Worksheet B Part II

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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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ALLOCATION OF CAPITAL-RELATED COSTS Provider CCN: 420004
PERIOD:
FROM 07/01/2021
TO 06/30/2022
Worksheet B,
Part II
Cost Center Descriptions Directly Assigned New Capital Related Costs Capital Related Costs
Subtotal
sum of cols. 0-2
 Employee Benefits Department Administrative & General Maintenance & Repairs Operation of Plant Laundry & Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services & Supply Pharmacy Medical Records & Library Social Service Other General Service Non- Physician Anesthetists Nursing Program Interns & Residents Salary and Fringes Interns & Residents Program Costs Paramedical Education (specify) Subtotal Intern & Resident Cost & Post Stepdown Adjustments Total  
Bldgs. & Fixtures Movable Equipment
0 1 2 2A 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
GENERAL SERVICE COST CENTERS                                                      
1 Capital Related Costs-Buildings and Fixtures       1
2 Capital Related Costs-Movable Equipment       2
4 Employee Benefits Department 4
5 Administrative and General 5
5.05 Other Administrative & General ### ### ### ### 5.05
5.30 Admitting ### ### ### ### 5.30
6 Maintenance and Repairs 6
7 Operation of Plant ### ### ### ### ### 7
8 Laundry and Linen Service ### ### ### ### ### 8
9 Housekeeping ### ### ### ### ### ### 9
10 Dietary ### ### ### ### ### ### 10
11 Cafeteria ### ### 11
12 Maintenance of Personnel 12
13 Nursing Administration ### ### ### ### ### ### ### ### ### 13
14 Central Services and Supply ### ### ### ### ### ### ### ### ### 14
15 Pharmacy ### ### ### ### ### ### ### ### 15
16 Medical Records & Medical Records Library ### ### ### ### ### ### ### ### 16
17 Social Service ### ### ### ### ### ### ### 17
18 Other General Service (specify) 18
19 Nonphysician Anesthetists 19
20 Nursing Program   20
21 Intern & Res. Service-Salary & Fringes (Approved) ### ### ### ### ###     ### 21
22 Intern & Res. Other Program Costs (Approved) ###       ### 22
23 Paramedical Education Program (specify) ### ### ### ### ### ###         ### 23
INPATIENT ROUTINE SERVICE COST CENTERS                                                        
30 Adults and Pediatrics (General Routine Care) ### ### ### ### ### ### ### ### ### ### ### ### ###         ### ### 30
31 Intensive Care Unit ### ### ### ### ### ### ### ### ### ### ### ### ###         ### ### 31
32 Coronary Care Unit         32
33 Burn Intensive Care Unit         33
34 Surgical Intensive Care Unit         34
35 Other Special Care Unit (specify) NEONATAL ICU ### ### ### ### ### ### ### ### ### ### ### ### ###         ### ### 35
40 Subprovider IPF ### ### ### ### ### ### ### ### ### ### ### ###         ### ### 40
41 Subprovider IRF         41
42 Subprovider (specify)         42
43 Nursery         43
44 Skilled Nursing Facility         44
45 Nursing Facility         45
46 Other Long Term Care         46
ANCILLARY SERVICE COST CENTERS                                                        
50 Operating Room ### ### ### ### ### ### ### ### ### ###         ### ### 50
51 Recovery Room ### ### ### ### ### ### ### ### ### ### ###         ### ### 51
52 Labor Room and Delivery Room ### ### ### ### ### ### ### ### ### ### ###         ### ### 52
53 Anesthesiology ### ### ### ### ### ### ### ### ### ###         ### ### 53
54 Radiology-Diagnostic ### ### ### ### ### ### ### ### ### ###         ### ### 54
55 Radiology-Therapeutic ### ### ### ### ### ### ### ### ### ### ###         ### ### 55
56 Radioisotope ### ### ### ### ### ### ### ### ### ###         ### ### 56
57 Computed Tomography (CT) Scan         57
58 Magnetic Resonance Imaging (MRI)         58
59 Cardiac Catheterization ### ### ### ### ### ### ### ### ### ### ###         ### ### 59
