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HCRIS Website User Manual - Health Financial Systems

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2. 901 sa 201 201 sap 0D 2an 200 117 Sie EE 118 SUBTOTALS sum of lines 1 117 NONREIMBURSABLE COST CENTERS es vcr es ctm m oco sa E 191 Research 1 Te 200 Cross Foot Adjustments 201 Negative Cost Centers 202 TOTAL sum lines 118 201 FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 IL SECTION 4021 40 546 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications we 08 11 ALLOCATION OF CAPITAL RELATED COSTS GENERAL SERVICE COST CENTERS Capital Related Costs Buildings and Fixtures Administrative and General Operation of Plant co o in Laundry and Linen Service Housekeeping FORM 5 2552 10 p Dietary Cafeteria 901 Maintenance of Personnel 901 901 Nursing Administration 201 B Central Services and Supply Pharmacy Medical Records amp Medical Records Library Social Service Other General Service specify Nursing School Intern amp Res Service Salary amp Fringes Approved Intern amp Res Other Program Costs Approved Paramedical Education Program specify INPATIENT ROU
3. Pharmacy srvices under contract Adj Salary 5 3 Part Il column 3 line 9 01 Pharmacy svcs under contract Paid Hours 5 3 Part Il column 4 line 9 01 2 Phrmcy svcs under contract Avg Hrly Wage 5 3 Il column 5 line 9 01 Laboaoy svcs under contract Adjsted Salary S 3 Part Il column 3 line 9 02 Laboratory svcs under contract Paid Hours Laboratory under contract Avg Hrly Wage 5 3 Part Il column 5 line 9 02 Mngmnt amp Admin under contract Adj Salary 5 3 Part Il column 3 line 9 03 5 3 Part Il Column 4 Line 12 Dietary under contract Paid Hours S 3 Part Il column 4 line 27 01 5 3 Part Column 5 Line 35 Dietary under contract Abg Hourly Wage S 3 Part Il column 5 line 27 01 5 3 Part Il Column 6 Line 35 Mngmnt amp Admin under contract Paid Hrs S 3 Part Il column 4 line 9 03 5 3 Part 11 Column 5 Line 12 Contract Labor Adjusted Salary 5 3 Part Il column 3 line 9 5 3 Part Il Column 4 Line 11 Mngmnt amp Admin contract Avg Hourly Rate 5 3 Part Il column 5 line 9 03 5 3 Part Il Column 6 Line 12 S 3 Parti column 5 line 9 03 Contract labor physician Part A Adj Salary 5 3 Part Il Column 4 Line 13 Contract labor physician Part A Paid Hrs 5 3 Part Il Column 5 Line 13 Contract physician Pt A Avg Hrly Wage 5 3 Part Il Column 6 Line 13 Home Office Adjusted Salary 5 3 Part Il Column 4 Line 14 Home Office
4. Medical Supplies Charged to Patients Implantable Devices Charged to Patients Drugs Charged to Patients ASC Non Distinct Part 201 sD SD Other Ancillary specify OUTPATIENT SERVICE COST CENTERS TERES d 9 11 11 1 201 201 201 DEE N EET 29011 201 201 201 201 1 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4020 42 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 1 1 FORM 5 2552 10 ALLOCATION GENERAL SERVICE COSTS am am al 011 al al 9 11 9 11 9 11 911 1 EESTI ZEEE ESET san am xm san m 3m Lmz
5. 901 al FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 IL SECTION 4020 Rev 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 4090 Cont FORM 5 2552 10 COST ALLOCATION GENERAL SERVICE COSTS PROVIDER CCV 201 201 201 iology 9a mn 90 E E 201 201 201 201 11 2AT 901 9 11 9 san am a Cardiac Catheterization 91 91 9 11 9 11 901 91 E 0 m le Blond ee 0 S Blnd some Pressing Tews s Respiratory Therapy san am aD 3M TH 011 1 9011 201 901 201 201 201 201 201 201 201 201 201 201 201 a 201 OUTPATIENT SERVICE COST CENTERS mo cca rc cca SS oae SS ee Em Qualified Health Center pedaly Quite 51 Emergency Har LL 92 Observation Beds mcm wmm recrear scene e eum 93 Other Outpatient Service specify FORM 5 2552 10 08 20
6. 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 EN HCRIS Website User Manual 4090 Cont FORM CMS 2552 10 COMPUTATION OF PROGRAM INPATIENT ANCILLARY SERVICE CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES Hospital Subprovider Cost Center Description 9 OUTPATIENT SERVICE COST CENTERS 55 Rural Health Climc RHC Titie V Title Part A Title XIX Capital Cost for Extraordinary Circumstances Wkst 1 1 Part L col 26 1 901 l 901 89 Federally Qualified Health Center FQHC 50 901 901 91 901 J 901 9 9 6 901 88 9 11 89 90 901 901 91 OTHER REIMBURSABLE COST CENTERS 94 Home Program Dialysis sa 92 Observation Beds 901 901 9 9 6 93 Other Outpatient specify 901 9 1 up 584 901 92 93 901 9 906 941 901 94 95 Ambulance Services 96 Durable Medical Equipment Rented 901 97 901 901 aD 95 96 97 901 911 901 901 200 Total sum of lines 50 through 199 A Worksheet line numbers 7 1 12 M Worksheets 08 11 ANALYSIS OF PROVIDER BASED RURAL HEALTH CLINIC FEDERALLY QUALIFIED HEALTH CENTER COSTS Check applicable box REC FQRC FACILITY HEALTH CARE STAFF COSTS Physician Durable Medical Equipment Sold 901 901 98
7. SUMMARY OF CAPITAL 7 st T ES Total 2 Insurance Taxes Costs sum of instructions Eu au aum RSS cols 9 pfe 15 _ 3 sum of lines 1 2 0 11 0 11 2 The amounts on lines and 2 must equa the corresponding amounts on Worksheet column 7 lines 1 and 2 Column 9 through 14 should include related Worksheet A 6 reclassifications Worksheet 8 adjustments and Worksheet 8 1 related organizations and home office costs See instructions FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTIONS 4015 40 528 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 81 HCRIS Website User Manual FORM 5 2552 10 4090 Cont PROVIDER CCN PERIOD WORKSHEET A FROM TO EXPENSE CLASSIFICATION ON WORKSHEET WHICH Wist THE AMOUNT IS BE ADJUSTED A 7 BASISCODE 2 AMOUNT COSTCENIER LINE Raf x __ ou i e i 3 1 bilding and fixtures 5 1 9 SOLES BS a on oa Uu R te e S 50 TOTAL ed mnm rz to Worksheet 6 line 200 1 Description chapter references in t
8. ing Care Continuous Home Care sD Physical Therapy o 3 Occupations Tampy an an 9 Medical Social Services 90 ietary Comseling san an 9 9 908 EE 000 GER EEE COE pcm ee us Bio pc ies Mti epe eee Se np 1 1 25 Specify ES EE eee SSS ee 26 fff d 27 Patient Transporation Patient Transporation 98 0 28 x x xe 3m m _ 30 MedicalSupplies san 901 oD 31 Outpatient Services GacdinsERDep sam sam sam sam 32 Radiation Therapy oD 5 33 Chemotherapy 1 1 sm _
9. 10 area Gee xD 3835 OTHER WAGES AND RELATED COSTS Parra RENI MNA II Commcthbor eemsmc es 55 T2 Management and administrative senises 13 Contract bor 2277 oD 5538 14 Home ofice salaries amp oD 538 15 Home fice 3985 16 Teaching physician salaries Gee weer sm 38 55 WAGE RELATED COSTS a ee ET Wagerehtedcost core Worksheet 5 3 31D 301 D 501 20 Non physician Pat A a 21 Non phyzician anesthetist Pat 901 22 501 3 501 24 Wage related cost 911 35 rans am approved 9 8 99 9 8 99 9 8 99 9 8 99 9 8 99 9 8 99 EE 2 2013 Health Financial Systems Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual FORM CMS 2552 10 4090 Cont Worksheet Reclasuficabon Adjusted Pad Hows Average A of Salaries Salanes Related Wage Line Amount fom column 2 to Salanes cohmm 4 Number Reported Worksheet A 6 column 3 column 4 column 5 l 2 4 5 6 Ge nva KEEN Em
10. of ie inurim ram reporting period Pogam 0 _ 9 303 Also show date of sach payment fnons write 0 sap awarppyvvv NONE or zero 1 Provider 05 MaMDDYYYY 35 50 san 35 4 02 385 1 01 15685 0 0185 331 _ sun 3 san amem ywwy 3 33 LETT EM EM o EM Pogam 00 50l 2 xacppvvvv d 50 Provider 03 AMIDDYYYY 50 Proude 50 MMDDYYYY 0 5 21 33 SM 5 5 99 7 TOTAL MEDICARE PROGRAM LIABILITY instructions 5 Nams of Contractor Contractor b Dam Month Day X 3 Cal 901 1 On Ene 3 5 and 6 where an amour i due provider to program show the amount and date on which ths provider ago to the amount of repayment even though total repayment is not accomplished until later date FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 II SECTION 4046 40 616 revised 4 19 2
11. sam san sam sam sam san 9a san sam san n 9a n 9 11 san 901 9 11 9 11 901 91 901 9 11 san san san users pce a in s ro HH Aide amp Homemaker Cont Home Care Other Analgesics Sedatives Hypnotics Other Specify Medical Supplies Outpatient Services including E R Dept Radiation Therapy Chemotherapy Other Bereavement Program Costs Volunteer Program Costs Fundraising Other Program Costs Totals sum of lines 1 33 2 Unit Cost Multiplier see instructions s _ sap ap sap ap 9a sap sa sap aD ap a 0 line 34 must agree with Wkst column 7 line 116 lumns 0 through 25 line 34 must agree with the corresponding columns of Wkst B Part I line 116 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 II SECTION 4062 1 FORM 2 40 639 40 6 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 184 FORM 5 2552 10 CATION OF GENERA
12. 58 Medical Social Service Visis amp O 901 901 901 901 Medical Social Service Visit Charges 901 901 901 9011 901 Home Health Aide Visits 90 Home Health Aide Visit Charges 901 901 901 901 Total visits sum of lines 21 23 25 27 29 and 31 Other Charges san Total Charges sum of lines 22 24 26 28 30 32 and 34 901 TotalNumberofEpisodes standardnonouier j 901 901 901 Total Number of Outlier Episodes 911 9011 901 Total Non Rougine Medical Supply Charges 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 28 HCRIS Website User Manual 08 11 FORM 5 2552 10 HOSPITAL RENAL DIALYSIS DEPARTMENT PROVIDER CCN STATISTICAL DATA RENAL DIALYSIS STATISTICS Number of patients on tran Number of patients transplanted during the cost reporting period fe ARANESP amount from Worksheet A for home dialysis program 19 Number of ARANESP units furnished relating to the renal dialysis department a5
13. 59 Cardiac 60 Laboratory 53 Anesthesiology 54 Radiolozy Disznostic 55 Radiology Therapeutic 61 PBP Clinical Laboratory Services Program Only 36 FESSES PEERS ET es 52 Whole Blood amp Packed Red Blood Cells 53 Blood Storing Processing amp Trans say Catheterization 901 65 Respiratory Therapy 66 Physical Therapy 67 64 Intravenous Therapy Lm 58 Speech Pathology sam 93 Other Outpatient Service specify FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 IL SECTION 4020 Rev 2 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 9 4090 Cont FORM 5 2552 10 COST ALLOCATION STATISTICAL BASIS SERVICE DIETARY POUNDS OF HOURS OF 22 i 001 9 P basse Epa x x 98 99 san san 80 100 Intem Resident Service not appvd tchne prem 101 Home Health Agency say SPECIAL PURPOSE COST CENTERS 0 us 901 NONREIMBURSABLE COST CENIERS Gift Flower Coffee Shop amp Canteen 190 a Unit lier Worksheet B Part eg E CM 9 4 9
14. can have multiple occurrences City Any entry in here will filter the records reports by the city listed in the Medicare Cost Report wildcard option can be used in this field 2552 96 City S 2 Line 1 01 Column 1 2552 10 City S 2 Line 1 01 Column 1 State 2552 96 5 2 Line 1 01 Column 2 2552 10 S 2 Line 1 01 Column 2 2552 96 S Line 2 Column 2 2552 10 S Line 2 Column 2 Type of Hospital 2552 96 S 2 Line 18 Column 1 Type of Subprovider 2552 96 S 2 Lines 3 4 5 6 7 7 01 9 11 12 14 15 and 16 Column 2 CBSA The wildcard option can be used in this field 2552 96 S 2 Line 21 03 Column 5 Bed Size Range revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc 2552 96 5 3 Part Line 12 Column 1 Organ 2552 96 5 2 Line 23 Column 1 DSH 2552 96 5 2 Line 21 01 Column 1 Teaching 2552 96 5 2 Line 25 01 Column 1 CAH 2552 96 S 2 Line 20 Column 1 SCH MDH 2552 96 5 2 Line 26 Column 1 greater than 0 or 5 2 Line 53 column 1 greater than 0 Urban Rural 2552 96 S 2 Line 21 03 Column 1 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 6 Appendix A HCRIS Data Scope amp Disclaimers This section contains information disclaimers and statements from CMS and the Research Data Assistance Center ResDac HCRIS d
15. E J sm am SSS SSS 30 08 El BEEN AB 201 201 201 9011 EU 201 201 201 55 am a 08 2 Magnetic Resonance Imaging MRI AB 011 Sal 9 11 9 11 AH 901 11 SP CmdmCmbeeiazim 9a 9a alm p sun n SEE NR __ 51 PEP Laboratory Servicer Program a Se ims eir E ecd 3 Whole Blood amp Packed Red Blood Cel Ps sa son san a 3121 201 201 201 i ap 201 201 e XB 201 9011 201 901 201 E Devices E 0D 9 73 Drugs Charged to Patients san 75 ASC ow DesmetPa 305 san 309 76 E RE ME MET NM ME NA OUTPATIENT SERVICE COST CENTERS a a rectos ren pese s
16. 901 901 901 al 201 201 901 9 11 201 201 201 a 201 9 11 201 201 9011 901 901 9 11 9 11 64 Intravenous Therapy 65 Respiratory Therapy 9 11 9 11 66 Physical Therapy 201 57 901 68 Speech Pathology 9 11 9 11 9 11 201 9 11 901 901 901 201 201 9011 201 FORM CMS 2552 10 08 2011 NSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTIONS 4023 Rev 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 117 HCRIS Website User Manual 4090 Cont FORM 5 2552 10 08 11 COMPUTATION OF RATIO OF COSTS TO CHARGES PROVIDER CCN PERIOD WORKSHEET M 3 PARTI COST CENTER DESCRIPTIONS Electrocardiolozy Electroencephalography Medical Supplies Charged to Patients Implantable Devices Charged to Patients Drugs Charged to Patients Renal Dialysis ASC Non Distinct Part Other Ancillary specify OUTPATIENT SERVICE COST CENTERS Rural Health Clinic RHC 501 201 89 Federally Qualified Health 90 Cime 89 201 91 Emp n eme un
17. e 20 21 22 23 24 25 26 27 28 29 30 3l 32 33 34 35 36 37 38 39 30 31 42 43 45 46 38 49 50 51 52 53 54 55 56 37 38 39 FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS 15 1 SECTION 4022 40 562 T2 Received HFS 262011 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 7 1 3 C Worksheets 08 11 COMPUTATION OF RATIO OF COSTS TO CHARGES FORM CMS 2552 10 PROVIDER CCN 4090 Cont WORKSHEET PARTI Total Cost from West B Part L Therapy Limit Total Costs 455 m Say col 26 Adi 1 2 INPATIENT ROUTINE SERVICE COST CENTERS Ate 201 ECCE tee cana 31 Intensive Care Unit 91 32 Coronary Care Unit 9 11 9d1 9 11 201 201 201 9 1 33 Burn Intensive Care Unit 34 Surgical Intensive Care Unit 35 Other Special Care specify 40 Subprovider 9 11 Subprovider IRF 201 201 201 201 901 901 901 jeg 201 san 901 901 201 9011 9 11 901 901 901 9 11 Skilled Nursing Facility 45 Nursing Facility 46 Ot
18. Clinic Emergency 901 34 34 Em 20 9 10 Observation Beds see mstructions Other Outpatient Service specify OTHER REIMBURSABLE COST CENTERS Home Program Dialysis Ambulance Services EE 9 11 9 11 9 11 9 11 Eun 201 9 10 an a Eo STE pe zc I Durable Medical Equipment Rented Durable Medical Equipment Sold 1 38 901 9 6 Other Reimbursable specify Outpatient Rehabilitation Provider specify Intern Resident Service not appvd tchng prem al 901 9 11 m 3 e 9 11 29011 9011 Kidney Acquisition 9 11 9 11 9011 911 al Heart Acquisition Liver Acquisition Lung Acquisition Pancreas Acquisition Intestinal Acquisition ab al al 201 m o san 9 so Islet Acquisition Other Organ Acquisition specify 201 201 201 201 Em 901 9 06 Ambulato urgical Center Distinct Part Hospice Other Special Purpose specify 901 901 san san 0 901
19. ims 5 als FORM CMS 2552 10 082011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4065 1 FORM Rev 2 40 647 40 6 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual Cont CATION OF ALLOWABLE COSTS FOR AORDINARY CIRCUMSTANCES FORM CMS 2552 10 PHARMACY 08 11 WORKSHEET L 1 PARTI Cont 409 AILO EXIR 1 9 11 901 901 911 901 901 901 901 901 901 9011 901 91 201 9011 9011 901 911 911 901 901 901 901 9 1 91 901 9 11 911 901 901 901 14 15 9011 901 841 901 9 11 901 16 9011 on S ro i Intern amp Res Service Salary amp Fringes Approved E 9011 sap 901 911 901 9011 901 901 9 11 9 11 901 901 901 9 11 Intern 5 Res Other Program Costs Approved Paramedical Ed Program specify INPATIENT ROUTINE SERVICE COST CENTERS Adults and Pediatrics General Routine Care 901 9011 901 911 9 11 9 11 91 911 901 901 901 941 901 9d 901 901 memi 901 901 901 901 941 901 941 90
20. line 47 times line 52 Msg cuu su cum the PART VI COWES ATION OF THERAPY LIMITATION AND EXCESS COST ADJUSTMENT 58 provider site fom lines 33 34 35 59 Travel allowance and expense Offsite services fom lines 44 45 46 60 Overtime allowance from column 5 line 56 61 Equipment cost see instructions Supplies see instructions 63 Total allowance sum of lines 57 62 64 Total cost of outside supplier services from provider records 65 Excess over limitation line 64 minus 63 if negative enter zero FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB 15 SECTIONS 4019 40 534 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 7 1 2 B Worksheets 08 11 FORM 5 2552 10 COST ALLOCATION STATISTICAL BASIS PROVIDER CCN 72 Pharmacy Cd 16 Medical Records amp Medical Records Library 18 Other General Senice spei O O 6 D 1 eee T using School Intern amp Res Service Salary amp Fringes Approved 901 Intern amp Res Other Program Costs Approved 9 11 Paramedical Education Program specify 90a INPATIENT ROUTINE SERVICE COST CENTERS one Intensive Care Unit 1 Coronary C
21. sess 008 901 FORM 40 651 40 6 15 HCRIS Website User Manual Cont FORM CMS 2552 10 08 11 CATION OF ALLOWABLE COSTS FOR PROVIDER CCN WORKSHEET L 1 AORDINARY CIRCUMSTANCES PARTI Cont Cost Center Descriptions ANCILLARY SERVICE COST CENTERS Operating Room INTERN amp INTERNS amp INTERNS amp RESIDENT RESIDENTS RESIDENTS PARAMEDI COST amp POST NURSING SALARY AND PROGRAM EDUCATION STEPDOWN SCHOOL FRINGES COSTS SPECIFY SUBTOTAL ADJUSTMENTS TOTAL 20 21 22 23 24 25 26 Recovery Room Labor Room and Delivery Room Anesthesiology gum m Sa EES 901 22 00 91 501 Loo Xb oD Radiology Diagnostic Radiology Therapeutic Radiotsotope R Ml 9 11 9 11 9 11 9a 90 901 901 9011 Computed Tomography CT Scan Magnetic Resonance Imaging MRI Cardiac Cathenzation 91 901 9 11 911 9 9 11 911 9011 Laboratory PBP Clinical Laboratory Service Program 9011 9 11 9011 9 11 901 SSE TEE FD 901 9 11 9011 Whole Blood 4 Packed Red Blood Cells t sing amp Trans 9d1 9 11 9 11 91 9 11 9011 91 911 91 91 91 9011 9011 Electroencephalography Medical Supplies Charged to Patients 91 911 9 11 9 11 9 11
22. 0 i isiti 201 201 9 11 201 201 201 201 T pus Ohm Opn 201 m urgical Center Distinct Part _ eap 115 Lu x 10 116 Special pec SUSTOTALS nem of lines LIT a ONE NONREIMBURSABLE COST CENTERS TTT al 191 h s Private Offices 192 Workers 303 525 29 Orr am Cross Foor Adjustments 2 2 san am Negative Centers 2 TOTAL sum lines 118 201 901 202 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 IL SECTION 4020 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 155 HCRIS Website User Manual 4090 Cont FORM 5 2552 10 ALLOCATION OF CAPITAL RELATED COSTS DIRECILY ASSIGNED NEW CAPITAL RELATED PROVIDER CCN SUBTOTAL sum of cols 0 2 6
23. 201 201 201 201 911 901 901 011 pecial Purpose specify 9 SUBTOTALS sum of lines 1 117 E san sam EES eren users rcm NONREIMBURSABLE COST CENTERS 1 Ph 9 9 11 11 911 is ES Em 194 901 201 901 201 201 9 11 201 200 Cross Foot Adjustments 201 1 1 0 9 0 1 FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4021 Rev 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 4090 Cont FORM 5 2552 10 ALLOCATION OF CAPITAL RELATED COSTS e in Cafeteria Nursing Administration Pharmacy Medical Records amp Medical Records Library Social Service Other General Service specify Intern amp Res Service Salary amp Fringes Approved Intern amp Res Other Program Costs Approved Paramedical Education Program specify INPATIENT ROUTINE SERVICE COST CENTERS Adults and Pediatrics General Routine Care Intensive Care Unit Coronary Care Unit Burn Intensive Care Unit Surgical Intensive Care Unit Other Special Care Unit specify pr
24. 9r 6 9 Subtotal sum of lines 50 thru 199 Less Observation Beds 901 201 11 901 EDT 9 6 Total line 200 minus line 201 01 9 11 FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTIONS 4023 amp 4023 2 40 566 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 12 7 1 4 D Worksheets 08 11 FORM CMS 2552 10 4090 Cont WORKSHEET D APPORTIONMENT OF INPATIENT ROUTINE PROVIDER CCN SERVICE CAPITAL COSTS Check applicable Title Part A TzFRA PPS Title Reduced Capital Capital Progam Related Cost Related Per Capital fom Wist Cost Total Diem inpatient B Part Bed col 1 mmm col 3 Progam col 26 Adnzumes col 2 Di col 4 Ds xcol 6 BENE ee 44 Skilled Nursing Fact ry 43 Nursing 200 Total Eme 30 199 A Worksheet Eme mbar FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 0 SECTIONS 4024 4024 1 Rev 2 Green 5 Purple 5 only T2 Received HFS 8 26 2011 2013 Health Financial Systems and amp Associates Inc P
25. l ap a am E 901 11 x11 gt 1 1 E E E 901 Em 201 201 201 NIS 30 201 201 901 a 9 11 111 9 11 9 11 112 112 san 15 15 9011 ER E 41 SONORES a EUM ME E E am san 9 1 oar 116 16 117 117 L3 9 11 al 901 901 201 201 201 m mE mm ERI 901 9 11 193 NEUEN Cross Foot Adjustments Negative Cost Centers TOTAL sum lines 118 201 1 2 200 aa E 201 1D FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 IL SECTION 4020 40 540 revised 4 19 2013 5an 202 2 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 12 FORM 5 2552 10 OTHER GENERAL SER
26. m O O ouo EX ONE ON X x o 63 62 Report Specifications 4 14 1 Protested Amounts Specifications The following table contains the specifications for the Protested Amounts Report References to data sources for the 2552 96 and 2552 10 form sets are included for your convenience 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual Protested Amounts Snapshot Report Specs repr een E 3 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Snap Shot Reports s 4 15 Available Cost Reports Available Facility Reports Sort By Provider 9 Number L Year Range 01 01 11 12 31 11 Status Submitted x Reports Available Facility Reports FYStart FYEnd Status HCRIS Creation 2552 10 213 Date Comp 1 1 2011 12 31 2011 As Submitted 1 06 12 2012 GED UE 1 1 2010 12 31 2010 As Submitted 1 06 17 2011 N A N A N A 1 1 2009 12 31 2009 As Submitted 1 06 10 2010 N A N A 1 1 2008 12 31 2008 As Submitted 1 02 09 2011 N A N A N A 1 1 2007 12 31 2007 As Submitted 1 02 09 2010 NIA N A N A 1 1 2006 12 31 2006 As Submitted 1 N A N A N A 1 1 2006 12 31 2006 As Submitted 1 N A N A N A Settled without Audit 2 1 1 2005
27. 201 A 5 201 901 901 303 SUBTOTALS sum of lines 1 117 9AD II E Nonpaid Workers 9d1 201 201 201 E E E E EE u MENU Tent Gee TEL ta TOTAL sum lines 118 201 a1 X11 0 FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4020 Rev 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual FORM 5 2552 10 08 11 08 1 7 WORKSHEETB COST 213 e a 201 201 901 12 13 Pharmacy 0 11 i Medical Records amp Medical Records Library gt 0 11 9 11 0 11 17 201 901 201 201 201 18 19 Nonphysician Anesthetists 21 Intern amp Res Service Salary amp Fringes Approved 900 22 amp Res Other Program Costs Approved 0 23 Paramedical Program peci M INPATIENT ROUTINE SERVICE COST CENT
28. 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 147 HCRIS Website User Manual FORM 5 2552 10 WORKSHEET PART VI Tre Var Im XIX revised 4 19 2013 2013 Health Financial Systems and amp Associates Inc Appendix B CMS HCRIS Specifications owe FORM CMS 2552 10 DIRECT GRADUATE MEDICAL EDUCATION GME amp ESRD OUTPATIENT DIRECT MEDICAL M E7777 T rs 25 Total drect amount sum of lings 19 and xo n B 14 15 16 18 19 20 21 2 23 M 25 26 27 28 29 30 3 DIRECT MEDICAL EDUCATION COSTS FOR ESKD COMPOSITE RATE TITLE ONLY NURSING SCHOOL AND PARAMEDICAL EDUCATION COSTS FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 1 SECTION 4034 40 598 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 08 11 FORM CMS 2552 10 Total Part A reasonable cost sum of lines 37 through 39 num lins 40 D 1 1 Total Part B rsasomible cost 42 minus lins 4 Total reasonable cost sum of lina 41 and 989990 Ratio of Part reasonable cost to total reasonable cost Ene 41 ime oom Ratio of Part B reasonable cost to total reasonable cost 44 lins 4 9986 CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 1 SECTION 4034 2013
29. 4 Care pz CIT RR DR SS CR RR 17 less me 1 Subtotal Eme 19 xus ine 20 21 zum line Allowable bad debts exchuds bad debts I 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 0 SECTION 4033 3 Kev 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual FORM 5 2552 10 Net Federal PPS pan rect Total PPS payments sam of me 1 and 2 Allowable bad debts excbade bad debts fer professional services Adjusted 11 MY Allowable tad debts Sor dual eligible beneficiaries vee imtmuctic of e 13 and 15 MD 18 ma ame payment cct items im accordance wits CMS Pub 15 2 section 1152 FORM CMS 2552 10 062011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4033 4 40 594 revised 4 19 2013 2013 Health Financial Systems and amp Associates Inc Appendix B CMS HCRIS Specifications 14 FORM 5 2552 10 rt crum 15 2 section 1152 SSS SS FORM CMS 2552 10 062011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4033 4 40 594 2013 Health Financial Systems and Toyon amp Ass
30. ow ELS elie 275 0 co Taino dus peovidar line 19 mime of li DD Protested amounts noaallowable cost raport accordance CMS Pub 15 IL section 115 2 FORM CMS 2552 10 06 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 IL SECTION 4032 40 590 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual FORM 5 2552 10 Net Fedaral PF PPS paya Net IPF PPS Outlier pan Not IPF PPS ECT pay Subtotal 16 loss ooo Allowable debt ted Hj b db emm 00000000 Allowable debt Sr 22211231 Subtotal sam of Enos 22 and 25 901 Dina medical pant m Workihest E4 lime san Other pass pN DID M FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4033 2 40 592 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 12 FORM 5 2552 10 L EPI Paes and
31. sS _ 1 _ __ COST CENTER DESCRIPTIONS omit cents GENERAL SERVICE COST CENTERS 1 Capital Related Costs Bldg and 2 Capital Related Costs Movable Equip 3 Plant Operation and Maintenance 4 Transportation Staff 5 Volunteer Service Coordination 6 Administrative and General INPATIENT CARE SERVICE 7 Inpatient General Care 8 Inpatient Respite Care VISITING SERVICES 9 Physician Services 10 Nursing Care n 13 Occupational Therapy 14 Speech ngusge Pathology 000000 16 Spiritual Counseling 17 Dietary 18 Counseling Other o 19 Home Heakh Aide and Homemaker oD 20 HH Aide amp Homemaker Cont Home Care 9 11 21 Other 901 OTHER HOSPICE SERVICE COSIS 23 Analgesics 24 26 Durable Medical Equipment Oxygen 27 29 Labs and Diagnostics 30 31 3l om ajose HOSPICE NONREIMBURSABLE SERVICE Eg c 35 Bereavement Program Costs 9 11 36 Volunteer Program Costs oan 911 3 Fm esme 38 Other Program Costs 901 39 Total sum of lines 1 thru 38 901 1 Transfer the amount in column 9 to Wkst column 1 itii i iii i E i amis ii iii FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 II SECTION 4058 Re
32. 5 42 410 IME Summary Analysis 44 4 10 1 IME Report 5 45 4 11 Reimbursement vs Cost Analysis 47 4 11 1 Reimbursement vs Cost Analysis 48 2013 Health Financial Systems and Toyon amp Associates Inc i HCRIS Website User Manual 4 12 Bad Debt Report E rr PCS e S EG 49 4 121 Bad Debt Report Specifications 50 4 13 SCH MDH Report ssa dk Rae E RS DR RR 52 4 13 4 SCH MDH Report Specifications 52 4 14 Protested 1 lt 54 4 14 1 Protested Amounts Specifications 54 4 15 Available Cost 5 56 4 15 1 Available Cost Reports Specifications 57 5 TOOS erida usq tdeo Past E etd En aS dus d 59 5 1 Provider Multi Facility 5 61 52 Wage Data Analysis by 61 53 My Provider Roll Up 63 54 Advanced Search and 69 6 Appendix A HCRIS Data S
33. 67 Occupational Therapy 9 8 68 Speech Pathology 201 9 11 9 11 9 11 9 6 69 Electrocardiology 9 6 73 Drugs Charged to Patiems sam 9 9 74 Renal Dialysis 341 9011 9 11 946 75 ASC Non D amp tinct Part 01 9 11 9 11 9 5 76 Other Ancillary specify 9 11 9 11 9 6 71 Medical Supplies Charged to Patients 9011 946 72 Implantable Devices Charged to Patients 01 9 11 9 11 9 6 70 aan 9 FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 II SECTIONS 4023 amp 4023 2 Rev 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 4090 Cont CALCULATION OF OUTPATIENT SERVICE COST TO CHARGE RATIOS NET OF REDUCTIONS FOR MEDICAID ONLY Cost Center Descriptions OUTPATIENT SERVICE COST CENTERS Rural Health Clinic RHC Federally Qualified Health Center FQHC HCRIS Website User Manual FORM CMS 2552 10 Tite V Title XIX Total Cost Wist B Part L col 26 1 eme 201 201 PROVIDER CCN PERIOD FROM TO 08 11 WORKSHEET C PART CONT
34. ers aer pesce 2 901 13 Method Home Patient oa 901 EES RC CN Etc m 14 incinded in Renal Deparment 15 AmENESPGncmdedinRemiDepemen j 1 17 Total sum of lines 2 16 1 penes peser 225 jc ca 18 Medical Educational Program Costs 19 Total Renal Costs line 17 line 18 FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 II SECTION 4049 40 618 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 16 08 11 5 2552 10 4090 Cont DIRECT AND INDIRECT RENAL DIALYSIS COST ALLOCATION PROVIDER CCN WORKSHEET 13 STATISTICAL BASIS CAPITAL a RELATED COSTS DIRECT PATIENT SALARY primiim pe EQUIPMENT COMPOSITE PAYMENT SERVICES DRUGS ous Eres mm Check applicable Total Renal Department Costs MAINTENANCE E Ez E CAPD ae CCDP OTHER BILLABLE SERVICES RRS Inpatient Dialysis Treatments 901 Col 0_ Method II Home Patient EPO Total Statistical Basis 901 oan oan oan Unit Cost Multiplier line 1 line 17 9 96 9 9 6 996 9 9 6 9 9 6 9 9 6 9 9 6 FORM 5 255
35. Others a on __ 901 9011 91 an x Total sum of lines 1 23 9 11 9 11 9 11 Column 6 line 24 should agree with the Worksheet column 3 line 101 or subscript as applicable FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN HCFA PUB 15 SECTION 4041 Rev 2 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 156 4090 Cont FORM 5 2552 10 08 11 COST ALLOCATION GENERAL SERVICE COST LLL PERIOD WORKSHEET H 1 FROM PARTI N TO NET EXPENSES CAPITAL FORCOST RELATED COSTS ALLOCATION PLANT ADMINIS pec muss supra Tame col 10 FIXTURES EQUIPMENT MAINTENANCE cols 0 4 amp GENERAL cols 4a 5 3 0 1 023 3 3 5 6 GENERAL SERVICE COST CENTERS ENERO 1 Capital Related Bl es and Fixtures 901 _______ ____ _____ ______ 2 Capital Related Movable Equipment 901 3 Plant Operation amp Maintenance san 9 11 901 E DESEE M 3 Transportation see instructions 901 901 941 NONREIMBURSABLE SERVICES 15 Home Dialysis Aide Services ii 24 Totals sum of lines 1 23 e FORM 5 2552 10 08 2011 INSTRUCTIONS F
36. 024002 ALASKA PSYCHIATRIC INSTITUTE ANCHORAGE Secondary 024002 ALASKIRPSYCHIATRIC INSTITUTE ANCHORAGE AK Secondary 020017 ALASKA REGIONAL HOSPITAL ANCHORAGE AK Secondary 022001 ALASKA SPECIALTY HOSPITAL LLC ANCHORAGE AK Secondary 020028 ALASKA SPECIALTY HOSPITAL LLC ANCHORAGE AK Secondary PROVIDENCE ALASKA MEDICAL 020001 CENTER ANCHORAGE Secondary 050599 UC DAVIS MEDICAL CENTER SACRAMENTO Primary e Add providers by clicking the Add option and then searching for individual providers or importing lists of providers e Delete providers by clicking on the left hand check box and then choose Delete The global check box at the top will select the page of providers e The provider marked as Primary will be used to populate the Snapshot Reports you choose You will still be able to choose another provider from the drop down list To mark as Primary click on the check box next to the provider and click Make Primary e To sort the list click on any column heading Note You can also access the My Provider List by clicking Preferences and selecting it from the drop down menu 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 4 Snap Shot Reports Snap Shot Reports have been created to look at key elements of the cost report Snap Shot Reports are either based on a single provider or multiple provi
37. am 99 9 3 a 3 me 90 Dm Medical 92999 oD e 1 a 599 Dm C wn 1 a xm ead Aa e rc c 41 59 0 amp 62 63 6 65 66 57 LNO 58 69 70 71 72 73 74 75 76 OUTPATIENT SERVICE COST CENTERS RH Healt Centar s HEEE FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 0 SECTION 4027 40 578 SEE HEE EE EE EE EE EE s 5 te 2013 Health Financial Systems Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 12 FORM 5 2552 10 19 55 ta td Ml PI E 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 12 HCRIS Website User Manual 4090 Cont FORM CMS 2552 10 COMPUTATION OF ORGAN ACQUISITION COSTS AND CHARGES PROVIDER CCN FOR HOSPITALS WHICH ARE CERTIFIED TRANSPLANT CENTERS PART COMPUTATION OF ORGAN ACQUISITION COSTS OTHER THAN INPATIENT ROUTINE
