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1272. FORM HCFA-2552-83 11-83

1272. SUPPLEMENTAL WORKSHEET E-3 -- APPLICATION OF THE LIMITATION ON OUTPATIENT RENAL DIALYSIS COSTS


The purpose of this worksheet is to apply the limitations for the cost of outpatient maintenance renal dialysis services (including both hemodialysis and peritoneal dialysis) and training self dialysis sessions. The appropriate box at the top of the worksheet should be checked for the applicable program.
This supplemental worksheet will not be applicable for these services furnished on or after 8/1/83, the effective date of the regulations for the composite rate.
The limitation is not applied to providers that do not regularly furnish outpatient routine maintenance dialysis services. Providers that furnish outpatient renal dialysis services on an emergency basis only, or infrequently as a maintenance service, should not complete this worksheet. Also, the limitation does not apply to dialysis services furnished to inpatients who are institutionalized for a medical reason other than to receive maintenance dialysis (e.g., tonsillectomy).
Providers which furnish hemodialysis and peritoneal dialysis may be subject to a separate limit for each of the two types of service. If hemodialysis is usually furnished in six-hour sessions three times a week and peritoneal dialysis is furnished in ten-hour sessions two times a week, separate limits may be appropriate. However, if both types of service are furnished in comparable time frames and frequencies, one limit may be applicable to both services. In this latter situation, both types of services should be entered in column l.
Columns 2-4 are provided for maintenance peritoneal dialysis. Column 2 is used when the dialysis session furnished is less than 20 hours. Column 3 is used when the session is 20-29 hours and column 4 is used when the session exceeds 29 hours.
LINE DESCRIPTIONS
Line 1--Enter the applicable charges for services furnished before August 1, 1983.
Line 3--For each type of outpatient dialysis service, enter from the provider records the total program charges for the renal dialysis related routine laboratory services performed before August 1, 1983 in the hospital's laboratory or in another laboratory under arrangements. These routine laboratory services were considered in the determination of the interim renal dialysis screens which were furnished to the provider by the intermediary.
NOTE: If all of the related routine laboratory services are performed by a certified independent or another laboratory, and such other laboratory bills its Part B carrier or its intermediary directly for such services, lines 3 and 4 need not be completed for Medicare. In this situation, the interim renal dialysis screen should have been adjusted accordingly.
Line 9--Enter the applicable limitation. In all cases, the cost will not include the routine laboratory cost when it is not necessary to complete lines 3 and 4 in accordance with the instructions. Unless a different cost limitation has been approved by the Department of Health and Human Services, the applicable limitations are:

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11-83 FORM HCFA-2552-83 1272. (Cont.)



Summary of Facilty Payment Screens


Treatment

Condition


Physicians on

Alternative Method(1)

Physicians Not On

Alternative

Method

Maintenance dialysis

with routine laboratory(2) 138 150


Maintenance dialysis

without routine laboratory(2) 133 145


Self-care dialysis training

with routine laboratory 158 170


Self-care dialysis training

without routine laboratory 153 165


Extended peritoneal dialysis

(20-29 hours duration)

with routine laboratory(3) 207 225
Extended peritoneal dialysis

(20-29 hours duration)

without routine laboratory(3) 199.50 217.50
Extended peritoneal dialysis

(30 hours or more)

with routine laboratory(4) 414 450
Extended peritoneal dialysis

(30 hours or more)

without routine laboratory(4) 399 435
Self-care intermittent

peritoneal dialysis training

with routine laboratory 158 170
Self-care intermittent

peritoneal dialysis training

without routine laboratory 153 165
Self-care continuous ambulatory

peritoneal dialysis training

with routine laboratory 150 162
Self-care continuous ambulatory

peritoneal dialysis training

without routine laboratory 145 157
(1) The alternative reimbursement method (ARM) for physician services is described in §90l.3 of the Provider Reimbursement Manual, Part II (HCFA-Pub. 15-II).

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1272 (Cont.) FORM HCFA-2552-83 11-83

(2)These rates apply to maintenance hemodialysis and maintenance intermittent peritoneal dialysis, but not to continuous ambulatory peritoneal dialysis (CAPD). CAPD is a home dialysis maintenance therapy and not an infacility maintenance therapy.