60 Laboratory ### ### ### ### ### ### ### ### ### ###         ### ### 60
61 PBP Clinical Laboratory Services-Program Only                                                       61
62 Whole Blood & Packed Red Blood Cells         62
63 Blood Storing, Processing, & Trans.         63
64 Intravenous Therapy         64
65 Respiratory Therapy ### ### ### ### ### ### ### ### ###         ### ### 65
66 Physical Therapy ### ### ### ### ### ### ### ### ### ###         ### ### 66
67 Occupational Therapy ### ### ### ### ### ### ### ### ###         ### ### 67
68 Speech Pathology ### ### ### ### ### ### ### ### ###         ### ### 68
69 Electrocardiology ### ### ### ### ### ### ### ### ### ### ###         ### ### 69
70 Electroencephalography ### ### ### ### ### ### ### ### ### ###         ### ### 70
71 Medical Supplies Charged to Patients ### ### ###         ### ### 71
72 Implantable Devices Charged to Patients ### ### ###         ### ### 72
73 Drugs Charged to Patients ### ### ###         ### ### 73
74 Renal Dialysis ### ### ### ### ### ### ### ### ### ###         ### ### 74
75 ASC (Non-Distinct Part)         75
76 Other Ancillary (specify)         76
76.30 Other Ancillary Cost Centers ### ### ### ### ### ### ### ### ### ### ###         ### ### 76.30
77 Allogeneic HSCT Acquisition         77
78 CAR T-Cell Immunotherapy         78
OUTPATIENT SERVICE COST CENTERS                                                        
88 Rural Health Clinic (RHC)         88
89 Federally Qualified Health Center (FQHC)         89
90 Clinic ### ### ### ### ### ### ### ### ### ### ###         ### ### 90
91 Emergency ### ### ### ### ### ### ### ### ### ###         ### ### 91
92 Observation Beds (Non-Distinct Part)         92
92.01 Observation Beds (Distinct Part)         92.01
93 Other Outpatient Service (specify)         93
93.99 Partial Hospitalization Program         93.99
OTHER REIMBURSABLE COST CENTERS                                                        
94 Home Program Dialysis         94
95 Ambulance Services         95
96 Durable Medical Equipment-Rented         96
97 Durable Medical Equipment-Sold         97
98 Other Reimbursable (specify)         98
99 Outpatient Rehabilitation Provider (specify)         99
100 Intern-Resident Service (not appvd. tchng. prgm.)         100
101 Home Health Agency         101
102 Opioid Treatment Program         102
SPECIAL PURPOSE COST CENTERS                                                        
105 Kidney Acquisition ### ### ### ### ### ### ### ### ###         ### ### 105
106 Heart Acquisition ### ### ### ### ### ### ### ### ###         ### ### 106
107 Liver Acquisition ### ### ### ### ### ### ### ### ###         ### ### 107
108 Lung Acquisition ### ### ### ### ### ### ### ### ###         ### ### 108
109 Pancreas Acquisition ### ### ###         ### ### 109
110 Intestinal Acquisition         110
111 Islet Acquisition         111
112 Other Organ Acquisition (specify) ### ###         ### ### 112
115 Ambulatory Surgical Center (Distinct Part)         115
116 Hospice         116
117 Other Special Purpose (specify)         117
118 SUBTOTALS (sum of lines 1 through 117) ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 118
NONREIMBURSABLE COST CENTERS                                                        
190 Gift, Flower, Coffee Shop, & Canteen ###         ### ### 190
191 Research         191
192 Physicians' Private Offices ### ### ### ### ### ### ### ###         ### ### 192
193 Nonpaid Workers         193
194 Other Nonreimbursable (specify) ### ### ### ### ### ### ###         ### ### 194
200 Cross Foot Adjustments ### ### ### ### ### 200
201 Negative Cost Centers   201
202 TOTAL (sum lines 118 through 201) ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 202
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4021)
12-22   Rev. 18