3690 (Cont.)		     FORM CMS-2552-96							12-99
ADJUSTMENTS TO EXPENSES			PROVIDER NO.		PERIOD:		WORKSHEET A-8		
					FROM ____________				
			________________		TO _______________				
					  EXPENSE CLASSIFICATION ON				
					  WORKSHEET A TO/FROM WHICH			Wkst.	
	DESCRIPTION (1)		(2)		  THE AMOUNT IS TO BE ADJUSTED			A-7	
			BASIS/CODE	AMOUNT	        COST CENTER		LINE #	Ref.	
			1	2	3		4	5	
1 	Investment income - old buildings and fixtures (chapter 2)			X	Old Buildings and Fixtures		1 		1 
2 	Investment income - old movable equipment (chapter 2)			X	Old Movable Equipment		2 		2 
3 	Investment income - new buildings and fixtures (chapter 2)			X	New Buildings and Fixtures		3 		3 
4 	Investment income - new movable equipment (chapter 2)			X	New Movable Equipment		4 		4 
5 	Investment income - other (chapter 2)			X					5 
6 	"Trade, quantity, and time discounts (chapter 8)"			X					6 
7 	Refunds and rebates of expenses (chapter 8)			X					7 
8 	Rental of provider space by suppliers (chapter 8)			X					8 
9 	Telephone services (pay stations excluded) (chapter 21)			X					9 
10 	Television and radio service (chapter 21)			X					10 
11 	Parking lot (chapter 21)			X					11 
12 	Provider-based physician adjustment		Wkst A-8-2	X					12 
13 	"Sale of scrap, waste, etc. (chapter 23)"			X					13 
14 	Related organization transactions (chapter 10)		Wkst A-8-1	X					14 
15 	Laundry and linen service			X					15 
16 	Cafeteria-employees and guests			X					16 
17 	Rental of quarters to employee and others			X					17 
18 	Sale of medical and surgical 			X					18 
	supplies to other than patients								
19 	Sale of drugs to other than patients			X					19 
20 	Sale of medical records and abstracts			X					20 
21 	"Nursing school (tuition, fees, books, etc.)"			X					21 
22 	Vending machines			X					22 
23 	"Income from imposition of interest,"			X					23 
	finance or penalty charges (chapter 21)								
24 	Interest expense on Medicare overpayments and			X					24 
	borrowings to repay Medicare overpayments								
25 	Adjustment for respiratory therapy		Wkst A-8-3/	X					25 
	costs in excess of limitation (chapter 14)		Wkst A-8-4		Respiratory Therapy		49 		
26 	Adjustment for physical therapy costs		Wkst A-8-3/	X					26 
	in excess of limitation (chapter 14)		Wkst A-8-4		Physical Therapy		50 		
27 	Adjustment for HHA physical therapy 			X					27 
	costs in excess of limitation		Wkst A-8-3		HHA		71 		
28 	Utilization review - physicians' compensation (chapter 21)			X	Utilization Review - SNF		89 		28 
29 	Depreciation - old buildings and fixtures			X	Old Buildings and Fixtures		1 		29 
30 	Depreciation - old movable equipment			X	Old Movable Equipment		2 		30 
31 	Depreciation - new buildings and fixtures			X	New Buildings and Fixtures		3 		31 
32 	Depreciation - new movable equipment			X	New Movable Equipment		4 		32 
33 	Non-physician Anesthetist			X	Nonphysician Anesthetist		20 		33 
34 	Physicians' assistant			X					34 
35 	Adjustment for occupational therapy costs			X					35 
	in excess of limitation (chapter 14)		Wkst A-8-4		Occupational Therapy		51 		
36 	Adjustment for speech pathology costs			X					36 
	in excess of limitation (chapter 14)		Wkst A-8-4		Speech Pathology		52 		
37 	Other adjustments (specify) (3)			X					37 
50 	TOTAL (sum of lines 1 thru 49)			X					50 
	"(Transfer to Worksheet A, column 6, line 101.)"								
(1) Description - all chapter references in this column pertain to HCFA Pub. 15-I.									
(2) Basis for adjustment (see instructions).									
"    A. Costs - if cost, including applicable overhead, can be determined."									
    B. Amount Received - if cost cannot be determined.									
(3) Additional adjustments may be made on lines 37 thru 49 and subscripts thereof.									
Note:  See instructions for column 5 referencing to Worksheet A-7.									
									
									
									
"FORM CMS-2552-96 (5/1999)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3613)"									
									
									
									
36-518									   Rev. 6