Worksheet L Parts I, II & III
Return to Profile
Filing History
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.
| CALCULATION OF CAPITAL PAYMENT | Provider CCN: 420004 | PERIOD: FROM 07/01/2021 TO 06/30/2022 |
WORKSHEET L | |||||
| Medicare -Title XVIII - Hospital | ||||||||
| PART I - FULLY PROSPECTIVE METHOD | ||||||||
| CAPITAL FEDERAL AMOUNT | ||||||||
| 1 | 1.01 | |||||||
| 1 | Capital DRG other than outlier | ### | 1 | |||||
| 1.01 | Model 4 BPCI Capital DRG other than outlier | 1.01 | ||||||
| 2 | Capital DRG outlier payments | ### | 2 | |||||
| 2.01 | Model 4 BPCI Capital DRG outlier payments | 2.01 | ||||||
| 3 | Total inpatient days divided by number of days in the cost reporting period (see instructions) | ### | 3 | |||||
| 4 | Number of interns & residents (see instructions) | ### | 4 | |||||
| 5 | Indirect medical education percentage (see instructions) | ### | 5 | |||||
| 6 | Indirect medical education adjustment (see instructions)) | ### | 6 | |||||
| 7 | Percentage of SSI recipient patient days to Medicare Part A patient days (Worksheet E, Part A line 30) (see instructions) | 7 | ||||||
| 8 | Percentage of Medicaid patient days to total days (see instructions) | 8 | ||||||
| 9 | Sum of lines 7 and 8 | 9 | ||||||
| 10 | Allowable disproportionate share percentage (see instructions) | 10 | ||||||
| 11 | Disproportionate share adjustment (see instructions) | 11 | ||||||
| 12 | Total prospective capital payments (see instructions) | ### | 12 | |||||
| PART II - PAYMENT UNDER REASONABLE COST | ||||||||
| 1 | Program inpatient routine capital cost (see instructions) | 1 | ||||||
| 2 | Program inpatient ancillary capital cost (see instructions) | 2 | ||||||
| 3 | Total inpatient program capital cost (line 1 plus line 2) | 3 | ||||||
| 4 | Capital cost payment factor (see instructions) | 4 | ||||||
| 5 | Total inpatient program capital cost (line 3 x line 4) | 5 | ||||||
| PART III - COMPUTATION OF EXCEPTION PAYMENTS | ||||||||
| 1 | Program inpatient capital costs (see instructions) | 1 | ||||||
| 2 | Program inpatient capital costs for extraordinary circumstances (see instructions) | 2 | ||||||
| 3 | Net program inpatient capital costs (line 1 minus line 2) | 3 | ||||||
| 4 | Applicable exception percentage (see instructions) | 4 | ||||||
| 5 | Capital cost for comparison to payments (line 3 x line 4) | 5 | ||||||
| 6 | Percentage adjustment for extraordinary circumstances (see instructions) | 6 | ||||||
| 7 | Adjustment to capital minimum payment level for extraordinary circumstances (line 2 x line 6) | 7 | ||||||
| 8 | Capital minimum payment level (line 5 plus line 7) | 8 | ||||||
| 9 | Current year capital payments (from Part I, line 12 as applicable) | 9 | ||||||
| 10 | Current year comparison of capital minimum payment level to capital payments (line 8 less line 9) | 10 | ||||||
| 11 | Carryover of accumulated capital minimum payment level over capital payment (from prior year Worksheet L, Part III, line 14) | 11 | ||||||
| 12 | Net comparison of capital minimum payment level to capital payments (line 10 plus line 11) | 12 | ||||||
| 13 | Current year exception payment (if line 12 is positive, enter the amount on this line) | 13 | ||||||
| 14 | Carryover of accumulated capital minimum payment level over capital payment for the following period (if line 12 is negative, enter the amount on this line) | 14 | ||||||
| 15 | Current year allowable operating and capital payment (see instructions) | 15 | ||||||
| 16 | Current year operating and capital costs (see instructions) | 16 | ||||||
| 17 | Current year exception offset amount (see instructions) | 17 | ||||||
| FORM CMS-2552-10 (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4064.1 - 4064.3) | ||||||||
| 07-23 | Rev. 21 | |||||||