38. 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual options below that use S 2 data to aid in filtering by provider type State Code List Provider Type List FY Users can use the drop down box to select either FYB or FYE The default is the first full year of the 2552 10 FYB 5 1 2010 4 30 2011 Users can type the desired dates in select with the calendar which will appear when clicked in that field or leave blank both dates are input the system will search for the range FYB Fiscal Year Beginning is reported from 2552 96 S 2 Line 17 Column 1 and 2552 10 S 2 Line 20 Column 1 FYE Fiscal Year End is reported from 2552 96 5 2 Line 17 Column 2 and 2552 10 5 2 Line 20 Column 2 Report Status This field defaults to Most Recent Using the drop down box the user can select blank As Submitted Settled without Audit Settled with Audit Reopened or Amended If a status is selected that allows for more than one occurrence Reopened and Amended the system will return the latest 2552 96 Available Status S Line 1 Column 1 are 1 As Submitted 2 Settled w o Audit 3 Settled with Audit 4 Reopened and 5 Amended Status 4 Reopened can have multiple occurrences 2552 10 Available Status S Line 5 Column 1 are 1 As Submitted 2 Settled w o Audit Settled with Audit 4 Reopened 5 Amended Status 4 and Status
39. HealthFinancial Systems 4 ASSOCIATES INC User Manual HFS Toyon HCRIS Website version 1 1 HealthFinancial Systems ASSOCIATES INC User Manual Health Financial Systems Toyon amp Associates Inc HCRIS Database Website Reports and Data Analysis Tools Revised 4 19 2013 version 1 1 2013 Health Financial Systems and Toyon amp Associates Inc All rights reserved No parts of this w ork may be reproduced in any formor by any means graphic electronic or mechanical including photocopying recording taping or information storage and retrieval systems without the written permission of the publisher Products that are referred to in this document may be either trademarks and or registered trademarks of the respective owners The publisher and the author make no claim to these trademarks While every precaution has been taken in the preparation of this document the publisher and the author assume no responsibility for errors or omissions or for damages resulting from the use of information contained in this document or from the use of programs and source code that may accompany it In no event shall the publisher and the author be liable for any loss of profit or any other commercial damage caused or alleged to have been caused directly or indirectly by this document Contents Contents 1 Welcome to the HCRIS 1 2 Getting
40. emnt cum tmu cmi ur eee eee Home Program Dialysis ee 1 Ambulance Services al aL Durable Medical Equipment Rented 0 11 Durable Medical Equipment Sold Other Reimbursable specify Outpatient Rehabilitation Provider specify Intern Resident Service not appvd tchng prem 0 Home Health Agency SPECIAL PURPOSE COST CENTERS Kidney Acquisition Heart Acquisition Liver Acquisition Lung Acquisition Pancreas Acquisition Tatestins Acquisition Islet Acquisition Other Organ Acquisition specify Ambulatory Surgical Center Distinct Part Hospice Other Special Purpose specify SUBTOTALS sum of lines 1 117 NONREIMBURSABLE COST CENTERS Gift Flower Coffee Shop amp Canteen Research Physicians Private Offices Nonpaid Workers 901 Other Noureimbursable specify ees ume ri ies Cross Foot Adjustments 9 11 901 9 11 Negative Cost Centers TOTAL sum lines 118 201 FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 II SECTION 4021 40 552 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 4090 Cont FORM 5 2552 10 08 11 a es 4 e a en eo e te
41. x x past mi 2 2 228225 52 x __ 01 Cost Reporting Period mm dd yyyy 22 Does this facility qualify for and receive disproportionate share hospital payment in accordance with 42 CFR 5412 106 or low income payment in accordance with 42 CFR 412 624 e 2 In 1 enter Y for yes or for no 15 this facility subject to 42 CFR 412 06 c 2 Pickle amendment hospital In column 2 enter Y for yes or N for no Which method is used to determine Medicaid days on lines 24 and or 25 below In column 1 enter 1 if date of admission 2 if census days or 3 if date of discharge Is the method of identifying the days in this cost reporting period different from the method used in the prior cost reporting period In column 2 enter Y for yes or for no 24 line 22 is yes and this provider is an IPPS hospital enter the in state Medicaid paid days in 1 in state 26 Enter your standard geographic classification not wage status at the beginning of the cost reporting period Enter 1 for urban or 2 for rural 27 Enter your standard geographic classification not wage status at the end of the cost reporting period Enter 1 for urban or 2 for rural FORM 5 2552 10 02 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4004 1 40 50
42. 1 11 Total deductions zam of Enos 57 31 p 59 sum of ines 29 and 36 mims Ene 52 tamir to G 3 lm MD FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4040 Rev 2 revised 4 19 2013 2013 Health Financial Systems and amp Associates Inc Appendix B CMS HCRIS Specifications 1 4090 Cont FORM 5 2552 10 08 11 Total patient revemaes fom Worksheet G 2 Part colum 3 Ene 25 contractzal allowances and discounts patients accounts Lass total operating expanses fom Worksheet G 2 Part IL lins 3 Net income Som service to patients Ene 3 ime from of medical and surgical supplies to other than pat Raveans from sale of dum 22 other than patients fom sale cfmedical 0 2 Tuition sale of textbooks uniforms etc of vending machines 136 Total ofer mcoms sam of ines 6 2 Total ime 5 pius 25 Net income or loss for ths perio 26 manus Ime 2 Rental Total FORM 5 2552 10 08 2011 NSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4040 40 604 2 2013 Health Financial Systems and 8 Associates Inc Published 4 19 2013 HCRIS Website User Manual 7 1 7 H Worksheets 08 11 FORM CMS 2552 10 4090 Cont ANALYSIS OF PROVIDER BASED PROVIDER CCN HOME HEALTH A
43. 5 3 Part line 6 column 6 Medicare SB SNF Days sum S 3 Part lines amp 4 column 4 sum S 3 Part I lines 5 amp 6 column 6 Medicare SNF Days 5 3 Part I line 15 column 4 5 3 Part I line 19 column 6 Medicare IPF Days S 3 Part I line 14 column 4 S 3 Part I line 16 column 6 5 3 Part I line 12 column 6 5 3 Part I line 3 5 3 Part I line 14 column 8 5 3 Part I line 5 Total Days column 6 5 3 Part I line 4 column 6 column 8 5 3 Part line 6 column 8 Total SB SNF Days Total SNF Days Total IPF Days HHA Medicare Day Visits HHA Total Days Visits H 3 Part I line 7 column 4 RHC Medicare Day Visits 1 Days Total Days IPF Days Total Days Medicare SNF Util 5 Days Total Days SNF Days Total Days Medicare Discharges 5 3 Part I line 1 column 13 5 3 Part I line 1 column 13 5 3 Part I line 1 column 4 S 3 Part I line 1 S 3 Part line 1 column 6 5 3 Part line 1 Medicare ALOS column 13 column 13 Total Discharges 5 3 Part I line 1 column 15 5 3 Part line 1 column 15 5 3 Part line 1 column 4 5 3 Part line 1 S 3 Part line 1 column 8 5 3 Part line 1 Total ALOS column 15 column 15 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 2 HCRIS Website User Manual Dashboard Hospital Related M
44. ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS FORM 5 2552 10 PROVIDER COV HOSPICE CCN PART I ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS RELATED COSTS EMPLOYEE BENEFITS BLDGS amp MOVABLE FIXTURES EQUIPMENT MAIN TENANCE amp OPERATION REPAIRS OFPLANT 7 o i 1 2 4 4 s s po 1 san san _2 2 9a1 901 901 901 901 saD 901 901 901 901 901 91 901 m ER 5 6 9a ap 7 7 oD s sD ap san on 9 9 9 aD 901 901 901 941 9a1 941 901 901 HH Aide amp Homemaker Cont Home Care Oe Analgesics Other Specify Imaging Services 28 901 901 901 91 941 i ij 901 901 sap om 1616 sap san sam om 17 17 sap aD 1 18 sap i sap san san 02 sap san sam san 22 up sam sam
45. I ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS LAUNDRY MAIN NURSING CENTRAL amp LINEN HOUSE TENANCEOF ADMINIS SERVICES amp SERVICE KEEPING DIETARY PERSONNEL TRATION SUPPLY 9 10 nu 2 ms s 901 san san san san ap san san sam san 9a sam san san say sam n sam sam sam san sam san sam sam sam sam sam ab 30 0 1 _ 941 941 san 91 941 91 9a1 san sam sam sam sam 9a san sam sam san sam 901 san san sam 3091 941 901 901 901 901 9 11 901 901 sam sam 9a san san san ap san sam sam 9a sam sam sam sam 9an san san sam san sam ap san sam sam san sam san san sam sam sam san san sam sam sam 9a sam san sam ap san sam sam sam 9a sm so 901 san 901 901 9 11 901 sam san sam
46. Nonallowable GME costs 2 0 901 201 901 201 201 201 201 201 201 201 201 Total Nonreimbursable Costs sum of lines 23 27 OVERHEAD 201 901 RdiyCos 8 1 31 Total Facility Overhead sum of lines 29 and 30 DM 201 201 201 32 901 The net expenses for cost allocation on Worksheet A for the RHC FQHC cost center line must equal the total facility costs in column 7 line 32 of this worksheet FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4066 Rev 2 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 202 4090 Cont FORM 5 2552 10 AILOCATION OF OVERHEAD TO RHC FQHC SERVICES ALLOWABLE COST n TO SERVICES Total costs of health care services fom Worksheet M L colum 7 line 22 Total nonreimbursable costs fom Worksheet 1 colum 7 line 28 Cost of all services excluding overhead sum of lines 10 and 11 Ratio services 10 divided by line 1 00 999 Parent provider overhead allocated to facility 901 The productivity standard for physicians is 4 200 and 2 100 for physician assistants and muse practitioners If an exception to the standard
47. Part A TEFRA boxes Title Hh 1 50 5 22 53 54 55 56 57 35 59 60 61 62 6 65 66 6 68 e 7 71 72 73 74 75 76 n OTHER REIMBURSABLE COST CENTERS T FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 0 SECTION 4024 4 40 570 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 12 4090 Cont FORM 5 2552 10 APPORTIONMENT OF MEDICAL AND OTHER HEALTH SERVICES COSTS ITE V OP Howpaal Tis Pat m Tis XIX OP jm PART V APPORTIONMENT OF MEDICAL AND OTHER HEALTH SERVICES COSTS 56 57 58 13 59 50 51 62 63 6 65 66 67 58 69 70 7 72 RI aja FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB 15 II SECTIONS 4024 5 40 572 2013 Health Financial Systems and Toyon amp Associates Inc siseses 2141 41 1418 8 9815 18 6 aaea in on Published 4 19 2013 HCRIS Website User Manual FORM 5 2552 10 Tie 1 1 Part A XIX IP TS FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 1 SECTIONS 4025 1 Rev 2 revised 4 19 2013 2013 Health Financi
48. We call this our 800 Report or mcrx to mcrx comparison As stated above HFS created mcrx files from the HCRIS records when they became public and HFS obtained a copy of the data The first public dataset was processed with HFS 2552 10 Medicare cost report software which at that time was based on Transmittal 2 of the 2552 10 When HFS Transmittal Z3 software was approved we thought it would be interesting to re calculate the files to see the effect of the new Transmittal Then we compared mcrx files created using HFS Transmittal 2 software with the morx files created with Transmittal 3 software If you need any help interpreting these differences call us A few notes 1 If you compare our re created mcrx or PDF cost report file to the actual cost report file and see differences we want to know Please send HFS your original data file for reconciling We have seen some differences and are documenting issues and explanations 2 Every now and then we see a duplicate report in the database We filter this data out when picking up data for the Snap Shot Reports and Advanced Search and Extract function We display the revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Snap Shot Reports s duplicate reports on this screen We define duplicate as a record that has the same provider fiscal year and status as a previous record report A duplicate might just be a processing issue It
49. 9 11 901 9 11 9011 Implantable Devices Charged to Patients Drugs Charged to Patients 9 11 9011 91 9011 901 9011 901 901 Renal Dialysis 9011 901 9 11 ASC Non Distinct Part Other Ancillary specify OUTPATIENT SERVICE COST CENTERS Rural Health Climie RHC Federally Qualified Health Center FOHC 9 11 9 11 X 901 po RI pp T 901 901 Emergency Observation Beds Other Outpatient ER po 91 9d1 qp 91 ee ee c 911 sub 905 9011 901 1CMS 2552 10 082011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4065 1 52 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 196 08 11 5 2552 10 4090 Cont 409 ALLOCATION OF ALLOWABLE COSTS FOR PROVIDER CCN MM WORKSHEET L 1 EXIRAORDINARY CIRCUMSTANCES PARTI Cont CAPITAL RELATED COSTS SUBTOTAL zumof pei amp nee amp OPERATION cob 0 4 REPAIRS OF PLANT 1 TIT I m 2 5 1 1 E 2921 ap 101 m omm mm mm 9 11 901 901 901 901 901 106
50. 9011 91 Other Organ Acquisition specify 9 11 Ambulatory Surgical Center Distinct Part 911 911 Hospice san 905 oD Other Special Purpose specify 91 911 901 901 201 901 911 9011 9 1 SUBTOTALS sum of lines 1 117 9011 911 901 9 11 941 91 941 911 901 901 9 11 901 NONREIMBURSABLE COST CENTERS Se ee eet SS BSS a LE ee eee Gift Flower Coffee Shop amp Canteen 9 11 901 Research 9 11 901 901 Physicians Private Offices 9 11 901 901 901 Nonpaid Workers 9011 901 901 901 Other Nonreimburzable specify 51 901 Cross Foot Adjustments Negative Cost Centers Total sum of line 118 and lines190 201 Total Statistical Basis Unit Cost Multiplier 1 CMS 2552 10 082011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4065 1 2 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 200 4090 Cont FORM CMS 2552 10 COMPUTATION OF PROGRAM INPATIENT ROUTINE SERVICE PROVIDER CCN CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES Tile V Title Part A Title XIX Inpatient Program Per Diem Capital Cost Cost Center Description j col 3 4 col 5 x col 6 INPATIENT ROUTINE SERVICE COST CENTERS Adults amp Pediatnes General Routine Care Intensive Care Unit 2
51. IP 3 21 Login to HCRIS 4 22 Create My Provider 5 5 3 My Provider 5 10 4 Snap aee E bg es 11 41 Single Provider Report 5 11 42 Multiple Provider Report 5 12 43 PPS Hospital 15 4 3 4 PPS Hospital Dashboard 5 16 44 IP PPS Dashboard 15 55 XR GR 22 441 IP PPS Dashboard 23 45 CAH Dashboard Gobo SiS 27 4 51 Dashboard 5 28 46 Balance Sheet 30 4 6 1 Balance Sheet Report Specifications 31 4 7 Data Snapshot Multi Years Hospitals 33 471 Wage Data Snapshot Specifications 34 48 DSH Summary 5 37 4 81 DSH Summary Specifications 39 49 Summary 5 40 4 9 1 GME Report
52. Laundry and Linen Service 9 11 00900 01000 Dietary j 1 201 xn 901 201 01100 dinis 01200 Iu 01300 Nursing Administration 201 201 san 1 901 201 901 E 01400 Services and Supply al 01500 Pharmacy 9011 01600 Medical Records amp Medical Records Libra an a 901 201 901 a e 901 o x __ 01700 Social Service 901 iL specify 9 11 9099 Nomphysician Anesthetists 901 201 901 901 02000 Nursing School 9011 02100 Itera amp Res LL amp Fringes Approved 02200 Intem amp Res Other m Costs Appro 2d 9011 201 201 201 m 201 201 901 02300 Paramedical Ed specify 9011 INPATIENT ROUTINE SERVICE COST CENTERS 303 san 201 sansa dl 9 11 901 Fausta tonem 3000 Adults and Pediatrics General Routine Care Intensive Care Unit Em 201 sai 201 201 201 03200 901 305 03300 Burn Intensive Care Unit E 03400 Surgical Intensive Care Unit al 201 201 xn 941 901 201 201 H Other Special Care specify 901 901 04000 Subprovider IPF
53. Other Reimbursable specify 901 901 901 5 2552 10 TOTAL col 1 2 901 93 6 901 901 98 oD 98 90 4090 Cont WORKSHEET M 1 RECLASSIFIED TRIAL BALANCE col 3 4 NET EXPENSES FOR ALLOCATION col 5 col RECLASS IFICATIONS Physician Assistant Nurse Practitioner j Visiting Nurse 901 901 EE Other Nurse Clinical Social Worker 201 201 201 201 901 9 11 9011 201 201 Laboratory Technician Subtotal sum of lines 1 9 COSTS UNDER AGREEMENT ov ro e s 201 201 201 201 201 201 oio e rn ee ESA EEE SES ea IRI n 901 13 Other Costs Under Agreement 201 sa 901 901 201 14 5 CARE COSTS Subtotal sum of lines 15 20 22 Total Cost of Health Care Services sum of lines 10 14 and 21 COSTS OTHER THAN RHCFQHC SERVICES a Optometry 201 25
54. Subprovider specify 9 11 43 Nursery 901 04400 Skilled Nursing Facility 9 11 1 9 11 201 901 201 941 201 3 35 04500 Nursing Facility 9 11 36 04600 Other Leng Term Care 201 9011 FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4013 40 524 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual FORM 5 2552 10 4090 PROVIDER CCN 1 WORKSHEET A 6 EXPLANATION OF RECLASSIFICATION S 36 X 36 X 36 X 36 X 36 Ann pm Lor X 36 X 36 9 3 99 xao wow n se X 36 X 36 36 X 36 X 36 X 36 xm 901 500 ee etc must be entered on each line to identify each reclassification entry Transfer the amounts in columns 4 5 8 and 9 to Worksheet A column 4 lines as appropriate FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4014 Rev 2 an X 36 Anna revised 4 19 2013 2013 Health Financial Systems and Toyon
55. es a o vn e o vn e ro 201 29011 Intern amp Res Service Salary amp Fringes Approved Intern amp Res Other Program Costs Approved 201 201 Paramedical Education Program specify INPATIENT ROUTINE SERVICE COST CENTERS 30 Adults and Pediatrics General Routine Care 31 Intensive Care Unit 9a1 9 11 32 Coronary Care Unit E m 33 Burn Intensive Care Unit 201 201 201 34 Surgical Intensive Care Unit sa Lm m 901 901 201 42 E m 43 Nursery 91 a 9 11 44 Skilled Nursing Facility 901 35 Nursing Facility san 20 46 Oher Long Tem sD FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 IL SECTION 4021 40 544 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc 201 201 201 Appendix B CMS HCRIS Specifications 16 08 11 FORM 5 2552 10 ALLOCATION OF CAPITAL RELATED COSTS PROVIDER CCN Magnetic Rusonance Cardiac Catheterization Laboratory PBP Clinical Laboratory Services Program Only 2 Whole Blood amp Packed Red Blood Cells Blood Storing Processing amp Trans Intravenous Therapy Respiratory Therapy Phys
56. revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 158 FORM 5 2552 10 08 11 08 1 ALLOCATION OF GENERAL SERVICE COSTS TO HHA COST CENTERS esses 205 san san san san sam Speech Pathology 9 Medical Social Services 10 Eee 20 Totals sum of lines 1 19 2 21 Unit Cost Multiplier column 26 line 1 divided by the sum of column 26 line 20 minus column 26 1 rounded to 6 decimal places 1 Column 0 line 20 must agree with Wkst A columm 7 line 101 2 Columns 0 through 26 line 20 must agree with the corresponding columns of Wkst B Part line 101 FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 II SECTION 4043 1 40 608 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 19 HCRIS Website User Manual 1 FORM CMS 2552 10 4090 Cont 4090 CATION OF GENERAL SERVICE PROVIDER CCN WORKSHEET H 2 AILO S TO HHA COST CENT
57. 04100 Subprovider IRF 201 201 xn 901 901 901 201 201 04200 Subprovider specify san MD 901 al Skilled Nursing Facility 04400 04600 Other Long Term Care al 901 201 9011 201 901 04500 901 201 201 FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 IL SECTION 4013 40 524 Green ECR HCRIS Purple HCRIS only revised 4 19 2013 T2 Received HFS 8 26 2011 2013 Health Financial Systems and Toyon amp Associates Inc 1S 0 0 a m 4090 Cont RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES COST CENTER DESCRIPTIONS omit cents GENERAL SERVICE COST CENTERS Capital Related Costs 35 _____ Other Special Care specify Appendix B CMS HCRIS Specifications FORM 5 2552 10 PROVIDER CCN TOTAL col 1 col 2 sah 201 san 201 901 201 san 201 san san 941 201 08 11 PERIOD WORKSHEET A FROM TO RECLASSIFIED NET EXPENSES TRIAL BALANCE FOR ALLOCATION col 3 coL4 ADJUSTMENTS col 5 01 6 1 2 o n as ro 40 04000 Subprovider IPF 31 901 901 201 san 201 04100 42 04200
58. 20 Number of ARANESP units furnished relating to the home dialysis department 901 PHYSICIAN PAYMENT METHOD Enter X for applicable method s 21 MCP X INITIAL METHOD 21 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 20 FORM 5 2552 10 HOSPITAL BASED COMMUNITY MENTAL HEALTH CENTER AND OTHER OUTPATIENT REHABILITATION PROVIDER STATISTICAL DATA COMMUNITY MENTAL HEALTH amp OTHER OUTPATIENT REHABILITATION PROVIDER NUMBER OF EMPLOYEES FULL TIME EQUIVALENT CORF OSP OPT Enter the mumber of hours in your normal workweek _ 9 3 99 Line 0 Col 1 Total Contract colunm 1 column 2 a E 1 Administrator and Assistant Administrat s 1 93 99 9 99 Director s and Assistant Director s 9359 9399 9399 Psychiatric Psychologi ice Supervi 18 Oher spei eA 999 2013 Health Financial Systems Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual FORM CMS 2552 10 Does this hospital have an agreement under either section 1883 or section 1913 for swing beds Enter Y for yes or N for no in cohmm 1 If yes enter the agreement date mm dd yyyy column 2 3 3 1 1 I this facility contains a hospital based SNF were patients under managed care or was there no Medicar
59. 252 558 31 55 ederally Qualified Health Center FQHC 91 11 E UNE ME NN M 2 93 Other Ourpatient Service specify 901 E pow xm pom 1m pL 70 FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 II SECTION 4021 40 548 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications o 08 11 FORM 5 2552 10 4090 Cont ALLOCATION OF CAPITAL RELATED COSTS PROVIDER CCN MAIN ADMINIS VIS amp NRI 0 9011 901 EU 201 sa sa dp sar 9a oa SPECIAL PURPOSE COST CENTERS eva cai ccm ce crt ro um Kidney Acquisition 901 Heart Acquisition an 1m p xm pm Dm 901 9 11 m
60. 3 Hosp FYE 4 Salaries L 1 Total Salaries 174 579 300 168 006 972 171 555 376 160 772 680 L 22 01 A amp 6 Under Contract 0 0 0 Housekeeping Under Contract L 27 01 Dietary Under Contract 0 0 0 Salaries Paid Hours L 26 01 L 1 Total Salaries 4 926 177 4 873 339 55 5 150 145 37 L 22 01 A amp G Under Contract 0 0 0 1 26 01 Under 0 0 0 ontract L 27 01 Dietary Under Contract 0 0 0 Salaries Average Hourly Wage AHW L 1 Total Salaries 35 44 34 47 33 31 32 00 L 22 01 A amp G Under Contract 0 00 0 00 0 00 0 00 1 26 01 Housekeeping Under 50 00 50 00 50 00 50 00 L 27 01 Dietary Under Contract 0 00 0 00 0 00 0 00 Other Wage amp Related Costs Contract Labor 14 652 836 6 579 404 8 087 458 8 654 888 Pharmacy Svc Under 0 0 0 Contract Laboratory Svc Under 0 0 0 Mgmt amp Sup Sve Under Contract Report Specifications revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Snap Shot Reports 4 7 1 Wage Data Snapshot Specifications The following tables contain the specifications for the Wage Index Report Each table represents a distinct part or section of this report References to data sources for the 2552 96 and 2552 10 form sets are included for your convenience 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual Report Element Data Source
61. 4 4 Ieo o prs p ad p 205 Unit cost multiplier Worksheet B 909906 9 4 9 6 9 4 9 6 HIG 9 4 9 5 9 4 9 5 9 4 9 6 904 909 HIG ES Cost to be allocated Worksheet B Pat T FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4020 40 558 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 08 11 COST ALLOCATION STATISTICAL BASIS FORM CMS 2552 10 a Ln Cafeteria Nursing Administration Central Services and Supply Pharmacy Medical Records amp Medical Records Library Social Service Other General Service specify tonphysician Anesthetists using School Intern amp Res Service Salary amp Fringes Approved 2 Intern amp Res Other Program Costs Approved Paramedical Education Program specify INPATIENT ROUTINE SERVICE COST CENTERS Adults and Pediatrics General Routine Care Intensive Care Unit Coronary Care Unit Burn Intensive Care Unit Surgical Intensive Care Unit Other Special Care Unit specify ubprovider FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4020 Rev 2 revised 4 19 2013 201
62. 5 coumni 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual Reclass CESA CBSA NO Reclass CBSA Table Reclass CSA 2010 Reclass CBSA 2009 Meare CMI 200 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc PPS Hospital Dashboard Utilization amp Census Acute 1 5 3 Part line 12 column 4 5 3 S 3 PartI line 14 column 6 5 3 Part I Partl line 12 column 6 line 14 column 8 Acute Medicare Days 5 3 Part I line 12 column 4 S 3 Part I line 14 column 6 Acute Medicare Discharges S 3 Part I line 12 column 13 S 3 Part I line 14 column 13 5 3 Part line 12 column 4 5 3 S 3 PartI line 14 column 6 5 3 Part I Part line 12 column 13 line 14 column 13 2 5 3 Part line 12 column 5 5 3 S 3 PartI line 14 column 7 5 3 Part I Part line 12 column 6 line 14 column 8 Acute Medicaid Days S 3 Part I line 12 column 5 S 3 Part I line 14 column 7 Acute Medicaid Discharges S 3 Part I line 12 column 14 S 3 Part I line 14 column 14 Acut me 5 3 Part1 line 12 column 5 S S 3 PartI line 14 column 7 S 3 Part I FONS 3 Part I line 12 column 14 line 14 column 14 Acute Medicare ALOS Acut Medicaid HMO Days 5 3 Part I line 14 e Medicaid HMO Ut NotonCost Report Acute Medicaid
63. 92 Observation Beds see instructions ae m 93 Other Outpatient Service specify OTHER REIMBURSABLE COST CENTERS N ST a cer carm ms 94 Home Program Dialysis J gt 901 MEE MN INN Ambulance Services 5 1 m m loo 27 Durable Medical Equipment Sodl san san OrherReimbursable specify Outpatient Rehabilitation Provider speci ___ ___ 100 Intem Resident Service not appvd prem 0 aD iol J SPECIAL PURPOSE COST CENTERS ESSERE exc Liver Acquisition Pancreas Acquisition Intestinal Acquisition Tslet Acquisition Other Organ Acquisition specify Ambulatory Surgical Center Distinct Part Subtotal see instructions Less Observation Beds FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTIONS 4023 40 564 revised 4 19
64. Gline29 columni O revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Snap Shot Reports 4 6 Balance Sheet Report The following screen shot shows the Balance Sheet Report 2 bs ASSETS CURRENT ASSETS Cash on hand in banks Temporary investments Notes receivable Accounts receivable Other receivable Allow for uncollectible notes and AR Inventory Prepsid expenses Other current sssets Due from other funds Total current assets sum of lines 1 10 FIXED ASSETS Land 14 465 033 12 01 Accumulsted depreciation 13 Land improvements 13 01 Accumulsted deprecistion 14 Buildings 14 01 Accumulsted deprecistion 15 Lessehold improvements 15 01 Accumulsted deprecistion 16 Fixed equipment 16 01 Accumulsted depreciation 17 Automobiles and trucks 17 01 Accumulated depreciation 18 Major movable equipment 18 01 Accumulsted depreciation Minor equipment deprecisble 19 01 Accumulated depreciation 20 Minor equipment nondeprecisble Total fixed assets sum of lines 12 20 OTHER ASSETS 22 Investments 23 Deposits on leases Due from owners officers Other assets Total other assets sum of lines 22 25 Total assets sum of lines 11 958 858 708 21 and 26 31 243 133 349 175 930 14 699 526 1 425 593 58 637 466 217 610 321 107 271 038 283 414 700 1 596 713 200 486 747 172 087 648 19 192 324 21 423 871 013 273 336 737 42 040 635 315 377 372 Report Sp
65. INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 IL SECTION 4065 1 54 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 199 HCRIS Website User Manual 1 FORM CMS 2552 10 4090 Cont CATION OF ALLOWABLE COSTS FOR PROVIDER CCN E WORKSHEET L 1 AORDINARY CIRCUMSTANCES PART I Cont INTERN amp INTERNS amp INTERNS amp RESIDENT OTHER RESIDENTS RESIDENTS PARAMEDICA COST amp POST Cost Center Descriptions GENERAL NONPHYSICIAN NURSING SALARY AND PROGRAM EDUCATION STEPDOWN SERVICE ANESTHETIST SCHOOL FRINGES COSTS SPECIFY SUBTOTAL ADJUSTMENTS _ TOTAL 18 1 20 2 3 201 7 26 OTHER REIMBURSABLE COST CENTERS SS e a eee ESS E Home Program Dialysis saD 5 Ambulance Service 911 901 901 Durable Medical Equipment Rented 901 9 11 9011 901 Durable Medical Eguipment Sold 9 11 901 Other Reimbursable specify 9 11 901 901 Outpatient Rehabilitation Provider specify 9 11 9 11 9 11 901 901 901 901 Intern Rezident Service not appvd tchng prem 9 11 9 11 9 11 901 Home Health Agency 9011 SPECIAL PURPOSE COST CENTERS Kidney Acquisition 901 1 9 1 901 901 9 11 941 9011 901 9 11 9 11 901 9011 901 9d1 901 901 901 901 901 911 9011 901 901 901 9011 901
66. Row Part Il WAGE DATA Hosp FYE 1 Hosp FYE 2 Hosp FYE 3 Hosp FYE 4 Salaries L 1 Total Salaries 109 951 354 102 657 826 103 748 653 104 812 277 L 22 01 A amp G Under Contract 0 0 0 681 309 Housekeeping Under 1 26 01 0 0 0 0 L 27 01 Dietary Under Contract 9 461 44 190 0 0 Salaries Paid Hours L 1 Total Salaries 4 505 183 4 377 391 4 534 117 1 22 01 amp G Under Contract 0 0 0 1 You can switch to other providers in your list by clicking the drop down box and selecting the provider you want 2 You can sort the Provider listing to order by Provider Number or Name 3 If you want to see data for a provider not already listed in your My Provider List then select the Click here to add a Provider link to return to the list of providers and use the Add Single or Multiple option Remember you can add providers as often as you want 4 You can change the fiscal year FY for any or all of the four columns By default the most recent cost report period for each of the four providers is displayed Use the drop down box to choose other available fiscal years 5 The cost report Status defaults to show the most recent iteration of the cost report for the applicable cost report year Use the drop down box to select other available statuses 6 If you would like to view a different Snap Shot Report click the Reports drop down box and choose a different Snap Shot Report You can also choose
67. basis had such pay been made in accordance with 42 CFR 413 6 char Subtotal ime 37 or numus ines 39 numm 3 91D sa Sas 90 sa 996 sa 90D sa ESS 900 0 01 ey 1 90 sa C aD O sa sm HEE EE EEE E HE n ES ES ELE FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 IL SECTION 40302 40 586 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 137 HCRIS Website User Manual 08 11 FORM 5 2552 10 4090 Cont PROVIDER CCN 90 90 91 Outher reconciliation adjas ammut 196 mstractioms 91 92 The rate used 12 calculate the Tims Value of Mo 92 93 Time Valas of Mc 93 SS Total sum of inss 91 and 54 FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 1 SECTION 4030 2 Rev 2 40 587 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications FORM 5 2552 10 Total interim payments sum of lines 1 2 and 3 99 transfer to Wkst E or Wkst E 3 line Subtotal sum of lines 5 01 5 49 minus s
68. in the first boxes to search for a particular provider Or leave blank and use the filter criteria to return a group of providers reports Report Type 2552 10 Providers rv FYE m 5 1 2011 4 30 2012 Report Status Most Recent v Type of Hospital m Provider Type CBSA Bed Size Range to Organ Teaching m SCH MDH Urban Rural m SUBMIT revised 4 19 2013 2013 Health Financial Systems and amp Associates Inc Report Type Users can pick between the 2552 96 and the 2552 10 databases The system defaults to the latest form set 2552 10 Providers You have four lines where they can enter either provider numbers or provider names for the search These can be left blank if the intent is not to search for a particular provider s These fields can also be used with wild cards Use the underline as the wild The Hospital Medicare provider number has logic built into it The first two digits of the provider number is a state code The state code for Alabama is 01 If a user wanted to return all of the hospitals in Alabama they could enter 01 that s 4 underlines Digits 3 6 identify type of provider Children s Hospitals use 3300 3399 so a user could enter 33 two underlines before and after the 33 to search for all Children s Hospitals The ranges for provider type will not always work for this so we have added options below that u
