2552-96 SPECS by vivi07

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									11-98

FORM CMS-2552-96
EXHIBIT 2 - ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE OF CONTENTS

3695

Topic Table 1: Table 2: Table 3: Record Specifications Worksheet Indicators List of Data Elements with Worksheet, Line, and Column Designations Worksheets Requiring No Input Tables to Worksheet S-2 Lines Which Cannot Be Subscripted Permissible Payment Mechanisms Line Numbering for Special Care Units Numbering Convention for Multiple Components Cost Center Coding Edits, Levels I & II

Page(s) 36-703 - 36-712 36-713 - 36-722

36-723 -36-749 36-750 36-750 36-751 - 36-752 36-753 36-753

Table 3A: Table 3B: Table 3C: Table 3D: Table 3E: Table 4:

36-754 - 36-755 36-757 - 36-761 36-762 - 36-779

Table 5: Table 6:

Rev. 4

36-701

11-98

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 1 - RECORD SPECIFICATIONS

3695 (Cont.)

Table 1 specifies the standard record format to be used for electronic reporting. Each electronic cost report submission (file ) has four types of records. The first group (type 1 records) contains information for identifying, processing, and resolving problems. The text used throughout the cost report for variable line labels (e.g., Worksheet A) and variable column headers (Worksheet B-1) are included in the type 2 records. Refer to Table 5 for cost center coding. The data, detailed in Table 3, is identified as type 3 records. The encryption coding at the end of the file, records 1, 1.01, and 1.02, are type 4 records. The medium for transferring cost reports submitted electronically to fiscal intermediaries is 3½" diskettes. These disks must be in IBM format. The character set must be ASCII. Providers should seek approval from their fiscal intermediaries regarding the method of submission to insure that the method of transmission is acceptable. The following are requirements for all records: 1. All alpha characters must be in upper case. 2. For micro systems, the end of record indicator must be a carriage return and line feed, in that sequence. 3. No record may exceed 60 characters. Below is an example of a set of type 1 records with a narrative description of their meaning. 1 2 3 4 5 6 123456789012345678901234567890123456789012345678901234567890 1 1 010123199727419982731C99P00519990201998273 1 4 .00000 1 5 .10000 1 6 .05800 Record #1: This is a cost report file submitted by Provider 010123 for the period from October 1, 1997 (1997274) through September 30, 1998 (1998273). It is filed on the Form CMS-2552-96. It is prepared with vendor number A99's PC based system, version number 5. Position 38 changes with each new test case and/or reapproval and is alpha. Positions 39 and 40 will remain constant for approvals issued after the first test case. This file is prepared by the hospital on January 20, 1999 (1999020). The electronic cost report specification, dated September 30, 1998 (1998273), is used to prepare this file.

Rev. 4

36-703

3695 (Cont.)

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 1 - RECORD SPECIFICATIONS The hospital was subject to an inpatient capital reduction of 0.0%, an outpatient capital reduction of 10.0%, and an outpatient payment reduction of 5.8%. Rates displayed should be published rates for applicable period, regardless of provider type. FILE NAMING CONVENTION

11-98

Records #4-6:

Name each cost report file in the following manner: ECNNNNNN.YYL, where 1. EC (Electronic Cost Report) is constant; 2. NNNNNN is the 6 digit Medicare hospital provider number; 3. YY is the year in which the provider's cost reporting period ends; and 4. L is a character variable (A-Z) to enable separate identification of files from hospitals with two or more cost reporting periods ending in the same calendar year.

RECORD NAME: Type 1 Records - Record Number 1 Size 1. Record Type 2. NPI 3. Space 4. Record Number 5. Spaces 6. Hospital Provider Number 7. Fiscal Year Ending DateDate Beginning 8. Fiscal Year Ending Date 9. MCR Version 1 10 1 1 3 6 Usage X 9 X X X 9 Loc. 1 2-11 12 13 14-16 17-22 Field must have 6 numeric characters Constant "1" Remarks Constant "1" Numeric only

7

9

23-29

YYYYDDD - Julian date; first day covered by this cost report YYYYDDD - Julian date; last day covered by this cost report Constant "1" (for Form CMS 2552-96)

7 1

9 9

30-36 37

36-704

Rev. 4

04-05

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 1 - RECORD SPECIFICATIONS

3695 (Cont.)

RECORD NAME: Type 1 Records - Record Number 1 (Continued) Size 10. Vendor Code 3 Usage X Loc. 38-40 Remarks To be supplied upon approval. Refer to page 36-703. P = PC; M = Main Frame Version of extract software, e.g., 001=1st , 002=2nd, etc. or 101=1st, 102=2nd. The version number must be incremented by 1 with each recompile and release to client(s). YYYYDDD - Julian date; date on which the file was created (extracted from the cost report) YYYYDDD - Julian date; date of electronic cost report specifications used in producing each file. Valid for cost reporting periods ending on or after 2005120 (04/30/2005). Prior approval(s) 2000274, 96274, 97273, 1998273, and 1999365.

11. Vendor Equipment 12. Version Number

1 3

X X

41 42-44

13. Creation Date

7

9

45-51

14. ECR Spec. Date

7

9

52-58

RECORD NAME: Type 1 Records - Record Numbers 2 - 99 Size 1. Record Type 2. Spaces 3. Record Number 1 10 Usage 9 X Loc. 1 2-11 #2 - Reserved for future use. #3 - Vendor information; optional record for use by vendors. Left justified in positions 21-60. Remarks Constant "1"

#4 - Inpatient capital reduction

Rev. 14

36-705

3695 (Cont.)

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 1 - RECORD SPECIFICATIONS

04-05

RECORD NAME: Type 1 Records - Record Numbers 2 - 99 (Continued) Size Usage Loc. Remarks factor. This is represented as a decimal point followed by five digits. Use positions 31-36. Example: 0% is expressed as .00000. #5 - Outpatient capital reduction factor. This is represented as a decimal point followed by five digits. Use positions 31-36. Example: 10% is expressed as .10000. #6 - Effective outpatient reasonable cost reduction factor. This is represented as a decimal point followed by five digits. Use positions 31-36. Example: 5.8% is expressed as .05800. #7 to #99 - Reserved for future use. 4. Spaces 5. ID Information 7 40 X X 14-20 21-60 Spaces (Optional) Left justified to position 21, except for records 4, 5, and 6 which are right justified to position 36.

RECORD NAME: Type 2 Records for Labels 1. Record Type 2. Worksheet Indicator 3. Spaces 4. Line Number 5. Subline Number 1 7 2 3 2 9 X X 9 9 1 2-8 9-10 11-13 14-15 Numeric Numeric Constant "2" Alphanumeric. Refer to Table 2.

36-706

Rev. 14

08-97

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 1 - RECORD SPECIFICATIONS RECORD NAME: Type 2 Records for Labels (Continued) Size Usage X 9 9 Loc. 16-18 19-20 21-24 Remarks Alphanumeric Numeric Numeric. Refer to Table 5 for appropriate cost center codes.

3695 (Cont.)

6. Column Number 7. Subcolumn Number 8. Cost Center Code

3 2 4

9. Labels/Headings a. Line Labels b. Column Headings Statistical b. Col.Basis & Code Headings c. Line Statistics

36

X

25-60

10 36

X X

21-30 21-57

Alphanumeric, left justified Worksheet I-1 basis

The type 2 records contain text which appears on the pre-printed cost report. Of these, there are three groups: (1) Worksheet A cost center names (labels); (2) column headings for stepdown entries; and (3) other text appearing in various places throughout the cost report. The standard cost center labels are listed below. A Worksheet A cost center label must be furnished for every cost center with cost or charge data anywhere in the cost report. The line and subline numbers for each label must be the same as the line and subline numbers of the corresponding cost center on Worksheet A. The columns and subcolumn numbers are always set to zero. Column headings for the General Service cost centers on Worksheets B-1, B, Parts I, II and III, and Worksheet J-1, Part II (lines 1-3) are supplied once, consisting of one to three records. The statistical basis shown on Worksheet B-1 is also reported. The statistical basis consists of one or two records (lines 4 and 5). Statistical basis code is supplied only to Worksheet B-1 columns and is recorded as line 6 and only for capital cost centers, columns 1-4 and subscripts as applicable. The statistical code must agree with the statistical basis indicated on lines 4 and 5, i.e., code 1 = square footage, code 2 = dollar value, and code 3 = all others. Refer to Table 2 for the special worksheet identifier to be used with column headings and statistical basis and to Table 3 for line and column references. See below for statistical basis line labels for Worksheet I-1. These line labels are required records in the file. (See 9c above for record placement.)

Rev. 3

36-707

3695 (Cont.)

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 1 - RECORD SPECIFICATIONS

08-97

Use the following type 2 cost center descriptions for all Worksheet A standard cost center lines. Line 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 20 21 22 23 24 25 26 27 28 29 31 33 34 35 36 37 38 39 40 41 Description
OLD CAP REL COSTS-BLDG & FIXT OLD CAP REL COSTS-MVBLE EQUIP NEW CAP REL COSTS-BLDG & FIXT NEW CAP REL COSTS-MVBLE EQUIP EMPLOYEE BENEFITS ADMINISTRATIVE & GENERAL MAINTENANCE & REPAIRS OPERATION OF PLANT LAUNDRY & LINEN SERVICE HOUSEKEEPING DIETARY CAFETERIA MAINTENANCE OF PERSONNEL NURSING ADMINISTRATION CENTRAL SERVICES & SUPPLY PHARMACY MEDICAL RECORDS & LIBRARY SOCIAL SERVICE NONPHYSICIAN ANESTHETISTS NURSING SCHOOL I&R SERVICES-SALARY & FRINGES APPRVD I&R SERVICES-OTHER PRGM COSTS APPRVD PARAMED ED PRGM-(SPECIFY) ADULTS & PEDIATRICS INTENSIVE CARE UNIT CORONARY CARE UNIT BURN INTENSIVE CARE UNIT SURGICAL INTENSIVE CARE UNIT SUBPROVIDER NURSERY SKILLED NURSING FACILITY NURSING FACILITY OTHER LONG TERM CARE OPERATING ROOM RECOVERY ROOM DELIVERY ROOM & LABOR ROOM ANESTHESIOLOGY RADIOLOGY-DIAGNOSTIC

Line 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 60 61 62 64 65 66 67 70 71 82 83 84 85 88 89 90 92 93 96 97 98 99

Description
RADIOLOGY-THERAPEUTIC RADIOISOTOPE LABORATORY PBP CLINICAL LAB SERVICES-PRGM ONLY WHOLE BLOOD & PACKED RED BLOOD CELLS BLOOD STORING, PROCESSING & TRANS. INTRAVENOUS THERAPY RESPIRATORY THERAPY PHYSICAL THERAPY OCCUPATIONAL THERAPY SPEECH PATHOLOGY ELECTROCARDIOLOGY ELECTROENCEPHALOGRAPHY MEDICAL SUPPLIES CHARGED TO PATIENTS DRUGS CHARGED TO PATIENTS RENAL DIALYSIS ASC (NON-DISTINCT PART) CLINIC EMERGENCY OBSERVATION BEDS (NON-DISTINCT PART) HOME PROGRAM DIALYSIS AMBULANCE SERVICES DURABLE MEDICAL EQUIP-RENTED DURABLE MEDICAL EQUIP-SOLD I&R SERVICES-NOT APPRVD PRGM HOME HEALTH AGENCY LUNG ACQUISITION KIDNEY ACQUISITION LIVER ACQUISITION HEART ACQUISITION INTEREST EXPENSE UTILIZATION REVIEW-SNF OTHER CAPITAL RELATED COSTS AMBULATORY SURGICAL CENTER (D.P.) HOSPICE GIFT, FLOWER, COFFEE SHOP & CANTEEN RESEARCH PHYSICIANS' PRIVATE OFFICES NONPAID WORKERS

36-707.1

Rev. 3

08-02

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 1 - RECORD SPECIFICATIONS

3695 (Cont.)

Type 2 records for Worksheet B-1, columns 1-24, lines 1-5 and line 6 (for columns 1-4 only (capital cost center columns)) are listed below. The numbers running vertical to line 1 descriptions are the general service cost center line designations. LINE 3
FIXTURES EQUIPMENT FIXTURES EQUIPMENT GENERAL REPAIRS SERVICE

1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 20 21 22 23 24
OLD CAP OLD CAP NEW CAP NEW CAP EMPLOYEE ADMINISMAINOPERATION LAUNDRY HOUSEDIETARY CAFETERIA MAINNURSING CENTRAL PHARMACY MEDICAL SOCIAL NONPHYSIC. NURSING I&R I&R PARAMED

2
BLDGS & MOVABLE BLDGS & MOVABLE BENEFITS TRATIVE & TENANCE & OF PLANT & LINEN KEEPING

4
SQUARE DOLLAR SQUARE DOLLAR GROSS ACCUM. SQUARE SQUARE POUNDS OF HOURS OF MEALS MEALS NUMBER DIRECT COSTED COSTED TIME TIME ASSIGNED ASSIGNED ASSIGNED ASSIGNED ASSIGNED

5
FEET VALUE FEET VALUE SALARIES COST FEET FEET LAUNDRY SERVICE SERVED SERVED HOUSED NRSING HRS REQUIS. REQUIS. SPENT SPENT TIME TIME TIME TIME TIME

6
1 2 1 2

TENANCE & ADMINISSERVICES & RECORDS & SERVICE ANESTHET. SCHOOL SALARY & PROGRAM EDUCATION

PERSONNEL TRATION SUPPLY LIBRARY

FRINGES COSTS

Type 2 records for Worksheet H-4, columns 1-5, lines 1-5 are listed below. The numbers running vertical to line 1 descriptions are the general service cost center line designations. LINE 3
FIXTURES EQUIPMENT MAINT. ION GENERAL

1
1 2 3 4 5 CAPITAL CAPITAL PLANT TRANSADMINIS-

2
BLDGS & MOVABLE OPER. & PORTATTRATIVE &

4
SQUARE DOLLAR SQUARE MILEAGE ACCUM.

5
FEET VALUE FEET COST

Type 2 records for Worksheet I-1, column 2 statistical basis labels for lines 1-8, 10-16, 18-24, 26-28, and 30-32 with subscripts as appropriate for line 32 are listed below.
Line Description 1 HOURS OF SERVICE 2 HOURS OF SERVICE Line Description 16 ACCUMULATED COST 18 SQUARE FEET

Rev. 9

36-707.2

3695 (Cont.)

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 1 - RECORD SPECIFICATIONS
19 20 21 22 23 24 26 27 28 30 31 32 PERCENTAGE OF TIME SQUARE FEET PERCENTAGE OF TIME SALARY ACCUMULATED COST SQUARE FEET REQUISITIONS REQUISITIONS ACCUMULATED COST CHARGES CHARGES CHARGES

08-02

3 4 5 6 7 8 10 11 12 13 14 15

HOURS OF SERVICE HOURS OF SERVICE HOURS OF SERVICE HOURS OF SERVICE ACCUMULATED COST ACCUMULATED COST SALARY SQUARE FEET PERCENTAGE OF TIME PERCENTAGE OF TIME REQUISITIONS REQUISITIONS

Type 2 records for Worksheet K-4, columns 1-6, lines 1-5 are listed below. The numbers running vertical to line 1 descriptions are the general service cost center line designations. LINE 3
FIXTURES EQUIPMENT MAINT. ION COORDI. GENERAL

1
1 2 3 4 5 6 CAPITAL CAPITAL PLANT TRANSVOLUNT. ADMINIS-

2
BLDGS & MOVABLE OPER. & PORTATSERVICES TRATIVE &

4
SQUARE DOLLAR SQUARE MILEAGE HOURS OF ACCUM.

5
FEET VALUE FEET SERVICE COST

Examples of type 2 records are below. Either zeros or spaces may be used in the line, subline, column, and subcolumn number fields (positions 11-20). Spaces are preferred. (See first two lines of the example.)* Refer to Table 6 for additional cost center code requirements. Examples: Worksheet A line labels with embedded cost center codes: * * 2A000000 1 0100OLD CAP REL COSTS-BLDS & FIXT 2A000000000000101000000101OLD CAP REL COSTS-WEST WING 2A000000 2 0200OLD CAP REL COSTS-MVBLE EQUIP 2A000000 6 0600ADMINISTRATIVE AND GENERAL 2A000000 22 2200I&R SERVICES-SALARY & FRINGES APPRVD 2A000000 22 1 2201I&R SALARY-SURGERY

Examples of column headings for Worksheets B-1, B, Parts I, II, and III, and Worksheet J-1, Part II (lines 1-3), statistical bases used in cost allocation on Worksheet B-1, Worksheet J-1, Part II (lines 4 and 5), and statistical codes used for Worksheet B-1

36-708

Rev. 9

11-98

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 1 - RECORD SPECIFICATIONS (line 6) are displayed below. Also below are examples of Worksheets H-4, Part II (4th character indicates the 1st HHA) and Worksheet I-1 for both renal and home program. 2B10000* 2B10000* 2B10000* 2B10000* 2B10000* 2B10000* 1 2 3 4 5 6 1 1 1 1 1 1 OLD CAP BLDGS & FIXTURES SQUARE FEET 1 2B10000* 2H41002* 2H41002* 2I1D000* 2I1D000* 2I1H000* 1 1 1 1 12 7 1 1 1 2 2 2

3695 (Cont.)

OLD CAP CAPITAL BLDG & HRS OF SERVICE PERCENTAGE OF TIME ACCUMULATED COST

Worksheet H-4, Part II records share the same size constraints as the Worksheet B-1 records. Worksheet I-1 may not exceed 36 characters.

RECORD NAME: Type 3 Records for Nonlabel Data Size 1. Record Type 2. Worksheet Indicator 3. Spaces 4. Line Number 5. Subline Number 6. Column Number 7. Subcolumn Number 8. Field Data a. Alpha Data 1 7 2 3 2 3 2 Usage 9 X X 9 9 X 9 Loc. 1 2-8 9-10 11-13 14-15 16-18 19-20 Numeric Numeric Alphanumeric Numeric Remarks Constant "3" Numeric. Refer to Table 2.

36

X

21-56

Left justified. (Y or N for yes/no answers; dates must use mm/dd/yyyy format - slashes, no hyphens). Refer to Table 6 for additional requirements for alpha data. Spaces (optional).

4

X

57-60

Rev. 4

36-709

3695 (Cont.)

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 1 - RECORD SPECIFICATIONS RECORD NAME: Type 3 Records for Nonlabel Data (Continued) Size Usage 9 Loc. 21-36 Remarks Right justified. May contain embedded decimal point. Leading zeros are suppressed; trailing zeros to the right of the decimal point are not. (See example below.) Positive values are presumed; no "+" signs are allowed. Use leading minus to specify negative values. Express percentages as decimal equivalents, i.e., 8.75% is expressed as .087500. All records with zero values are dropped. Refer to Table 6 for additional requirements regarding numeric data.

11-98

b. Numeric Data

16

A sample of type 3 records and a number line for reference are below. 3 6 32961 1336393 185599 17750 1014775 1767922 14596 768441 2746235 4982 22476 18021

123456789 3A000000 3A000000 3A000000 3A000000 3A000000 3A000000 3A000000 3A000000 3A000000 3A000000 3C000001 3C000001 4 21 21 62 1 1 2 21 21 62 62 62

5 8 1 1 1 1 2 2 2 2 2 2 1 1

1 1 1

1 1

The line numbers are numeric. In several places throughout the cost report (see list below), the line numbers themselves are data. The placement of the line and subline numbers as data must be uniform.

36-710

Rev. 4

11-96

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 1 - RECORD SPECIFICATIONS Worksheet A-6, columns 3, 7, and 10 Worksheet A-8, columns 4 and 5 Worksheet A-8-1, Part A, column 1 Worksheet A-8-2, column 1 Worksheet B-2, column 3

3695 (Cont.)

Examples of records (*) with a Worksheet A line number as data and a number line for reference are below. 1 3 13 13 13 13 13 13 14 14 14 14 15 16 1 8 0 1 3 4 6 7 0 1 3 4 0 0 2 1 TO SPREAD INTEREST EXPENSE G 1 221409 87 225321 BETWEEN CAPITAL-RELATED COST G 401 3912 BUILDING & FIXTURES AND ADMINISTRATIVE AND GENERAL

123456789 3A600010 3A600010 3A600010 3A600010 3A600010 3A600010 3A600010 3A600010 3A600010 3A600010 3A600010 3A600010

* *

*

RECORD NAME: TYPE "3" RECORDS 1 3 37 37 37 37 37 37 37 1 1 8 0 1 2 4 0 2 4 1 2 1 PBP ADJUSTMENT - EMERGENCY ROOM A -250935 61 PBP ADJUSTMENT - HEART ACQUISITION -114525 85 41

123456789 3A800000 3A800000 3A800000 3A800000 3A800000 3A800000 3A800000 3A800000

*

*

Rev. 2

36-711

3695 (Cont.)

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 1 - RECORD SPECIFICATIONS RECORD NAME: TYPE 3 RECORDS (Continued)

11-96

* *

*

3A810000 3A810000 3A810000 3A820010 3A820010 3A820010 3A820010 3A820010 3A820010 3A820010 3A820010 3A820010 3A820010 3A820010 3A820010 3A820010 3A820010 3A820010 3A820010 3A820010 3A820010 3A820010

3 4 5 3 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5

3 4 5 3 4 4 4 4 4 4 4 4 4

1 1 1 1 1 2 3 4 5 6 7 12 14 1 2 3 4 5 6 7 12 14

CAT SCANS 13352 11122 4101 4101 DR. B 126292 94719 31573 124900 741 6860 12000 4101 DR. C 189439 142079 47360 124900 333 5750 18900

RECORD NAME: TYPE 4 RECORDS - File Encryption This type 4 record consist of 3 records: 1, 1.01, and 1.02. These records are created at the point in which the ECR file has been completed and saved to disk and insures the integrity of the file.

36-712

Rev. 2

06-03

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 2 - WORKSHEET INDICATORS

3695 (Cont.)

This table contains the worksheet indicators that are used for electronic cost reporting. A worksheet indicator is provided only for those worksheets from which data are to be provided. The worksheet indicator consists of seven characters in positions 2-8 of the record identifier. The first two characters of the worksheet indicator (positions 2 and 3 of the record identifier) always show the worksheet. The third character of the worksheet indicator (position 4 of the record identifier) is used in several ways. First, it may be used to identify worksheets for multiple hospital-based components, such as subprovider, or to identify various types of hospital services such as kidney, heart, lung, or liver acquisitions. Alternatively, it may be used as part of the worksheet, e.g., A81. The fourth character of the worksheet indicator (position 5 of the record identifier) represents the type of provider, by using the keys below. Except for Worksheet A-6 (to handle multiple worksheets) and Worksheet I-4 (to handle multiple payment rates), the fifth and sixth characters of the worksheet indicator (positions 6 and 7 of the record identifier) identify worksheets required by a Federal program (18 = Title XVIII, 05 = Title V, or 19 = Title XIX) or worksheet required for the facility (00 = Universal). The seventh character of the worksheet indicator (position 8 of the record identifier) represents the worksheet part.

Provider Type - Fourth Digit of the Worksheet Identifier Universal.................................0 (Zero) Hospital.......................................... A Subprovider.................................... B SNF................................................. C Swing Bed SNF........................................... D NF................................................... E Swing Bed NF....................................... F CMHC........................................... G CORF............................................ H ICF/MR........................................... I OPT............................................... J OOT................................................. K OSP................................................. L FQHC................................ Q RHC.................................................. R

Rev. 10

36-713

3695 (Cont.) FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 2 - WORKSHEET INDICATORS Worksheets Which Apply to the Hospital Complex Worksheet Indicator S000002 S200000 S300001 S300002 S300003 S410000 (a) S500000 S61?000 (b) S700000 S81?000 (n) S910000 S100000 A000000 A600010 (c) A700001 A700002 A700003 A700004 A800000 A81000A A81000B A820010 (c) A83P000 (d) (l) A83R000 (d) (l) A84?000 (d) (m) B10000* B000001 B000002 B000003 B100000 B200010 (c) C000001 C000002 C000003 C000004 C000005

06-03

Worksheet S, Part II S-2 S-3, Part I S-3, Part II S-3, Part III S-4 S-5 S-6 S-7 S-8 S-9 S-10 A A-6 A-7, Part I A-7, Part II A-7, Part III A-7, Part IV A-8 A-8-1, Part A A-8-1, Part B A-8-2 A-8-3 A-8-4 B-1 (For use in column headings) B, Part I B, Part II B, Part III B-1 B-2 C, Part I C, Part II C, Part III C, Part IV C, Part V

36-714

Rev. 10

09-01

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 2 - WORKSHEET INDICATORS Worksheets Which Vary by Program (Continued) Worksheet D, Part III: Hospital D, Part IV: Hospital Subprovider SNF NF ICF/MR D, Part V: Hospital Subprovider SNF Swing Bed SNF NF Swing Bed NF ICF/MR D, Part VI: Hospital Subprovider SNF Swing Bed SNF NF Swing Bed NF ICF/MR Title V Title XVIII Title XIX

3695 (Cont.)

D00A053

D00A183

D00A193

D00A054 D01B054 (e) D00C054 D00E054 D00I054

D00A184 D01B184 (e) D00C184 * *

D00A194 D01B194 (e) D00C194 D00E194 D00I194

D00A055 D01B055 (e) D00C055 D00D055 D00E055 D00F055 D00I055

D00A185 D01B185 (e) D00C185 D00D185 * * *

D00A195 D01B195 (e) D00C195 D00D195 D00E195 D00F195 D00I195

D00A056 D01B056 (e) D00C056 D00D056 D00E056 D00F056 D00I056

D00A186 D01B186 (e) D00C186 D00D186 * * *

D00A196 D01B196 (e) D00C196 D00D196 D00E196 D00F196 D00I196

D-1, Parts I through IV: (d) Hospital D10A051 Subprovider D11B051 (e) SNF D10C051 NF D10E051 ICF/MR D10I051

D10A181 D11B181 (e) D10C181 * *

D10A191 D11B191 (e) D10C191 D10E191 D10I191

Worksheets Which Apply to the Hospital Complex Worksheet Indicator D200000

Worksheet D-2, Parts I & II (d)

Rev. 8

36-715

3695 (Cont.) FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 2 - WORKSHEET INDICATORS Worksheet Which Varies by Program Worksheet D-4: Hospital Subprovider SNF Swing Bed SNF NF Swing Bed NF ICF/MR Title V Title XVIII Title XIX

09-01

D40A050 D41B050 (e) D40C050 D40D050 D40E050 D40F050 D40I050

D40A180 D41B180 (e) D40C180 D40D180 * * *

D40A190 D41B190 (e) D40C190 D40D190 D40E190 D40F190 D40I190

Worksheets Which Apply to the Hospital Complex Worksheet Indicator D6K0000 (h) D6H0000 (h) D6L0000 (h) D6P0000 (h) D6N0000 (h) D6I0000 (h) D9H0001 (i) D9M0001 (i)

Worksheet D-6, Part I, II and IV: (d)

D-9, Part I:

Worksheet Which Varies by Component D-9, Part II: Hospital Subprovider

D90A002 D91B002 (e)

Worksheets Which Vary by Component and/or Program Worksheet E, Part A: Hospital Subprovider Title V Title XVIII Title XIX

* *

E00A18A E01B18A (e)

* *

36-716

Rev. 8

05-99

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 2 - WORKSHEET INDICATORS Worksheets Which Vary by Component and/or Program (Continued) Worksheet E, Part B: Hospital Subprovider SNF E, Part C: Hospital Subprovider E, Part D: Hospital Subprovider E, Part E: Hospital Subprovider E-1: Hospital Subprovider SNF Swing Bed SNF E-2: Swing Bed SNF Swing Bed NF E-3, Part I: Hospital Subprovider E-3, Part II: Hospital Subprovider SNF Title V Title XVIII Title XIX

3695 (Cont.)

