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["DRAFT",null,null,"FORM CMS-2552-10",null,null,null,"4090 (Cont.)"]
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[{"$nulls":4},"______________","FROM__________"]
[{"$nulls":5},"TO____________"]
["Check applicable box:",null," [ ] Renal Dialysis Department     [ ] Home Program Dialysis"]
[null,null,null,"TOTAL",null,null,"FTEs per"]
[null,null,null,"COSTS","BASIS","STATISTICS","2080 Hours"]
[null,null,null,"1","2","3","4"]
[1,"Registered Nurses",null,null,"Hours of Service",null,null,1]
[2,"Licensed Practical Nurses",null,null,"Hours of Service",null,null,2]
[3,"Nurses Aides",null,null,"Hours of Service",null,null,3]
[4,"Technicians",null,null,"Hours of Service",null,null,4]
[5,"Social Workers",null,null,"Hours of Service",null,null,5]
[6,"Dieticians",null,null,"Hours of Service",null,null,6]
[7,"Physicians",null,null,"Accumulated Cost",null,null,7]
[8,"Non-patient Care Salary",null,null,"Accumulated Cost",null,null,8]
[9,"Subtotal (sum of lines 1-8)",{"$nulls":5},9]
[10,"Employee Benefits",null,null,"Salary",null,null,10]
[11,"Capital Related Costs-Bldgs. & Fixtures",null,null,"Square Feet",null,null,11]
[12,"Capital Related Costs-Mov. Equip.",null,null,"Percentage of Time",null,null,12]
[13,"Machine Costs & Repairs",null,null,"Percentage of Time",null,null,13]
[14,"Supplies",null,null,"Requisitions",null,null,14]
[15,"Drugs",null,null,"Requisitions",null,null,15]
[16,"Other ",null,null,"Accumulated Cost",null,null,16]
[17,"Subtotal (sum of lines 9-16)*",{"$nulls":5},17]
[18,"Capital Related Costs-Bldgs. & Fixtures",null,null,"Square Feet",null,null,18]
[19,"Capital Related Costs-Mov. Equip.",null,null,"Percentage of Time",null,null,19]
[20,"Employee Benefits",null,null,"Salary",null,null,20]
[21,"Administrative and General",null,null,"Accumulated Cost",null,null,21]
[22,"Maint./Repairs-Operation-Housekeeping",null,null,"Square Feet",null,null,22]
[23,"Medical Education Program Costs",{"$nulls":5},23]
[24,"Central Services & Supplies",null,null,"Requisitions",null,null,24]
[25,"Pharmacy",null,null,"Requisitions",null,null,25]
[26,"Other Allocated Costs",null,null,"Accumulated Cost",null,null,26]
[27,"Subtotal (sum of lines 17-26)*",{"$nulls":5},27]
[28,"Laboratory (see instructions)",null,null,"Charges",null,null,28]
[29,"Respiratory Therapy (see instructions)",null,null,"Charges",null,null,29]
[30,"Other (see instructions)",null,null,"Charges",null,null,30]
[31,"Total costs (sum of lines 27-30)",{"$nulls":5},31]
[]
[null,"*  Line 17, column 1 should agree with Worksheet A, column 7 for line 71 or line 94 as appropriate,"]
[null,"     and line 27, column 1 should agree with Worksheet B, Part I, column 26 for line 71 or line 94 as appropriate."]
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["Statistics","Exception Requests"]
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["Charges","No S/W I-2 Part II"]
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["Weighted Treatments","I/P = 2"]
[null,"O/P & Home = 1"]
[null,"Training = 3"]

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["ALLOCATION OF RENAL DEPARTMENT COSTS TO TREATMENT MODALITIES",{"$nulls":6},"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET I-2"]
[{"$nulls":7},"________________",null,"FROM __________"]
[{"$nulls":9},"TO _____________"]
["Check applicable box:",null," [ ] Renal Dialysis Department    [ ] Home Program Dialysis"]
["OUTPATIENT SERVICES"]
["COMPOSITE PAYMENT RATE",null,"CAPITAL AND",null,"DIRECT PATIENT",{"$nulls":4},"ROUTINE","SUBTOTAL",null,"TOTAL"]
[null,null,"RELATED COSTS",null,"CARE SALARY",null,"EMPLOYEE",null,"MEDICAL","ANCILLARY","(sum of ",null,"(col. 9 +"]
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[null,"MAINTENANCE"]
[2,"  Hemodialysis",{"$nulls":11},2]
[3,"  Intermittent Peritoneal",{"$nulls":11},3]
[null,"TRAINING"]
[4,"  Hemodialysis",{"$nulls":11},4]
[5,"  Intermittent Peritoneal",{"$nulls":11},5]
[6,"  CAPD",{"$nulls":11},6]
[7,"  CCDP",{"$nulls":11},7]
[null,"HOME"]
[8,"  Hemodialysis",{"$nulls":11},8]
[9,"  Intermittent Peritoneal",{"$nulls":11},9]
[10,"  CAPD",{"$nulls":11},10]
[11,"  CCDP",{"$nulls":11},11]
[null,"OTHER BILLABLE SERVICES"]
[12,"  Inpatient Dialysis",{"$nulls":11},12]
[13,"  Method II Home Patient",{"$nulls":11},13]
[14,"  EPO (included in Renal Department)",{"$nulls":11},14]
[15,"  ARENESP (included in Renal Department)",{"$nulls":11},15]
[16,"  Other",{"$nulls":11},16]
[17,"Total (sum of lines 2-16)",{"$nulls":11},17]
[18,"Medical Educational Program Costs",{"$nulls":11},18]
[19,"Total Renal Costs (line 17 + line 18)",{"$nulls":11},19]
{"$rows_empty":13}
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[]
["40-618",{"$nulls":12},"Rev. 1"]

