Worksheet S-7, Part IV
- Return to Cost Report Summary
- Form S704
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3514.4, REV 14
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CONCORD, NH 03301
CONCORD, NH 03301
Medicare Provider Number: 305045
Cost report status: Settled Without Audit
[Record Code 198321 - 1996]
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PROSPECTIVE PAYMENT FOR SNF STATISTICAL DATA | PROVIDER NO: 305045 |
PERIOD FROM 10/01/2002 TO 09/30/2003 |
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 |