FORM CMS ( 10/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3525 ) Rev RELATED COSTS
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1 10-99 FORM CMS (Cont.) DIRECTLY CAP. REL. CAP. REL. EMPLOYEE ADMINIS- PLANT OPER. ASSIGNED BUILDINGS MOVABLE SUBTOTAL BENEFITS TRATIVE MAINTENANCE COST CENTER CAPITAL & FIXTURES EQUIPMENT & GENERAL & REPAIRS RELATED COSTS A GENERAL SERVICE COST CENTERS 1 Capital-Related Costs - Building & Fixture Capital-Related Costs - Movable Equipment Employee Benefits Administrative and General 4 5 Plant Operation, Maintenance and Repairs 5 6 Laundry and Linen Service 6 7 Housekeeping 7 8 Dietary 8 9 Nursing Administration 9 10 Central Services and Supply Pharmacy Medical Records and Library Social Service Intern & Residents (Approved Teaching Program) Other General Service cost 15 INPATIENT ROUTINE SERVICE COST CENTERS 16 Skilled Nursing Facility Nursing Facility Intermediate Care Facility/Mentally Retarded Other Long Term Care Other Inpatient Routine Service Cost 20 ANCILLARY SERVICE COST CENTER 21 Radiology Laboratory Intravenous Therapy Oxygen (Inhalation) Therapy Physical Therapy Occupational Therapy Speech Pathology 27 Electrocardiology Medical Supplies Charged to Patients Drugs Charged to Patients Dental Care - Title XIX only Support Surfaces Other Ancillary Service Cost 33 Rev
2 3590 (Cont.) FORM CMS DIRECTLY CAP. REL. CAP. REL. EMPLOYEE ADMINIS- PLANT OPER. ASSIGNED BUILDINGS MOVABLE SUBTOTAL BENEFITS TRATIVE MAINTENANCE COST CENTER CAPITAL & FIXTURES EQUIPMENT & GENERAL & REPAIRS RELATED COSTS A OUTPATIENT SERVICE COST CENTERS 34 Clinic R H C Other Outpatient Service Cost 36 OTHER REIMBURSABLE COST CENTERS 37 Administrative and General - HHA Skilled Nursing Care - HHA Physical Therapy - HHA Occupational Therapy - HHA Speech Pathology - HHA Medical Social Services - HHA Home Health Aide - HHA Durable Medical Equipment - Rented - HHA Durable Medical Equipment - Sold - HHA Home Delivered Meals - HHA Other Home Health Services - HHA Ambulance Interns and Residents (Not An Approved Teaching Program) Outpatient Rehabilitation Provider Other Reimbursable Cost 51 SPECIAL PURPOSE COST CENTERS 55 Hospice Other Special Purpose Cost Subtotals 57 NON REIMBURSABLE COST CENTERS 58 Gift, Flower, Coffee Shops and Canteen Barber and Beauty Shop Physicians' Private Offices Nonpaid Workers Patients Laundry Other Non Reimbursable Cost Cross Foot Adjustments Negative Cost Center Total Rev. 6
3 10-99 FORM CMS (Cont.) LAUNDRY HOUSE DIETARY NURSING CENTRAL PHARMACY & LINEN KEEPING ADMINIS- SERVICES COST CENTER SERVICE TRATION & SUPPLY GENERAL SERVICE COST CENTERS 1 Capital-Related Costs - Building & Fixture 1 2 Capital-Related Costs - Movable Equipment 2 3 Employee Benefits 3 4 Administrative and General 4 5 Plant Operation, Maintenance and Repairs 5 6 Laundry and Linen Service 6 7 Housekeeping 7 8 Dietary 8 9 Nursing Administration 9 10 Central Services and Supply Pharmacy Medical Records and Library Social Service Intern & Residents (Approved Teaching Program) Other General Service cost 15 INPATIENT ROUTINE SERVICE COST CENTERS 16 Skilled Nursing Facility Nursing Facility Intermediate Care Facility/Mentally Retarded Other Long Term Care Other Inpatient Routine Service Cost 20 ANCILLARY SERVICE COST CENTER 21 Radiology Laboratory Intravenous Therapy Oxygen (Inhalation) Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Medical Supplies Charged to Patients Drugs Charged to Patients Dental Care - Title XIX only Support Surfaces Other Ancillary Service Cost 33 Rev