* * *

E00A18B E01B18B (e) E00C18B

* * *

E00A05C E01B05C (e)

E00A18C E01B18C (e)

E00A19C E01B19C (e)

E00A05D E01B05D (e)

E00A18D E01B18D (e)

E00A19D E01B19D (e)

E00A05E E01B05E (e)

E00A18E E01B18E (e)

E00A19E E01B19E (e)

* * * *

E10A180 E11B180 (e) E10C180 E10D180

* * * *

E20D050 E20F050

E20D180 *

E20D190 E20F190

* *

E30A181 E31B181 (e)

* *

* * *

E30A182 E31B182 (e) E30C182

* * *

Rev. 5

36-717

3695 (Cont.) FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 2 - WORKSHEET INDICATORS Worksheets Which Vary by Component and/or Program (Continued) Worksheet E-3, Part III: Hospital Subprovider SNF NF ICF/MR Title V Title XVIII Title XIX

05-99

E30A053 E31B053 (e) E30C053 E30E053 E30I053

* * E30C183 * *

E30A193 E31B193 (e) E30C193 E30E193 E30I193

NOTE:

Refer to Table 3 for instructions on the reporting of data for hospital-based SNF reimbursed prospectively under title XVIII.

E-3, Part IV: Universal E-3, Part V:

E300054 *

E300184 E300185

E300194 *

Worksheets Which Apply to the Hospital Complex Worksheet Indicator G000000 G100000 G200000 G300000 H010000 H110000 H210000 H310000 H410001 H410002 H510001 H510002

Worksheet G G-1 G-2, Parts I & II (d) G-3 H H-1 H-2 H-3 H-4, Part I H-4, Part II H-5, Part I H-5, Part II

(a) (a) (a) (a) (a) (a) (a) (a)

36-718

Rev. 5

09-01

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 2 - WORKSHEET INDICATORS Worksheet Which Varies by Program Worksheet H-6, Part I H-6, Part II H-6, Part III H-7, Part I H-7, Part II Title V H610051 (a) H610052 (a) H610053 (a) H710051 (a) H710052 (a) Title XVIII H610181 (a) H610182 (a) H610183 (a) H710181 (a) H710182 (a) Title XIX H610191 (a) H610192 (a) H610193 H710191 (a) H710192 (a)

3695 (Cont.)

Worksheets Which Apply to the Hospital Complex (Continued) Worksheet Indicator H810000 I1D0000 I1H0000 I2D0000 I2H0000 I3D0000 I3H0000 I4D0010 I4H0010 I500000 J11?001 J11?002 J21?001 J21?002 J41?000 K010000 K110000 K210000 K310000 K410001 K410002 K510001 K510002 K510003 K610000 L100001 M11?000 M21?000 (a) (j) (j) (j) (j) (j) (j) (j, k) (j, k) (b) (b) (b) (b) (b) (a) (a) (a) (a) (a) (a) (a) (a) (a) (a) (n) (n)

Worksheet H-8 I-1 I-2 I-3 I-4 I-5 J-1, Part I J-1, Part II J-2, Part I J-2, Part II J-4 K K-1 K-2 K-3 K-4, Part I K-4, Part II K-5, Part I K-5, Part II K-5, Part III K-6 L-1, Part I M-1 M-2

Rev. 8

36-719

3695 (Cont.) FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 2 - WORKSHEET INDICATORS Worksheet Which Varies by Component and/or Program Worksheet J-3 L, Part I: Hospital Subprovider L, Part II: Hospital Subprovider L, Part IV: Hospital Subprovider L-1, Part II: Universal (0) M-3 M-4 M-5 Title V J31?050 (b) Title XVIII J31?180 (b) Title XIX J31?190 (b)

09-01

L00A051 L01B051 (e)

L00A181 L01B181 (e)

L00A191 L01B191 (e)

L00A052 L01B052 (e)

L00A182 L01B182 (e)

L00A192 L01B192 (e)

L00A054 L01B054 (e)

L00A184 L01B184 (e)

L00A194 L01B194 (e)

L100052 M31?050 (n) M41?050 (n) *

L100182 M31?180 (n) M41?180 (n) M51?180 (n)

L100192 M31?190 (n) M41?190 (n) *

36-720

Rev. 8

09-01

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 2 - WORKSHEET INDICATORS

3695 (Cont.)

FOOTNOTES: (a) Multiple Hospital-Based HHAs and Hospices The third digit of the worksheet indicator (position 4 of the record) is numeric from 1 to 0 to accommodate multiple hospital-based HHAs and 1 through 5 for hospital-based Hospices. If there is only one of the components, the default is 1. This affects both H and K series worksheets including Worksheet S-4 and Worksheet S-9. Multiple Outpatient Rehabilitation Providers The third digit of the worksheet indicator (position 4 of the record) is numeric from 1 to 0 to accommodate multiple providers. If there is only one outpatient provider type, the default is 1. The fourth character of the worksheet indicator (position 5 of the record) indicates the outpatient rehabilitation provider as listed below. These affect Worksheets S-6; J-1, Parts I and II; J-2, Parts I and II; J-3; and J-4. G = CMHC (c) H = CORF J = OPT K = OOT L = OSP

(b)

Multiple Worksheets for Reclassification and Adjustments Before and After Stepdown The fifth and sixth digits of the worksheet indicator (positions 6 and 7 of the record) are numeric from 01-99 to accommodate reports with more lines on Worksheets A-6, A-8-2, and/or B-2. For reports which do not need additional worksheets, the default is 01. For reports which do need additional worksheets, the first page of each worksheet is numbered 01. The number for each additional page of each worksheet is incremented by 1. Worksheets With Multiple Parts Using Identical Worksheet Indicator Although this worksheet has several parts, the lines are numbered sequentially. This worksheet identifier is used with all lines from this worksheet regardless of the worksheet part. This differs from the Table 3 presentation which still identifies each worksheet and part as they appear on the printed cost report. This affects Worksheets A-8-3, A-8-4, D-1, D-2, D-6, G-2, H-7, and J-2. Multiple Subproviders The third digit of the worksheet indicator (position 4 of the record) is a numeric from 1 to 0 to accommodate facilities with two or more subproviders. If there is only subprovider, the default is 1. This affects Worksheets D, Parts II-VI; D-1; D-4; D-9, Part II; E, Parts A and B; E-1; E-3, Parts I, II, and III; and L, Parts II and IV. To be used at a later date.

(d)

(e)

(f)

Rev. 8

36-721

3695 (Cont.) FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 2 - WORKSHEET INDICATORS FOOTNOTES (Continued): (h) Worksheet D-6 The third digit of the worksheet indicator (position 4 of the record) must be K for kidney acquisitions, an H for heart acquisitions, an L for liver acquisitions, an N for pancreas acquisitions, a P for lung acquisitions, or I for intestine. Worksheet D-9, Part I The third digit of the worksheet indicator (position 4 of the record) must be either an H for hospital staff data or an M for medical staff data. Renal Dialysis The third digit of the worksheet indicator (position 4 of the record) must contain either a D for renal dialysis department or an H for home program dialysis. This applies to Worksheets I-1, I-2, I-3, and I-4. Multiple ESRD Payment Rates The sixth digit of the worksheet indicator (position 7 of the record) is a numeric from 1 to 9 to accommodate two or more payment rates in effect during one cost reporting period. If there is only a single payment rate, the default is 1. This applies only to Worksheet I-4. Multiple Worksheet A-8-3 This worksheet is used for either physical or respiratory therapy services furnished by outsider suppliers. The forth digit of the worksheet indicator (position 5 of the record) is an alpha character of either P for physical therapy or R for respiratory therapy services. Multiple Worksheet A-8-4 This worksheet is used for occupational, physical, or respiratory therapy and speech pathology services furnished by outsider suppliers. The forth digit of the worksheet indicator (position 5 of the record) is an alpha character of O for occupational therapy, P for physical therapy, R for respiratory therapy, and S for speech pathology services. Multiple Health Clinic Providers The third digit of the worksheet indicator (position 4 of the record) is numeric from 1 to 0 to accommodate multiple providers. To accommodate providers 11 - 25, use alpha characters A through O. If there is only one health clinic provider type, the default is 1. The fourth character of the worksheet indicator (position 5 of the record) indicates the health clinic provider. Q indicates Federally Qualified Health Center, and R indicates Rural Health Clinic.

09-01

(i)

(j)

(k)

(l)

(m)

(n)

36-722

Rev. 8

04-05

FORM CMS-2552-96

3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

INTRODUCTION This table identifies those data elements necessary to calculate a hospital cost report. It also identifies some figures from a completed cost report. These calculated fields (e.g., Worksheet B, column 27) are needed to verify the mathematical accuracy of the raw data elements and to isolate differences between the file submitted by the hospital complex and the report produced by the fiscal intermediary. Where an adjustment is made, that record must be present in the electronic data file. For explanations of the adjustment required, refer to the cost report instructions. Table 3 "Usage" column is used to specify the format of each data item as follows: 9 Numeric, greater than or equal to zero. -9 Numeric, may be either greater than or less than zero. 9(x).9(y) Numeric, greater than zero, with x or fewer significant digits to the left of the decimal point, a decimal point, and exactly y digits to the right of the decimal point. X Character. Consistency in line numbering (and column numbering for general service cost centers) for each cost center is essential. The sequence of some cost centers does change among worksheets. The special care units are the most likely to cause errors. Table 3E provides an example with a chart of special care unit line numbers for reference. Refer to Table 4 for line and column numbering conventions for use with complexes which have more components than appear on the preprinted Form CMS-2552-96. Table 3 refers to the data elements needed from a standard cost report. When a standard line is subscripted, the subscripted lines must be numbered sequentially with the first subline number displayed as "01" or "1" in field locations 14-15. It is unacceptable to format in series of 10, 20, or skip subline numbers (i.e., 01, 03, except for skipping subline numbers for prior year cost center(s) deleted in the current period or initially created cost center(s) no longer in existence after cost finding). Exceptions are specified in this manual. For "Other (specify)" lines, i.e. Worksheets S-4, S-6, S-8, settlement series and any other non cost center lines, all subscripted lines should be in sequence and consecutively numbered beginning with subscripted subline "01". Automated systems should reorder these numbers where the provider skips or deletes a line number in the series. Drop all records with zero values from the file. Any record absent from a file is treated as if it were zero. All numeric values are presumed positive. Leading minus signs may only appear in data with values less than zero which are specified in Table 3 with a usage of "-9". Italic script within this table denotes adjustments which are not displayed in the print image or hard copy of the cost report, but are contained in the ECR file. Examples of these type entries are Worksheets D-2, Part I; D, Part III; and D, Part IV.

Rev. 14

36-723

3695 (Cont.)

FORM CMS-2552-96

04-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION WORKSHEET S Part II: Balances due provider or program: Title V Title XVIII, Part A Title XVIII, Part B Title XIX Providers as assigned In total

LINE(S)

COLUMN(S)

USAGE

1-9 1-3, 5, 7 1-3, 5, 7-9 1-9 10-99 100

1 2 3 4 1-4 1-4

11 11 11 11 11 11

-9 -9 -9 -9 -9 -9

WORKSHEET S-2 For the hospital only: Street P.O. Box City State Zip Code County For the hospital and hospital-based components: Component name Provider number (xxxxxx) Certification date (mm/dd/yyyy) Title V payment system (See Table 3D.) Title XVIII payment system (See Table 3D.) Title XIX payment system (See Table 3D.) Cost reporting period beginning date (mm/dd/yyyy) Cost reporting period ending date (mm/dd/yyyy) Type of control (See Table 3B.) Type of hospital/subprovider (See Table 3B.) Indicate if your hospital is either (1) urban or (2) rural at the end of the cost reporting period If your hospital is geographically classified or located in a rural area, is your bed size less than or equal to 100 beds, enter "Y" for yes and "N" for no Does your facility qualify and is currently receiving payment for disproportionate share in accordance with 42CFR412.106? Has your facility received a geographic reclassification? If yes, enter effective date (mm/dd/yyyy). Enter in column 1 your geographic location either (1) urban (2) rural. If you answered urban in column 1 indicate if you received either: a wage or standard geographic reclassification to a rural location, enter in column 2 "Y" for yes and "N" for no. If column 2 is yes, enter in column 3 the effective date (dd/mm/yyyy) Does your facility contain 100 or fewer beds in accordance with 42 CFR 412.105? Enter "Y" for yes and "N" for no. For standard geographic reclassification (not wage), what is the status at the beginning of the cost reporting period. Enter (1) for urban (2) for rural.

1 1 1.01 1.01 1.01 1.01

1 2 1 2 3 4

36 9 36 2 10 36

X X X X X X

2-9, 11-12, 14-16 2-7, 9, 11-12, 14-16 2-7, 9, 11-12, 14-16 2-7, 9, 11, 14-15.49 2-4, 6, 9, 11, 14-15.49 2-7, 9, 11, 14-15.49 17 17 18 19 & 20 21

1 2 3 4 5 6 1 2 1 1 1

36 6 10 1 1 1 10 10 2 1 1

X X X X X X X X 9 9 X

21 21.01 21.02 21.02 21.03

2 1 1 2 1

1 1 1 10 1

X X X X 9

21.03 21.03 21.03

2 3 4

1 10 1

X X X

21.04

1

1

9

36-724

Rev. 14

05-04

FORM CMS-2552-96

3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S) WORKSHEET S-2 (Continued)

COLUMN(S)

USAGE

For standard geographic reclassification (not wage), what is the status at the end of the cost reporting period. Enter (1) for urban (2) for rural. 21.05 Are you classified as a referral center? (Y=yes, N=no) 22 Does this facility operate a transplant center? 23 If this is a Medicare certified kidney transplant center, enter the certification date (mm/dd/yyyy). 23.01 If this is a Medicare certified heart transplant center, enter the certification date (mm/dd/yyyy). 23.02 If this is a Medicare certified liver transplant center, enter the certification date (mm/dd/yyyy). 23.03 If this is a Medicare certified lung transplant center, enter the certification date (mm/dd/yyyy). 23.04 If this is a Medicare certified pancreas transplant center, enter the certification date (mm/dd/yyyy). 23.05 If this is a Medicare certified intestinal transplant center, enter the certification date (mm/dd/yyyy). 23.06 If this is an organ procurement organization (OPO), enter the OPO number. 24 Is this a teaching hospital or affiliated with a teaching hospital? 25 Is this teaching program approved in accordance with CMS Pub. 15-I, chapter 4? 25.01 If line 25.01 is yes, was Medicare participation and approved teaching program status in effect during the first month of the cost reporting period? If "Y", complete Wkst. E-3, Part IV. If "N", complete Wkst. D-2, Part II. 25.02 As a teaching hospital, did you elect cost reimbursement for physicians' services as defined in CMS Pub. 15-I, section 2148? If "Y", complete Worksheet D-9. 25.03 Are you claiming costs on line 70 of Worksheet A? If "Y", complete Worksheet D-2. 25.04 If this is a sole community hospital (SCH), enter number of 26 periods. Beginning date SCH status applies in this period (mm/dd/yyyy) 26.01 Ending date SCH status applies in this period (mm/dd/yyyy) 26.01 Does this hospital have an agreement under either of sections 1883 or 1913 of the Act for swing beds? 27 If yes, enter the agreement date (mm/dd/yyyy). 27 If facility contains hospital-based SNF, are all patients under managed care or there were no Medicare utilitization: 28 If hospital based SNF enter appropriate transition period 1, 2, 3, or 100. 28.01 Hospital based SNF wage index adjustment factors 28.01 Hospital based SNF facility specific rate. 28.02 Hospital based SNF classification, Urban(1) or Rural(2) 28.02 Hospital based SNF MSA code or State code 28.02 A notice published in the Federal Register Vol. 68 No. 149 which provided for an increase in the RUG payments for services beginning 10/01/2003. This increase is expected to be used for direct patient care and related expenses. Enter the percentage of total expenses for each of the following categories to total SNF revenue from inpatient care service Staffing 28.03 Recruitment 28.04 Retention of employees 28.05 Training 28.06

1 1 1 2 2 2 2 2 2 2 1 1

1 1 1 10 10 10 10 10 10 6 1 1

9 X X X X X X X

X X X

1

1

X

1 1 1 1 2 1 2 1 1 2&3 1 2 3

1 1 1 10 10 1 10 1 3 6 11 1 4

X X 9 X X X X X 9(3) 9.9(4) 9(8).99 X X

1 1 1 1

4 4 4 4

9(3).99 9(3).99 9(3).99 9(3).99

Rev. 12

36-725

3695 (Cont.)

FORM CMS-2552-96

05-04

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S) WORKSHEET S-2 (Continued)

COLUMN(S)

USAGE

Is the increased spending associated with direct patient care and related spending reflects each of the categories? (Y/N) Staffing 28.03 Recruitment 28.04 Retention of employees 28.05 Training 28.06 Other (Specify) 28-07-28.20 Enter the percentage of total expenses for other expenses to total SNF revenue from inpatient care service 28-07-28.20 Is the increased spending associated with direct patient care and related spending reflects Other?(Y/N) 28-07-28.20 Is this a rural hospital with a certified SNF which has fewer than 50 beds in the aggregate for both components, using the swing bed optional method of reimbursement? (Y/N) 29 Does this hospital qualify as a rural primary care hospital? (Y/N) 30 If so, is this the initial 12 month period for the RPCH\CAH facility? 30.01 If this facility qualifies as a RPCH\CAH, has it elected the all-inclusive method of payment for outpatient services? 30.02 If this facility qualifies as an CAH, is it eligible for cost reimbursement for ambulance services? 30.03 If yes enter in column 2 the date of the eligibility determination (mm/dd/yyyy). Date must be on or after 12/21/00. 30.03 If this facility qualifies as CAH is it eligible for cost reimbursement for I&R training program? 30.04 Is this a rural hospital qualifying for an exception to the CRNA fee schedule? 31 Is this an all-inclusive provider? 32 If yes, enter the method (A, B, or E methods only). 32 Is this a new hospital under 42 CFR 412.300 (PPS capital)? 33 If yes, for cost reporting periods beginning on or after October 1, 2002, do you elect to be reimbursed at 100% Federal capital payment? 33 Is this a new hospital under 42 CFR 413.40(f)(1)(i) (TEFRA)? 34 Have you established a new subprovider (excluded unit) under 42 CFR 413.40(f)(1)(i)? 35 Prospective payment system (PPS) capital response for titles V, XVIII, and XIX: Do you elect fully prospective payment methodology for capital costs? 36 Does your facility qualify and receive payment for disproportionate share in accordance with 42 CFR 412.320? (see instructions) 36.01 Do you elect hold harmless payment methodology for capital costs? 37 If hold harmless, are you filing on the basis of 100% of Federal rate? 37.01 Title XIX inpatient hospital services Do you have title XIX inpatient hospital services? Is this hospital reimbursed for title XIX through the cost report either in full or in part? Does the title XIX program reduce capital following the Medicare methodology? If column 6, lines 6 and 7 both contain a response of either "O" or "P" and all of the nursing facility beds are title XIX certified, are there title XVIII shared beds being used by title XIX patients? (See instructions) Do you operate an ICF/MR facility for purposes of title XIX?

2 2 2 2 0 1 2

1 1 1 1 36 4 1

X X X X X 9(3).99 X

1 1 1 1 1 2 1 1 1 2 1

1 1 1 1 1 10 1 1 1 1 1

X X X X X X X X X X X

2 1 1 1-3 1-3 1-3 1-3

1 1 1 1 1 1 1

X X X X X X X

38 38.01 38.02

1 1 1

1 1 1

X X X

38.03 38.04

1 1

1 1

X X

36-726

Rev. 12

04-05

FORM CMS-2552-96

3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S) WORKSHEET S-2 (Continued)

COLUMN(S)

USAGE

Are there any related organization or home office costs as defined in CMS Pub. 15-I, chapter 10? 40 If yes, enter home office chain number, if applicable. 40 Are provider-based physicians' costs included in Worksheet A? 41 Are physical therapy services provided by outside suppliers? 42 Are occupational therapy services provided by outside suppliers? 42.01 Are speech pathology services provided by outside suppliers? 42.02 Are respiratory therapy services provided by outside suppliers? 43 If you are claiming cost for renal services on Worksheet A, are they inpatient services only? 44 Have you changed your cost allocation methodology from the previously filed cost report (see CMS Pub. 15-II, section 3617)? 45 If yes, enter approval date (mm/dd/yyyy). 45 Was there a change in the statistical basis? 45.01 Was there a change in the order of allocation? 45.02 Was the change to the simplified cost finding method? 45.03 If you are participating in the NHCMQ demonstration project (must have a hospital-based SNF) during this cost reporting period, enter the phase. 46 If LCC applies, enter "Y" for each component and type of service. Enter "N" if not exempt. (See 42 CFR 413.13.) Hospital 47 Subprovider 48 SNF 49 HHA 50 Outpatient Rehab. Providers 51.10-51.49 Does this hospital claim expenditures for extraordinary circumstances in accordance with 42 CFR 412.348(e)? (See instructions) 52 Does your facility qualify for special exceptions payment pursuant to 42 CFR 412.348(g) for cost reporting periods beginning on or after October 1, 2001? Enter "Y" for yes and "N" for no. 52.01 If this is a Medicare dependent hospital (MDH), enter number of periods. 53 Beginning date MDH status applies in this period (mm/dd/yyyy) 53.01 Ending date MDH status applies in this period (mm/dd/yyyy) 53.01 List amounts of malpractice premiums and paid losses: Premiums: 54 Paid losses: 54 Self insurance: 54 Are malpractice premiums & paid losses reported in other than Administrative and General cost center? 54.01 Does your facility qualify for additional prospective payment in accordance with 42 CFR 412.107? 55 Enter the ambulance limit rate change dates (mm/dd/yyyy) 56 - 56.03 Are you claiming ambulance costs? 56 Enter payment limit for ambulance services as applicable 56 - 56.03 Enter whether this is first year rendering services 56 Enter, if applicable, the fee schedules amounts for the period beginning on or after 4/1/2002. 56 - 56.03 Are you claiming nursing and allied costs? 57 Are you an inpatient rehabilitation facility (IRF) or do you contain an IRF subprovider? 58 If you are an inpatient rehabilitation facility, have you made the election for 100% Federal PPS reimbursement? 58 Are you a long term care hospital (LTCH) or do you contain LTCH subprovider? 59

1 2 1 1 1 1 1 1 1 2 1 1 1 1

1 6 1 1 1 1 1 1 1 10 1 1 1 1

X X X X X X X X X X X X X 9

1-5 1-5 1&2 1&2 2 1

1 1 1 1 1 1

X X X X X X

1 1 1 2 1 2 3 1 1 0 1 2 3 4 1 1 2 1

1 1 10 10 11 11 11 1 1 10 1 11 1 9 1 1 1 1

X 9 X X 9 9 9 X X X X 9(8).99 X 9 X X X X

Rev. 14

36-726.1

04-05

FORM CMS-2552-96

3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S) WORKSHEET S-2 (Continued)

COLUMN(S)

USAGE

If you are a Long Term Care Hospital (LTCH), or a subprovider, have you made the election for 100% Federal PPS reimbursement? Are you an Inpatient Pschyatric Facility (IPF), or do you contain an IPF subprovider? Enter in column 1 "Y" for yes and "N" for no. If yes, is the IPF or IPF subprovider a new facility? Enter in column 2 "Y for yes and "N" for no. (see instructions) If line 60, column 1 is Y, does the facility have a teaching program? Does the facility have a new teaching program in accordance with 42 CFR Sec. 412.426 and Sec. 413.79 (e)(1)(i) and (ii) Enter "Y" for yes and "N" for no. If column 2 is Y, enter 1, 2, or 3 respectively in column 3 to indicate the I&R academic year that begins during the current cost reporting period. Enter 4 if the current cost reporting period covers the beginning of the fourth or subsequent academic year of the teaching program

59

2

1

X

60 60 60.01

1 2 1

1 1 1

X X X

60.01

2

1

X

60.01

3

1

9

60.01

2

1

9

WORKSHEETS S-3, PART I For hospital adults and pediatrics (excluding swing beds, et al), swing bed SNF, swing bed NF, adult and pediatrics in total, each special care unit, the nursery, in total for the hospital, each subprovider, the hospital-based SNF, and in total for the facility, enter:

Number of beds Bed days available Numbers of hours for CAH patients Title V inpatient days/visits Title XVIII inpatient days/visits/trips

Title XIX inpatient days/visits/trips Title XIX observation bed day patient admitted Title XIX observation bed day patient not admitted Total inpatient days/visits Observation bed day patient admitted Observation bed day patient not admitted Total interns & residents (approved programs) Interns & residents replacing non-phys. anes. Employees on payroll Nonpaid workers Title V discharges Title XVIII discharges Title XIX discharges Total discharges Employee discount days

1, 5-10,12,14-17, 21 1, 5-10,12,14-17, 21 1, 6-10 1, 3-16, 18, 23, 24 1- 3, 5-10, 12-15, 18, 21, 23, 24, 27-27.03 1-16, 18, 21, 23, 24 26 26 1-18, 21, 23, 24, 26 26 26 12, 14-24 12, 14-24 12, 14-24 12, 14-24 1, 12-14 1, 12-14 1, 12-14 1, 12-14, 17 28 & 28.01

1 2 2.01 3

9 9 11 9

9 9 9(8).99 9

4 & 4.01 5 5.01 5.02 6 6.01 6.02 7 8 10 11 12 13 14 15 6

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

9 9 9 9 9 9 9 9(8).99 9(8).99 9(8).99 9(8).99 9 9 9 9 9

Rev. 14

36-727

3695 (Cont.)

