08-99,,,,,FORM CMS 1728-94,,,3290 (Cont.)
,,,,   PROVIDER NO.:,, PERIOD:,,
,   ADJUSTMENTS TO EXPENSES,,,  _______________,,From: __________,  WORKSHEET A-5,
,,,,,,To: __________,,
,,,, ,, Expense Classification on Worksheet A,,
,,,, ,, To/From Which The Amount is to be Adjusted,,
,     Description (1),,,(2),,,,
,,,,BASIS/CODE,Amount,Cost Center,Line No.,
,,,,1,2,3,4,
 1,"Excess funds generated from operations,",,,B,"(3,985)",A&G Shared Costs,5.01 , 1
,other than net income,,,,,,,
 2,"Trade, quantity, time and other discounts",,,B,,,, 2
,on purchases (Chap. 8),,,,,,,
 3, Rebates and refunds of expenses (Chap. 8),,,B,,,, 3
 4, Home office costs (Chap. 21),,,A,"15,250 ",A&G Reimb. Costs,5.02 , 4
 5,Adjustments resulting from transaction,,,From Wks,#REF!,#REF!,#REF!, 5
,with related organization (Chap. 10),,,A-6,,,,
 6, Sale of medical records and abstracts,,,B,,,, 6
 7,"Income from imposition of interest,",,,B,,,, 7
,finance or penalty charges (Chap. 21),,,,,,,
 8,Sale of medical and surgical supplies to,,,A,,,, 8
,other than patients,,,,,,,
 9, Sale of Drugs to other than patients,,,A,,,, 9
10,Physical therapy adjustment (Chap. 14),,,From Supp,,,,10
,,,,Wks A-8-3,,Physical Therapy,7,
10.1,Occupational therapy adjustment (Chap. 14),,,From Supp,,,,10.1
,,,,Wks A-8-3,,Occupational Therapy,8 ,
10.2,Speech pathology adjustment (Chap. 14),,,From Supp,,,,10.2
,,,,Wks A-8-3,,Speech Pathology,9 ,
11,Interest expense on Medicare overpayments and,,,A,,,,11
,borrowings to repay Medicare overpayments,,,,,,,
12,Lobbying Activities,,,A,"(2,050)",A&G Nonreimb. Costs,5.03 ,12
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21, TOTAL (Sum of lines 1-20),,,,#REF!,,,21
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,(1) Description - All line references in this column pertain to the Provider,,,,,,,
,"    Reimbursement Manual, Part I.",,,,,,,
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,(2) Basis for adjustment (See Instructions),,,,,,,
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,"    A.  Costs - if cost, including applicable overhead, can be determined",,,,,,,
,    B.  Amount Received - If cost cannot be determined,,,,,,,
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"FORM CMS-1728-94-A-5  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3211)",,,,,,,,
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Rev. 7,,,,,,,,32-313