(3)When extended peritoneal dialysis of 20-29 hours duration is needed more frequently than twice a week, additional medical evidence must be submitted to and accepted by the intermediary before additional payment can be made.
(4)When extended peritoneal dialysis of 30 hours or more is needed more frequently than once per week, additional medical evidence must be submitted to and accepted by the intermediary before additional payment can be made.
Line 10--Compute the total cost limitation for each specified type of dialysis service by multiplying the number of sessions on line 8 by the amount on line 9. If more than one limitation for a type of renal dialysis service is applicable during a cost reporting period, the amount of total cost limitation must be computed by taking all unit cost limitations into account to the extent that each limitation was applicable during the cost reporting period by multiplying each unit cost limitation applicable during the cost reporting period by the number of sessions furnished during the period that the limitation was applicable. Providers should add a supporting schedule to the cost report showing this computation.
Line 11--Compute the excess of actual costs over the maximum limitations by subtracting the amount on line 10 from the amount on line 7 in each column. If, in any column, the amount on line 7 is equal to or less than the amount on line 10, enter zero on line ll. Transfer the sum of columns 1 through 5 to Worksheet E, Part II, column 2, line 25.
1274. SUPPLEMENTAL WORKSHEET I-1
1274.1 Supplemental Worksheet I-1, Cost Analysis - Renal Dialysis Department Costs.--This worksheet provides for the analysis of the direct and indirect expenses related to the renal dialysis cost centers, allocation of cost between inpatient and outpatient renal dialysis services, where separate cost centers are not maintained, and the allocation of the cost to the various modes of outpatient dialysis treatment. The ancillary renal dialysis cost center is serviced by the general cost centers and includes all reimbursable cost centers within the provider organization which provide services to the renal dialysis department. The analysis of the cost for the renal dialysis department is obtained, in part, from Worksheets A; B, Part I; C; and D-7.
If the provider's cost reporting period begins before August 1, l983, the effective date of the composite date, the cost report covers a split period. In this situation, part of the provider's reimbursement for outpatient renal dialysis services will be based on cost settlement, and part will be reimbursed under the composite rate reimbursement. The cost of the renal dialysis services rendered before August 1, l983 will be entered on Worksheet E as part of the computation of net cost of covered services, but the cost of renal dialysis services rendered after August 1, 1983 must not be entered on Worksheet E, since the composite rate payment is the total reimbursement due the provider for these services.

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11-83 FORM HCFA-2552-83 1274.1 (Cont.)

A separate copy of this supplemental worksheet must be completed for each of the following:


1. If the provider has reported cost for more than one renal dialysis department, a separate Supplemental Worksheet I must be completed for each department.
2. If the provider has reported cost for home program dialysis separately from the renal dialysis ancillary cost center, i.e., amounts are entered on Worksheet B, Part I, lines 41 and 59, respectively, the provider will be responsible for completing a separate Supple­mental Worksheet I for each such cost center.
3. If the provider has elected the Target Rate Reimbursement for home dialysis services and has reported cost on Worksheet B, Part I, line 59, Home Program Dialysis -Other, the provider will be responsible for completing a separate Supplemental Worksheet I for each such cost center.
NOTE: On or after August 1, 1983, the effective date of the composite rate, Target Rate Reimbursement for home dialysis services is no longer an option available to the provider.
1274.1A Part I - Direct Renal Dialysis Cost Analysis -- This part provides for recording the direct salaries and other direct expenses applicable to the total inpatient and outpatient renal dialysis cost center or outpatient renal dialysis cost center where the provider maintains a separate and distinct outpatient renal dialysis cost center. When the provider maintains more than one renal dialysis cost center or has a separate home program dialysis cost center, the provider must complete a separate Supplemental Worksheet I-l for each cost center. Do not combine the total renal dialysis cost, as listed on Worksheet A, with the home program or Target Reimbursement Rate if listed on Worksheet A, line 59.
COLUMN 1 - SALARIES
LINE DESCRIPTIONS
Lines 2 through 11--Enter on these lines the direct salaries as recorded on the providers accounting records for each classification of employee identified.
Line 13--If the physicians have elected the initial method of reimbursement for their physician supervisory services, enter the amount of the salaries on this line.
Physicians' Supervisory Services--Supervisory services are those physicians' services related to the care of the dialysis patient and his/her need for medical management during maintenance or training dialysis. These services are not one-time, nonroutine services furnished during the dialysis session, e.g., declotting of shunt. Examples of physicians' supervisory services are:
1. Being available to patients and to staff for consultation on the care of the patients;

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1274.1 (Cont.) FORM HCFA-2552-83 11-83

2. Overseeing the performance of dialysis on individual patients including, but not limited to, review of laboratory tests and adjustments of dialysis procedures;


3. Monitoring the patient's medical status and vital signs, including needed adjust­ments in medications;
4. Determining the need for supplies and medications and authorizing them;
5. Reviewing dietary issues and modifying dietary control as needed;
6. Evaluating the appropriateness of the patient's proposed treatment modality;
7. Reviewing psychosocial issues;
8. Making pre- and post-dialysis examinations where medically appropriate; and
9. Repeated insertions of a catheter for patients on maintenance peritoneal dialysis who are not provided an indwelling catheter.
NOTE: There are two methods for reimbursing physicians' supervisory services: (1) the initial method (known as method no. 1). These services are reimbursed to the provider and are included in the provider's costs. (2) The alternative method (known as method no. 2). These services are reimbursed directly to the physician and are not included in the provider's costs. Therefore, if the physicians have elected the alternative method, the amount listed on line 13 of Supplemental Worksheet I-1, Part I must be zero. On or after August 1, 1983, the effective date of the composite rate, no physician supervisory services will be reimbursed through the cost report. Any cost for physician supervisory services included in the renal dialysis cost center for services rendered on or after August 1, 1983, must be eliminated by an adjustment on Worksheet A-8, line 13.
Line 18--The sum of lines 12 through 17 must agree with the amount of direct salaries reported on Worksheet A, column 1, line 41.
COLUMN 2 - OTHER
LINE DESCRIPTIONS
Line 14--From the provider's records, enter the directly assigned dialysis machine and/or supportive equipment depreciation which is reported in other expenses, Worksheet A, column 2, line 41.
Line 15--Enter on this line the direct cost of total ESRD supplies (but not drugs) included in other direct expenses used in furnishing all dialysis services. Include only the cost of routine supplies provided to the facility's patients (Exclude the cost of meals served patients. If these costs are included adjust them out on Worksheet A-8). Non-routine supplies are billed separately and are included in medical supplies charged to patients cost center.

