Worksheet D, Part II
- Return to Cost Report Summary
- Form D002
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3530.2, REV 12
MCHS WILMINGTON
WILMINGTON, DE 19803
WILMINGTON, DE 19803
Medicare Provider Number: 085028
Cost report status: Settled Without Audit
[Record Code 328467 - 1996]
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APPORTIONMENT OF ANCILLARY AND OUTPATIENT COST AND REDUCTION OF THERAPY COST FOR TITLE XVIII | PROVIDER NO: 085028 |
PERIOD: FROM 06/01/2007 TO 12/20/2007 |
WORKSHEET D Part II |
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Select other programs and payment systems available | |||||||
PART II - APPORTIONMENT OF VACCINE COST | |||||||
1 | Drugs charged to patients - ratio of cost to charges (From Worksheet C, column 3, line 30) | ### | 1 | ||||
2 | Program vaccine charges (From your records, or the P S & R.) | 2 | |||||
3 | Program costs (Line 1 X line 2) (Title XVIII, PPS providers, transfer this amount to Worksheet E, Part III, line 20) | 3 | |||||
PART III - CALCULATION OF PASS THROUGH COSTS FOR INTERNS & RESIDENTS | |||||||
Cost Centers | Total Cost (From Worksheet B, Part I, Col 18) |
Intern and Residents Costs (From Wkst. B, Part I, Column 14) |
Ratio of Intern & Residents Costs To Total Costs - Part A (Col. 2 / Col.. 1) |
Program Part A Cost (From Wkst. D. Part 1, Col. 4) |
Program Intern & Residents Costs for Pass Through (Col. 3 X Col. 4) |
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1 | 2 | 3 | 4 | 5 | |||
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 | 29 | |||||
30 | Drugs Charged to Patients | 30 | |||||
31 | Dental Care - Title XIX only | 31 | |||||
32 | Support Surfaces | 32 | |||||
33 | Other Ancillary Service Costs | 33 | |||||
75 | Total (Sum of lines 21 - 33) | 75 |