SNFData - 425168 - 06/2016 - Worksheet D Parts II & III

FOUNTAIN INN CONVALESCENT HOME
FOUNTAIN INN, SC 29644

Medicare Provider Number: 425168

Cost report status: Settled Without Audit

[Record Code 1221334 - 2010]

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APPORTIONMENT OF ANCILLARY AND OUTPATIENT COST		Provider CCN: 425168		PERIOD: FROM 10/01/2015 TO 06/30/2016		WORKSHEET D PARTS II & III
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)
Cost Center Description		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