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03-84 FORM HCFA-2552-83 1274.1 (Cont.)

Line 16--Enter on this line the cost of inpatient services included in other direct expenses purchased under arrangement from other ESRD facilities.
Line 17--Enter on this line the total of all other expenses which have not been directly identified and entered on lines 14, 15 and 16. List on a separate sheet of paper and submit with the Supplemental Worksheet I-1 a detailed breakout of the expenses reported on this line. The breakout of expenses must identify the type and amount of expenses. The total of the breakout must agree with the amount reported on this line.
Line 18--The sum of lines 12 through 17 must agree with the amount of total expenses reported on Worksheet A, column 2, line 41.
COLUMN 3 - TOTAL COST
The cost listed in this column is the sum of columns 1 and 2 for each line 2 through 18. The sum of column 3, lines 12 through 17 must equal the total expense amount reported on Worksheet A, column 3, line 41.
COLUMN 4
Enter in this column the amounts of any reclassifications applicable to the renal dialysis department from Worksheet A, column 4, line 41. The reclassifications of direct expenses must be identified and recorded on the respective lines 2 through 11 and 13 through 17.
COLUMN 5
Adjust the amounts entered in column 3 by the amount entered in column 4 (increase or decrease) for each respective line and enter the results in this column.
COLUMN 6
Enter in this column the amounts of any adjustments applicable to the renal dialysis department from Worksheet A, column 6, line 41. The adjustments must be identified and recorded on the respective lines 2 through ll and 13 through 17. Any cost for physician supervisory services included in the renal dialysis cost center for services rendered on or after August 1, 1983, must be eliminated from this column.
COLUMN 7
Adjust the amounts entered in column 5 by the amounts entered in column 6 (increase or decrease) for each respective line and enter the results in this column. The sum of lines 12 thourgh 17 must equal the net expense amount for cost allocation as reported on Worksheet A, column 7, line 41.
Line 13--Physician supervisory services are not allocated to the various modes of treatment since the provider receives a standard amount per treatment when the physician elects the initial method of payment. Where the physicians have elected the alternative method, and for services rendered on or after August 1, 1983, the effective date of the composite rate, no physician supervisory services are reimbursed through the cost report. Therefore, no amount should be reported on this line.

Rev. 2 12-163



1274.1 (Cont.) FORM HCFA-2552-83 03-84

COLUMNS 8 THROUGH 24
These columns will be completed in conjunction with Supplemental Worksheet I-1, Part IV. Supplemental Worksheet I-1, Part IV is used to develop the statistical bases for allocating the direct cost reported in column 7 to the various modes of treatment identified in columns 8 through 23.
COLUMN 23
Enter in this column the direct costs of any services not included in columns 8 through 21. This must include the cost of any direct home support services to Medicare beneficiaries dialyzing at home and electing to deal directly with the Medicare program and make his/her own arrangement for securing the necessary supplies and equipment to dialyze at home.
1274.1B Part II - Indirect Renal Dialysis Cost Analysis.--This part provides for recording the indirect expenses applicable to the total renal or outpatient renal dialysis department, obtained from Worksheet B, Part l, columns 2 through 20, line 41. When completing a separate Supplemental Worksheet I-1 for the home program or Target Rate Reimbursement, the indirect expenses will be transferred from Worksheet B, Part I, columns 2 through 20, line 59. Do not combine the cost of the renal dialysis department with the home program or Target Rate Reimbursement cost if listed separately on Worksheet B, Part I, line 59.
COLUMN 7
Lines 19 through 21, 23 through 27 and 29 through 38--Enter in this column the amounts from the corresponding general service cost centers, Worksheet B, Part I, columns 2 through 20, line 41 on the appropriate lines in this column. The cost centers on this worksheet are listed in a manner which facilitates the sequential order for transfer of the various cost centers from Worksheet B, Part I.
Line 22--Enter the sum of lines 18, 19, 20 and 21 on this line.
Line 28--Dietary cost is not allocated to the various modes of treatment because these costs are not reimbursable when furnished to outpatients.
Line 39a--Enter on this line the adjusted renal dialysis cost for providers that use inpatient routine beds to furnish outpatient renal dialysis services as determined on Supplemental Worksheet D-7, Part I, column 3, line 9.
Line 39b--Enter on this line the adjusted renal dialysis cost for providers that use beds or other accommodations in the outpatient area (outside the renal dialysis department) in furnishing outpatient renal dialysis services as determined on Supplemental Worksheet D-7, Part II, column 3, line 4.
Line 40--Enter the sum of the amounts on lines 22 through 39b on this line. This amount should agree with the total cost of the renal dialysis department reported on Worksheet C, column 1, line 21a, minus Worksheet B, Part I, column 10, line 41.

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03-84 FORM HCFA-2552-83 1274.1 (Cont.)