69. into your hospital during in this cost reporting period of HRSA THC program instructions Teaching Hospitals that Claim Residents in Non Provider Settings 63 Haz your facility trained residents non provider setting during this cost reporting period Enter Y for yes or N for no complete lines 64 67 instructions Section 5504 of the Base Year FTE Residents in Nonprovider settings This base year iz your cost reporting period that begins on or after July 1 2009 and before June 30 2010 col 1 col 2 64 65 Enter in column 1 the number of unweighted non primary care resident attributable to rotations occurring in non provider settings Enter in column 2 the number af unweighted non primary care resident FTEs that trained in your hospital Enter in column 3 the ratio of column 1 divided by column 1 column 2 see instructions Program Code peut pro 3 Enter in column I the program name Enter in column 2 program code enter in column 3 the number of unweighted primary care FTE residents arributable to rotation occurring in non provider settings Enter in column 4 the number of unweighted primary care resident FTEs that mained in your hospital Enter in column 5 the ratio of column 3 divided by column 3 column 4 see instructions X10 9996 FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE
70. 10 4090 Cont CATION OF GENERAL SERVICE COSTS TO WORKSHEET 1 1 MUNITY MENTAL HEALTH CENTERS PART CONT CORF COST CENTER omit cents Administrative and General Skilled Nursing Care Physical Therapy Occupational Therapy Speech Pathology Medical Social Services Respiratory Therapy Psychiatric Psychological Services Individual Therapy Group Therspy Family Counseling Diagnostic Services Approved Patient Training amp Education Prosthetic and Orthotic Devices Drugs and Biologicals Medical Supplies Medical Appliances Durable Medical Equipment Rented Durable Medical Equipment Sold All Others Totals sum of lines 1 21 Total Cost to be Allocated Unit Cost Multiplier see instructions say say say 90 a 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4053 2 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 173 HCRIS Website User Manual 4090 Cont FORM 5 2552 10 COMPUTATION OF COMMUNITY MENTAL HEALTH CENTER PROVIDER COSTS PARTI APPORTIONMENT OF CMHC COST CENTERS Title V Title Component Component Costs col 3 Drugs and Biologicals Medical Supplies Medical Appliances All Others 1 Totals sum of lines 1 19 Enter am
71. 682 683 654 and 685 gt amp charges exchuding than 10 you do not quake ta chading MS DRG 652 652 683 684 an 655 instructions stay to ons week ime 43 Guided by lms 41 dnaded by 7 dy cost for teatueme 100 instractioms Total additional 45 times line 55 times Ene 41 Subtoml seo mituctoms ital from Worksheet L Parts service othar pass through costs Worksheet D Past IV col 11 ime 200 Total sum of amounts on ime 59 tizcugi 2 Total for beneficii 59 mmus Ene 60 Allowable bad debts for daal bensSciane imstuctens amount payab bad debt i50 zs tuctoms 31 42 4 45 46 7 3 49 50 51 52 53 54 55 56 57 58 59 60 61 63 9 5 5 57 55 6 70 71 72 73 74 75 epe epe AIEEE gt Operating amount from Worksheet E Part A lins 2 pital outbar fom Worksheet Part L ime 2 Opermnscutlierreccnciiston 0002 FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 II SECTION 4030 1 Rev 2 revised 4 19 2013 2013 Health Financial Systems and amp Associates Inc Appendix B CMS HCRIS Specifications 136 FORM CMS 2552 10 a Sfo o a om a Im Amounts Gat would havo been realized from patents able for payment for services on charge
72. 8 through 11 are included in the Medicare and Medicaid lines 4 through 7 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 19 HCRIS Website User Manual 7 1 11 L Worksheets 4090 Cont FORM CMS 2552 10 CALCULATION OF CAPITAL PAYMENT Tile V Title Pat A Total inpatient days divided by number of days in the cost reporting period see mstructions Percentage of SSI recipient patient days to Medicare Part A patient days Worksheet E Part A 20 see instructions Percentage of Medicaid pati total days reported on Worksheet 5 2 Part line 24 see instructions Allowable disproportionate share percentage see instructions 8 Disproportionate share adjustment line 10 times lines 1 Total prospective capital payments sum of lines 1 2 6 and 11 990 90D 0999 Current year comparison of capital minimum payment level to capital payments line 8 less line 9 Carryover of accumulated capital mimimum payment level over capital payment from prior year Worksheet L Part IIL line 14 Net compa n ofca level to c n D Current exception payment if line 12 is positive enter the amount on this line 901 Current year allowable operating and capital payment see mstructions 16 Curent year operating and capital costs see instructions 17 Current year exception offset amount see mstructions revised 4 19 20
73. 9 11 dn 76 Ome Ancillary pecifyy sam mE mM _ OUTPATIENT SERVICE COST CENTERS 83 Rural Health Clinic RHC oe 90 09000 91 a 35 38 92 09200 Observation Beds 93 i a l 1 EE FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4013 Rev 2 4090 Cont FORM CMS 2552 10 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 4090 Cont RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES COST CENTER DESCRIPTIONS omit cents GENERAL SERVICE COST CENTERS 00100 Capital Related Costs Buildings and Fixmures 00300 Other Capital Related Costs 00400 Employee Benefits o 00500 Administrative and General san 5 2552 10 PROVIDER TOTAL RECLASSIFI TRIAL BALANCE FOR ALLOCATION OTHER col 1 2 3 Ll 3 ADJUSIMENIS col 5 5 901 00200 901 20 901 san 201 201 901 1 201 201 901 00600 Maintenance and Repairs 9011 00700 Operation of Plant 901 901 201 o san 901 9 11 941 9 11 9 11 9 11 00800
74. 901 9011 901 Physicians Private Offices 901 901 9 11 91 91 901 1 901 Nonpaid Workers Other Nonrembursable specify Cross Foot Adjustments Negative Cost Centers 901 901 901 91 941 901 941 941 901 Total sum of line 118 and lines190 201 Total Statistical Basis Unit Cost Multiplier 1 CMS 2552 10 082011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 IL SECTION 4065 1 54 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 098 Cont CATION OF ALLOWABLE COSTS FOR AORDINARY CIRCUMSTANCES Cost Center Descriptions OTHER REIMBURSABLE COST CENTERS Home Program Dialysis Ambulance Services Durable Medical Equpment Rented Durable Medical Equipment Sold MAIN HOUSE TENANCE OF DIETARY CAFETERIA PERSONNEL 9 EET FETE en our mmt 901 901 901 FORM CMS 2552 10 91 9 11 901 08 11 08 1 EE rim ALLO EE antic EXTR MEDICAL ENES amp amp SUPPLY PHARMACY E pace xx ensem oum corum pena conem 901 9 11 9 11 9 11 901 Other Reimbursable specify 901 901 901 9011 91 91 901 901 Outpatient Rehabilit
75. Clinical Laboratory Services Program Only Whole Blood amp Packed Red Blood Cells mg Processing amp Trans are aay san sah EE ipee ene eid 901 39 11 01 90 9 11 9 11 9 ESE edi are El aD FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 IL SECTION 4020 Rev 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual FORM 5 2552 10 MM mE lium 08 11 08 1 DIETARY 1 amp 11 201 E mm mm Er 901 201 201 201 201 1 1 9 pom 9 11 9 11 9 11 9r EEL 25204 201 901 901 101 201 201 1 201 a 201 201 EERE
76. Coronary Care Unit Bum Intensive Care Unit Surgical Intensive Care Unit Other Special Care Unit specify D xe Do 128 o m m m Tal om fs 30199 ee 4 Worksheet numbers 08 11 FORM CMS 2552 10 4090 Cont COMPUTATION OF PROGRAM INPATIENT ANCILLARY SERVICE PROVIDER CCN CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES COMPONENT Hospital Tie V Subprovider Title Part A Title XIX 2 Cost Center Description rures een 2 totis m 4 4 9 581 559 1 901 9366 901 901 901 95 6 901 901 901 901 9 96 901 901 Magnetic Resonance Imaging 901 san 9 96 901 901 Cardiac Catherization o 9 o Laboratory 22 9 _ oD PBP Clinical Laboratory Sercice Program SSE SE pcs e ee ee Whole Blood amp Packed Red Blood Cells o f o f o oo f Blood Storing Processing amp Trans 305 95 909 901 Intravenous Therapy 350 Em 901 9366 901 901 901 say o 9a 901 901 936 901 901 901 9366 901 901 901 9366 901 901 901 901 9 56 901 901 901 9 96 901 9101 901 9 9 6 901 901 __ ___ 260 ANCILLARY SERVICE COST CENTERS
77. FORM 5 2552 10 PROVIDER 201 201 201 ajajajaj 201 m 201 201 al 4 ns 5 8m AD E ER 201 201 201 201 Cafeteria gt 24 I 5 Social Service 201 11 201 18 a Geel e e m Nursing Se n a 11 201 201 201 901 201 901 3 Paramedical Education Program specify INPATIENT ROUTINE SERVICE COST CENTERS 30 Adults and Pedistrics General Routine Care m 301 _ 201 2 Coronary Care Unit Bum Intensive Care Unit _ 201 201 201 5 SureicalintensiveCareUnit 45 201 201 9dr 201 al 11 2 Sse pe 5 E E 99 201 901 9 11 901 901 201 44 Skilled Nursing Facility l 45 m 201 201 9 11 9 11 9 11 201 901 201 46 OterLongTemCare
78. HOSPITAL Status 1 Fiscal Year End 12 31 2011 Sal Net of Excl 0 Other Wages 0 Wage Relsted Costs 0 Total Paid Hours 2893674 Total Wages of Total 0 00 Total Hours of Total 1 52 AHW 234882 83 36 Above Below CBSA Avg 3 64 010024 JACKSON HOSPITAL AND CLINIC INC Status 1 Fiscal Year End 12 31 2011 58 Net of 343617 Other Wages 0 Wage Related Costs 0 Total Paid Hours 72172170 Total Wages of Total 100 0056 Total Hours 96 of Total 37 9896 AHW 2458526 28 36 Above Below CBSA Avg 38 13 You have the option of printing the results to a PDF document file or exporting the results to an Excel data file See the specifications for a list of all cost report data elements used to display these results Wage Data Analysis by CBSA Specifications 5 3 My Provider Roll Up Reports The My Provider Roll Up Report is a single provider report that includes data from one or more additional cost reports from other providers Overview The heading of this report contains numerous options that you will select and based on your selections you will see a particular Snap Shot Report for the chosen provider You will also see a column of data that represents an instant comparison between the chosen provider based on the data in the selected Snap Shot Report and against multiple other providers cost report data for the same Snap Shot Report We collect all the relevant comparison data and display a number we ca
79. Health Financial Systems and Toyon amp Associates Inc revised 4 19 2013 Appendix B CMS HCRIS Specifications 7 1 6 Worksheets 2 5 255 10 mni FORM I rs Dus fom other funds Total current assets sum of ines 1 10 D 12 29 5 Total other assets sam of nos 31 Total assets sum of Imes 11 30 and 3 f you we acuproprisary amd do not lt FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 1541 SECTION 4040 Published 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc HCRIS Website User Manual 08 11 FORM CMS 2552 10 4090 Cont isar and de not 59 Total fmd balances sum lines 52 21 60 Total and Send balances sum of imo 51 and 59 0 FORM 5 2552 10 082011 QNSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4040 Rev 2 40 601 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 152 4090 Cont FORM CMS 2552 10 08 11 STATEMENT OF CHANGES IN FUND BALANCES PROVIDER PERIOD WORKSHEET G 1 FROM PLANT FUND o1 2 3s 4 s 6 7 8 1 Fund balances at beginning of period 1 2 Net income 055 Worksheet 3 lin
80. My Provider List 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual If you choose to add Multiple providers you will need to have a csv or txt file containing the provider numbers My Provider List My Providers Snap Shot Reports Use this list to manage your default providers PPS Hosp Dashboard IP PPS Dashboard Back to My Provider List CAH Dashboard Balance Sheet Will you be adding a single provider or multiple providers Single Multiple Wage Index DSH Overview Multiple Providers GME Summary You may upload a set of provider numbers or provider names either a csv or txt file that is comma seperated IME Summary Reimb vs Cost D Choose File No file chosen 2 Upload Analysis Bad Debt Report This procedures is a two step process 1 Click the Choose File button to open a file browser window so you can find your file containing the provider numbers When you locate and select the file the file name will be displayed to the right of the Choose File button 2 Click the Upload button to upload the provider number data from the file you selected Your My Provider List will be populated with the providers that match the provider numbers that you uploaded from your file Now that you have your My Provider List populated with one or more providers you are ready to run reports and utilize the the various data analysis Tools that are based on My P
81. PUBLISHED IN CMS PUB 15 IL SECTION 4004 1 Rev 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 4090 Cont HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX IDENTIFICATION DATA FORM 5 2552 10 WORKSHEET 5 2 PART I CONT unweighted non primary care resident FTEs that trained in your hospital Enter in column 3 the ratio of column 1 divided by column 1 column 2 see instructions Program Name 1 7 Enter in column 1 the program name Enter in column 2 the program code Enter in column 3 the number of unweighted primary care FTE resident attributable to rotations occurring in all non provider settings Enter in column 4 the number of unweighted primary care resident FTE that trained in your hospital Enter in column 5 the ratio of column 3 divided by column 3 column 4 cee instructions Column 1 Did the facility have a teaching program in the most recent cost report filed on or before November 15 2004 Enter Y for yes or N for no Column 2 Did this facility train residents in a new teaching program in accordance with 42 5412424 4 1 Enter Y for yes or N for no Column 3 If column 2 is enter 1 2 or 3 respectively in column 3 see instructions If this cost reporting period covers the beginning of the fourth year enter 4 in column 3 or if the subsequent academic years of the new teaching progr
82. Table Reclass CBSA 2010 Reclass CBSA 2009 Data Source s 2552 10 Non HCRIS data table Non HCRIS datatable Non HCRIS data table Non HCRIS datatable Non HCRIS data table Non HCRIS data table Non HCRIS data table Non HCRIS data table revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Snap Shot Reports z Report Element Data Source s 2552 10 PPS Rate WI Table Non HCRIS data table Medicare Utilization Acute Report Element Data Source s 2552 10 S 3 Ptl In 12 col 4 5 3 Ptl In12 S 3 PtI In 14 col 6 S 3 Pt I In 14 col Acute Medicare Util 96 col 6 Acute Medicare Days 5 3 In 12 col 4 5 3 Pt I In 14 col 6 Acute Medicare Discharges 5 3 In 12 col 13 5 3 Pt I In 14 col 13 5 3 Pti 12 col 4 S 3 Pt In 12 S 3 Pti In 14 col 6 S 3 Pt I In 14 col Acute Medicare ALOS col 13 13 S 3 Ptl In 12 col 5 5 3 Pt I In 12 5 3 Pt I In 14 col 7 S 3 Pt I In 14 col Acute Medicaid Util 96 col 6 8 Acute Medicaid Days 5 3 PtI In 12 col 5 5 3 In 14 col 7 Acute Medicaid Discharges 5 3 Pt I In 12 col 14 5 3 Pt I In 14 col 14 S 3 Ptl In 12 col 5 S 3 In 12 S 3 Pt In 14 col 7 5 3 Pt I In 14 col Acute Medicaid ALOS 14 14 Acute Medicaid HMO days below S Acute Medicaid HMO Util 6 No Total on Cost Report 3 Pt I In 14 c
83. Travel Expense 40 Therapists sum of columns 1 and 2 line 9 times column 2 line 10 43 Optional travel expense line 8 times the sum of columns 1 3 line 13 Total Travel Allowance and Travel Expense Offsite Services Complete one of the following three lines 44 45 46 as appropriate 44 Standard travel allowance and standard travel expense sum of lines 38 and 39 see instructions 901 45 Optional travel allowance and standard travel expense sum of lines 39 and 42 see instructions 901 46 Optional allowance and optional travel expense sum of lines 42 and 43 see instructions oan FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB 15 SECTIONS 4019 Rev 2 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications s 4090 Cont FORM CMS 2552 10 REASONABLE COST DETERMINATION FOR THERAPY SERVICES PROVIDER CCN WORKSHEET 8 3 FURNISHED BY OUTSIDE SUPPLIERS PARTS V VI PART OVERTIME COMPUTATION Overtime hours worked during reporting period if column 5 line 47 is zero or equal to or greater than 2 080 do not complete lines 48 55 and enter zero in each column of line 56 Adjusted hourly salary equivalency amount see instructions 3 Overtime cost limitation 51 times line 52 Portion of overtime already included in hourly computation at the AHSEA
84. applicable column 994 FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 IL SECTION 4004 1 40 506 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 08 11 FORM 5 2552 10 4090 Cont HOSPITAL AND HOSPITAL HEALTH CARE PROVIDER CCN PERIOD WORKSHEET 5 2 COMPLEX IDENTIFICATION DATA FROM TO Rural Providers 105 Does this hospital qualify as a Critical Access Hospital 106 If this facility qualifies as a has it elected the all inclusive method of payment for outpatient services see instructions 107 Column 1 If this facility qualifies as a is it eligible for cost reimbursement for amp R training programs Enter Y for yes or for no in column 1 see instructions If yes the GME elimination would not be on Worksheet B Part L colunn 25 and the program would be cost reimbursed If yes complete Worksheet D 2 Part Column 2 If this facility is do I amp Rs in an approved medical education program train in the excluded IPF and or IRF unit Enter Y for yes or for no in column 2 see instructions Ts this a rural hospital qualifying for an exception to the fee schedule See 42 CFR 5312 11366 Enter for no If this hospital qualifies as or cost provider are therapy serv
85. col 1 sum E Pt A In 2 2 01 col 1 01 sum E Pt A 2 2 01 col 1 02 Hume Pta maoa erama pps capital En msogo eran liume ta maza Emam mn 00007 E Pt A 2 2 01 Organ Acquisition E Pt A In 12 col 1 EPtAInSS Total IP Service Costs E Pt A 16 col 1 E Pt A In 24 28 29 col 1 IP PPS Hospital Statement of Revenues amp Expenses GrossPatientRevenue G licol O Less Contractual Allowances G 3Un2 col 7 NetPatient Revenue G 3lnjcol G Inicol O OperaingExpene G 3In4col NetOperatingGain loss G 3InScol G InScol Add Otherinome G jin25coll Less Other Expense G 3in30col cold Netincome loss ________ G 3in3Lcoli 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 4 5 CAH Dashboard CAH Dashboard single report View Provider Number SS FYE Beds 25 SubProvider RPF SB SNF Patient Days Medicare Total Utilization SB SNF 885 1 308 Acute SNF 1279 1 946 65 72 67 66 ALOS 4 11 3 69 Acute 311 527 Discharges Medicare Total CAH Dashboard 06 30 2012 SubProvider IPF Status As Submitted Sub 1 Hospital Related Medicare Cost Charge Cost Reimb 1 609 80
86. efas sa e notespayee fe 47 34 39 unsecuredions efas 14 ss unsecuredicons fe 5001 Loanstromowners Priorto7 yes_ 6 4001 14 wa 40 02 Loanstromowners Onorater7 yes 8 4002 a wa 43 othertongtermiibiities 49 14 Other long term liabilities 41 1 4 Total long term liabilities sum of lines 37 thru Total long term liabilities sum of lines 46 thru 41 1 4 49 1 4 Total liabilities sum of lines 36 and42 za 51 Total liabilities sum oflines 45 anaso 51 14 General fund balance laa 214 Is2 General fund balance 51 Totalfund balances sum oflines44twuso _ 6 51 4 Total fund balances sum ofliness2 wus 6 59 14 Total liabilities and fund balances sum of lines bale thse Total liabilities and fund balances sum of lines 43 and 51 14 51 and 59 14 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 47 Wage Data Snapshot Multi Years Hospitals Wage Data Snapshot 4 Column Format 01 01 11 12 31 11 v 01 01 10 12 31 10 01 01 09 12 31 09 01 01 08 12 31 08 Cost Report Status As Submitted 1 As Submitted 1 As Submitted 1 As Submitted 1 PDF Available Not Available Not Available Not Available CBSA 11260 11260 11260 Row Part Il WAGE DATA Hosp FYE 1 Hosp FYE 2 Hosp FYE
87. line 17 column 1 2 line 2 column 1 5 2 Part I line 3 column 1 5 2 line 17 column 2 5 2 Part line 20 column 2 Status S Part Il line 2 column 1 SlineS colum 1 Teaching Hospital Indicator concatenate S 2 line 25 01 column 1 5 2 Part I line56 S 2 Part I line 56 E Part A line 3 00 column 1 E Part A line 3 04 column 1 E PartA line 3 08 column 1 E Part A line 3 13 column 1 E Part A line 3 14 column 1 E Part A line 3 15 column 1 E Part A line 3 16 column 1 E PartA line 3 17 column 1 E Part A line 3 18 column 1 PYI amp R to Bed Ratio E Part A line 3 19 column 1 E Part A Line 20 Total IME Payments E Part A line 3 24 column 1 E Part A Line 22 DRG Non Outlier Payments on or after 10 1 E Part A line 1 01 column 1 Report Element Data Source s 2552 96 Data Source s 2552 10 E Part A line 1 00 column 1 n E Part A line 1 02 column 1 E Part A line 1 07 column 1 z sum E Part A lines 1 00 1 01 1 02 1 07 col 1 E Part A line 1 03 column 1 MA E Part A line 1 04 column 1 MA E Part A line 1 05 column 1 E Part A line 1 06 column 1 E Part A line 1 08 column 1 zIsum E Part A lines 1 01 1 06 1 08 col 1 L Part I Title XVIII Hospital line 1 column 1 L Part Title XVIII Hospital line 2 column 1 L Part I Title Hospital column 1 NA NA Capital DRG after 1
88. line 19 column 3 SNF Total Days S 3 Part I line 15 column 6 S 3 Part I line 19 column 8 PPS Hospital Dashboard Medicare Reimbursement Report Element Data Source s 2552 96 Data Source s 2552 10 Inpatient PPS sum E Part A lines 17 19 20 26 sum E Part A lines 60 62 63 71 Outpatient PPS sum E Part B Hospital Sub 1 Sub 2 SNF sum E Part B Hospital IPF SNF lines lines 18 18 01 24 32 25 26 31 40 sum E 3 Part I Subp1 Title XVIII lines5 7 9 17 sum E 3 Part II IPF lines 17 19 21 31 Inpatient IRF sum E 3 Part I Subp2 Title XVIII lines5 7 9 17 sum E 3 Part III IRF lines 18 20 22 32 2 sum E 3 Part III Title XVIII SNF lines 33 36 55 sum E 3 Part VI lines 6 7 13 15 sum E 2 Title XVIII lines 10 16 17 D 2 Title XVIII line 12 columns 1 2 sum H 4 Part II line 31 columns 1 2 sum H 7 Part I line 24 columns 1 3 sum H 4 Part Il line 9 columns 1 2 3 sum M 3 line 24 columns 1 2 sum M 3 line 24 columns 1 2 Organ Acquisition E Part A line 12 column 1 E Part A line 13 column 1 Total IP Service Costs E Part A line 16 column 1 sum E Part A lines 24 28 29 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual GrossPatientRevenue G ilinei column 7 column Allowances NetPatientReve
89. s 2552 96 s 2552 10 5 2 line 17 column 1 5 2 Line 20 Column 1 5 2 line 17 column 2 5 2 Line 20 Column 2 2021 21 11 S Line 10 Column 1 FI Received On Status 5 1 5 2 Line 3 Column 3 Provider Number 5 2 Line 3 Column 2 Provider Name 5 2 Line 3 Column 1 Subprovider Numbers S 2 Line 4 Column 2 Subprovider Numbers 5 2 Line 5 Column 2 Total Salary Adjusted Salary 5 3 Part Il Column 4 Line 1 Total Salary Paid Hours 5 3 Part Il Column 5 Line 1 Total Salary Average Hourly Rate 5 3 Part Il Column 6 Line 1 A amp G Under Contract Adjusted Salary 5 3 Part Column 4 Line 28 A amp G Under Contract Paid Hours 5 3 Part Il Column 5 Line 28 A amp G Under Contract Average Hourly Wage 5 3 Part column 5 line 22 01 5 3 Part 11 Column 6 Line 28 Housekpng under contract Adjusted Salary S 3 Part Il column 3 line 26 01 5 3 Part Il Column 4 Line 33 Housekpng under contract Paid Hours 5 3 Part Il column 4 line 26 01 5 3 Part Il Column 5 Line 33 Hsekpng under contract Avg Hourly Wage 5 3 Part column 5 line 26 01 5 3 Part Il Column 6 Line 33 Dietary under contract Adjusted Salary S 3 Part Il column 3 line 27 01 5 3 Part Il Column 4 Line 35 Contract Labor Paid Hours 5 3 Part column 4 line 9 5 3 Part Il Column 5 Line 11 Contract Labor Average Hourly Wage 5 3 Part Il column 5 line 9 5 3 Part Il Column 6 Line 11 2
90. the city listed in the Medicare cost report The amp o _ wildcard option can be used in this field 2552 96 City S 2 Line 1 01 Column 1 2552 10 City S 2 Line 1 01 Column 1 State 2552 96 S 2 Line 1 01 Column 2 2552 10 S 2 Line 1 01 Column 2 2552 96 S Line 2 Column 2 2552 10 S Line 2 Column 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 st HCRIS Website User Manual Type of Hospital 2552 96 S 2 Line 18 Column 1 Type of Subprovider 2552 96 S 2 Lines 3 4 5 6 7 7 01 9 11 12 14 15 and 16 Column 2 CBSA The wildcard option can be used in this field 2552 96 S 2 Line 21 03 Column 5 Bed Size Range 2552 96 5 3 Part I Line 12 Column 1 Organ 2552 96 5 2 Line 23 Column 1 DSH 2552 96 5 2 Line 21 01 Column 1 Teaching 2552 96 S 2 Line 25 01 Column 1 2552 96 S 2 Line 20 Column 1 SCH MDH 2552 96 5 2 Line 26 Column 1 greater than 0 or 5 2 Line 53 column 1 greater than 0 Urban Rural 2552 96 5 2 Line 21 03 Column 1 Recent Reports Contact Us 51 My Provider Multi Facility Comparisons In development Not available 5 2 Wage Data Analysis by CBSA This tool allows you to select a year and a CBSA or Reclassified CBSA code and use them as search criteria to retrieve applicable wage data for providers that were within the scope of your search There is also a link t
91. 0 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 II SECTION 4054 2 Rev 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 175 HCRIS Website User Manual 4090 Cont FORM CMS 2552 10 CALCULATION OF REIMBURSEMENT SETILEMENT COMMUNITY PROVIDER MENTAL HEALTH CENTER PROVIDER SERVICES Tite V 11 1 Cort of component arcs Torktheet 13 2 Part 29 5 Total reasonable cost see mstructions 6 Total charges for program services CUSTOMARY CHARGES 7 Aggregate amount actually collected from patients liable for services on a charge basis 8 Amount that would have been realized from patients liable for payment for services on a charge basis had such payment been made accordance with 42 CFR 413 13 9 Ratio of line 7 to line 8 not to exceed 1 000000 see instructions 10 11 12 E SETILEMENT 13 14 Part B deductible billed to program patients __ 0 15 16 Excess ofreasonable cost over customary charges fom ime 17 18 19 20 21 Reimbursable bad debts provider records see mstructions MMC es 23 Reimbursable bad debts for dual eligible beneficiaries see instructions __ 00 24 25 26 27 Interim payments see instructions MD 28 Tentative settlement for contractor use onb S S O 29 30 Protested amounts nonallowable cost report items m accordance with CMS Pub
92. 0 1 97 L Part Title XVIII Hospital line 3 01 col 1 Redistribution Cap E Part A line 3 07 column 1 E Part A Line 9 IP Days divided by CR period days L Part Title XVIII Hospital line 4 column 1 L Part I Line 3 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 4 11 Reimbursement vs Cost Analysis Report Reimbursement vs Cost Analysis 4 Column Format Reimb vs Cost Analysis Report 01 01 11 12 31 11 01 01 10 12 31 10 v 01 01 09 12 31 09 w 01 01 08 12 31 08 Cost Report Status As Submitted 1 As Submitted 1 As Submitted 1 As Submitted 1 v PDF Available Not Available Not Available Not Available Inpatient Medicare Acute Reimb 72 278 216 71 535 939 67 652 461 67 406 969 Acute Costs 88 335 324 77 615 336 81 189 218 78 363 380 of Reimb to Costs 82 92 83 Medicare CMI FFY FR 1 19 Medicare Wage Index FR Percentage Change PY Medicare Medicare Wage Index Medicare Days Medicare Discharges ALOS Per Diem Analysis Medicare Reimb 3 131 1 3 340 77 3 198 7 Medicare Cost 3 826 69 3 624 68 3 838 73 Gain Loss 695 59 283 91 640 03 Percentage Change PY Medicare Reimb Day 6 2896 10 1596 Medicare Cost Day 5 5796 13 7196 Gain Loss Day 145 0096 35 6096 Report Specifications revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Snap Shot Reports 4 4 1
93. 013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 1 7 1 8 IWorksheets 08 11 ANALYSIS OF RENAL DIALYSIS DEPARTMENT COSTS plicable box imi 1 4 08 4514 1494 aM 1 2 3 4 5 7 5 Subito sum mes 1 9 10 12 13 31 Total costs sum of linas 75 Lins 17 columm 1 should with Worksheet column 7 for imo 74 line 94 appropriate and lins 27 columm 1 should agree with Worksheet B Part I columm 26 for Ene 74 or ime 94 as appropriate FORM 5 2552 10 082011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4045 Rev 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 165 HCRIS Website User Manual 4090 Cont FORM 5 2552 10 ALLOCATION OF RENAL DEPARTMENT COSTS TO TREATMENT MODALITIES Check applicable box OUTPATIENT SERVICES COMPOSITE PAYMENT RATE CAPITAL AND RELATED COSTS 1 Total Renal Department Costs MAINTENANCE TEE TESTES ES eee 2 e 901 901 TABBG pee 3 901 5 Intermittent Peritoneal ap sam s n 9 sap 7 an jean ean a 921 HOME Se 901 Intermittent Peritoneal 901 901 901 901 on 11 J fp 901 OTHER BILLABLE SERVICES
94. 1 9011 9011 941 901 901 901 901 9011 E 901 9 11 91 901 901 sab 901 201 901 901 501 901 9a aD 901 901 901 901 901 901 911 901 911 901 9011 9011 901 9 901 901 941 901 9011 9 11 9 11 901 9d1 9d1 901 901 901 901 911 9011 91 9011 901 911 901 9 11 901 9 11 901 901 901 201 91 1CMS 2552 10 082011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 IL SECTION 4065 1 48 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc 941 9 11 901 Cont CATION OF ALLOWABLE COSTS AORDINARY CIRCUMSTANCES Cost Center Descriptions GENERAL SERVICE COST CENTERS Appendix B CMS HCRIS Specifications 122 FORM CMS 2552 10 INTERNS amp I 08 11 WORKSHEET 1 1 PARTI Cont RESIDENT COST amp POST STEPDOWN Capital Related Costs Buildings and Fixtures Capital Related Costs Movable Equpment Employee Benefits Administrative and General Maintenance and Repairs Intern amp Res Service Salary amp Fringes Approved Intern amp Res e ap Paramedical Ed INPATIENT ROUTINE SERVICE COST CENIERS Adults
95. 1 1 Reimbursement vs Cost Analysis Specifications The following table contains the specifications for the Reimbursement vs Cost Analysis Report References to data sources for the 2552 96 and 2552 10 form sets are included for your convenience Data Sources 2552 10 Acute Reimb E Part A line 16 column 1 sum E Part A lines 59 70 96 70 97 Acute Costs D 1 Part II line 49 column 1 D 1 Part Il line 49 E Part A line 16 column 1 D 1 Part sum E Part A lines 59 70 96 70 97 96 of Reimb to Costs Il line 49 column 1 D 1 Part II line 49 Medicare CMI FFY FR PPS Table 2 PPS Table 2 Medicare Wage Index FR PPS Table 2 PPS Table 2 Percentage ChangePY Calculated based on values from Federal Medicare CMI Register Medicare Days S 3 Part I line 12 column 4 i i 23 Calculated based on values from Federal Medicare Wage Index Register 3 Part I line 14 column6 5 Medicare Discharges 5 3 Part I line 12 column 13 5 3 Part I line 14 column 13 S 3 Part line 12 col 4 5 3 Part I line S 3 Partl line 14 column 6 5 3 ALOS Partl line 14 column 13 EE NE ERE E PartA line 16 column 1 5 3 Parti 5 PartA lines 59 70 96 70 97 Medicare Reimb line 12 column 4 S 3 Part I line 14 6 0 1 Part II line 49 column 1 S 3 Part D 1 Partll line 49 5 3 Part I line Medicare C
96. 10 WORKSHEET E PARTA Adjustment increase or decrease the FTE count for allopathic and osteopathic programs affiliated programs in accordance with 42 CFR 413 75 b 413 79 2 01 and Vol 64 Federal Register May 12 1998 page 26340 and Vol 6 Federal Register 2 The of increase Yf the hospial was awarded FTE cap 1o from dosed teaching hospital under section 5506 of ACA sce Instructions ines and 7 01 Aes or and 322 sec instructions m Tomi pior ed 13 Total allowable FTE count Sor the pamitimmto year if that year ended on or September 30 1997 otharaiso antar zaro 9699 14 15 20 Prior year resident t bed ratio UU 21 CESES 22 DME payment awit for the Add on for Section 422 of the FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4030 1 40 584 Green ECR HCRIS Purple HCRIS only 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual FORM CMS 2552 10 WORKSHEET E PART A Cont PART INPATIENT HOSPITAL SERVICES UNDER PPS Addincaal for lng centage of ESRD acharse Total Medicare discharges on Worksheet 5 3 Part I axchading discharges for MS DRGs 652
