Worksheet D Parts II & III
- Return to Cost Report Summary
- Form D002
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3530.2, REV 12
BLUE RIDGE NURSING CENTER
STUART, VA 24171
STUART, VA 24171
Medicare Provider Number: 495306
Cost report status: Settled Without Audit
[Record Code 1052767 - 2010]
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APPORTIONMENT OF ANCILLARY AND OUTPATIENT COST | Provider CCN: 495306 | PERIOD: FROM 01/01/2012 TO 12/31/2012 |
WORKSHEET D PARTS II & III |
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TITLE XVIII ONLY | |||||||
PART II - APPORTIONMENT OF VACCINE COST | |||||||
1 | Drugs charged to patients - ratio of cost to charges (from Wkst. C, col. 3, line 49) | ### | 1 | ||||
2 | Program vaccine charges (From your records or the PS&R report) | ### | 2 | ||||
3 | Program costs (line 1 x line 2) (Title XVIII, PPS providers, transfer this amount to Wkst. E, Pt. I, line 18) | ### | 3 | ||||
PART III - CALCULATION OF PASS THROUGH COSTS FOR NURSING & ALLIED HEALTH | |||||||
Cost Center Description | Total Cost (from Wkst. B, Pt. I, col. 18) | Nursing & Allied Health (from Wkst. B, Pt. I, col. 14) | Ratio of Nursing & Allied Health Costs to Total Costs - Part A (col. 2 / col. 1) | Program Part A Cost (from Wkst. D., Pt. I, col. 4) | Part A Nursing & Allied Health Costs for Pass Through (col. 3 x col. 4) | ||
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 | |||||
100 | Total (sum of lines 40 - 52) | ### | ### | 100 | |||
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4124.1) | |||||||
03-18 | Rev. 8 |