FORM CMS-2552-96

04-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S) WORKSHEET S-3, PART II

COLUMN(S)

USAGE

Reported salaries Reclassification of salaries from Wkst. A-6 Paid hours related to salary in column 3 Data source

1-35 1-35 1-12.01, 21-35 2-12.01, 19.01 WORKSHEET S-3, PART III

1 2 4 6

11 11 11 36

9 -9 9(8).99 X

Total overhead: Cost Reclassification Paid hours WORKSHEET S-4 County Home health aide hours Titles as appropriate Totals Unduplicated census count Titles as appropriate Totals Number of hours in a normal work week Other (specify) Number of full-time equivalent employees: Staff Contract staff and consultants How many MSAs did you provide services to during this cost reporting period? List those MSA code(s) serviced this period. PPS Activity Data WORKSHEET S-5 Renal Dialysis Statistics Number of patients in program at end of cost reporting period Number of times per week patient receives dialysis Average patient dialysis time including setup CAPD/CCPD exchanges per day Number of days in year dialysis furnished Number of stations Treatment capacity per day per station Utilization (see instructions) Average times dialyzers reused Percentage of patients reusing dialyzers Transplant Information Number of patients on transplant list Number of patients transplanted during fiscal year

13 13 13

1 2 4

11 11 11

9 -9 9(8).99

0 1 1 2 & 2.01 2 & 2.01 3 18 3-18 3-18 19 20 21-32, 34, & 36-38

1 1-4 5 1-4 5 0 0 1 2 1 1 1-6

36 11 11 11 11 6 36 6 6 2 4 11

X 9 9 9(8).99 9(8).99 9(3).99 X 9(3).99 9(3).99 9 X 9

1 2 3 4 5 6 7 8 9 10 11 12

1-6 1-6 1-4 4&6 1-2 1-4 1-2 1-2 1-2 1-2 1 1

6 5 5 5 3 3 11 6 6 6 11 11

9 9(2).99 9(2).99 9(2).99 9 9 9 9(3).99 9(3).99 9(3).99 9 9

36-728

Rev. 14

04-05

FORM CMS-2552-96

3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S) WORKSHEET S-5 (Continued)

COLUMN(S)

USAGE

EPOIETIN (EPO) Net costs of epoietin furnished to all maintenance dialysis patients by the provider Epoietin amount from Wkst. A for Home Dialysis (see instructions) Number of EPO units furnished for line 13 Physician Payment Method (enter "X" if applicable) MCP Initial method

13 13.01 14

1 1 1

11 11 11

9 9 9

15 15

1 2

1 1

X X

WORKSHEET S-6 Number of hours in a normal week Other (specify) Number of full-time equivalent employees on the payroll Number of full-time equivalent contract personnel If paid fully under established fee schedules enter Y or N 0 18 1-18 1-18 19 1 0 1 2 1 6 36 6 6 1 9(3).99 X 9(3).99 9(3).99 X

Rev. 14

36-728.1

05-04

FORM CMS-2552-96

3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION WORKSHEET S-7 NHCMQ Demonstration and Prospective Payment for SNF Statistical Data Rate (see instructions) Days (see instructions) High Cost RUGs days Total (see instructions)

LINE(S)

COLUMN(S)

USAGE

1-45 1-45 7,10-11 & 15-26 1-45

3, 4 & 4.02 3.01, 4.01, 4.03 & 4.06 4.05 5

6 6 6 11

9(3).99 9 9 9

WORKSHEET S-8 RHC/FQHC identification: Street City State Zip code County Designation (for FQHCs only) - "R" for rural or "U" for urban Source of Federal Funds: Amount of Federal Funds Award Date (mm/dd/yyyy) Other (specify) Physician(s) furnishing services at the clinic or under agreement Physician name Billing number Supervision (see instructions) Supervisory physician name Number of hours of supervision during period Does this facility operate as other than an RHC or FQHC? Indicate number of other operations. Type of Operation Facility hours of operations: from/to*

1 1.01 1.01 1.01 1.01 2 3-8 3-8 8 9 9 10 10 11 11 12.01-12.10 12

1 1 2 3 4 1 1 2 0 1 2 1 2 1 2 0 1-14

36 36 2 10 36 1 11 10 36 36 36 36 11 1 2 36 4

X X X X X X 9 X X X X X 9(8).99 X 9 X 9

* List hours of operations based on a 24 hour clock. For example: 8:00am is 0800, 6:30pm is 1830, and midnight is 2400. Have you received an approval for an exception to the productivity standards? Is this a consolidated cost report as defined in CMS Pub. 27, section 508(D)? Enter the number of providers included in this report. Provider name Provider number Have you provided all or substantially all GME costs? Number of program visits performed by Intern & Residents. Bed size less than 50 beds during the year (see instructions).

13 14 14 15 15 16 16 17

1 1 2 1 2 1 2, 3, 4 1

1 1 2 36 6 1 11 1

X X 9 X X X 9 X

WORKSHEET S-9 Part I - Enrollment Days Continuous Home Care Routine Home Care Inpatient Respite Care General Inpatient Care

1 2 3 4

1-5 1-5 1-5 1-5

11 11 11 11

9 9 9 9

Rev. 12

36-729

3695 (Cont.)

FORM CMS-2552-96

05-04

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S) WORKSHEET S-9 (Continued)

COLUMN(S)

USAGE

Part II - Census Data Number of Patients Receiving Hospice Care Unduplicated Continuous Medicare Hours Average Length of Stay (line5/line 6) Unduplicated Census Count WORKSHEET S-10 Uncompensated Care Information Do you have a written charity care policy? Are patient write-off identified as charity? If yes, is it at the time of admission? If yes, is it at the time of first billing? If yes, is it after collection effort has been made? Other methods of write-offs (specify) Are charity write-offs made for partial bills? Are charity determinations based upon judgment without financial data? Are charity determinations based upon income data only? Are charity determinations based upon net worth (assets ) data? Are charity determinations based upon income and net worth data? Does your accounting system separately identify charity from bad debt? If yes, do you account for inpatient and outpatient services? Is discerning charity from bad debt a high priority in your institution? If no, is it because there is not enough staff to determine eligibility? If no, is it because there is no financial incentive to separate charity from bad debt? If no, is it because there is no clear directive policy on charity determination? If no, is it because your institution does not deem the distinction important? If charity determination is based upon income data, what is the maximum income that can be earned by patients (single without dependent) and still be determined to be a charity write off? If charity determination is based upon income data, is the income directly tied to Federal poverty level? If yes, is the percentage level less than 100% of the Federal poverty level? If yes, is the percentage level between 100% and 150% of the Federal poverty level? If yes, is the percentage level between 150% and 200% of the Federal poverty level? If yes, is the percentage level greater than 200% of the Federal poverty level? Are partial write offs given higher income patients on a gradual scale? Is there charity consideration given to high net worth patients who have catastrophic or other extraordinary medical expenses?

6 7 8 9

1-5 1&3 1-5 1-5

11 11 11 11

9 9(8).99 9(8).99 9

1 2 2.01 2.02 2.03 2.04 3 4 5 6 7 8 8.01 9 9.01 9.02 9.03 9.04

1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1

1 1 1 1 1 36 1 1 1 1 1 1 1 1 1 1 1 1

X X X X X X X X X X X X X X X X X X

10 11 11.01 11.02 11.03 11.04 12

1 1 1 1 1 1 1

11 1 1 1 1 1 1

9 X X X X X X

13

1

1

X

36-729.1

Rev. 12

05-04

FORM CMS-2552-96

3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S) WORKSHEET S-10 (Continued)

COLUMN(S)

USAGE

Is your hospital state and local government owned? If yes, do you receive direct financial support from that government entity for the purpose of providing uncompensated care?

14

1

1

X

14.01

1

1

X

Do you receive restricted grants for rendering care to patients? Are other non-restricted grants used to subsidize charity care? Uncompensated Care Revenue Revenue from uncompensated care Gross Medicaid revenues Revenues from state and local indigent care programs Revenue related to SCHIP (see instruction) Restricted grants Non-restricted grants Uncompensated Care Cost Total charges for patients covered by state and local indigent care programs Total SCHIP charges Total gross Medicaid charges Total gross uncompensated care charges

15 16

1 1

1 1

X X

17 17.01 18 19 20 21

1 1 1 1 1 1

11 11 11 11 11 11

9 9 9 9 9 9

23 26 28 30

1 1 1 1

11 11 11 11

9 9 9 9

WORKSHEET A Direct salaries by department 5-31, 33-44, 46-61, 62.01-71, 82-86, 89, 92-94, 96-100 101 1-31, 33-61, 62.01-71, 82-86, 88-90, 92-94, 96-100 101 1-31, 33-61, 62.01-71, 82-86, 88-90, 92-94, 96-100 101

Total direct salaries Other direct costs by department

1 1

11 11

-9 9

Total other direct costs Net expenses for allocation by department

2 2

11 11

-9 9

Total expenses for allocation

7 7

11 11

-9 9

WORKSHEET A-6 For each expense reclassification: Explanation Increases: Adjustment letter(s) Worksheet A line number Reclassification salary amount Reclassification other amount Decreases: Worksheet A line number Reclassification salary amount Reclassification other amount Worksheet A-7 column reference

1-35 1-35 1-35 1-35 1-35 1-35 1-35 1-35 1-35

0 1 3 4 5 7 8 9 10

36 2 6 11 11 6 11 11 2

X X 9(3).99 9 9 9(3).99 9 9 9

Rev. 12

36-729.2

3695 (Cont.)

FORM CMS-2552-96

05-04

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION WORKSHEET A-7 For land, land improvements, buildings and fixtures, building improvements, fixed and movable equipment, and in total: Parts I & II - Analysis of changes in capital asset balances Beginning balance Purchases Donations Disposals and retirements Fully depreciated assets NOTE: Part I is for old capital. Part II is for new capital. Part III - Reconciliation of capital cost centers Gross assets and capitalized leases Ratio Insurance, taxes, and other capital-related costs Summary of old and new capital Depreciation, lease, interest, insurance, taxes, and other capital-related costs Part IV - Reconciliation of amounts from Worksheet A, column 2, lines 1-4. Summary of old and new capital Depreciation, lease, interest, insurance, taxes, and other capital-related costs WORKSHEET A-8 Description of adjustment Basis (A or B) * Amount * Worksheet A line number + Worksheet A-7 column reference

LINE(S)

COLUMN(S)

USAGE

1-9 1-9 1-9 1-9 1-9

1 2 3 5 7

11 11 11 11 11

9 9 9 9 9

1-4 1-4 1-5

1&2 4 5, 6 & 7

11 8 11

9 9.9(6) 9

1-4

9-14

11

-9

1-4

9-14

11

-9

37-49 1-11, 13, 15-24, 28-34, 37-49 1-11, 13, 15-24, 28-34, 37-49 5-11, 13, 15-24, 34, 37-49 1-24, 29-32, 34, 37-49

0 1 2 4 5

36 1 11 6 2

X X -9 9(3).99 9

* These include subscripts of lines 1-4 and 28-32 requiring records for columns 1 and 2. These subscripts should occur based on Worksheet A layout. + Do not include preprinted lines, i.e. lines 1-4 and 25-33. Include only subscripts of those lines, if activated by an entry in either of columns 1 or 2.

36-730

Rev. 12

11-98

FORM CMS-2552-96

3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION WORKSHEET A-8-1 Part A - For costs incurred and adjustments required as a result of transactions with related organization(s): Worksheet A line number Expense item(s) Amount allowable in reimbursable cost Amount included in Worksheet A Worksheet A-7, Part III, column reference (9-14 only) Part B - For each related organization: Type of interrelationship (A through G) If type is G, description of relationship must be included. Name of individual or partnership with interest in provider and related organization Percent of ownership of provider Name of related organization Percent of ownership of related organization Type of business

LINE(S)

COLUMN(S)

USAGE

1-4 1-4 1-4 1-4 1-4 1-5 1-5 1-5 1-5 1-5 1-5 1-5

1 3 4 5 7 1 0 2 3 4 5 6

6 36 11 11 2 1 36 15 6 15 6 15

9(3).99 X 9 9 9 X X X 9(3).99 X 9(3).99 X

WORKSHEET A-8-2 By each cost center or physician: Worksheet A line number Physician identifier and aggregate only Total physicians' remuneration Physicians' remuneration professional component Physicians' remuneration provider component RCE amount Number of physicians' hours - provider component Cost of memberships and continuing education Physician cost of malpractice insurance In total for the facility (sum of lines 1-100): Total physicians' remuneration Physicians' remuneration professional component Physicians' remuneration provider component Number of physicians' hours - provider component Cost of memberships and continuing education Physician cost of malpractice insurance

1-100 1-100 1-100 1-100 1-100 1-100 1-100 1-100 1-100 101 101 101 101 101 101

1 2 3 4 5 6 7 12 14 3 4 5 7 12 14

6 36 11 11 11 11 11 11 11 11 11 11 11 11 11

9(3).99 X 9 9 9 9 9 9 9 9 9 9 9 9 9

Rev. 4

36-730.1

3695 (Cont.)

FORM CMS-2552-96

11-98

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION WORKSHEET A-8-3

LINE(S)

COLUMN(S)

USAGE

Total number of weeks during which outside suppliers (other than aides) worked 1 Number of unduplicated days in which the following categories, as appropriate, are on the provider's site and have the highest AHSEA, where applicable Supervisors or therapists 3 Therapy assistants and no supervisors or therapists 4 Registered therapists 5 Certified therapists 6 Nonregistered, noncertified therapists 7 Number of unduplicated HHA visits - supervisors or therapists 8 Number of unduplicated HHA visits - therapy assistants (see instructions) 9 Standard travel expense rate 10 Optional travel expense rate per mile 11 Total hours worked by discipline 12 ASHEA by discipline 13 Number of travel hours (HHA only) by discipline 15 Number of miles driven (HHA only) by discipline 16 Therapists and assistants (standard and optional) 41, 42, 45, & 46 Subtotals 43 & 47 Standard and optional travel expenses 44 & 48 Travel allowance and expense - include only one 49, 50, 51 Overtime hours worked during period by discipline (see instructions) 52 Provider standard workyear for one full time employee 56 Travel allowance and expense - HHA services 64 Equipment cost (see instructions) 66 Supplies (see instructions) 67 Total cost of outside supplier services 69 Total cost of outside supplier services - hospital 71 Total cost of outside supplier services - HHA 72

1

11

9

1 1 1 1 1 1 1 1 1 1-11 1-11 1-9 1-9 1 1 1 1 1-7 8 1 1 1 1 1 1

11 11 11 11 11 11 11 5 3 11 5 11 11 11 11 11 11 11 7 11 11 11 11 11 11

9 9 9 9 9 9 9 99.99 .99 9(8).99 99.99 9 9 9 9 9 9 9(8).99 9(4).99 9 9 9 9 9 9

WORKSHEET A-8-4 Total number of weeks worked during which outside supplies worked Number of unduplicated days on which supervisor or therapist was on provider site (see instructions) Number of unduplicated days on which therapy assistant was on provider site but neither supervisor nor therapist was on provider site (see instructions) Number of unduplicated offsite visits - supervisors or therapist 1 3 1 1 11 11 9 9

4 5

1 1

11 11

9 9

36-730.2

Rev. 4

04-05

FORM CMS-2552-96

3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S) WORKSHEET A-8-4 (Continued)

COLUMN(S)

USAGE

Number of unduplicated offsite visits - therapy assistants (include only visits made by therapy assistant and on which supervisor and/or therapist was not present during the visit(s)) (see instructions) Standard travel expense rate Optional travel expense rate per mile Total hours worked by discipline ASHEA by discipline Number of travel hours by discipline Number of miles driven by discipline Travel allowance and expense - include only one Travel allowance and expense - include only one Overtime hours worked during period by discipline (see instructions) Allocation of provider's standard workyear for one full-time employee times the percentages on line 50 (see instructions) Equipment cost (see instructons) Supplies (see instructions) Total cost of outside supplier services (from your records) Cost of outside supplier services - (from your records) * Excess of cost over limitation (specify component) *

6 7 8 9 10 12 13 33, 34, 35 44, 45, 46 47 51 61 62 64 66-66.60 69-69.60

1 1 1 1-5 1-5 1-3 1-3 1 1 1-4 5 1 1 1 1 1

11 5 3 11 5 11 11 11 11 11 7 11 11 11 11 11

9 99.99 .99 9(8).99 99.99 9 9 9 9 9(8).99 9(4).99 9 9 9 9 9

Line designation for hospital and components: Hospital = 66.00, CORF = 66.01-66.10, CMHC = 66.11-66.20, OPT = 66.21-66.30, HHA = 66.31-66.40, OOT = 66.41-66.50, and OSP = 66.51-66.60. This sequence should be used on lines 68 and 69.

WORKSHEETS B-1; B, PARTS I-III; H-5, PART I; J-1, PART II; and L-1, PART I HEADINGS* Column heading (cost center name) Statistical basis 1-3* 4, 5* 1-5, 6-24 1-5, 6-24 10 10 X X

WORKSHEET B, PART I Total adjustments after cost finding Costs after cost finding and post stepdown adjustments by department 103 25-31, 33-61, 62.01-71, 82-86, 92-94, 96-100, 102 103 26 11 -9

Total costs after cost finding and post stepdown adjustments *

27 27

11 11

-9 9

Refer to Table 1 for specifications and Table 2 for the worksheet identifier for column headings. There may be up to five type 2 records (3 for cost center name and 2 for the statistical basis) for each column. However, for any column which has less than five type 2 record entries, blank records or the word "blank" is not required to maximize each column record count.

Rev. 14

36-731

3695 (Cont.)

FORM CMS-2552-96

04-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION WORKSHEET B, PART II Directly assigned old capital related costs by department

LINE(S)

COLUMN(S)

USAGE

Total directly assigned capital related costs Total adjustments after cost finding Total capital related costs after cost finding by department

5-31, 33-44, 46-61, 62.01-71, 82-86, 92-94, 96-100 103 103 25-31, 33-44, 46-61, 62.01-71, 82-86, 92-94, 96-100 103

0 0 26

11 11 11

9 9 -9

Total capital related costs after cost finding in total

27 27

11 11

-9 9

WORKSHEET B, PART III Directly assigned new capital related costs by department 5-31, 33-44 46-61, 62.01-71, 82-86, 92-94, 96-100 103 103 25-31, 33-44, 46-61, 62.01-71, 82-86, 92-94, 96-100 103

Total directly assigned capital related costs Total adjustments after cost finding Total capital related costs after cost finding by department

0 0 26

11 11 11

9 9 -9

Total capital related costs after cost finding in total

27 27

11 11

-9 9

WORKSHEET B-1 For each cost allocation using accumulated costs as the statistic, include a record containing an X. All cost allocation statistics

Reconciliation

Cost to be allocated *

0 1-31, 33-44 46-61, 62.01-71, 82-86, 92-94, 96-100 6-31, 33-61, 62.01-71, 82-86, 92-94, 96-100 103

6-24

1

X

1-24*

11

9

6A-24A 1-24+

11 11

-9 9

In each column using accumulated costs as the statistical basis for allocating costs, identify each cost center which is to receive no allocation with a negative 1 (-1) placed in the accumulated cost column. Providers may elect to indicate total accumulated cost as a negative amount in the reconciliation column. However, there should never be entries in both the reconciliation column and accumulated column simultaneously on the same line. For those cost centers which are to receive partial allocation of costs, provide only the cost to be excluded from the statistic as a negative amount on the appropriate line in the reconciliation column. If line 6 is fragmented, line 6 must be deleted and subscripts of line 6 must be used. Include any column which uses accumulated cost as it basis for allocation. WORKSHEET B-2

+

For post stepdown adjustment: Adjustment for EPO costs in Renal Dialysis Adjustment for EPO costs in Renal Dialysis Adjustment for EPO costs in Renal Dialysis Adjustment for EPO costs in Renal Dialysis

1 1 1 1

1 2 3 4

36 1 6 11

X 9 9(3).99 -9

36-732

Rev. 14

04-05

FORM CMS-2552-96

3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION WORKSHEET B-2 For post stepdown adjustment: Adjustment for EPO costs for in Home Program Adjustment for EPO costs for in Home Program Adjustment for EPO costs for in Home Program Adjustment for EPO costs for in Home Program Explanation Worksheets B and L-1, Part numbers (1=B, Part I; 2=B, Part II; 3=B, Part III; and 4=L-1) Worksheet A line number Amount of adjustment

LINE(S)

COLUMN(S)

USAGE

2 2 2 2 3-59 3-59 3-59 3-59

1 2 3 4 1 2 3 4

36 1 6 11 30 1 6 11

X 9 9(3).99 -9 X 9 9(3).99 -9

NOTE: On Worksheet B-2, if there are more than 59 lines needed, use multiple worksheets. (Refer to the footnote to this worksheet in Table 2.) WORKSHEET C, PART I Observation bed cost (see instructions) Total cost (line 101 minus line 102) Total charges by department (inpatient) Total charges by department (inpatient/outpatient) Total charges (inpatient/outpatient) WORKSHEET C, PART II Total capital and outpatient reductions WORKSHEET C, PART III Total inpatient ancillary charges by department Total inpatient ancillary charges WORKSHEET C, PART IV Inpatient service cost per diem Total program swing-bed inpatient routine cost WORKSHEET C, PART V Total outpatient charges by department Total outpatient charges 37-68 101 5 5 11 11 9 9 5 9 1 1-3 9 11 9(6).99 9 37-68 101 3 3 11 11 9 9 103 4-5 11 -9 62 103 25-36 37-68 101 1 1 6 6-7 6-7 11 11 11 11 11 9 9 9 9 9

WORKSHEET D, PART III Apportionment of inpatient routine service other pass through costs Where post stepdown adjustments affecting either nonphysician anesthetists or direct medical education costs are made, furnish only the net change for each cost center. Nonphysician anesthetist change by department Nonphysician anesthetist change in total Direct medical education change by department Direct medical education change in total Nursing Services* Nursing Services change in total*

25-31, 33-35 101 25-31, 33-35 101 25-31, 33-35 101

1 1 2 2 2 2

11 11 11 11 11 11

-9 -9 -9 -9 -9 -9

Rev. 14

36-733

3695 (Cont.)

FORM CMS-2552-96

04-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S) WORKSHEET D, PART III (Continued)

COLUMN(S)

USAGE

Allied Health (Paramedical) Cost* Allied Health (Paramedical) change in total* Other Medical Educational Costs* Other Medical Educational change in total* Total inpatient program pass through cost

25-31, 33-35 101 25-31, 33-35 101 101

2.01 2.01 2.02 2.02 8

11 11 11 11 11

-9 -9 -9 -9 -9

* =Where Worksheet S-2, line 57 is answered "Yes", subscript column 2 to 2, 2.01 & 2.02, include only the net changes. WORKSHEET D, PART IV Apportionment of inpatient ancillary service other pass through costs Where post stepdown adjustments affecting either nonphysician anesthetists or direct medical education costs are made, furnish only the net change for each cost center. Nonphysician anesthetist change by department Direct medical education change by department Nursing Services* Allied Health (Paramedical) Cost* Other Medical Education Cost* Blood clotting for Hemophiliacs Total program pass through costs and charges+

37-44, 46-64, 66-68 37-44, 46-64, 66-68 37-44, 46-64, 66-68 37-44, 46-64, 66-68 37-44, 46-64, 66-68 46.3 101

1 2 2 2.01 2.02 2.03 1, 2, 7, & 9

11 11 11 11 11 11 11

-9 -9 -9 -9 -9 -9 -9

* =Where Worksheet S-2, line 57 is answered "Yes", subscript column 2 to 2, 2.01, & 2.02 include only the net changes. (*)=Blood clotting factor should be on subscripted line 46.3. Subscript column 2.03 to allow for these changes + =Include columns 2.01 and 2.02 if applicable. WORKSHEET D, PART V Apportionment of medical and other health services costs Outpatient ambulatory surgical center Outpatient radiology Other outpatient diagnostic All other Part B Ambulance Subtotal program charges CRNA charges Net program costs

37-68 37-68 37-68 37-68 65-65.03 101 102 104

2 & 2.01 3 & 3.01 4 & 4.01 5-5.02 & 10 9 & 9.02 2-5.02 & 10 2-2.01, 5-5.01 & 10 6-9.02 & 11

11 11 11 11 11 11 11 11

9 9 9 9 9 9 -9 9

NOTE: If Worksheet A, line 20 is subscripted and the provider qualifies for the exception as described in CMS Pub. 15-II, section 3610 for nonphysician anesthetist services, include the combined charges of those lines on Worksheet D, Part V, line 102, column 2. WORKSHEET D, PART VI Vaccine cost apportionment Program vaccine charges, include line 2.01, if applicable*

2

1

11

9

* CAH only, line 2 contains all vaccines except hepatitis B which should be place on line 2.01

36-734

Rev. 14

05-04

FORM CMS-2552-96

3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION WORKSHEET D-1 Part I - All Provider Components Inpatient days (including private room days and swing-bed days, excluding newborn) Inpatient days (including private room days, excluding swing-bed and newborn days) Total private room days Swing-bed SNF type inpatient days through 12/31 * Swing-bed SNF type inpatient days after 12/31 * Swing-bed NF type inpatient days through 12/31 * Swing-bed NF type inpatient days after 12/31 * Inpatient days including private room days applicable to the program (excluding swing-bed and newborn days) Swing-bed SNF days through 12/31 (title XVIII) * Swing-bed SNF days after 12/31 (title XVIII) * Swing-bed NF days through 12/31 (titles V and XIX) * Swing-bed NF days after 12/31 (titles V and XIX) * Medically necessary private room program days Medicare rates for: Swing-bed SNF services through 12/31 Swing-bed SNF services after 12/31 Non-Medicare rates for: Swing-bed NF services through 12/31 Swing-bed NF services after 12/31 General inpatient routine service charges Private room charges Semi-private room charges * Hospital or subprovider only Part II - Hospital and Subproviders Only Program overflow days by each special care unit for hospital and subproviders only (This data is added to program routine days from Worksheet S-3, Part I, line 1, columns 3-5, as appropriate.) See CMS Pub. 15-II, section 3622.2. Total program inpatient costs TEFRA target amount per discharge Bonus payment (see instructions) Lesser of lines 53/54 or 55 of 1996 cost report ending period updated and compounded by the market basket. Lesser of lines 53/54 or 55 of prior year cost report updated by the market basket (see instructions) If line 53/54 is less than the lower of lines 55, 58.01, or 58.02 (see instructions). Relief Payment (see instructions) Program discharges prior to July 1 Program discharges after to July 1 Program discharges (see instructions) Part III - Skilled Nursing Facility, Nursing Facility Only, and ICF/MR Aggregate charges to beneficiaries for excess costs Inpatient routine service cost per diem limitation Utilization review - physicians' compensation Total program inpatient operating costs

LINE(S)

COLUMN(S)

USAGE

1 2 3 5 6 7 8 9 10 11 12 13 14 17 18 19 20 28 29 30

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

11 11 11 11 11 11 11 11 11 11 11 11 11 6 6 6 6 11 11 11

9 9 9 9 9 9 9 9 9 9 9 9 9 9(3).99 9(3).99 9(3).99 9(3).99 9 9 9

43-47 49 55 58 58.01 58.02 58.03 58.04 59.02 59.03 59.04

4 1 1 1 1 1 1 1 1 1 1

11 11 9 11 11 11 11 11 11 11 11

9 9 9(6).99 9 9(8).99 9(8).99 9 9 9 9 9

75 77 81 82

1 1 1 1

11 6 11 11

9 9(3).99 9 9

Rev. 12

36-735

3695 (Cont.)

FORM CMS-2552-96

05-04

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S) WORKSHEET D-1 (Continued)

COLUMN(S)

USAGE

Part IV - Computation of Observation Bed Cost Hospitals and/or Subproviders only Total observation bed days (see instructions) Observation bed cost (title XVIII only) WORKSHEET D-2 Part I: Percent of assigned time of interns and residents (not in approved programs) Title XVIII, Part B inpatient days (Part A adjustment only) (1) Title XVIII, Part A only charges (see note below) Subtotal (sum of lines 2 through 8) Subtotal (sum of lines 20 through 23) Part II: Title XVIII, Part B inpatient days

83 85

1 1

11 11

9 9

2-8, 10, 12-18, 20-23 2-7, 10, 12 20-23 9 24 26, 27, 29-33, 35, 37

1 6 6 8-10 8-10

6 11 11 11 11

9(3).99 -9 -9 -9 -9

6

11

9

(1) Display only the Part A coverage days adjustment, negative amount, in the ECR record(s). See section 3623.1 for proper submission of reconciliation of these days. Note: For Part A only charges, the amount reported is only the title XVIII Part B ancillary charges. This will be used to reduce ancillary charges from Worksheet D-4, column 2 and Worksheet D, Part III, sum of columns 2-5 in order to properly calculate the Part B ancillary charges.

