08-97 FORM CMS-2552-96 3690 (Cont.) COMPUTATION OF OUTPATIENT COST PER VISIT - RURAL PRIMARY CARE HOSPITAL PROVIDER NO.: PERIOD: "WORKSHEET C," FROM_________ PART V ______________ TO___________ Provider-based Total Ancillary Total Ratio of Out- Total Total Cost Physician Charges Outpatient patient Charges Outpatient "(from Wkst. B," Adjustment Total Costs "(from Wkst. C," Charges to Total Charges Costs COST CENTER DESCRIPTIONS "Part I, col. 27)" (see instructions) (col. 1 + col. 2) "Part III, col. 2)" (see instructions) (col. 5 ÷ col. 4) (col. 3 x col. 6) 1 2 3 4 5 6 7 ANCILLARY SERVICE COST CENTERS 37 Operating Room X X X X 37 38 Recovery Room X X X X 38 39 Delivery Room and Labor Room X X X X 39 40 Anesthesiology X X X X 40 41 Radiology-Diagnostic X X X X 41 42 Radiology-Therapeutic X X X X 42 43 Radioisotope X X X X 43 44 Laboratory X X X X 44 45 PBP Clinical Laboratory Services-Prgm. Only X X X X 45 46 Whole Blood & Packed Red Blood Cells X X X X 46 47 "Blood Storing, Processing, & Transfusion" X X X X 47 48 Intravenous Therapy X X X X 48 49 Respiratory Therapy X X X X 49 50 Physical Therapy X X X X 50 51 Occupational Therapy X X X X 51 52 Speech Pathology X X X X 52 53 Electrocardiology X X X X 53 54 Electroencephalography X X X X 54 55 Medical Supplies Charged to Patients X X X X 55 56 Drugs Charged to Patients X X X X 56 57 Renal Dialysis X X X X 57 58 ASC (Non-Distinct Part) X X X X 58 59 Other Ancillary (specify) X X X X 59 "FORM CMS-2552-96 (9/96) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3620.5)" Rev. 3 36-566 08-97 FORM CMS-2552-96 3690 (Cont.) COMPUTATION OF OUTPATIENT COST PER VISIT - RURAL PRIMARY CARE HOSPITAL PROVIDER NO.: PERIOD: "WORKSHEET C," FROM_________ PART V (CONT.) ______________ TO___________ Provider-based Total Ancillary Total Ratio of Out- Total Total Cost Physician Charges Outpatient patient Charges Outpatient "(from Wkst. B," Adjustment Total Costs "(from Wkst. C," Charges to Total Charges Costs COST CENTER DESCRIPTIONS "Part I, col. 27)" (see instructions) (col. 1 + col. 2) "Part III, col. 2)" (see instructions) (col. 5 ÷ col. 4) (col. 3 x col. 6) 1 2 3 4 5 6 7 OUTPATIENT SERVICE COST CENTERS 60 Clinic X X X X 60 61 Emergency X X X X 61 62 Observation Beds (see instructions) X X X X 62 63 Other Outpatient Services (specify) X X X X 63 OTHER REIMBURSABLE COST CENTERS 64 Home Program Dialysis X X X X 64 65 Ambulance Services X X X X 65 66 Durable Medical Equipment-Rented X X X X 66 67 Durable Medical Equipment-Sold X X X X 67 68 Other Reimbursable (specify) X X X X 68 101 Total (sum of lines 37-68) X X X X 101 102 Total outpatient visits X 102 103 Aggregate cost per visit (line 101 ´ line 102) X 103 104 Title V outpatient visits 104 105 Title XVIII outpatient visits 105 106 Title XIX outpatient visits 106 107 Title V outpatient costs (line 103 x line 104) 107 108 Title XVIII outpatient costs (line 103 x line 105) 108 109 Title XIX outpatient costs (line 103 x line 106) 109 "FORM CMS-2552-96 (9/96) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3620.5)" Rev. 3 36-567