Suggested Citation:"Appendix H: S-3 Worksheet." Institute of Medicine. 2012. Geographic Adjustment in Medicare Payment: Phase I: Improving Accuracy. Washington, DC: The National Academies Press. doi: 10.17226/13138.
×
Suggested Citation:"Appendix H: S-3 Worksheet." Institute of Medicine. 2012. Geographic Adjustment in Medicare Payment: Phase I: Improving Accuracy. Washington, DC: The National Academies Press. doi: 10.17226/13138.
×
| 04-05 | FORM CMS-2552-96 | 3690 (Cont.) | |||||||||||||||||||
| HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX STATISTICAL DATA | PROVIDER NO.: | PERIOD FROM ______ TO ______ |
WORKSHEET S-3, PART I | ||||||||||||||||||
| Component | No. of Beds | Bed Days Available | I/P Days / O/P Visits / Trips | Interns & Residents FTEs | Full Time Equivalent | Discharges | |||||||||||||||
| Title V | Title XVIII | Title XIX | Total All Patients | Obs. Beds Admittec | Obs. Beds Mot Adm | Total | Less I & R Replacing Non-Phys. Anesthetist | Net | Employees On Payroll | Nonpaid Workers | Title V | Title XVIII | Title XIX |
Total All Patients | |||||||
| Total Title XIX |
Obs. Beds Admittec | Obs. Beds Not Adm | |||||||||||||||||||
| 1 | 2 | 3 | 4 | 5 | 5.01 | 5.02 | 6 | 6.01 | 602 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | |||
| 1 | Hospital Adults & Peds. (columns 3, 4, 5 and 6, exclude Swing Bed Observation Bed and Hospice days) | 1 | |||||||||||||||||||
| 2 | HMO | 2 | |||||||||||||||||||
| 3 | Hospital Adults & Peds. Swing Bed SNF | 3 | |||||||||||||||||||
| 4 | Hospital Adults & Peds. Swing Bed NF | 4 | |||||||||||||||||||
| 5 | Total Adults and Peds. (exclude observation beds) (see instructions) | 5 | |||||||||||||||||||
| 6 | Intensive Care Unit | 6 | |||||||||||||||||||
| 7 | Coronary Care Unit | 7 | |||||||||||||||||||
| 8 | Burn Intensive Care Unit | 8 | |||||||||||||||||||
| 9 | Surgical Intensive Care Unit | 9 | |||||||||||||||||||
| 10 | Other Special Care | 10 | |||||||||||||||||||
| 11 | Nursery | 11 | |||||||||||||||||||
| 12 | Total (see instructions) | 12 | |||||||||||||||||||
| 13 | RPCH\CAH visits | 13 | |||||||||||||||||||
| 14 | Subprovider | 14 | |||||||||||||||||||
| 15 | Skilled Nursing Facility | 15 | |||||||||||||||||||
| 16 | Nursing Facility | 16 | |||||||||||||||||||
| 17 | Other Long Term Care | 17 | |||||||||||||||||||
| 18 | Home Health Agency | 18 | |||||||||||||||||||
| 20 | ASC (Distinct Part) | 20 | |||||||||||||||||||
| 21 | Hospice (Distinct Part) | 21 | |||||||||||||||||||
| 23 | Outpatient Rehab. Provider (specify) | 23 | |||||||||||||||||||
| 24 | RHC/FQHC (specify) | 24 | |||||||||||||||||||
| 25 | Total (sum of lines 12-24) | 25 | |||||||||||||||||||
| 26 | Observation Bed Days | 26 | |||||||||||||||||||
| 27 | Ambulance Trips | 27 | |||||||||||||||||||
| 28 | Employee discount days (see instru.) | 28 | |||||||||||||||||||
FORM CMS-2552-96 (4-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3605.1)
Rev. 14
Suggested Citation:"Appendix H: S-3 Worksheet." Institute of Medicine. 2012. Geographic Adjustment in Medicare Payment: Phase I: Improving Accuracy. Washington, DC: The National Academies Press. doi: 10.17226/13138.
