Worksheet D Part V

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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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APPORTIONMENT OF MEDICAL AND OTHER HEALTH SERVICES COSTS Provider CCN: 420004
PERIOD:
FROM 07/01/2021
TO 06/30/2022
 WORKSHEET D, PART V
- Select other programs and provider types available
PART V - APPORTIONMENT OF MEDICAL AND OTHER HEALTH SERVICES COSTS
  Cost to Charge Ratio from Worksheet C, Part I, col. 9 Program Charges Program Cost  
PPS Reimbursed Services (see instructions) Cost Reimbursed Services Subject to Ded. & Coins. (see instructions) Cost Reimbursed Services Not Subject to Ded. & Coins. (see instructions) PPS Services (see instructions) Cost Reimbursed Services Subject to Ded. & Coins. (see instructions) Cost Reimbursed Services Not Subject to Ded. & Coins. (see instructions)
(A) Cost Center Description 1 2 3 4 5 6 7
ANCILLARY SERVICE COST CENTERS                
50 Operating Room ### ### ### 50
51 Recovery Room ### ### ### 51
52 Labor & 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 Clinic 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
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 Bed (Non-Distinct Part) ### ### ### 92
92.01 Observation Bed (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     95
96 Durable Medical Equipment-Rented 96
97 Durable Medical Equipment-Sold 97
98 Other Reimbursable Cost Center 98
200 Subtotal (see instructions)   ### ### ### ### ### ### 200
201 Less PBP Clinic Lab. Services-Program Only Charges       201
202 Net Charges (line 200 - line 201 )   ### ### ### ### ### ### 202
FORM CMS-2552-10  (07-2023)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, §4024.5)
07-23   Rev. 21