WORKSHEET D-4 For each component under titles V, XVIII, and XIX, except for SNFs under title XVIII: Inpatient Part A ancillary charges by department Total program charges (sum of lines 37-64 and 66-68) Total program costs (sum of lines 37-64 and 66-68)

25-31, 37-64, 66-68 101 101

2 2 3

11 11 11

9 9 9

WORKSHEET D-6 Part I: Inpatient routine service charges for organ acquisition Medicare organ acquisition days Part A inpatient ancillary organ acquisition charges Part III: Provider charges for interns and residents services only where the provider charges separately Total charges applicable to costs in column 1 only where the provider has a schedule of charges for the various direct organ acquisition costs Total usable organs Medicare usable organs Revenue for organs sold Organ acquisition charges billed to Medicare under Part B Net organ acquisition cost and charges

1-6 1-6 8-34

1 3 2

11 11 11

9 9 9

49 & 50

3

11

9

51 54 55 58 60 61

3 2 2 1&3 1 1-4

11 11 11 11 11 11

9 9 9 9 9 -9

36-736

Rev. 12

05-04

FORM CMS-2552-96

3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S) WORKSHEET D-6 (Continued)

COLUMN(S)

USAGE

Part IV: Statistics for living related kidney acquisitions, partial liver & partial lung; Organs excised at provider Organs purchased from other transplant hospitals Organs purchased from non-transplant hospitals Organs purchased from OPOs Organs transplanted Organs sold to other hospitals Organs sold to OPOs Organs sold to transplant hospitals Organs sold to military or VA hospitals Organs sold outside the U.S. Organs sent outside the U.S. (no revenue) Organs used for research Unusable or discarded organs Statistics for cadaveric heart, liver, lung, kidney, pancreas or intestine acquisition; Organs excised at provider Organs purchased from other transplant hospitals Organs purchased from non-transplant hospitals Organs purchased from OPOs Organs transplanted Organs sold to other hospitals Organs sold to OPOs Organs sold to transplant hospitals Organs sold to military or VA hospitals Organs sold outside the U.S. Organs sent outside the U.S. (no revenue) Organs used for research Unusable or discarded organs Revenue for hearts, livers, lungs, pancreas, intestine and kidneys transplanted into non-Medicare patients; Organs transplanted Organs sold to other hospitals Organs sold to OPOs Organs sold to transplant hospitals Organs sold to military or VA hospitals Organs sold outside the U.S.

62 63 64 65 67 68 69 70 71 72 73 74 75

1 1 1 1 1 1 1 1 1 1 1 1 1

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

9 9 9 9 9 9 9 9 9 9 9 9 9

62 63 64 65 67 68 69 70 71 72 73 74 75

2 2 2 2 2 2 2 2 2 2 2 2 2

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

9 9 9 9 9 9 9 9 9 9 9 9 9

67 68 69 70 71 72

3 3 3 3 3 3

11 11 11 11 11 11

9 9 9 9 9 9

WORKSHEET D-9 Part I: Physicians' remuneration - in total Physicians' remuneration - professional component RCE amount Number of physicians' hours - professional component Cost of memberships and continuing education Cost of physician malpractice insurance

1-11 1-11 1-11 1-11 1-11 1-11

3 4 5 6 11 13

11 11 11 11 11 11

9 9 9 9 9 9

Rev. 12

36-737

3695 (Cont.)

FORM CMS-2552-96

05-04

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S) WORKSHEET D-9 (Continued)

COLUMN(S)

USAGE

Part II: - For the hospital and each subprovider: Total inpatient days and outpatient visit days Patient days (The same days and visit days are used for both the hospital staff and medical staff costs.) Title V inpatient days Title V outpatient visit days Title XVIII inpatient days (Part A) Title XVIII outpatient visit days (Part B) Title XIX inpatient days Title XIX outpatient visit days Total kidney acquisition days and outpatient visit days Total liver acquisition days and outpatient visit days Total heart acquisition days and outpatient visit days Total lung acquisition days and outpatient visit days Total pancreas acquisition days and outpatient visit days Total intestinal acquisition days and outpatient visit days

2

1

11

9

4 5 6 7 8 9 10 11 12 13 13.01 13.02

1 1 1 1 1 1 1 1 1 1 1 1

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

9 9 9 9 9 9 9 9 9 9 9 9

WORKSHEET E, PART A For SCH & MDH providers that have changed status during the cost reporting period, lines 1 through 6 and subscripts are to be subscripted into column 1.01 (see instructions) For the hospital and subprovider(s) DRG amounts - other than outlier payments prior to 10/1 1 1 - 1.02 11 Other than Outlier Payments occurring on or after 10/1 and before 1/1 1.01 1 - 1.02 11 Other than Outlier Payments occurring on or after 1/1 1.02 1 - 1.02 11 Managed Care Patients Simulated payments (see instructions) 1.03 1 - 1.02 11 Payments on or after 10/1 and prior to 1/1 1.04 1 - 1.02 11 Simulated payments (see instructions) 1.05 1 - 1.02 11 Additional amount received or to be received (see instruct.) 1.06 1 - 1.02 11 Payments for discharges on 4/1/2001 thru 9/30/2001. 1.07 1 - 1.02 11 Simulated payments from 4/1/2001 thru 9/30/2001. 1.08 1 - 1.02 11 Outlier payments for discharges prior to 10/1/1997 (see instruct.) 2 1 - 1.02 11 Outlier payments for discharges on or after 10/1/1997 2.01 1 - 1.02 11 Indirect medical education adjustment Bed days available divided by number of days in cost reporting period 3 1 9 Number of interns and residents (see instructions) 3.01 1 9 Indirect medical education percentage (see instructions) 3.02 1 6 FTE count for allopathic and osteopathic before December 31, 1996 3.04 1 9 FTE count for allopathic and osteopathic add-on to cap for new programs 3.05 1 9 Adjustment to FTE count for allopathic and osteopathic program 3.06 1 9 FTE count for allopathic and osteopathic in the current year 3.08 1 9 For periods beginning prior to 10/1, enter the percentage of discharges occurring prior to 10/1 3.09 1 4 For periods beginning prior to 10/1, enter the percentage of discharges occurring on or after 10/1 3.10 1 4 FTE count for the period identified in line 3.09 3.11 1 9 FTE count for the period identified in line 3.10 3.12 1 9 FTE count for residents in dental and podiatric programs 3.13 1 9 Current year allowable FTE (see instructions) 3.14 1 9 No FTE in this period, but teaching in prior year 3.15 0 1 Total allowable FTE count for the prior year 3.15 1 9 No FTE in this period, but teaching in prior period 3.16 0 1

9 9 9 9 9 9 9 9 9 9 9 9(6).99 -9(6).99 9(3).99 9(6).99 9(6).99 -9(6).99 9(6).99 9.99 9.99 9(6).99 9(6).99 9(6).99 9(6).99 9 9(6).99 9

36-738

Rev. 12

04-05

FORM CMS-2552-96

3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S) WORKSHEET E, PART A (Continued)

COLUMN(S)

USAGE

Total allowable count for the penultimate year if that year ended on or after 9/30/1997, otherwise enter zero Add to calculation the FTE residents in initial years of the program that meet the exception in 42 CFR 413.86(g)(6). Display the FTE add on amount. Current year resident to bed ratio (see instructions) Prior year resident to bed ratio Discharges occurring prior to 10/1 (see instructions) Discharges occurring on or after 10/1, but before 1/1 Discharges occurring on or after 1/1 (see instructions) Disproportionate share adjustment SSI recipient patient days to Medicare Part A patient days Percentage of Medicaid patient days to total days Allowable disproportionate share percentage (see instructions) Disproportionate share adjustment amount Additional payment for high percentage of ESRD beneficiary discharges Total Medicare discharges excluding discharges for DRGs 302, 316, and 317 Total ESRD Medicare discharges excluding DRGs 302, 316, and 317 ESRD Medicare discharges to total Medicare discharges Total Medicare ESRD inpatient days excluding DRGs 302, 316, and 317 Average weekly cost for dialysis treatments (see instructions) Hospital specific payments (to be completed by SCH and MDH, small rural hospitals only) Hospital specific payments (to be completed by SCH and MDH, small rural hospitals only) for fiscal year beg. On or after 10/1/2000 and before 10/1/2003. Nursing and Allied Health Managed Care Special Add-on payment for new technologies Primary payer payments (see instructions) Deductibles billed to program beneficiaries Coinsurance billed to program beneficiaries Reimbursable bad debts (see instructions) Reimbursable bad debts adjustment (see instructions) Reimbursable bad debts for dual eligible beneficiaries (see instructions) Recovery of excess depreciation Other adjustments (see instructions) (specify) Other adjustments (see instructions) (specify) Amounts applicable to prior periods - asset disposition Sequestration adjustment (see note below) Protested amounts

3.16

1

9

9(6).99

3.17 3.18 3.19 3.21 3.22 3.23 4 4.01 4.03 4.04

1 1 1 1 - 1.02 1 - 1.02 1 - 1.02 1 1 0 - 1.02 1 - 1.02

9 8 8 11 11 11 11 9 9 11

9(6).99 9.9(6) 9.9(6) 9 9 9 9.9(4) 9.9(4) 9.9(4) 9

5 5.01 5.02 5.03 5.05 7

1 - 1.02 1 - 1.02 1 - 1.02 1 - 1.02 1 - 1.02 1 - 1.02

11 11 9 11 9 11

9 9 9(6).99 9 9(6).99 9

7.01 11.01 11.02 17 19 20 21 21.01 21.02 23 24 24 25 27 30

1 - 1.02 1 1 1 1 1 1 1 1 1 0 1 1 1 1

11 11 11 11 11 11 11 11 11 11 36 11 11 11 11

9 9 9 9 9 9 -9 9 9 9 X -9 -9 -9 -9

For the sequestration adjustment, in all cases except for Worksheet E, Part A, the value must be the effective sequestration adjustment, expressed as a decimal equivalent. Hospitals under PPS have the option to use the effective rate or to calculate the sequestration adjustment as services were rendered (i.e., on a bill by bill basis). If the value is less than one, it is applied against the amount due provider. Otherwise it is subtracted from the amount due provider. See CMS Pub. 15-II, chapter 36, section 3630 for applicable sequestration amount. Column 1 can be subscripted for the following items:Transitional Corridor, Geographic Reclassification and SCH/MDH elections. See CMS Pub. 15-II, chapter 36, section 3630 for the applicable lines.

Rev. 14

36-738.1

05-04

FORM CMS-2552-96

3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION WORKSHEET E, PART B For the hospital, each subprovider, and SNF (title XVIII only) PPS payments received including outliers 1996 hospital specific payment to cost ratio Transitional corridor payment (see instructions) Ancillary service charges for physicians' professional services (see note below) Interns and residents service charges Teaching physicians charges Aggregate amount collected from beneficiaries Amounts collectible Deductibles and coinsurance (for nominal charge providers, report deductibles only) Coinsurance related to amount on line 17.01 Primary payer payments All other bad debts, net of recoveries (see instructions) Reimbursable bad debts for dual eligible beneficiaries (see instructions) Recovery of excess depreciation Other adjustments (see instructions) (specify) Other adjustments (see instructions) (specify) Amounts applicable to prior periods - asset disposition Sequestration adjustment (see note to Worksheet E, Part A) Protested amounts

LINE(S)

COLUMN(S)

USAGE

1.02 1.03 1.06 6 7 9 11 12 18 18.01 24 27 27.02 29 30 30 31 33 36

1,1.01, 1.02 1,1.01, 1.02 1,1.01, 1.02 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1

11 5 11 11 11 11 11 11 11 11 11 11 11 11 36 11 11 7 11

9 9.9(3) 9 -9 9 9 9 9 9 9 9 -9 9 9 X -9 -9 9.9(5) -9

For ancillary service charges, the amount reported is the sum of (1) the program ancillary service charges attributable to physicians' professional services included in total charges on Worksheet C, Part I, (2) program charges applicable to excess cost of luxury items, and (3) your charges to beneficiaries for excess costs. This sum is used to reduce ancillary service charges from Worksheet D-4 or Worksheet D, Part V in order to properly calculate the lower of cost or charges on Worksheet E, Parts B through E, and Worksheet E-3, Parts II and III. Column 1 can be subscripted for the following items:Transitional Corridor, Geographic Reclassification and SCH/MDH elections. See CMS Pub. 15-II, chapter 36, section 3630 for the applicable lines.

WORKSHEET E, PART C For settlement of outpatient ambulatory surgical centers (ASC) services under titles V, XVIII, or XIX: Standard overhead amount (ASC fee) Deductibles, excluding any billed for the professional component of provider based physicians services Ancillary service charges for physicians' professional services (see note to Worksheet E, Part B) Aggregate amount collected from beneficiaries Amounts collectible Deductibles and coinsurance, excluding any billed for the professional component of provider based physicians services (for nominal charge providers, report deductibles only) Part B deductibles and coinsurance (see instructions)

1 2 7 8 9

1 & 1.01 1 1 & 1.01 1 & 1.01 1 & 1.01

11 11 11 11 11

9 9 -9 9 9

15 20

1 1.01

11 11

9 9

Rev. 12

36-739

3695 (Cont.)

FORM CMS-2552-96

05-04

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION WORKSHEET E, PART D For settlement of outpatient radiology services under titles V, XVIII, or XIX: Prevailing charges Deductibles, excluding any billed for the professional component of provider based physicians services Ancillary services charges for physicians' professional services (see note to Worksheet E, Part B) Aggregate amount collected from beneficiaries Amounts collectible Deductibles and coinsurance, excluding any billed for the professional component of provider based physicians services (for nominal charge providers, report deductibles only) Less deductibles and coinsurance (see instructions)

LINE(S)

COLUMN(S)

USAGE

1 3 7 8 9

1 & 1.01 1 1 & 1.01 1 & 1.01 1 & 1.01

11 11 11 11 11

9 9 -9 9 9

15 20

1 1.01

11 11

9 9

WORKSHEET E, PART E For settlement of all other diagnostic services under titles V, XVIII, or XIX: Prevailing charges Deductibles, excluding any billed for the professional component of provider based physicians services Ancillary service charges for physicians' professional services (see note to Worksheet E, Part B) Aggregate amount collected from beneficiaries Amounts collectible Deductibles and coinsurance, excluding any billed for the professional component of provider based physicians services (for nominal charge providers, report deductibles only) Less deductibles and coinsurance (see instructions)

1 3 7 8 9

1 & 1.01 1 1 & 1.01 1 & 1.01 1 & 1.01

11 11 11 11 11

9 9 -9 9 9

15 20

1 1.01

11 11

9 9

WORKSHEET E-1 For the hospital, each subprovider, SNF, and swing-bed SNF title XVIII only: Total interim payments paid to provider Interim payments payable Date of each retroactive lump sum adjustment (mm/dd/yyyy) Amount of each retroactive lump sum adjustment: Program to provider Provider to program

1 2 3.01-3.98 3.01-3.49 3.50-3.98

2&4 2&4 1&3 2&4 2&4

11 11 10 11 11

9 9 X 9 9

36-740

Rev. 12

04-05

FORM CMS-2552-96

3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION WORKSHEET E-2 Inpatient routine services - swing bed-SNF Title XVIII, Part B swing-bed days Utilization review - physician compensation for SNF optional method only Amounts paid/payable under workmen's compensation or other primary payers Deductibles, excluding any billed for the professional component of provider based physicians services Coinsurance, excluding any billed for the professional component of provider based physicians services Other adjustments (see instruction) (specify) Other adjustments (see instruction) (specify) Reimbursable bad debts Reimbursable bad debts for dual eligible beneficiaries (see instructions) Sequestration adjustment (see note to Worksheet E, Part A) Interim payments (titles V and XIX only) Protested amounts

LINE(S)

COLUMN(S)

USAGE

1 5 7 9 11 13 16 16 17 17.01 19 20 22

1&2 2 1&2 1&2 1&2 1&2 0 1&2 1&2 1&2 1&2 1&2 1&2

11 11 11 11 11 11 36 11 11 11 7 11 11

9 9 9 9 9 9 X -9 -9 9 9.9(5) 9 -9

WORKSHEET E-3, PART I Inpatient hospital services IRF PPS Payments (for cost reporting periods beginning on or after 1/1/2002 excluding LIP and Outlier Payments) Medicare SSI ratio (IRF PPS only)(see instructions) IRF LIP Payments IRF Outlier Payments Nursing and Allied Health Managed Care payments Inpatient Psychiatric Facility(IPF) Net Federal IPF PPS Payments (excluding outlier, ECT, stop-loss, and medical education payments) Net IPF PPS Outlier Payments Net IPF PPS ECT Payments Unweighted intern and resident FTE count for latest cost report filed prior ro November 15, 2004 New Teaching program adjustment (see instructions) Current year's unweighed FTE count of I&R other than FTE's in the first 3 years of a "new taching program". Current year's unweighed I&R FTE count for residents within the first 3 years of a "new teaching program". Primary payer payments Deductibles - Part A Coinsurance (see instructions) Reimbursable bad debts (see instructions) Reimbursable bad debts for dual eligible beneficiaries (see instructions) Recovery of excess depreciation Other adjustment (see instructions) (specify) Other adjustment (see instructions) (specify) Amount applicable to prior periods - asset disposition Sequestration adjustment (see note to Worksheet E, Part A) Protest amounts 1 1.02 1.03 1.04 1.05 1.07 1 1 1 1 1 1 11 11 7 11 11 11 9 9 9.9(4) 9 9 9

1.08 1.09 1.10 1.11 1.12 1.13 1.14 5 7 9 11 11.02 14 15 15 16 18 21

1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1

11 11 11 11 11 11 11 11 11 11 11 11 11 36 11 11 7 11

9 9 9 9 9 9 9 9 9 9 -9 9 9 X 9 -9 9.9(5) -9

Rev. 14

36-741

3695 (Cont.)

FORM CMS-2552-96

04-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S)

COLUMN(S)

USAGE

WORKSHEET E-3, PART II Nursing and Allied Health Managed Care payments Primary payer payments Routine service charges Ancillary service charges for physicians' professional services (see note to Worksheet E, Part B) Organ acquisition charges, net of revenue Reasonable charges for teaching physicians Aggregate amount collected Amounts collectible Deductibles, excluding any billed for the professional component of PBP services Coinsurance (for SNF, Part A only), excluding any billed for professional component of provider based physicians services Reimbursable bad debts (see instructions) Reimbursable bad debts for dual eligible beneficiaries (see instructions) Recovery of excess depreciation Other adjustments (see instructions) (specify) Other adjustments (see instructions) (specify) Amount applied to prior periods - asset disposition Sequestration adjustment (see note to Worksheet E, Part A) Protest amounts 1.01 5 7 8 9 10 12 13 20 23 25 25.02 27 28 28 29 31 34 1 1 1 1 1 1 1 11 11 11 11 11 11 11 9 9 9 -9 9 9 9

1 1 1 1 1 0 1 1 1 1

11 11 11 11 11 36 11 11 7 11

9 9 -9 9 9 X 9 -9 9.9(5) -9

36-741.1

Rev. 14

3695 (Cont.)

FORM CMS-2552-96

04-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S)

COLUMN(S)

USAGE

WORKSHEET E-3, PART III Organ acquisition (certified transplant centers only) Inpatient primary payer payments Outpatient primary payer payments Routine service charges Ancillary service charges for physicians' professional services (see note to Worksheet E, Part B) Interns and residents service charges Teaching physicians Aggregate amount collected Amount collectible Other than outlier payments Outlier payments Customary charges (title XIX PPS covered services only) Deductibles (exclude professional component) Coinsurance excluding any billed for professional component of provider based physicians services Reimbursable bad debts (see instructions) Reimbursable bad debts for dual eligible beneficiaries (see instructions) Utilization review Medicare inpatient routine charges Aggregate amount collected Amount collectible Recovery of excess depreciation Other adjustment (specify) Other adjustment Amounts applicable to prior periods - asset disposition. Indirect medical education adjustment Sequestration adjustment (see note to Wkst. E, Part A) Interim payments Protested amounts 4 7 8 10 11 12 14 17 18 24 25 31 33 36 38 38.02 39 42 43 44 49 50 50 51 53 56 57 59 1 1&2 1 1 1&2 1 1 1&2 1&2 1&2 1 1 1&2 1&2 1&2 2 1&2 2 2 2 1&2 0 1&2 1&2 1 2 1 1&2 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 36 11 11 11 7 11 11 9 9 9 9 -9 9 9 9 9 9 9 9 9 9 -9 9 9 9 9 9 9 X -9 -9 9 9.9(5) 9 -9

36-742

Rev. 14

05-04

FORM CMS-2552-96

3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S) WORKSHEET E-3, PART IV

COLUMN(S)

USAGE

Direct graduate medical education (GME) and ESRD Outpatient direct medical education costs Number of FTE residents for OB/GYN and primary care (see instructions) Number of FTE residents for all other (see instructions) Update per resident amount for OB/GYN and primary care (see instructions) Update per resident amount for all other (see instructions) Unweighted resident FTE count for allopathic and osteopathic programs for periods ending on or before December 31, 1996 Unweighted resident FTE count for allopathic and osteopathic programs for add on to cap for new programs Unweighted resident FTE count for allopathic and osteopathic programs for affiliated programs Unweighted resident FTE count for allopathic and osteopathic programs for current year from your records Weighted FTE count for primary care physicians in an allopathic and osteopathic program for the current year Weighted FTE count for all other physicians in an allopathic and osteopathic program for the current year Weighted dental and podiatric resident FTE count, current year Total weighted resident FTE count for prior cost reporting year If none, enter 1 here. Total weighted resident FTE count for the penultimate cost reporting year If none, enter 1 here. Rolling average FTE count. Primary care physician per resident amount Other program per resident amount FTE resident count (see instructions) Primary care physician per resident amount Other program per resident amount Other unadjusted approved (see instructions). See instructions. Medicare managed care days occurring on or after January 1 of this cost reporting period Percentage for inclusion of managed care days (see instructions) Medicare managed care days occurring before January 1 of this cost reporting period Percentage using criteria from line 6.04 above (see instructions) Medicare outpatient ESRD charges (see instructions) Part A reasonable cost (see instructions) Part B reasonable cost (see instructions)

1 1.01 2 2.01 3.01 3.02 3.03 3.05 3.07 3.08 3.11 3.13 3.13 3.14 3.14 3.15 3.16 3.17 3.18 3.19 3.20 3.22 3.23 6.02 6.04 6.06 6.07 10 12 17

1 1 1 1 1 1 1 1 0 or 1 0 or 1 0 or 1 1 0 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

9 9 9 9 6 6 6 6 6 6 6 6 1 6 1 6 11 11 11 11 11 11 11 11 4 11 4 11 11 11

9(6).99 9(6).99 9(6).99 9(6).99 9(3).99 9(3).99 -9(3).99 9(3).99 9(3).99 9(3).99 9(3).99 9(3).99 9 9(3).99 9 9(3).99 9(8).99 9(8).99 9 9(8).99 9(8).99 9(8).99 9(8).99 9 9(3).99 9 9(3).99 9 9 9

WORKSHEET E-3, PART V Total demonstration cost 25 1 11 9

WORKSHEET G For all hospitals or hospital complexes: Balance sheet accounts

1-10, 12-20, 22-25, 28-35, 37-41, 44

1

11

-9

Rev. 12

36-743

3695 (Cont.)

FORM CMS-2552-96

05-04

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S) WORKSHEET G (Continued)

COLUMN(S)

USAGE

For hospitals or hospital complexes using fund accounting: Specific purpose fund account balances

Endowment fund account balances

Plan fund account balances

1-10, 12-20, 22-25, 28-32, 34-35, 37-41, 45 1-10, 12-20, 22-25, 28-32, 34-35, 37-41, 46-48 1-10, 12-20, 22-25, 28-32, 34-35, 37-41, 49-50

2

11

-9

3

11

-9

4

11

-9

NOTE: All columns for line 6 and subscripted lines 13.01 through 19.01 should contain negative amounts.

WORKSHEET G-1 For hospitals using fund accounting: Text as needed for blank lines Beginning fund balances Additions and reductions to beginning fund balances

4-9, 12-17 1 4-9, 12-17

0 2, 4, 6, 8 1, 3, 5, 7

36 11 11

X -9 -9

WORKSHEET G-2 Part I: Other patient revenue (specify) Inpatient revenues for routine care by component Inpatient revenues for intensive care by special care unit Total revenues for routine and special care Inpatient ancillary services revenue Outpatient services revenue (associated with admissions) Ambulance revenue (associated with admissions) ASC revenue Hospice revenue Other patient revenue (specify) Inpatient ancillary services revenue (rendered in outpatient) Outpatient services revenue Home health agency revenue Ambulance revenue Outpatient rehabilitation providers ASC revenue Hospice revenue Other outpatient revenue Total inpatient and outpatient revenue Part II: Text as needed for blank lines Increases to operating expenses reported on Worksheet A Decreases to operating expenses reported on Worksheet A Total operating expenses

24 1-9 10-15 16 17 18 20 22 23 24 17 18 19 20 21-21.49 22 23 24 25 27-32, 34-38 27-32 34-38 40

0 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 1-3 0 1 1 2

36 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 36 11 11 11

X 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 X 9 9 9

36-743.1

Rev. 12

08-02

FORM CMS-2552-96

3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION WORKSHEET G-3 Text as needed for blank lines Contractual allowances and discounts on patients' accounts Total operating expenses Other revenues Other expenses Total other expenses Net income

LINE(S)

COLUMN(S)

USAGE

24, 27-29 2 4 6-24 27-29 30 31

0 1 1 1 1 1 1

36 11 11 11 11 11 11

X 9 9 9 9 -9 -9

WORKSHEET H Salaries Employee Benefits Transportation Contracted/Purchased Services Other costs Reclassifications Adjustments Net expense for allocation 3-23 3-23 1-23 3-23 1-23 1-23 1-23 24 1 2 3 4 5 7 9 10 11 11 11 11 11 11 11 11 9 9 9 9 9 -9 -9 9

Note: Line 23.50 for Wksts. H through H-4 and line 19.50 for Wkst. H-5 is to be used exclusively for telemedicine, if applicable. Note: For cost reporting periods beginning on or after 10/1/2000 the amounts in columns 1, 2 and 4 are to be input, and Worksheets H-1, H-2 and H-3 are no longer applicable.

WORKSHEET H-1 Salaries and wages All other 3-12, 15-23 3-23 1-2, 4-7 8 11 11 9 9

WORKSHEET H-2 Employee benefits All other 3-11, 15-23 3-23 1-2, 4-7 8 11 11 9 9

WORKSHEET H-3 Contracted services/purchased services All other 3-11, 15-23 3-23 WORKSHEET H-4, PARTS I & II Part I Total Cost allocation 24 6-23 1-4 6 11 11 9 9 1-7 8 11 11 9 9

Part II Reconciliation 5-23 5A All cost allocation statistics 1-23 1-4* * See note to Worksheet B-1 for treatment of administrative and general accumulated cost column.

11 11

-9 9

Rev. 9

36-743.2

3695 (Cont.)

