Worksheet S-7, Part IV
- Return to Cost Report Summary
- Form S704
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3514.4, REV 14
BARNSDALL NURSING HOME
BARNSDALL, OK 74002
BARNSDALL, OK 74002
Medicare Provider Number: 375482
Cost report status: Settled Without Audit
[Record Code 332268 - 1996]
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PROSPECTIVE PAYMENT FOR SNF STATISTICAL DATA | PROVIDER NO: 375482 |
PERIOD FROM 07/01/2007 TO 06/30/2008 |
WORKSHEET S-7, PART IV |
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GROUP (1) | M3PI REV CODE | SERVICES PRIOR TO October 1 | SERVICES ON OR AFTER October 1 | AIDS Diagnosis 042 Prior to 10/01 | HIGH COST RUGs (2) | TOTAL (see instructions) | |||||
RATE | DAYS | RATE | DAYS | RATE | DAYS | DAYS | |||||
1 | 2 | 3 | 3.01 | 4 | 4.01 | 4.02 | 4.03 | 4.05 | 5 | ||
1 | RUC | ### | 1 | ||||||||
2 | RUB | 2 | |||||||||
3 | RUA | 3 | |||||||||
3.01 | RUX | ### | 3.01 | ||||||||
3.02 | RUL | 3.02 | |||||||||
4 | RVC | ### | 4 | ||||||||
5 | RVB | ### | 5 | ||||||||
6 | RVA | ### | 6 | ||||||||
6.01 | RVX | ### | 6.01 | ||||||||
6.02 | RVL | ### | 6.02 | ||||||||
7 | RHC | ### | 7 | ||||||||
8 | RHB | ### | 8 | ||||||||
9 | RHA | ### | 9 | ||||||||
9.01 | RHX | 9.01 | |||||||||
9.02 | RHL | 9.02 | |||||||||
10 | RMC | 10 | |||||||||
11 | RMB | 11 | |||||||||
12 | RMA | 12 | |||||||||
12.01 | RMX | ### | 12.01 | ||||||||
12.02 | RML | ### | 12.02 | ||||||||
13 | RLB | 13 | |||||||||
14 | RLA | 14 | |||||||||
14.01 | RLX | 14.01 | |||||||||
15 | SE3 | 15 | |||||||||
16 | SE2 | 16 | |||||||||
17 | SE1 | 17 | |||||||||
18 | SSC | 18 | |||||||||
19 | SSB | 19 | |||||||||
20 | SSA | 20 | |||||||||
21 | CC2 | 21 | |||||||||
22 | CC1 | 22 | |||||||||
23 | CB2 | 23 | |||||||||
24 | CB1 | ### | 24 | ||||||||
25 | CA2 | 25 | |||||||||
26 | CA1 | 26 | |||||||||
27 | IB2 | 27 | |||||||||
28 | IB1 | 28 | |||||||||
29 | IA2 | 29 | |||||||||
30 | IA1 | 30 | |||||||||
31 | BB2 | 31 | |||||||||
32 | BB1 | 32 | |||||||||
33 | BA2 | 33 | |||||||||
34 | BA1 | 34 | |||||||||
35 | PE2 | 35 | |||||||||
36 | PE1 | 36 | |||||||||
37 | PD2 | 37 | |||||||||
38 | PD1 | 38 | |||||||||
39 | PC2 | 39 | |||||||||
40 | PC1 | 40 | |||||||||
41 | PB2 | 41 | |||||||||
42 | PB1 | 42 | |||||||||
43 | PA2 | 43 | |||||||||
44 | PA1 | 44 | |||||||||
45 | Default rate | 45 | |||||||||
46 | TOTAL | ### | 46 |