Worksheet A-8
- Return to Cost Report Summary
- Form A800
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3519, REV 4
LIFE CARE CENTER OF FARMINGTON
FARMINGTON, NM 87401
FARMINGTON, NM 87401
Medicare Provider Number: 325103
Cost report status: Settled Without Audit
[Record Code 1080651 - 2010]
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ADJUSTMENTS TO EXPENSES | Provider CCN: 325103 | PERIOD: FROM 01/01/2012 TO 12/31/2012 |
WORKSHEET A-8 | |||
Description (1) | Basis for Adjustment (2) | Amount | Expense Classification on Wkst. A to/from which the amount is to be adjusted |
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Cost Center | Line No. | |||||
0 | 1 | 2 | 3 | 4 | ||
1 | Investment income on restricted 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 with related organizations (Chapter 10) | 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 | Utilization review--physicians' compensation (Chapter 21) | Utilization Review- SNF | 82 | 22 | ||
23 | Depreciation--buildings and fixtures | Capital Related Cost- Building | 1 | 23 | ||
24 | Depreciation--movable equipment | Capital Related Cost-Movable | 2 | 24 | ||
25 | Other Adjustment specify - | 25 | ||||
31.02 | MISCELLANEOUS REVENUE | ### | ### | ### | ### | 31.02 |
31.03 | LOBBYING EXPENSE | ### | ### | ### | ### | 31.03 |
31.04 | X-RAY CONT SVCS (70% NON-ALLOWABLE) | ### | ### | ### | ### | 31.04 |
31.05 | CLAIMS FOR LOSS/SETTLEMENTS | ### | ### | ### | ### | 31.05 |
31.08 | PT CONTRACT EXPENSES | ### | ### | ### | ### | 31.08 |
31.09 | ST CONTRACT EXPENSES | ### | ### | ### | ### | 31.09 |
31.10 | OT CONTRACT EXPENSES | ### | ### | ### | ### | 31.10 |
31.11 | THERAPY CONTRACT BENEFITS | ### | ### | ### | ### | 31.11 |
31.12 | UNFUNDED MALPRACTICE - TAIL/EXCESS | ### | ### | ### | ### | 31.12 |
31.13 | UNFUNDED MALPRACTICE - RETRO | ### | ### | ### | ### | 31.13 |
31.14 | PURCHASE REBATES - DIETARY | ### | ### | ### | ### | 31.14 |
31.15 | PURCHASE REBATES - ROUTINE | ### | ### | ### | ### | 31.15 |
31.16 | PURCHASE REBATES - A&G | ### | ### | ### | ### | 31.16 |
31.17 | NON-ALLOWABLE AMBULANCE EXPENSE | ### | ### | ### | ### | 31.17 |
31.18 | O/P THERAPY LEASE | ### | ### | ### | ### | 31.18 |
31.19 | CABLE TV SVC IN RESIDENT ROOMS | ### | ### | ### | ### | 31.19 |
100 | TOTAL (sum of lines 1 through 99) (transfer to Wkst. A, col. 6, line 100) |
### | 100 | |||
(1) Description - all chapter references in this column pertain to CMS Pub. 15-1 (2) Basis for adjustment (see instructions) |
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A. Costs - if cost, including applicable overhead, can be determined B. Amount Received - if cost cannot be determined |
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FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4116) | ||||||
41-320 | Rev. 1 |