11-98 FORM CMS 2552-96 3690 (Cont.) 3690 (Cont.) FORM CMS-2552-96 11-98 . APPORTIONMENT OF COST OF PROVIDER NO.: PERIOD: "WORKSHEET D-2," APPORTIONMENT OF COST OF PROVIDER NO.: PERIOD: "WORKSHEET D-2," SERVICES RENDERED BY FROM ___________ PARTS I-III SERVICES RENDERED BY FROM ____________ PARTS I-III (Cont.) INTERNS AND RESIDENTS __________________ TO _____________ INTERNS AND RESIDENTS _____________ TO _______________ PART I - NOT IN APPROVED TEACHING PROGRAM PART I - NOT IN APPROVED TEACHING PROGRAM Percent of Total Inpatient Health Care Program Inpatient Days Title V Title XVIII Title XIX Assigned Expense Days - All Average Cost Title Title XVIII Title (col. 4 x (col. 4 x (col. 4 x Cost Centers Time Allocation Patients Per Day V Part B XIX col. 5) col. 6) col. 7) 1 2 3 4 5 6 7 8 9 10 1 Total cost of services rendered 100.00 1 1 1 Hospital Inpatient Routine Services: 2 Adults & pediatrics (general routine care) 2 2 2 3 Intensive care unit 3 3 3 4 Coronary care unit 4 4 4 5 Burn Intensive Care Unit 5 5 5 6 Surgical Intensive Care Unit 6 6 6 7 Other Special Care (specify) 7 7 7 8 Nursery 8 8 8 9 Subtotal (sum of lines 2 through 8) 9 9 X X 9 10 Subprovider - Inpatient routine service 10 10 X X 10 12 Skilled Nursing Facility 12 12 X X 11 13 Nursing Facility 13 13 X 12 14 Other Long Term Care 14 14 14 15 Home Health Agency 15 15 15 16 Outpatient Rehabilitation Providers 16 16 16 17 Ambulatory Surgical Center 17 17 17 18 Hospice 18 18 18 19 Subtotal (sum of lines 9 through 18) 19 19 19 Total Charges Ratio of Cost Titles V and XIX Outpatient and Titles V and XIX Outpatient and (from Wkst. C. to Charges Title XVIII Part B Charges Title XVIII Part B Cost "Part I, col. 8," (col. 2 ÷ Title Title XVIII Title Title Title XVIII Title Hospital Outpatient Services: lns 60 thru 63) col. 3) V Part B XIX V Part B XIX 20 Clinic 20 20 20 21 Emergency 21 21 21 22 Observation beds 22 22 22 23 Other Outpatient Service (specify) 23 23 23 24 Subtotal (sum of lines 20 through 23) 24 24 24 25 Total (sum of lines 19 and 24) 100.00 25 25 25 "PART II - IN AN APPROVED TEACHING PROGRAM (TITLE XVIII, PART B INPATIENT ROUTINE COSTS ONLY)" "PART II - IN AN APPROVED TEACHING PROGRAM (TITLE XVIII, PART B INPATIENT ROUTINE COSTS ONLY) " Expenses allocated Expenses To cost centers on Net cost Total Average Cost Title XVIII Applicable "Wkst. B, Part I" Swing bed (col. 1 plus Inpatient Days - Per Day Part B to Title XVIII cols. 22 & 23 Amount col. 2 ) All Patients (col. 3 ÷ col. 4) Inpatient Days (col. 5 x col. 6) Hospital Inpatient Routine Services: 1 2 3 4 5 6 7 26 Adults & Pediatrics (general routine care) 26 26 26 27 Swing Bed - SNF 27 27 27 28 Swing Bed - NF 28 28 28 29 Intensive care unit 29 29 29 30 Coronary care unit 30 30 30 31 Burn Intensive Care Unit 31 31 31 32 Surgical Intensive Care Unit 32 32 32 33 Other Special Care (specify) 33 33 33 34 " Subtotal (sum of lines 26, and 29 through 33)" 34 34 X 34 35 Subprovider - Inpatient routine service 35 35 X 35 37 Skilled Nursing Facility 37 37 X 37 38 Total (sum of lines 34 through 37) 38 38 X 38 PART III - SUMMARY FOR TITLE XVIII (TO BE COMPLETED ONLY IF BOTH PARTS I AND II ARE USED) PART III - SUMMARY FOR TITLE XVIII (TO BE COMPLETED ONLY IF BOTH PARTS I AND II ARE USED) Not In Approved Teaching Program In Approved Teaching Program Total Title XVIII Costs (from Part I:) Amount "(from Part II, col. 7, - )" Amount "(to Wkst. E, Part B - )" (col. 2 + col. 4) Hospital 1 2 3 4 5 6 39 Inpatient " col. 9, line 9" 39 39 line 34 39 40 Outpatient " col. 9, line 24" 40 40 40 41 Total Hospital (sum of lines 39 and 40) 41 41 line 2 41 42 Subprovider " col. 9, line 10" 42 42 line 35 line 2 42 44 Skilled Nursing Facility " col. 9, line 12" 44 44 line 37 line 2 44 "FORM CMS-2552-96 (11/98) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3623-3623.3)" "FORM CMS-2552-96 (11/98) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3623-3623.3)" Rev. 4 36-579 36-580 Rev. 4