97. 107 9 18 90 19 uo 90 12 9m 90 90 15 90 16 Other Special Purpose specify 10 SUBTOTALS sum of lines 1 117 9 11 901 901 901 901 901 118 NONREIMBURSABLE COST CENTERS Gift Flower Coffee Shop 5 Canteen Research Physicians Private Offices Nonpaid Workers Other Nonrennbursable specify Cross Foot Adjustments Total sum of line 118 and hnes190 20 FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 IL SECTION 4065 1 FORM Rev 2 40 653 40 6 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 197 HCRIS Website User Manual Cont CATION OF ALLOWABLE COSTS FOR AORDINARY CIRCUMSTANCES Cost Center Descriptions OTHER REIMBURSABLE COST CENTERS Home Program Dialysis Ambulance Services Durable Medical Equpment Rented Durable Medical Equipment Sold MAIN HOUSE TENANCE OF DIETARY CAFETERIA PERSONNEL 9 EET FETE en our mmt 901 901
98. 11 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 II SECTION 4020 40 536 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 08 11 FORM 5 2552 10 COST ALLOCATION GENERAL SERVICE COSTS PROVIDER CCN OTHER REIMBURSABLE COST CENTERS ee Home Progam Dialys Em z Durable Medical Equipment Rented 9 11 0011 0 11 Durable Medical Equpment Sold 211 Other Reimbursable specify SAD 201 201 201 a Outpatient Rehabilitation Provider specify a 01 211 Service not apvd tchnz prem 201 a 201 en 11 oT 9 11 901 901 903 aD 405 MD MD o 11 M oan al 9dr 901 9 11 NONREIMBURSABLE COST CENTERS EIER Ret Gift Flower Coffee Shop amp Canteen Other Noureimbursable specify 9 11 9 11 A1 Cross Foot Adjustments E 201 201 201 201 201 201 201 201
99. 116 117 peal epee E sa 118 15 Gum of ines 1117 901 saD 90 NONEEIMBURSABLE COST CENTERS aS a SS eee 190 Gift Flower Coffee Shop 05 Em x xm Private Offices 1 194 OterNowembwse gedW Costs besine Pr 205 Unit cost mmbiplier Worksheet B Pat 7 FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4020 Rev 2 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 4090 Cont FORM 5 2552 10 COST ALLOCATION STATISTICAL BASIS Pharmacy 16 Medical Records amp Medical Records Library 18 Other General Service specify 19 om 2 20 Nursing School 21 luem amp Res Service Salary amp Fringes Ape sam san san san sm sam sam sam 22 amp Res Other Program Costs Approved 5 INPATIENT ROUTINE SERVICE COST CENTERS 30 Adults and Pediatrics General Routine Care an 31 Intensive Care Unit sam ES EE EE 33 Bum Intensive Ca
100. 12 31 2005 Reopened 4 04 10 2009 03 24 2009 N A N A N A Settled without Audit 2 MCRX PDF 1 1 2006 12 31 2006 04 23 2008 04 21 2008 N A NIA 1 1 2005 12 31 2005 N A N A N A 1 1 2005 12 31 2005 Settled without N A N A N A Audit 2 1 1 2005 12 31 2005 As Submitted 1 N A N A N A 1 1 2004 12 31 2004 Reopened 4 04 22 2009 04 17 2009 N A N A NA m 1 1 2004 12 31 2004 You can view all the available reports in the database for an individual provider by selecting the Available Reports link in the list of Snap Shot Reports This will show reports from the 2552 96 and 2552 10 databases Reports available are sorted with the most recent at the top of the list This report like all other Snap Shot Reports will display results for all providers in your My Provider List The year range and status boxes are not applicable to this report Regardless of how these boxes are set all cost report periods and statuses will be displayed Report Specifications 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 4 15 1 Available Cost Reports Specifications The following section contains the specifications for Available Facility Reports Report References to data sources for the 2552 96 and 2552 10 form sets are included for your convenience FYB Fiscal Year Beginning is reported fro
101. 12 O ADO PROG City LONE PINE State CA Type of Hospital Provider Type Swing Beds SNF SNF RHC EEE MAC 01001 CBSA 99905 Beds 4 Organ N DSH Teaching NCAH Y SCH Urban Rural Rural 051304 JOHN C FREMONT HEALTHCARE DISTRICT Status As Submitted Fiscal Year 07 01 2011 06 30 2012 O A00 PROV City MARIPOSA State Type of Hospital Provider Type Swing Beds SNF SNF HHA Hospice MAC 01001 CBSA 99905 Beds 18 Organ DSH Teaching NCAH Y SCH Urban Rural Rural On the Search Results screen the heading displays information about the provider cost report you selected and the number of reports in the comparison group Below the heading the cost reports in the comparison group are listed For each report in the comparison group relevant information about the cost report provider is displayed You have the option of adding any of the listed providers to your My Provider List and downloading any available reports in the list You can chose how the list is sorted by selecting any of the links in the Sort By area located directly above the list of cost reports Combined Extract Results Select the Combined Extract Results tab to save the results of your report in an Excel compatible file 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 6 HCRIS Website User Manual _ My Provider s Provider 050599 UC DAVIS MEDICAL CEN
102. 13 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 190 08 11 5 2552 10 4090 Cont 409 ALLOCATION OF ALLOWABLE COSTS FOR E WORKSHEETL 1 ALLO EXTRAORDINARY CIRCUMSTANCES PARTI EXTR pem L1 1 901 901 901 5 5 901 6 6 901 901 901 901 90 91 901 901 901 901 901 9 11 Nursing Administration 911 Central Services and Supply 901 Pharmacy 901 Medical Records amp Medical Records Library 901 Social Service 901 Other General Service specify 901 Nonphysician Anesthetists 901 Nursing School 901 901 901 Intern amp Service Salary amp Fringes Approved 901 901 sa Intern amp Res Other Program Costs Approved 901 201 901 Paramedical Ed Program specify 901 901 9011 INPATIENT ROUTINE SERVICE COST CENTERS mp Sa er Adults and Pediatric General Routine Care sD 901 Intensive Care Unit 901 Coronary Care Unit 901 Bum Intensive Care Unit 901 Surgical Intensive Care Unit 901 Other Special Care Unit specify 901 Subprovider IPF 901 901 Subprovider IRF 901 901 Subprovider 901 901 901 Nursery 901 901 9011 Skilled Nursing Facility 901 901 sa 901 4 44 Nursing Facility 901 901 901 Other Long Term Care 901 901 901 901 901 901 46 46 a on cn ae to
103. 15 IL section 115 2 AD revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 176 08 11 FORM CMS 2552 10 4090 Cont CENTER FOR SERVICES RENDERED TO PROGRAM BENEFICIARIES Title LL t payable on individual either subuntted or to be submitted to the intermediary for services rendered the cost reporting penods If the interim rate for the i cost reporting period Also show date of exch payment If none write NONE i or enter zero 1 Subtotal sum of limes 3 01 3 49 minus sum of lines 3 50 3 98 201 Um Total interim payments sum of line 1 2 and 3 99 transfer to Worksheet 1 3 line 27 901 MMDDYYYY 300552 f MMDD YYYY ME Provider to Program 02 MMDD YYYY Total Medicare liability Name of Contractor Month Day Year Col 0 Col 1 901 Col 2 1 On lines 3 5 and 6 where an amount is due provider to program show the amount and date on which you agree to the amount of repayment even though the total repayment is not accomplished until a later date 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 177 HCRIS Website User Manual 7 1 10 K Worksheets 4090 Cont FORM CMS 2552 10 ANALYSIS OF PROVIDER BASED PROVIDER CCN HOSPICE COSTS HOSPICE CCN EMPLOYEE SALARIES BENEFITS SUBTOTAL COST CENTE
104. 2 Labs and Diagnostics 29 9a1 Medical Radiation ical Suppl Outpatient Services including E R Dept non Therapy Bereavement Program Costs Volunteer Program Costs Other Program Costs pe o cal Bereavement Program Costs i Fundraising Totals sum of lines 1 33 2 Unit Cost Multiplier see instructions 1 Cohmm 0 line 34 must agree with Wkst A column 7 line 116 30 32 33 35 7 3 gt 901 901 901 a sam sam 91 oan 23 23 901 2 saD an 26 5 90 7 27 say ap 28 90 9 gt 9 30 3 901 9011 2 Columns 0 through 25 line 34 must agree with the corresponding columns of Wkst B Part I line 116 501 941 901 FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4062 1 40 638 2013 Health Financial Systems and Toyon amp Associates Inc 941 901 Published 4 19 2013 183 HCRIS Website User Manual 1 FORM CMS 2552 10 4090 Cont 4090 CATION OF GENERAL SERVICE PROVIDER PERIOD WORKSHEET K 5 ALLO S HOSPICE COST CENTERS PARTI Cont COST HOSPICE CCN
105. 2 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4050 Rev 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 167 HCRIS Website User Manual 4090 Cont FORM 5 2552 10 COMPUTATION OF AVERAGE COST PER TREATMENT PROVIDER CCN FOR OUTPATIENT RENAL DIALYSIS Check box Average Cost Total Cost of Program Program Average fom Wkst Treatments Expenses Payment Rate 1 2 col 11 col 2 col 1 4 3 6 4 2 3 5 7 9011 9 11 9 3 99 9 3 99 9011 9 11 9 3 99 9 3 99 9011 9011 9 3 99 9 3 99 901 9011 9 3 99 9 3 99 901 9011 9 3 99 9 3 99 901 oan 9 3 99 9 3 99 941 941 9 3 99 9 3 99 901 941 9 3 99 9 3 99 Home Program Continuous Ambulatory Peritoneal Dialysis 9 1 9 11 X 9 3 99 Home Prof Contimous Cycling Peritoneal 1 sal X 9 3 99 Totals sum o lines 1 8 columns 1 and 4 sum of lines 1 10 columns 2 5 and 7 o e o o ed FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4051 40 620 FORM CMS 2552 10 CALCULATION OF REIMBURSABLE BAD DEBTS TITLE XVIII PARTB 1 Total expenses related to care of program beneficiames see instructions Total payment om Worksheet L4 column 6 ne 11 Deductibles billed to Medicare Part B patient
106. 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 08 11 FORM CMS 2552 10 4090 Cont CALCULATION OF OUTPATIENT SERVICE COST TO T eV CHARGE RATIOS NET OF REDUCTIONS FOR MEDICAID ONLY Title Capital Cost Operating Cost Total Cost Wkst B Netof Cost Center Descriptions Wist Part Capital Cost Capital Reduction Part I col 26 26 col 1 col 2 Reduction 1 2 ANCILLARY SERVICE COST CENTERS eee ee api En san j san Em Recovery Room 01 2 Labor Room and Delivery Room 9D 9D om x E 58 E i 01 01 9 5 1 an 56 Radioisotope 8 san san 3a m zing 0 oa ay 9 6 39 Cardiac Cateiztion 201 201 201 201 9 6 61 PBP Clinical Laboratory Services Prem Only 11 201 9 0 62 Whole Blood amp Packed Red Blood Cells 946 san 90 san 201 201 201 201 201 201 9 6 66 9
107. 2013 Health Financial Systems and Toyon amp Associates Inc iii HCRIS Website User Manual 1 Welcome to the HCRIS Website Welcome to the HFS Toyon HCRIS database website This website and the various tools and reports you will find here are the result of the joint efforts of Health Financial Systems and Toyon amp Associates Inc We have been developing this website for several years The HFS Toyon HCRIS website contains all HCRIS data for the 2552 96 and 2552 10 cost report form sets The Medicare Cost Report data contains thousands of data elements per report for several thousand Hospital providers with several report time periods and iterations of those reports In other words it is a lot of data too much for most users to be able to handle with the tools typically available This website focuses on bringing key elements of the data into clear view allowing users to look at only who and what they are interested in and easily filtering down to and extracting the data they want for further analysis We designed the website reports and tools to give users access to the CMS HCRIS database through an easy to use interface Specifically users of the HCRIS website will enjoy fast and reliable access to the complete HCRIS hospital databases 2552 96 Cost Report Data 9 30 96 fiscal year end to fiscal year begin 4 29 2010 This data is available in our snapshot reports our comparison reports and the search and extract features 2552 10 Cost Re
108. 27 24 71 65 12 269 Util 0 00 0 00 Report Specifications revised 4 19 2013 Total Hospital Medicare Reimbursement Inpatient PPS Outpatient PPS Inpatient Sub2 EN HHA Medicare Service Total Inpatient PPS 178 038 616 73 95 Outpatient PPS 59 912 958 24 89 Inpatient Sub2 2 039 222 0 85 762 997 0 32 Total Medicare Reimbursement 240 753 793 Hospital Statement of Revenues and Expenses Gross Patient Revenue 5 772 670 937 Less Contractual 4 538 064 863 Allowances Net Patient Revenue 1 234 606 074 Operating Expense 1 186 268 341 Net Operating Gain Loss 48 337 733 Add Other Income 79 935 680 Less Other Expense 10 644 484 Net Income Loss 117 628 929 2013 Health Financial Systems and Toyon amp Associates Inc 4 3 1 PPS Hospital Dashboard Specifications The following tables contain the specifications for PPS Dashboard Report Each table represents a distinct part or section of this report References to data sources for the 2552 96 and 2552 10 form sets are included for your convenience PPS Hospital Dashboard Report Heading Report Element Data Source s 2552 96 Provider Name 5 2 Part I line 2 column 1 Provider S 2 Part I line 2 column 2 Sub Provider1 5 2 Part I line 3 column 2 Sub Provider2 5 2 Part I line 3 01 column 2 5 2 Part I line 6 column 2 FE ___________5 2 Part line 17 column CRStatus 5 1
109. 291 Total interim payments sum of lines 1 2 and 3 99 transfer to Worksheet M 3 line 27 TO BE COMPLETED BY CONIRACTOR List separately each tentative settlement payment after desk review Also show date of each payment i I none write NONE 1 9 or enter zero 1 5 911 Pn MMDDYYYY 901 MMDD YYYY 901 Total Medicare liability see instructions Name of Contractor lumber 0 36 MMDDYYYY Col 2 1 On lines 3 5 and 6 where an amount is due provider to program show the amount and date on which you agree to the amount of repayment even though the total repayment 15 not accomplished until a later date Subtotal sum of lines 5 01 5 49 mmus sum of lines 5 50 5 98 revised 4 19 2013 2013 Health Financial Systems and amp Associates Inc Appendix B CMS HCRIS Specifications 206 7 1 13 S Worksheets 08 11 FORM 5 2552 10 This report ix by lw 42 USC 13958 42 CFR 413 Fuslare to report rend all ileri severis made the 42 USC demp PROVIDER CC X cost raport 9 If this is amended report enter the number of times the provider rezubextted this cost report X Medicare Utilization Enter for full or L for low 3 9 j Cost Report 6 Date Received _ 10 NPR Date _ 1 Submitted 7 Comractor M10 11 Contract
110. 3 i Sub1 IPF Medicaid Days S 3 Part I line 14 column 5 S 3 Part I line 16 column 7 Sub1 IPF Medicaid Dschg 5 3 Part I line 14 column 14 S 3 Part I line 16 column 14 5 S 3 PartI line 14 column 5 5 3 S 3 Partl line 16 column 7 5 3 Part I Seti wr edic LOS Partl line 14 column 14 line 16 column 14 Sub1 IPF Total Util 5 3 Part I line 14 column 6 Total sum 5 3 Partl line 16 columns 8 S Available Days S 3 line 14 column 1 3 Part I line 16 column 3 Sub1 IPF Total Days S 3 Part I line 14 column 6 S 3 Part I line 16 column 8 Sub1 IPF Total Discharges S 3 Part I line 14 column 15 S 3 Part I line 16 column 15 S 3 Part line 14 column 6 5 3 S 3 Part I line 16 column 8 5 3 Part I Partl line 14 column 15 line 16 column 15 PPS Hospital Dashboard Utilization amp Census Subprovider 2 IRF P S 3 Part line 14 01 column 4 S S 3 Part line 17 column 6 5 3 Part I 3 Part I line 14 01 column 6 line 17 column 8 Sub2 IRF Medicare Days 5 3 Part I line 14 01 column 4 S 3 Part I line 17 column 6 Sub2 IRF Medicare Dscgs 5 3 Part I line 14 01 column 13 S 3 Part I line 17 column 13 S 3 Part line 14 01 column 4 S S 3 Part line 17 column 6 5 3 Part I Sub2 WF Medicae ALOS 4 Parti 14 61 column13 line 17 column 13 Sub IR
111. 3 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 4090 Cont FORM 5 2552 10 COST ALLOCATION STATISTICAL BASIS NON INTERNS RESIDENTS PHYSICIAN NURSING WS PROGRAM ANES SCHOOL FRINGES COSIS THETISTS ASSIGNED ASSIGNED ASSIGNED ASGND TIME TIME TIME TIME aa a a 2 up sn ah so REN san Lm m ze pepe 52 Whole Blood amp Packed Red Blood Cells 1 901 63 Blood Storing Processing amp Trans 0 66 Physical Therapy 91 67 panon 68 60 Electrocardiolozy 1r 70 Electroencephalography 901 71 Medical Supplies Charged to Patients oan 5 73 D ged to Patients 74 75 76 Other Ancillary specify 941 941 OUTPATIENT SERVICE COST CENTERS Saas FERA 88 Rural Health Clinic RHC 901 fied Health Center FQHC E 92 Observation Beds oS o 93 Other Ourpatient Service specify 9011 911 FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4020 40 560 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 55 HCRIS Website User Manual 08 11 FORM 5 2552 10 COST ALLOCATION STATISTICAL BASIS PROVIDER CCN INTERNS amp RESIDENTS SALARY AND PROGRAM MEDICAL FRINGES ASSIGNED 101 Home Health SPECIAL PUR
112. 30 column 8 E Part A line 4 01 E Part line 31 Allowable Capital DSH96 1 Part line 5 03 L Part Line 10 Total Medicaid Days sum S 3 Part I lines 1 2 29 column 5 PY 1 sum S 3 Part I Lines 1 2 7 col 7 PY 1 Total Acute Hospital Days 5 3 Partl line 12 column 6 5 3 Partl line 14 column 8 li Total Hospital Days DSH sum S 3 Part lines 12 26 28 29 6 PY 1 sum S 3 PartI Lines 14 28 30 col 8 PY 1 N Employee Discount Days 5 3 Part line 28 column 6 5 3 Part I line 30 column 8 Labor Room Days 5 3 Partl line 29 column 6 5 2 line 21 03 column 5 5 2 line 3 column 3 Part A line 4 01 PY 1 8 5 I amp Lineso Py 1 py 1 indicates the same data elements are used as indicated in the first half of the equation but the data is derived from the prior year cost report 49 Summary Analysis GME Report 4 Column Format The GME report is very long too long to fit on one printed page so in the following example we only show the top half of the report Even so you can see what it looks like and get an idea of the type of data collected and displayed in this report 2013 Health Financial Systems and amp Associates Inc Published 4 19 2013 HCRIS Website User Manual EEE eee u X FYE 07 01 10 06 30 11 07 01 0
113. 4 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications FORM 5 2552 10 4090 Cont HOSPITAL AND HOSPITAL HEALTH CARE PROVIDER CCN PERIOD WORKSHEET 5 2 COMPLEX IDENTIFICATION DATA PART I CONT 35 If this is a sole commumity hospital SCH enter the mmber of periods SCH status in effect in the cost reporting period 36 Enter applicable beginning and ending dates of SCH status Subscript line 36 for number of periods in excess of one and enter subsequent dates 37 If this is a Medicare dependent hospital MDH enter the number of periods MDH status in effect in the cost reporting period 38 Enter applicable beginning and ending dates of MDH status Subscript line 38 for number of periods in excess of one and enter subsequent dates Prospective Payment System PPS Capital 45 Does this facility qualify and receive capital payment for disproportionate share in accordance with 42 CFR 5412 3207 see instructions 46 Is this facility eligible for the special exceptions payment pursuant to 42 5412 348 5 7 If yes complete Worksheet Part and L 1 Parts I through 47 Is this a new hospital under 42 CFR 412 300 PPS capital Enter Y for yes or N forno 48 Is the facility electing full federal capital payment Enter Y for yes or N for 56 Is this hospital
114. 4 line 8 column 1 E 4 line 8 column 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 43 HCRIS Website User Manual Cap Allocation Total Weighted I amp R FTEs E 3 Part IV Title 18 line 3 09 column 1 E 4 line 8 column 3 Cap Allocation CY Allowable Egtd I amp R FTEs E 3 Part IV Title 18 line 3 10 column 1 E 4 line 9 column 3 Cap Allocation CY Dental amp Podiatry I amp R FTEs E 3 Part IV Title 18 line 3 11 column 1 E 4 line 10 column 2 Primary Care GME Costs GME Calc Primary Care CY Allowable Wgtd I amp R FTEs E 3 Part IV Title 18 line 3 17 column 1 E 4 line 11 column 1 GME Calc Primary Care PY Allowable Wgtd I amp R FTEs E 3 Part IV Title 18 line 3 18 column 1 E 4 line 12 column 1 GME Calc Primary Care 2 Yr Allowable Wgtd I amp R FTEs E 3 Part IV Title 18 line 3 19 column 1 E 4 line 13 column 1 GME Calc Primary Care 3 Yr Avg Allowable Wgtd 1 amp R FTEs E 3 Part IV Title 18 line 3 20 column 1 E 4 line 14 column 1 Adj for New Program E 4 line 15 column 1 Adj for Displaced Residents E 4 line 16 column 1 Adj 3 yr Rolling Avg FTE E 3 Part IV Title 18 line 3 15 column 1 E 4 line 17 column 1 GME Calc Primary Care Per Resident Amount E 3 Part IV Title 18 line 3 21 column 1 E 4 line 18 column 1 Approved Primary Care Resident Costs Other GME Costs GME Calc CY Allowable Wgtd I
115. 9 1 042 218 2 675 045 5 327 072 Charges 2 526 621 63 71 852 248 6 394 242 9 713 111 Inpatient Swing Bed SNF Outpatient Total 122 2996 41 84 54 51 NetWSA 16723 198 Expense Medicare Cost 31 85 Report Specifications revised 4 19 2013 Total Medicare CAH Reimb Inpatient Swing Bed SNF Outpaitent Total 1 609 809 30 23 1 042 218 19 57 2 673 125 50 20 5 325 152 100 00 Medicare Service Inpatient Swing Bed SNF Outpatient Total Medicare Reimbursement Hospital Statement of Revenues and Expenses Gross Patient Revenue 41 860 449 Less Contractual Allowances 21 146 768 Net Patient Revenue 20 711 661 Operating Expense 21 791 711 1 080 050 723 687 Net Operating Gain Loss Add Other Income Less Other Expense Net Income Loss 356 363 2013 Health Financial Systems and amp Associates Inc 4 51 Dashboard Specifications The following tables contain the specifications for Critical Access Hospital Dashboard Report Each table represents a distinct part or section of this report References to data sources for the 2552 96 and 2552 10 form sets are included for your convenience Patient Days Sub Report Report Element 5 3 Part line 12 column 4 5 3 Part I line 3 5 3 Part I line 14 column 6 5 3 Part I line 5 Medicare Acute Days column 4 5 3 Part line 4 column 4 column 6
116. 9 06 30 10 07 01 08 06 30 09 107 01 07 06 30 08 iv Cost Report Status Amended 1 As Submitted 1 As Submitted 1 As Submitted 1 Available Not Available Not Available Not Available Teaching Hospital Y Y Y Y Indicator Base Year Unweighted FTE Cap 411 95 414 07 Redist Cap Increase 2 170 587 168 906 Affiliation Agree Dist 0 0 FTE Adjustment Cap 411 95 414 07 CY Unweighted FTEs B 5 479 33 468 2 CY Allowable FTEs 5 i 411 95 414 07 CY Wgtd FTE Primary E 146 88 147 41 CY Wgtd FTE Other 2 284 13 276 33 CY Wgtd FTE Total 431 01 423 74 CY Wgtd Allowed 126 23 130 37 Primary CY Wgtd Allowed Other 244 19 244 38 CY Wgtd Allowed Total 370 42 374 75 Wgtd Dental Podiatry FTE CY Adjusted Allowed Other Primary Care GME Costs CY Allowable FTE PY Allowable FTE 2 Yr Allowable FTE 3 Yr Rolling Avg FTE Add Adj for New Program Add Adj for Displaced Res Report Specifications revised 4 19 2013 2013 Health Financial Systems and amp Associates Inc Snap Shot Reports 4 4 9 1 Report Specifications The following table contains the specifications for the Graduate Medical Education Summary Report References to data sources for the 2552 96 and 2552 10 form sets are included for your convenience GME Summary Report Snapshot Report Specifications Report Element Data Source s 2552 96 S 2 line 2 c
117. 901 FORM CMS 2552 10 91 9 11 901 08 11 08 1 S ALLO EE parica EXIR MEDICAL ENES amp amp SUPPLY PHARMACY E pace xx ensem oum corum pena conem 901 9 11 9 11 9 11 901 Other Reimbursable specify 901 901 901 9011 91 91 901 901 Outpatient Rehabilitation Provider specify Intern Resident Service not appvd prem Home Health Agency 901 901 901 901 901 901 901 901 san san sa san al Emme oes rae es area say say 901 911 901 941 901 9 11 901 901 Other Organ Acquisition specify 901 901 901 901 9011 901 9 11 9 11 901 901 901 901 901 901 sao san 505 Ambulatory Surgical Center Distinct Part Hospice Other Special Purpose specify SUBTOTALS sum of lines 1 117 901 901 901 901 901 san 91 9011 901 9011 901 901 901 901 9d 901 901 901 9 11 901 901 911 NONREIMBURSABLE COST CENTERS Gif Flower Coffee Shop amp Canteen Research 901 901 9 11 9 11 SEET Rear aru 901 9011
118. A line 21 01 E 3 sum E Part A Line 65 E 3 Part Line 12 E 3 Part Il line 25 01 E 3 Part I line Part 11 Line 24 E 3 Part 111 Line 25 E 3 Part IV Line sum E Part A line 21 02 3 z sum E Part A Line 66 E 3 Part I Line 13 E 3 Part Il line 25 02 3 Part line Part Il Line 25 E 3 Part 11 Line 26 E 3 Part IV Line Dual Eligible Claims IP 11 02 SubAII 16 E 3 Part V Line 27 E 3 Part VI Line 10 Par B ine 27 Sum of Bad Debts Claimed IP Bad Sum of Bad Debts Claimed IP Bad Debts pem Sum of Adjusted Bad Debt IP Sum of Adjusted Bad Debt IP Adjusted Bad Adjusted Bad Debt Hosptl Adjusted Bad Debt OP Debt OP Sum of Dual Eligible Claims IP Dual Sum of Dual Eligible Claims IP Dual Eligible Dual Eligible Claims Hosptl Eligible Claims OP Claims OP Bad Debt Claimed IPF E 3 Part line 11 E 3 Part line 23 Dual Eligible Claims IPF E 3 Part line 11 02 E 3 Part line 25 E Adjusted Bad Debt IPF E 3 Part line 11 01 E 3 Part line 24 Bad Debt Claimed IRF E 3 Part line 11 3 Part line 24 Adjusted Bad Debt IRF E 3 Part line 11 01 E 3 Part III line 25 Bad Debt Claimed SNF 3 Part VI line 8 E 3 Part VI line 8 Adjusted Bad Debt SNF Dual Eligible Claims IRF E 3 Part line 11 02 E 3 Part III line 26 E 3 Part VI line9 E 3 Part VI line 9 Dual Eligible Claims SNF Bad Debt Cl
119. AND ANCILLARY SERVICE COSTS Servico of and Resident Not Eos D 2 p In Approved Teaching Program Past I 4 Lem t mE Gaz ER an 1 07 Care Ui 3 9 9 i Bo of Con Tz Ome Charges Acqua Charges from Wist D 2 Costs seo mstucticas 1 cob 4 col 1 xcol 2 D DI 7 yee rir 7 emam KD 5 Xe KD m 7 x revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 130 FORM 5 2552 10 4090 Cont COMPUTATION OF ORGAN ACQUISITION COSTS AND CHARGES FOR HOSPITALS WHICH ARE CERTIFIED TRANSPLANT CENTERS 34 cut 1 ibl lins 30 1 Organs procured outside center by 2 procurement team Som your center are not inciuded the count 2 Organs procured outside your center by 2 procurement team are zxcInded in ths count FORM 5 2552 10 08 2011 NSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 1 SECTIONS 4028 3 Rev 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 4090 Cont FORM 5 2552 10 APPORTIONMENT OF COST FOR THE SERVICES OF TEACHING PHYSICIANS PARTI REASONABLE COMPENSATION EQUIVALENT COMPUTATI
120. D IN CMS PUB 15 SECTIONS 4019 40 532 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 6 HCRIS Website User Manual 08 11 FORM CMS 2552 10 4090 Cont REASONABLE COST DETERMINATION FOR THERAPY SERVICES PROVIDER CCN WORKSHEET 8 3 FURNISHED BY OUTSIDE SUPPLIERS PARTS amp IV Check applicable box PART STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION PROVIDER SITE Standard Travel Allowance 24 Therapists line 3 times 2 line 11 901 25 Assistants 4 times column 3 line 11 91 Standard travel expense 7 times line 3 for respiratory therapy sum of lines 3 and 4 for all others 91 Total standard travel allowance and standard travel expense at the provider site sum of lines 26 and 27 Optional Travel Allowance and Optional Travel Expense 29 Therapists colunm 2 10 times the sum of columns 1 and 2 Ime 12 30 Assistants column 3 line 10 times column 3 12 Subtotal line 29 for respiratory therapy or sum of lines 29 and 30 for all others Standard travel allowance and standard travel expense line 28 9 11 Optional travel allowance and standard travel expense sum of lines 27 and 31 oan Optional travel allowance and optional travel expense sum of lines 31 and 32 39 Standard travel expense line 7 times the sum of lines 5 and 6 Optional Travel Allowance and Optional
121. DSH Entitlement Days Medicaid Days Medicaid HMO Medicaid Labor Room Days Total Medicaid Total Acute Hospital Days Observation Days Admitted Employee Discount Days Labor Room Days Total Hospital Days DSH Medicaid 551 Total DSH96 Allowable DSH96 Allowable Capital DSH Percentage Change PY Total Medicaid Days Total Hospital Days DSH Medicaid 2013 Health Financial Systems and Toyon amp Associates Inc 01 01 11 12 31 11 01 01 10 12 31 10 As Submitted 1 Available 0 348 13 48 346 004 21 89 10 582 940 3 943 055 8 3596 329 245 0 96 798 31 5296 8 0996 39 6196 21 89 8 35 v As Submitted 1 11260 361 48 811 457 20 3096 9 908 726 4 022 166 7 93 318 958 0 90 007 28 68 9 00 37 68 20 30 7 93 01 01 09 12 31 09 Submitted 1 11260 361 47 436 264 19 05 9 036 608 3 938 917 7 60 299 358 0 90 081 27 17 9 00 36 17 19 05 7 60 01 01 08 12 31 08 v As Submitted 1 v 11260 358 46 896 102 17 5296 8 216 197 3 995 448 7 19 287 273 Published 4 19 2013 HCRIS Website User Manual Report Specifications 4 8 1 DSH Summary Specifications The following table contains the specifications for the Disproportionate Share Hospital Report The references in the table apply to the four columns of this report References to data sources for the 2552 96 and 2552 10
122. ERS z LX Lm Intensive Care Unit Coronary Care Unit 303 201 201 901 201 303 303 gt Bum Intensive Care Unit _ 01 m 34 Surgical Intensive Care Unit z Special Care Unit pet 901 Sme 5 iei E 9 11 9 11 9 11 saa ag RG sa sa a sm san H san sa 5 36 Other Long Term Care FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 IL SECTION 4020 40 538 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 10 08 11 FORM 5 2552 10 COST ALLOCATION GENERAL SERVICE COSTS 1900 5 5 xm sm m m I xm mm a we m x sD dn 9a 5 sm m m m sm m PBP
123. ERS PARTI CONI _______ OF 5 M DIETARY SUPPLY LEA m SS 201 am m m san 0 201 901 201 201 EE ORE EE 201 9 11 Private Duty Nursing 901 Clinic Health Promotion Activities Day Care Program Home Delivered Meals Program Homemaker Service All Others Totals sum of Imes 1 19 2 oan san Unit Cost Multiplier column 26 line 1 divided by the sum of column 26 line 20 minus column 26 line 1 rounded to 6 decimal places lumas 0 through 26 line 20 must agree with the corresponding columns of Wkst B Part I line 101 5 2552 10 Draft INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 II SECTION 4043 1 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 160 1 FORM 5 2552 10 4090 Cont CATION OF GENERAL SERVICE PROVIDER CCN 3 WORKSHEET H2 S COST CENTERS PART I CONT ISTICAL BASIS Sf ofjoj ajo 2 ws m 1 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 41 SECTION 4043 2 2 2013 Health Financial Systems and amp Associates Inc Publis
124. F Medicaid Util S 3 Part 1 line 14 01 column 5 S 5 3 Part I line 17 column 7 5 3 Part I 3 Part I line 14 01 column 6 line 17 column 8 Sub2 IRF Medicaid Days 5 3 Part I line 14 01 column 5 S 3 Part I line 17 column 7 Sub2 IRF Medicaid Dscgs 5 3 Part I line 14 01 column 14 S 3 Part I line 17 column 14 2 S 3 Part line 14 01 column 5 S S 3 PartI line 17 column 7 5 3 PartI Sub2 IRF Medicaid ALOS 3 Part ine 14 01 column14 line 17 column 14 S 3 Part line 17 column 8 S 3 Part I Subh2 RF Total Util Noton cost report line 17 column 3 Sub2 IRF Total Days S 3 Part I line 14 01 column 6 S 3 Part I line 17 column 8 5402 IRF Total Dscharges 5 3 Part I line 14 01 column 15 S 3 Part I line 17 column 15 5 3 Part line 14 01 column 6 5 3 5 3 PartI line 17 column 8 5 3 Part I Sub2 IRF Total ALOS Parti line 14 01 column 15 line 17 column 15 revised 4 19 2013 2013 Health Financial Systems and amp Associates Inc PPS Hospital Dashboard Utilization amp Census SNF 5 3 PartI line 15 column 4 5 3 5 3 Part I line 19 column 6 5 3 Part I Me m Partl line 15 column 2 line 19 column 3 SNF Medicare Days S 3 Part I line 15 column 4 S 3 Part I line 19 column 6 SNF Total Util 96 S 3 PartI line 19 column 8 S 3 PartI Noton cost report
125. Found under Permitted Uses and Disclosures section of the Summary of the HIPAA Privacy Rule Public Use Files PUF A PUF also known as a Non ldentifiable File is a file that has been stripped of any personal identifying information PUFs provide aggregate or summarized information on utilization payment and or charges Because a PUF does not include protected health information these files can be requested and used without a Data Use Agreement DUA HFS Comment By definition CMS HCRIS data is transmitted to HFS Toyon in a Public Use File HFS Toyon reorganize and store the data but the data is not modified in any way Therefore the data on the HCRIS website does not include protected health information revised 4 19 2013 2013 Health Financial Systems and amp Associates Inc Appendix B CMS HCRIS Specifications 7 Appendix B CMS HCRIS Specifications Enter topic text here 71 2552 10 CMS Worksheets with References The following sections contain screen shots of all 2552 10 worksheets with color coded references for each cell indicating whether the cell is in the ECR and HCRIS specification or only the HCRIS specification These are all copied from the document published by CMS 7 1 1 AWorksheets 08 11 FORM 5 2552 10 4090 Cont RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES WORKSHEET A FROM ______ 03 NET EXPENSES COST CENTER DESCRIPTIONS TOTAL RECLASSIFI TRIAL BALANCE FOR ALLOCA