NOTE: If the provider completes a separate Supplemental Worksheet I-1 for home program dialysis Target Rate Reimburse­ment for the period prior to August 1, 1983, the effective date of the composite rate, or home program cost, the amount entered on column 7, line 40 must agree with he appropriate cost on Worksheet C, column 1, line 29a.
COLUMNS 8 THROUGH 24
These columns will be completed in conjunction with Supplemental Worksheet I-1, Part V. Supplemental Worksheet I-1, Part V is used to develop the statistical basis for allocating the indirect cost reported in column 7 to the various modes of renal dialysis identified in columns 8 through 24.
1274.1C Part III -- Ancillary Cost Analysis.--This part provides for allocating the outpatient routine ancillary services from Worksheet C-1, to the modes of outpatient dialysis treatments in columns 12 through 21 and 23. Lines 41, 42 and 43 are divided by a dotted line into two parts: Part a (Cost) and Part b (Charges). Cost data is entered on each Part a line when the Part b line is completed.
COLUMNS A AND B - RATIOS FROM WORKSHEET C.--Column B is used to record the ratios used to apportion the routine ancillary cost to the modes of dialysis treatments. Column A provides the line reference from Worksheet C.
Lines 41, 42 and 43--Enter on the appropriate lines the ratio of the routine ancillary cost centers. The ratios are obtained from Worksheet C, column 2.
Column 24
Lines 41b, 42b and 43b--Enter on the appropriate lines, the total ancillary charges for routine items and services applicable to the outpatient renal department. The amounts entered on the respective lines are the sum of the routine ancillary charges obtained from Worksheet C-1, columns 4, 7, and 9, when the provider's cost reporting period straddles August 1, 1983, the effective date of the composite rate. If the provider's cost reporting period begins on or after August 1, 1983, the amounts entered on these respective lines are obtained from Worksheet C-1, columns 7 and 9 only.
Enter on lines 41, 42 and 43, Part b, columns 12 through 21 and 23, the charges for the routine ancillary services rendered by each mode of outpatient dialysis services. For each line the charges entered in Part b columns 12 through 21 and 23 must crossfoot to the total charges entered in column 24 Part b.
The cost for each mode of treatment is determined by multiplying the charges listed in Part b of each line by the ratio in column B of the same line.
After all of the expenses of the outpatient renal departments have been properly allocated on this worksheet, enter in column 22, the sum of columns 12-21. Enter in column 24, the sum of columns 22 and 23.
Enter on line 44, columns 12 through 24, the sum of lines 40, 41a, 42a and 43a.

Rev. 2 12-165



1274.1 (Cont.) FORM HCFA-2552-83 03-84

Transfer the totals on Supplemental Worksheet I-1, Part III, columns 12 through 21, line 44, to Supplemental Worksheet I-2, columns and lines as follows:


FROM SUPPLEMENTAL TO SUPPLEMENTAL



WORKSHEET I-1, LINE 44 WORKSHEET I-2, COLUMN 2
Column 12 Line 1

Column 13 Line 2

Column 14 Line 3

Column 15 Line 4

Column 16 Line 5

Column 17 Line 6

Column 18 Line 7

Column 19 Line 8

Column 20 Line 9

Column 21 Line 10


If a separate worksheet is completed for the home program, other than the Target Rate Reimbursement, transfer the cost from line 44, columns 18 through 21, to the appropriate lines on Supplemental Worksheet I-2. If the provider has elected the Target Rate Reimbursement for home dialysis services and has completed a separate Supplemental Worksheet I, transfer the cost from line 44, columns 18 through 21, to a separate Supplemental Worksheet I-2. If there is more than one Supplemental Worksheet I completed for separate outpatient departments, transfer the amounts on line 44, columns 12 through 21, to separate Supplemental Worksheets I-2.
1274.1D and 1274.1E Parts IV and V - Direct and Indirect Renal Dialysis Cost Allocation - Statistical Basis.--To accomplish the allocation of the providers direct and indirect cost reported on Supplemental Worksheet I-1, Part I and Part II, column 7 between inpatient, outpatient and mode of renal dialysis service, or only to the modes of renal dialysis service when the provider maintains separate inpatient and outpatient departments, the provider must maintain statistics related to the renal services. To facilitate the allocation process, the general format of Supplemental Worksheet I-1, Parts I and II is identical to Parts IV and V. The columns and line numbers are identical.
The recommended statistics to be used for the allocation of the renal expenses are as follows:
Supplemental Worksheet I-1, Part I
Line No. Cost Center Basis of Allocation
2 Physicians Hours of Service
3 Registered Nurses Hours of Service
4 Licensed Practical Nurses Hours of Service
5 Nurses Aids Hours of Service
6 Technicians Hours of Service

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11-83 FORM HCFA-2552-83 1274.1 (Cont.)

