Worksheet A

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FORM CMS-2552-10
INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, , REV 1

MEDICAL UNIVERSITY OF SOUTH CAROLINA - CHARLESTON, SC
Cost report status - As Submitted
[Record Code 741780 - 2010]
This is a prior filing for this period.

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RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES Provider CCN: 420004
PERIOD: FROM 07/01/2021
TO 06/30/2022
 WORKSHEET A
COST CENTER DESCRIPTIONS (omit cents) SALARIES OTHER TOTAL (col. 1 + col. 2) RECLASSIFI- CATIONS RECLASSIFIED TRIAL BALANCE (col. 3 ± col. 4) ADJUSTMENTS NET EXPENSES FOR ALLOCATION (col. 5 ± col. 6)  
1 2 3 4 5 6 7
  GENERAL SERVICE COST CENTERS                
1 00100 Capital Related Costs-Buildings and Fixtures   ### ### ### ### 1
2 00200 Capital Related Costs-Movable Equipment   ### ### ### ### 2
3 00300 Other Capital Related Costs   -0- 3
4 00400 Employee Benefits Department 4
5 00500 Administrative and General 5
5.05   Other Administrative & General ### ### ### ### ### ### ### 5.05
5.30   Admitting ### ### ### ### ### 5.30
6 00600 Maintenance and Repairs 6
7 00700 Operation of Plant ### ### ### ### ### ### ### 7
8 00800 Laundry and Linen Service ### ### ### ### ### 8
9 00900 Housekeeping ### ### ### ### ### 9
10 01000 Dietary ### ### ### ### ### ### ### 10
11 01100 Cafeteria ### ### ### ### 11
12 01200 Maintenance of Personnel 12
13 01300 Nursing Administration ### ### ### ### ### ### ### 13
14 01400 Central Services and Supply ### ### ### ### ### ### 14
15 01500 Pharmacy ### ### ### ### ### ### ### 15
16 01600 Medical Records & Medical Records Library ### ### ### ### ### 16
17 01700 Social Service ### ### ### ### ### 17
18   Other General Service (specify) 18
19 01900 Nonphysician Anesthetists ### ### ### 19
20 02000 Nursing Program 20
21 02100 Intern & Res. Service-Salary & Fringes (Approved) ### ### ### ### ### ### 21
22 02200 Intern & Res. Other Program Costs (Approved) ### ### ### ### 22
23 02300 Paramedical Ed. Program (specify) ### ### ### ### ### ### ### 23
  INPATIENT ROUTINE SERVICE COST CENTERS                
30 03000 Adults and Pediatrics (General Routine Care) ### ### ### ### ### ### ### 30
31 03100 Intensive Care Unit ### ### ### ### ### ### 31
32 03200 Coronary Care Unit 32
33 03300 Burn Intensive Care Unit 33
34 03400 Surgical Intensive Care Unit 34
35 ### Other Special Care (specify) NEONATAL ICU ### ### ### ### ### ### 35
40 04000 Subprovider - IPF ### ### ### ### ### ### 40
41 04100 Subprovider - IRF 41
42 04200 Subprovider (specify) 42
43 04300 Nursery 43
44 04400 Skilled Nursing Facility 44
45 04500 Nursing Facility 45
46 04600 Other Long Term Care 46
  ANCILLARY SERVICE COST CENTERS                
50 05000 Operating Room ### ### ### ### ### ### ### 50
51 05100 Recovery Room ### ### ### ### ### ### 51
52 05200 Labor Room and Delivery Room ### ### ### ### ### ### ### 52
53 05300 Anesthesiology ### ### ### ### ### ### ### 53
54 05400 Radiology-Diagnostic ### ### ### ### ### ### ### 54
55 05500 Radiology-Therapeutic ### ### ### ### ### ### ### 55
56 05600 Radioisotope ### ### ### ### ### ### 56
57 05700 Computed Tomography (CT) Scan 57
