Worksheet D-1 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]
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| COMPUTATION OF INPATIENT OPERATING COST | Provider CCN: 420004 | PERIOD: FROM 07/01/2021 TO 06/30/2022 |
WORKSHEET D-1, PART II | |||||
| - Select other programs and provider types available | ||||||||
| PART II - HOSPITAL AND SUBPROVIDERS ONLY | ||||||||
| PROGRAM INPATIENT OPERATING COST BEFORE PASS-THROUGH COST ADJUSTMENTS | 1 | |||||||
| 38 | Adjusted general inpatient routine service cost per diem (see instructions) | ### | 38 | |||||
| 39 | Program general inpatient routine service cost (line 9 x line 38) | ### | 39 | |||||
| 40 | Medically necessary private room cost applicable to the Program (line 14 x line 35) | 40 | ||||||
| 41 | Total Program general inpatient routine service cost (line 39 + line 40) | ### | 41 | |||||
| Total Inpatient Cost | Total Inpatient Days | Average Per Diem col. 1 ÷ col. 2) ( |
Program Days | Program Cost (col. 3 x col. 4) |
||||
| 1 | 2 | 3 | 4 | 5 | ||||
| 42 | Nursery (title V & XIX only) | 42 | ||||||
| Intensive Care Type Inpatient Hospital Units | ||||||||
| 43 | Intensive Care Unit | ### | ### | ### | ### | ### | 43 | |
| 44 | Coronary Care Unit | 44 | ||||||
| 45 | Burn Intensive Care Unit | 45 | ||||||
| 46 | Surgical Intensive Care Unit | 46 | ||||||
| 47 | Other Special Care Unit (specify) | ### | ### | ### | 47 | |||
| 1 | ||||||||
| 48 | Program inpatient ancillary service cost (Worksheet D-3, column 3, line 200) | ### | 48 | |||||
| 48.01 | Program inpatient cellular therapy acquisition cost (Worksheet D-6, Part III, line 10, column 1) | 48.01 | ||||||
| 49 | Total Program inpatient costs (sum of lines 41 through 48.01) (see instructions) | ### | 49 | |||||
| PASS-THROUGH COST ADJUSTMENTS | ||||||||
| 50 | Pass through costs applicable to Program inpatient routine services (from Worksheet D, sum of Parts I and III) | ### | 50 | |||||
| 51 | Pass through costs applicable to Program inpatient ancillary services (from Worksheet D, sum of Parts II and IV) | ### | 51 | |||||
| 52 | Total Program excludable cost (sum of lines 50 and 51) | ### | 52 | |||||
| 53 | Total Program inpatient operating cost excluding capital related, nonphysician anesthetist, and medical education costs (line 49 minus line 52) | ### | 53 | |||||
| TARGET AMOUNT AND LIMIT COMPUTATION | ||||||||
| 54 | Program discharges | 54 | ||||||
| 55 | Target amount per discharge | 55 | ||||||
| 55.01 | Permanent adjustment amount per discharge | 55.01 | ||||||
| 55.02 | Adjustment amount per discharge (contractor use only) | 55.02 | ||||||
| 55.03 | CAR T-cell amount paid as an interim payment | 55.03 | ||||||
| 56 | Target amount (line 54 x sum of lines 55, 55.01, 55.02 and 55.03) | 56 | ||||||
| 57 | Difference between adjusted inpatient operating cost and target amount (line 56 minus line 53) | 57 | ||||||
| 58 | Bonus payment (see instructions) | 58 | ||||||
| 59 | Trended costs (lesser of line 53 ÷ line 54, or line 55 from the cost reporting period ending 1996, updated and compounded by the market basket) | 59 | ||||||
| 60 | Expected costs (lesser of line 53 ÷ line 54, or line 55 from prior year cost report, updated by the market basket) | 60 | ||||||
| 61 | Continuous improvement bonus payment (if line 53 ÷ line 54 is less than the lowest of lines 55 plus 55.01, or line 59, or line 60, enter the lesser of 50% of the | 61 | ||||||
| 62 | Relief payment (see instructions) | 62 | ||||||
| 63 | Allowable Inpatient cost plus incentive payment (see instructions) | 63 | ||||||
| PROGRAM INPATIENT ROUTINE SWING BED COST | ||||||||
| 64 | Medicare swing-bed SNF inpatient routine costs through December 31 of the cost reporting period (see instructions) (title XVIII only) | 64 | ||||||
| 65 | Medicare swing-bed SNF inpatient routine costs after December 31 of the cost reporting period (see instructions) (title XVIII only) | 65 | ||||||
| 66 | Total Medicare swing-bed SNF inpatient routine costs (line 64 plus line 65) (title XVIII only; for CAH, see instructions.) | 66 | ||||||
| 67 | Title V or XIX swing-bed NF inpatient routine costs through December 31 of the cost reporting period (line 12 x line 19) | 67 | ||||||
| 68 | Title V or XIX swing-bed NF inpatient routine costs after December 31 of the cost reporting period (line 13 x line 20) | 68 | ||||||
| 69 | Total title V or XIX swing-bed NF inpatient routine costs (line 67 + line 68) | 69 | ||||||
| FORM CMS-2552-10 (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4025.2) | ||||||||
| 07-23 | Rev. 21 | |||||||