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["DIRECT AND INDIRECT RENAL DIALYSIS COST ALLOCATION -",{"$nulls":4},"PROVIDER NO.: ",null,null,"PERIOD:",null,"WORKSHEET I-3"]
["STATISTICAL BASIS",{"$nulls":4},"_",null,null,"FROM __________"]
[{"$nulls":8},"TO _____________"]
["Check applicable box:",null," [ ] Renal Dialysis Department      [ ] Home Program Dialysis"]
[null,null,"CAPITAL AND"]
[null,null,"RELATED COSTS",null,"DIRECT PATIENT",{"$nulls":4},"ROUTINE"]
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[1,"Total Renal Department Costs",{"$nulls":10},1]
[null,"MAINTENANCE"]
[2,"  Hemodialysis",{"$nulls":10},2]
[3,"  Intermittent Peritoneal",{"$nulls":10},3]
[null,"TRAINING"]
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[5,"  Intermittent Peritoneal",{"$nulls":10},5]
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[7,"  CCDP",{"$nulls":10},7]
[null,"HOME"]
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[10,"  CAPD",{"$nulls":10},10]
[11,"  CCDP",{"$nulls":10},11]
[null,"OTHER BILLABLE SERVICES"]
[12,"  Inpatient Dialysis Treatments __________",{"$nulls":10},12]
[13,"  Method II Home Patient",{"$nulls":10},13]
[14,"  EPO",{"$nulls":10},14]
[15,"ARENESP",{"$nulls":10},15]
[16,"  Other",{"$nulls":10},16]
[17,"Total Statistical Basis",{"$nulls":10},17]
[18,"Unit Cost Multiplier (line 1 ÷ line 17)",{"$nulls":10},18]
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["4090 (Cont.)",null,null,"FORM CMS-2552-10",{"$nulls":6},"DRAFT"]
["COMPUTATION OF AVERAGE COST PER TREATMENT",{"$nulls":4},"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET I-4"]
["FOR OUTPATIENT RENAL DIALYSIS",{"$nulls":4},"___________________",null,"FROM ____________"]
[{"$nulls":7},"TO ________________"]
["Check applicable box:",null,"[  ]  Renal Dialysis Department","[  ]  Home Program Dialysis"]
[]
[{"$nulls":5},"Average Cost",null,"Total"]
[null,null,null,"Number","Total Cost","of Program","Number","Program","Total","Average"]
[null,null,null,"of Total","(from Wkst.","Treatments","of Program","Expenses","Program","Payment Rate"]
[null,null,null,"Treatments","I-2, col. 11)","(col. 2 ÷ col. 1)","Treatments","(col. 4 x col. 3)","Payment","(col. 6 ÷ col. 4)"]
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[1," Maintenance - Hemodialysis",{"$nulls":8},1]
[2," Maintenance - Peritoneal Dialysis",{"$nulls":8},2]
[3," Training - Hemodialysis",{"$nulls":8},3]
[4," Training - Peritoneal Dialysis",{"$nulls":8},4]
[5," Training - Continuous Ambulatory Peritoneal Dialysis",{"$nulls":8},5]
[6," Training - Continuous Cycling Peritoneal Dialysis",{"$nulls":8},6]
[7," Home Program - Hemodialysis",{"$nulls":8},7]
[8," Home Program - Peritoneal Dialysis",{"$nulls":8},8]
[null,null,null,"Patient Weeks",null,null,"Patient Weeks"]
[9," Home Program - Continuous Ambulatory Peritoneal Dialysis",{"$nulls":8},9]
[10," Home Program - Continuous Cycling Peritoneal Dialysis",{"$nulls":8},10]
[11," Totals (sum of lines 1-8, columns 1 and 4)",{"$nulls":8},11]
[null,"                (sum of lines 1-10, columns 2, 5, and 7)"]
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["40-620",{"$nulls":9},"Rev. 1"]

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[{"$nulls":4},"TO ______________"]
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[null,"Description"]
[]
[" 1"," Total expenses related to care of program beneficiaries (see instructions)",{"$nulls":4}," 1"]
[" 2"," Total payment (from Worksheet I-4, column 6, line 11)",{"$nulls":4}," 2"]
[" 3"," Deductibles billed to Medicare (Part B) patients",{"$nulls":4}," 3"]
[" 4"," Coinsurance billed to Medicare (Part B) patients",{"$nulls":4}," 4"]
[" 5","Bad debts for deductibles and coinsurance, net of bad debt recoveries",{"$nulls":4}," 5"]
[6,{"$nulls":5},6]
[7," Reimbursable bad debts for dual eligible beneficiaries (see instructions)",{"$nulls":4},7]
[8," Net deductibles and coinsurance billed to Medicare (Part B) patients (sum of lines 3 and 4 less line 5)",{"$nulls":4},8]
[9," Program payment (line 2 less line 3, times 80 percent)",{"$nulls":4},9]
[10," Unrecovered from Medicare (Part B) patients (Lesser of line 1 or line 2 minus the sum of lines 7 and 8.",{"$nulls":4},10]
[null," If negative, enter zero and do not complete line 11.)"]
[11," Reimbursable bad debts (lesser of line 10 or line 5) (transfer to Worksheet E, Part B, line 33)",{"$nulls":4},11]
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[]
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