126. GENCY COSTS ______ TRANSPOR m TOTAL MEUM ofcols 55 OTHER EE UG 6 col ee GENERAL SERVICE COST CENTERS j merae rpm THE TUNES 2 Capital Related Movable Equipment 1 5 Administrative and General HHAREIMBURSABLE SERVICES Saar 5 Skilled Nursing Care 901 7 Physical Therapy sD 90 o E sap Medical Social Services e 901 Em Supplies see instructions L3 7 7 901 901 901 pags Drugs C San 14 um a eo ee HHA NONREIMBURSABLE SERVICES 55 16 Respiratory Therapy 901 901 901 901 901 ET 901 901 17 Private Dury Nursing 901 901 9an 901 901 sai 901 18 Clinic 901 9 11 say 8 901 ap 19 20 ee 901 21 pce aD oD 22 Homemaker Serice a
127. H MDH Y N Urban or Rural U R You may use one or any combination of more than one of these filters The more filters you apply the smaller the group of comparison reports After you finish selecting the filter options click Submit to apply the filters to the HCRIS database Select Clear to remove all applied filters and start again with only the first three default filters applied In the example shown below only the first three default filters are applied This results in 1459 cost reports included in the comparison group The number of cost reports included in the comparison group is displayed in the report heading as the Count Provider Search Click here to add a Provider Type Provider E tha f et beens te My Provider Rollup Report search for a provider Or leave and use the filter Dicere My Provider s de e ERI gt Provider 050599 0 DAVIS MEDICAL CENTER v Sort By Provider 8 Number Name SUBMIT CLEAR Year Range 07 01 10 06 30 11 Status Amended v Reports PPS Reimbursement v Report Type 2552 10 Report Search Results Combined Extract Results Focal Yanri Inpatient Medicare PPS Reimbursement Cost Comparison 2012 2 Report Status Count 1459 Most Recent v 050599 UC DAVIS MEDICAL CENTER The record count will decrease dramatically when one or more additional filters selected In the following example providers were filtered by 2552 10 FYE 2012 M
128. HMO Days 3 Part I line 2 column 5 S 3 Part I line 2 column 7 Acute Medicaid HMO Dschrgs Noton Cost Report Noton Cost Report Acute Medicaid HMO ALOS Noton Cost Report Noton Cost Report i Acute Total Util 96 Noton Cost Report Noton Cost Report Acute Total Days S 3 Part I line 12 column 6 S 3 Part I line 14 column 8 Acute Total Discharges S 3 Part I line 12 column 15 S 3 Part I line 14 column 15 ine 12 1 S 3 Parti line 12 column 6 5 3 S 3 Parti line 14 column 8 S 3 Part Partl line 12 column15 line 14 column 15 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 19 HCRIS Website User Manual PPS Hospital Dashboard Utilization amp Census Subprovider 1 IPF eum S 3 Partl line 14 column 4 5 3 S 3 Part line 16 column 6 5 3 Part I Partl line 14 column 6 line 16 column 8 5401 Medicare Days 5 3 Part I line 14 column 4 S 3 Part I line 16 column 6 Sub1 IPF Medicare Dschg S 3 Part I line 14 column 13 S 3 Part I line 16 column 13 Sub1 IPF Medicare ALOS 5 3 Part 1 line 14 column 4 5 3 S 3 PartI line 16 column 6 5 3 Part I Partl line 14 column 13 line 16 column 13 1 S 3 Partl line 14 column 5 S 3 S 3 Partl line 16 column 7 5 3 Part I Ep Partl line 14 column 6 line 16 column 8
129. ICIANS ADJUSTMENTS PROVIDER CCN E WORKSHEET 8 2 901 901 901 san san 901 901 901 901 901 o o __ ee sar TH 9 901 901 901 901 901 911 9a1 9011 241 9011 an san san 901 200 E FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4018 Rev 1 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 4090 Cont FORM CMS 2552 10 08 11 REASONABLE COST DETERMINATION FOR THERAPY SERVICES PROVIDER CCN PERIOD WORKSHEET 8 3 FURNISHED BY OUTSIDE SUPPLIERS FROM PARTSI amp I TO Check applicable box Occupational Physical Respiratory Speech Pathology PARTI GENERAL INFORMATION Total number of weeks worked excluding aides see instructions 2 Line 1 nxitiplied by 15 hours per week Number of unduplicated days in which supervisor or therapist was on provider site see instructions Number of unduplicated days in which therapy assistant was on provider site but neither supervisor nor therapist was on provider site see instructions Number of unduplicated offsite visits supervisors or therapists see instructions Number of unduplicated offsite visits therapy assistants mchude
130. IN CMS PUB 15 SECTION 4061 40 636 2013 Health Financial Systems and Toyon amp Associates Inc 241 Published 4 19 2013 tat HCRIS Website User Manual 08 11 FORM CMS 2552 10 4090 Cont COST ALLOCATION HOSPICE STATISTICAL BASIS PROVIDERCCN ________ PERIOD WORKSHEET K4 FROM PARTH HOSPICE CCN TO ADMINIS GENERAL SERVICE COST CENTERS Capital Related Costs Bldg and Capital Related Costs Movable Equip Plant Operation and Mamtenance Transportation Staff Volunteer Service Coordination Administrative and General INPATIENT CARE SERVICE Inpatient General Care Inpatient Respite Care ITING SERVICES HH Aide amp Homemaker Cont Home Care Other OTHER HOSPICE SERVICE COSTS Drugs Biological and Infusion Therapy Analgesics Sedatives Hypnotics Other Specify Outpatient Services including E R Dept Radiation Therapy Chemotherapy Other HOSPICE NONREIMBURSABLE SERVICE Bereavement Program Costs Volunteer Program Costs Fundraising 901 901 Other Program Costs 901 901 Cost To be Allocated per Wist K4 Part I 901 901 FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 41 SECTION 4061 Rev 2 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 122 4090 Cont
131. IS login will allow you access to view and download various reports PPS Hosp Dashboard IP PPS Dashboard CAH Dashboard Sign In to your account Balance Sheet User Name Wage Index GME Summary IME Summary Forgot User Name and or Password Reimb vs Cost Analysis L Remember me Bad Debt Report SCH MDH Report If you check the Remember me box a cookie will be saved so you ll be automatically signed in next time Protested Amounts Sign In New User Available Facility Reports Tools My Provider Multi Facility Comparsions Wage Data Analysis by CBSA My Provider Roll Up Report s Advanced Search and Extract To access the website you will need to be a registered user of the HCRIS website You will also need a username and password If you are an existing HFS Medicare cost report software user you will 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual use your existing username and password Demo users will have user names and passwords activated for two weeks If you have not received a username and password please contact support hfssoft com If you cannot remember your username or password you can click the Forgot Username and or Password link to retrieve your username If our database contains a username that is associated with your email address it will be sent to you at the email address you provided If you arrived a
132. L SERVICE WORKSHEET K 5 S HOSPICE COST CENTERS PART I Cont I ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS RENE PHYSICIAN INTERNS amp RESIDENTS MEDICAL GENERAL ANES NURSING EDUCATION SUBTOTAL STEPDOWN SUBTOTAL SERVICE THETISIS SCHOOL FRINGES COSTS SPECIFY 2 D 2 21 2 27 6 i9 21 3 3 3 7 38 Administrative and General 91 ____ ____ 1 General Care san san Inpatient Respite Care san 901 sam 901 Nursing Care Contimous Home Care 901 901 Occupational Therapy 901 901 901 901 901 901 901 901 901 HH Aide amp Homemaker Cont Home Care sa 901 Drugs Biological and Infusion Therapy Analgesics 901 901 901 Durable Medical Equipment Oxygen 901 i ap Labs and Diagnostics Medical Supplies 901 Outpatient Services including E R Dept 901 Radiation Therapy sa san 901 sa Bereavement Program Costs sap 511 Fundraising 9 11 901 901 901 Other Program Costs 911 9 11 901 9 11 xn Unit Cost Multiplier see instructi
133. ON Physician Specialty Total Professional RCE Professional Unadjusted Description Physician Identifier Renumeration Component Amount Component Hours RCE Limit 2 L 3 4 5 s 7 2 General Practitioner Family Practice sD PT General Practitioner Family Practice n 941 941 901 9a 9011 901 FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTIONS 4029 1 40 582 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 132 FORM CMS 2552 10 Tids Pirt A e 3 x ne a 1 Part B mme Transfer the amounts in comm 3 as follows Add ines 18 and 19 amd transfer to Worksheet E 3 Part VII Lins 20 to Workshost E Part Workihost E 3 Part I to as appropriate Lins 21 to Workshest E Part B Add Ene 22 and 23 and transfer to Worksheet E 3 Part VIL a appropriato FORM 5 2572 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 191 SECTIONS 4029 2 Rev 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 133 HCRIS Website User Manual revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 14 7 1 5 E Worksheets FORM CMS 2552
134. OR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 IL SECTION 4042 40 606 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 157 HCRIS Website User Manual 08 11 FORM CMS 2552 10 4090 Cont COST ALLOCATION EHA STATISTICAL BASIS PROVIDER CCN 3 WORKSHEET H I PARTI HHA CCN CAPITAL RELATED COSTS PLANT ADMINIS BIDGS amp MOVABLE OPERATION amp TRATIVE FIXTURES EQUIPMENT MAINTENANCE TRANS amp GENERAL SQUARE DOLLAR SQUARE PORTATION RECONCIL ACCUM FEET VALUE FEET MILEAGE TATION cosT _ gt s 5 GENERAL SERVICE COST CENTERS mus utc ee Fra n _ t Capital Related Movable Equipment 1 90 1 901 901 901 HHANONREIMBURSABLE SERVICES 15 ae ae a D TE E Respiratory Therapy 5 5 oD ee u Clinic 901 911 901 901 901 15 Heath Promotion Activites Home Delivered Meals Program 9 11 oan 9 11 Homemaker Serice 1 Il EE EE 24 901 901 901 25 Cost To Allocated per Worksheet m 5 sa 26 Unit Cost Multiplier _____ 99 FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 II SECTION 4042 Rev 2
135. POSE COST CENTERS io ise tcm sa sa EOE E sot san m 1 116 Hospi 1 011 1 9 11 1 117 Special Purpose sa ean san say o san 118 SUBTOTALS sum of lines 1 117 san oan oan sa oan NONREIMBURSABLE COST CENTERS eser ai IN ue c SER EEF Ey n 180 Gif Flower Coffee Shop amp Canen 191 Reseach 192 Physicians Prane sm san san umm 193 Nonpaid Workers 901 ss 194 Other Nonreimbursable specify 91 oan EERE Seis RE LEE ey 200 Cross foot adjustments p mT 201 Negative cost centers PEDI ARRIERE o CERA SN BS 202 Cost to be allocated per Worksheet Part xD sD 212 ram 204 Cost to be allocated per Worksheet B Part 204 205 HHH HH up NS FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 1 SECTION 4020 Rev 2 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 08 11 COST ALLOCATION GENERAL SERVICE COSTS
136. PS Dashboard Annual Subscription for users at the same company CAH Dashboard ner z i E omui 1 2 Users 1 000 Balance Sheet 5 3 5 Users 1 500 Wage Index Pm 6 10 Users 2 000 ELM 1 Summary z SD GG of Recreated 20 Users 4 000 Reimb vs Cost t p lene 2552 10 Reports 30 Users 4 500 Analysis 50 Users 5 000 100 Users 7 500 Bad Debt Report The HFS Toyon HCRIS Website gives users access to the CMS public use Medicare Cost Report SCH MDH Report data The Medicare Cost Report data contains thousands of data elements per report for several thousand Hospital providers with several report time periods and iterations of those Available Lacy reports In other words it is a lot of data too much for most users to be able to handle with FAQ the tools typically available This website focuses on bringing key elements of the data into clear view allowing users to look at only who and what they are interested in and easily filtering down to and extracting the data they want for further analysis Support Wage Data Analysis by CBSA This is a new product and we are very interested in what you think and your ideas for making it My Provider Roll Up better Whether you are a user a potential client or just interested in Medicare cost report Report s data please feel free to contact us with your thoughts or sugges
137. Paid Hours S 3 Part Il Column 5 Line 14 S 3 Part Il column 4 line 9 02 revised 4 19 2013 2013 Health Financial Systems and amp Associates Inc Contract Phys PartA Adjusted Salary 3 Part I column 3 line18 O Contract Phys Part A Paid Hours 5 3 column Contract Phys Part Average Hourly Wage S 3 Part I column 5 line 18 O Net Salaries Paid Hours 5 3 Part Ill column 4 line 1 5 3 Part Ill Column 5 Line 1 Sub total Paid Hours 5 3 Part Ill column 4 line 3 5 3 Part Ill Column 5 Line 3 Sub Total Other Wage amp Sal Paid Hours S 3 Part Ill column 4 line 4 5 3 Part Ill Column 5 Line 4 Total Paid Hours 5 3 Part Ill column 4 line 6 5 3 Part Ill Column 5 Line 6 Net Salaries Average Hourly Wage 5 3 Part column 5 line 1 5 3 Part Ill Column 6 Line 1 Total Adjusted Salary 5 3 Part Ill column 3 line 6 5 3 Part Ill Column 4 Line 6 Excluded Salaries Paid Hours 5 3 Part Ill column 4 line 2 5 3 Part Column 5 Line 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 4 8 DSH Summary Analysis DSH Overview 4 Column Format revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc FYE Cost Report Status PDF CBSA Number of Beds DRG Reimbursement Allow DSH 96 DSH Entitlement Capital PPS Reimb Allow Capital DSH96 Capital
138. R DESCRIPTIONS fom col 6 Wkst Wkst K Z col GENERAL SERVICE COST CENTERS 1 Capital Related Costs Bldg and Fint 2 3 Plant Operation and Maintenance E 5 Volunteer Service Coordination INPATIENT CARE SERVICE smi amc cma meu cmm E Scie 7 Impatient General Care VISITING SERVICES 9 Physician Services 10 i n 14 D M 5 5 19 Home Health Aide and Homemaker 20 HH Aide amp Homemaker Cont Home Care 21 ee ee es OTHER HOSPICE SERVICE COSTS 5 23 Analgesics 25 Other Specify 26 Durable Medical EqupmentOxyeen 27 29 Labs andD mois 30 Outpatient Services including Dept HOSPICE NONREIMBURSABLE SERVICE 35 Bereavement Progam Costs J 37 Fundraisin 3 OmePemmces 39 FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4057 40 632 Green ECR HCRIS Purple HCRIS only T2 Received HFS 826 2011 revised 4 19 2013 2013 Health Financial Systems and amp Associates Inc Appendix B CMS HCRIS Specifications 178 08 11 4090 Cont HOSICE COMPENSATION ANALYSIS PERIOD WORKSHEET K 1 SALARIES AND WAGES HOSPICE CCN FROM MEDICAL pe E p DIRECTOR WORKERS VISORS THERAPISTS ALLOTHER TOTAL 9
139. Step 3 Provider Search Type in a Provider Name or in the first boxes to search for a particular provider Or leave blank and use the filter criteria to return a group of providers reports Report Type 2552 10 Providers rv FYE 10 1 11 to 9 30 12 Report Status Most Recent City State FI Num Type of Control Hospital Type of Subprovider 5 CBSA Bed Size Range ORGAN DSH Teaching SCH MDH Urban Rural SUBMIT The various screen elements shown above are defined as follows Report Type Users can pick between the 2552 96 and the 2552 10 databases The system defaults to the latest form set 2552 10 Providers You have four lines where they can enter either provider numbers or provider names for the search These can be left blank if the intent is not to search for a particular provider s These fields can also be used with wild cards Use the underline as the wild card The hospital Medicare provider number has logic built into it The first two digits of the provider number is a state code The state code for Alabama is 01 If a user wanted to return all of the hospitals in Alabama they could enter 01 thats 4 underlines Digits 3 6 identify a type of provider Children s Hospitals use 3300 3399 so a user could enter 33 two underlines before and after the 33 to search for all Children s Hospitals The ranges for provider type will not always work for this so we have added
140. TER 7 Sort By Provider Number Name Year Range 07 01 10 06 30 11 Status Amended Reports PPS Reimbursement v Report Search Results Combined Extract Results Combined Extract Results Extract Title HCRIS extract Send Data to CSV 2 Extract You will need to enter the name of the file or Extract Title and chose the format of the file to be exported csv etc Click the Extract button to create the extract file 5 4 Advanced Search and Extract The Advanced Search and Extract rool allows you to filter searches down to a subset of hospitals or choose all hospitals Then you choose which cost report elements you want to download You can choose the data elements in our Snap Shot Reports a series of cost report worksheets A B C or define your own not yet available The Advanced Search and Extract feature works with one database at a time either 2552 96 or 2552 10 Reminder The 2552 96 data is a subset of the cost report the 2552 10 is a complete data set and has every element of the Medicare cost report Step 1 of the Advanced Search and Extract feature is depicted below This screen is used to select the database the user wants to extract data from and filter the list of reports providers that should be included in the extract pool revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Advanced Search amp Extract Tool Step 1 Step 2
141. TINE SERVICE COST CENTERS Adults and Pediatrics General Routine Care Intensive Care Unit Coronary Care Unit Burn Intensive Care Unit Surgical Intensive Care Unit Other Special Care Unit specify provider IPF ubprovider IRF Subprovider specify Nursery Skilled Nursing Facility Nursing Facility Other Long Term Care E O san ay an 05 E E Gm n 00 lan 900 san 3 00 _ n an san sa sa 9a san sa 205 0 FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 IL SECTION 4021 Rev 2 2 2013 Health Financial Systems and amp Associates Inc Published 4 19 2013 109 HCRIS Website User Manual 4090 Cont FORM 5 2552 10 AILOCATION OF CAPITAL RELATED COSTS PROVIDER CCN PERIOD ANCILLARY SERVICE COST CENTERS Eo 50 Operan 0 911 9 0 5 0 51 SS
142. TION omit cents col 1 col 2 CATIONS _ col 3 col 4 ADJUSTMENTS eek CGU a ST CS ae wns a 30 05000 Operating Room 9 11 9 11 9 11 9 11 9 11 ee 52 an 33 630 lt Em 55 05500 Radiology Therapeutic 941 9 11 56 5 57 ay son 58 05800 Magnetic Resonance Imaging MRD sana oo 06000 Laboratory 9011 901 9 11 9 11 Su EC RE en AMNEM Au 85 45 1 85 8 61 06200 Whole Blood amp Packed Red Blood Cels an 1 3298 63 Sa X m am m o oes 65 91r 901 9 11 66 oan sn san 67 mop 68 06800 san a am am 69 70 n o 72 DC 73 oro Denes Charged e Pan 75 07500 ASC Non Distinct 9 11 9 11
143. VICE 18 GENERAL SERVICE COST CENTERS Capital Related Costs Buildines and Fixtures Capital Related Costs Movable Equipment ul Cafeteria Js Nurs Central Services and Supply Pharmacy Medical Records amp Medical Records Library Social Service Other General Service specify onphysician Anesthetists Nursing School Intern amp Res Service Salary amp Fringes Approved Intern amp Res Other Program Costs Approved Paramedical Education Program specify INPATIENT ROUTINE SERVICE COST CENTERS Adults and Pediatrics General Routine Care Intensive Care Unit 9 0 Coronary Care Unit Burn Intensive Care Unit 901 E m sa Other Special Care Unit specify 9 11 n aD m aD am 901 9 11 9 9 2 5 d 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 II SECTION 4020 2 2013 Health Financial Systems and amp Associates Inc Published 4 19 2013 103 HCRIS Website User Manual Clinical Laboratory Services Program Whole Blood amp Packed Red Blood Cells Blood Storing Processing amp Trans Intravenous Therapy Respiratory Therapy Occupation
144. ___ aom 1 5 NONREIMBURSABLE SERVICE ucc mnn 35 36 Voter Progam coss 37 Fundraising O O O 3 Pomm Cut dj Tia mca comm Po WC K column 4 FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 II SECTION 4060 Rev 2 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 10 4090 Cont FORM 5 2552 10 08 11 COST ALLOCATION HOSPICE GENERAL SERVICE COST GENERAL SERVICE COST CENTERS PROVIDER HOSPICE CCN NET EXPENSES CAPITAL RELATED COST FOR COST MOVABLE FIXTURES MAINT Lemos WORKSHEET 4 PARTI TOTAL 5 I Capital Related Costs Bl g and Fit PE 2 Capital Related Costs Movable Equip 411 114 901 Plant Operation and Maintenance 901 91 2 Transportation Staff ta 901 5 Volunteer Service Coordination INPATIENT CARE SERVICE 901 SS uen mt 5 s sd san evi vnm pour Sie o san 801 901 oan amo 901 901 901 901 941 941 901 911 say 20 HH Aide amp Hom
145. aimed HHA E 3 Part VI line 10 E 3 Part VI line 10 H 4 line 27 H 4 line 27 E ira ine 27 ine 28 sims 1 5 line 11 5 line 11 J 3 line 23 Adjusted Bad Debt HHA revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Snap Shot Reports 52 4 13 SCH MDH Report SCH MDH Report 4 Column Format 07 01 10 06 30 11 v 07 01 09 06 30 10 07 01 08 06 30 09 v 07 01 07 06 30 08 v Cost Report Status As Submitted 1 As Submitted 1 Amended 1 Amended 1 v PDF Available Not Available Not Available Not Available Inpatient Medicare Federal PPS DRG Payments Hospital Specific Payments Acute Care Reimbursement 38 642 895 33 019 625 40 055 281 38 419 281 43 063 290 36 865 827 0 0 43 063 290 46 314 848 40 055 281 38 419 281 Acute Care Costs 48 719 060 53 328 103 50 224 197 46 339 116 Net Margin Loss 5 654 770 7 013 255 10 168 916 7 919 835 96 of Reimb to Costs 88 87 83 Utilization Analysis Medicare Discharges Total Discharges Medicare Utilization 96 Change in Medicare Discharges 96 Change in Total Discharges Change in Medicare Utilization Report Specifications 4 13 1 SCH MDH Report Specifications The following table contains the specifications for Sole Community Hospital Medicare Dependent Hospital Report References to data sources for the 2552 96 and 2552 10 form sets are included for your convenience 2013 Health Finan
146. al Systems and amp Associates Inc Appendix B CMS HCRIS Specifications us FORM 5 2552 10 Tei V IP Title Part A FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 II SECTION 4025 2 40 574 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 revised 4 19 2013 127 HCRIS Website User Manual 4090 Cont FORM 5 2552 10 INPATIENT ANCILLARY SERVICE COST APPORTIONMENT Check Tie V Hospital Subprovider other Swame Bod SNF PPS applicable 11 Tide Part A SNF 1 Swing Bed NF 0 E Tide IRF NF MR 3 ICE Ratio of Cost Inpatient Ixpasent Program COST CENTER DESCRIPTION toCh Program Chars col 1 x col 2 ___ INPATIENT ROUTINE SERVICE COST CENTERS puppe Adult and Pediatrics General Routine Car co liane Cae t __ 2 Coronary Caso Umit Burn Intumzive Case Unit Je ____969_ ANCILLARY SERVICE COST CENTERS Operating Rooms Radiolo Room Rxdlogyw Thermeutic Computed Scan 2 Room D olos n D 747 d tic Resonance 9 Medical asd to Patents Devices 1 xm me 90 mm 59 0
147. am in existence enter 5 see instructions Column 1 Did the facility have a teaching program in the most recent cost reporting period ending on or before November 15 2004 Enter Y for yes or N for Column 2 Did this facility train residents new teaching program in accordance with 42 CFR 412 424 d 1 ui D Enter Y for yes or N for no Column 3 If column 2 is Y enter 1 2 or 3 respectively in column 3 see instructions If this cost reporting period covers the beginning of the fourth year enter 4 in cohmm 3 or if the subsequent academic years of the new teaching program in existence enter 5 see instructions Long Term Care Hospital PPS 80 this a Long Term Care Hospital TCH Enter Y for yes or for TEFRA Providers 85 Is this a new hospital under 42 CFR 413 40 f 1 TEFRA Enter Y for yes N for no Did this facility establish a new Other subprovider excluded unit under 42 CFR 5413 40 f 1Xii Enter Y for yes or for no Title V and XIX Inpatient Services Does this facility operate an ICF MR facility for purposes of title V and Enter Y for yes or for no in the applicable column 54 95 If line 94 is Y enter the reduction ir ji percentage in the applicable column Does title V or title XIX reduce operating cost Enter Y for yes or N for no in the applicable column If lime 96 is Y enter the reduction percentage in the
148. amp Associates Inc Appendix B CMS HCRIS Specifications 4090 Cont FORM 5 2552 10 08 11 RECONCILIATION OF CAPITAL COSTS CENTERS AJ PART I ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCES E 3 o Movable Equipment an om E 8 Subtotal sum of lines 1 7 91 11 10 Total ine 7 minus line 9 PARTII RECONCILIATION OF AMOUNTS FROM WORKSHEET A 2 LINES 1 2 SUMMARY OF CAPITAL Total 1 sum of mum A 9 ERA MEN 14 3 Total sum of lines 1 3 1 The amount in columns 9 through 14 must equal the amount on Worksheet A column 2 lines and 2 Enter in each column the appropriate amounts including any directly assigned cost that may have been included in Worksheet column 2 lines 1 and 2 All lines numbers are to be consistent with Worksheet A line numbers for cost centers PART RECONCILIATION OF CAPITAL COSTS CENTERS COMPUTATION OF RATIOS ALLOCATION OF OTHER CAPITAL Assets Other Capital Assets mem catia 1 we 2 _ EN BE Costs cols 5 E 7 Se 5 5 2 Capital Related Costs Movable Equipment 901 9906 901 941 901 n 3 Total sum of lines 1 2 305 1000
149. amp R FTEs GME Calc PY Allowable Wgtd I amp R FTEs E 3 Part IV Title 18 line 3 22 column 1 E 3 Part IV Title 18 line 3 12 column 1 E 3 Part IV Title 18 line 3 13 column 1 E 4 line 19 column 1 E 4 line 11 column 2 E 4 line 12 column 2 Report Element Data Source s 2552 96 Data Source s 2552 10 E 3 Part IV Title 18 line 3 14 column 1 E 4 line 13 column 2 GME Calc 3 Year Avg Allowable I amp R FTEs E 3 Part IV Title 18 line 3 15 column 1 E 4 line 14 column 2 Adj for New Program E 3 Part IV Title 18 line 3 16 column 1 E 4 line 15 column 2 Adj for Displaced Residents E 4 line 16 column 2 Adj 3 Yr Rolling Avg FTE E 3 Part IV Title 18 line 3 21 column 1 E 4 line 17 column 2 Per Resident Amount E 3 Part IV Title 18 line 3 16 column 1 E 4 line 18 column 2 Approved Other Resident Costs E 3 Part IV Title 18 line 3 17 column 1 E 4 line 19 column 2 Total Approved Resident Costs Part A Program Days E 3 Part IV Title 18 line 3 25 column 1 E 3 Part IV Title 18 line 4 00 column 1 E 4 line 19 column 3 E 4 line 26 column 1 Total Patient Days E 3 Part IV Title 18 line 5 00 column 1 E 4 line 27 column 1 Medicare Utilization Ratio E 3 Part IV Title 18 line 6 00 column 1 E 4 line 28 column 1 Medicare GME Reimbursements E 3 Part IV Title 18 line 6 01 c
150. ancial Systems and Toyon amp Associates Inc Getting Started select the correct provider and add it to your list In fact although this option is for adding a single provider you can add one or more providers depending on the results of your search My Providers Use this list to manage your default providers Back to My Provider List Will you be adding a single provider or multiple providers Single O Multiple Single Provider Type a provider name or number to search for provider Main Provider Alaska Search Add Provider Number Provider Name City 020001 PROVIDENCE ALASKA MEDICAL CENTER 0 020017 ALASKA REGIONAL HOSPITAL ANCHORAGE ANCHORAGE 020026 ALASKA NATIVE MEDICAL CENTER ANCHORAGE 0 020028 ALASKA SPECIALTY HOSPITAL LLC ANCHORAGE 022001 ALASKA SPECIALTY HOSPITAL LLC ANCHORAGE 0 024002 ALASKA PSYCHIATRIC INSTITUTE ANCHORAGE In the example above we entered Alaska as the provider name to search for We clicked Search and the database returned a table displaying six providers with the word Alaska as part of each providers name Select one or more of the providers displayed in the search results You can select all of the providers by clicking the check box in row 1 column 1 of the table After you select the desired provider s click the Add button to add the provider s to your My Provider List Add Multiple Providers to
151. and Pediatrics General Routine Care Intensive Care Unit Coronary Care Unit Bum Intensive Care Unit Surgical Intensive Care Umt Other Special Care Unit specify Subprovider IPF Subprovider IRF Subprovider Nursery Skilled Nursing Facility Nursing Facility Other Long Term Care 4 REESE mE sa a 911 SUBTOTAL ADJUSTMENIS 2 901 25 Um 90 901 po 9 11 91 9 11 9 11 9011 901 5 901 941 9011 901 9011 91 901 9a 901 901 9 11 5 2552 10 082011 INSTRUCTIONS FOR THIS WORKSHEET PUBLISHED IN CMS PUB 15 IL SECTION 4065 1 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 123 HCRIS Website User Manual 4690 Cont FORM CMS 2552 10 08 11 08 1 ALLOCATION OF ALLOWABLE COSTS FOR J WORKSHEET L 1 ALLO EXTRAORDINARY CIRCUMSTANCES PARTI Cont EXIR EXIRA ORDINARY CAPITAL Cost Center Descriptions RELATED BLDGS amp FIXTURES 0 ANCILLARY SERVICE COST CENTERS Operating Room 911 Recovery 901 Labor Room and Delivery Room 9 11 Anesthesiology 901 Radiology Diagnostic Radiology Therapeutic Radioisotope 901 Magnetic Resonance Imaging MRI Cardiac Cathenzation Laboratory Whole Blood amp Packed Red Blood Cells 9011 Blood Storin
152. are Unit 901 34 Surgical Intensive Care Unit rr omen E 46 Omer leng TemaCae FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4020 Rev 2 Green ECR HCRIS Purple HCRIS only T2 Received HFS 8 26 2011 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 4090 Cont FORM CMS2552 10 COST ALLOCATION STATISTICAL BASIS PROVIDER CCN FIXTURES SQUARE DOLLAR T FEET E BE Whole Blood amp Packed Red Blood Cells ng amp Trans OUTPATIENT SERVICE COST CENTERS Rural Health Clinic RHC ederally Qualified Health Center Clinic Emergency Observation Beds Other Outpatient Service specify FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 IL SECTION 4020 40 554 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 08 11 FORM 5 2552 10 COST ALLOCATION STATISTICAL BASIS PROVIDER CCN 94 Home Program Dialysis 95 Ambulance Services _ 99 Outpatient Rehabilitation Provider specify 101 Home Health A SPECIAL PURPOSE COST CENTERS 115 Seen
153. art L line 7 column 3 In cohmm 3 enter Y or N for no if the spending reflects increases associated with direct patient care and related expenses for each category see instructions 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual FORM 5 2552 10 10 Does this facility operate as other than an RHC or FQHC Enter Y for yes N for no in colunm 1 yes indicate the number of other operations in cohmm 2 List hours of operation based on 24 hour clock For example 8 00am is 0800 6 30pm is 1830 and midnight is 2400 Have you received an approval for an exception to the productivity standard Is this a consolidated cost report as defined in CMS Pub 27 section 508 D Enter Y for yes or N for no in cohzm 1 If yes enter in column 2 the number of providers included in this report List the names of all providers and numbers below Have you provided all or substantially all GME cost Enter Y for yes or N for no in column 1 I yes enter in 2 3 and 4 the number of program visits performed by Intern amp Residents for titles V and XIX as applicable see instructions revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 24 FORM 5 2552 10 PART CENSUS DATA 6 Number of Patients Receiving Hospice Care Total Number of Unduplicated Co
