Department of Health and Medicare Human Services (DHHS) Provider Reimbursement Manual Centers for Medicare and Part 2, Provider Cost Reporting Forms and Medicaid Services (CMS) Instructions, Chapter 41, Form CMS-2540-10 Transmittal 7 Date: August 19 2016 HEADER SECTION NUMBERS PAGES TO INSERT PAGES TO DELETE Table of Contents – 4104 (Cont.) 41-1 - 41-18 (20 pp.) 41-1 - 41-18 (16 pp.) 4104.1 (Cont.) - 4105.4 (Cont.) 41-21 - 41-30 (10 pp.) 41-21 - 41-30 (10 pp.) 4106 (Cont.) - 4113 41-33 - 41-40 (10 pp.) 41-33 - 41-40 (8 pp.) 4120 (Cont.) – 4131 (Cont.) 41-57 - 41-74 (20 pp.) 41-57 - 41-74 (20 pp.) 4140.3 (Cont.) - 4141 41-81 - 41-84 (4 pp.) 41-81 - 41-84 (4 pp.) 4141 (Cont.) - 4142 41-87 - 41-88 (2 pp.) 41-87 - 41-88 (2 pp.) 4145 - 4157 (Cont.) 41-97 - 41-118 (22 pp.) 41-97 - 41-118 (22 pp.) 4161 (Cont.) – 4164.5 (Cont.) 41-129 - 41-146 (18 pp.) 41-129 - 41-132 (4 pp.) 4190 - 4190 (Cont.) 41-301 - 41-302 (2 pp.) 41-301 - 41-302 (2 pp.) 41-303 - 41-309.1 (8 pp.) 41-303 - 41-309.1 (8 pp.) 41-311 - 41-316 (6 pp.) 41-311 - 41-316 (6 pp.) 41-321 - 41-348 (28 pp.) 41-321 - 41-348 (28 pp.) 41-351 - 41-354 (4 pp.) 41-351 - 41-354 (4 pp.) 41-363 - 41-370 (8 pp.) 41-363 - 41-370 (8 pp.) 41-381 - 41-382 (2 pp.) 41-381 - 41-382 (2 pp.) 41-395 - 41-408 (14 pp.) 41-395 - 41-395 (1 pp.) 4195 (Cont.) - 4195 (Cont.) 41-501 - 41-508 (10 pp.) 41-501 - 41-508 (8 pp.) 41-513 - 41-516 (4 pp.) 41-513 - 41-516 (4 pp.) 41-531 - 41-534 (6 pp.) 41-531 - 41-534 (4 pp.) 41-549 - 41-556 (10 pp.) 41-549 - 41-556 (10 pp.) 41-559 - 41-570 (16 pp.) 41-559 - 41-570 (14 pp.) NEW/REVISED MATERIAL--EFFECTIVE DATE: Cost Reporting Periods Beginning on or After October 1, 2015. This transmittal updates Chapter 41, Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Cost Reports, Form CMS-2540-10 to incorporate §3132 of the Patient Protection and Affordable Care Act (ACA) which require that CMS collect appropriate data and information to facilitate hospice payment reform. The effective dates vary. Revisions include: • Addition of Worksheets S-8 Parts III & IV, O, O-1, O-2, O-3, O-4, O-5, O-6 Parts I & II, O- 7 and O-8 • Revised instructions for Worksheets S-5, I-1, I-2, I-3, I-4 and I-5 • Addition of specifications for Worksheets S-8 Parts III & IV, O, O-1, O-2, O-3, O-4, O-5, O-6 Parts I & II, O-7 and O-8 • Addition of edits 1065S, 1300S, 1310S, 1320S, 1330S, 1340S, 1350S, 1010A, 1060A 1020K, 1000O, 1010O, 1020O, 1030O, 1040O, 1050O and 1060O • Revised edit 1020I REVISED ELECTRONIC SPECIFICATIONS EFFECTIVE DATE: Changes to the electronic reporting specifications are effective for cost reporting periods beginning on or after October 1, 2015. DISCLAIMER: The revision date and transmittal number apply to the red italicized material only. Any other material was previously published and remains unchanged. Pub 15-2-41 CHAPTER 41 SKILLED NURSING FACILITY AND SKILLED NURSING FACILITY HEALTH CARE COMPLEX COST REPORT FORM CMS-2540-10 Section General .......................................................................................................................4100 Rounding Standards for Fractional Computations ..................................................4100.1 Acronyms and Abbreviations .................................................................................4100.2 Recommended Sequence for Completing a SNF Cost Report ..................................4101 Recommended Sequence for Completing a SNF or SNF Health Care Complex - Full Cost Report ................................................................4101.1 Sequence of Assembly ...............................................................................................4102 Worksheet S - Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Cost Report Certification and Settlement Summary ........................4103 Part I - Cost Report Status ......................................................................................4103.1 Part II - Certification ...............................................................................................4103.2 Part III - Settlement Summary ................................................................................4103.3 Worksheet S-2 - Part I Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Identification Data ..............................................4104 Part II - Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Reimbursement Questionnaire .........................................4104.1 Worksheet S-3, Parts I - Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Statistical Data ...............................................................4105 Part II - SNF Wage Index Information - Direct Salaries........................................4105.1 Part III - SNF Wage Index Information - Overhead Costs - Direct Salaries .........4105.2 Part IV - SNF Wage Related Costs .........................................................................4105.3 Part V - SNF Reporting of Direct Care Expenditures ............................................4105.4 Worksheet S-4 - SNF-Based Home Health Agency Statistical Data .........................4106 Worksheet S-5 - SNF-Based RHC/FQHC Statistical Data........................................4107 Worksheet S-6 - SNF-Based Community Mental Health Centers and Other Outpatient Rehabilitation Provider Statistical Data ...................................................4108 Worksheet S-7 – Prospective Payment for Skilled Nursing Facilities Statistical Data ........................................................................................................4109 Worksheet S-8 - SNF-Based Hospice Identification Data .........................................4110 Part I - Enrollment Days for Cost Reporting Periods Beginning Before October 1, 2015 ........................................................................................4110.1 Part II - Census Data for Cost Reporting Periods Beginning Before October 1, 2015 ........................................................................................4110.2 Part IIII- Enrollment Days Based on level of Care for Cost Reporting Periods Beginning On or After October 1, 2015 .................................................4110.3 Part IV - Contracted Statistical Data for Cost Reporting Periods Beginning On or After October 1, 2015 .................................................4110.4 Rev. 7 41-1 SKILLED NURSING FACILITY AND SKILLED NURSING FACILITY HEALTH CARE COMPLEX COST REPORT FORM CMS-2540-10 Section Worksheet A - Reclassification and Adjustment of Trial Balance of Expenses ...............................................................................................4113 Worksheet A-6 - Reclassifications.............................................................................4114 Worksheet A-7 - Analysis of Changes in Capital Asset Balances .............................4115 Worksheet A-8 - Adjustments to Expenses ...............................................................4116 Worksheet A-8-1 - Statement of Costs of Services From Related Organizations and Home Office Costs ...........................................................................................4117 Worksheet A-8-2 - Provider-Based Physician Adjustments ......................................4118 Worksheet B, Part I - Cost Allocation - General Service Costs and Worksheet B-1 - Cost Allocation - Statistical Basis .......................................................................................................4120 Worksheet B, Part II - Allocation of Capital-Related Cost .......................................4121 Worksheet B-2 - Post Step Down Adjustments .........................................................4122 Worksheet C - Ratio of Cost to Charges for Ancillary and Outpatient Cost Centers ....................................................................................................................4123 Worksheet D - Apportionment of Ancillary and Outpatient Cost ...........................4124 Part I - Calculation of Ancillary and Outpatient Cost .............................................4124.1 Part II - Apportionment of Vaccine Cost ................................................................4124.2 Part III - Calculation of Pass Through Costs for Nursing & Allied Health ............4124.3 Worksheet D-1 - Computation of Inpatient Routine Costs ........................................4125 Part I - Calculation of Inpatient Routine Costs .......................................................4125.1 Part II - Calculation of Inpatient Nursing & Allied Health Cost for PPS Pass through ......................................................................................4125.2 Worksheet E - Parts I and II .......................................................................................4130 Part I - Calculation of Reimbursement Settlement Title XVIII ...............................4130.1 Part II - Calculation of Reimbursement Settlement for Title V and Title XIX Only .....................................................................................................4130.2 Worksheet E-1 - Analysis of Payments to Providers for Services Rendered ...................................................................................................4131 Financial Statement Worksheets ................................................................................4140 Worksheet G - Balance Sheet ....................................................................................4140.1