Cost Report Data - 110006 - D005

Worksheet D Part V

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

ST MARYS HEALTH CARE SYSTEM INC - ATHENS, GA

Cost report status - As Submitted

[Record Code 708218 - 2010]

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APPORTIONMENT OF MEDICAL AND OTHER HEALTH SERVICES COSTS				Provider CCN: 110006		PERIOD: FROM 07/01/2019 TO 06/30/2020		WORKSHEET D, PART V
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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
		Cost to Charge Ratio from Worksheet C, Part I, col. 9	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
69.30	Cardiology	###	### ###			### ###			69.30
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 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