Worksheet S-3 Parts II & III
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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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| HOSPITAL WAGE INDEX INFORMATION | Provider CCN: 420004 | PERIOD: FROM 07/01/2021 TO 06/30/2022 |
WORKSHEET S-3 PART II and III | |||||
| Part II - Wage Data | ||||||||
| Wkst. A Line Number | Amount Reported | Reclassification of Salaries (from Wkst. A-6) | Adjusted Salaries (column ± column 3) | Paid Hours Related to Salaries in column 4 | Average Hourly Wage (column 4 ÷ column 5) | |||
| 1 | 2 | 3 | 4 | 5 | 6 | |||
| SALARIES | ||||||||
| 1 | Total salaries (see instructions) | ### | ### | ### | ### | ### | ### | 1 |
| 2 | Non-physician anesthetist Part A | 2 | ||||||
| 3 | Non-physician anesthetist Part B | ### | ### | ### | ### | 3 | ||
| 4 | Physician-Part A - Administrative | 4 | ||||||
| 4.01 | Physician-Part A - Teaching | 4.01 | ||||||
| 5 | Physician and Non Physician -Part B | 5 | ||||||
| 6 | Non-physician-Part B for hospital-based RHC and FQHC services | 6 | ||||||
| 7 | Interns & residents (in an approved program) | ### | ### | ### | ### | ### | 7 | |
| 7.01 | Contracted Interns & residents (in an approved program) | 7.01 | ||||||
| 8 | Home office and/or related organization personnel | ### | ### | ### | ### | 8 | ||
| 9 | SNF | ### | 9 | |||||
| 10 | Excluded area salaries (see instructions) | ### | ### | ### | ### | ### | 10 | |
| OTHER WAGES AND RELATED COSTS | ||||||||
| 11 | Contract labor: Direct Patient Care | ### ### |
### ### |
### ### |
### ### |
11 | ||
| 12 | Contract labor: Top level management and other management and administrative services | ### ### |
### ### |
### ### |
### ### |
12 | ||
| 13 | Contract labor: Physician-Part A | ### ### |
### ### |
### ### |
### ### |
13 | ||
| 14 | Home office and/or related organization salaries and wage-related costs | 14 | ||||||
| 14.01 | Home office salaries | ### | ### | ### | ### | 14.01 | ||
| 14.02 | Related organization salaries | 14.02 | ||||||
| 15 | Home office: Physician Part A | 15 | ||||||
| 15.01 | Home office Physicians Part A - Administrative | 15.01 | ||||||
| 15.02 | Home office Contract Physicians Part A - Administrative | 15.02 | ||||||
| 16 | Home office & Contract Physicians Part A - Teaching | 16 | ||||||
| 16.01 | Home office Physicians Part A - Teaching | 16.01 | ||||||
| 16.02 | Home office contract Physicians Part A - Teaching | 16.02 | ||||||
| WAGE-RELATED COSTS | ||||||||
| 17 | Wage-related costs (core) (see instructions) | ### ### |
### ### |
17 | ||||
| 18 | Wage-related costs (other) (see instructions) | 18 | ||||||
| 19 | Excluded areas | ### ### |
### ### |
19 | ||||
| 20 | Non-physician anesthetist Part A | 20 | ||||||
| 21 | Non-physician anesthetist Part B | ### ### |
### ### |
21 | ||||
| 22 | Physician Part A - Administrative | 22 | ||||||
| 22.01 | Physician Part A - Teaching | 22.01 | ||||||
| 23 | Physician Part B | 23 | ||||||
| 24 | Wage-related costs (RHC/FQHC) | 24 | ||||||
| 25 | Interns & residents (in an approved program) | ### ### |
### ### |
25 | ||||
| 25.50 | Home office wage-related (core) | ### | ### | 25.50 | ||||
| 25.51 | Related organization wage-related (core) | 25.51 | ||||||
| 25.52 | Home office: Physician Part A - Administrative - wage-related (core) | 25.52 | ||||||
| 25.53 | Home office: Physicians Part A - Teaching - wage-related (core) | 25.53 | ||||||
| OVERHEAD COSTS - DIRECT SALARIES | ||||||||
| 26 | Employee Benefits Department | ### | 26 | |||||
| 27 | Administrative & General | ### | ### | ### | ### | ### | ### | 27 |
| 28 | Administrative & General under contract (see instructions) | ### ### |
### ### |
### ### |
### ### |
28 | ||
| 29 | Maintenance & Repairs | ### | 29 | |||||
| 30 | Operation of Plant | ### | ### | ### | ### | ### | 30 | |
| 31 | Laundry & Linen Service | ### | 31 | |||||
| 32 | Housekeeping | ### | ### | ### | ### | ### | 32 | |
| 33 | Housekeeping under contract (see instructions) | ### | ### | ### | ### | 33 | ||
| 34 | Dietary | ### | ### | ### | ### | ### | ### | 34 |
| 35 | Dietary under contract (see instructions) | ### | ### | ### | ### | 35 | ||
| 36 | Cafeteria | ### | ### | ### | ### | ### | 36 | |
| 37 | Maintenance of Personnel | ### | 37 | |||||
| 38 | Nursing Administration | ### | ### | ### | ### | ### | ### | 38 |
| 39 | Central Services and Supply | ### | ### | ### | ### | ### | 39 | |
| 40 | Pharmacy | ### | ### | ### | ### | ### | ### | 40 |
| 41 | Medical Records & Medical Records Library | ### | ### | ### | ### | ### | 41 | |
| 42 | Social Service | ### | ### | ### | ### | ### | 42 | |
| 43 | Other General Service | ### | 43 | |||||
| Part III - Hospital Wage Index Summary | ||||||||
| 1 | Net salaries (see instructions) | ### ### |
### | ### ### |
### ### |
### ### |
1 | |
| 2 | Excluded area salaries (see instructions) | ### | ### | ### | ### | ### | 2 | |
| 3 | Subtotal salaries (line 1 minus line 2) | ### ### |
### | ### ### |
### ### |
### ### |
3 | |
| 4 | Subtotal other wages and related costs (see instructions) | ### ### |
### ### |
### ### |
### ### |
4 | ||
| 5 | Subtotal wage-related costs (see instructions) | ### ### |
### ### |
5 | ||||
| 6 | Total (sum of lines 3 through 5) | ### ### |
### | ### ### |
### ### |
### ### |
6 | |
| 7 | Total overhead cost (see instructions) | ### ### |
### | ### ### |
### ### |
### ### |
7 | |
| FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4005.2 - 4005.3) | ||||||||
| 12-22 | Rev. 18 | |||||||