3690 (Cont.) FORM CMS-2552-96 08-02 COMPUTATION OF INPATIENT PROVIDER NO.: COMPONENT NO.: PERIOD: "WORKSHEET D-1," OPERATING COST FROM __________ PART I __________________ __________________ TO ____________ Check [ ] Title V - I/P [ ] Hospital [ ] NF [ ] PPS applicable " [ ] Title XVIII, Part A" [ ] Subprovider [ ] ICF/MR [ ] TEFRA boxes [ ] Title XIX - I/P [ ] SNF [ ] Other PART I - ALL PROVIDER COMPONENTS INPATIENT DAYS 1 " Inpatient days (including private room days and swing-bed days, excluding newborn)" X 1 2 " Inpatient days (including private room days, excluding swing-bed and newborn days)" X 2 3 Private room days (excluding swing-bed private room days) X 3 4 Semi-private room days (excluding swing-bed private room days) X 4 5 Total swing-bed SNF type inpatient days (including private room days) through December 31 of the cost reporting period X 5 6 Total swing-bed SNF type inpatient days (including private room days) after December 31 of the cost reporting period (if X 6 " calendar year, enter 0 on this line)" 7 Total swing-bed NF type inpatient days (including private room days) through December 31 of the cost reporting period X 7 8 Total swing-bed NF type inpatient days (including private room days) after December 31 of the cost reporting period (if X 8 " calendar year, enter 0 on this line) " 9 Total inpatient days including private room days applicable to the Program (excluding swing-bed and newborn days X 9 10 Swing-bed SNF type inpatient days applicable to title XVIII (including private room days) through December 31 of the X 10 cost reporting period (see instructions). 11 Swing-bed SNF type inpatient days applicable to title XVIII (including private room days) after December 31 of the X 11 " cost reporting period (if calendar year, enter 0 on this line)" 12 Swing-bed NF type inpatient days applicable to titles V or XIX (including private room days) through December 31 of X 12 the cost reporting period. 13 Swing-bed NF type inpatient days applicable to titles V or XIX (including private room days) after December 31 of the X 13 " cost reporting period (if calendar year, enter 0 on this line) " 14 Medically necessary private room days applicable to the Program ( excluding swing-bed days) X 14 15 Total nursery days (title V or XIX only) X 15 16 Nursery days (title V or XIX only) X 16 SWING BED ADJUSTMENT 17 Medicare rate for swing-bed SNF services applicable to services through December 31 of the cost reporting period X 17 18 Medicare rate for swing-bed SNF services applicable to services after December 31 of the cost reporting period X 18 19 Medicaid rate for swing-bed NF services applicable to services through December 31 of the cost reporting period X 19 20 Medicaid rate for swing-bed NF services applicable to services after December 31 of the cost reporting period X 20 21 Total general inpatient routine service cost (see instructions) X 21 22 Swing-bed cost applicable to SNF type services through December 31 of the cost reporting period (line 5 x line 17) X 22 23 Swing-bed cost applicable to SNF type services after December 31 of the cost reporting period (line 6 x line 18) X 23 24 Swing-bed cost applicable to NF type services through December 31 of the cost reporting period (line 7 x line 19) X 24 25 Swing-bed cost applicable to NF type services after December 31 of the cost reporting period (line 8 x line 20) X 25 26 Total swing-bed cost (see instructions) X 26 27 General inpatient routine service cost net of swing-bed cost (line 21 minus line 26) X 27 PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 General inpatient routine service charges (excluding swing-bed charges) X 28 29 Private room charges (excluding swing-bed charges) X 29 30 Semi-private room charges (excluding swing-bed charges) X 30 31 General inpatient routine service cost/charge ratio (line 27 ÷ line 28) X 31 32 Average private room per diem charge (line 29 ÷ line 3) X 32 33 Average semi-private room per diem charge (line 30 ÷ line 4) X 33 34 Average per diem private room charge differential (line 32 minus line 33) X 34 35 Average per diem private room cost differential (line 34 x line 31) X 35 36 Private room cost differential adjustment (line 3 x line 35) X 36 37 General inpatient routine service cost net of swing-bed cost and private room cost differential (line 27 minus line 36) X 37 "FORM CMS-2552-96 (8/2002) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3622-3622.1)" 36-576 Rev. 9