Worksheet D-3

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Filing History
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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INPATIENT ANCILLARY SERVICE COST APPORTIONMENT Provider CCN: 420004
PERIOD:
FROM 07/01/2021
TO 06/30/2022
 WORKSHEET D-3
- Select other programs and provider types available
(A) COST CENTER DESCRIPTION Ratio of Cost to Charges Inpatient Program Charges Inpatient Program Costs (col. 1 x col. 2)  
1 2 3
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)     35
40 Subprovider IPF     40
41 Subprovider IRF     41
42 Subprovider (Specify)     42
43 Nursery     43
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
200 Total (sum of lines 50 through 94 and 96 through 98) ### ### 200
201 Less PBP Clinic Laboratory Services-Program only charges (line 61)     201
202 Net Charges (line 200 minus line 201)   ###   202
(A) Worksheet A line numbers
FORM CMS-2552-10  (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4027)
07-23   Rev. 21