Worksheet S-2 Part II

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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]
This is a prior filing for this period.

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08-11 FORM CMS-2552-10 4090 (Cont.)
HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX REIMBURSEMENT QUESTIONNAIRE Provider CCN: 420004
PERIOD:
FROM 07/01/2021
TO 06/30/2022
 WORKSHEET S-2 Part II
PART II - HOSPITAL AND HOSPITAL HEALTHCARE COMPLEX REIMBURSEMENT QUESTIONNAIRE
General Instruction:
Enter Y for all YES responses. Enter N for all NO responses.
Enter all dates in the mm/dd/yyyy format.
COMPLETED BY ALL HOSPITALS
  Y/N Date    
Provider Organization and Operation 1 2  
1 Has the provider changed ownership immediately prior to the beginning of the cost reporting period? If yes, enter the date of the change in column 2. (see instructions) ###   1
  Y/N Date V/I  
1 2 3
2 Has the provider terminated participation in the Medicare Program? If yes, enter in column 2 the date of termination and in column 3, "V" for voluntary or "I" for involuntary. ### 2
3 Is the provider involved in business transactions, including management contracts, with individuals or entities (e.g., chain home offices, drug or medical supply companies) that are related to the provider or its officers, medical staff, management personnel, or members of the board of directors through ownership, control, or family and other similar relationships? (see instructions) ###     3
  Y/N Type Date  
Financial Data and Reports 1 2 3
4 Column 1: Were the financial statements prepared by a Certified Public Accountant? Column 2: If yes, enter "A" for Audited, "C" for Compiled, or "R" for Reviewed. Submit complete copy or enter date available in column 3. (see instructions) If no, see instructions. ### ### ### 4
5 Are the cost report total expenses and total revenues different from those on the filed financial statements? If yes, submit reconciliation. ###     5
  Y/N Y/N  
Approved Educational Activities 1 2
6 Column 1: Are costs claimed for a nursing program? Column 2: If yes, is the provider is the legal operator of the program? ### 6
7 Are costs claimed for allied health programs? If yes, see instructions. ###   7
8 Were nursing programs and/or allied health programs approved and/or renewed during the cost reporting period? If yes, see instructions. ###   8
9 Are costs claimed for Interns and Residents in approved GME programs in the current cost report? If yes, see instructions. ###   9
10 Was an approved Intern and Resident GME program initiated or renewed in the current cost reporting period? If yes, see instructions. ###   10
11 Are GME costs directly assigned to cost centers other than I & R in an Approved Teaching Program on Worksheet A? If yes, see instructions. ###   11
Bad Debts Y/N  
12 Is the provider seeking reimbursement for bad debts? If yes, see instructions. ### 12
13 If line 12 is yes, did the provider's bad debt collection policy change during this cost reporting period? If yes, submit copy. ### 13
14 If line 12 is yes, were patient deductibles and/or coinsurance amounts waived? If yes, see instructions ### 14
Bed Complement
15 Did total beds available change from the prior cost reporting period? If yes, see instructions. ### 15
  Part A Part B  
Y/N Date Y/N Date
PS&R Report Data 1 2 3 4
16 Was the cost report prepared using the PS&R Report only? If either column 1 or 3 is yes, enter the paid-through date of the PS&R Report used in columns 2 and 4. (see instructions) ### ### ### ### 16
17 Was the cost report prepared using the PS&R Report for totals and the provider's records for allocation? If either column 1 or 3 is yes, enter the paid-through date in columns 2 and 4. (see instructions) ### ### 17
18 If line 16 or 17 is yes, were adjustments made to PS&R Report data for additional claims that have been billed but are not included on the PS&R Report used to file the cost report? If yes, see instructions. ###   ###   18
19 If line 16 or 17 is yes, were adjustments made to PS&R Report data for corrections of other PS&R Report information? If yes, see instructions. ###   ###   19
20 If line 16 or 17 is yes, were adjustments made to PS&R Report data for Other? Describe the other adjustments: ANCILLARY CHGS IN CLINICS (LINE 90) ###   ###   20
21 Was the cost report prepared only using the provider's records? If yes, see instructions. ###   ###   21
COMPLETED BY COST REIMBURSED AND TEFRA HOSPITALS ONLY (EXCEPT CHILDRENS HOSPITALS)
Capital Related Cost
22 Have assets been relifed for Medicare purposes? If yes, see instructions. 22
23 Have changes occurred in the Medicare depreciation expense due to appraisals made during the cost reporting period? If yes, see instructions. 23
24 Were new leases and/or amendments to existing leases entered into during this cost reporting period? If yes, see instructions. 24
25 Have there been new capitalized leases entered into during the cost reporting period? If yes, see instructions. 25
26 Were assets subject to Sec.2314 of DEFRA acquired during the cost reporting period? If yes, see instructions. 26
27 Has the provider's capitalization policy changed during the cost reporting period? If yes, see instructions. 27
Interest Expense
28 Were new loans, mortgage agreements or letters of credit entered into during the cost reporting period? If yes, see instructions. 28
29 Did the provider have a funded depreciation account and/or bond funds (Debt Service Reserve Fund) treated as a funded depreciation account? If yes, see instructions. 29
30 Has existing debt been replaced prior to its scheduled maturity with new debt? If yes, see instructions. 30
31 Has debt been recalled before scheduled maturity without issuance of new debt? If yes, see instructions. 31
Purchased Services
32 Have changes or new agreements occurred in patient care services furnished through contractual arrangements with suppliers of services? If yes, see instructions. 32
33 If line 32 is yes, were the requirements of Sec. 2135.2 applied pertaining to competitive bidding? If no, see instructions. 33
Provider-Based Physicians
34 Were services furnished at the provider facility under an arrangement with provider-based physicians? If "Y" see instructions. 34
35 If line 34 is yes, were there new agreements or amended existing agreements with the provider-based physicians during the cost reporting period? If yes, see instructions.   35
  Y/N Date  
Home Office Costs 1 2
36 Are home office costs claimed on the cost report?   36
37 If line 36 is yes, has a home office cost statement been prepared by the home office? If yes, see instructions.   37
38 If line 36 is yes, was the fiscal year end of the home office different from that of the provider? If yes, enter in column 2 the fiscal year end of the home office. 38
39 If line 36 is yes, did the provider render services to other chain components? If yes, see instructions.   39
40 If line 36 is yes, did the provider render services to the home office? If yes, see instructions.   40
Cost Report Preparer Contact Information
41 First Name: * Last Name: * Title: * 41
42 Employer: * 42
43 Phone number: * Email Address: * 43
FORM CMS-2552-10 (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 4004.2)
12-22 Rev. 18
 
* Cost Report Preparer Contact Information has been redacted by CMS