Worksheet D Part IV

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FORM CMS-2552-10
INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, , REV 1

NOVANT HEALTH MINT HILL MEDICAL CTR - CHARLOTTE, NC
Cost report status - Amended
[Record Code 738811 - 2010]
This is a prior filing for this period.

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APPORTIONMENT OF INPATIENT/OUTPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS Provider CCN: 340190
PERIOD:
FROM 01/01/2020
TO 12/31/2020
 WORKSHEET D, PART IV
Medicare -Title XVIII - Hospital
  Non Physician Anesthetist Cost Nursing Program Post Stepdown Adjustments Nursing Program Allied Health Post Stepdown Adjustments Allied Health All Other Medical Education Cost Total cost (sum of col 1 through col 4) Total Outpatient Cost (sum of col 2, 3 and 4) Total Charges (from Wkst. C, Part I, col 8) Ratio of Cost to Charges (col 5 ÷ col 7) (see instructions) Outpatient Ratio of Cost to Charges (col 6 ÷ col 7) Inpatient Program Charges Inpatient Program Pass- Through Costs (col 8 x col 10) Outpatient Program Charges Outpatient Program Pass- Through Costs (col 9 x col 12)  
(A) Cost Center Description 1 2A 2 3A 3 4 5 6 7 8 9 10 11 12 13
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, & Transfusing 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
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 199) ###     ### ### 200
(A) Worksheet A line numbers
FORM CMS-2552-10  (07-2023)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4024.4)
07-23   Rev. 21