154. ata originates with providers who file their cost reports with the Medicare Administrative Contractors MAC The 5 process and finalize the reports and when a report is finalized the MAC submits a file containing the report data to CMS CMS loads the data files into the Healthcare Cost Report Information System HCRIS which is a data base file The HCRIS data files are Public Use Files A Public Use File PUF does not contain protected health information as defined by HIPAA because it contains data that cannot be used to identify individual Medicare beneficiaries ResDac maintains the PUF files and disseminates the PUF files to entities that request it Toyon and HFS obtained multiple PUF and loaded it into are manageable database system However the data itself remains unchanged and is exactly the same as it was when we received it from ResDac CMS includes the following statements defining the scope of cost reports stored in the 2552 96 2552 10 HCRIS database The text below is copied from the Readme txt files that accompany every HCRIS public use file 2552 96 copied from CMS readme txt file associated with HCRIS data files The CMS Form 2552 96 Hospital Cost Report HOSP96 data files contain cost reports with fiscal years ending on or after September 30 1996 The data files contain the highest level of Medicare cost report status If HCRIS has both an as submitted report and a final settled report for a hospital for a partic
155. ation Provider specify Intern Resident Service not appvd prem Home Health Agency 901 901 901 901 901 901 901 901 san san sa san al a EEN oes rae es area say say 901 911 901 941 901 9 11 901 901 Other Organ Acquisition specify 901 901 901 901 9011 901 9 11 9 11 901 901 901 901 901 901 sao san 505 Ambulatory Surgical Center Distinct Part Hospice Other Special Purpose specify SUBTOTALS sum of lines 1 117 901 901 901 901 901 san 91 9011 901 9011 901 901 901 901 9d 901 901 901 9 11 901 901 911 NONREIMBURSABLE COST CENTERS Gif Flower Coffee Shop amp Canteen Research 901 901 9 11 9 11 EET E TERRAS arcup 901 9011 901 9011 901 Physicians Private Offices 901 901 9 11 91 91 901 1 901 Nonpaid Workers Other Nonrembursable specify Cross Foot Adjustments Negative Cost Centers 901 901 901 91 941 901 941 941 901 Total sum of line 118 and lines190 201 Total Statistical Basis Unit Cost Multiplier 1 CMS 2552 10 082011
156. ble I amp R FTEs 414 07 414 07 414 07 411 95 E Allowable I amp R 414 07 414 07 414 07 412 95 CY I amp R to Bed Ratio 75 9396 76 4696 76 37 75 99 PY I amp R to Bed Ratio 76 46 76 37 76 3896 75 8796 Total IME Payments 33 031 916 31 607 923 28 581 339 25 255 184 DRG Payments Before 10 1 17 382 742 16 200 140 13 874 899 On or Afer 10 1 19 086 774 16 455 623 15 253 410 On or After 1 1 40 794 087 35 405 501 31 348 806 From 4 01 to 9 01 0 0 0 Reimbursement 82 130 054 77 263 603 68 061 264 60 477 115 Managed Care Simulated Before 10 1 4 089 265 3 393 838 2 589 838 10 1 amp Before 3 603 861 3 486 693 2 755 121 On or After 1 1 amp Before 4 1 ot 10 1 Additional Received Receivable From 4 01 to 9 01 0 0 0 5 669 334 7 006 457 7 359 712 0 0 0 Report Specifications 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 4 HCRIS Website User Manual 4 10 1 IME Report Specifications The following table contains the specifications for Indirect Medical Education Summary Report References to data sources for the 2552 96 and 2552 10 form sets are included for your convenience revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Snap Shot Reports 4 IME Summary Report Snapshot Report Specifications Process Date S Part Il line 2 5 column 1 NR SPor lires column 1 5 2 line 40 01 column 2 S 2
157. c Appendix B CMS HCRIS Specifications 170 FORM 5 2552 10 4090 Cont 409C AILOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTERS PART ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS STATISTICAL BASIS Unit Cost Multiplier see instructions FORM CMS 2552 10 08 2011 NSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4053 2 Rev 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 171 HCRIS Website User Manual FORM 5 2552 10 08 11 08 1 CATION OF GENERAL SERVICE COSTS TO WORKSHEET 1 1 MUNITY MENTAL HEALTH CENTERS H ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS STATISTICAL BASIS PART MAIN TENANCE HOUSE KEEPING DIETARY CAFETERIA PERSONNEL TRATION HOURSOF MEALS MEALS NUMBER SERVICE SERVED SERVED NURS HRS Durable Medical Equipment Rented Durable Medical Equipment Sold All Others Totals sum of lines 1 21 Total Cost to be Allocated Unit Cost Multiplier see instructions 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 II SECTION 4053 2 26 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 172 FORM CMS 2552
158. cial Systems and amp Associates Inc Published 4 19 2013 HCRIS Website User Manual SCH MDH Data Report Snapshot Report Specifications Data Source s 2552 96 Data Source s 2552 10 Inpatient Medicare O Federal PPS DRG Payments E Part A line 6 E Part A line 1 Higher of E P line 7 Hospital Specific Payments erof E PaitA Moe ae E Part A line 48 Utilization Analysis Medicare Discharges S 3 line 1 column 13 S 3 line 1 column 13 Total Discharges S 3 line 1 column 15 S 3 line 1 column 15 96 Change in Total Discharges current prev prev current prev prev psa ipis current prev prev current prev prev Revised April 3 2013 Medicare Utilization Report line 7 report line 8 Report 7 report line 8 96 Change in Medicare Discharges current prev prev current prev prev revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Snap Shot Reports 5 4 14 Protested Amounts Protested Amounts 4 Column Format 01 01 11 12 31 11 v 01 01 10 12 31 10 01 01 09 12 31 09 01 01 08 12 31 08 Cost Report Status As Submitted 1 As Submitted 1 v As Submitted 1 As Submitted 1 PDF Available Not Available Not Available Not Available Protested Amounts IP Part A 1 629 423 OP Part B 3 672 IP Sub 1 OP Sub 1 IP Sub 2 OP Sub 2 IP SNF OP SNF IP HHA OP HHA RHC 1 RHC 1 RHC 2 RHC 2 gt
159. claimers regarding HCRIS data and Public Use Files apply to the HCRIS website and any data therein The following section of quoted material pertains to the legal character of HCRIS data CMS manages vast amounts of data much of which is protected health information The following section makes it perfectly clear that nothing in the HCRIS database is protect health information The data is released by CMS in a public use file which by definition does not contain any personal identifying information or protected health information This is an important distinction HCRIS data is not covered by HIPAA or the HIPAA Privacy Rule Federal Regulations Relating to the Release of CMS Data copied from ResDac website http www resdac org resconnect articles 147 Overview Data with beneficiary or physician identifiers are subject to the Privacy Act of 1974 HIPAA and 2013 Health Financial Systems and amp Associates Inc Published 4 19 2013 HCRIS Website User Manual other Federal government rules and regulations As such the information is confidential and is to be used only for reasons compatible with the purpose s for which the data are collected CMS maintains a list of all the data that CMS collects and the provisions of release within the Systems of Records SOR For each System of Record CMS provides the primary purpose for the data collection and the reasons under which the data can be released The Research pr
160. cope amp 5 lt t Quad raus T3 7 Appendix B CMS HCRIS 5 76 7 1 2552 10 CMS Worksheets with 5 76 A Worksheets 76 42 BWo rksheets TIR IG cta pd 87 7 1 3 CWorksheets 205 ERE es is eS os 116 7 1 4 D Worksheets 2020025 n soe Peu etie 120 7 1 5 E Worksheets Vo arce oJ wee OR Rx 134 T16 GWorksneets D ERU a aC e paces ea ue ut 150 TET Worksheets E EORR EPA dedu 155 7 1 8 AWorkshe ls a BER aera ORAS BOUES 164 7 1 9 Worksheets 12 2 5445 5 168 1 110 KW rksheets Sa NUUS AE URSI 177 EWorksh ets ideo Center dee Eines 189 741712 M Worksheets rises 201 1 12 S Worksheels Ieee peiora 206 2013 Health Financial Systems and Toyon amp Associates Inc 7 2 2552 96 HCRIS 5 225 8 Appendix C Provider Types Number ea ci ibd A CEA aUa rp aa 226 9 Appendix D State 5 228
161. data and these useful tools for many years to come and we will do everything possible to make sure that you are completely satisfied with this product and with your experience when using it Please read the next section entitled Getting Started It contains step by step instructions on how to get started using the website The rest of the sections in this manual contain detailed information regarding all of the HCRIS reports and features 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 mcris Website User Manual o oS 2 Getting Started This section is intended for new users of the HCRIS website It explains how to locate login to and perform the initial setup that is required before you can use the HCRIS website Please read and follow these instructions carefully Unless you complete these first procedures you will not be able to access the HCRIS reports and tools To start using the HCRIS website open your internet browser and go to the www hfssoft com website At the top of the HFS home page you will see four colored tabs Select the red HCRIS tab at the top of the page 0 Car Contact Us HealthFinancial Automating the Medicare Cost Report Process Syste ms Check out our helpful tutorials Next you will see the HCRIS Website main page Health Financial HCRIS Website Systems ASSOCIATES INC My Provider List Snap Shot Reports PPS Hosp Dashboard IP P
162. ders This data will be presented for the provider that you have selected as your primary provider in the My Provider List The system default is to always show the most recent time period and status for the selected provider When multiple years of data from the 2552 96 and 2552 10 form sets are combined into one report the HFS 2552 96 to 2552 10 cross walk logic is used to map the data correctly The following is a current list and sample of all available Snap Shot Reports that may be selected and viewed for any provider s Not all reports pertain to all providers PPS Hospital Dashboard IP PPS Dashboard CAH Dashboard Balance Sheet Wage Index DSH Overview GME Summary IME Summary Reimb vs Cost Analysis Bad Debt Report SCH MDH Report Protested Amounts Available Facility Reports You will find examples of each report in the sections that follow You will also find the report specifications for each report The specification for a report identifies the source for every data element in the report The data sources for these reports are HCRIS data files and relevant non HCRIS tables NOTE Each specification has a source column for 2552 96 and 2552 10 because the data may come from either type of cost report depending on user preferences 4 1 Single Provider Report Options Single Provider Reports There are various options for the single provider reports The numbered arrows in the picture below correspond to the numbered items li
163. djustments specify see mstructions Col MM Net reimbursable amount lines 22 plus 23 plus or minus line 25 MM ___ 5825 90 30 Protested amounts nonallowable cost report items in accordance with CMS Pub 15 IL chapter section 115 2 1 Lines 8 through 14 Fiscal year providers use columns 1 amp 2 calendar year providers use column 2 only For line 15 use cohmm 2 only for graduate medical education pass through cost revised 4 19 2013 2013 Health Financial Systems and amp Associates Inc Appendix B CMS HCRIS Specifications 2 4090 Cont FORM CMS 2552 10 COMPUTATION OF PNEUMOCOCCAL AND INFLUENZA VACCINE COST Check RHC Title V Title XIX applicable boxes FQHC Title 1 2 1 Health care staff cost from Worksheet M 1 column 7 lme 10 9 11 9 11 2 Ratio of pneumococcal and influenza vaccine staff time to total health care staff time 92 909 3 Pneumococcal and influenza vaccine health care staff cost line 1 x line 2 i on ERSTER x your records Direct cost of pneumococcal and influenza vaccine 3 plus line 4 0 9d 6 Total direct cost of the facility fom Worksheet M 1 column 7 line 22 900 10D 7 Total overhead from Worksheet M 2 16 91 9 11 8 of pneumococcal and influenza vaccine direct cost to total direc
164. e utilization Enter Y for yes and do not complete the rest of this worksheet dale co al atu m 4 b z sea a toa L EH EH SS La fe LS he m G e gt gt RMB 99 PRB RLA LESS PSE _ 99 2 O HD gt gt O gt 9 9 5 Ac M mt 8 5 5151 BY EEE revised 4 19 2013 2013 Health Financial Systems and amp Associates Inc Appendix B CMS HCRIS Specifications 22 201 Enter in columm 1 the SNF CBSA code or 5 character non CBSA code if a rural facility in effect at the beginning of the cost reporting period Enter in columm 2 the code in effect on or after October 1 of the cost reporting period if applicable A notice published in the Federal Register Volume 68 No 149 August 4 2003 provided for an increase in the RUG payments beginning 10 01 2003 Congress expected this increase to be used for direct patient care and related expenses For lines 202 through 207 Enter in colum 1 the amount of the expense for each category Enter in column 2 the percentage of total expenses for each category to total SNF revenue from Worksheet 2 P
165. e 29 n hae 3 Total sum of line line 2 3 3 Additions credit adjustments specify 06 4 5 36 5 5 36 5 7 36 7 5 E 36 9 10 Total additions sum of lines 4 0 10 ETS 1 3 3 0 12 Deductions debit adjustments specify 36 12 13 36 13 14 14 15 15 16 36 16 17 26 17 18 Total deductions sum of lines 12 17 uu 19 Fund balance at end of period per balance 19 E E EM o FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4040 40 602 Rev 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual FORM CMS 2552 10 Other 227777 Oo of lines 11 1 Total mpatisnt routine care services of ines 10 and 16 Rural Health Clinic RHC xD xD 0 rababilitation 909 EET X35 1 5 Worksheet G 3
166. e cost repart x LIT TLE ee J yes 200 instructions E 36 v Y 199 Extructions x 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 08 11 FORM 5 2552 10 4090 Cont HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX STATISTICAL DATA pie xe o 9 99 9859 9 5 99 Rin emen a E saD san 9 8 99 9 8 99 999 san Labor amp delivery days see instructions LTCH non covered days FORM 5 2552 10 08 2011 NSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4005 1 Rev 2 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 24 4090 Cont FORM CMS 2552 10 HOSPITAL WAGE INDEX INFORMATION PERIOD FROM TO 2 Adjusted Pad Hours Average Salanes Related Hourly Wage column 2 to Salanes column 4 6 5 cohmm3 i 5 3 4 35 6 SALARIES TE a 1 Total 5 55555 9 8 99 9 8 99 9 8 99 9 8 99 9 8 99 9 8 99 9 8 99 9100 7 tems amp residents Gin an approved proga san an aD 9 S 5
167. ecifications Balance Sheet Report General Special EndowmentPlant Fund Purpose Fund Fund General Fund Fund LIABILITIES AND FUND BALANCES CURRENT LIABILITIES Accounts payable Salaries wages and fees payable Payroll taxes payable Notes and loans payable short term Deferred income Accelerated payments Due to other funds Other current liabilities 19 433 754 Total current liab sum of Ins 95 077 977 28 thru 35 10 415 322 19 783 437 5 925 273 39 350 457 169 734 LONG TERM LIABILITIES 7 Mortgage payable 38 Notes psysble 39 Unsecured loans Loans from owners Prior to 262 096 208 7 1 66 Loans from owners On or after 7 1 66 41 Other long term lisb 262 096 308 Total long term liab sum of 262 268 807 lines 37 41 Total lisb sum of lines 36 357 346 784 and 42 CAPITAL ACCOUNTS General fund balance Specific purpose fund Donor crested endow fund bal restr Donor cested endow fund bal unrestr Govbody crested endow fund bal Pisnt fund bslance invested in plant Plant fund bslance reserve for plant improvement replacement and expansion Total fund sum of lines 599 511 922 44 50 Total liab amp fund bal sum of 956 858 706 In 43 amp 51 40 01 262 268 807 42 43 599 511 922 Crested on 3 14 2013 5 44 27 2013 Health Financial Systems and Toyon amp Associates Inc Special Endowment Plant Purpose Fund Fund Fund Published 4 19 2013 HCRIS Webs
168. ed Blood Cells 901 901 EI 911 901 901 901 901 901 501 901 901 9 11 9011 901 911 9011 901 9011 90 90 900 9 11 9 11 941 901 Sse SSS EEE 901 901 Blood Storing Processing amp Trans 901 91 901 901 9 91 E 9011 901 901 901 941 901 901 91 9011 9011 91 9011 9013 901 9 11 9 11 9 11 901 901 901 901 901 9011 9d1 901 9011 941 9011 sab 911 91 901 9 11 9011 901 9 11 9 11 9 11 901 901 901 901 901 9 11 901 901 9011 901 901 91 91 91 941 9011 9011 901 901 901 901 901 901 901 901 9011 901 px 901 901 901 9 11 901 901 cease cae 901 901 901 911 901 901 901 osse 901 901 901 esr 901 11 901 9011 901 501 901 901 9 11 91 901 901 901 901 901 911 901 901 9 11 901 901 901 941 9011 901 1CMS 2552 10 082011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED CMS PUB 15 IL SECTION 4065 1 2013 Health Financial Systems and Toyon amp Associates Inc 901 Published 4 19 2013 eere eng E sa 9 901 901
169. edicaid ALOS S 3 Pt I In 17 col 7 5 3 Pt 17 col 14 Sub2 Total Util S 3 Pt I In 17 col 5 3 Pt In 17 col 3 Sub2 Total Days 3 Pt I In 17 col 8 Sub2 Total ALOS 5 3 Pt In 14 01 col 6 S 3 Pt 14 01 col 15 Data Source s 2552 10 Sub2 Medicare utis 515 3 Pt In 17 col 6 5 3 Pt In 17 col 8 Sub2 Medicare Days s3 ptlina7col6 Sub2 Medicare Dschres 17 coli3 Sub2 Medicare ALOS __ 15 3 In 17 col 6 53 PI In 17 col 13 Sub2 Medicaid Utile 15 3 In 17 col 7 553 Pt 017 018 suba Medicaid Days s3 PtLina7col7 Sub2 Medicaid Dschres 0 Sub2 Medicaid 15 3 In 17 col 7 853 Pt In 17 col 14 sub2 Total utiss 5 3 17 col 53 Ini7 col3 Sub2 Total Days s3 ptm 17 SNF Medicare Util m 15 col 4 5 3 Pt I In 15 col 2 PtI In 19 col 6 5 3 Pt I In 19 col SNF Medicare Days 5 3 Ptl In 15 col 4 5 3 Pt I In 19 col 6 SNF Total Days 5 3 PtI In 15 col 6 5 3 PtI In 19 col 8 revised 4 19 2013 2013 Health Financial Systems and amp Associates Inc IP Medicare Service Reimbursement sum E Pt A Ins 1 1 01 1 02 1 07 col 1 sum E Pt A Ins 1 1 01 1 02 1 07 col 1 01 sum E Pt A Ins 1 1 01 1 02 1 07 col 1 02 sum E Pt A In 2 2 01
170. edicare Cost Charge 96 Sub Report cost reim __ Part Title lines 18 20 22 32 Cost small PartB ines2526 31 40 sum D 4 Hospital Title XVIII lines 25 26 101 sum D 3 Hospital Title XVIII lines 30 31 202 IP Charges column 2 column 2 sum D 4 Hosp Title XVIII line 25 column 2 times S sum D 3 Hosp Title XVIII line 30 column 2 times 3 line 3 column 4 5 3 Part I line 1 column 4 0 4 S 3 line 5 column 6 5 3 Part I line 1 column 6 SB SNF Charges SB SNF Title XVIII line 101 column 2 D 3 SB SNF Title XVIII line 202 column 2 sum D 4 SNF Title XVIII line 101 D 4 Hospital sum D 3 SNF Title XVIII line 202 D 3 Title XVIII line 25 S 3 Part line 1 column 4 S Hospital Title XVIII line 30 5 3 Part line 1 SNF Charges 3 Part line 15 column 4 column 6 S 3 Part line 19 column 6 Total Charges calculated calculated Wkst A Net Expense Medicare Cost Dashboard Total Medicare Reimbursements Outpatient SumofallE Part lines 25 26 31 40 O O column 2 4 4 Part line 27 columns 1 amp 2 mc 5 5 25 1820000004 ined GrosPatien Rev G 3 line1 column1 G3lieicoumni O NetOp Gain Loss G 3 line5 column1 G3lieScoumni 0 Netincome Loss G 3 line 31 column1 _
171. emaker Cont Home Care to 901 901 sai 91 9an 21 Other OTHER HOSPICE SERVICE COSTS L 22 1 99 901 awn 901 NM NN 901 901 EE MN EE AN 901 941 941 911 911 901 911 901 941 9 11 26 901 9 11 901 9an 27 Patient Transportation 28 Imaging Services 9 1 901 901 901 901 901 29 Labs and Diagnosties 901 say san 30 Medical Sppies_ an san 901 941 31 Services including ER Dept 33 Chemotherapy 21 oar 11 4 aD san 901 901 901 34 901 9 11 901 sa san 278512 25 52 51 rcr e rc occ ra cmn HOSPICE NONREIMBURSABLE SERVICE 35 Bereavement Program Costs 25212810 sD oD 37 Fundraising 901 901 39 Total sum of lines 1 thru 38 941 FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED
172. er Numbers2 02T001 Bad Debt Claimed IP 359 868 555 858 718 739 297 538 Dual Eligible Days IP 293 114 474 063 Bad Debt Adjusted IP 251 908 389 101 503 117 208 277 Bad Debt Claimed OP 72 120 196 824 181 406 135 905 Dual Eligible Days OP 24 477 81 213 Bad Debt Adjusted OP 50 484 137 777 126 984 95 134 Bad Debt Claimed Hospital Bad Debt Adjusted Hospital Dual Eligible Days Hospital Bad Debt Claimed Sub Bad Debt Adjusted Sub 1 Dual Eligible days Sub Bad Debt Claimed Sub 11 Bad Debt Adjusted Sub 11 Dual Eligible days Sub 1 431 988 752 682 900 145 433 443 302 392 526 878 630 101 303 411 317 591 555 276 Report Specifications revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Snap Shot Reports s 4 12 1 Bad Debt Report Specifications The following table contains the specifications for the Bad Debt Report References to data sources for the 2552 96 and 2552 10 form sets are included for your convenience 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual sum E Part A line 21 E 3 Part II sum E Part A Line 64 E 3 Part Line 11 E 3 line 25 3 Part line 11 Suball E Part ll Line 23 E 3 Part III Line 24 E 3 Part IV Line 3 Part Ill SNF line 38 H7 line 17 14 E 3 Part V Line 25 E 3 Part VI Line 8 Bad Debt Claimed IP column 1 sum E Part
173. form sets are included for your convenience revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Snap Shot Reports 4 FYB FYE Status CBS 5 2 line 17 column 2 5 2 line 20 column 2 Pe 2 2 fine 20 columma j Stine 0 coum sums s michm E Part A line 4 03 column 1 E Part A line 33 E Part A line 34 Alt Allow DSH E Part A line 4 03 column 0 2 DSH Entitlement EPartA lines 4 04 column 1 Medicaid Days 5 3 Part line 1 column 5 5 3 Part I line 1 column 7 Capital PPS Reimbursement L Part line 2 column 1 L Part line 1 column 1 Medicaid Labor Room Days 5 3 Part I line 29 column 5 Medicaid HMO Days 5 3 Part line 2 column 5 z sum S 2 Part I line 24 columns 1 6 Observation Bed Days Admitted 5 3 Partl line 26 column 6 5 3 Part I line 28 column 8 556 ____________ EPartA line 400 E Part line 30 Total DSH E Part A line 4 02 E Part A line 32 Allowable Capital DSH L Part line 5 03 column 1 L Part line 1 column 10 Allowable DSH E PartA line 4 03 E PartA line 33 Capital DSH Entitlement L Part line 5 04 column 1 L Part line 1 column 11 sum S 3 Part line 1 2 29 column 5 sum S 2 Part line 24 um of columns 1 6 Total Hospital Days DSH sum S 3 Part I lines 12 26 28 29 column 6 sum S 3 Part I lines 14 28
174. g Processing amp Trans 901 Intravenous Therapy 9011 Respwatory Therapy 901 Physical Therapy 901 941 901 901 9011 9011 9d OUTPATIENT SERVICE COST CENTERS Rural Health Clinic Federally Qualified Health Center Clinic Emergency Observation Beds Other Outpatient specify FORM CMS 2552 10 082011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4065 1 FORM 40 650 Rev 2 Rev revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 1 3 FORM CMS 2552 10 4090 Cont 469 CATION OF ALLOWABLE COSTS FOR AORDINARY CIRCUMSTANCES LAUNDRY amp LINEN HOUSE SERVICE KEEPING 8 31 9041 5 1 ome rmn cse ce mre 941 9011 9 11 9 11 9 11 911 901 901 9 11 901 MEDICAL RECORDS amp LIBRARY SERVICES amp SUPPLY PHARMACY 9 11 9 11 9 11 san WORKSHEETL 1 ALLO PARTI Cont EXTR 901 901 901 901 901 9 11 91 91 91 911 901 901 9 11 9 11 901 941 901 11 91 901 901 9 11 91 91 201 9 11 901 9 11 9011 9011 PBP Climcal Laboratory Service Program Only Whole Blood amp Packed R
175. has been granted Worksheet 5 8 line 12 equals colum 3 lines 3 of this worksheet should contain at a minimum one element that is different than the standard 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 203 HCRIS Website User Manual FORM CMS 2552 10 4090 Cont Total allowable cost of RHC FQHC services liom Worksheet line 20 Cost of vaccines and their administration from Worksheet 4 line 15 Total allowable cost excluding vaccine line 1 mimus line 2 Total visits from Worksheet M 2 column 5 line 8 Physicians visits under agreement from Worksheet 2 column 5 line 9 Total adjusted visits line 4 plus line 5 Adjusted cost per visit line 3 divided by line 6 Pnor to On or after Jamary 1 Jamary 1 1 22 Per visit payment limit fom CMS Pub 27 Sec 505 or your contractor 9 939 9 Rate for Program covered visits Gee meto om 935 CALCULATION OF SETILEMENT 10 Program covered visits excludime mental health services fom contractor records 12 14 15 re Less Beneficiary deductible for RHC only ee instructions fom contractor records 90 Less Beneficiary coinsurance for RHC FQHC services see instructions fom contractor records 90D rr X Reimbursable bad debts for dual eligible beneficiaries see instructions TT Other a
176. hed 4 19 2013 HCRIS Website User Manual 4090 Cont FORM CMS 2552 10 APPORTIONMENT OF PATIENT HERE EE RH 15 30 a oun 0 Total FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 171 SECTION 5044 40 614 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 162 FORM CMS 2552 10 Amount would have been realized from patient bable for payment for services on a charge basis bad such payment been made in accordance wats 42 CFR 413 13 b Ratio of 3 to line 4 not to exceed 1 000000 Total customary charges 2 Subtotal zum of Enos 10 20 numus Ene 21 3 Protested amounts report items accordance with CMS Pub 15 IL section 115 2 FORM 5 2552 12 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 11 SECTION 3045 1 3045 2 Rev 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 163 HCRIS Website User Manual 4090 Cont FORM CMS 2552 10 ANALYSIS OF PAYMENTS TO PROVIDER BASED HHA FOR SERVICES TO PROGRAM BENEFICIARIES 0 22
177. her Long Term Care ANCILLARY SERVICE COST CENTERS 9 01 201 NU 901 e m EEEE EB 901 san oan CEE __ mt nl PEE E E ee 50 Operating Room S merken 201 al 901 52 Labor Room Delivery Room 53 Anesthesiology 9011 22221 201 9011 201 901 901 E 9011 201 201 201 201 201 54 Radiology Diagnostic 55 Peu Donius 56 g 201 201 201 901 201 a Um 901 201 911 201 901 901 9 11 9 11 1 57 Computed CT Scan LL 58 Magnetic Resonance Imaging 901 59 Cardiac Catheterization 901 911 60 lt gt __ san 201 901 al 901 901 911 201 011 201 201 61 PBP Clinical Laboratory Services Prem Only 62 Whole Blood amp Packed Red Blood Cells _ 201 63 Blood Storing Processing amp Tr ap
178. his colunm partum to CMS Pub 15 1 Basis for adjustment 90 mstuctions Costs applicable ovechsad detarmined Amoum Received if cost cannot be determined G Additional adjustments be mads on lines 33 thru 40 and subscripts Note Ses instractioms 5 referencing to Worksbest 7 FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 11 SECTION 4016 Rev 2 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications FORM 5 2552 10 08 11 PROVIDER CCN PERIOD WORKSHEET A 6 1 FROM TO COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS The lines 1 rough 4 and subscripts as appropriate are transferred detail Worksheet A colum 6 Ene as appropriate been to Worksheet 1 and or 2 amount allowable should be indicated 4 of this B INTERRELATIONSHIP TO RELATED ORGANIZA AND OR HOME OFFICE The Secretary by vitus of the anthority zxamted under section 1514 bX 1 of the Social Security Act requires that you furnish the z ccmation requested under Part B of this worksheet Thx used by the Centers for Modicaze and Medicaid Services and intermediario contractor determuung that the costs applicable to services facilities amd sup
179. hot Report by going to the link in the left hand task pane 7 You can print the report to a PDF that can be saved or viewed Or you can click the Excel icon to save the report as an Excel worksheet 4 2 Multiple Provider Report Options Multiple Provider Reports There are various options for the multiple provider and multiple report presentations The numbered arrows in the picture below correspond to the items below 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual Click here to add a Provider wp 3 1 w My Provider Single Report Comparison A 6 Provider 230021 LAKELAND MEDICAL CENTER ST 408 5 Reports Wage Index Report Sort By Provider 9 Number gd 2 m This screen defaults to the most recent 4 fiscal years and the most recent status for each period m Use the drop down boxes in the report heading to change the FY and status for each column independently Wage Data Snapshot Multiple Years Hospitals 230021 LAKELAND 230021 LAKELAND 230021 LAKELAND 230021 LAKELAND MEDICAL CENTER MEDICAL CENTER MEDICAL CENTER MEDICAL CENTER ST JOSEPH ST JOSEPH ST JOSEPH ST JOSEPH 4 FYE 10 01 10 09 30 11 5 10 01 09 09 30 10 10 01 08 09 30 09 5 10 01 07 09 30 08 Cost Report Status Submitted 1 As Submitted 1 5 As Submitted 1 As Submitted 1 PDF a Available Not Available Not Available Not Available CBSA 5 He g 35660 N 35660
180. ical Therapy Occupational Therapy Speech Pathology Electrocandiology Electroencephalography Medical Supplies Charged to Patients Cuin Bunte Drug ed to Patients Renal Dialysi ASC Non Distinct Part Other Ancillary specify OUTPATIENT SERVICE COST CENTERS Rural Health Clinic RHC ederally Qualified Health Center san E NM __ 201 FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4021 Rev 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 107 HCRIS Website User Manual 4090 Cont FORM 5 2552 10 ALLOCATION OF CAPITAL RELATED COSTS PROVIDER CCN RELATED COSTS BLDGS amp sum of FIXIURES qme OTHER REIMBURSABLE COST CENIERS 94 Home Dislysi 96 Durable Medical Equipment Rented 901 9011 911 901 11 91 97 Durable Medical EqupmentSod sa 9a aD 9a SP O amp erRemmabe ped emn ee M it E E ET E ET m m 101 Home Health Agency 011 011 011 901 SPECIAL PURPOSE COST CENTERS RENT EEE FE ERN ANNE ESE EER RS TOS Exbey Acqueisen Fa MAC OR CR 106 Hear
181. ices provided by outside supplier Enter Y for yes or N for for each therapy 1 ider 1 1 2 Is this facility classified as a referral center Enter TT for yes or for no x is i 9 If this is a Medicare certified Ever transplant center tbe date in column 1 and termination dat Happiest 1 cohn gt SS DD ag transpls ble 3 uno If yes enter the approval date mm dd yyyy in column 2 149 FORM 5 2552 10 raf NSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB SECTION 40011 Rev 2 4090 Cont FORM CMS 2552 10 WORKSHEET 5 2 HOSPITAL AND HOSPITAL HEALTH CARE N COMPLEX IDENTIFICATION DATA PART I CONT Does this facility contain a provider that qualifies for an exemption from the application of the lower of costs or charges Enter Y for yes or N for no for each component for Part A and Part See 42 CFR 541313 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual FORM CMS 2552 10 FROM TO FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 II SECTIONS 4004 2 Rev 2 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 22 FORM CMS 2552 10 WORKSHEET 5 1 Part CONT Am home office costs claimed th
182. involved in training residents in approved GME program 7 Enter Y for yes or N for Jf line 56 is is this the first cost reporting period during which residents in approved GME programs trained at this facility Enter Y for yes or N for no in column 1 Jf column 1 iz Y did residents start training in the first month of this cost reporting period Enter Y for or for no in column 2 f column 2 iz Y complete Worksheet E 4 f column 2 is complete Worksheet Part amp IV and D 2 Part IL if applicable If line 56 is yes did this facility elect cost reimbursement for physicians services as defined in CMS Pub 15 1 section 21487 IE yes complete Worksheet D 5 Did your facility receive additional FTE slots under ACA section 5503 Enter Y for yes or for no in column 1 If Y effective for portions of cost reporting periods beginning on or after July 1 2011 enter the average number of primary care FTE residents for IME in column 2 and direct GME in column 3 from the hospital s three most recent cost reports ending and submitted before March 23 2010 see instructions ACA Provisions Affecting the Health Resources and Services Administration HRSA Enter the number of FTE residents that your hospital trained in this cost reporting period for which your hospital recetved HRSA PCRE funding see instructions Enter number of FTE residents that rotated from a Teaching Health Center THC