Line No. Cost Center Basis of Allocation
7 Social Workers Hours of service
8 Dieticians Hours of Service
9 Administrative Hours of Service
10 Management Hours of Service
11 Other Hours of Service
14 Directly Assigned Time Weighted Square Feet Depreciation
15 Supplies Costed Requisitions

16 Services Purchased Under Direct Assignment

Arrangement
17 Other Direct Assignment

Supplemental Worksheet I-1, Part II




Line No. Cost Center Basis of Allocation
19 Depreciation - Time Weighted Square Feet

Buildings & Fixtures


20 Depreciation - Time Weighted Square Feet

Movable Equipment


21 Employee Health & Welfare Hours of Service
23 Administrative & General Subtotal on line 22
24 Maintenance & Repairs Time Weighted Square Feet
25 Operation of Plant Time Weighted Square Feet
26 Laundry & Linen Pounds of Laundry
27 Housekeeping Time Weighted Square Feet
29 Cafeteria Hours of Service
30 Maintenance of Personnel Hours of Service

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1274.1 (Cont.) FORM HCFA-2552-83 11-83

Line No. Cost Center Basis of Allocation
31 Nursing Administration Hours of Service
32 Central Services & Supply Costed Requisitions
33 Pharmacy Costed Requisitions
34 Medical Records, Library Number of Treatments
35 Social Service Number of Treatments
36 Nursing School Assigned Time
37 Intern-Resident Service

(in approved teaching Assigned Time

program)
38 Other Direct Assignment
39A Inpatient Routine Service Inpatient Days Applicable to Outpatient Renal Dialysis
39B Outpatient Service Charges Outpatient Service Charges

Cost Adjustment For

Renal Patients
NOTE: If the provider wishes to change its allocation basis for a particular general cost center and not use the recommended basis of allocation because it believes the change will result in more appropriate and more accurate allocations, the provider may use the alternative allocation basis, providing that the substitute basis is a permissible basis for Worksheet B-1 and the intermediary approves of the alternative basis through written notification before the start of the cost reporting period for which the alternative basis is to be used.

COLUMN 7
To accomplish the allocation of expenses entered on Supplement Worksheet I-1, Parts I and II, column 7, lines 2 through 39B, determine for each line the total statistic to be used to allocate the cost, and enter the total statistic for each line in column 7.
COLUMNS 8 THROUGH 10, 12 THROUGH 21, AND 23
In these columns, enter on lines 2 through 39B, the portion of the total statistical base over which the direct and indirect cost are to be allocated. The statistical base to be used for each line is cited under the caption "basis of allocation".
COLUMNS 11 AND 22
Enter in column 11, lines 2 through 39B, the sum of columns 8, 9 and 10 for each respective line. Enter in column 22, lines 2 through 39B, the sum of columns 12 through 21 for each respective line.

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11-83 FORM HCFA-2552-83 1274.2

Column 24
Enter the sum of columns 22 and 23 for each line 2 thorugh 39B on the respective lines in this column. The total sum of the statistical bases entered in columns 11 and 24 for each line 2 through 39B must agree with the total statistical base entered in column 7 for each of the lines 2 through 39B.
Column 25
Enter in this column, lines 2 through 39B, the cost to be allocated. The amounts are obtained from Parts I and II, column 7, lines 2 through 39B of this worksheet.
Column 26
Divide the cost entered on each line 2 through 39B of column 25 by the total statistical basis entered on the same lines 2 through 39B of column 7. Enter the resulting unit cost multiplier on each of the lines 2 through 39B of this column. The unit cost multiplier must show six decimal places.
For each of the lines 2 through 39B, multiply the Unit Cost Multiplier entered in column 26 by that portion of the total statistical basis entered in each of the columns 8, 9, 10, 12 through 21 and 23. Enter the results of each computation in Parts I and II of this worksheet in the corresponding line and column.
After the Unit Cost Multipliers have been applied to all of the columns 8, 9, 10, 12 through 21 and 23 for each line, and the results have been entered on the corresponding lines and columns in Parts I and II of this worksheet, the sum of columns 11, 22, and 23 for each line in Parts I and II must equal the amounts of cost entered in column 7, lines 2 through 40, respectively.
1274.2 Supplemental Worksheet I-2 - Computation of Average Cost per Treatment for Outpatient Renal Dialysis.--This supplemental worksheet records the apportionment of total outpatient costs to the types of dialysis treatment furnished by the provider and shows the computation of expenses of dialysis items and services that the provider furnished to Medicare dialysis patients. This information will be used for overall program evaluation, determining the appropriateness of program reimbursement rates and meeting statutory requirements of determining the cost of ESRD care.
Complete a separate supplemental worksheet for providers electing the Target Rate Reimbursement, cost reimbursement for home program dialysis and for providers reporting cost for more than one outpatient renal dialysis department.
Columns 1-3 refer to total outpatient statistics, i.e., to all outpatient dialysis services furnished, whether reimbursed directly by the program or not.

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1274.2 (Cont.) FORM HCFA-2552-83 __11-83

