Worksheet E Part B
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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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| CALCULATION OF REIMBURSEMENT SETTLEMENT | Provider CCN: 420004 | PERIOD: FROM 07/01/2021 TO 06/30/2022 |
WORKSHEET E, PART B | |||
| - Select other programs and provider types available | ||||||
| PART B - MEDICAL AND OTHER HEALTH SERVICES | ||||||
| 1 | 1.01 | |||||
| 1 | Medical and other services (see instructions) | ### | 1 | |||
| 2 | Medical and other services reimbursed under OPPS (see instructions). | ### | 2 | |||
| 3 | OPPS payments | ### | 3 | |||
| 4 | Outlier payment (see instructions) | ### | 4 | |||
| 4.01 | Outlier reconciliation amount (see instructions) | 4.01 | ||||
| 5 | Enter the hospital specific payment to cost ratio (see instructions) | 5 | ||||
| 6 | Line 2 times line 5 | 6 | ||||
| 7 | Sum of lines 3, 4 and line 4.01 divided by line 6 | 7 | ||||
| 8 | Transitional corridor payment (see instructions) | 8 | ||||
| 9 | Ancillary service other pass through costs including REH direct graduate medical education costs from Wkst. D, Pt. IV, col. 13, line 200 | ### | 9 | |||
| 10 | Organ acquisition | 10 | ||||
| 11 | Total cost (sum of lines 1 and 10) (see instructions) | ### | 11 | |||
| 1 | ||||||
| COMPUTATION OF LESSER OF COST OR CHARGES | ||||||
| Reasonable charges | ||||||
| 12 | Ancillary service charges | ### | 12 | |||
| 13 | Organ acquisition charges (from Wkst. D-4, Part III, col. 4, line 69) | 13 | ||||
| 14 | Total reasonable charges (sum of lines 12 and 13) | ### | 14 | |||
| Customary charges | ||||||
| 15 | Aggregate amount actually collected from patients liable for payment for services on a charge basis | 15 | ||||
| 16 | Amounts that would have been realized from patients liable for payment for services on a charge basis had such payment been made in accordance with 42 CFR 413.13(e) | 16 | ||||
| 17 | Ratio of line 15 to line 16 (not to exceed 1.000000) | 17 | ||||
| 18 | Total customary charges (see instructions) | ### | 18 | |||
| 19 | Excess of customary charges over reasonable cost (complete only if line 18 exceeds line 11) (see instructions) | ### | 19 | |||
| 20 | Excess of reasonable cost over customary charges (complete only if line 11 exceeds line 18) (see instructions) | 20 | ||||
| 21 | Lesser of cost or charges (see instructions) | ### | 21 | |||
| 22 | Interns and residents (see instructions) | 22 | ||||
| 23 | Cost of physicians' services in a teaching hospital (see instructions) | 23 | ||||
| 24 | Total prospective payment (sum of lines 3, 4,4.01, 8, and 9) | ### | 24 | |||
| COMPUTATION OF REIMBURSEMENT SETTLEMENT | ||||||
| 25 | Deductibles and coinsurance amounts (see instructions) | ### | 25 | |||
| 26 | Deductibles and Coinsurance amounts relating to amount on line 24 (see instructions) | ### | 26 | |||
| 27 | Subtotal {(lines 21 and 24 minus the sum of lines 25 and 26) plus the sum of lines 22 and 23} (see instructions) | ### | 27 | |||
| 28 | Direct graduate medical education payments (from Wkst. E-4, line 50) | ### | 28 | |||
| 28.50 | REH facility payment amount (see instructions) | 28.50 | ||||
| 29 | ESRD direct medical education costs (from Wkst. E-4, line 36) | 29 | ||||
| 30 | Subtotal (sum of lines 27 through 29) | ### | 30 | |||
| 31 | Primary payer payments | ### | 31 | |||
| 32 | Subtotal (line 30 minus line 31) | ### | 32 | |||
| ALLOWABLE BAD DEBTS (EXCLUDE BAD DEBTS FOR PROFESSIONAL SERVICES) | ||||||
| 33 | Composite rate ESRD (from Wkst. I-5, line 11) | 33 | ||||
| 34 | Allowable bad debts (see instructions) | ### | 34 | |||
| 35 | Adjusted reimbursable bad debts (see instructions) | ### | 35 | |||
| 36 | Allowable bad debts for dual eligible beneficiaries (see instructions) | ### | 36 | |||
| 37 | Subtotal (see instructions) | ### | 37 | |||
| 38 | MSP-LCC reconciliation amount from PS&R | ### | 38 | |||
| 39 | Other adjustments (specify) (see instructions) | ### | 39 | |||
| 39.98 | Credits for replaced devices.CMS Pub 100-04 Chap 4, §61.3. | 39.98 | ||||
| 39.50 | Pioneer ACO demonstration payment adjustment (see instructions) | 39.50 | ||||
| 39.75 | N95 respirator payment adjustment amount (see instructions) | 39.75 | ||||
| 39.97 | Demonstration payment adjustment amount before sequestration | 39.97 | ||||
| 39.98 | Partial or full credits received from manufacturers for replaced devices (see instructions) | ### | 39.98 | |||
| 39.99 | Recovery of Accelerated depreciation | 39.99 | ||||
| 40 | Subtotal (see instructions) | ### | 40 | |||
| 40.01 | Sequestration adjustment (see instructions) | ### | 40.01 | |||
| 40.02 | Demonstration payment adjustment amount after sequestration | 40.02 | ||||
| 40.03 | Sequestration adjustment-PARHM pass-throughs | 40.03 | ||||
| 41 | Interim payments | ### | 41 | |||
| 41.01 | Interim payments-PARHM | 41.01 | ||||
| 42 | Tentative settlement (for contractors use only) | 42 | ||||
| 42.01 | Tentative settlement-PARHM (for contractors use only) | 42.01 | ||||
| 43 | Balance due provider/program (see instructions) | ### | 43 | |||
| 43.01 | Balance due provider/program-PARHM (see instructions) | 43.01 | ||||
| 44 | Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1,115.2 | 44 | ||||
| TO BE COMPLETED BY CONTRACTOR | ||||||
| 90 | Original outlier amount (see instructions) | ### | 90 | |||
| 91 | Outlier reconciliation adjustment amount (see instructions) | 91 | ||||
| 92 | The rate used to calculate the Time Value of Money | 92 | ||||
| 93 | Time Value of Money (see instructions) | 93 | ||||
| 94 | Total (sum of lines 91 and 93) | 94 | ||||
| FORM CMS-2552-10 (02-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, §4030.2) | ||||||
| 02-24 | Rev. 22 | |||||