183. ite User Manual 4 6 1 Balance Sheet Report Specifications The following tables contain the specifications for the Balance Sheet Report Each table represents a distinct part or section of this report References to data sources for the 2552 96 and 2552 10 form sets are included for your convenience FRI 2 ts fe 44 notesrecenable 3 Accounts receivable se otherreceivable O HE n Lofe accounts receivable accounts receivable inventory 67 14 inventor 7 t mi S orner current amets Due from otherfunds 10 Due from otherfunds Duetromatherfunds 11 Tetacorentesets sumornesi29 14 2 ime faz Land improvements 120 Accumulated deprecation 14 accumulated deprecation as 14 01 Accumulated depreciation 16 Accumulated deprecation is 14 45 iemenodimmvemess 17 teasehotdimprovements zz Accumulated depreciation Accumulated depreciation as 14 Fixedequismee sf 16 fe fis 14 20 Accumulated depreciation 14 21 automobilesandtruts G 17 01 Accumulated depreciation e 1701 14 22 22 14 Major movable equipment 6 18 14 23 Major movable equipment Me 24 Accumulated depreciation Minor equipme
184. l li amp Insurance lfemployeeisownerorbeneciuy 9 Accident Insurance l employee is owner __ 90 4 Part B Other than Core Related Cost 25 Other Wage Related Costs specify 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 217 HCRIS Website User Manual 4090 Cont FORM CMS 2552 10 08 11 HOSPITAL WAGE RELATED COSTS PROVIDER CCN PERIOD WORKSHEET S 3 FROM PARTIV S TO Part IV Wage Related Cost Pat A Core List Tax Sheltered Anmuty TSA Employer Contribution Qualified and Non Qualified Pension Plan Cost 4 Prior Year Pension Service Cost PLAN ADMINISTRATIVE COSTS Paid to External Orgamization 5 401k TSA Plan Administration fees Legal Accounting Management Feez Penzion Plan 7 Employee Managed Care Program Administration Fees HEALTH AND INSURANCE COST 10 ll li amp Insurance lfemployeeisownerorbeneciuy 9 Accident Insurance l employee is owner __ 90 4 Part B Other than Core Related Cost 25 Other Wage Related Costs specify revised 4 19 2013 2013 Health Financial Systems and amp Associates Inc Appendix B CMS HCRIS Specifications 28 FORM 5 2552 10 HOSPITAL BASED HOME HEALTH AGENCY STATISTICAL DATA HOME HEALTH AGENCY STATISTICAL DATA et Ras
185. ll the comparative average This number is simply the average for the particular data element in the report for all the providers included in the current comparison revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Provider Search here to add a Provider Wa Sa My Provider Rollup Report or in the first boxes to search for a pun ar r Or ai ien My Provider s Provider 050599 0 DAVIS MEDICAL CENTER T SUBMIT CLEAR Sort By Provider Number 5 year Range 07 01 10 06 30 11 Status Amended Reports PPS Reimbursement v Report Type 2552 10 v 6 Combined extract Resul 8 aes Inpatient icare PPS Reimbursement Cost Comparison 2012 v Bepo Statis How to Configure the Roll Up Report The following steps correspond to the numbered screen elements in the Roll Up Report screen depicted in the example above Choose a provider from your My Provider List 1 or your default provider will be automatically selected You may sort by name or provider number CCN 2 e Select a cost report Year Range 3 and a cost report Status 4 Choose of the Snap Shot Reports to display and compare 5 The resulting report and comparison will be displayed on the Report tab Z6 The on screen report title will change to reflect your report selection You ca
186. m 2552 96 S 2 Line 17 Column 1 and 2552 10 S 2 Line 20 Column 1 FYE Fiscal Year End is reported from 2552 96 5 2 Line 17 Column 2 and 2552 10 5 2 Line 20 Column 2 Status 2552 96 Available Status S Line 1 Column 1 are 1 As Submitted 2 Settled w o Audit Settled with Audit 4 Reopened and 5 Amended Status 4 Reopened can have multiple occurrences 2552 10 Available Status S Line 5 Column 1 are 1 As Submitted 2 Settled w o Audit Settled with Audit 4 Reopened and 5 Amended Status 4 Reopened and Status 5 Amended can have multiple occurrences Notice of Program Reimbursement Date is reported from 2552 96 S Line 2 Column 4 and 2552 10 S Line 10 Column 1 This field is applicable for statuses 2 5 HCRIS Creation Date The date that the file was processed and added to the HCRIS database by CMS MCRX This is a re created Medicare Cost Report It is made from the HCRIS data record and the available HFS software at the point that the data was made public by CMS Health Financial Systems data file that can be downloaded opened in Health Financial Systems Medicare Cost Report software May be calculated and edited This option will only be available for 2552 10 cost reports PDF PDF copy of the re created MCRX file HFS software is not required to view these files as they are in standard Adobe format This option will only be available for 2552 10 cost reports 2552 10 T2 T3 Comp
187. might not be significant at all If your facility has a duplicate record like this we would suggest that you compare the mcrx to mcrx with the 800 report in the HFS software to focus on the differences If there are no differences then it s just a processing issue and no changes to the filing were actually made If you see differences feel free to contact HFS to help interpret those differences 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 5 Tools Advanced Search and Extract The Advanced Search and Extract option allows the user to filter searches down to a subset of hospitals or all hospitals The user then chooses which cost report elements they would like to download Users can choose the data elements in our Snap Shot Reports a series of cost report worksheets A B C or define their own not yet available The Advanced Search and Extract feature will work with one database at a time either 2552 96 or 2552 10 Reminder The 2552 96 data is a subset of the cost report the 2552 10 is a complete data set and has every element of the Medicare cost report Step 1 of the Advanced Search and Extract feature is depicted below This screen is used to select the database the user wants to extract data from and filter the list of reports providers that should be included in the extract pool Advanced Search amp Extract Tool Step 1 Step 2 Step 3 Provider Search Type in a Provider Name or
188. n change the view from Report 46 to Search Results 7 or Combined Extract Results Z8 Select which view you want to see by selecting one of the three tabs You can print the report to PDF or export the report data to an Excel spreadsheet clicking either of the two report buttons 9 You can add one or more providers to your My Provider List by clicking the link at the top of the screen 10 See the section below for a discussion of the various filters that be applied to define the group of providers that will be used for comparisons After you are finished configuring the filter options click Submit to apply the filters and define the comparison group 11 Click Clear 12 to remove the filters and start from scratch If you clear the filters all Medicare providers that match the three default critieria will be the comparison group See below The data for the report will be displayed in the first column of the report The second column displays comparative average data derived from cost reports from the group of cost reports defined by the filters you applied Apply Filters to Define Comparison Group 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 6 HCRIS Website User Manual There are numerous drop down lists on the left side of the report screen Each of these lists can be used to select filter out providers By defining the type of cost
189. nt depreciable n Minor equipment depreciable 19 03 Accumulated depreciation rere Accumulated depreciation A Accumulated depreciation MM O 20 minorequipment rondepreciable 6 29 14 29 minorequipment nondepreciable e 14 22 Total fixed assets sumot1ines1220 22 14 22 investments investments e pepositsonieases Jeja 14 2 24 14 33 e 33 14 ornerases tf os s omerases 1 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Snap Shot Reports 32 35 Totalotherassets sumofiines2225 as 14 27 rotalassets sumotiiness 21 and26 14 7 accountspayabie fe 14 salaries wages anafespayatle__ G 14 14 St 14 14 notesandicanspayabie snortterm G 14 as 41 27 E Payoltmespsgbe 31 Notesandioanspayable shortterm 2 E 14 FW Accelerated payments 14 ss ovetootherfunds is s 14 55 rotatcurrentiatities sumottines37thruaa a 45 1 4 46 Wonggepsse 6
190. ntinuous Care Hours Billable to Medicare ne 5 NOTE Parts I amp columns 1 and 2 also include the days reported in columns 3 and 4 _ 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual FORM 5 2552 10 PROVIDER CCN E FROM_ TO eee line 4 is no enter DSH or supplemental payments from Medicaid Medicaid cost 1 times Ime 6 Difference between net revenue and costs for Medicaid program line 2 plus line 5 mimus 7 nM RE 5or9 ee Total unreimbursed cost for Medicaid SCHIP and state and local indigent care programs sum of lines 8 12 and 16 OG ME quic MEER 7 2 2552 96 HCRIS Specifications Enter topic text here revised 4 19 2013 2013 Health Financial Systems and amp Associates Inc Appendix C Provider Types Number Ranges 2 8 Appendix Provider Types Number Ranges Provider Types Number Ranges Type of Facility Short Term General and Specialty Hospitals Reserved for Hospitals participating in ORD Demo Project 1 1 1 880 D ent compre Ned 1300 Rural Primary Care Hospitals 1400 Continuation of CMHC s 4900 4999 series ura primary care rospi TT 7 17 O 3975 3999 Rural Health Clinics Provider Based 4000 Psychiatric Hospitals Excluded from PPS 2013 Health Financial Systems and amp A
191. nue G iline3columni 77 column Net Operating Gain Loss 6 3 5 G 3 line5 column Add Other income ____ 6 3 ine 25 column1 6 3 line25 coumni Netincome Loss G 3 line31 column G 3 line29 column g revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Snap Shot Reports 44 IP PPS Dashboard IP PPS Dashboard Single Report View IP PPS Dashboard IP Medicare Acute PPS Reimb Provider Number Hospital DRG Reimb Sub Prov 1 SCH Outliers DSH Sub Prov 2 CAH PPS Capital SNF MDH IME EN 27 Pass Through FYE 06 30 2011 Hospital Organ Acquisition CR Status Amended DSH v Beds 548 Teaching Y City SACRAMENTO OrgAcq Y State CA County SACRAMENTO Code Description DRG Reimb 82 130 054 46 48 2 Outliers 9 229 758 5 2296 cS DSH 26 799 037 15 1796 Reclass CBSA PPS Capital 10 256 955 5 80 MCare 33 032 392 18 6996 GME 6 263 828 3 5496 14203 Tene Pass Through 44 367 0 0396 Her Tn Organ Acquisition 8 946 360 5 06 Util Days Discharge ALOS Bad Debt 1 311 223 0 7496 Medicare 24 9096 40 825 6 513 6 27 Medicaid 28 42 46 609 487 77 95 56 Total IP Service Reimb 178 038 616 100 0096 Medicaid HMO 9 2296 15 123 Other 20907 6025 23 Total 163 974 28 728 Wage Index Sub 1 Util Days Discharge Hospital Statement of Revenues and Expense
192. o a CBSA lookup tool where you enter the state and county and we retrieve the CBSA code This is the opening screen revised 4 19 2013 2013 Health Financial Systems and amp Associates Inc 5 HCRIS Products Wage Data By CBSA We are currently working on this page Please be patient as we will continue to bring you the best web experience possible Fiscal Year Ending in FFY 2013 v CBSA Reclassified CBSA on 2 Click here to Lookup CBSA To perform a search you need to select a year from the drop down box Then enter a CBSA code and or a reclassified CBSA code Then click submit to perform your search When a search is performed providers and data are retrieved and the following report format appears on your screen 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 EM HCRIS Website User Manual Wage Data By CBSA We are currently working on this page Please be patient as we will continue to bring you the best web experience possible Fiscal Year Ending in FFY CBSA Reclassified CBSA Submit La Click here to Lookup CBSA 010023 BAPTIST MEDICAL CENTER SOUTH Status 1 Fiscal Year End 06 30 2012 Sal Net of 0 Other Wages 0 Wage Related Costs 0 Total Paid Hours 114964138 Total Wages 36 cf Total 0 00 Total Hours 96 of Total 60 5096 AHW 3753829 99 36 Above Below CBSA Avg 58 2296 010097 ELMORE COMMUNITY
193. ociates Inc Published 4 19 2013 15 HCRIS Website User Manual FORM 5 2552 10 CALCULATION OF REIMBURSEMENT SETTLEMENT FOR MEDICARE PART SERVICES COST REIMBURSEMENT CAH Sub sum imos ay Total 3 lows 6 For CARL we bau pr i Ratio of Eme 11 to 12 not to exceed 1 000000 Total customary charges wo immuctiom COMPUTATION OF REIMBURSEMENT SETTLEMENT Direct medical education payment 3 Cost of servicos sum of Enes 6 md 18 909 Dedncibiss exchde pro amp euomicempomm I 7 Suxomi Ene9mim sum of linsa 20 md D 0 MD d 1 d me Allowable bad debts Sor dual bensdicianes mstructons of ime 2 Subeotal sum of lios 24 and 25 or 26 ine 26 Cd TaD mo 11 FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4033 5 Rev 2 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 16 4090 Cont FORM CMS 2552 10 PART VI CALCULATION OF REIMBURSEMENT SETILEMEMENT ALL OTHER HEALTH SERVICES FOR TITLE XVIII PART A PPS SNF SERVICES FORM 5 2552 10 082011 NSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4033 6 40 596 Rev 2
194. ociates Inc Published 4 19 2013 HCRIS Website User Manual 08 11 FORM 5 2552 10 ALLOCATION OF CAPITAL RELATED COSTS ANCILLARY SERVICE COST CENTERS PEP Clinical Laboratory Services Program Whole Blood amp Packed Red Blood Cells Blood Storing Processing amp Trans Intravenous Therapy Respiratory Therapy Physical Therapy per Elecroencephalograp y 5 4 Eee Implantable Devices Charged to Patients Drugs Charged to Patients Renal Dialysi 5 ASC Non Distinct Part Other Ancillary specify OUTPATIENT SERVICE COST CENTERS 88 Rural Health Clinic RHO Federally Qualified Health Center FQHC Clinic Emergency Observation Beds Other Outpatient Service specify FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 1 SECTION 4021 Rev 2 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications ma 4090 Cont FORM CMS 2552 10 ALLOCATION OF CAPITAL RELATED COSTS NON INTERNS amp INTERNS amp OTHER PHYSICIAN RESIDENTS RESIDENTS PARAMEDICAL GENERAL ANES NURSING SALARY AND PROGRAM EDUCATION SERVICE THETISIS SCHOOL FRINGES COSTS SPECIFY SUBTOTAL 2 24 18 19 20 21 22 23 2 OTHER REIMBURSABLE COST CENTERS
195. ol 8 Acute Medicaid HMO Days 5 3 In 2 col 7 Acute Medicaid HMO Dschrgs N A notcalculated Acute Medicaid HMO ALOS N A not calculated Acute Total Util 96 not calculated Acute Total Days 5 3 Ptl In 14 col 8 Acute Total Discharges 5 3 In 14 col 15 5 3 Ptl 12 col 6 5 3 Ptl In 12 S 3 Pti 14 col 8 5 3 Pt I In 14 col Acute Total ALOS col 15 15 ae denen ate Medes ys 0 ite Medien Simma ae Medd Ate Meda ite median Dn n reakuiate1 acsi eese 1 nia reread ens ae al 1 Smee 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual S 3 Ptl 14 col 5 S 3 Pt I In 14 6 5 3 Ptl In 16 col 7 S 3 Pt Ln 16 col 8 5 3 Pt In 16 col 3 S 3 Pti In 16 col 8 5 3 Pt I In 16 col 15 rt Element Data Source s 2552 10 Sub2 Medicare Util 1 5 3 Pt I In 17 col 6 5 3 Pt1 17 col 8 Sub2 Medicare Days 53 Pt I In 17 col 6 Sub2 Medicare Dschrgs 5 3 Pt I 17 col 13 Sub2 Medicare ALOS S 3 Pt I In 17 col 6 5 3 Pt In 17 col 13 5052 Medicaid Util S 3 Pt I 17 col 7 5 3 Pt In 17 col 8 Sub2 Medicaid Days 5 3 Pt I In 17 col 7 Sub2 Medicaid Dschrgs 5 3 Pt 17 col 14 Sub2 M
196. olumn 1 Data Source s 2552 10 S 2 Part I line 3 column 1 S Part I line 3 S Part I line 10 S Part line 20 S Part III line 6 Provider Name Report Number N S Part II line 2 5 column 1 S Part II line 3 column 1 FI Receipt Date S Part II line 1 column 1 Provider Number 5 2 Part 1 line 3 column 2 S Part III line 7 S 2 line 2 column 2 PR 5 2 line 17 column 1 FYE S 2 line 17 column 2 Status S Part II line 2 column 1 5 2 Part line 20 column 1 5 2 Part line 20 column 2 S line 5 column 1 5 2 Part I line 56 Teaching Hospital Indicator lt concat gt S 2 line 25 01 column 1 E 3 Part IV Title 18 line 3 01 column 1 E 4 line 1 Redistribution Cap Increase E 3 Part IV Title 18 line 3 02 column 1 E 4 line 20 Affiliation Agreement Dist ACA Section 5503 Cap Increase ACA Section 5506 Cap Increase E 3 Part IV Title 18 line 3 03 column 1 N A N A E 4 line 4 E 4 line 4 01 E 4 line 4 02 FTE Adjustment Cap CY Unweighted FTEs E 3 Part IV Title 18 line 3 04 column 1 E 4 line 2 E 3 Part IV Title 18 line 3 05 column 1 E 4 line 6 CY Allowable I amp R FTEs E 3 Part IV Title 18 line 3 06 column 1 E 4 line 7 Cap Allocation Allopathic amp Osteopathic E 3 Part IV Title 18 line 3 07 column 1 Cap Allocation All Other E 3 Part IV Title 18 line 3 08 column 1 E
197. olumn 1 E 4 line 29 column 1 Medicare Managed Care Days E 3 Part IV Title 18 line 6 02 column 1 E 4 line 26 column 2 Total Patient Days E 3 Part IV Title 18 line 6 03 column 1 E 4 line 27 column 2 Medicare Managed Care Utilization Ratio E 3 Part IV Title 18 line 6 04 column 1 E 4 line 28 column 2 Medicare GME Reimbursements less 10 5096 after 1 1 00 and 14 13 after 1 1 01 Less Nrsg amp Allied Health Adjusted Program GME Reimb Total Medicare GME Reimbursements E 3 Part IV Title 18 line 6 05 column 1 E 3 Part IV Title 18 line 23 01 column 1 E 4 line 29 column 2 E 4 line 30 column 2 E 4 line 30 column 2 E 4 Line 29 E 4 line 30 E 4 line 31 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Snap Shot Reports 4 10 IME Summary Analysis IME Summary 4 Column Format FYE 07 01 10 06 30 11 m 07 01 09 06 30 10 07 01 08 06 30 09 07 01 07 06 30 08 Cost Report Status Amended 1 v As Submitted 1 As Submitted 1 As Submitted 1 PDF Available Not Available Not Available Not Available Teaching Hospital Y Y Indicator Bed Days Available Base Year FTE Cap Redistribution Cap CY Actual I amp R FTEs Dental Prog I amp R FTEs CY Allowable I amp R FTEs 414 07 414 07 414 07 411 95 PY Allowable I amp R FTEs 414 07 414 07 414 07 411 95 2 Yr Allowa
198. only visits made by therapy assistant and on which supervisor and or therapist was not present during the visit s see instructions Standard travel expense rate Optional travel expense rate per mile Total hours worked AHSEA see instructions Standard travel allowance columns 1 and 2 one half of column 2 line 10 3 one half of column 3 10 Number of travel hours see instructions Number of miles driven see instructions SALARY EQUIVALENCY COMPUTATION Supervisors column 1 line 9 times column 1 line 10 Therapists column 2 line 9 times column 2 10 Assistants column 3 line 9 times column 3 10 Subtotal allowance amount sum of lines 14 and 15 for respiratory therapy or lines 14 16 for all others Aides column 4 line 9 times column 4 ime 10 Trainees column 5 line 9 times column 9 line 10 Total allowance amount sum of lines 17 19 for respiratory therapy or lines 17 and 18 for all others the sum of columns 1 and 2 for respiratory therapy or columns 1 through 3 for physical therapy speech pathology or occupational therapy line 9 15 greater than line 2 make no entries on lines 21 and 22 and enter on line 23 the amount from line 20 Otherwise complete lines 21 through 23 22 Weighted allowance exciuding aides and trainees line 2 times line 21 Total salary equivalency see mstructions FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS FORM ARE PUBLISHE
199. ons TEES sese 0 line 34 must agree with Wkst colum 7 line 116 lumns 0 through 25 line 34 must agree with the corresponding columns of Wkst B Part I line 116 P BE 1 901 E sa 305 1 305 n al 9 901 i 901 901 sis 8 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4062 1 40 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 15 HCRIS Website User Manual 08 11 ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS STATISTICAL BASIS FORM CMS 2552 10 ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS STATISTICAL BASIS 4090 Cont 409 WORKSHEET 5 PARTI 941 941 201 201 26 Services including ER Dept san oD 26 26 28 san sup 30 Bereavement Program Costs ap Chemotherapy 29 Other _ 901 28 28 29 29 901 9 11 30 50 an 31 Volunteer Progam Coss o 901 san Other P
200. or s Vendor _ 2 Sertled withour audir 8 Initial Report for this Provider 12 9 If Ime 4 column 1 15 4 Enter number 3 Sertled with audi 9 X Final Report for this Provider times reopened 0 9 4 Reopened 13 HCRIS CREATE DATE MM DD TY MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL CIVIL AND ADMINISTRATIVE ACTION FINE AND OR IMPRISONMENT UNDER FEDERAL LAW FURTHERMORE IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY A KICKBACK OR WERE OTHERWISE ILLEGAL CIVIL AND ADMINISTRATIVE ACTION FINES AND OR IMPRISONMENT MAY RESULT CERTIFICATION BY OFFICER O amp ADMINISTRATOR OF PROVIDER S IHEREBY CERTIFY that I have mad the above stateznont and that 1 have examined the accompanying electronically Sled or sabusitted cost report and the Balance Sheet and Statement of Revenue and Expenses prepared by Provider Name s and Namber for cost reporting pariod beginning and ending and to the best of my knowledge and belief it is a true correct and complete statemeat prepared from the books and records of provider in accordance with applicable instructions except as noted I farther certify chat fanibar with the lew and regziations the provision of health care services in this cost report were p
201. or tools that enable users to search retrieve compare and analyze HCRIS data for all iterations of all hospital cost reports published in the CMS HCRIS Public Use Files for 2552 96 and 2552 10 cost report form sets Our HCRIS website is the only tool that can re create a complete PDF copy of any 2552 10 cost report We can also re create 2552 10 cost reports as HFS Hospital cost report data files that can be opened using the HFS revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Welcome to the HCRIS Website 2 2552 10 Medicare cost report software We spent several months in beta testing because we wanted to discover the bugs before you did Please notify us immediately if you encounter any problems as you use the tools and run the reports You can report problems and get technical support by contacting our support team Monday through Friday 5 00 a m to 5 00 p m PST The best ways to reach us is by email at support hfssoft com or call our toll free number 888 216 6041 The website is still a work in progress and probably will be for the foreseeable future We welcome your comments questions and suggestions We hope you will contact us with your requests for additional reports and new comparisons you would like to see added in the future We believe this product is truly the first of its kind and we thank you for choosing the HFS Toyon HCRIS database website We look forward to providing you with this valuable
202. ost I line 12 column 4 14 column 6 E PartA line 16 column 1 5 3 Part I Part A lines 59 70 96 70 97 line 12 column 4 D 1 Part II line 49 5 3 Part line 14 column 6 D 1 Part Il Gain Loss column1 5 3 Part I line 12 column 4 e 49 53 Part line 14 column 6 pnm A Reimb Day CY Reimb Day PY Reimb Day CY Reimb Day PY Medicare Reimb Day Reimb Day PY Reimb Day PY Cost Day CY Cost Day PY Cost Day CY Cost Day PY Medicare Cost Day Cost Day PY Cost Day PY Gain Loss Day CY Gain Loss Day PY Gain Loss Day CY Gain Loss Day Gain Loss Day Gain Loss Day PY PY Gain Loss Day PY 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 4 12 Bad Debt Report Bad Debt Report 4 Column Format FY 01 01 11 12 31 11 v 01 01 10 12 31 10 01 01 09 12 31 09 01 01 08 12 31 08 v Status As Submitted 1 v As Submitted 1 v As Submitted 1 v As Submitted 1 v PDF Available Not Available Not Available Not Available 01 01 2011 01 01 2010 01 01 2009 01 01 2008 12 31 2011 12 31 2010 12 31 2009 12 31 2008 Received On Status As Submitted As Submitted As Submitted As Submitted Provider Number 020001 020001 020001 020001 Provider Name Subprovider Numbers 027001 027001 027001 Subprovid
203. ost Recent report status California Y and Rural Y This filter produced a group of eight cost reports filed by eight providers 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual The next example shows the Report screen The data from the cost report of the selected provider is displayed in the first column The second column of data are the comparative averages calculated from the data in the cost reports from the comparison group Report Search Results Combined Extract Results Inpatient Medicare PPS Reimbursement Cost Comparison 2 050599 UC DAVIS MEDICAL CENTER Status Amended Fiscal Year 07 01 2010 06 30 2011 City SACRAMENTO State Type of Hospital Provider Type IRF HHA Hospice MAC 01001 CBSA 40900 Beds 409 Organ Y DSH Y Teaching SCH Urban Rural Urban My Comparitive Provider Average Cost Report Data Elements Needed Medicare Days 40 825 Total Days 163 974 Medicare Discharges 6 513 Medicare Ancillary Costs 97 648 978 Medicare Total Costs 168 915 604 Medicare Reimbursement Total PPS 176 727 393 Bad Debt Reimbursement 1 311 223 Calculations Necessay to Create Report Medicare Routine Costs 71 266 626 Medicare Reimbursement 178 038 616 Report Display Medicare Days 52 49 ALOS 4 45 Medicare Costs Routine Cost Day 1 745 66 1 367 42 Ancillary Cost Day 2 391 89 1 322 08 Total Co
204. other Snap Shot Reports by revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Snap Shot Reports 14 selecting the report links on the left side of the page 7 You can print the report to a PDF document by clicking the PDF button Click the Excel button to save the report as an Excel worksheet 8 If there is re created cost report available for your providers you will see a link to open the PDF version of the report and view the full MCR 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 4 3 PPS Hospital Dashboard PPS Hospital Dashboard Single Report View PPS Hospital Dashboard nnnc nd Provider Number Hospital Sub Prov 1 Sub Prov 2 SNF FYE CR Status Beds City State County CBSA Reclass CBSA Aft 10 1 Bef 10 1 Acute Medicare Medicaid Medicaid HMO Other Total Sub 1 Medicare Medicaid Total Sub 2 Medicare Medicaid Total SNF Medicare Total SCH eae CAH MDH 06 30 2011 Hospital Type Amended DSH Y 548 Teaching Y SACRAMENTO OrgAcq Y CA SACRAMENTO Code Description Sacramento Arden 40900 Arcade Roseville CA Wage Index MCare CMI 1 4203 1 2716 0 0000 0 Util Days Discharge ALOS 24 90 40 825 6 513 6 27 28 4296 46 609 487 77 95 56 9 2296 15 123 20907 602523 163 974 28 728 Util Days Discharge 0 00 0 00 0 00 Util Discharge 28 65 82
205. ount in column 1 from Worksheet 7 1 Part I column 28 line 21 FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 1541 SECTION 4054 1 40 628 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 174 FORM CMS 2552 10 4090 Cont COMPUTATION OF COMMUNITY MENTAL HEALTH CENTER PROVIDER COSTS PROVIDER CCN T COMPONENT PART APPORTIONMENT OF COST OF CMHC PROVIDER SERVICES FURNISHED BY SHARED HOSPITAL DEPARTMENTS v6 x c cu un ox Physical Therapy 0 sao ap san 23 Occupational Therapy 24 o sao 00 o 26 Implantable Devices om om om sa Poe Coe Pe __ l I I I I I I ee 28 Total sum of tines 21 28 00 0 29 Tui component Add the amount from Part I line 20 and the amounts from line 28 columns 5 7 and 9 3 901 901 1 From Worksheet C Part I column 9 lines as appropriate 2 Charges for columns 4 and 5 are obtained from your records 3 Transfer the amounts on line 28 columns 5 7 and 9 25 appropriate to Worksheet 7 3 1 FORM 5 2552 1
206. ovider IPF Subprovider IRF Subprovader specify Nursery Skilled Nursing Facility Nursing Facility Other Long Term Care FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 1541 SECTION 4021 40 550 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 112 4090 Cont FORM 5 2552 10 ALLOCATION OF CAPITAL RELATED COSTS e in Cafeteria Nursing Administration I oM CemmiSeniessdSupy OO 4 Pharmacy Medical Records amp Medical Records Library Social Service Other General Service specify Anesthetists using School Intern amp Res Service Salary amp Fringes Approved Intern amp Res Other Program Costs Approved Paramedical Education Program specify INPATIENT ROUTINE SERVICE COST CENTERS Adults and Pediatrics General Routine Care Intensive Care Unit Coronary Care Unit Burn Intensive Care Unit Surgical Intensive Care Unit Other Special Care Unit specify Subprovider IPF Subprovider IRF Subprovader specify Nursery Skilled Nursing Facility Nursing Facility Other Long Term Care FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 1541 SECTION 4021 40 550 2013 Health Financial Systems and Toyon amp Ass
207. ovision of release governs how external entities can request the use of CMS data A Summary of the HIPAA Privacy Rule provides an overview of HIPAA and states under the Permitted Uses and Disclosures that Research is any systematic investigation designed to develop or contribute to generalizable knowledge The privacy level of the requested file identifiable or limited data set determines the documentation that is required and the review process Research Identifiable Files RIF RIF data contain beneficiary level protected health information PHI Requests for RIF data require a Data Use Agreement DUA and are reviewed by CMS s Privacy Board to ensure that the beneficiary s privacy is protected and the need for identifiable data is justified Further CMS provides the criteria for the release of CMS identifiable data which provides researchers with a list of how the data can be used and what the CMS Privacy Board expects as part of the data request Limited Data Sets LDS LDS files are defined by HIPAA as protected health information from which certain specified direct identifiers of individuals and their relatives household members and employers have been removed A limited data set may be used and disclosed for research health care operations and public health purposes provided the recipient enters into a data use agreement promising specified safeguards for the protected health information within the limited data set
208. plies firuished by organizations related to you by common ownership or control represent reasonable costs 25 determined under section 1861 of the Social Security Act If you do not provide all part of ths requested information the cost report is considered mccmplets and act acceptable for purposes of claiming reimbursemnent under tido 1 Use the SoDowing symbols to indicate intarelationship to related organization haz financial interest stockbolder partner ot in both related and m provider B Corporation pastnership other orgazezation has financial interest provider C Provider has financial interest corporation partnership or other orgazization D Director officer administrator or key parson of provider or relative of such peron ba nancial intecest in related organization E Indnidual i director officer administrator key person of provider and Telsted F Director officer administrator or key person of related organization or relative of such person zancial zterest in provider G Other amp nancial or non zancial specify X 36 FORM 5 2522 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 IL SECTION 4017 40 530 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 83 HCRIS Website User Manual 08 11 FORM CMS 2552 10 4090 Cont PROVIDER BASED PHYS
209. ployee Benefits 4 AD 9D 98 99 98 99 Administrative amp General 5 MD 9859 98 99 Administrative amp General under contract see instructions 91 90 9899 95 99 Operation of Pant n 7 938 99 95 99 Lxdry amp limenSevie 8 9D 938 99 95 99 9 9859 95 99 Housekeeping under contract see instructions 9D 901 989 9599 HOSPITAL WAGE INDEX INFORMATION 901 ital Wage Summary 901 901 901 90D 90D 90D 90D revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 26 4090 Cont FORM CMS 2552 10 08 11 HOSPITAL WAGE RELATED COSTS PROVIDER CCN PERIOD WORKSHEET S 3 FROM PARTIV CS 10 Part IV Wage Related Cost Part A Core List Tax Sheltered Anmuty TSA Employer Contribution Qualified and Non Qualified Pension Plan Cost 4 Prior Year Pension Service Cost PLAN ADMINISTRATIVE COSTS Paid to External Orgamization 5 401k TSA Plan Administration fees Legal Accounting Management Feez Penzion Plan 7 Employee Managed Care Program Administration Fees HEALTH AND INSURANCE COST 10 l