58 05800 Magnetic Resonance Imaging (MRI) 58
59 05900 Cardiac Catheterization ### ### ### ### ### ### 59
60 06000 Laboratory ### ### ### ### ### ### ### 60
61 06100 PBP Clinical Laboratory Services-Program Only   61
62 06200 Whole Blood & Packed Red Blood Cells 62
63 06300 Blood Storing, Processing, & Trans. 63
64 06400 Intravenous Therapy 64
65 06500 Respiratory Therapy ### ### ### ### ### ### ### 65
66 06600 Physical Therapy ### ### ### ### ### ### ### 66
67 06700 Occupational Therapy ### ### ### ### ### ### ### 67
68 06800 Speech Pathology ### ### ### ### ### ### ### 68
69 06900 Electrocardiology ### ### ### ### ### ### 69
70 07000 Electroencephalography ### ### ### ### ### ### 70
71 07100 Medical Supplies Charged to Patients ### ### ### 71
72 07200 Implantable Devices Charged to Patients ### ### ### 72
73 07300 Drugs Charged to Patients ### ### ### 73
74 07400 Renal Dialysis ### ### ### ### ### ### 74
75 07500 ASC (Non-Distinct Part) 75
76   Other Ancillary (specify) 76
76.30   Other Ancillary Cost Centers ### ### ### ### ### ### 76.30
77 07700 Allogeneic HSCT Acquisition 77
78 07800 CAR T-Cell Immunotherapy 78
  OUTPATIENT SERVICE COST CENTERS                
88 08800 Rural Health Clinic (RHC) 88
89 08900 Federally Qualified Health Center (FQHC) 89
90 09000 Clinic ### ### ### ### ### ### ### 90
91 09100 Emergency ### ### ### ### ### ### 91
92 09200 Observation Beds (Non-Distinct Part) 92
92.01 09201 Observation Beds (Distinct Part) 92.01
93   Other Outpatient Service (specify) 93
93.99 09400 Partial Hospitalization Program 93.99
  OTHER REIMBURSABLE COST CENTERS                
94 09400 Home Program Dialysis 94
95 09500 Ambulance Services 95
96 09600 Durable Medical Equipment-Rented 96
97 09700 Durable Medical Equipment-Sold 97
98   Other Reimbursable (specify) 98
99   Outpatient Rehabilitation Provider (specify) 99
100 10000 Intern-Resident Service (not appvd. tchng. prgm.) 100
101 10100 Home Health Agency 101
102 10200 Opioid Treatment Program 102
  SPECIAL PURPOSE COST CENTERS                
105 10500 Kidney Acquisition ### ### ### ### ### ### ### 105
106 10600 Heart Acquisition ### ### ### ### ### ### ### 106
107 10700 Liver Acquisition ### ### ### ### ### ### ### 107
108 10800 Lung Acquisition ### ### ### ### ### ### ### 108
109 10900 Pancreas Acquisition ### ### ### ### ### ### 109
110 11000 Intestinal Acquisition 110
111 11100 Islet Acquisition 111
112   Other Organ Acquisition (specify) ### ### ### 112
113 11300 Interest Expense   - 0 - 113
114 11400 Utilization Review-SNF - 0 - 114
115 11500 Ambulatory Surgical Center (Distinct Part) 115
116 11600 Hospice 116
117   Other Special Purpose (specify) 117
118   SUBTOTALS (sum of lines 1 through 117) ### ### ### ### ### ### ### 118
  NONREIMBURSABLE COST CENTERS                
190 19000 Gift, Flower, Coffee Shop, & Canteen ### ### ### ### 190
191 19100 Research 191
192 19200 Physicians' Private Offices ### ### ### ### ### ### 192
193 19300 Nonpaid Workers 193
194   Other Nonreimbursable (specify) ### ### ### ### ### ### ### 194
200   TOTAL (sum of lines 118 through 199) ### ### ### - 0 - ### ### ### 200
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, § 4013)
12-22   Rev. 18