×
| 3690 | FORM CMS-2552-96 | 04-05 | ||||||
| HOSPITAL WAGE INDEX INFORMATION | PROVIDER NO.: _________ |
PERIOD: FROM _________ TO _________ |
WORKSHEET S-3, PART III | |||||
| PART II - WAGE DATA | ||||||||
| Amount Reported | Reclass. of Salaries (from Wkst. A-6) | Adjusted Salaries (col. 1 ± col. 2) | Paid Hours Related to Salaries in col. 3 | Average Hourly Wage (col. 3 + col. 4) | Data Source | |||
| 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 | 4 | ||||||
| 4.01 | Teaching physician salaries (see instructions) | 4.01 | ||||||
| 5 | Physician-Part B | 5 | ||||||
| 5.01 | Non-physician-Part B | 5.01 | ||||||
| 6 | Interns & residents (in an approved program) | 6 | ||||||
| 6.01 | Contract services, I&R (see instructions) | 6.01 | ||||||
| 7 | Home office personnel | 7 | ||||||
| 8 | SNF | 8 | ||||||
| 8.01 | Excluded area salaries (see instructions) | 8.01 | ||||||
| OTHER WAGES & RELATED COSTS | ||||||||
| 9 | Contract labor (see instructions) | 9 | ||||||
| 9.01 | Pharmacy services under contract | 9.01 | ||||||
| 9.02 | Laboratory services under contract | 9.02 | ||||||
| 9.03 | Management and administrative services | 9.03 | ||||||
| 10 | Contract labor: physician-Part A | 10 | ||||||
| 10.01 | Teaching physician under contract (see instru.) | 10.01 | ||||||
| 11 | Home office salaries & wage-related costs | 11 | ||||||
| 12 | Home office: physician Part A | 12 | ||||||
| 12.01 | Teaching physician salaries (see instructions) | 12.01 | ||||||
| WAGE-RELATED COSTS | ||||||||
| 13 | Wage-related costs (core) | CMS 339 | 13 | |||||
| 14 | Wage-related costs (other) | CMS 339 | 14 | |||||
| 15 | Excluded areas | CMS 339 | 15 | |||||
| 16 | Non-physician anesthetist Part A | CMS 339 | 16 | |||||
| 17 | Non-physician anesthetist Part B | CMS 339 | 17 | |||||
| 18 | Physician Part A | CMS 339 | 18 | |||||
| 18.01 | Part A teaching physicians (see instructions) | CMS 339 | 18.01 | |||||
| 19 | Physician Part B | CMS 339 | 19 | |||||
| 19.01 | Wage-related costs (RHC/FQHC) | CMS 339 | 19.01 | |||||
| 20 | Interns & residents (in an approved program) | CMS 339 | 20 | |||||
Suggested Citation:"Appendix H: S-3 Worksheet." Institute of Medicine. 2012. Geographic Adjustment in Medicare Payment: Phase I: Improving Accuracy. Washington, DC: The National Academies Press. doi: 10.17226/13138.
×
_______
FORM CMS-2552-96 (5/2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3605.2)
| 36-506.2 06-03 |
FORM CMS-2552-96 | Rev. 14 3690 (Cont.) |
||||||
| HOSPITAL WAGE INDEX INFORMATION | PROVIDER NO.: _______ |
PERIOD: FROM ______ TO ______ |
WORKSHEET S-3, PART III | |||||
| PART II - WAGE DATA | ||||||||
| Amount Reported | Reclass. of Salaries (from Wkst. A-6) | Adjusted Salaries (col. 1 ± col. 2) | Paid Hours Related to Salaries in col. 3 | Average Hourly Wage (col. 3 + col. 4) | Data Source | |||
| 1 | 2 | 3 | 4 | 5 | 6 | |||
| OVERHEAD COST - DIRECT SALARIES | ||||||||
| 21 | Employee Benefits | 21 | ||||||
| 22 | Administrative & General | 22 | ||||||
| 22.01 | Administrative & General under contract (see inst.) | 22.01 | ||||||
| 23 | Maintenance & Repairs | 23 | ||||||
| 24 | Operation of Plant | 24 | ||||||
| 25 | Laundry & Linen Service | 25 | ||||||
| 26 | Housekeeping | 26 | ||||||
| 26.01 | Housekeeping under contract (see instructions) | 26.01 | ||||||
| 27 | Dietary | 27 | ||||||
| 27.01 | Dietary under contract (see instructions) | 27.01 | ||||||
| 28 | Cafeteria | 28 | ||||||
| 29 | Maintenance of Personnel | 29 | ||||||
| 30 | Nursing Administration | 30 | ||||||
| 31 | Central Services and Supply | 31 | ||||||
| 32 | Pharmacy | 32 | ||||||
| 33 | Medical Records & Medical Records Library | 33 | ||||||
| 34 | Social Service | 34 | ||||||
| 35 | Other General Service | 35 | ||||||
| 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 & related costs (see inst.) | 4 | ||||||
| 5 | Subtotal wage-related costs (see inst.) | 5 | ||||||
| 6 | Total (sum of lines 3 thru 5) | 6 | ||||||
| 7 | Net salaries (see instructions) | 7 | ||||||
| 8 | Excluded area salaries | 8 | ||||||
| 9 | Subtotal salaries (line 7 minus line 8) | 9 | ||||||
| 10 | Subtotal other wages & related costs (see inst.) | 10 | ||||||
| 11 | Subtotal wage-related costs (see inst.) | 11 | ||||||
| 12 | Total (sum of lines 9 thru 11) | 12 | ||||||
| 13 | Total overhead costs (see inst.) | 13 | ||||||
