Worksheet D 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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APPORTIONMENT OF INPATIENT ANCILLARY SERVICE CAPITAL COSTS Provider CCN: 420004
PERIOD:
FROM 07/01/2021
TO 06/30/2022
WORKSHEET D,
PART II
- Select other programs and provider types available
  Capital Related Cost (from Wkst. B, Part II, col. 26) Total Charges (from Wkst. C, Part I, col. 8) Ratio of Cost to Charges (col. 1 ÷ col. 2) Inpatient Program Charges Capital Costs (column 3 x column 4)  
(A) Cost Center Description 1 2 3 4 5  
  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 ### ### ### ### ### 60
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
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 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 4024.2)
07-23   Rev. 21