Worksheet D Part I
- Return to Cost Report Summary
- Form D001
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3530.1, REV 12
ACCORDIUS HEALTH AT LYNCHBURG LLC
LYNCHBURG, VA 24501-1443
LYNCHBURG, VA 24501-1443
Medicare Provider Number: 495151
Cost report status: Settled Without Audit
[Record Code 1341269 - 2010]
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APPORTIONMENT OF ANCILLARY AND OUTPATIENT COST | Provider CCN: 495151 | PERIOD: FROM 01/01/2020 TO 12/31/2020 |
WORKSHEET D PART I | ||||
SNF - SNF Medicare - Title XVIII | |||||||
PART I - CALCULATION OF ANCILLARY AND OUTPATIENT COST | |||||||
Cost Center Description | Ratio of Cost to Charges (from Wkst. C, col. 3) | Health Care Program Charges | Healthcare Program Cost | ||||
Part A | Part B | Part A ( col. 1 x col. 2 ) | Part B ( col. 1 x col. 3 ) | ||||
1 | 2 | 3 | 4 | 5 | |||
ANCILLARY SERVICE COST CENTERS | |||||||
40 | Radiology | 40 | |||||
41 | Laboratory | 41 | |||||
42 | Intravenous Therapy | 42 | |||||
43 | Oxygen (Inhalation) Therapy | 43 | |||||
44 | Physical Therapy | ### | ### | ### | 44 | ||
45 | Occupational Therapy | ### | ### | ### | 45 | ||
46 | Speech Pathology | ### | ### | ### | 46 | ||
47 | Electrocardiology | 47 | |||||
48 | Medical Supplies Charged to Patients | 48 | |||||
49 | Drugs Charged to Patients | ### | ### | ### | 49 | ||
50 | Dental Care - Title XIX only | 50 | |||||
51 | Support Surfaces | 51 | |||||
52 | Other Ancillary Service Cost | 52 | |||||
OUTPATIENT COST CENTERS | |||||||
60 | Clinic | 60 | |||||
61 | Rural Health Clinic (RHC) | 61 | |||||
62 | FQHC | 62 | |||||
63 | Other Outpatient Service Cost | 63 | |||||
71 | Ambulance (2) | 71 | |||||
100 | Total (sum of lines 40 - 71) | ### | ### | 100 | |||
(1) For titles V and XIX use columns 1, 2 and 4 only. (2) Line 71 columns 2 and 4 are for titles V and XIX. No amounts should be entered here for title XVIII. | |||||||
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4124) | |||||||
08-16 | Rev. 7 |