SNFData - 185169 - 12/2017 - Worksheet D Part I

4036 JEFFERSON MANOR REHAB & WELLNES
LOUISVILLE, KY 40222

Medicare Provider Number: 185169

Cost report status: Settled Without Audit

[Record Code 1206910 - 2010]

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APPORTIONMENT OF ANCILLARY AND OUTPATIENT COST		Provider CCN: 185169		PERIOD: FROM 01/01/2017 TO 12/31/2017		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
		Ratio of Cost to Charges (from Wkst. C, col. 3)	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