Worksheet D-1 Parts III & IV
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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]
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| COMPUTATION OF INPATIENT OPERATING COST | Provider CCN: 420004 | PERIOD: FROM 07/01/2021 TO 06/30/2022 |
WORKSHEET D-1, PARTS III & IV | |||||
| - Select other programs and provider types available | ||||||||
| PART III - SKILLED NURSING FACILITY, OTHER NURSING FACILITY. AND ICF/IID ONLY | ||||||||
| 70 | Skilled nursing facility/other nursing facility/ICF/IID routine service cost (line 37) | 70 | ||||||
| 71 | Adjusted general inpatient routine service cost per diem (line 70 ÷ line 2) | 71 | ||||||
| 72 | Program routine service cost (line 9 x line 71) | 72 | ||||||
| 73 | Medically necessary private room cost applicable to Program (line 14 x line 35) | 73 | ||||||
| 74 | Total Program general inpatient routine service costs (line 72 + line 73) | 74 | ||||||
| 75 | Capital-related cost allocated to inpatient routine service costs (from Worksheet B, Parts II, column 26, line 45) | 75 | ||||||
| 76 | Per diem capital-related costs (line 75 ÷ line 2) | 76 | ||||||
| 77 | Program capital-related costs (line 9 x line 76) | 77 | ||||||
| 78 | Inpatient routine service cost (line 74 minus line 77) | 78 | ||||||
| 79 | Aggregate charges to beneficiaries for excess costs (from provider records) | 79 | ||||||
| 80 | Total Program routine service costs for comparison to the cost limitation (line 78 minus line 79) | 80 | ||||||
| 81 | Inpatient routine service cost per diem limitation | 81 | ||||||
| 82 | Inpatient routine service cost limitation (line 9 x line 81) | 82 | ||||||
| 83 | Reasonable inpatient routine service costs (see instructions) | 83 | ||||||
| 84 | Program inpatient ancillary services (see instructions) | 84 | ||||||
| 85 | Utilization review - physician compensation (see instructions) | 85 | ||||||
| 86 | Total Program inpatient operating costs (sum of lines 83 through 85) | 86 | ||||||
| PART IV - COMPUTATION OF OBSERVATION BED PASS-THROUGH COST | ||||||||
| 87 | Total observation bed days (see instructions) | ### | 87 | |||||
| 88 | Adjusted general inpatient routine cost per diem (line 27 ÷ line 2) | ### | 88 | |||||
| 89 | Observation bed cost (line 87 x line 88) (see instructions) | ### | 89 | |||||
| COMPUTATION OF OBSERVATION BED PASS THROUGH COST | ||||||||
| Cost | Routine Cost (from line 27) | column 1 ÷ column 2 | Total Observation Bed Cost (from line 89) | Observation Bed Pass-Through Cost (col. 3 x col. 4) (see instructions) | ||||
| 1 | 2 | 3 | 4 | 5 | ||||
| 90 | Capital-related cost | ### | ### | ### | ### | ### | 90 | |
| 91 | Nursing Program cost | ### | ### | 91 | ||||
| 92 | Allied Health cost | ### | ### | ### | ### | ### | 92 | |
| 93 | All other Medical Education | ### | ### | 93 | ||||
| FORM CMS-2552-10 (01/2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4025.3 - 4025.4) | ||||||||
| 01-22 | Rev. 17 | |||||||