SNFData - 185168 - 12/1999 - Worksheet D, Part I

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Form D001
INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3530.1, REV 12

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MONROE HEALTH & REHAB. CENTER
TOMPKINSVILLE, KY 42167-

Medicare Provider Number: 185168

Cost report status: Settled Without Audit

[Record Code 20773 - 1996]

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APPORTIONMENT OF ANCILLARY AND OUTPATIENT COST AND REDUCTION OF THERAPY COST COSTS							PROVIDER NO: 185168	PERIOD: FROM 04/01/1999 TO 12/31/1999		WORKSHEET D Part I
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)
		RATIO OF COST TO CHARGES (Fr. Wkst. C Column 3)	Part A	Part B	Part A (Col. 1 X Col. 2)	Part B (Col. 1 X Col. 3)	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)
		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.