Worksheet S-7, Part IV
- Return to Cost Report Summary
- Form S704
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3514.4, REV 14
ARLINGTON VILLA RETIREMENT COMMUNITY
ARLINGTON, TX 76012
ARLINGTON, TX 76012
Medicare Provider Number: 675916
Cost report status: Settled Without Audit
[Record Code 381774 - 1996]
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| PROSPECTIVE PAYMENT FOR SNF STATISTICAL DATA | PROVIDER NO: 675916 |
PERIOD FROM 07/01/2009 TO 12/31/2009 |
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 | ||||||||