Worksheet C Part I

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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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COMPUTATION OF RATIO OF COSTS TO CHARGES Provider CCN: 420004
PERIOD:
FROM 07/01/2021
TO 06/30/2022
WORKSHEET C
PART I
COST CENTER DESCRIPTIONS Total Cost (from Wkst. B, Part I, col. 26) Therapy Limit Adj. Costs Charges Cost or Other Ratio TEFRA Inpatient Ratio PPS Inpatient Ratio  
Total Costs RCE Disallowance Total Costs Inpatient Outpatient
Total
(column 6
+ column 7)
1 2 3 4 5 6 7 8 9 10 11
- Select other programs and provider types available
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 (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-Prgm. 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
200 Subtotal (see instructions) ### ### ### ### ### ###       200
201 Less Observation Beds ###   ###   ###             201
202 Total (see instructions) ### ### ### ### ### ###       202
FORM CMS-2552-10  (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4023)
12-22   Rev. 18