4 3590 (Cont.) FORM CMS LAUNDRY HOUSE DIETARY NURSING CENTRAL PHARMACY & LINEN KEEPING ADMINIS- SERVICES COST CENTER SERVICE TRATION & SUPPLY OUTPATIENT SERVICE COST CENTERS 34 Clinic R H C Other Outpatient Service Cost 36 OTHER REIMBURSABLE COST CENTERS 37 Administrative and General - HHA Skilled Nursing Care - HHA Physical Therapy - HHA Occupational Therapy - HHA Speech Pathology - HHA Medical Social Services - HHA Home Health Aide - HHA Durable Medical Equipment - Rented - HHA Durable Medical Equipment - Sold - HHA Home Delivered Meals - HHA Other Home Health Services - HHA Ambulance Interns and Residents (Not An Approved Teaching Program) Outpatient Rehabilitation Provider Other Reimbursable Cost 51 SPECIAL PURPOSE COST CENTERS 55 Hospice Other Special Purpose Cost Subtotals 57 NON REIMBURSABLE COST CENTERS 58 Gift, Flower, Coffee Shops and Canteen Barber and Beauty Shop Physicians' Private Offices Nonpaid Workers Patients Laundry Other Non Reimbursable Cost Cross Foot Adjustments Negative Cost Center Total Rev. 6
5 10-99 FORM CMS (Cont.) MEDICAL SOCIAL INTERNS & OTHER POST COST CENTER RECORDS SERVICE RESIDENTS GENERAL SUBTOTAL STEPDOWN & LIBRARY SERVICE ADJUSTMENTS TOTAL COST GENERAL SERVICE COST CENTERS Capital-Related Costs - Building & Fixture 1 2 Capital-Related Costs - Movable Equipment 2 3 Employee Benefits 3 4 Administrative and General 4 5 Plant Operation, Maintenance and Repairs 5 6 Laundry and Linen Service 6 7 Housekeeping 7 8 Dietary 8 9 Nursing Administration 9 10 Central Services and Supply Pharmacy Medical Records and Library Social Service Intern & Residents (Approved Teaching Program) Other General Service cost 15 INPATIENT ROUTINE SERVICE COST CENTERS 16 Skilled Nursing Facility Nursing Facility Intermediate Care Facility/Mentally Retarded Other Long Term Care Other Inpatient Routine Service Cost 20 ANCILLARY SERVICE COST CENTER 21 Radiology Laboratory Intravenous Therapy Oxygen (Inhalation) Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Medical Supplies Charged to Patients Drugs Charged to Patients Dental Care - Title XIX only Support Surfaces Other Ancillary Service Cost 33 Rev
6 3590 (Cont.) FORM CMS MEDICAL SOCIAL INTERNS & OTHER POST RECORDS SERVICE RESIDENTS GENERAL SUBTOTAL STEPDOWN TOTAL COST CENTER & LIBRARY SERVICE ADJUSTMENTS COST OUTPATIENT SERVICE COST CENTERS 34 Clinic R H C Other Outpatient Service Cost 36 OTHER REIMBURSABLE COST CENTERS 37 Administrative and General - HHA Skilled Nursing Care - HHA Physical Therapy - HHA Occupational Therapy - HHA Speech Pathology - HHA Medical Social Services - HHA Home Health Aide - HHA Durable Medical Equipment - Rented - HHA Durable Medical Equipment - Sold - HHA Home Delivered Meals - HHA Other Home Health Services - HHA Ambulance Interns and Residents (Not An Approved Teaching Program) Outpatient Rehabilitation Provider Other Reimbursable Cost 51 SPECIAL PURPOSE COST CENTERS 55 Hospice Other Special Purpose Cost Subtotals 57 NON REIMBURSABLE COST CENTERS 58 Gift, Flower, Coffee Shops and Canteen Barber and Beauty Shop Physicians' Private Offices Nonpaid Workers Patients Laundry Other Non Reimbursable Cost Cross Foot Adjustments Negative Cost Center Total Rev. 6
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Blue Choice. Hospital/$50, Physician's Office/Lesser of $50 or 20%; physician $40, facility $50. $35/trip $100/trip $50/trip $100/trip $100/trip
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Telemedicine services $0 copay Not applicable Primary care provider (PCP) CYD/Coinsurance CYD/Coinsurance CYD/Coinsurance CYD/Coinsurance
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