SNFData - 135051 - 12/2018 - Worksheet D Part I

CANYON WEST OF CASCADIA
CALDWELL, ID 83605

Medicare Provider Number: 135051

Cost report status: Settled Without Audit

[Record Code 1236630 - 2010]

Excel

PDF

You are not logged in or you have not purchased this report. This report has had its actual values replaced with dummy text ('###').

If you would like to become a subscriber, please look at our subscription details.

If you are already a subscriber, please login.

APPORTIONMENT OF ANCILLARY AND OUTPATIENT COST		Provider CCN: 135051		PERIOD: FROM 01/01/2018 TO 12/31/2018		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