Column 1--Enter on the appropriate lines in this column, the total number of outpatient treatments by type for all renal dialysis patients from the provider's records. These statistics include all treatments furnished to all patients in the outpatient renal department, both Medicare and non-Medicare.
Column 2--Enter on the appropriate lines in this column, the total cost transferred from Supplemental Worksheet I-1, Part III, columns 12 through 21, line 44. Enter on line 12, the total cost of Home Program Dialysis Equipment-100% Medicare, transferred from Worksheet B, Part I, column 21, line 68.
NOTE: On or after August 1, 1983, the effective date of the composite rate, Home Program Dialysis Equipment-100% is no longer an option available to the provider. However, equipment related services (e.g., maintenance, repair) for equipment delivered to the patient's home on or before 7/31/83 may be reimbursed under this option.
Column 3--The amounts to be entered in this column on the appropriate lines are determined by dividing the cost entered on each line in column 2 by the number of treatments entered on each line in column 1. Enter on line 12 the average cost of machines obtained by dividing the cost entered in column 2 by the number of machines entered in column 4.
Line 9--Report Continuous Ambulatory Peritoneal Dialysis (CAPD) in terms of weeks. Patient weeks are computed by totaling the number of weeks each patient was dialyzed at home by CAPD.
Line 12--Enter the number of machines used by your home dialysis patients that have been purchased under a 100 percent reimbursement agreement for home dialysis equipment. This provision refers exclusively to Medicare patients.
Columns 4-7 refer only to treatments furnished to Medicare beneficiaries that were billed to and reimbursed by the program directly. (Amounts entered in these columns should be reconcilable to the provider's records.)
Column 4--Enter on the appropriate lines in this column, the number of treatments billed to the Medicare program directly. Obtain this information from the provider's records.
Column 5--The amounts to be entered in this column on the appropriate lines are determined by multiplying the number of treatments entered on each line in column 4 by the average cost per treatment entered on each corresponding line in column 3. For cost reporting periods beginning on or after August 1, 1983, the effective date of the composite rate, transfer the total expenses from this column, line 11, to Supplemental Worksheet 1-3, line 1. For providers completing separate Supplemental Worksheets I-1 and I-2 add the sum of the cost from this column, line 11 and transfer the total to Supplemental Worksheet I-3, line 1.
Where the providers cost reporting period straddles August 1, 1983, a separate Supplemental Worksheet I-2 must be completed to determine the cost of services rendered after that date. This separate calculation is necessary in order to reimburse the provider the Part B bad debts related to renal dialysis services rendered after August 1, 1983. The cost of the services rendered after August 1, 1983, will be determined in the following manner.

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11-83 FORM HCFA-2552-83 1274.3

Enter in column 3 the average cost per treatment developed for the entire cost reporting period. Enter in column 4 on the appropriate lines the number of treatments billed to the Medicare program directly for services rendered after August 1, 1983. Enter in column 5 on the appropriate lines the product determined by multiplying the number of treatments entered in column 4 by the average cost per treatment entered on the corresponding line in column 3.


Transfer the cost of services rendered after August 1, 1983, from column 5, line 11 to Supplemental Worksheet I-3, line 1. Where the provider completes a separate supple­mental worksheet, i.e., satellite facilities or home program, add the sum of the cost from column 5, line 11 and transfer the total to Supplemental Worksheet I-3, line 1.
Column 6--Enter the provider's Medicare Program payment rates by type of treatment for the reporting period. If the cost reporting period covers a time when the provider had more than one rate for a particular treatment type (e.g., the incentive rate may have been updated during the period) a separate Supplemental Worksheet I-2, for columns 4, 5 and 7 must be completed for each payment rate. The separate supplemental worksheets must be completed to calculate the total payment due for each payment rate. When the provider completes a separate Supplemental Worksheet I-2 because more than one payment rate was in effect during the cost reporting period, column 6 will not be completed. However, columns 4, 5 and 7 will consist of the sum of the totals computed on the separate Supplemental Worksheets I-2 for each payment rate.
Column 7--The amounts to be entered on the appropriate lines are determined by multiplying the number of treatments entered on each line in column 4 by the payment rate entered on each corresponding line in column 6.
Line 11--Transfer the total payment from this column, line 11, to Supplemental Worksheet I-3, line 2. For providers completing separate supplemental worksheets, i.e., satellite facilities or home program, add the sum of the cost from this column, line 11, and transfer the total to Supplemental Worksheet I-3, line 2. For cost reporting periods straddling August 1, 1983, the amount to be transferred to Supplemental Worksheet I-3, line 11, will be the total payments calculated for services rendered after August 1, 1983 only.
1274.3 Supplemental Worksheet I-3 - Calculation of Reimbursable Bad Debts-Title XVIII-Part B.--This supplemental worksheet provides for the calculation of reimbursable Part B bad debts relating to outpatient renal dialysis services furnished on or after August 1, 1983. If the provider has completed more than one supplemental Worksheet I-2, a consolidated bad debt computation must be made.
Line 1--If the provider's cost reporting period begins on or after August 1, 1983, enter the amount from Supplemental Worksheet I-2, column 5, line 11. If the provider completes more than one Supplemental Worksheet I-2, i.e., satellite facilities and/or home program, enter the sum of the total from each Supplemental Worksheet I-2, column 5, line 11.

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1274.3 (Cont.) FORM HCFA-2552-83 11-83

Bad debts related to uncollectable deductible and coinsurance amounts for renal dialysis services furnished before August 1, 1983 must be included with other hospital bad debts on Worksheet E column 2 line 56.


