Worksheet E-4
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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]
The data in this report have been replaced because you do not own it or are not logged in.
| DIRECT GRADUATE MEDICAL EDUCATION (GME) & ESRD OUTPATIENT DIRECT MEDICAL EDUCATION COSTS | Provider CCN: 420004 | PERIOD: FROM 07/01/2021 TO 06/30/2022 |
WORKSHEET E-4 | |||
| Medicare -Title XVIII - Hospital | ||||||
| COMPUTATION OF TOTAL DIRECT GME AMOUNT | ||||||
| 1 | Unweighted resident FTE count for allopathic and osteopathic programs for cost reporting periods ending on or before December 31, 1996 | ### | 1 | |||
| 1.01 | FTE cap adjustment under §131 of the CAA 2021 (see instructions) ) | 1.01 | ||||
| 2 | Unweighted FTE resident cap add-on for new programs per 42 CFR 413.79(e)(see instructions) | 2 | ||||
| 2.26 | Rural track program FTE cap limitation adjustment after the cap-building window closed under §127 of the CAA 2021 (see instructions) | 2.26 | ||||
| 3 | Amount of reduction to Direct GME cap under §422 of MMA | 3 | ||||
| 3.01 | Direct GME cap reduction amount under ACA §5503 in accordance with 42 CFR §413.79 (m). (see instructions for cost reporting periods straddling 7/1/2011) | 3.01 | ||||
| 3.02 | Adjustment (increase or decrease) to the hospital’s rural track FTE limitation(s) for rural track programs with a rural track Medicare GME affiliation agreement in accordance with 413.75(b) and 87 FR 49075 (August 10, 2022) (see instructions) | 3.02 | ||||
| 4 | Adjustment (plus or minus) to the FTE cap for allopathic and osteopathic programs due to a Medicare GME affiliation agreement (42 CFR §413.75(b) and § 413.79 (f)) | 4 | ||||
| 4.01 | ACA § 5503 increase to the Direct GME FTE Cap (see instructions for cost reporting periods straddling 7/1/2011) | 4.01 | ||||
| 4.02 | ACA §5506 number of additional direct GME FTE cap slots (see instructions for cost reporting periods straddling 7/1/2011) | ### | 4.02 | |||
| 4.21 | The amount of increase if the hospital was awarded FTE cap slots under §126 of the CAA 2021 (see instructions) | 4.21 | ||||
| 5 | FTE adjusted cap (line 1 plus and 1.01, plus line 2, plus lines 2.26 through 2.49, minus lines 3 and 3.01, plus or minus line 3.02, plus or minus line 4, plus lines 4.01 through 4.27 | ### | 5 | |||
| 6 | Unweighted resident FTE count for allopathic and osteopathic programs for the current year from your records (see instructions) | ### | 6 | |||
| 7 | Enter the lesser of line 5 or line 6 | ### | 7 | |||
| Primary Care | Other | Total | ||||
| 1 | 2 | 3 | ||||
| 8 | Weighted FTE count for physicians in an allopathic and osteopathic program for the current year | ### | ### | ### | 8 | |
| 9 | If line 6 is less than 5 enter the amount from line 8, otherwise multiply line 8 times the result of line 5 divided by the amount on line 6. For cost reporting periods beginning on or after October 1, 2022, or if Worksheet S-2, Part I, line 68, is "Y", see instructions. | ### | ### | ### | 9 | |
| 10 | Weighted dental and podiatric resident FTE count for the current year | ### | 10 | |||
| 10.01 | Unweighted dental and podiatric resident FTE count for the current year | ### | 10.01 | |||
| 11 | Total weighted FTE count | ### | ### | 11 | ||
| 12 | Total weighted resident FTE count for the prior cost reporting year (see instructions) | ### | ### | 12 | ||
| 13 | Total weighted resident FTE count for the penultimate cost reporting year (see instr.) | ### | ### | 13 | ||
| 14 | Rolling average FTE count (sum of lines 11 through 13 divided by 3) | ### | ### | 14 | ||
| 15 | Adjustment for residents in initial years of new programs | 15 | ||||
| 15.01 | Unweighted adjustment for residents in initial years of new programs | 15.01 | ||||
