Worksheet D-4 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 ORGAN ACQUISITION COSTS AND CHARGES FOR A TRANSPLANT HOSPITAL WITH A MEDICARE-CERTIFIED TRANSPLANT PROGRAM Provider CCN: 420004
PERIOD:
FROM 07/01/2021
TO 06/30/2022
 WORKSHEET D-4, PART I
- Select other programs and provider types available
PART I - COMPUTATION OF ORGAN ACQUISITION COSTS (INPATIENT ROUTINE AND ANCILLARY SERVICES)
Computation of Inpatient Routine Service Costs Applicable to Organ Acquisition Inpatient Routine Organ Charges Per Diem Costs (from Wkst. D-1, Part II) Organ Acquisition Days Cost (col. 2 x col. 3)  
1 D 2 3 4
1 Adults and Pediatrics ### 38 ### ### ### 1
2 Intensive Care ### 43 ### ### ### 2
3 Coronary Care 44 3
4 Burn Intensive Care Unit 45 4
5 Surgical Intensive Care Unit 46 5
6 Other Special Care (specify) NEONATAL ICU 47 ### 6
7 TOTAL (sum of lines 1 through 6) ###     ### ### 7
 
Computation of Ancillary Service Costs Applicable to Organ Acquisition Ratio of Cost to Charges (from Wkst. C) Organ Acquisition Ancillary Charges Organ Acquisition Ancillary Costs  
C 1 2 3
8 Operating Room 50 ### ### ### 8
9 Recovery Room 51 ### ### ### 9
10 Labor Room & Delivery Room 52 10
11 Anesthesiology 53 ### ### ### 11
12 Radiology-Diagnostic 54 ### ### ### 12
13 Radiology-Therapeutic 55 13
14 Radioisotope 56 ### ### ### 14
15 Computed Tomography (CT) Scan 57 15
16 Magnetic Resonance Imaging (MRI) 58 16
17 Cardiac Catheterization 59 ### ### ### 17
18 Laboratory 60 ### ### ### 18
19 PBP Clinical Laboratory Services-Program Only 61 19
20 Whole Blood & Packed Red Blood Cells 62 20
21 Blood Storage, Processing, & Transfusing 63 21
22 IV Therapy 64 22
23 Respiratory Therapy 65 ### ### ### 23
24 Physical Therapy 66 24
25 Occupational Therapy 67 25
26 Speech Pathology 68 26
27 Electrocardiology 69 ### ### ### 27
28 Electroencephalography 70 ### ### ### 28
29 Medical Supplies Charged to Patients 71 ### ### ### 29
30 Implantable Devices Charged to Patients 72 30
31 Drugs Charged to Patients 73 ### ### ### 31
32 Renal Dialysis 74 32
33 ASC (non-distinct part) 75 33
34 Other Ancillary (specify) 76 ### ### 34
35 Rural Health Clinic (RHC) 88 35
36 Federally Qualified Health Center (FQHC) 89 36
37 Clinic 90 ### ### ### 37
38 Emergency Room 91 ### ### ### 38
39 Observation Beds 92 39
40 Other Outpatient Service (specify) 93 40
41 TOTAL (sum of lines 8 through 40)     ### ### 41
 
C = Worksheet C line numbers D = Worksheet D-1 line numbers
FORM CMS-2552-10 (04-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, §4028.1)
04-20   Rev. 16