09-01		           FORM CMS-2552-96					 3690 (Cont.)							
CALCULATION OF HOSPICE PER DIEM COST		PROVIDER NO.:___________		PERIOD:		WORKSHEET K-6								
				FROM ________________										
		HOSPICE NO.: ____________		TO ________________										
														
														
	COMPUTATION OF PER DIEM COST		TITLE XVIII	TITLE XIX	OTHER	TOTAL								
			1 	2 	3 	4 								
1	Total cost (see instructions)					X	1							
2	"Total Unduplicated Days (Worksheet S-9, column 6, line 5)"					X	2							
3	Average cost per diem (line 1 divided by line 2)					X	3							
4	"Unduplicated Medicare Days (Worksheet S-9, column 1, line 5)"		X				4							
5	Aggregate Medicare cost (line 3 times line 4)		X				5							
6	"Unduplicated Medicaid Days (Worksheet S-9, column 2, line 5)"			X			6							
7	Aggregate  Medicaid cost (line 3 times line 6)			X			7							
8	"Unduplicated SNF days (Worksheet S-9, column 3, line 5)"		X				8							
9 	Aggregate SNF cost (line 3 times line 8)		X				9 							
10 	"Unduplicated NF days (Worksheet S-9, column 4, line 5)"			X			10 							
11 	Aggregate NF cost (line 3 times line 10)			X			11 							
12 	"Other Unduplicated days (Worksheet S-9, column 5, line 5)"				X		12 							
13 	Aggregate cost for other days (line 3 times line 12)				X		13 							
														
														
Note:  The data for the SNF and NF on lines 8 through 11 are included in the Medicare and Medicaid lines 4 through 7.														
														
														
														
														
														
														
														
														
														
														
														
														
														
														
														
														
														
														
														
														
														
														
														
														
														
														
														
														
														
														
"FORM  CMS-2552-96 (9/2000 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II, SECTION 3634.9)"														
														
Rev. 8							36-634.14