| 16 | Adjustment for residents displaced by program or hospital closure | 16 | ||||
| 16.01 | Unweighted adjustment for residents displaced by program or hospital closure | 16.01 | ||||
| 17 | Adjusted rolling average FTE count | ### | ### | 17 | ||
| 18 | Per resident amount | ### | ### | 18 | ||
| 18.01 | Per resident amount under §131 of the CAA 2021 | 18.01 | ||||
| 19 | Approved amount for resident costs | ### | ### | ### | 19 | |
| 1 | ||||||
| 20 | Additional unweighted allopathic and osteopathic direct GME FTE resident cap slots received under 42 §413.79(c )(4) | ### | 20 | |||
| 21 | Direct GME FTE unweighted resident count over cap (see instructions) | ### | 21 | |||
| 22 | Allowable additional direct GME FTE resident count (see instructions) | ### | 22 | |||
| 23 | Enter the locality adjustment national average per resident amount (see instructions) | ### | 23 | |||
| 24 | Multiply line 22 time line 23 | ### | 24 | |||
| 25 | Total direct GME amount (sum of lines 19 and 24) | ### | 25 | |||
| COMPUTATION OF PROGRAM PATIENT LOAD | Inpatient Part A | Managed Care Prior to 1/1 | Managed Care On or After 1/1 | Total | ||
| 1 | 2 | 2.01 | 3 | |||
| 26 | Inpatient days (see instructions) | ### | ### | ### | 26 | |
| 27 | Total inpatient days (see instructions) | ### | ### | ### | 27 | |
| 28 | Ratio of inpatient days to total inpatient days | ### | ### | ### | 28 | |
| 29 | Program direct GME amount | ### | ### | ### | ### | 29 |
| 29.01 | Percent reduction for MA DGME | ### | ### | 29.01 | ||
| 30 | Reduction for direct GME payments for Medicare Advantage | ### | ### | ### | 30 | |
| 31 | Net Program direct GME amount | ### | 31 | |||
| DIRECT MEDICAL EDUCATION COSTS FOR ESRD COMPOSITE RATE - TITLE XVIII ONLY (NURSING PROGRAM AND PARAMEDICAL EDUCATION COSTS) | ||||||
| 1 | ||||||
| 32 | Renal dialysis direct medical education costs (from Wkst. B, Pt. I, sum of col. 20 and 23, lines 74 and 94) | 32 | ||||
| 33 | Renal dialysis and home dialysis total charges (Wkst. C, Pt. I, col. 8, sum of lines 74 and 94) | ### | 33 | |||
| 34 | Ratio of direct medical education costs to total charges (line 32 ÷ line 33) | 34 | ||||
| 35 | Medicare outpatient ESRD charges (see instructions) | 35 | ||||
| 36 | Medicare outpatient ESRD direct medical education costs (line 34 x line 35) | 36 | ||||
| APPORTIONMENT OF MEDICARE REASONABLE COST OF GME | ||||||
| Part A Reasonable Cost | ||||||
| 37 | Reasonable cost (see instructions) | ### | 37 | |||
| 38 | Organ acquisition costs (Wkst. D-4, Pt. III, col. 1, line 69) | ### | 38 | |||
| 39 | Cost of physicians' services in a teaching hospital (see instructions) | 39 | ||||
| 40 | Primary payer payments (see instructions) | ### | 40 | |||
| 41 | Total Part A reasonable cost (sum of lines 37 through 39 minus line 40) | ### | 41 | |||
| Part B Reasonable Cost | ||||||
| 42 | Reasonable cost (see instructions) | ### | 42 | |||
| 43 | Primary payer payments (see instructions) | ### | 43 | |||
| 44 | Total Part B reasonable cost (line 42 minus line 43) | ### | 44 | |||
| 45 | Total reasonable cost (sum of lines 41 and 44) | ### | 45 | |||
| 46 | Ratio of Part A reasonable cost to total reasonable cost (line 41 ÷ line 45) | ### | 46 | |||
| 47 | Ratio of Part B reasonable cost to total reasonable cost (line 44 ÷ line 45) | ### | 47 | |||
| ALLOCATION OF MEDICARE DIRECT GME COSTS BETWEEN PART A AND PART B | ||||||
| 48 | Total program GME payment (line 31) | ### | 48 | |||
| 49 | Part A Medicare GME payment (line 46 x 48)(Title XVIII only) (see instructions) | ### | 49 | |||
| 50 | Part B Medicare GME payment (line 47 x 48) (title XVIII only) (see instructions) | ### | 50 | |||
| FORM CMS-2552-10 (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, § 4034) | ||||||
| 07-23 | Rev. 21 | |||||