FORM CMS-2552-96

08-02

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S) WORKSHEET H-5, PARTS I & II

COLUMN(S)

USAGE

Part I Post stepdown adjustment (including total) Total cost after cost finding Total cost

1-20 2-19 20

26 29 0-5 & 6-24

11 11 11

-9 9 9

Part II Centers - Statistical Basis Reconciliation 5-19 6A-24A 11 All cost allocation statistics 1-19 1-24* 11 * See note to Worksheet B-1 for treatment of administrative and general accumulated cost column. Do not include X on line 0 of accumulated cost column since this is a replica of Worksheet B-1.

-9 9

WORKSHEET H-6, PART I Total visits Program visits Cost limits by discipline Program visits by discipline and MSA Total charges for DME rented and sold and medical supplies Charges for medical supplies - Medicare Parts A and B Program unduplicated census from Worksheet S-4 (see instructions) Agency specific per beneficiary annual limitation (from intermediary) 1-6 1-6 8-13 8-13 15-16 15-16 17 18 4 6-7 5 6-7 4 6-8 2 2 11 11 11 11 11 11 11 11 9 9 9(8).99 9 9 9 9(8).99 9(8).99

WORKSHEET H-6, PARTS II & III Part II Total HHA charges HHA shared ancillary costs Part III Cost Per Visit Program Visits prior to 1/1/1998 Program Visits on or after 1/1/1998 and prior to 1/1/1999 Program Visits on or after 1/1/1999

1-5 1-5

2 3

11 11

9 9

1-3 1-3 1-3 1-3

2 2.01 3 5

11 11 11 11

9(8).99 9 9 9

WORKSHEET H-7, PART I Part I Total charges for title XVIII - Parts A and B services Amount collected from patients Amounts collectible from patients Primary payer payments Part II PPS Payments

2 3 4 9 10.01 - 10.14

1-3 1-3 1-3 1-3 1-2

11 11 11 11 11

9 9 9 9 9

36-744

Rev. 9

04-05

FORM CMS-2552-96

3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S) WORKSHEET H-7, PART II

COLUMN(S)

USAGE

Part II (Continued) Part B deductibles billed to Medicare patients Coinsurance billed to Medicare patients Reimbursable bad debts Reimbursable bad debts for dual eligible beneficiaries (see instructions) Amount applicable to prior periods Recovery of excess depreciation Other adjustments (specify) Other adjustments (specify) Sequestration adjustment (see note to Worksheet E, Part A) Interim payments (titles V and XIX only) Protested amounts

11 15 17 17.01 19 20 21 21 23 25 27

2 2 1&2 1&2 1&2 1&2 0 1&2 1&2 1 1&2

11 11 11 11 11 11 36 11 7 11 11

9 9 -9 9 9 -9 X -9 9.9(5) 9 -9

WORKSHEET H-8 Total interim payments paid to provider Interim payments payable Date of each retroactive lump sum adjustment (mm/dd/yyyy) Amount of each lump sum adjustment: Program to provider Provider to program 1 2 3.01-3.98 3.01-3.49 3.50-3.98 2&4 2&4 1&3 2&4 2&4 11 11 10 11 11 9 9 X 9 9

WORKSHEET I-1 Total costs by department Total cost Statistics FTEs per 2080 hours Charges 1-8, 10-16, 18-28, 30-32 33 1-6 1-6 30-32

1 1 3 4 3

11 11 11 11 11

9 9 9(8).99 9(8).99 9

WORKSHEET I-2 EPO costs Totals Columnar totals 14 1-13, 15 & 17 16 6 11 1-8, 10 11 11 11 9 9 9

WORKSHEET I-3 All cost allocation statistics Percentage of time statistics Hourly statistics Inpatient dialysis treatments 2-15 2-15 2-15 12 1, 5-8 2 3&4 0 11 6 11 11 9 9(3).99 9(8).99 9

Rev. 14

36-745

3695 (Cont.)

FORM CMS-2552-96

04-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION WORKSHEET I-4 Total number of outpatient treatments Total CAPD patient weeks Total CCPD patient weeks Number of outpatient treatments - Medicare CAPD patient weeks - Medicare CCPD patient weeks - Medicare Payment rates Total program payment

LINE(S)

COLUMN(S)

USAGE

1-8, 11 9 10 1-8, 11 9 10 1-10 1-11

1 1 1 4 & 4.01 4 & 4.01 4 & 4.01 6 & 6.01 7

11 11 11 11 11 11 6 11

9 9 9 9 9 9 9(3).99 9

WORKSHEET I-5 Part B deductibles billed Part B coinsurance billed Reimbursable bad debts Reimbursable bad debts for dual eligible beneficiaries (see instructions) 3 4 5 5.01 1 1 1 1 11 11 11 11 -9 9 -9 9

WORKSHEET J-1, PART I General Service Cost Allocation Net expenses for cost allocation Post stepdown adjustments (including total) Total (sum of lines 1-21)

1-21 1-22 22

0 26 0-5, 6-24

11 11 11

9 -9 9

WORKSHEET J-1, PART II General Service Cost Statistics Reconciliation Cost allocation statistics

1-21 1-21

6A-24A 1-24*

11 11

-9 9

* See note to Worksheet B-1 for treatment of administrative and general accumulated cost column. Do not include X on line 0 of accumulated cost column. WORKSHEET J-2, PARTS I & II Part I Apportioned Outpatient Rehabilitation Costs Total component charges Title V charges Title XVIII charges Title XIX charges Part II Charges for Allocation of A&G Costs Title V charges Title XVIII charges Title XIX charges

2-19 2-19 2-19 2-19

2 4 6 & 6.01 8

11 11 11 11

9 9 9 9

21-26 21-26 21-26

4 6 & 6.01 8

11 11 11

9 9 9

36-746

Rev. 14

05-04

FORM CMS-2552-96

3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION WORKSHEET J-3 To be completed separately for titles V, XVIII, and XIX (data items apply to titles V, XVIII, and XIX, except as indicated): Cost of component services Cost of health services (see instructions) PPS payments received including outliers Line 1.02 divided by line 1.01 Transitional corridor payment Primary payer payments Total charges for program services Aggregated amount collected Amount collectible Part B deductibles billed Coinsurance billed Reimbursable bad debts Reimbursable bad debts for dual eligible beneficiaries (see instructions) Amounts applicable to prior periods resulting from depreciable asset disposition Recovery of excess depreciation Other adjustments (see instructions) (specify) Other adjustments (see instructions) (specify) Sequestration adjustment (see note to Wkst. E, Part A) Interim payments (titles V and XIX only) Protested amounts

LINE(S)

COLUMN(S)

USAGE

1 1.01 1.02 1.05 1.06 2 4 5 6 12 17 19 19.01 21 22 23 23 25 27 29

1 & 1.01 1 & 1.01 1 & 1.01 1 & 1.01 1 & 1.01 1 & 1.01 1 & 1.01 1 & 1.01 1 & 1.01 1 & 1.01 1 & 1.01 1 & 1.01 1 & 1.01 1 & 1.01 1 & 1.01 0 1 & 1.01 1 & 1.01 1 & 1.01 1 & 1.01

11 11 11 6 11 11 11 11 11 11 11 11 11 11 11 36 11 7 11 11

9 9 9 9(3).99 9 9 9 9 9 9 9 -9 9 9 9 X -9 9.9(5) 9 -9

WORKSHEET J-4 Total interim payments paid to provider Interim payments payable Date of each retroactive lump sum adjustment (mm/dd/yyyy) Amount of each retroactive lump sum adjustment: Program to provider Provider to program 1 2 3.01-3.98 3.01-3.49 3.50-3.98 2 2 1 2 2 11 11 10 11 11 9 9 X 9 9

WORKSHEET K Transportation Other costs Reclassifications Adjustments Net expense for allocation 1-33 1-33 1-33 1-33 34 3 5 7 9 10 11 11 11 11 11 9 9 -9 -9 9

WORKSHEETS K-1, K-2, & K-3 Salaries, benefits & Contract Services 3-19, 22-33 1-8 11 9

Rev. 12

36-747

05-04

FORM CMS-2552-96

3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S) WORKSHEET K-4, PARTS I & II

COLUMN(S)

USAGE

Part I Total Cost allocation

34 7-33

1-5 7

11 11

9 9

Part II Reconciliation 7-33 6A All cost allocation statistics 1-33 1-6* * See note to Worksheet B-1 for treatment of administrative and general accumulated cost column.

11 11

-9 9

WORKSHEET K-5, PARTS I & II Part I Post stepdown adjustment (including total) Total cost after cost finding Total cost

1-29 2-28 29

26 29 0-5, 6-24 & 26

11 11 11

-9 9 9

Part II Centers - Statistical Basis Reconciliation 1-28 6A-24A 11 All cost allocation statistics 1-28 1-24* 11 * See note to Worksheet B-1 for treatment of administrative and general accumulated cost column. Do not include X on line 0 of accumulated cost column since this is a replica of Worksheet B-1.

-9 9

WORKSHEET K-5, PART III Total Hospice Charges (Provider records) 1-10 2 11 9

WORKSHEET L Part I - Fully Prospective Method: Capital hospital specific rate payments Capital DRG other than outlier Capital DRG outlier payments for services on or after 10/01/1997 Total inpatient days available divided by number of days in the cost reporting period. Indirect medical education percentage (see instructions) Percentage of SSI recipient patient days to Medicare Part A patient days. Percentage of Medicaid patient days to total days Allowable disproportionate share percentage (see instructions) Part II - Hold Harmless Method: Total capital payment under 100% Federal rate (see instructions) Factor for hold harmless payment (see instructions) Part IV - Computation of Exception Payments: Applicable exception percentage (see instructions) Percentage adjustment for extraordinary circumstances (see instructions) Carryover of accumulated capital minimum payment level over capital payment (prior year Worksheet L, Part IV, line 14)
*

1 2 3.01 4 4.02 5 5.01 5.03 5 6 4 6 11

1 1 1 1 1 1 1 1 1 1 1 1 1

11 11 11 11 6 6 6 6 11 4 4 4 11

9 9 9 9(8).99 9(3).99 9.9(4) (*) 9.9(4) (*) 9.9(4) (*) 9 9.99 9.99 9.99 -9

For cost reporting periods ending on or after 1/31/2004

36-748

Rev. 12

05-04

FORM CMS-2552-96

3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S) WORKSHEET L-1, PART I

COLUMN(S)

USAGE

Extraordinary capital related costs

Total extraordinary capital related costs Total adjustments after cost finding Total extraordinary capital related costs after cost finding by department

3-31, 33-44, 46-61, 62.01-71, 82-86, 92-94, 96-100 103 103 25-31, 33-44, 46-61, 62.01-71, 82-86, 92-94, 96-100 103

0 0 25

11 11 11

9 9 9

27 27

11 11

9 9

Total extraordinary capital related costs after cost finding in total

WORKSHEET L-1, PART II Computation of program inpatient routine service capital costs for extraordinary circumstances Swing-bed adjustment

25 & 31

2

11

9

WORKSHEET M-1 Provider based cost 1-9, 11-13, 15-20, 23-27, & 29-30

1, 2, 4, 6, & 7

11

-9

WORKSHEET M-2 Number of FTE personnel Total visits Productivity standard * Greater of columns 2 or 4 Parent provider overhead allocated to facility (see instru.) 1-3, & 5-7 1-3, 5-7, & 9 1-3 4 15 1 2 3 5 1 6 11 11 11 11 9(3).99 9 9 9 9

* Use the standard visits per the instructions as the default. Those standards may change if an approved exception is granted. (See Worksheet S-8 for response to approved exception to the standard productivity visits.)

WORKSHEET M-3 Adjusted cost per visit Maximum rate per visit (from your intermediary) Rate for program covered visits Program covered visits excluding mental health services (from your intermediary) Program covered visits for mental health services (from your intermediary) Primary payer payments Beneficiary deductible (from your intermediary) Reimbursable bad debts Reimbursable bad debts for dual eligible beneficiaries (see instructions) 7 8 9 10 12 16.01 17 22 22.01 1 1 & 2*+ 1 & 2*+ 1 & 2*+ 1 & 2*+ 2 2 2 2 6 6 6 11 11 11 11 11 11 9(3).99 9(3).99 9(3).99 9 9 9 9 -9 9

Rev. 12

36-748.1

05-04

FORM CMS-2552-96

3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS FIELD SIZE

DESCRIPTION

LINE(S) WORKSHEET M-3 (Continued)

COLUMN(S)

USAGE

Other adjustments (specify) (see instructions) Other adjustments (specify) (see instructions) Interim payments (titles V and XIX only) Protested amounts

23 23 25 27

0 2 2 2

36 11 11 11

X 9 9 9

* = Providers who answer "Yes" to Worksheet S-8, line 17, add column 3 for the lines asterisked. + = Add column 3 for cost reporting periods overlapping 1/1/2003 and 3/1/2003.

WORKSHEET M-4 Ratio of pneomococcal and vaccine staff time to total health care staff time Medical supplies cost - pneumococcal and influenza vaccine Total number of pneumococcal and influenza vaccine injections Number of pneumococcal and influenza vaccine injections administered to Medicare beneficiaries

2 4 11 13

1&2 1&2 1&2 1&2

8 11 11 11

9.9(6) 9 9 9

WORKSHEET M-5 Total interim payments paid to provider Interim payments payable Date of each retroactive lump sum adjustment (mm/dd/yyyy) Amount of each retroactive lump sum adjustment: Program to provider Provider to program 1 2 3.01-3.98 3.01-3.49 3.50-3.98 2 2 1 2 2 11 11 10 11 11 9 9 X 9 9

Rev. 12

36-749

3695 (Cont.)

FORM CMS 2552-96
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3A - WORKSHEETS REQUIRING NO INPUT

05-04

WORKSHEET S, PART I WORKSHEET A-8-3, PARTS II & III WORKSHEET C, PART V WORKSHEET D, PARTS I & II WORKSHEET D-1, PART IV WORKSHEET D-2, PART III WORKSHEET D-6, PART II WORKSHEET H-4, PART I WORKSHEET K-6 WORKSHEET L-1, PART III

TABLE 3B - TABLES TO WORKSHEET S-2 TABLE I: Type of Control 1= 2= 3= 4= 5= 6= 7= Voluntary Nonprofit, Church Voluntary Nonprofit, Other Proprietary, Individual Proprietary, Corporation Proprietary, Partnership Proprietary, Other Governmental, Federal 8= 9= 10 = 11 = 12 = 13 = Governmental, City-County Governmental, County Governmental, State Governmental, Hospital District Governmental, City Governmental, Other

TABLE II: Type of Hospital 1= 2= 3= 4= 5= General Short Term General Long Term Cancer Psychiatric Rehabilitation 6 = Religious Nonmedical Health Care Institutions 7 = Childrens 8 = Alcohol & Drug 9 = Other

36-750

Rev. 12

04-05

FORM CMS 2552-96
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3C - LINES WHICH CANNOT BE SUBSCRIPTED (BEYOND THOSE PREPRINTED)

3695 (Cont.)

Worksheet S, Part II, lines 1, 3-5, and 100 Worksheet S-2, lines 1-2, 4, 6, 8, 17-19, 21-25.04, 27-30.04, 32-34, 36-38.04, 40-46, 47, 49, 52-52.01, 54.01-55, 57, 58 and 59. (Lines 10, 13, and 39 may not be used.) Worksheet S-3, Part I, lines 1, 3, 5, 11-13, 15-17, 25, and 27-27.03. (Lines 19 and 22 may not be used.) Worksheet S-3, Parts II and III Worksheet S-4, lines 1-17 and 19 Worksheet S-5 Worksheet S-6, lines 1-17, 19 Worksheet S-7 Worksheet S-8, lines 1-7, 11, and 13 Worksheet S-9, Parts I and II Worksheet S-10 Worksheet A, lines 25, 33-34, 36, 45, 57, 64, 65, 70, 82-84, 88-90, and 101 (Lines 32, 62, 72-81, 87, and 91 may not be used.) Worksheet A-6 Worksheet A-7, Parts I and II Worksheet A-7, Part III, line 5 Worksheet A-8, lines 5-24, 28, and 34 Worksheet A-8-1, Part A, lines 1-3 Worksheet A-8-1, Part B, lines 1-4 Worksheet A-8-2 Worksheet A-8-3 (except lines 8, 9, 15, 16, 41-51, 64, 72, 75, and 77) Worksheet A-8-4 (except lines 12, 13, 66, and 69) Worksheet B, Parts I-III, lines 25, 33-34, 36, 45, 57, 64, 65, 70, 82-84, and 101-103 (Lines 32, 72-81, and 87-91 may not be used.) Worksheet B-1, lines 25, 33-34, 36, 45, 57, 64, 65, 70, 82-84, and 101-108 (Lines 32, 72-81, and 87-91 may not be used.) Worksheet B-2 Worksheet C, Part I, lines 33-34, 36, 45, 57, 64, 65, and 101-103 Worksheet C, Part II, Lines 45, 57, 65, and 101-103 Worksheet D, Part III, lines 25, 33, and 101 Worksheet D, Part IV, lines 45, 57, 64, and 101 Worksheet D, Part V, lines 45, 57, 64 and 101-104 Worksheet D-1, Part I Worksheet D-1, Part II, (except lines 43-47) Worksheet D-1, Part III Worksheet D-2, Part I, lines 2, 8-9, 12-14, and 24 Worksheet D-2, Part II, lines 26-28 Worksheet D-4, line 25, 45, 57, 64, 65, and 101 Worksheet D-6, Part I, lines 1, 16, and 28 Worksheet D-6, Parts III and IV Worksheet D-9, Parts I and II Worksheet E, Part A (except lines 24, 50-53) Worksheet E, Part B (except line 30) Worksheet E, Parts C, D, and E Worksheet E-1, lines 1, 2, 3.01-3.04, and 3.50-3.53 Worksheet E-2 (except line 16)

Rev. 14

36-751

3695 (Cont.)

FORM CMS 2552-96
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3C - LINES WHICH CANNOT BE SUBSCRIPTED (BEYOND THOSE PREPRINTED)

04-05

Worksheet E-3, Part I (except line 15) Worksheet E-3, Part II (except line 28) Worksheet E-3, Part III (except line 50) Worksheet E-3, Part IV Worksheet E-3, Part V (except lines 10-24) Worksheet G Worksheet G-1, line 1 Worksheet G-2, Part I, lines 1, 4-7.01, 8-9, 15-17, and 25 Worksheet G-2, Part II, line 40 Worksheet G-3, lines 2, 4, 6-23, and 30-31 Worksheet H (except line 23) Worksheet H-1 (except line 23) Worksheet H-2 (except line 23) Worksheet H-3 (except line 23) Worksheet H-4, Parts I and II (except line 23) Worksheet H-5, Parts I and II (except line 19) Worksheet H-6, Part I (except lines 8-13 and 17-18) Worksheet H-6, Parts II and III Worksheet H-7, Parts I and II (except line 21) Worksheet H-8, lines 1-3.04 and 3.50-3.53 Worksheet I-1 (except line 32) Worksheet I-2 Worksheet I-3 Worksheet I-4 Worksheet I-5 Worksheet J-1, Parts I and II Worksheet J-2, Part I Worksheet J-3 (except line 23) Worksheet J-4, lines 1-3.04 and 3.50-3.53 Worksheet K Worksheet K-1 Worksheet K-2 Worksheet K-3 Worksheet K-4, Part I Worksheet K-4, Part II Worksheet K-5, Part I Worksheet K-5, Part II Worksheet K-6 Worksheet L Worksheet L-1, Part I, lines 25, 33-34, 36, 45, 57, 64, 65, 70, 82-84, and 103 (Lines 32, 72-81, and 87-91 may not be used.) Worksheet L-1, Part II, line 25 Worksheet M-1 Worksheet M-2 Worksheet M-3 (except line 23) Worksheet M-4 Worksheet M-5, lines 1-3.04 and 3.50-3.53

36-752

Rev. 14

04-05

FORM CMS 2552-96
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 3D - PERMISSIBLE PAYMENT MECHANISMS

3695 (Cont.)

P = Prospective Payment Component Hospital Subprovider Swing-Bed SNF Swing-Bed NF SNF NF ICF/MR HHA ASC (Distinct Part) RHC FQHC CORF CMHC OPT OOT OSP

T = TEFRA

O = Other

N = Not applicable Title XVIII P, T, or O P, T, or O P or O * P * * P or O O O O O O O O O Title XIX P, T, or O P, T, or O P or O O P or O P or O O P or O O O O O O O O O

Title V P, T, or O P, T, or O P or O O P or O P or O O P or O O O O O O O O O

(b) (a)

(a) The payment mechanism for Swing Bed SNF will be "O" for Cost reporting periods beginning before 7/1/2002 and "P" for cost reporting period periods beginning on or after 7/1/2002 for Title V, XVIII and XIX. (b) For CAH the payment method should be "O" since they are paid under cost. TABLE 3E - LINE NUMBERING FOR SPECIAL CARE UNITS Cost center integrity for variable worksheets (listed below) must be maintained throughout the cost report. If you use a line designated as "(specify)" or subscript a line, the relative position must flow throughout the cost report. EXAMPLE: If you add a special care unit after the surgical intensive care unit on line 6 of Worksheet S-3, Part I, it must also be on the first additional special care unit line of Worksheet A (line 30), Worksheet D-1, Part II (line 47), Worksheet D-2, Part I (line 7), etc.

Worksheet S-3, Part I A B, Parts I-III B-1 L-1, Part I C, Part I D, Part I D-1, Part II D-2, Part I D-2, Part II D-6, Part I D-6, Part II G-2, Part I

Burn Care 8 28 " " " " " 45 5 31 4 39 12

Surgical Care 9 29 " " " " " 46 6 32 5 40 13

Lines for Additional Special Care Units #1 #2 10 10.01 30 30.01 " " " " " " " " " " 47 47.01 7 7.01 33 33.01 6 6.01 41 41.01 14 14.01

#3 10.02 30.02 " " " " " 47.02 7.02 33.02 6.02 41.02 14.02

Rev. 14

36-753

3695 (Cont.)

FORM CMS 2552-96
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 4 - NUMBERING CONVENTION FOR MULTIPLE COMPONENTS

04-05

This table provides line and column numbering conventions for health care complexes with more than one hospital-based component of the same kind. Table 4 is necessary to insure that data associated with each component is consistently identified throughout the cost report. This table provides for four additional components. Component II is subline .01, component III is .02, component IV is .03, and component V is .04. The only deviation from this subline numbering is to CMHC component on Worksheets S-2 and S-3 as listed below. Providers should continue this numbering conventions for multiple components in excess of five (5) components. SUB LINES

WKST I.

PART

COLUMNS

LINES

For use in facilities with more than one subprovider S S-2 S-2 S-2 S-3 S-3 A B B B B-1 C D D-2 D-2 G-2 L-1 L-1 II 1-4 1-6 1 1 1-8 & 10-15 6 1-2 & 7 27 0, 27 0, 27 1-24 6-7 1, 2 1, 6 6 1 0,27 2 2 3 20 35 14 26* 31 31 31 31 31 31 31 10 35 2 31 31 1-9 1-9 1-9 1-9 1-9 1-2 1-9 1-9 1-9 1-9 1-9 1-9 1-9 1-9 1-9 1-9 1-9 1-9

SUBPROVIDER II-X SUBPROVIDER II-X SUBPROVIDER II-X SUBPROVIDER II-X SUBPROVIDER II-X SUBPROVIDER I-II SUBPROVIDER II-X SUBPROVIDER II-X SUBPROVIDER II-X SUBPROVIDER II-X SUBPROVIDER II-X SUBPROVIDER II-X SUBPROVIDER II-X SUBPROVIDER II-X SUBPROVIDER II-X SUBPROVIDER II-X SUBPROVIDER II-X SUBPROVIDER II-X

I I I II III I III I II I I II

* This line may only be subscripted for those subproviders with all numberic provider numbers and is an exception to the additional component ruling above. Subprovider I will be subline 26.01 and is limited to two components. II. For use in facilities with more than one HHA HHA II-X HHA II-X HHA II-X HHA II-X HHA II-X HHA II-X HHA II-X HHA II-X HHA II-X HHA II-X HHA II-X HHA II-X HHA II-X HHA II-X S S-2 S-3 A A-8-3 A-8-3 A-8-3 A-8-3 B B B B-1 G-2 L-1 II I I I IV VI-VII I II III I I 1-4 1-6 3-8 & 10-11 1-2 & 7 1 4, 8, & 9 1 1 27 0, 27 0, 27 1-24 2 0, 27 7 9 18 71 8-9 15-16 41-51 64, 72, 75, & 77 71 71 71 71 19 71 1-9 1-9 1-9 1-9 1-9 1-9 1-9 1-9 1-9 1-9 1-9 1-9 1-9 1-9

36-754

Rev. 14

09-01

FORM CMS 2552-96
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 4 - NUMBERING CONVENTION FOR MULTIPLE COMPONENTS SUB LINES

3695 (Cont.)

WKST

PART

COLUMNS

LINES

III. For use in facilities with multiple outpatient rehabilitation facilities * O/P Rehab. Provider O/P Rehab. Provider O/P Rehab. Provider O/P Rehab. Provider O/P Rehab. Provider O/P Rehab. Provider O/P Rehab. Provider O/P Rehab. Provider O/P Rehab. Provider O/P Rehab. Provider O/P Rehab. Provider S S-2 S-3 A B B B B-1 D-2 G-2 L-1 II I I II III 1 & 3-4 1-6 7-8 & 10-11 1-2 & 7 27 0, 27 0, 27 1-24 1 2 0, 27 8 15 23 69 69 69 69 69 16 21 69 0-49 0-49 0-49 0-49 0-49 0-49 0-49 0-49 0-49 0-49 0-49

I I

* Subscripts for this line are CORF 00-09, CMHC 10-19, OPT 20-29, OOT 30-39, and OSP 40-49.

IV. For use in facilities with multiple RHC/FQHC providers * RHC/FQHC (specify) Hospital Based Clinic RHC/FQHC (specify) Other O/P Service Other O/P Service Other O/P Service Other O/P Service Other O/P Service Other O/P Service Other O/P Service Other O/P Service Other O/P Service Other O/P Service Other O/P Service Other O/P Service Other O/P Service S S-2 S-3 A B B B B-1 D D D D-2 D-4 D-6 G-2 L-1 II I I II III II IV V I I I I 1 & 3-4 1-6 7-8 & 10-11 1-2 & 7 27 0, 27 0, 27 1-24 4 1-2 & 6 1-5 1, 5-7 2 2 2 0, 27 9 14 24 63 63 63 63 63 63 63 63 23 63 34 18 63 0-50 0-50 0-50 50-99 50-99 50-99 50-99 50-99 50-99 50-99 50-99 50-99 50-99 50-99 50-99 50-99

* Subscripts for Worksheets S, S-2 and S-3 are RHC 00-09, 35-50 and FQHC 10-34. For all other worksheets which are on line 63, subscripts are RHC 50-59, 85-99 and FQHC 60-84.

Rev. 8

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10-96

FORM CMS 2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 5 - COST CENTER CODING INSTRUCTIONS FOR PROGRAMMERS

3695 (Cont.)

