Worksheet D-4 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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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 II
- Select other programs and provider types available
PART II - COMPUTATION OF ORGAN ACQUISITION COSTS (OTHER THAN INPATIENT ROUTINE AND ANCILLARY SERVICE COSTS)
Computation of the Cost of Inpatient Services of Interns and Residents Not In Approved Teaching Program Average Cost Per Day (from Wkst. D-2, Part I, col. 4) Organ Acquisition Days Organ Acquisition Costs (col. 1 x col. 2)  
D 1 2 3
42 Adults & Pediatrics (General routine care) 2 ### 42
43 Intensive Care Unit 3 ### 43
44 Coronary Care Unit 4 44
45 Burn Intensive Care Unit 5 45
46 Surgical Intensive Care Unit 6 46
47 Other Special Care (specify) 7 47
48 TOTAL (sum of lines 42 through 47)     ### 48
Computation of the Cost of Outpatient Services of Interns and Residents Not In Approved Teaching Program Organ Charges (see instructions) Ratio of Cost to Charges from Wkst. D-2, Part I, col. 4) Organ Acquisition Costs (col. 1 x col. 2)  
1 D 2 3
49 Rural Health Clinic (RHC) 21 49
50 Federally Qualified Health Center (FQHC) 22 50
51 Clinic ### 23 51
52 Emergency ### 24 52
53 Observation Beds 25 53
54 Other Outpatient Service (specify) 26 54
55 TOTAL (sum of lines 49 through 54) ###     55
D = Worksheet D-2, Part I, line numbers
FORM CMS-2552-10 (04-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4028.2)
04-20     Rev. 16