Worksheet A-8
- Return to Cost Report Summary
- Form A800
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3519, REV 4
HERITAGE INN HEATH & REHABILITATION
STATESBORO, GA 30459-
STATESBORO, GA 30459-
Medicare Provider Number: 115597
Cost report status: Settled Without Audit
[Record Code 153084 - 1996]
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| ADJUSTMENTS TO EXPENSES | PROVIDER NO: 115597 |
PERIOD: FROM 07/01/2000 TO 06/30/2001 |
WORKSHEET A-8 | |||
| DESCRIPTION (1) | BASIS FOR ADJUSTMENT (2) | AMOUNT | EXPENSE CLASSIFICATION ON WORKSHEET A - TO / FROM WHICH THE AMOUNT IS TO BE ADJUSTED | |||
| COST CENTER | LINE NO. | |||||
| 1 | 2 | 3 | 4 | |||
| 1 | Investment income on restricted funds (ch.2) funds (chapter 2) | 1 | ||||
| 2 | Trade, quantity and time discounts on purchases (chapter 8) | 2 | ||||
| 3 | Refunds and rebates of expenses (Chapter 8) | 3 | ||||
| 4 | Rental of provider space by suppliers (Chapter 8) | 4 | ||||
| 5 | Telephone services (pay stations excluded) (chapter 21) | 5 | ||||
| 6 | Television and radio service (Chapter 21) | 6 | ||||
| 7 | Parking lot (chapter 21) | 7 | ||||
| 8 | Remuneration applicable to provider- based physician adjustment | Worksheet A-8-2 | 8 | |||
| 9 | Home office costs (chapter 21) | 9 | ||||
| 10 | Sale of scrap, waste, etc. (chapter 23) | 10 | ||||
| 11 | Nonallowable costs related to certain Capital expenditures (chapter 24) | 11 | ||||
| 12 | Adjustment resulting from transactions | Worksheet A-8-1 | ### | 12 | ||
| 13 | Laundry and Linen service | 13 | ||||
| 14 | Revenue - Employee meals | ### | 14 | |||
| 15 | Cost of meals - Guests | 15 | ||||
| 16 | Sale of medical supplies to other than patients | 16 | ||||
| 17 | Sale of drugs to other than patients | 17 | ||||
| 18 | Sale of medical records and abstracts | 18 | ||||
| 19 | Vending machines | 19 | ||||
| 20 | Income from imposition of interest, finance or penalty charges (chapter 21) | 20 | ||||
| 21 | Interest expense on Medicare overpayments and borrowings to repay Medicare overpayments | 21 | ||||
| 22 | Other Adjustment | (3) | 22 | |||
| 23 | Other Adjustment | (3) | 23 | |||
| 24 | Adjustment for respiratory therapy costs in excess of limitation (chapter 14) | (3) | Oxygen (Inhalation) Therapy | 24 | 24 | |
| 25 | Adjustment for physical therapy costs in excess of limitation | (3) | Physical Therapy | 25 | 25 | |
| 26 | Adjustment for HHA physical therapy costs in excess of limitation | See Instructions | Physical Therapy - HHA | 39 | 26 | |
| 27 | SUBTOTAL (Sum of lines 1-26) | 27 | ||||
| 28 | Utilization review - physicians' compensation (chapter 21) | Utilization Review- SNF | 54 | 28 | ||
| 29 | Depreciation - buildings and fixtures | Capital Related Cost- Building | 1 | 29 | ||
| 30 | Depreciation - movable equipment | Capital Related Cost-Movable Equipment | 2 | 30 | ||
| 31 | Other Adjustment | 31 | ||||
| 32 | TOTAL (line 27 plus the sum of lines 28 - 31) (Transfer to Worksheet A, col. 6, line 75) | ### | 32 | |||
| (1) Description - all chapter references in this column pertain to CMS Pub. 15-I | ||||||
| (2) Basis for adjustment | ||||||
| A. Costs - if costs, including applicable overhead, can be determined. | ||||||
| B. Amount Received - if cost cannot be determined. | ||||||
| (3) See Instructions to report therapy services provided on and after April 10, 1998. | ||||||