Cost center coding is required because there are thousands of unique cost center names in use by providers. Many of these names are peculiar to the reporting provider and give no hint as to the actual function being reported. By using codes to standardize meanings, practical data analysis becomes possible. The methodology to accomplish this must be rigidly controlled to enhance accuracy. For any added cost center names (the preprinted cost center labels must be precoded), the preparer must be presented with the allowable choices for that line or range of lines from the lists of standard and nonstandard descriptions. They will then select a description that best matches their added label. The code associated with the matching description, including increments due to choosing the same description more than once, will then be appended to the user's label by the software. Additional guidelines are: o o o Any pre-existing codes for the line must not be allowed to carry over. All "Other . . ." lines must not be precoded. The order of choice is standard first, followed by specific nonstandard, and, lastly, the nonstandard "Other . . ." cost centers. When the nonstandard "Other . . ." is chosen, the preparer must be prompted with "Is this the most appropriate choice?" and offered a chance to answer yes or to select another description. The cost center coding process must be able to be invoked again for purposes of making corrections. A separate list showing the preparer's added cost center names on the left with the chosen standard or nonstandard description and code on the right must be printed for review. The number of times a description can be selected on a given report must be displayed on the screen next to the description and this number must decrease with each usage to show the remaining numbers available. The numbers are shown on the standard and nonstandard cost center tables. Standard cost center lines, descriptions, and codes are not to be changed. The acceptable format for these are displayed in the STANDARD COST CENTER DESCRIPTIONS AND CODES listed on pages 28-760 and 28-761. The proper line number is the first two digits of the cost center code. The only exceptions to the descriptions are: "Paramedical Education Program-(specify)" for which the parenthesis and specify are to be replaced by the program name, i.e., Radiology, Cytotechnology; and "Other Organ Acquisition (specify)" should be changed to specify the acquisition as listed on lines 82-85. All "Other" nonstandard lines should be changed to the appropriate cost center name and "Subprovider (specify)" type should be indicated, i.e., rehabilitation, psychiatric. etc.

o

o o

o

o

Rev. 1 3695 (Cont.)

FORM CMS 2552-96

36-757 10-96

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-92 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 5 - COST CENTER CODING INSTRUCTIONS FOR PREPARERS Coding of Cost Center Labels Cost center coding is a methodology for standardizing the meaning of cost center labels as used by hospitals on the Medicare cost report. The use of this coding methodology allows providers to continue to use their labels for cost centers that have meaning within the individual institution. The four digit codes that are required to be associated with each label provide standardized meaning for data analysis. Normally, it is only necessary to code any added labels because the preprinted STANDARD labels are automatically coded by CMS approved cost report software. Additional cost center descriptions have been identified through analysis of provider labels. The meanings of these additional descriptions were sufficiently different when compared to the Standard labels to warrant their use. These additional descriptions are hereafter referred to as the NONSTANDARD labels. Included with the nonstandard descriptions are "Other . . ." designations to provide for situations where no match in meaning can be found. Refer to Worksheet A, lines 19, 30, 59, 63, 68, 94, and 100. Both the standard and nonstandard cost center descriptions along with their cost center codes are shown on Table 5. The "USE" column on that table indicates the number of times that a given code can be used on one cost report. You are required to compare your added label to the descriptions shown on the standard and nonstandard table for purposes of selecting a code. Most CMS approved software provides an automated process to present you with the allowable choices for the line/column being coded and automatically associate the code for the selected matching description with your label. Additional Guidelines Categories You must make your selection from the proper category such as general service description for general service lines, ancillary descriptions for ancillary cost center lines, etc. Additional Hospital-Based Components The Form CMS 2552-96 provides a preprinted label for one subprovider on line 31. However, this designation should be changed to coincide with the specific provider name. Where the preparer has the need to report two or more subproviders, line 31 must be subscripted as needed. After the provider's label for the first subprovider is entered, the standard description for subprovider (code 3100) is selected. The preparer then enters the provider's label for the second subprovider on subscripted line 31.01. The appropriate description "subprovider" is again selected as the correct match. The standard code 3100, incremented by one (3101), is applied to the second subprovider. Additional subproviders are handled in the same manner. This same procedures applies to all multiple components. (See Table 4.) Lines 69 and 86 require specific designations from the nonstandard cost center listing.

36-758 11-00

FORM CMS 2552-96

Rev. 1 3695 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 5 - COST CENTER CODING

Intensive Care Cost Centers When an intensive care type of cost center label is added and it does not closely match the standard or nonstandard cost center descriptions, then a subscript of the intensive care description (code 2600) should be used or a nonstandard code, i.e., 2601-2629 and/or one of the nonstandard inpatient routine service cost center codes. There is no "Other Intensive Care" description available. Use of Cost Center Coding Description More Than Once Often a description from the standard or nonstandard tables applies to more than one of the labels being added by the preparer. In the past, it was necessary to determine which code was to be used and then increment the code number upwards by one for each subsequent use. This was done to provide a unique code for each cost center label. Now, most approved software associate the proper code, including increments as required, once a matching description is selected. Remember to use your label. You are matching to CMS's description only for coding purposes. Cost Center Coding and Line Restrictions Cost center codes may only be used in designated lines in accordance with the classification of the cost center(s), i.e., lines 1 through 24 may only contain cost center codes within the general service cost center category of both standard and nonstandard coding. For example, in the general service cost center category for Operation of Plant cost, line 8 and subscripts thereof should only contain cost center codes of 0800-0819 and nonstandard cost center codes. This logic must hold true for all other cost center categories, i.e., ancillary, inpatient routine, outpatient, other reimbursable, special purpose, and nonreimbursable cost centers. There are exceptions, which are contained in Table 6 edits. An example of an exception is A&G cost. Line 6 and subscripts thereof may only contain cost center codes of 0600, 0610-0669, 1080-1099, and 1140-1179 (standard and nonstandard cost center codes). Other cost center lines contain exceptions that only the standard cost center codes and subscripts (usage) of that code may be used on that line and subscripts of that line. These exceptions are also contained in Table 6.

Rev. 7

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3695 (Cont.)

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 5 - STANDARD COST CENTER DESCRIPTIONS AND CODES
CODE USE CODE ANCILLARY SERVICE COST CENTERS (Continued) 0100 0200 0300 0400 0500 0600 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 2000 2100 2200 2300 2400 (50) (50) (50) (50) (20) (01) (20) (20) (20) (20) (20) (20) (20) (20) (20) (20) (20) (20) (20) (20) (20) (20) (100) Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Electroencephalography Med Supplies Charged to Patient Drugs Charged to Patients Renal Dialysis ASC (Non-Distinct Part) OUTPATIENT SERVICE COST CENTERS Clinic Emergency Observation Beds (Non-Distinct Part) OTHER REIMBURSABLE COST CENTERS Home Program Dialysis Ambulance Services Durable Medical Equip. - Rented Durable Medical Equip. - Sold I&R Services - Not Apprvd. Prgm. Home Health Agency SPECIAL PURPOSE COST CENTERS Lung Acquisition Kidney Acquisition Liver Acquisition Heart Acquisition Interest Expense Utilization Review - SNF Other Capital Related Costs Ambulatory Surgical Center (D.P.) Hospice NONREIMBURSABLE COST CENTERS 8200 8300 8400 8500 8800 8900 9000 9200 9300 6400 6500 6600 6700 7000 7100 6000 6100 6200 4900 5000 5100 5200 5300 5400 5500 5600 5700 5800

11-00

USE

GENERAL SERVICE COST CENTERS Old Cap Rel Costs-Bldg & Fixt Old Cap Rel Costs-Mvble Equip New Cap Rel Costs-Bldg & Fixt New Cap Rel Costs-Mvble Equip Employee Benefits Administrative & General Maintenance & Repairs Operation of Plant Laundry & Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services & Supply Pharmacy Medical Records & Library Social Service Nonphysician Anesthetists Nursing School I&R Services-Salary & Fringes Apprvd I&R Services-Other Prgm. Costs Apprvd Paramed. Ed. Prgm.-(specify) INPATIENT ROUTINE SERVICE COST CENTERS Adults & Pediatrics Intensive Care Unit Coronary Care Unit Burn Intensive Care Unit Surgical Intensive Care Unit Subprovider (specify) Nursery Skilled Nursing Facility Nursing Facility Other Long Term Care ANCILLARY SERVICE COST CENTERS Operating Room Recovery Room Delivery Room & Labor Room Anesthesiology Radiology - Diagnostic Radiology - Therapeutic Radioisotope Laboratory PBP Clinical Lab. Service - Prgm. Only Whole Blood & Packed Red Blood Cells Blood Storing, Processing, & Trans. Intravenous Therapy 3700 3800 3900 4000 4100 4200 4300 4400 4500 4600 4700 4800 (30) (30) (30) (30) (30) (30) (30) (30) (01) (30) (30) (30) 2500 2600 2700 2800 2900 3100 3300 3400 3500 3600 (01) (20) (20) (20) (20) (10) (01) (01) (01) (01)

(30) (30) (30) (30) (30) (30) (30) (30) (01) (30)

(99) (20) (01)

(01) (01) (20) (20) (01) (10)

(01) (01) (01) (01) (01) (01) (01) (20) (05)

Gift, Flower, Coffee Shop, & Canteen Research Physicians' Private Offices Nonpaid Workers

9600 9700 9800 9900

(20) (20) (20) (20)

36-760

Rev. 7

04-05

FORM CMS-2552-96 3695 (Cont.) ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 5 - NONSTANDARD COST CENTER DESCRIPTIONS AND CODES
CODE USE CODE ANCILLARY SERVICE COST CENTERS (Continued) 0610 0620 0630 0640 0650 0660 1080 1140 1160 1950 (10) (10) (10) (10) (10) (10) (20) (20) (20) (50) Magnetic Resonance Imaging (MRI) Mammography Nuclear Medicine - Diagnostic Nuclear Medicine - Therapeutic Oncology Ophthalmology Osteopathic Therapy Prosthetic Devices Psychiatric/Psychological Services Pulmonary Function Testing Recreational Therapy Stress Test Ultra Sound Urology Vascular Lab Other Ancillary Service Cost Centers Blood Clotting for Hemophiliacs OUTPATIENT SERVICE COST CENTERS Family Practice Telemedicine Other Outpatient Service Cost Centers Observation Beds (Distinct Part) Rural Health Clinic Rural Health Clinic (Continued) Federally Qualified Health Center OTHER REIMBURSABLE COST CENTERS Other Reimbursable Cost Centers Support Surfaces - Rented Support Surfaces - Sold Outpatient Rehabilitation Providers: CORF CMHC OPT OOT OSP SPECIAL PURPOSE COST CENTERS Other Special Purpose Cost Centers Pancreas Acquisition Intestinal Acquisition Other Organ Acquisition (specify) NONREIMBURSABLE COST CENTERS Other Nonreimbursable Cost Centers 7950 (50) 6950 8510 8520 8600 (50) (01) (01) (20) 5950 6620 6720 6900 6910 6920 6930 6940 (50) (05) (05) (10) (10) (10) (10) (10) 4040 4050 4950 6201 6310 6350 6320 (10) (10) (50) (10) (10) (15) (25) 3430 3440 3450 3470 3480 3520 3530 3540 3550 3560 3580 3620 3630 3640 3650 3950 4650 (10) (10) (10) (10) (10) (10) (10) (10) (10) (10) (10) (10) (10) (10) (10) (50) (1) USE

GENERAL SERVICE COST CENTERS Nonpatient Telephones Data Processing Purchasing Receiving and Stores Admitting Cashiering/Accounts Receivable Other Administrative and General Inservice Education Management Services Communications Other General Service Cost Center INPATIENT ROUTINE SERVICE COST CENTERS Detoxification Intensive Care Unit Neonatal Intensive Care Unit Pediatric Intensive Care Unit Premature Intensive Care Unit Psychiatric Intensive Care Unit Trauma Intensive Care Unit ICF/MR ANCILLARY SERVICE COST CENTERS Acupuncture Angiocardiography Audiology Bacteriology & Microbiology Biopsy Birthing Center Cardiac Catheterization Laboratory Cardiology Cardiopulmonary Chemistry Chemotherapy Circumcision CAT Scan Cytology Dental Services Echocardiography EKG and EEG Electromyography Electroshock Therapy Endoscopy Gastro Intestinal Services Hematology Histology Holter Monitor Immunology Laboratory - Clinical Laboratory - Pathological 3020 3030 3040 3050 3060 3070 3120 3140 3160 3180 3190 3220 3230 3240 3250 3260 3280 3290 3320 3330 3340 3350 3360 3370 3380 3390 3420 (10) (10) (10) (10) (10) (10) (10) (20) (20) (10) (10) (10) (10) (10) (10) (10) (10) (10) (10) (10) (10) (10) (10) (10) (10) (10) (10) 2040 2060 2080 2120 2140 2180 3510 (20) (20) (20) (20) (20) (20) (01)

Rev. 14

36-761

3695 (Cont.) FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Medicare cost reports submitted electronically must meet a variety of edits. These include mathematical accuracy edits, certain minimum file requirements, and other data edits. Any vendor software which produces an electronic cost report file for Medicare hospitals must automate all of these edits. Failure to properly implement these edits may result in the suspension of a vendor's system certification until corrective action is taken. The vendor's software should provide meaningful error messages to notify the hospital of the cause of every exception. The edit message generated by the vendor systems must contain the related 4 digit and 1 alpha character, where indicated, reject/edit code specified below. Any file submitted by a provider containing a level I edit will be rejected by the fiscal intermediary. Notification must be made to CMS for any exceptions. The edits are applied at two levels. Level I edits (1000 series reject codes) are those which test the format of the data to identify for correction of those error conditions which will result in a cost report rejection. These edits also test for the presence of some critical data elements specified in Table 3. Level II edits (2000 series edit codes) identify potential inconsistencies and/or missing data items. These items should be resolved at the provider site and appropriate worksheets and/or data submitted with the cost report. Failure to submit the appropriate data with your cost report may result in payments being withheld pending resolution of the issue(s). The vendor requirements (above) and the edits (below) reduce both intermediary (FI) processing time and unnecessary rejections. Vendors should develop their programs to prevent their client hospitals from generating an electronic cost report file where Level I edits conditions exist. Ample warnings should be given the provider where Level II edit conditions are violated.

04-05

The Level I edit conditions are to be applied against title XVIII services only. However, any inconsistencies and/or omission which would cause a Level I condition for non title XVIII services should be resolved prior to acceptance of the cost report. [12/31/1999]
Note: Dates in brackets [ ] at end of edit indicate effective date of that edit for cost reporting periods ending on or after that date. Dates followed by a "b" are for cost reporting periods beginning on or after and the date followed by an "s" are for services rendered on or after the specified date. [9/30/2000] I. Level I Edits (Minimum File Requirements) Edit 1000 1005 1010 Condition The first digit of every record must be either 1, 2, 3, or 4 (encryption code only). [9/30/1996] No record may exceed 60 characters. [9/30/1996] All alpha characters must be in upper case. This is exclusive of the vendor information, type 1 record, record number 3 and the encryption code, type 4 record, record numbers 1, 1.01, and 1.02. [9/30/1997] For micro systems, the end of record indicator must be a carriage return and line feed, in that sequence. [9/30/1996] The hospital provider number (record #1, positions 17-22) must be valid and numeric. [ 9/30/1996]

1015

1020

36-762

Rev. 14

04-05

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Condition All dates (record #1, positions 23-29, 30-36, 45-51, and 52-58) must be in Julian format and a possible date. [ 9/30/1998] The fiscal year beginning date (record #1, positions 23-29) must be less than the fiscal year ending date (record #1, positions 30-36). [ 9/30/1998] The cost reporting period must be greater than 27 days and less that 459 days. [4/30/2005] The vendor code (record #1, positions 38-40) must be a valid code. [9/30/1996] The inpatient and outpatient capital reduction rates and the outpatient reasonable cost reduction rate (type 1 records #4-#6, respectively) must be present and in the proper format. Only published rates may be displayed in these records which are applicable for the period and not the provider type. [9/30/1996] The type 1 record #1 must be correct and the first record in the file. [9/30/1996] All record identifiers (positions 1-20) must be unique. [9/30/1996] NOTE: FIs attempt to correct if all record identifiers are not unique in their working copy and continue processing the cost report. If the condition is correctable, they notify the provider's vendor and send copy of ECR file both to the vendor and CMS Central Office. CMS Central Office requires a vendor software update to resolve condition. [9/30/1997]

3695 (Cont.)

Edit 1025

1030

1032 1035 1045

1050 1055

1060 1065

Only a Y or N are valid for fields which require a yes/no response. [9/30/1996] Variable columns (Worksheet B, Parts I, II, and III and Worksheet B-1) must have a corresponding type 2 record (Worksheet A label) with a matching line number. [9/30/1996] All line, subline, column, and subcolumn numbers (positions 11-13, 14-15, 16-18, and 19-20, respectively) must be numeric, except as noted below for reconciliation columns. [9/30/1996] NOTE: If the administrative and general (A&G) cost center (Worksheet A, line 6) is fragmented into two or more cost centers, then line 6 must be deleted. Fragmented A&G lines must be in sequential order. Any cost center with accumulated costs as its statistic must have its Worksheet B-1 reconciliation column numbered the same as its Worksheet A line number followed by an "A" as part of the line number followed by the subline number. For example, the following cost centers appear on Worksheet A, lines 6.01 to 6.06. 6.01 Nonpatient telephones 6.02 Data processing 6.03 Purchasing, receiving, and stores 6.04 Admitting 6.05 Cashiering/accounts receivable 6.06 Other administrative and general 0610 0620 0630 0640 0650 0660

1070

Rev. 14

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3695 (Cont.) FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Edit Condition If line 6.06, other administrative and general, is allocated based on accumulated cost, then the reconciliation column must be numbered 6A.06. This edit does not require consecutive numbering, only sequential. Line numbers may be skipped but must be in sequential order, e.g., 6.01, 6.02, 6.04, 6A.06. [9/30/1997] 1075 Cost center integrity for variable worksheets must be maintained throughout the cost report. For subscripted lines, the relative position must be consistent throughout the cost report. (See Table 3E). [9/30/1996] An exception to the rule is subscripts of line 65 on Worksheet D, Part V, line 65.01 through 65.04 should be excluded from this check. [4/1/2002s] EXAMPLE: If you add a neonatal intensive care unit on line 6 of Worksheet S-3, Part I, it must also be on the first other special care unit line of Worksheet A (line 30), Worksheet D-1, Part II (line 47), Worksheet D-2, Part I (line 7), etc. 1080 For every line used on Worksheets A; B, Part I; C, Part I; D, Part V; and D-4, there must be a corresponding type 2 record. [9/30/1996] An exception to this requirement is subscripts of line 65 on Worksheet D, Part V, line 65.01 through 65.04. These subscripted lines should be excluded from this edit check. [4/1/2002s] Bad debt for dual eligible beneficiaries new amounts cannot exceed total bad debts (e.g. for Worksheet E Part A, line 21.02, must be less than or equal to line 21"). Do not apply this edit if the total bad debt line is negative. This edit applies to the following worksheets: E, Part A, line 21; E, Part B, line 27; E-2, line 17; E-3, Part I, line 11; E-3 Part II, line 25; E-3, Part III, line 38; H-7 line 17; I-5, line 5; J-3, line 19; and M-3, line 22. [4/1/2004b] Fields requiring numeric data (days, charges, discharges, costs, FTEs, etc.) may not contain any alpha character. [9/30/1996] A numeric field cannot exceed more than 11 positions. Apply to settled and reopened cost reports only. [4/30/2005] In all cases where the file includes both a total and the parts which comprise that total, each total must equal the sum of its parts. [9/30/1996] EXAMPLE: The inpatient departmental charges on Worksheet C, Part I, column 6, sum of lines 25-68 must equal total departmental charges as reported on Worksheet C, Part I, column 6, line 101. 1000S The hospital address, city, state, zip code and county (Worksheet S-2 lines 1 and 1.01, columns 1, 2, 3, and 4, respectively) must be present and valid. [2/29/2004] The cost report ending date (Worksheet S-2, column 2, line 17) must be on or after 9/30/96. [9/30/1996] The type of control (Worksheet S-2, column 1, line 18) must be present and a valid code of 1 thru 13. [2/29/2004]

04-05

1085

1090

1095

1100

1005S

1007S

36-764

Rev. 14

04-05

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Condition All provider and component numbers displayed on Worksheet S-2, column 2, lines 2-7 and 9-16 must contain six (6) alphanumeric characters. [9/30/1996] The cost report period beginning date (Worksheet S-2, column 1, line 17) must precede the cost report ending date (Worksheet S-2, column 2, line 17). [9/30/1996]

3695 (Cont.)

Edit 1010S

1015S

1020S

The hospital name, provider number, certification date, and title XVIII payment mechanism (Worksheet S-2, line 2, columns 1, 2, 3, and 5, respectively) must be present and valid. [9/30/1996] Moved to a level II Edit 2022S. If Worksheet S-2, either of lines 2 or 3, column 5 is P, Worksheet S-3, Part II, column 1, sum of lines 2-35 must be greater than zero. This edit applies to Short Term Acute Care Hospitals subject to PPS but not an LTCH (Provider number 2000-2299), an IRF (Provider number 3025-3099), or a Psychiatric (Provider number 4000-4499), or if the third digit of the provider number is an "S" or a "T". [1/1/2002b] For each provider name reported (Worksheet S-2, column 1, lines 2-7 and 9-16), there must be corresponding entries made on Worksheet S-2, lines 2-7 and 9-16 for the provider number (column 2), the certification date (column 3), and the payment system for either titles V, XVIII, or XIX (columns 4, 5, or 6, respectively except lines 12 and 16) indicated with a valid code (P, T, O, or N). (See Table 3D.) If there is no component name entered in column 1, then columns 2 through 6 for that line must also be blank. [8/31/2000] For Fiscal years ending 08/01/2000 to 02/28/2004, Worksheet S-2, line 21, 21.01 and 21.02 must have a response in the ECR File. For Fiscal years ending 02/29/2004 and after, Worksheet S-2, line 21.03, column 1 and 4 must have a response in the ECR File. If line 21.03 column 1 is "1" for Urban, then line 21.03 column 2 must be present in the ECR File. If line 21.03, column 2 is "Y", then column 3 must contain a date within the cost reporting fiscal year. [02/29/2004] On Worksheet S-2, there must be a response in every file in column 1, lines 17-19, 21-23 , 25, 25.01 (when line 25 =Y) , 25.04, 27, 29-30, 31-33, 35, 38, 40-43, 45, 52, 56 , 57 and applicable subscripts (for services rendered on or after 1/1/2000) and column 2, line 17. [08/31/2000] NOTE: Line 35 contains a default response of "N" for facilities which do not contain a subprovider type component. [3/31/2000]

1022S 1025S

1030S

1034S

1035S

1036S

If there is an IRF (S-2, line 2 or 3 and subscript, column 2 is in the range of 3025 to 3099, or there is a “T” in the third position of the provider number), for cost reporting periods beginning on or after 1/1/2002, S-2, line 58, column 1 must be "Y" and for cost reporting periods beginning on or after 1/1/2002 and before 10/1/2002, column 2 must be "Y" or "N". If there is not an IRF as the provider or subprovider, then Worksheet S-2, line 58, column 1 must be "N". [01/01/2002b]

Rev. 14

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3695 (Cont.) FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Edit 1037S Condition For CAH, if Worksheet S-2, column 1, line 25 equal "Yes" , and column 1, line 30 is also "Yes", then questions 25.02-25.04 do not apply and are replaced with question 30.04. [2/29/2004] If there is an LTCH (S-2, line 2, column 2 is in the range of 2000 to 2299), for cost reporting periods beginning on or after 10/1/2002, Worksheet S-2, line 59, column 1 must be "Y" and for cost reporting periods beginning on or after 10/1/2002 and before 10/1/2006, column 2 must be "Y" or "N". If there is not a LTCH as the provider, then Worksheet S-2, line 59 must be "N".[10/01/2002b] If there is an IPF (S-2, line 2 or 3 and subscript, column 2 is in the range of 4000 to 4499, or there is a “S” in the third position of the provider number), for cost reporting periods beginning on or after 1/1/2005, S-2, line 60, column 1 must be "Y" and for cost reporting periods beginning on or after 1/1/2005 and before 1/1/2008, column 2 must be "Y" or "N". If there is not an IPF as the provider or subprovider, then Worksheet S-2, line 60, column 1 must be "N". [01/01/2005b] If Worksheet S-2, column 1, lines 23, 25, 38, or 45 contain a "Y", the corresponding column 1, subscripted line(s) 25.01, 25.03-25.04, 38.01-38.04, 45.01-45.03, and at least one of column 1, lines 23.01-23.05 must contain a response. This edit does not apply if Worksheet S-2, line 30.04 is "Y" for lines 25.03 -25.04. [12/31/1999] Worksheet S-2, lines 36 and 37 are mutually exclusive. If line 36, column 2 is answered "Y", then line 37, column 2 must be answered "N". Conversely, if line 37, column 2 is "Y", then line 36, column 2, must be answered "N". Both lines can be answered "N" but both cannot be answered "Y". [2/29/2004] If Worksheet S-2, column 5, either of lines 2 or 3 contain a "P," then lines 36 and 37, column 2 must contain either a "Y" or a "N" response. If column 2, line 36 or 37, contain a "Y", then column 2, line 36.01 or 37.01, must contain either a "Y" (or a "P" for line 36.01) or a "N". [ 9/30/1998] If Worksheet S-2, lines 25 and 25.01 response is "Y", then line 25.02 must contain a response "Y" or "N". This edit does not apply if Worksheet S-2, line 30.04 is "Y" for line 25.02. [9/30/1998] If this hospital qualifies for sole community hospital (SCH) status (see 42 CFR 412.92) and Worksheet S-2, line 26 is greater than zero, then the beginning and ending dates on line 26.01 must be present. The number entered on line 26 should agree with the number of times line 26 is being subscripted and vice versa. The beginning and ending dates, line 26.01 and any continuation of the subscripts, columns 1 and 2 must be within the parameters of the cost reporting period's beginning and ending dates, and the ending date may not be earlier than the beginning date. Conversely, if there is a date on line 26.01, then line 26 must be greater than zero. [9/30/1997] Lines 26 and 26.03, column 1, can only have a response of -0-, 1, or 2. [02/29/2004] If Worksheet S-2, line 26.03 is greater than zero, then line 26.04 must be present in the ECR file. [02/29/2004]

04-05

1038S

1039S

1040S

1043S

1045S

1050S

1055S

1056S

36-766

Rev. 14

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FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Condition

3695 (Cont.)

