours","RCE Limit","RCE Limit"]
[1,2,null,null,"3","4","5","6","7","8"]
[1,"General Practitioner Family Practice",{"$nulls":8},1]
[2," Internal Medicine",{"$nulls":8},2]
[3," Surgery",{"$nulls":8},3]
[4," Pediatrics",{"$nulls":8},4]
[5," Obstetrics-Gynecology",{"$nulls":8},5]
[6," Radiology",{"$nulls":8},6]
[7," Psychiatry",{"$nulls":8},7]
[8," Anesthesiology",{"$nulls":8},8]
[9," Pathology",{"$nulls":8},9]
[10," All Other",{"$nulls":8},10]
[11," Total",{"$nulls":8},11]
[]
[{"$nulls":4},"Cost of",null,"Cost of",null,null,"Adjust Cost"]
[{"$nulls":4},"Membership ","Professional","Physician","Professional",null,"of Physician's"]
["Line","Specialty",null,null,"& Continuing","Component","Malpractice","Component","Adjusted","Direct Medical &"]
[" No.","Description/Physician Identifier",null,null,"Education","Share of col. 11","Insurance","Share of col. 13","RCE Limit","Surgical Services"]
["   9",10,null,null,"11","12","13","14","15","16"]
[1," General Practitioner Family Practice",{"$nulls":8},1]
[2," Internal Medicine",{"$nulls":8},2]
[3," Surgery",{"$nulls":8},3]
[4," Pediatrics",{"$nulls":8},4]
[5," Obstetrics-Gynecology",{"$nulls":8},5]
[6," Radiology",{"$nulls":8},6]
[7," Psychiatry",{"$nulls":8},7]
[8," Anesthesiology",{"$nulls":8},8]
[9," Pathology",{"$nulls":8},9]
[10," All Other",{"$nulls":8},10]
[11," Total  (transfer the amount in column 16, line 11, to ",{"$nulls":8},11]
[null," Part II, line 1, column 1 or 2, as appropriate)"]
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4029.1)"]
[]
["40-582",{"$nulls":9},"Rev. 1"]

{"sheet":"D5II","index":14,"n_rows":69,"n_cols":30,"rows_kept":69,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["DRAFT",null,"                            FORM CMS-2552-10",null,null,null,"4090 (Cont.)"]
["APPORTIONMENT OF COST FOR THE",null,null,"PROVIDER NO.:","PERIOD:","WORKSHEET D-5,",{"$nulls":23},"  ."]
["SERVICES OF TEACHING PHYSICIANS",null,null,null,"FROM________","PART II"]
[null,null,null,"________________","TO___________"]
["Check",null,"  [ ]  Hospital","[ ] IPF"]
["Applicable Box:",null,"  [ ] IRF","[ ] Subprovider (other)"]
[{"$nulls":4},"Medical School","Total"]
[null,null,null,"Hospital Staff","Faculty","(col 1 + col 2)"]
[null,null,null,"1","2","3"]
[1," Adjusted Cost of Physician's Direct Medical and Surgical Services",{"$nulls":4},1]
[2," Total Inpatient Days and Outpatient Visit Days",{"$nulls":4},2]
[3," Average Per Diem (line 1 ÷ line 2)",{"$nulls":4},3]
[]
[null," HEALTH CARE PROGRAM REIMBURSABLE DAYS"]
[]
[4," Title  V - Inpatient",{"$nulls":4},4]
[5," Title  V - Outpatient",{"$nulls":4},5]
[6," Title  XVIII - Part A",{"$nulls":4},6]
[7," Title  XVIII - Part B",{"$nulls":4},7]
[8," Title  XIX - Inpatient",{"$nulls":4},8]
[9," Title  XIX - Outpatient",{"$nulls":4},9]
[10," Inpatient and Outpatient Kidney Acquisition",{"$nulls":4},10]
[11," Inpatient and Outpatient Liver Acquisition",{"$nulls":4},11]
[12," Inpatient and Outpatient Heart Acquisition",{"$nulls":4},12]
[13," Inpatient and Outpatient Lung Acquisition",{"$nulls":4},13]
[14," Inpatient and Outpatient Pancreas Acquisition",{"$nulls":4},14]
[15," Inpatient and Outpatient Intestine Acquisition",{"$nulls":4},15]
[16," Inpatient and Outpatient Islet Acquisition",{"$nulls":4},16]
[17,"Other Organ Acquisition",{"$nulls":4},17]
[]
[null," HEALTH CARE PROGRAM REIMBURSABLE COST"]
[]
[18," Title  V - Inpatient (line 3 x line 4)",{"$nulls":4},18]
[19," Title  V - Outpatient (line 3 x line 5)",{"$nulls":4},19]
[20," Title  XVIII - Part A (line 3 x line 6)",{"$nulls":4},20]
[21," Title  XVIII - Part B (line 3 x line 7)",{"$nulls":4},21]
[22," Title  XIX - Inpatient (line 3 x line 8)",{"$nulls":4},22]
[23," Title  XIX - Outpatient (line 3 x line 9)",{"$nulls":4},23]
[24," Inpatient and Outpatient Kidney Acquisition (line 3 x line 10)",{"$nulls":4},24]
[25," Inpatient and Outpatient Liver Acquisition (line 3 x line 11)",{"$nulls":4},25]
[26," Inpatient and Outpatient Heart Acquisition (line 3 x line 12)",{"$nulls":4},26]
[27," Inpatient and Outpatient Lung Acquisition (line 3 x line 13)",{"$nulls":4},27]
[28," Inpatient and Outpatient Pancreas Acquisition (line 3 x line 14)",{"$nulls":4},28]
[29," Inpatient and Outpatient Intestine Acquisition (line 3 x line 15)",{"$nulls":4},29]
[30," Inpatient and Outpatient Islet Acquisition (line 3 x line 16)",{"$nulls":4},30]
[31," Inpatient and Outpatient Other Organ Acquisition (line 3 x line 17)",{"$nulls":4},31]
[]
[null,"  Transfer the amounts in column 3 as follows:"]
[null,"     Add lines 18 and 19, and transfer to Worksheet E-3, Part VII"]
[null,"     Line 20 to Worksheet E, Part A, or Worksheet E-3, Part I to V as appropriate"]
[null,"     Line 21 to Worksheet E, Part B"]
[null,"     Add lines 22 and 23, and transfer to Worksheet E-3, Part VI, as appropriate"]
[null,"     Sum of lines 24 through  31 to Worksheet D-4, Part III, line 53"]
{"$rows_empty":13}
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4029.2)"]
[]
["Rev. 1",{"$nulls":5},"40-583"]