Worksheet E-3 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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CALCULATION OF REIMBURSEMENT SETTLEMENT Provider CCN: 420004
PERIOD:
FROM 07/01/2021
TO 06/30/2022
 WORKSHEET E-3, PART II
Medicare -Title XVIII - Psych Subprovider
PART II - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER IPF PPS
1 Net Federal IPF PPS payment (excluding outlier, ECT, and medical education payments) ### 1
2 Net IPF PPS Outlier payment ### 2
3 Net IPF PPS ECT payment ### 3
4 Unweighted intern and resident FTE count in the most recent cost report filed on or before November 15, 2004 (see instructions) ### 4
4.01 Cap increases for the unweighted intern and resident FTE count for residents that were displaced by program or hospital closure, that would not be counted without a temporary cap adjustment under 42 CFR § 412.424(d)(1)(iii)(F)(1) or (2) (see instructions) 4.01
5 New teaching program adjustment (see instructions) 5
6 Current year unweighted FTE count of I&R excluding FTEs in the new program growth period of a new teaching program (see instructions) ### 6
7 Current year unweighted I&R FTE count for residents within the new program growth period of a new teaching program (see instructions) 7
8 Intern and resident count for IPF PPS medical education adjustment (see instructions) ### 8
9 Average daily census (see instructions) ### 9
10 Teaching Adjustment Factor {((1 + (line 8/line 9)) raised to the power of .5150 -1}. ### 10
11 Teaching Adjustment (line 1 multiplied by line 10). ### 11
12 Adjusted Net IPF PPS Payments (sum of lines 1, 2, 3, and 11) ### 12
13 Nursing and allied health managed care payment (see instruction) 13
14 Organ acquisition DO NOT USE THIS LINE 14
15 Cost of physicians' services in a teaching hospital (see instructions) 15
16 Subtotal (see instructions) ### 16
17 Primary payer payments 17
18 Subtotal (line 16 less line 17). ### 18
19 Deductibles ### 19
20 Subtotal (line 18 minus line 19) ### 20
21 Coinsurance ### 21
22 Subtotal (line 20 minus line 21) ### 22
23 Allowable bad debts (exclude bad debts for professional services) (see instructions) ### 23
24 Adjusted reimbursable bad debts (see instructions) ### 24
25 Allowable bad debts for dual eligible beneficiaries (see instructions) ### 25
26 Subtotal (sum of lines 22 and 24) ### 26
27 Direct graduate medical education payments (from Wkst. E-4, line 49) (For freestanding IPF only) (see instructions) 27
28 Other pass through costs (see instructions) ### 28
29 Outlier payments reconciliation 29
30 Other adjustments (specify) (see instructions) __ 30
30.50 Pioneer ACO demonstration payment adjustment (see instructions) 30.50
30.99 Demonstration payment adjustment amount before sequestration 30.99
31 Total amount payable to the provider (see instructions) ### 31
31.01 Sequestration adjustment (see instructions) ### 31.01
31.02 Demonstration payment adjustment amount after sequestration 31.02
32 Interim payments ### 32
33 Tentative settlement (for contractor use only) 33
34 Balance due provider/program line (31 minus lines 31.01, 31.02, 32, and 33) ### 34
35 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2 35
TO BE COMPLETED BY CONTRACTOR
50 Original outlier amount from Worksheet E-3, Part II, line 2 (see instructions) ### 50
51 Outlier reconciliation adjustment amount (see instructions) 51
52 The rate used to calculate the Time Value of Money (see instructions) 52
53 Time Value of Money (see instructions) 53
FORM CMS-2552-10 (04/2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4033.2)
04-20     Rev. 16