Edit 1057S

If this hospital qualifies for medical dependent hospital (MDH) status (see 42 CFR 412.108) and Worksheet S-2, line 53 is greater than zero, then the beginning and ending dates on line 53.01 must be present. The beginning and ending dates, line 53.01 and any continuation of of the subscripts, columns 1 and 2 must be within the parameters of the cost reporting period's beginning and ending dates, and the ending date may not be earlier than the beginning date. Conversely, if there is a date on line 53.01 then line 53 must be greater than zero. [9/30/1997] If Worksheet S-2, column 1, line 32 equals "Yes", column 2, line 32 must have a designation of A, B, or E. [9/30/1996] If Worksheet S-2, line 33, column 1 equals "Y", then column 2 must have a response for all cost reports beginning on or after 10/01/2002. [2/29/2004] If Worksheet S-2, line 33, column 2 is "Y", then Worksheet S-2 line 36, column 2 must be "Y" and line 37, column 2 must be "N". [2/29/2004] If Worksheet S-2, line 29 is "Y" (certified SNF using the swing bed optional method of reimbursement), then Worksheet S-3, Part I, column 1, sum of lines 1 and 15 subscripts, as applicable, must be less than 50 beds. [9/30/1996] If the hospital has rendered title XIX inpatient services (Worksheet S-2, line 38 is 'Y'), then title XIX hospital days (Worksheet S-3, Part I, column 5, line 12) and title XIX hospital discharges (Worksheet S-3, Part I, column 14, line 12) must both be greater than zero. [9/30/1996] All amounts reported on Worksheet S-3, Part I must not be less than zero. [9/30/1996] For Worksheet S-3, Part I, the sum of the inpatient days/outpatient visits in columns 3, 4, and 5 for each of lines 1, 3-16, 18, 21, and 24 must be equal to or less than the total inpatient days/outpatient visits in column 6 for each line. [9/30/1996] Worksheet S-3, Part I, line 26 column 5 must equal the sum of line 26 columns 5.01 and 5.02 and line 26, column 6 must equal line 26 columns 6.01 and 6.02. [4/30/2005] For fiscal years ending on or after 08/01/2000 through 02/28/2004 , if Worksheet S-2, column 1, line 21.02 equals "Y'', then the date in column 2 must be after the beginning date of the cost reporting period and on or prior to the ending date of the cost reporting period. For Fiscal year 02/29/2004 and after, if Worksheet S-2, line 21.03, column 2 equals "Y", then the date in column 3 must be after the beginning date of the cost reporting period and on or prior to the ending date of the cost reporting period. [08/01/2000] If the hospital and/or subprovider is subject to PPS but not an LTCH (Provider number 2000-2299), an IRF (Provider number 3025-3099), or a Psychiatric (Provider number 4000-4499), or if the third digit in the provider number is an "S' or a "T", (Worksheet S-2 line 2 and/or 3 , column 5 = "P"), Worksheet S-3, Part II, column 4 lines 1-35 must equal to or greater than zero. [9/30/1996]

1060S

1062S

1064S

1065S

1070S

1075S 1080S

1085S

1090S

1100S

Rev. 14

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3695 (Cont.) FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Edit 1105S Condition For Worksheet S-3, Part I, the sum of the discharges in columns 12, 13, and 14 for each of lines 1, 12, and 14 must be equal to or less than the total discharges in column 15 for each line indicated. [9/30/1996] If Worksheet S-2, column 1, line 56 equals "Y", and the cost reporting period beginning month is October, Worksheet S-2, column 2, line 56 and Worksheet S-3, column 4, line 27 must each be greater than zero. No subscripts of the afore mentioned lines should be present. However, if Worksheet S-2, column 3, line 56 equals "Y" this edit should be ignored. [8/31/2000] For cost reporting periods overlapping 1/1/2001 and after this edit is void. [1/1/2001s] If Worksheet S-2, column 1, line 56 equals "Y", and the cost reporting periods beginning month is other than October, Worksheet S-2, column 2, sum of lines 56 and 56.01 must be greater than zero and Worksheet S-3, column 4, sum of lines 27 and 27.01 must be greater than zero. However, if Worksheet S-2, column 3, line 56 equals "Y", this edit should be ignored. If short period cost report does not overlap October, only line 56 and 27 of the aforementioned worksheets are required. [8/31/2000]. For cost reporting periods overlapping 1/1/2001 and after this edit is void. [1/1/2001s] If Worksheet S-2, column 1 line 56 equals "Y", then column 2, line 56 and subscripts must also contain amounts greater than zero and at least one of the corresponding lines on Worksheet S-3, Part I line 27 and subscripts must contain amounts greater than zero. Do not apply this edit if CAH and Worksheet S-2, line 30.03, column 1, equals "Y" and the date in column 2 is on or after 12/21/2000. For a new ambulance program (S-2 line 56, column 3=Y), the limit in column 2 is not required. [01/01/2001s] If Worksheet S-2, column 1, line 56 equals "Y", for services on or after 4/1/2002, then column 2 must contain a limit amount and column 4 a fee schedule amount for applicable lines. A new ambulance program(S-2 line 56, column 3=Y) which answers column 1 as "Y", will not have a limit in column 2, but must have a fee schedule amount in column 4. Do not apply this edit if CAH and Worksheet S-2, line 30.03 column 1 equals "Y" and the date in column2 is on or after 12/21/2000. [04/01/2002s] If Worksheet S-2, column 2, line 58 equals "Y", then column 5, line 2 if it is the hospital or line 3 if it is the subprovider has to be "P". If column 2, line 58, is "N", then column 5 line 2 if it is the hospital , line 3 if it is the subprovider has to be "T". [1/10/2002b] If there is a LTCH (Worksheet S-2, line 2, column 2 is in the range of 2000 to 2299) for fiscal year beginning on or after 10/1/2002, then Worksheet S-2 line 59, column 1 must be "Y" and for cost reporting beginning on or after 10/1/2002 and before 2006, column 2 must be "Y" or "N". [2/29/2004] If Worksheet S-2, line 60.01, column 1 is "Y", then Worksheet S-2, line 60, column 1 must be "Y". [01/01/2005b] If Worksheet S-2, column 1, line 9 and subscripts are present, then Worksheet S-4, column 1, line 19 must be greater than zero and the number of MSA codes on line 20 and subscripts must equal the number identified on line 19. [10/1/1997b] This edit is no longer applicable for cost reporting period beginning on or after 10/01/2000.

04-05

1125S

1130S

1132S

1134S

1136S

1138S

1139S

1140S

36-766.2

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FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Condition If Worksheet S-2, column 1, line 28 equals "Y", then Worksheet S-3, Part I, column 4, line 15 must equal zero and vice versa. [8/31/2000] If the trips on Worksheets S-3, Part I, column 4, line 27 and subscripts are greater than zero, then the limits must be reported on the corresponding Worksheet S-2, column 2, line 56 and subscripts. Apply this edit if Worksheet S-2, line 56 column 1 equals "Y" and column 3 equals "N". [9/30/2000] If Worksheet S-3, Part I, line 27, column 4 and subscripts are greater than zero, then Worksheet D, Part V, the corresponding line 65 and subscripts, column 5.02 must be greater than zero and vice versa. If one amount is greater than zero, then both amounts must be greater than zero. In addition, for each corresponding subscript of Worksheet S-2 line 56, columns 2 and 4 must be greater than zero. Apply this edit if Worksheet S-2, line 56 column 1 equals "Y" and column 3 equals "N". Do not apply this edit to CAHs.[4/01/2002s] Moved to Level II edit # 2160S

3695 (Cont.)

Edit 1145S

1155S

1157S

1160S

The following Wage Index edits are to be applied against PPS Short Term Acute Care Hospital Providers only, edit numbers 1200S, 1205S, 1210S, 1215S, 1220S and 1225S. These edits do apply if the hospital is subject to PPS but not an LTCH (Provider number 2000-2299), an IRF (Provider number 3025-3099), a Psychiatric (Provider number 4000-4499) or if the third digit of the provider number is an "S" or a "T". 1200S For Worksheet S-3, Part II, sum of columns 1 and 2, each of lines 1-35 and subscripts as applicable must be equal to or greater than zero. [9/30/1998] The amount of salaries reported for Interns & Residents in approved programs, Worksheet S-3, Part II, column 1, line 6 must be equal to the amount on Worksheet A, column 1, line 22 (including subscripts). [10/1/2000b] The amount on Worksheet S-3, Part II, sum of columns 1 & 2, line 8 must equal the corresponding amount on Worksheet A, column 1, line 34 plus or minus any related amounts reported on Worksheet A-6, columns 4 and/or 8 for line 34 designation indicated in columns 3 and/or 7. [9/30/1998] The amount on Worksheet S-3, Part II, sum of columns 1 & 2, line 8.01 must equal the corresponding amount on Worksheet A, column 1, lines 21, 24, 31, 35, 36, 64, 65, 68-71, 82-86, 89, 92-94, and 96-100 and subscripts thereof, plus or minus any related amounts reported on Worksheet A-6, columns 4 and/or 8 for lines 21, 24, 31, 35, 36, 64, 65, 68-71, 82-86, 92-94, and 96-100 and subscripts thereof, indicated in columns 3 and/or 7. [9/30/1998] Worksheet S-3, Part II, sum of columns 1 & 2, line 13 must be greater than zero. Apply this edit to PPS providers only. [9/30/1998]

1205S

1210S

1215S

1220S

Rev. 14

36-766.3

04-05

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Condition If Worksheet S-3, Part II, sum of columns 1 and 2, lines 1-12 and 21-35 is greater than zero, then the corresponding line for column 4 must be greater than zero. If the sum of column 4, lines 8 and 8.01 divided by the sum of column 4, line 1 minus lines 3, 5, and 7 is less than 15%, then lines 21-35 are not required to be completed. [12/31/1999] If Worksheet S-2, sum of columns 1-3, line 54 is greater than zero, then column 1, line 54.01 must contain a "Y" or "N" response. [9/30/1998] If Worksheet S-4, line 20, column 1 has data then it must be a four digit number. [4/30/2005] The sum of Worksheet S-7, columns 3.01, 4.01, and 4.03, lines 1 thru 45 must agree with Worksheet S-3, Part I, column 4, line 15. [8/31/2000] The sum of Worksheet S-7, columns 4.06, lines 1 thru 45 must agree with Worksheet S-3, Part I, column 4, line 3. Do not apply this edit to CAHs.[7/01/2002b] Worksheet S-6, line 19 must contain a response of "Y" or "N". [4/01/2001b] Worksheet A, columns 1 or 2, line 101 must be greater than zero. [9/30/1996] If the hospital is not a rural hospital qualifying for an exception to the CRNA fee schedule (Worksheet S-2, line 31, column 1 = "N"), then nonphysician anesthetist costs after reclassification and adjustment (Worksheet A, column 7, line 20) must equal zero. [9/30/1996] Interest expense, utilization review-SNF, and other capital-related costs after reclassification and adjustment (Worksheet A, column 7, lines 88-90) must equal zero. [9/30/1996] Worksheet A, Line 90, columns 2 and 7 should be zero for cost reporting periods beginning on or after October 1, 2001 and Worksheet S-2, line 36, column 2 is yes. [10/01/2001b] For reclassifications reported on Worksheet A-6, the sum of all increases (columns 4 and 5) must equal the sum of all decreases (columns 8 and 9). [9/30/1996] Worksheet A-6, column 1 must be present for each line with a column 3, 4, 5, 7, 8, 9, or 10 entry. There must be an entry on each line of columns 4 or 5 for each entry in column 3 and vice versa and an entry on each line of columns 8 or 9 for each entry in column 7 and vice versa All entries must be valid; for example, no salary adjustments on columns 3 and/or 7, lines 1-4 for capital. [9/30/1998] If Worksheet S-2, column 5, either of lines 2 or 3 equals P and Worksheet S-2, line 18 equals 1, 2, 3, 4, 5, or 6, then Worksheet A-7, sum of Parts I and II, columns 1-3, line 9 minus column 5, line 9 must be greater than zero and Worksheet A-7, Part III, sum of columns 9-14, lines 1-4 must be greater than zero. [4/30/2005] . Worksheet A-7, Part III, sum of columns 9-14, lines 1-4 and subscripts must equal Worksheet A, column 7, sum of lines 1-4 and subscripts. [4/30/2005] .

3695 (Cont.)

Edit 1225S

1230S

1232S 1235S

1237S

1250S 1000A 1005A

1015A

1017A

1020A

1025A

1030A

1035A

36-766.4

Rev. 14

04-05

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Condition For Worksheet A-8 adjustments on lines 5-11, 13, 15-24, or 34, if either columns 1, 2, or 4 has an entry, then all three columns for that line must have entries and if any one of columns 0, 1, 2, or 4 for lines 37-49 and subscripts thereof has an entry, then all four columns for that line must have entries. [9/30/1998] If Worksheet A-8-1, Part A, either of columns 4 or 5, lines 1 through 4 does not equal zero, then column 1, the corresponding line must be present. [8/31/2000] If there are any transactions with related organizations or home offices as defined in CMS Pub. 15-I, chapter 10 (Worksheet S-2, column 1, line 40 is "Y"), Worksheet A-8-1, Part A, columns 4 or 5 (amounts in columns 4 or 5 must have a parallel line number in column 1 and vice versa), sum of lines 1-4 must be greater than zero; and Part B, column 1, any one of lines 1-5 must contain any one of alpha characters A thru G. Conversely, if Worksheet S-2, column 1, line 40 is "N", Worksheet A-8-1 should not be present. [9/30/1997] Worksheet A-8-2, column 3 must be equal to or greater than the sum of columns 4 and 5 and columns 6 and 7 must each be greater than zero if column 5 is greater than zero. Critical Access Hospitals (CAH) are exempt from completing columns 6 & 7. [10/31/1997] Worksheet A-8-3, column 1, line 69 must equal the sum of column 1, lines 71 and 72. [9/30/1996] This edit is no longer applicable for services rendered on or after 4/10/1998. [4/10/1998s.] Worksheet A-6, column 10 must contain values of 9-14 (Worksheet A-7, Part III, column reference) for the corresponding line of column 3 or column 7 which contains a capital related line number value of 1-4 and/or subscripts thereof. [ 4/30/2005]. Worksheet A-8, column 5 must contain a value of 9-14 (Worksheet A-7, Part III, column reference) for any line in column 4, including lines 1-4 and 29-32 which contain a capital related line reference of 1-4 and/or subscripts thereof and has a basis code in column 1 and/or an amount in column 2. [4/30/2005] Worksheet A-8-1, Part A, column 7, lines 1-4 and subscripts thereof must contain a value of 9-14 (Worksheet A-7, Part III, column 7 reference) if column 1, the corresponding line is 1-4 and/or subscripts thereof. [4/30/2005] . If Worksheet A-8-4, sum of columns 1-4, line 47 is equal to zero, column 5, line 51 must also be equal to zero. Conversely, if Worksheet A-8-4, sum of columns 1-4, line 47 is greater than zero, column 5, line 51 must be greater than sum of columns 1-4, line 47 and equal to or less than 2080 hours. [12/31/1999] Worksheet A-8-4, column 1, lines 66-66.60 must equal column 1, line 64. [9/30/1998] If Worksheet S-2, line 41 equals "Y", Worksheet A-8-2 must be present. [9/30/1996]

3695 (Cont.)

Edit 1040A

1044A

1045A

1050A

1055A

1065A

1070A

1075A

1080A

1085A 1090A

Rev. 14

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3695 (Cont.) FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Edit 1000B Condition On Worksheet B-1, all statistical amounts must be greater than zero, except for reconciliation columns. [9/30/1996] Worksheet B, Part I, column 27, line 103 must be greater than zero. [9/30/1996] For each general service cost center with a net expense for cost allocation greater than zero (Worksheet B-1, columns 1 through 24, line 103), the corresponding total cost allocation statistics (Worksheet B-1; column 1, line 1; column 2, line 2, etc.) must also be greater than zero. Exclude from this edit any column which uses accumulated cost as its basis for allocation and any reconciliation column. [9/30/1996] For any column which uses accumulated cost as its bases of allocation (Worksheet B-1), there may not exist on any statistical line an amount both in the reconciliation column and the accumulated cost column, including a negative one, simultaneously. [9/30/1997] If Worksheet S-2, column 1, line 30 equals "Y", then Worksheet C, Part III, column 3, line 101 must be greater than zero. Conversely, if Worksheet S-2, column 1, line 30 equals "N", then Worksheet C, Part III must not be present. This edit is not applied if Worksheet S-3, Part I, column 4, line 12 equals zero (no title XVIII inpatient days). Worksheet C, Part III is not required. Not applicable for cost reporting periods beginning on or after 10/01/1997. [9/30/1996] If Worksheet S-2, column 1, line 30.02 equals "Y", then Worksheet C, Part V, column 5, line 101 must be greater than zero. Not applicable for cost reporting periods beginning on or after 10/01/1997. [10/01/1997b] On Worksheet C, Part I, all amounts must be equal to or greater than zero. [9/30/1996] Worksheet C, Part II, columns 4 and 5, line 103 must each be greater than zero if Worksheet S-2, line 30 is "N" and line 26 equal "0" or line 26 contains a value of "1" and the period in line 26.01 does not cover the entire cost reporting period. If Worksheet C, Part I, column 7, line 101 equals zero, do not apply this edit. Only apply this edit for services rendered prior to 8/1/2000. [9/30/1998] Worksheet C, Part I, column 1, line 62 must equal the sum of all title XVIII, Worksheets D-1, column 1, line 85 for hospital and subprovider components. [12/31/1999] If Worksheet S-3, Part I, column 6, lines 1, 6 through 10 are greater than zero, the corresponding line (lines 25 through 30) on Worksheet C, Part I, column 6 must also be greater than zero. [9/30/1996] On Worksheet D, Part V, all amounts must be equal to or greater than zero, except column 2, line 102 which may contain either a positive or negative amount. [9/30/1998]

04-05

1005B 1010B

1015B

1000C

1005C

1010C 1015C

1020C

1025C

1000D

36-768

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FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Condition If Medicare hospital inpatient days (Worksheet S-3, Part I, column 4, line 12 minus line 3) are greater than zero, then Medicare hospital inpatient costs (hospital, title XVIII Worksheet D-1, Part II, column 1, line 49) must be greater than zero. Apply this edit only if Worksheet S-2, line 30 equals "N". Conversely, if Worksheet S-2, line 30 equals "Y" and inpatient days are greater than zero, then inpatient service cost per diem (Worksheet C, Part IV, line 5) must also be greater than zero. Not applicable for cost reporting periods beginning on or after 10/01/1997. [9/30/1996] If Medicare hospital inpatient days (Worksheet S-3, Part I, column 4, line 12) and Medicare hospital inpatient ancillary pass through costs (Worksheet D, Part IV, column 7, line 101) are greater than zero and the hospital does not have an all inclusive rate (Worksheet S-2, column 1, line 32 is "N"), then Medicare hospital inpatient ancillary service costs (Worksheet D-4, column 3, line 101) must also be greater than zero. [9/30/1997] The total inpatient charges on each line of Worksheet C, Part I, column 6 must be greater than or equal to the sum of all Worksheets D-4, column 2, lines as appropriate. [8/31/2000] This edit has been changed to a Level II edit. It is now edit 2017D The sum of all Worksheet D-1, Part IV, line 83 for title XVIII hospital and/or applicable subprovider(s) must equal Worksheet S-3, Part I, column 6, line 26 and subscripts. [9/30/1997] Worksheet D-1, column 1, sum of lines 5 and 6 must equal Worksheet S-3, Part I, column 6, line 3 and Worksheet D-1, column 1, sum of lines 10 and 11 must be equal to or less than Worksheet D-1, column 1, sum of lines 5 and 6. [8/31/2000] If Worksheet S-2, columns 1 and 2, line 59 are both "Y", then do not complete lines 59.0259.08 on Worksheet D-1. If Worksheet S-2, columns 1 is "Y", but column 2 is "N", then lines 59.02, 59.03 and 59.08 on Worksheet D-1, must greater than zero. Do not include line 59.03 in this edit if Fiscal Year end does not overlap July 1. [10/01/2002b] If the sum of Worksheet D-2, column 1, lines 2-8, 10, 12-18, and 20-23 is greater than zero, it must equal 100 percent. [9/30/1996] The sum of all Worksheets D-1, column 1, line 81 for all titles for both SNF and/or NF components must be equal to or less than the absolute value of Worksheet A-8, line 28. If Worksheet S-2, column 1, line 29 equals "Y", add Worksheet(s) E-2, column 1, line 7 to Worksheet D-1 for the comparison of the absolute value of Worksheet A-8, line 28. [12/31/1999] If observation bed charges are present on the subprovider component of Worksheet D, Part V, columns 2-5 (and subscripts of column 5) , line 62 and/or Worksheet D-4, column 2, line 62, then Worksheet S-2, column 2, line 3 and subscripts as applicable must contain a numeric 6 digit provider number (no alpha characters present). [9/30/1997] Do not apply this edit for periods ending on 09/30/2000 and before 02/29/2004

3695 (Cont.)

Edit 1005D

1010D

1015D

1017D 1020D

1025D

1027D

1030D

1035D

1050D

Rev. 14

36-769

3695 (Cont.) FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Edit 1055D Condition If Worksheet S-2, column 1, line 56 equals "Y", then Worksheet S-3, Part I, column 4, the sum of line 27 and subscripts, Worksheet D, Part V, column 5 (column 5.02 for cost reporting periods overlapping 8/1/2000 or after for OPPS hospitals), line 65 and subscripts both must be greater than zero, and vice versa. [8/1/2000s] If Worksheet S-3, Part I, column 4, lines 1, 6-10 are greater than zero, then the corresponding line on Worksheet D-4, column 2, lines 25-30 must also be greater than zero and vice versa. [8/31/2000] If Worksheet D, Part V, column 5 or 5.02 for line 65 and subscripts is greater than zero, then the corresponding column 9 or 9.02 must be greater than zero and vice versa. For cost reporting periods overlapping 10/1/1997 and after. [10/1/1997s] For cost reports, which overlap 8/1/2000, column 9 is to be excluded from the calculation. CAHs are not affected since they use column 5 and 9. If title XVIII SNF payment system (Worksheet S-2, column 5, line 6) equals P, then the prospective payments, other than outlier payments (Worksheet E-3, Part III, column 2, line 24), must be greater than zero. Do not apply this edit if Worksheet S-2, line 28 equals "Y" and Worksheet S-3, Part I, column 4, line 15 equals zero. [8/31/2000] If Worksheet E, Parts C, D, or E are present for subprovider(s), Worksheet S-2, column 2, line 3, subscripts as applicable, must contain six (6) numeric characters. [9/30/1996] This edit is no longer applicable for cost reporting periods beginning on or after 8/1/2000. If Worksheet E, Part A, line 7 is greater than zero, Worksheet S-2, lines 26 or 53 must be greater than zero and conversely, if Worksheet S-2, lines 26 or 53 is greater than zero then Worksheet E, Part A, line 7 must be greater than zero. For title XVIII PPS providers whose certification date is after 10/01/1987, do not apply this edit. [9/30/1996] If Worksheet E, Part A, line 7.01, for the sum of column 1 and subscripts, is greater than zero, for cost reports beginning on or after 10/1/2000 and before 10/1/2003, then Worksheet S-2 line 26 must be greater than zero. For title XVIII PPS providers whose certification date is after 10/1/1987, do not apply this edit. [10/1/2000b] If Worksheet S-2, line 21.01 is "N", then Worksheet E, Part A for lines 4, 4.01, 4.03, and 4.04 must each be equal to zero and conversely if line 21.01 is "Y" each of the aforementioned lines must be greater than zero, unless the period overlaps 1/20/2000 then only line 4.04 presence is required. If Worksheet S-3, Part I, column 5, lines 12 and 2 are zero then line 4.01 should be zero. Apply to column 1for lines 4, 4.01, 4.03 and 4.04: and the sum of column zero, 1 and 1.01 if applicable, for lines 4.03 and 4.04 only. [12/31/1999] If Worksheet S-2, column 5, line 2 equals "P" and line 25.01 equals "Y", then Worksheet E, Part A, lines 3.01, and 3.02 must all be greater than zero, otherwise each must equal zero. Apply this edit to title XVIII PPS providers whose certification date is prior to 10/01/1987. For cost reporting periods overlapping 10/01/1997 or after, lines 3.01-3.02 must each equal zero. Apply to column 1 and column 1.01, if applicable. [12/31/1999]

04-05

1060D

1065D

1000E

1005E

1010E

1012E

1015E

1020E

36-770

Rev. 14

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FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Condition If Worksheet S-2, line 25.02 equals "Y", then the number of FTE interns and residents on Worksheet E-3, Part IV, sum of lines 1 and 1.01 and the sum of the per resident amount on lines 2 and 2.01 must each be greater than zero. This edit is no longer effective for cost reporting periods beginning on or after 10/01/1997. [9/30/1998] Worksheet E, Part A, line 5, sum of column 1 plus column 1.01, if applicable (for hospital, title XVIII only) must be equal to or less than Worksheet S-3, Part I, column 13, line 12. [9/30/1996] If Worksheet L, Part I, line 5 has an amount in it, then that amount should be the same as Worksheet E, Part A line 4. [07/31/2004]

3695 (Cont.)

Edit 1030E

1035E

1037E

1040E

If Worksheet S-2, line 58, column 1, equals "Y", then line 1.02 on Worksheet E-3, Part I, for the rehabilitation facility must be greater than zero and “vice versa” . The provider number on S-2, column 2 line 2 must be in the range of 3025-3099 or line 3 or subscripts must have in the third position the letter code "T". [01/01/2002b] If Worksheet S-2, line 59, column 1 is "Y", then Worksheet E-3, Part I, line 1.02, for Long Term Care facility must be greater than zero and vice versa. The provider number on Worksheet S-2, line2, column 2 must be in the range of 2000-2299. [10/01/2002b]. If Worksheet S-2, line 60, column 1 is "Y", then Worksheet E-3, Part I, line 1.08 for Inpatient Psychiatric Facility must be greater than zero and vice versa. The provider number on Worksheet S-2, line2, column 2 must be in the range of 4000-4499 or line 3or subscripts must have in the third position the letter "S". [01/01/2005] If Worksheet S-2, line 60.01, column 1 is "Y", and column 2 is "N", then Worksheet E-3, Part I, line 1.12 must have an amount greater than zero and vice versa. [01/01/2005b] If Worksheet S-2, line 60.01, column 1 is "N" and column 2 is "Y", and column 3 is 1, 2, or 3, then Worksheet E-3, Part I line1.14 must be greater than zero and vice versa. [01/01/2005b] If Worksheet S-2, line 60.01, column 1 in "N", column 2 is "Y", column 3 is "4", then Worksheet E-3, Part I lines 1.12, 1.13 and 1.14 must be greater than zero and vise versa. [01/01/2005b] If Worksheet S-2 line 60.01, column 1 in "N", column 2 is "Y", column 3 is "5", then Worksheet E-3, Part I lines 1.12 and 1.13 must be greater than zero and vise versa. [01/01/2005b]

1045E

1050E

1055E

1060E

1065E

1070E

Rev. 14

36-770.1

3695 (Cont.) FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Edit 1005H Condition Worksheet H-5, Part II, sum of lines 1-19 for each of columns 1-5 and 6-24 (including the reconciliation column and accumulated cost column with negative one entries only) must equal the corresponding column of Worksheet B-1, line 71 and subscripts as appropriate. [9/30/1998] Worksheet A, column 7, line 71 and subscripts as applicable plus Worksheet H-5, Part I, sum of columns 1-5, 6-24, and 26, lines 1-19 must agree with Worksheet B, Part I, column 27, line 71 and subscripts as applicable. [9/30/1998] If Worksheet H-4, Part I, any of columns 1-4, line 24 is greater than zero, then Worksheet H-4, Part II, sum of the corresponding columns must be greater than zero. [9/30/1998] Total visits on Worksheet H-6, Part I, sum of column 4, lines 1-6 must be equal to or greater than the unduplicated census count, Worksheet S-4, sum of columns 1-4, line 2 and subscripts. Do not apply this edit if Worksheet S-4, sum of columns 1-3, line 2 and subscripts equal zero. [9/30/1998] Total program visits on Worksheet H-6, Part I, sum of columns 6-7, lines 1-6 plus Part III, sum of columns 2.01, 3 and 5, lines 1-3 must equal program visits on Worksheet S-3, Part I, line 18, columns 3, 4, or 5, as appropriate. [9/30/1998] Do not apply this edit for cost reports beginning on or after 10/01/2000. The sum of Worksheet H-6, Part I, column 2, line 17 and subscripts must equal the corresponding unduplicated census count on Worksheet S-4, columns 1, 2, or 3, line 2 as appropriate. Do not apply this edit if the sum of these columns on S-4 equal zero. [09/30/1998]. Not applicable for cost reports beginning on or after 10/01/2000. The sum of visits on H-6, Part I, each of columns 6 and 7, each of lines 1-6 must equal the sum of the visits in each of columns 6 and 7, each of lines 8-13 and subscripts of the associated line. [9/30/1998]. Not applicable for cost reports beginning on or after 10/01/2000. Worksheet H-1, sum of columns 1-8, lines 3-23 must equal Worksheet A, column 1, line 71 and/or subscripts as applicable. [10 /01/1997]. Not applicable for cost reports beginning on or after 10/01/2000. Worksheet H, column 10, line 24 must equal Worksheet A, column 7, line 71 and/or subscripts as applicable.[12/31/1999] The number indicated on Worksheet S-4, line 19 must agree with line 20 and subscript count and Worksheet H-6, Part I, column 1, lines 8 through 13 and subscript count for each line, and vice versa. [12/31/1999] Do not apply this edit for cost reporting periods beginning on or after 10/1/2000.