Where the provider's cost reporting period straddles August 1, 1983, the provider must complete a separate Supplemental Worksheet I-2 in order to calculate the cost of services rendered after August 1, 1983 and transfer to this line only the cost of services rendered after that date. (See instruction to Supplemental Worksheet I-2, column 5 for calculating this cost.)
Line 2--Enter the amount from Supplemental Worksheet I-2, column 7, line 11, (net of deductibles) if the provider's cost reporting period begins on or after August 1, 1983. If the provider completes more than one Supplemental Worksheet I-2, i.e., satellite facilities and/or Target Rate Reimbursement, enter the sum of the total from each Supplemental Worksheet I-2, column 7, line 11 (net of deductibles).
Where the provider's cost reporting period straddles August 1, l983, the provider must complete a separate Supplemental Worksheet I-2 in order to calculate program payments for services rendered after August 1, 1983, and transfer to this line only the amount of program payments for services rendered after August 1, 1983. (See instructions to Supplemental Worksheet I-2, column 7 for calculating these payments.)
Line 3--Enter 80 percent of line 2.
Line 4--Enter the lesser of line 1 or line 2, minus line 3.
Line 5--Enter the amount shown in the provider's records for deductibles and coinsurance billed to Medicare (Part B) patients for services furnished on or after August 1, 1983.
Line 6--Enter the uncollectible portion of the amount entered on line 5, reduced by any amount recovered during the cost reporting period. The pre August 1, 1983 services bad debts will be directly included with other hospital bad debts on Worksheet E, column 2, line 56.
Line 7--Subtract line 6 from line 5.
Line 9--Transfer the reimbursable Medicare (Part B) bad debts to Worksheet E, column 2, line 56.

12-172 Rev. 1



11-83 FORM HCFA-2552-83 1276.

1276. SUPPLEMENTAL WORKSHEET S-6 -- HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX STATISTICAL DATA


In accordance with 42 CFR 405.406(a), 42 CFR 405.453(a) and 42 CFR 405.453(c), providers are required to maintain statistical records for proper determination of costs payable under the Medicare program. The statistics required to be reported on this Supplemental Worksheet pertain to a hospital-based CORF. The data needed to be maintained, depending on the services provided by the CORF, include number of program treatments, total number of treatments, number of program patients, total number of patients. In addition, FTE data is required by employee staff, contracted staff, and total.
CORF Treatments--Lines 1a through 1h are used to identify the number of service treatments and corresponding number of patients. The patient count in columns 2, 4, 6 and 8 should include each individual who recieved each type of service. The sum of the patient count in columns 2, 4, 6 and 8 will equal the total in column 10 for each line.
Columns 1, 3, 5 and 7--Enter the number of treatments for titles V, XVIII, XIX and other, respectively, for each discipline. Enter the total for each column on line li.
Columns 2, 4, 6 and 8--Enter the number of patients corresponding to the number of treatments in columns 1, 3, 5 and 7 for titles V, XVIII, XIX and other, respectively, for each discipline.
Columns 9 and 10--Enter in column 9 the total of columns 1, 3, 5 and 7. Enter in column 10 the total of columns 2, 4, 6 and 8.
LINES DESCRIPTIONS
Lines 1a through 1g--These lines identify the type of CORF services which are reimbursable by the program. These lines should reflect the number of times a person was a patient receiving a particular service.
Line 1h--This line identifies other services not listed on lines 1a through 1g which are not reimbursable by the program.
Line li--Enter in columns 1, 3 and 5 the total of lines 1a through 1g. Enter in columns 7 and 9 the total of lines 1a through 1h.
Lines 2a through 2s--These lines provide statistical data related to the human resources of the CORF. The human resources statistics are required for each of the job categories specified on lines 2a through 2q. Enter any additional categories needed on lines 2r and 2s.
Enter the number of hours in your normal work week in the space provided.
Report in column 1 the full-time equivalent (FTE) employees on the CORF's payroll. These are staff for which an IRS form W-2 is used.
Report in column 2 the FTE contracted and consultant staff of the CORF.

Rev. 1 12-173



1278. FORM HCFA-2552-83 11-83

Staff FTE's are computed for column 1 as follows: sum of all hours for which employees were paid divided by 2080 hours, round to two decimal places, e.g., .04447 should be rounded to .04. Contract FTE's are computed for column 2 as follows: sum of all hours for which contracted and consultant staff worked divided by 2080 hours, round to two decimal places.


If employees are paid for unused vacation, unused sick leave, etc., exclude the hours so paid from the numerator in the calculations.
1278. COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY (CORF)
1278.1 Supplemental Worksheet J-1.--This supplemental worksheet is to be used only if a provider operates a certified hospital-based CORF as part of its complex.
1278.1A Part I -- Allocation of General Service Costs to CORF Cost Centers.--Supplemental Worksheet J-1, Part I, provides for the allocation of the expenses of each general service cost center to those cost centers which receive the services. The total direct expenses (column 1, line 16) are obtained from Worksheet A, column 7, line 76. The cost center allocation (column 1, lines 1 through 15) is obtained from the provider's records.
1278.1B Part II -- Computation of Unit Cost Multiplier for Allocation of CORF Administrative and General Costs.--
1278.1C Part III -- Allocation of General Services Costs to CORF Cost Centers -Statistical Basis.--Supplemental Worksheet J-1, Parts II and III provide for the proration of the statistical data needed to equitably allocate the expenses of the general service cost centers on Supplemental Worksheet J-1, Part I.
To facilitate the allocation process, the general format of Supplemental Worksheet J-1, Parts I and III is identical.
The statistical basis shown at the top of each column on Supplemental Worksheet J-1, Part III is the recommended basis of allocation of the cost center indicated.
Note: A provider wishing to change its allocation basis for a particular cost center must make a written request to its intermediary for approval of the change and submit reasonable justification for such change prior to the beginning of the cost reporting period for which the change is to apply. The effective date of the change will be the beginning of the cost reporting period for which the request has been made. (See HCFA-Pub. 15-I, ' 2313.)
Lines 1 through 15--On Supplemental Worksheet J-1, Part III, for all cost centers to which the general service cost center is being allocated, enter that portion of the total statistical base applicable to each.

