Worksheet D, Part I
- Return to Cost Report Summary
- Form D001
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3530.1, REV 12
PLEASANTVIEW CENTER
CONCORD, NH 03301
CONCORD, NH 03301
Medicare Provider Number: 305045
Cost report status: Reopened
[Record Code 166681 - 1996]
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| APPORTIONMENT OF ANCILLARY AND OUTPATIENT COST AND REDUCTION OF THERAPY COST COSTS | PROVIDER NO: 305045 |
PERIOD: FROM 10/01/1998 TO 09/30/1999 |
WORKSHEET D Part I |
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| SNF - SNF Medicare - Title XVIII | |||||||||||
| PART I - CALCULATION OF ANCILLARY AND OUTPATIENT COST | |||||||||||
| Cost Center | RATIO OF COST TO CHARGES (Fr. Wkst. C Column 3) |
HEALTH CARE PROGRAM CHARGES |
HEALTH CARE PROGRAM COST |
TITLE XVIII CHARGES ON AND AFTER 1/1/1998 |
PART B THERAPY COSTS ON AND AFTER 1/1/1998 Col. 1 X 6) |
10% REDUCTION OF THERAPY (Col. 7 X 10%) |
NET ALLOWABLE PART B COSTS Col. 5 less Col. 8) |
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| Part A | Part B | Part A (Col. 1 X Col. 2) |
Part B (Col. 1 X Col. 3) |
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| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||
| ANCILLARY SERVICE COST CENTERS | |||||||||||
| 21 | Radiology | ### | ### | 21 | |||||||
| 22 | Laboratory | 22 | |||||||||
| 23 | Intravenous Therapy | 23 | |||||||||
| 24 | Oxygen (Inhalation) Therapy | ### | ### | 24 | |||||||
| 25 | Physical Therapy | ### | ### | ### | ### | ### | ### | ### | ### | 25 | |
| 26 | Occupational Therapy | ### | ### | ### | ### | ### | ### | ### | ### | 26 | |
| 27 | Speech Pathology | ### | ### | ### | ### | ### | ### | ### | ### | 27 | |
| 28 | Electrocardiology | 28 | |||||||||
| 29 | Medical Supplies Charged To Patients | ### | ### | 29 | |||||||
| 30 | Drugs Charged to Patients | ### | ### | 30 | |||||||
| 31 | Dental Care - Title XIX | 31 | |||||||||
| 32 | Support Surfaces | 32 | |||||||||
| 33 | Other Ancillary Services | 33 | |||||||||
| OUTPATIENT COST CENTERS | |||||||||||
| 34 | Clinic | 34 | |||||||||
| 35 | R H C | 35 | |||||||||
| 36 | Other Outpatient Services | 36 | |||||||||
| 48 | Ambulance (2) | ### | 48 | ||||||||
| 75 | Total (Sum of lines 21 - 48) | ### | ### | ### | ### | ### | ### | ### | ### | 75 | |
| (1) For titles V and XIX use columns 1, 2 and 4 only. | |||||||||||
| (2) Line 48 columns 2 and 4 are for titles V and XIX. No amounts should be entered here for title XVIII. | |||||||||||