04-05

1010H

1015H

1020H

1025H

1030H

1035H

1040H

1045H

1050H

36-770.2

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04-05

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Condition Worksheet H-6, sum of lines 1 through 6, column 4, must equal Worksheet S-3, Part I, column 6, line 18 and subscripts as applicable. [09/30/96] Worksheet H-6, Part I, the Medicare visits, columns 6-7, lines 1-6 respectively, must be equal to Worksheet S-4, columns 1-6, lines 21, 23, 25, 27, 29, and 31 respectively . [10/01/2000b]

3695 (Cont.)

Edit 1055H

1060H

1000I

Worksheet I-1(Renal Dialysis), column 1, sum of lines 1-8 and 10-16 must equal Worksheet A, column 7, line 57. Worksheet I-1 (Home Program), column 1, sum of lines 1-8 and 10-16 must equal Worksheet A, column 7, line 64. If worksheet S-2, line 44 equals "Y", do not apply this edit to Renal Dialysis department. (Do not complete Renal Dialysis department Worksheets I-1 through I-4 for this cost report). [12/31/1999] Worksheet I-1 (Renal Dialysis), column 1, sum of lines 1-8, 10-16, and 18-28 must equal the amount from Worksheet B, Part I, column 27, line 57. Worksheet I-1(Home Program), column 1, sum of lines 1-8, 10-16, and 18-28 must equal the amount from Worksheet B, Part I, column 27, line 64. If Worksheet S-2, line 44 equals "Y", do not apply this edit to Renal Dialysis departments. Do not complete Renal Dialysis department Worksheets I-1 through I-4 for this cost report.[12/31/1999] If Worksheet B, Part I, Line 57, column 27 is greater than zero, or if Worksheet I-4 (Renal), line 11, column 4 is greater than zero, then Renal Dialysis Worksheets S-5, I-1, I-2, I-3, and I-4, should be present and vice versa. Do not apply this edit if S2, Line 44, column 1 is "Y". [10/1/2003b] If Worksheet B, Part I, Line 64, column 27 is greater than zero, or if I-4 (Home Program), line 11, column 4 is greater than zero, then Home Program Worksheets S-5, I-1, I-2, I-3, and I-4 should be present and vice versa . Do not apply this edit if S-2, Line 44, Col 1 is 'Y'. [10/1/2003b] If Worksheet I-2, any of columns 1-8, line 16 is greater than zero, then Worksheet I-3 for related columns 1-8, sum of lines 2-15 must be greater than zero. [9/30/1997] If Worksheet S-2, line 44 equals "N" and Worksheet A, column 7, line 57 is greater than zero, then the I series worksheets must be present for renal dialysis services. [9/30/1996] If Worksheet I-1, column 1, line 33 is greater than zero, then Worksheet I-4, column 1, sum of lines 1-10 must also be greater than zero. [8/31/2000]

1005I

1007I

1009I

1010I

1015I

1020I

Rev. 14

36-770.3

3695 (Cont.) FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Edit 1000J Condition Worksheet J-1, Part I, sum of columns 0-5, 6-24, and 26, line 22 must equal the corresponding Worksheet B, Part I, column 27, line 69 or appropriate subscript as identifies this provider type and vice versa. If S-6, line 19 response is "Yes", ignore this edit. [8/31/2000] Worksheet J-1, Part II, sum of lines 1-21 for each of columns 1-5 and 6-24 must equal the corresponding columns of Worksheet B-1, line 69 and/or subscripts as appropriate. Include reconciliation and accumulated cost columns with negative one entries only. If S-6, line 19 response is "Yes", ignore this edit. [8/31/2000] If Worksheet S-2, column 5, line 2 or line 3 equals "P" and column 1, line 33 equals "N", then Worksheet L, Part IV, line 4, must contain a value which does not equal zero in accordance with section 3660.4 of the instructions. [9/30/1996] This edit is no longer applicable for cost reporting periods beginning on or after 10/1/2001. [10/1/2001b] If Worksheet S-2, line 36 is "Y" and 36.01 is "N", then Worksheet L, Part I, lines 5, 5.01, and 5.03 must each equal zero; conversely if line 36.01 is "Y" each of the aforementioned lines must be greater than zero, or if line 36.01 equals "P", lines 5 and 5.01 must each equal zero and line 5.03 must equal 11.89 percent. If Worksheet S-2, column 2, line 37 has a "Y" answer ignore this edit. If Worksheet S-3, Part I column 5, line 12 and 2 are zero then line 5.01 on Worksheet L should be zero. [12/31/1999] If Worksheet S-2, line 52 is "N", then Worksheet L-1, should not be completed. [2/29/2004] If Worksheet S-8 is present, then worksheet M-1 must be present. Conversely, if Worksheet M-1 is present, then Worksheet S-8 must be present. [1/01/1998s] If Worksheet S-8, line 13 equals "Y", Worksheet M-2, column 3, lines 1, 2, and 3 must each be greater than zero and at least one line must contain a value other than the standard amount. Conversely if Worksheet S-8, line 13 equals "N", Worksheet M-2, column 3, lines 1, 2, and 3 must contain the values 4200, 2100, and 2100. Apply this edit to both the RHC and FQHC components. [1/1/1998s] If Worksheet S-8, line 16 equals "Y", Worksheet M-1, column 7, line 20 must be greater than zero. [1/01/1998s] The sum of Worksheet M-1, column 7, lines 1-9, 11-13, 15-19, 23-27, and 29-30 must equal the amount on Worksheet A, column 7, RHC/FQHC line as appropriate. [1/01/1998s]

04-05

1005J

1000L

1005L

1010L 1005M

1010M

1015M

1020M

Rev. 14

36-771

3695 (Cont.) FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Edit Condition

04-05

II. Level II Edits (Potential Rejection Errors) These conditions are usually, but not always, incorrect. These edit errors should be cleared when possible through the cost report. When corrections on the cost report are not feasible, provide additional information in schedules, note form, or any other manner as may be required by your fiscal intermediary. Failure to clear these errors in a timely fashion, as determined by your FI, may be grounds for withholding of payments. Edit 2000 Condition All type 3 records with numeric fields and a positive usage must have values equal to or greater than zero (supporting documentation may be required for negative amounts). [9/30/1996] Only elements set forth in Table 3, with subscripts as appropriate, are required in the file. [9/30/1996] The cost center code (position 21-24) (type 2 records) must be a code from Table 5, Cost Center Coding, and each cost center code must be unique. [9/30/1996] Standard cost center lines, descriptions, and codes should not be changed. (See Table 5 for standard descriptions and codes.) This edit applies to the standard line only and not subscripts of that code. [9/30/1996] All standard cost center codes must be entered on the designated standard cost center line and subscripts thereof as indicated in Table 5. [9/30/1996] All nonstandard cost center codes may be placed on any standard subscripted cost center line and or generic cost center line within the cost center category, i.e. only nonstandard cost center codes of the general service cost center may be placed on standard cost center lines of general service cost centers. Exceptions are listed in edit 2030. [9/30/1996]

2005

2010

2015

2020

2025

36-772

Rev. 14

04-05

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Condition The following standard cost centers listed below must be reported on the lines as indicated and the corresponding cost center codes may only appear on the lines as indicated. No other cost center codes may be placed on these lines or subscripts of these lines, unless indicated herein. [12/31/1999] Cost Center Old Cap. Rel. Costs - Bldg. & Fixt. Old Cap. Rel. Costs - Moveable Equip. New Cap. Rel. Costs - Bldg. & Fixt. New Cap. Rel. Costs - Moveable Equip. Employee Benefits Adults & Pediatrics Subprovider Nursery Skilled Nursing Facility Nursing Facility Other Long Term Care PBP Clinical Lab Service - Prgm. Only Renal Dialysis Observation Beds (Non-Distinct Part) Home Program Dialysis Ambulance Services I&R Services-Not Approved Program Home Health Agency Lung Acquisition Kidney Acquisition Liver Acquisition Heart Acquisition Pancreas Acquisition Intestine Acquisition Interest Expense Utilization Review - SNF Other Capital Related Costs Ambulatory Surgical Center (D.P.) Hospice Gifts, Flower, Coffee Shop, & Canteen Research Physicians' Private Offices Nonpaid Workers Line 1 2 3 4 5 25 31 33 34 35 36 45 57 62 64 65 70 71 82 83 84 85 85.01 85.02 88 89 90 92 93 96 97 98 99 Code 0100-0149 0200-0249 0300-0349 0400-0449 0500-0519 2500 3100-3109 3300 3400 3500 3600 4500 5700 6200 6400 6500 7000 7100-7109 8200 8300 8400 8500 8510* 8520* 8800 8900 9000 9200-9219 9300-9304 9600-9619 9700-9719 9800-9819 9900-9919

3695 (Cont.)

Edit 2030

* Non-standard, indicated for establishing line number and cost center code use.
2035 Administrative and general cost center codes 0600 and 0610-0669 (standard and nonstandard) may only appear on line 6 and subscripts of line 6. Other nonstandard descriptions and codes may also appear on subscripts of line 6, but must be within the general services cost center category. [9/30/1997]

Rev. 14

36-773

3695 (Cont.) FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Edit 2040 Condition All calendar format dates must be edited for 10 character format, e.g., 01/01/1996 (MM/DD/YYYY). [9/30/1998] All dates must be possible, e.g., no "00", no "30" or "31" of February. [9/30/1996] Worksheet S, Part II, sum of columns 2 and 3 for line 100 (title XVIII) should not equal zero. [9/30/1996] The combined amount due the provider or program (Worksheet S, Part II, line 100, sum of columns 1-4) should not equal zero. [9/30/1996] The hospital certification date (Worksheet S-2, column 3, line 2) should be on or before the cost report beginning date (Worksheet S-2, column 1, line 17). [9/30/1996] For hospitals subject to PPS (Worksheet S-2, line 2, column 5 = "P") in which interns and residents in the hospital (Worksheet S-3, Part I, column 7, line 12) are greater than zero, the number of interns and residents (Worksheet E, Part A, column 1, line 3.01) should also be greater than zero for cost reporting periods ending prior to 10/1/1997. [9/30/1998] If a hospital or a subprovider component's certification date (S-2, line 2 or 3), is in excess of 10 years the provider must answer "Yes" to Worksheet S-2, line 36 and complete Worksheet L, Part I only. [8/31/2000] Do not apply this edit for cost reporting periods ending on or after 04/30/2003. If the Medicare hospital payment mechanism (Worksheet S-2, column 5, line 2) is equal to P, then apply the following edits for codes 2025S and 2030S: 2025S a. The DRG payments other than outlier payments (Worksheet E, Part A, column 1, sum of lines 1 thru 1.02, and 1.07) should be both greater than zero and greater than the outlier payments (Worksheet E, Part A, column 1, sum of lines 2 and 2.01). [9/30/1998] b. The cost of Medicare Part A services under TEFRA (Worksheet E-3, Part I, column 1, line 1) should not be present. [9/30/1996] If Worksheet S-2, line 21.03, column 2 is "Y" for Standard Geographic Reclassification (not Wage), then lines 21.04 and 21.05 must have a response in the ECR File. (Since line 21.03 can be "Y" for either Wage or Standard Reclassifications). [02/29/2004] A valid code for the type of hospital must be present in Worksheet S-2, column 1, line 19, as indicated in Table 3B. [9/30/1996] For every valid subprovider on Worksheet S-2, line 3 and subscripts thereof, a corresponding line 20 and subscripts, as appropriate, must be present with a valid type of hospital code from Table 3B. [9/30/1996] Worksheet S-2, line 18 (type of control) must have a value of 1 through 13. (See Table 3B.) [9/30/1996]

04-05

2045 2000S

2005S

2015S

2020S

2022S

2030S

2034S

2035S

2040S

2045S

36-774

Rev. 14

04-05

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Condition If the provider has a charge structure (Worksheet S-2, column 1, line 32 is No), for each cost center on lines 25-31, 33-61, and 62.01-68, if either total charges (Worksheet C, Part I, sum of columns 6 and 7) or total costs after stepdown (Worksheet B, Part I, column 27) equal zero, then both should equal zero. Do not apply this edit RHC/FQHC components. [8/31/2000]

3695 (Cont.)

Edit 2055S

2057S

For cost reporting periods beginning on or after 10/01/2000 and before 10/01/2003, which overlaps October 1st, if Worksheet S-2, line 26, column 1 is greater than zero, then Worksheets E, Part A, columns 1 and 1.01, sum of lines 1 through 2.01 must be greater than zero. [10/01/2000s] Do not apply this edit to cost reports beginning on or after 10/1/2003. Worksheet S-2, column 2, lines as indicated below may only contain those provider numbers as indicated for that line. The type of provider is also indicated. [12/31/1999] Line 2 Provider # (1) 0001-0899 1225-1299 1300-1399 1990-1999 2000-2299 3025-3099 3300-3399 4000-4499 Type Provider Short Term Hospitals Medical Assistance Facility RPCH/CAH Christian Science Hospitals Long Term Hospitals Rehabilitation Hospitals Children's Hospitals Psychiatric Hospitals

2060S

3

3rd digit of provider number is S (Psychiatric unit)* 3rd digit of provider number is T (Rehabilitation unit)* 0001-0899 Short Term Unit of Non-PPS Hospital 3025-3099 Rehabilitation Hospital as Subprovider 4000-4499 Psychiatric Hospital as Subprovider 5000-6499 6990-6999 G000-G999 H000-H999 3100-3199 7000-8499 9000-9999 C000-C999 1500-1799 Hospital-Based SNF Skilled Nursing Facilities ICF/MR " Home Health Agencies " " " " " " Ambulatory Surgical Center Hospital-Based Hospice

6

7.01

9

11 12

Rev. 14

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3695 (Cont.) FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Edit Line 14 Condition Provider # (1) 1800-1989 3400-3499 3975-3999 8500-8999 Type Provider Hospital-Based FQHC Hospital-Based RHC " " " " " "

04-05

* These are hospital components (excluded unit) whose last three (3) numbers match those last three (3) numbers of the hospital. 15 3200-3299 4500-4599 4800-4899 1400-1499 4600-4799 4900-4999 6500-6989 2300-2499 3500-3799 CORF " " CMHC " " O/P Rehab. Providers (OPT, OOT, OSP) Renal - Hospital Satellites "

16

(1) The first two characters of the provider number (not listed here) identify the state. The last 4 characters (listed above) identify the type of provider. 2070S If Worksheet S-2, column 1, line 45 response is "Y", providers should insure that proper documentation has been submitted to their fiscal intermediary in accordance with CMS Pub. 15-I, section 2313. [9/30/1996] For fiscal years ending 12/31/1999 to 02/28/2004, if Worksheet S-2, column 2, line 28.02 does not equal column 1, line 21 has the hospital received a geographic reclassification in accordance with section 1886(d)(8)(B) of the Act. [12/31/1999] This edit does not apply for cost reporting periods ending on or after 02/29/2004. [02/29/2004] If Worksheet S-2 column 1, line 30 response is "Y", then Worksheet S-3, Part I, column 2.01 the sum of lines 1, and 6 thru 10 should be greater than zero. [8/31/2002] If the hospital is new, Worksheet S-2, line 33, column 1 is "Y", and the facility's certification date, Worksheet S-2, line 2 is on or after October 1, 2001, then the facility does not qualify for Hold Harmless; Worksheet S-2 line 37 must equal "N". [2/29/2004]

2080S

2090S

2095S

36-776

Rev. 14

04-05

FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Condition The following statistics from Worksheet S-3, Part I should be greater than zero: a. Number of beds for the hospital (column 1, line 12) [9/30/1996]; b. Number of beds for the facility (column 1, sum of lines 12-21) [9/30/1996]; d. Total inpatient days for all patients in the hospital (column 6, line 12) [9/30/1996]; and e. Total inpatient days for all patients in the facility (column 6, sum of lines 1-11 and 13-24). [9/30/1996]

3695 (Cont.)

Edit 2100S

2105S

If Medicare hospital inpatient days (Worksheet S-3, Part I, column 4, line 12) is greater than zero, then the following fields on Worksheet S-3, Part I should also be greater than zero. a. Total hospital discharges (column 15, line 12) [9/30/1996]; b. Medicare hospital discharges (column 13, line 12) [9/30/1996]; and c. Hospital full time equivalent employees (column 10, line 12). [9/30/1996]

2110S

Total hospital inpatient days (Worksheet S-3, Part I, column 6, lines 1, 5-10, 14-17, & 21) should be less than or equal to hospital bed days available (Worksheet S-3, Part I, column 2, lines 1, 5-10, 14-17, & 21). [8/31/2000] The hospital and each component in a health care complex reporting interns and residents in full time equivalents (Worksheet S-3, Part I, column 7, lines 12 and 14-24) should have corresponding cost allocation statistics for interns and residents (Worksheet B-1, sum of columns 22 and 23, sum of lines 25-31, 33-36, 69, 71, 92, and 93, respectively) and conversely there should be FTEs on the aforementioned Worksheet S-3 if there are statistics on the aforementioned Worksheet B-1. [9/30/1998] For prospective payment system hospital cost reports, where the ratio of Worksheet S-3, Part II, column 4, sum of lines 8 and 8.01 divided by the result of column 4, line 1 minus the sum of column 4, lines 3, 5, and 7 is equal to or greater than 5 percent, Worksheet S-3, Part III, columns 1 and 4, line 13 must be present. [9/30/1997] For prospective payment system hospital cost reports, where the ratio of Worksheet S-3, Part II, column 4, sum of lines 8 and 8.01 divided by the result of column 4, line 1 minus the sum of column 4, lines 3, 5, and 7 is equal to or greater than 15 percent, Worksheet S-3, Part II, column 1, lines 21 through 35 must be present, if the corresponding line on Worksheet A, column 1 is greater than zero. [9/30/1998]

2115S

2130S

2135S

Rev. 14

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3695 (Cont.) FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS
Edit 2140S Condition If Worksheet S-3, Part II, sum of columns 1 & 2, lines 8 and 8.01 are greater than zero, then the sum of columns 1 & 2, line 15 must also be greater than zero. Provider should submit supporting documentation when the sum of lines 8 and 8.01 is greater than zero and line 15 equals zero. [9/30/1998] If Worksheet S-2, column 1, line 9 and subscripts are present, then Worksheet S-4, column 1, line 19 must be greater than zero and the number of MSA codes on line 20 and subscripts must equal the number identified on line 19. [10/01/2000b] Worksheet S-10 should only be completed for Short Term Acute Care hospitals (provider numbers in the range of 0001-0899). Worksheet S-10 for cost reporting periods ending 4/30/2003 through reporting periods ending 4/30/2004, there must be a response for all of the main lines 1-16.[4/30/2003] This edit does not apply for cost reporting periods beginning on or after 5/01/2004 If Worksheet S-2, line 28 equals "N", lines 28.01 and 28.02, all columns must be completed. Exception: If line 28.01, column 1 equals 100, line 28.02, column 1 is not required. For cost reporting periods beginning October 1st of the year, line 28.01, column 2 is not required. Conversely if line 28.01, column 1 is greater than zero, line 28, column 1 must contain a response. [8/31/2000] Worksheet A-6, column 1 (reclassification code) must be an alpha character. [9/30/1996] Worksheet A-7, Part III, column 2 must be less than or equal to column 1 for lines 1 through 4 and subscripts thereof. [4/30/2005] If there are provider-based physician adjustments on Worksheet A-8-2, then column 1 may only contain Worksheet A, line numbers 5-69, 82-86, 92, and subscripts thereof. [9/30/1996] If Worksheet A, column 7, either of lines 57 or 64 is greater than zero, then Worksheet S-5, columns 1 or 2, line 15 must contain an X. [9/30/1996] Move to a Level II edit 1035A. If Worksheet A-8-3 is used for physical therapy services, column 1, lines 5-7; columns 1-3, 5-7; column 11 for lines 12 and 13; columns 1-3 and 5-7 for lines 15 and 16; and columns 1-3 and 7 for line 52 may not be completed. [9/30/1997] If Worksheet A-8-3 is used for respiratory therapy services, column 1, lines 8-9, 11, 49-51, 64, and 72; columns 1-9, lines 15 and 16; columns 4, 8, and 9, lines 12 and 13; and columns 4 and 5, line 52 may not be completed. [9/30/1997] Column headings (Worksheets B-1, B, Parts I, II, and III, J-1, Part II, and L-1, Part I) are required as indicated for codes 2000B and 2005B:

04-05

2145S

2150S

2160S

2000A 2010A

2015A

2020A

2035A 2050A

2060A

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FORM CMS-2552-96 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-96 TABLE 6 - EDITS Condition
a. At least one cost center description (lines 1-3), at least one statistical bases label (lines 4-5), and one statistical bases code (line 6) (capital cost center lines only) must be present for each general service cost center with cost greater than zero (Worksheet B-1, columns 1 through 24, line 103). Exclude any reconciliation columns from this edit. [9/30/1997] b. The column numbering among these worksheets must be consistent. For example, data in old capital related costs - buildings and fixtures is identified as coming from column 1 on all applicable worksheets. [9/30/1996] Worksheet B, Part III, column 27, sum of lines 25-94 and 96-100 and subscripts as allowed must be equal to or greater than zero. Not applicable for critical access hospitals (CAH). [9/30/1996]

3695 (Cont.)

Edit
2000B

2005B

2010B

2017D

The total outpatient charges on each line (except line 56) of Worksheet C, Part I, column 7 must be greater than or equal to the sum of all Worksheets D, Part V, columns 2-5.04, for the same respective line (except line 56). For Worksheet C, Part I column 7, line 56, it must be greater than or equal to the sum of Worksheet D, Part V, columns 2-5.04, line 56 plus Worksheet D, Part VI, sum of lines 2 and 2.01. For cost reporting period overlapping 4/1/2002, and after the comparison of line 65 plus subscripts on D, Part V should be made to C, Part I, column 7, line 65. [8/31/2000] If the provider has a charge structure (Worksheet S-2, line 32, column 2 is not A, B, or E) and total inpatient days (Worksheet D-1, column 1, line 1 for the hospital and all components and all titles) is greater than zero, then general inpatient routine service charges (Worksheet D-1, column 1, line 28, for the hospital and all components and all titles) must also be greater than zero. If Worksheet D-1, column 1, line 3 equals line 2, do not apply this edit. [9/30/1997] If Worksheet D-6, Part III, column 1, line 58 is greater than zero or Part IV, sum of columns 1 and 2, lines 68-72 are greater than zero, then both must be greater than zero. [9/30/1996] If Worksheet B, Part I, column 27, lines 82-86, as appropriate, is greater than zero or Worksheet D-6, Part IV, sum of columns 1 and 2, lines 62-65 are greater than zero, then both should be greater than zero. [9/30/1996] Worksheet D-6, Part IV, sum of columns 1 and 2, lines 62-65 should equal the sum of columns 1 and 2, lines 67-75. [9/30/1996] Worksheet E, Part A, Lines 2, 3.01, 3.02, and 3.03 must equal zero for cost reporting periods beginning on or after 10/01/1997. [10/01/1997b]

2100D

2175D

2180D

2185D

2000E

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3695 (Cont.)

FORM CMS-2552-92 ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-92 TABLE 6 - EDITS Condition

04-05

Edit
2050E

If Worksheet S-2 line 21.03, column 4 is "Y", then Worksheet E, Part A line 3 must be less than or equal to 100. [4/30/2005] Total assets on Worksheet G (sum of each of columns 1-4, lines 1-10, 12-20 (subscripts as indicated), and 22-25) must equal total liabilities and fund balance (sum of each of columns 1-4, lines 28-35, 37-41, and 44-50). [9/30/1996] Total patient revenue (Worksheet G-2, Part I, column 3, line 25) should equal the sum of inpatient and outpatient revenue (Worksheet G-2, Part I, sum of columns 1 and 2, line 25). [9/30/1996] Net income or loss (Worksheet G-3, column 1, line 31) should not equal zero. [9/30/1996] If Worksheet I-1, column 1, lines 1-6 have amounts greater than zero, then the corresponding line for columns 3 and 4 must contain amounts which do not equal zero. [9/30/1996] If Worksheet I-1, column1, line 33 is greater than zero, then worksheet I-4, column 7, sum of lines 1-10 must be greater than zero and vice versa. [8/31/2002] Worksheet I-2, column 11, sum of lines 2-15 and 17 must equal Worksheet I-1, column 1, sum of lines 1-8, 10-16, 18-28, and 30-32. [8/31/2000] If Worksheet I-2, column 11, line 12 is greater than zero, then the treatments reported on Worksheet I-3, column 0, line 12 should also be greater than zero. [9/30/1996] Worksheet I-4, column 4, lines 1 through 10 should be equal to or less than the corresponding amounts in column 1 for each line. [9/30/1996] If Worksheet I-4, column 1, sum of lines 1 through 10 is greater than zero, then Worksheet I-2, column 11, sum of lines 2 through 11 must also be greater than zero. [9/30/1996]

2000G

2005G

2010G 2005I

2010I

2015I

2020I

2030I

2035I

Apply the following K series edits if Worksheet S-2, columns 2 and 3, line 12 are present. 2000K 2005K Worksheet A, column 7, line 93 must be greater than zero. Worksheet K, column 10 line 34 must be equal to Worksheet A, column 7, line 93. [8/01/99b] Worksheet K-5, sum of columns 0-5, 6-24, and 26, plus subscripts, line 29 must equal Worksheet B, Part I, column 27, line 93. If Worksheet S-2, column 5, line 2 equals "P" and column 1, line 33 equals "N", then Worksheet L, Part IV, column 1, line 11 if present should be less than zero. [9/30/1996]

2010K

2000L

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FORM CMS-2552-92 3695 (Cont.) ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-92 TABLE 6 - EDITS Condition
Worksheet M-2, sum of column 2, lines 1-3, 5-7, and 9 should agree with Worksheet S-3, Part I, column 6, lines 24, and subscripts as applicable. [8/31/2000] Total FTEs on Worksheet M-2, column 1, sum of lines 1-3 and 5-7 should be equal to or less than the FTEs on Worksheet S-3, Part I, column 10, line 24, and subscripts as applicable [8/31/2000] NOTE: CMS reserves the right to require additional edits to correct deficiencies that become evident after processing the data commences and, as needed, to meet user requirements.

Edit
2000M

2005M

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36-781


								
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