210. port Data 5 1 2010 fiscal year begin and after We use 2552 10 data in our snap shot reports comparison reports and the search and extract features You can re create complete cost reports from the reports in this database and view them as PDF files or open them as regular HFS hospital cost report data files using HFS Medicare Hospital cost report software The HCRIS website will be updated periodically whenever CMS releases new HCRIS data Please read Section 6 of this manual where we included selected portions of official CMS and ResDac publications regarding the integrity and scope of HCRIS data and take a minute to review the CMS disclaimers regarding use and interpretation of HCRIS data Licensed users of the HCRIS website will access to the following data which may be viewed and analyzed using our suite of reports and tools Quick access to available cost report Data for all 2552 96 amp 2552 10 Reporting Years Recreated Cost Reports for viewing and downloading of mcrx files for all 2552 10 reports Quick Review and Analysis of multiple years Canned Reports for useful review and analysis Comparison s of multiple hospital s common information Powerful Search Function for Drill Down and Analysis Purposes Data Extract Function for Spreadsheet Database Analysis We are very excited about the HCRIS database website Although there are other commercially available HCRIS database tools there are no other products
211. ppen if a hospital changes its FY or if there is a CHOW Change of Ownership during the year We have also found cost reports that were sent in error with an incorrect FYB or FYE For the most part HCRIS trys to eliminate these incorrect submissions by contacting the FI MAC and deleting a cost report that the FI MAC identifies as incorrect revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix A HCRIS Data Scope amp Disclaimers The following paragraph is copied from the CMS ResDac website This is from the webpage where HCRIS data is ordered from CMS ResDac The same disclaimer applies to the use of the HFS Toyon HCRIS website It is important to remember that HFS Toyon does not modify any HCRIS data We merely organize it and retrieve it in useful ways The data itself is unchanged HCRIS Data Request Disclaimer The Centers for Medicare amp Medicaid Services CMS has made a reasonable effort to ensure that the provided data records reports are up to date accurate complete and comprehensive at the time of disclosure This information reflects data as reported to the Healthcare Cost Report Information System HCRIS by Medicare Administrative Contractors These reports are a true and accurate representation of the data on file at CMS Authenticated information is only accurate as of the point in time of validation and verification CMS is not responsible for data that is misrepresented misinter
212. preted or altered in any way Derived conclusions and analysis generated from this data are not to be considered attributable to CMS or HCRIS quoted from CMS website http www cms gov Research Statistics Data and Systems Files for Order CostReports index html CMS Disclaimer User Agreement Public Use Data Data accuracy CMS public data is derived from data that is used by the agency for operational purposes CMS does not insure 10096 accuracy of all records and all fields Some data fields that are not used for agency functions may contain incorrect or incomplete data CMS publishes data limitations for their statistical data sources on the internet Users must familiarize themselves with the data limitations documents and accept the quality of the data they receive Privacy protection CMS is obligated by the federal Privacy Act 5 U s C Section 552a and the HIPAA Privacy Rule 45 C F R Parts 160 and 164 to protect the privacy of individual beneficiaries and other persons Public data files consist of aggregated data that do not permit direct identification of individuals Attempting to determine individual identities from public data is a violation of the federal Privacy Act 5 U S C and the HIPAA Privacy Rule HFS Comment HCRIS data files are only released as Public Use Files They do not contain information that would permit identification of individuals HFS TOYON does not edit the data we receive from CMS for accuracy The CMS dis
213. r see instructions 1 Columns 0 through 26 line 22 must agree with the corresponding columns of Wkst B Part lines as appropriate See instructions FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4053 1 40 622 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 19 HCRIS Website User Manual FORM 5 2552 10 ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTERS i iu i v i AmusssskemdGmed _ san san sa san san san san Cae sum sum san sa sam san 99 MD ee ee a an a Respira Te san dp san sa 20D san sm san 200 901 201 san say san 1 Columns 0 through 26 line 22 must agree with the corresponding columns of Wkst B Part lines as appropriate See instructions FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4053 1 Rev 2 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates In
214. re Unit 901 901 901 9a 34 Surgical Intensive Care Unit 901 901 901 san sab 35 Other Special Care Unit speci sam ao aD 40 Subprosider 901 ap oD 31 subproider RF 44 Skilled Nursing Faciiy 9 35 NwsingFadiy an 905 99 95 95 46 Oher Long Tem Cae j sam xD FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 IL SECTION 4020 40 556 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 08 11 COST ALLOCATION STATISTICAL BASIS FORM 5 2552 10 LAUNDRY amp IINEN HOUSE SERVICE KEEPING DIETARY POUNDSOF HOURSOF MEALS LAUNDRY SERVICE SERVED SERO ME ANCILLARY SERVICE COST CENTERS r 30 Operating Room Si RecwryRom 52 Labor Room and Delivery Room CAFETERIA MEALS SERVED EEA E say say m zm mm mm 901 San 901 91
215. reports and relevant characteristics of the providers that filed those cost reports you can define the group of cost reports used for the comparison The following picture shows all available filter types Provider Search in a Provider Name or in the boxes to search for a particular provider Or leave blank and use the filter criteria to return group of providers reports Report Type 2552 10 Fiscal Year End 2012 Report Status Most Recent State Type of Hospital Medica Provider Type Total D Medica 22 Medicare Total Bad Debt DSH Calcul Medica Teaching CAH The first three filters are mandatory Report Type 2552 96 or 2552 10 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Fiscal Year End Note that we include all cost reports with a fiscal year end date that falls within the selected year Report Status or As Submitted These first three filters will default to 2552 10 2012 and Most Recent The remaining filters are optional and will not be used unless you select them and pick a value from the drop down list of available values or types The optional filters are State Type of Hospital Provider Type CBSA code Bed Size Range Organ Transplants Y N DSH Eligibitlity Y N Teaching Hospital Y N CAH Y N e SC
216. rogram 32 33 205 san 32 2 901 901 a 34 Totals sum of lines 1 33 2 9a1 901 35 Totlcosttobeallocsted 5 5 901 say 900 36 9966 9 966 35 901 901 36 FORM CMS 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4062 2 Rev 2 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 16 Cont FORM 5 2552 10 08 11 08 1 CATION OF GENERAL SERVICE COSTS TO 2 WORKSHEETK S ALLO ICE COST CENTERS STATISTICAL BASIS PART II Cont HOSP H ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS STATISTICAL BASIS HH Aide amp Homemaker Cont Home Care Other Imaging Services Labs and Diagnostics Medical Supplies Outpatient Services including E R Dept Radiation Therapy Chemotherapy Other Bereavement Program Costs Volunteer Program Costs Fundraise Other Program Costs Totals sum of lines 1 33 2 Unit Cost Multiplier see instructions 9 0 6 9 0 6 9 9 6 99 6 99 6 99 6 99 6 9 9 6 9 9 6 1 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4062 2 42 2013 Health Financial Systems Toyon amp Associates Inc Published 4 19 2013 187 HCRIS Website User Man
217. rovided in Sed Oficer or Adm tratar of Provider s According to the Paperwork Reduction Act of 1995 persons are requred io respon to a colinction of information aden dapieys valid control The vakd OME control murnber for collection ix 038 0050 The tme sequsred to the nformaten collection extrmsied 673 hours the tae to review matuto search Gusting remocroca gather the data amd complete and review the collection 1f you have ary comments concerning the accuracy of the time waggextiora for ing thes form write to CMS 7500 Secunty Boulevard PRA Clearance Officer Mal C4 26 05 Marylural 21244 1850 FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 1 SECTIONS 4003 1 4003 3 Rev 2 2013 Health Financial Systems Toyon amp Associates Inc Published 4 19 2013 207 HCRIS Website User Manual 4090 Cont FORM CMS 2552 10 HOSPITAL AND HOSPITAL HEALTH CARE PROVIDER CCN PERIOD COMPLEX IDENTIFICATION DATA FROM ital and Hospital Based Component Identification Payment System P T O or N 4 2 32 1 Hospital Based Health 1 Hospital Based CMEC Renal Dialysis 7
218. rovider List When you login to the website in the future you will not be prompted to add providers Comment Generally you will go directly to the first of the Snap Shot Reports The exception to this rule occurs when you are not logged in but you click on Wage Data Analysis by CBSA or the Advanced Search and Extract tools If you are not logged in and you click on either of these you will be prompted to sign in and after you do you will go directly to the screens where you input criteria for the tool you selected Neither of these tools relies on the My Provider List for its data source Please refer to the sections that follow for detailed information regarding My Provider List Snap Shot Reports and data analysis Tools revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc My Provider List 3 My Provider List The My Providers List will be used to populate the drop down selection boxes for My Provider Reports My Provider Single Facility Comparisons and My Provider Multi Facility Comparisons This list will be saved for future sessions and can be modified by you at any time To modify your My Provider List click on the link for My Provider List to see the screen shown below Make Primary Delete Add Provider Most R t HCRIS Creat Provider Name City State Type m ecen reation 020026 ALASKA NATIVE MEDICAL CENTER ANCHORAGE 03 07 2011
219. s Comsurance billed to Medicare Part B patients Bad debts for deductibles and coinsurance net of bad debt recoveries Reimbursable bad debts for dual eligible beneficiaries see instructions Net deductibles and coinsurance billed to Medicare Part B patients sum of lines 3 and 4 less line 5 9 Program payment line 2 less 3 time 80 percent 10 Unrecovered from Medicare Part B patients lesser of line 1 or 2 minus the sum of Imes 5 and 0 Gf negative enter zero and do not complete line 11 Reimbursable bad debts lesser of line 10 or line 5 transfer to Worksheet E Part line 33 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 168 7 1 9 J Worksheets FORM 5 2552 10 ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTERS oa Medical Socal 901 sup san omn m 91 91 ivi 901 901 m 0 0 5 0 CL 5 1 xm xm xm xm edt Medical Appliances gt sD ap ap Sap Rae m a 23 Unit Cost Multiplie
220. s Medicare 0 0096 Gross Patient Revenue 5 772 670 937 Medicaid 0 0096 Less Contractual Allowances 176 702 751 0 00 Sub 2 Util Days Discharge Net Patient Revenue 1 234 606 074 Medicare 28 6596 1 294 82 Operating Expense 1 186 268 341 Medicaid 27 2496 1 230 71 Total 65 1296 4 516 269 Net Operating Gain Loss 48 337 733 Add Other Income 79 935 680 SNF Util Days Less Other Expense 10 644 484 Medicare 0 0096 Total 0 0096 117 628 929 Report Specifications 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 441 IP PPS Dashboard Specifications The following tables contain the specifications for Inpatient PPS Dashboard Report Each table represents a distinct part or section of this report References to data sources for the 2552 96 and 2552 10 form sets are included for your convenience Element Provider Name samman e san amp cia s PhhRelz Im same sarma CBSA Code Data Source s 2552 96 S 2 In 21 03 col 5 Not HCRIS Data External Data Tables Not HCRIS Data External Data Tables Not HCRIS Data External Data Tables Not HCRIS Data External Data Tables Not HCRIS Data External Data Tables Not HCRIS Data External Data Tables Not HCRIS Data External Data Tables Report CBSA No CBSA No Table CBSA No 2010 CBSA No 2009 Reclass CBSA CBSA No Reclass CBSA
221. s list is called My Provider List This list is how you determine the scope of your data analysis on the HCRIS website You need to add at least one provider to My Provider List before you can run any of the Snap Shot Reports and before you can use some of the data analysis Tools You can modify your list of providers as often as you want by adding and deleting providers To create your My Provider List click the Add Provider link The Add Provider screen will present you with several options My Provider List Snap Shot Reports PPS Hosp Dashboard My Providers Use this list to manage your default providers IP PPS Dashboard Back to My Provider List CAH Dashboard Balance Sheet Will you be adding a single provider or multiple providers O Single O Multiple Wage Index DSH Overview GME Summary IME Summary Reimb vs Cost Analysis Bad Debt Report SCH MDH Report Protested Amounts Available Facility Reports Toole Choose whether to add a single provider or multiple providers to your My Provider List New users should select Single because it is an easier process Select either Single or Multiple 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual Add a Single Provider to My Provider List When you select Single you will see the screen below My Provider List My Providers Snap Shot Reports Use this list to manage your default providers PPS Hosp Da
222. se S 2 data to aid in filtering by provider type State Code List Link Provider Type List Link FY Users can use the drop down box to select either FYB or FYE The default is the first full year of the 2552 10 FYB 5 1 2010 4 30 2011 Users can type the desired dates in select with the calendar which will appear when clicked in that field or leave blank both dates are input the system will search for the range FYB Fiscal Year Beginning is reported from 2552 96 S 2 Line 17 Column 1 and 2552 10 S 2 Line 20 Column 1 FYE Fiscal Year End is reported from 2552 96 5 2 Line 17 Column 2 and 2552 10 5 2 Line 20 Column 2 Report Status This field defaults to Most Recent Using the drop down box the user can select blank As Submitted Settled without Audit Settled with Audit Reopened or Amended If a status is selected that allows for more than one occurrence Reopened and the system will return the latest 2552 96 Available Status S Line 1 Column 1 are 1 As Submitted 2 Settled w o Audit 3 Settled with Audit 4 Reopened and 5 Amended Status 4 Reopened can have multiple occurrences 2552 10 Available Status S Line 5 Column 1 are 1 As Submitted 2 Settled w o Audit Settled with Audit 4 Reopened 5 Amended Status 4 and Status can have multiple occurrences City Any entry in here will filter the records reports by
223. shboard IP PPS Dashboard Back to My Provider List CAH Dashboard Balance Sheet Will you be adding a single provider or multiple providers O Multiple Wage Index DSH Overview Single Provider GME Summary Type a provider name or number to search for provider IME Summary Reimb vs Cost Main Provider Analysis Bad Debt Report SCH MDH Report Protested Amounts Available Facility Reports Tools My Provider Multi Facility Comparsions To add a single provider enter the provider number the name of the provider or part of a provider name PREFERENCES ACCOUNT HCRIS Products SUPPORT My Providers Use this list to manage your default providers Back to Preference Will you be adding a single provider or multiple providers Single Multiple Single Provider Type a provider name or number to search for provider and fiscal year you would like to default view Main Provider Alaska In the screen shown above we entered Alaska and then clicked the Search button to find the provider or providers with names containing the word Alaska A name search will often produce multiple search results If you search by provider number your search should retrieve only the provider associated with the provider number you entered The system will return a table containing the names of one or more providers that match the data you typed in the search box You can then revised 4 19 2013 2013 Health Fin
224. ssociates Inc Published 4 19 2013 227 HCRIS Website User Manual 4500 4599 Comprehensive Outpatient Rehabilitation Facilities 4600 4799 Community Mental Health Centers 4800 4899 Continuation of CORF s 4500 4599 series 4900 4999 Continuation of CMHC s 4600 4799 series revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix D State Codes me 9 Appendix D State Codes Name State Code UNKNOWN o Alabama 1 Alaska 2 Arizona 3 Arkansas 4 california 5 california 55 california 75 Colorado 6 Florida Idaho Indiana 15 16 76 Kansas v Kansas 70 Kentucky 18 Louisiana 19 Louisiana Mame 20 Maryland Maryland so Massachusetts 22 Michigan 23 Minnesota 2 Name Ststecode Misso Mota 2 Newiesey 31 Mexico New York North Carolina 2 28 29 M 32 North Dakota 35 Ohio 36 Ohio Oregon 3 Pemsana 3 Puerorico a South Carona 42 SouhDakota a Temese 4 Texas 4 as 9 Utah 46 Wgmsands a Virginia 49 washington 5 DWesvmgma s Wisconsin 52 wyoming s Amerkenemos 8 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013
225. st Day 4 137 55 2 689 50 Medicare Cost Discharge 25 935 15 10 764 49 Medicare Reimb Cost 105 40 0 00 Search Results Screen A list of the cost reports included in the current comparison group may be viewed by selecting the Search Results tab revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc My Provider s Provider 050599 UC DAVIS MEDICAL CENTER Sort By Provider Number Name Year Range 07 01 10 06 30 11 Status Amended Reports PPS Reimbursement v Report Search Results Combined Extract Results Search Results 2 050599 UC DAVIS MEDICAL CENTER Count 8 Status As Submitted Fiscal Year 07 01 2010 06 30 2011 City SACRAMENTO State Type of Hospital Provider Type IRF HHA Hospice MAC 01001 CBSA 40900 Beds 409 Organ DSH Y Teaching SCH Urban Rural Urban Sort By Provider Name Provider Number Status FYB FYE City State Type of Hospital Provider Type CBSA Beds Organ DSH Teaching SCH Urban 051300 EASTERN PLUMAS HEALTH CARE Status As Submitted Fiscal Year 07 01 2011 06 30 2012 ADO PROV City PORTOLA State CA Type of Hospital Provider Type Swing Beds SNF SNF HHA RHC MAC 01001 CBSA 99905 Beds 9 Organ N DSH Teaching SCH Urban Rural Rural 051302 SOUTHERN INYO HOSPITAL Status As Submitted Fiscal Year 07 01 2011 06 30 20
226. sted below revised 4 19 2013 2013 Health Financial Systems and amp Associates Inc Snap Shot Reports 12 Click here to add a Provider My Provider s 2 Provider 230097 MUNSON MEDICAL CENTER Sort By Provider 9 Number Name 2 Year Range 07 01 11 06 30 12 x Status As Submitted Reports PPS Hospital Dashboard PPS Hospital Dashboard 1 You can switch to other providers in your list by clicking the drop down box and selecting the provider you want 2 You can sort the Provider listing to order by Provider Number or Name 3 If you want to see data for a provider not already listed in your My Provider List then click this link to return to the list and use the Add Single or Multiple option Remember you can add providers at any time 4 The Year Range for the reports found for the selected provider will be displayed in this box Use the drop down box to show and choose other time periods for this provider 5 The report Status is limited to the status of cost reports for this provider and this cost report period that are in the HCRIS database Possible status options are As Submitted Settled without Audit Amended To choose a different status or view the available statuses click the down arrow 6 If you would like to view a different Snap Shot Report click the Reports drop down box and choose a different Snap Shot Report You can also choose to switch to another Snap S
227. t cost line 5 divided by line 6 9 Overhead cost pneumococcal and mfluenza vaccine line 7 x line 8 925 administration costs sum of lines 5 and 9 91 amp om your records 12 Cost per pneumococcal and influenza vaccine injection ime 10 11 93 99 9 3 99 13 Number of pneumococcal and influenza vaccine injections administered 14 Program cost of pneumococcal and influenza vaccines and their administration costs line 12 x line 13 901 15 Total cost of pneumococcal and influenza vaccines 1 1 and 2 10 transfer this amount to Worksheet M 3 line 2 16 Total Program cost of pneumococcal and influenza vaccines and their administration costs sum of column 1 and 2 line 14 transfer this amount to Worksheet M 3 21 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 205 HCRIS Website User Manual 08 11 FORM CMS 2552 10 4090 Cont ANALYSIS OF PAYMENTS TO HOSPITAL BASED 3 E WORKSHEET M 5 RHC FQHC PROVIDER FOR SERVICES RENDERED TO PROGRAM BENEFICIARIES RHC FQHC inferim payments paid to providers MMDDYYYY 900 2 Interim payments payable on individual bills either subuatted or to be submitted to the intermediary for services rendered in the cost reporting periods If i or enter zero 1 Subtotal sum of lines 3 01 3 49 minus sum of lines 3 50 3 98
228. t this page and are not yet a licensed and registered user select the New User button to become a registered user of the website Enter your information in the areas provided If you have a user name and password enter your user name and password in the text boxes Remember your user name and your password are case sensitive so make sure you type them exactly as they appear in the email you received from us When finished typing your user name and password click the Sign In button You may want to select the Remember Me option by clicking the check box If you select this option you will not need to enter your user name and password the next time you access the HCRIS website because the website will remember them for you When you sign in for the first time you will see the My Provider List screen In the unlikely event that you signed in directly to one of the advanced data analysis tools you should select the My Provider List link located at the top of the column of links on the left side of the web page See the next section for instructions on how to Create My Provider List 22 Create My Provider List First Time Users Selecting Your Provider s When you login for the first time you will see the My Providers screen revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Getting Started 6 My Provider List Snap Shot Reports PPS Hosp Dashboard IP PPS Dashboard CAH Dashboard Balance Sheet Wage Inde
229. tions You can use the Contact Advanced Search and Us link located under the More Info area on the right and in blue or e mail us at more Info 0 xtra support HFSSOFT com to give us feedback Tools View HCRIS Presentation This database currently contains data from the 2552 96 and 2552 10 cost reports that has Contact Us If you are interested in the HCRIS database and you want to try it out before you buy it click Request Demo We will send you a user name and password and give you temporary access to the HCRIS website so you can use the HCRIS tools and reports and decide if you want to become a licensed user revised 4 19 2013 2013 Health Financial Systems and amp Associates Inc Getting Started 4 If you have not yet purchased a license to use this product you can click on the Purchase link and follow the prompts to become a registered licensed user of the HCRIS website 2 14 Login to HCRIS Website On the HCRIS website home page you can login by clicking the Sing In link located in the upper right corner of the web page In fact you will open the Sign In screen by clicking the Sign In link or clicking any of the various links displayed on the left side of the web page When you click on any of these links the screen will change and you will be prompted to sign in Contact Us HCRIS Website PREFERENCES ACCOUNT HCRIS Products COMPANY My Provider List Welcome to HFS Sign In Snap Shot Reports HCR
230. ual 1 FORM CMS 2552 10 4090 Cont CATION OF GENERAL SERVICE COSTS TO 7 WORKSHEET K 5 ICE COST CENTERS STATISTICAL BASIS H ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS STATISTICAL BASIS a o on a ro Ourpatient Services including E R Radiation Therapy Chemotherapy Other Bereavement Program Costs Volunteer Program Costs Fundraising Other Program Costs Totals sum of lines 1 33 2 Total cost to be allocated Unit Cost Multiplier see instructions 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 II SECTION 4062 2 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 188 4090 Cont FORM CMS 2552 10 APPORTIONMENT OF HOSPICE SHARED SERVICES PROVIDER PERIOD FROM_ HOSPICE TO PART COMPUTATION OF TOTAL HOSPICE SHARED COSTS aot 1x2 Outpatient Services including E R 3 _ 986 RadatonTherpy 3 om Ober 6 60 Totals sum of lines 1 10 sab 5 2552 10 CALCULATION OF HOSPICE DIEM COST Undupheated NF d orksh mn Oe ue kel Other Unduplicated days Worksheet 5 9 comm 5 ine 3 12777777 cost for other j Note The data for the SNF and NF on lines
231. ublished 4 19 2013 HCRIS Website User Manual 4090 Cont FORM CMS 2552 10 APPORTIONMENT OF INPATIENT ANCILLARY PROVIDER CON COMPONENT CCN Tile V Tifo XVIL Part A EES EES EE D sp sse ao so O 94 95 96 97 98 200 FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 II SECTION 4024 2 40 568 revised 4 19 2013 2013 Health Financial Systems and Toyon amp Associates Inc Appendix B CMS HCRIS Specifications 122 08 11 FORM CMS 2552 10 4090 Cont APPORTIONMENT OF INPATIENT ROUTINE PROVIDER CCN WORKSHEET D PART OI SERVICE OTHER PASS THROUGH COSTS applicable Title XVIII Part A Check Tile V boxes Title m 31 Intensive Care Unit 33 Burn Intensive Care Unit 34 Surgical Intensive Care Unit Total sum of lines 30 199 A Worksheet line numbers FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 IL SECTION 4024 3 Rev 2 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 HCRIS Website User Manual 4090 Cont FORM CMS 2552 10 APPORTIONMENT OF INPATIENT OUTPATIENT ANCILLARY PROVIDER CC PERIOD SERVICE OTHER PASS THROUGH COSTS FROM Check tie V 1 i 5 applicable Title
232. ular year the data files will only contain the final settled report If HCRIS has an as submitted final settled and reopened report for a hospital for a particular year the data files will contain the reopened cost report It is possible for 1 Hospital to submit 2 or more cost reports for a given year for the same cost report status This may happen if a hospital changes its FY or if there is a CHOW Change of Ownership during the year We have also found cost reports that were sent in error with an incorrect FYB or FYE For the most part HCRIS trys to eliminate these incorrect submissions by contacting the Fl and deleting a cost report that the Fl identifies as incorrect 2552 10 copied from CMS readme txt file associated with HCRIS data files providers with full 12 months or greater cost reporting periods which begin on or after May 1 2010 and end on or after April 30 2011 should file on the CMS Form 2552 10 The 2552 10 data files contain the highest level of Medicare cost report status If HCRIS has both an as submitted report and a final settled report for a hospital for a particular year the data files will only contain the final settled report If HCRIS has an as submitted final settled and reopened report for a hospital for a particular year the data files will contain the reopened cost report It is possible for 1 Hospital to submit 2 or more cost reports for a given year for the same cost report status This may ha
233. um of lines 5 50 5 98 Determined net settlement amount balance due based the cost repo 1 On lines 3 5 and 6 where an amount is due provider to program show the amount and date on which the provider agrees to the amount of repayment even though total repeyment is not accomplished until a later date FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 SECTION 4031 40 588 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 18 HCRIS Website User Manual FORM 5 2552 10 Medicare Whe 5 3 Part L cokan 6 sum of limes 1 5 12 Total inpatient bed Som 5 3 Part I cohmm 8 sum of linss 1 8 12 charges from Wist C Part L 5 Eme 200 charity care charges Whst S 10 3 INPATIENT HOSPITAL SERVICES UNDER PPS amp FORM 5 2552 10 08 2011 INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15 1 SECTION 4031 1 Rev 2 revised 4 19 2013 2013 Health Financial Systems and amp Associates Inc Appendix B CMS HCRIS Specifications 10 FORM 5 2552 10 wj ILL Primary payar payments MD 8mEn Eme Dedactibles billed to program patients axcInde amount applicable t physician professional varios 1 10 mms m2 of Part B costs lins 12x80
234. v 2 Green ECR HCRIS Purple HCRIS only T2 Received HFS 8262011 2013 Health Financial Systems and Toyon amp Associates Inc Published 4 19 2013 179 HCRIS Website User Manual 08 11 FORM 5 2552 10 4090 Cont HOSPICE COMPENSATION ANALYSIS PROVIDER COV m WORKSHEET K 3 CONTRACTED SERVICES PURCHASED SERVICES HOSPICECCN 00000000 COST CENTER DESCRIPTIONS omit cents DIRECTOR wosxaes Lomas ams _ ALL OTHER OTHER oo a __ GENERAL SERVICE COST CENTERS Kr H gt e 2 Ecran pe xs cut e er ie tcr 3 Plant Operation and Maintenance sD an 9 9 00 4 Transportation Staff 00 5 Volunteer Service Coordination 6 Administrative and General ss oa sap 1 INPATIENT CARE SERVICE ursa ar wma ESAE HR ERR ef Inpatient General Care Inpatient Respite Care oa 90 VISITING SERVICES pm ue 1 n mr nnnm pne emen pem n1 ec emen Physician Services 00 Nursing Care
235. x DSH Overview GME Summary IME Summary Reimb vs Cost Analysis Protested Amt Available Facility Reports Tools My Provider Single Facility parisons My Provider Multi Facility parsions Wage Data Analysis by CBSA My Provider Roll Up Report s Advanced Search and Extract Export Partial EC File My Providers Use this list to manage your default providers The My providers list will be used to populate the drop down selection boxes for My Provider Reports My Provider Single Facility Comparisons and My Provider Multi Facility Comparisons This list will be saved for future sessions and can be modified by you at anytime Add providers by clicking the Add option and then searching for individual providers or importing lists of providers Delete providers by clicking on the left hand check box and then choose Delete The global check box at the top will select the page of providers The provider marked as Primary will be used to populate the reports that you choose on the My Provider Reports You will still be able to choose another provider from the drop down list To mark as Primary click on the check box next to the provider and click Make Primary To sort the li ick on any field in the heading Click Here When you access the website for the first time you are required to add one or more Medicare hospital cost report providers to your list of providers This is a necessary first step for using the HCRIS website Thi

HCRIS Website User Manual - Health Financial Systems

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