12-174 Rev. 1



03-84 FORM HCFA-2552-83 1278.2

Line 16--Enter the total of lines 1 through 15 for each column. The total in each column must be the same as shown for the corresponding column on Worksheet B-1, line 71.
Line 17--Enter the total expenses of the cost center to be allocated. This amount is obtained from Worksheet B, Part I, line 71, from the same column used to enter the statistical base on Supplemental Worksheet J-1, Part III (for example, in the case of Depreciation Buildings and Fixtures, this amount is on Worksheet B, Part I, column 2, line 71).
Line 18--Enter the "Unit Cost Multiplier" which is obtained by dividing the cost entered on line 17 by the total statistic entered in the same column on line 16. The "Unit Cost Multiplier" must be rounded to six decimal places.
Multiply the "Unit Cost Multiplier" by that portion of the total statistics applicable to each cost center receiving the services. Enter the result of each computation on Supplemental Worksheet J-1, Part I, in the corresponding column and line.
After the "Unit Cost Multiplier" has been applied to all the cost centers receiving the services, the total cost (line 16, Part I) must equal the total cost on line 17, Part III.
The preceding procedures must be performed for each general service cost center.
In column 21, Part I, enter the total of columns 4a through 20.
In Part II, compute the "Unit Cost Multiplier" for allocation of CORF Administrative and General costs as follows:
Line 1--Enter the amount from Part I, column 21, line 16.
Line 2--Enter the amount from Part I, column 21, line 1.
Line 3--Subtract the amount on line 2 from the amount on line 1 and enter the result rounded to six decimal places.
Line 4--Divide the amount on line 2 by the amount on line 3 and enter the result.
In column 22, Part I, for lines 2 through 15, multiply the amount in column 21 by the "Unit Cost Multiplier" on line 4, Part II, and enter the result in this column. On line 16, enter the total of lines 2 through 15. The total in line 16 should equal the amount on column 21, line 1.
In column 23, Part I, enter on lines 2 through 16 the sum of the amounts in columns 21 and 22. The total on line 16 should equal the total in column 21, line 16.
1278.2 Supplemental Worksheet J-2 -- Computation of CORF Costs.--This supplemental worksheet is to be used only if the provider operates a hospital-based CORF.
1278.2A Part I -- Apportionment of CORF Cost Centers.--

Rev. 2 12-175



1278.2 (Cont.) FORM HCFA-2552-83 03-84

Column 1--Enter on each line, the total cost for the cost center as previously computed on Supplemental Worksheet J-1, Part I, column 23. To facilitate the apportionment process, the line numbers are the same on both supplemental worksheets.
Column 2--Enter the charges for each cost center. The charges will be obtained from the provider's records.
Column 3--For each cost center, enter the ratio derived by dividing the cost in column 1 by the charges in column 2.
Columns 4, 6, and 8--For each cost center, enter the charges from the provider's records for title V, title XVIII and title XIX CORF patients, respectively.
Columns 5, 7 and 9--For each cost center, enter the costs obtained by multiplying the charges in columns 4, 6 and 8, respectively, by the ratio in column 3.
Line 16--Enter the totals for columns 1, 2, and 4 through 9.
1278.2B Part II -- Apportionment of Cost of CORF Services Furnished by Shared Hospital Departments.--This part is to be used only when the hospital complex maintains a separate department for any of the cost centers listed on this worksheet, and the department provides services to patients of the hospital's CORF.
Column 3--For each of the cost centers listed, enter the ratio of cost to charges that is shown on Worksheet C, column 2, from the appropriate line for each cost center.
Columns 4, 6 and 8--For each cost center, enter the charges from the provider's records for title V, title XVIII and title XIX CORF patients, respectively.
Columns 5, 7 and 9--For each cost center enter the costs obtained by multiplying the charges in columns 4, 6 and 8 respectively by the ratio in column 3.
Line 9--Enter the totals for columns 4 through 9.
1278.2C Part III -- Total CORF Costs.--
Columns 5, 7, and 9--Enter the total costs from Part I, columns 5, 7 and 9, line 16 plus Part II, columns 5, 7 and 9, line 9, respectively. Transfer these amounts to the appropriate Supplemental Worksheet J-3, line 1.
1278.3 Supplemental Worksheet J-3 Calculation of Reimbursement Settlement -- CORF Services.--A separate Supplemental Worksheet J-3 is to be submitted for each title (V, XVIII, or XIX) under which reimbursement is claimed.
Line 1--Enter the cost of CORF services from Supplemental Worksheet J-2, Part III, line 1 from columns 5, 7, or 9, as applicable (column 5 - title V, column 7 - title XVIII, column 9 - title XIX).

12-176 Rev. 2



03-84 FORM HCFA-2552-83 1278.3 (Cont.)

Line 2--Enter the amounts from Worksheet D-8 as follows:
Title V
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