Cost Report Data - Worksheet Formats

Worksheet Formats

Worksheet formats are based on information supplied by the Centers for Medicare and Medicaid Studies (CMS). Forms and instructions can be downloaded from the CMS website and are presented here as a convenient reference.

S20	Worksheet S-2 Hospital and Hospital Health Care Complex Identification Data	form	instructions
S31	Worksheet S-3, Part I Hospital and Hospital Health Care Complex Statistical Data	form	instructions
S32	Worksheet S-3, Part II Hospital Wage Index Information - Wage Data	form	instructions
S33	Worksheet S-3, Part III Hospital Wage Index Information - Wage Index Summary	form	instructions
S10	Worksheet S-10 Hospital Uncompensated Care Data	form	instructions
A00	Worksheet A Reclassification and Adjustment of Trial Balance of Expenses	form	instructions
A71	Worksheet A-7, Parts I & II Analysis of Changes During Cost Reporting Period in Capital Asset Balance	form	instructions
A73	Worksheet A-7, Parts III & IV Reconciliation of Capital Cost Centers	form	instructions
A80	Worksheet A-8 Adjustments to Expenses	form	instructions
81A	Worksheet A-8-1, Part A Statement of Costs of Services from Related Organizations and Home Office Costs - Costs and Adjustments	form	instructions
81B	Worksheet A-8-1, Part B Statement of Costs of Services from Related Organizations and Home Office Costs - Interrelationships	form	instructions
B01	Worksheet B, Part I Cost Allocation - General Service Costs	form	instructions
B10	Worksheet B-1 Cost Allocation - Statistical Basis	form	instructions
C01	Worksheet C, Part I Computation of Ratio of Costs to Charges	form	instructions
C02	Worksheet C, Part II Calculation of Outpatient Service Cost to Charge Ratios Net of Reductions	form	instructions
D01	Worksheet D, Part I Apportionment of Inpatient Routine Service Capital Costs	form	instructions
D02	Worksheet D, Part II Apportionment of Inpatient Ancillary Service Capital Costs	form	instructions
D03	Worksheet D, Part III Apportionment of Inpatient Routine Service Other Pass Through Costs	form	instructions
D04	Worksheet D, Part IV Apportionment of Inpatient/Outpatient Ancillary Service Other Pass Through Costs	form	instructions
D05	Worksheet D, Parts V & VI Apportionment of Medical, Other Health Services Costs and Vaccine Cost	form	instructions
D11	Worksheet D-1, Part I Computation of Inpatient Operating Cost - All Provider Components	form	instructions
D12	Worksheet D-1, Part II Computation of Inpatient Operating Cost - Hospital and Subproviders Only	form	instructions
D13	Worksheet D-1, Parts III & IV Computation of Inpatient Operating Cost - SNF, NF, ICF/MR, and Observation Beds	form	instructions
D40	Worksheet D-4 Inpatient Ancillary Service Cost Apportionment	form	instructions
D60	Worksheet D-6, Parts III & IV Computation of Organ Acquisition Costs and Charges	form	instructions
E0A	Worksheet E, Part A Calculation of Reimbursement Settlement - Inpatient Hospital Services Under PPS	form	instructions
E0B	Worksheet E, Part B Calculation of Reimbursement Settlement - Medical and Other Health Services	form	instructions
E0C	Worksheet E, Part C Calculation of Reimbursement Settlement - Outpatient Ambulatory Surgical Center	form	instructions
E0D	Worksheet E, Part D Calculation of Reimbursement Settlement - Outpatient Radiology Services	form	instructions
E0E	Worksheet E, Part E Calculation of Reimbursement Settlement - Other Outpatient Diagnostic Procedures	form	instructions
E20	Worksheet E-2 Calculation of Reimbursement Settlement - Swing Beds	form	instructions
E31	Worksheet E-3, Part I Calculation of Medicare Reimbursement Settlement under TEFRA, IRF PPS, LTAC PPS, and IPF PPS	form	instructions
E32	Worksheet E-3, Part II Calculation of Reimbursement Settlement - Medicare Part A Services - Cost Reimbursement	form	instructions
E33	Worksheet E-3, Part III Calculation of Reimbursement Settlement - Title V or Title XIX Services or Title XVIII SNF PPS Only	form	instructions
E34	Worksheet E-3, Part IV Direct Graduate Medical Education (GME) & ESRD Outpatient Direct Medical Education Costs	form	instructions
E35	Worksheet E-3, Part V Calculation of NHCMQ Demonstration Reimbursement Settlement	form	instructions
E36	Worksheet E-3, Part VI Calculation of GME & IME Payments for Redistribution of Unused Residency Slots	form	instructions
G00	Worksheet G Balance Sheet	form	instructions
G20	Worksheet G-2, Parts I & II Statement of Patient Revenues and Operating Revenues	form	instructions
G30	Worksheet G-3 Statement of Revenues and Expenses	form	instructions
H60	Worksheet H-6 Apportionment of Patient Service Costs [HHA]	form	instructions
H70	Worksheet H-7 Calculation of HHA Reimbursement Settlement	form	instructions
L00	Worksheet L Calculation of Capital Payment	form	instructions
M10	Worksheet M-1 Analysis of Provider-Based Rural Health Clinic / Federally Qualified Health Center Costs	form	instructions
M20	Worksheet M-2 Allocation of Overhead to RHC/FQHC Services	form	instructions
M30	Worksheet M-3 Calculation of Reimbursement Settlement for RHC/FQHC Services	form	instructions
M40	Worksheet M-4 Computation of Pneumococcal and Influenza Vaccine Cost	form	instructions
M50	Worksheet M-5 Analysis of Payments to Hospital-Based RHC/FQHC Provider for Services Rendered to Program Beneficiaries	form	instructions

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Reports or datasets can be produced to your exact specifications. Custom reports and data sets are prepared quickly and economically by experienced analysts. Economical, predefined datasets are also available for the most commonly requested cost report data. <more>