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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
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.
×
Page 191
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.
×
Page 192
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.
×
Page 193
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.
×
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Medicare is the largest health insurer in the United States, providing coverage for 39 million people aged 65 and older and 8 million people with disabilities, and reaching more than an estimated $500 billion in payments in 2010. Although Medicare is a national program, it adjusts fee-for-service payments according to the geographic location of a practice. While there is widespread agreement about the importance of providing accurate payments to providers, there is disagreement about how best to adjust payment based on geographic location.

At the request of Congress and the Department of Health and Human Services (HHS), the Institute of Medicine (IOM) examined ways to improve the accuracy of data sources and methods used for making the geographic adjustments to payments. The IOM recommends an integrated approach that includes moving to a single source of wage and benefits data; changing to one set of payment areas; and expanding the range of occupations included in the index calculations. The first of two reports, Geographic Adjustment in Medicare Payment: Phase I: Improving Accuracy, assesses existing practices in regards to accuracy, criteria consistency, evidence for adjustment, sound rationale, transparency, and separate policy adjustments to reform the current payment system. Adopting the recommendations outlined in this report will mean a change in the way that the indexes are calculated, and will require a combination of legislative, rule-making, and administrative actions, as well as a period of public comment.

Geographic Adjustment in Medicare Payment will inform the work of government agencies such as HHS, the Centers for Medicare and Medicaid Services, congressional members and staff, the health care industry, national professional organizations and state medical and nursing societies, and Medicare advocacy groups.

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