3290 (Cont.),,,,,,,,,FORM CMS 1728-94,,,,,,,05-07 APPORTIONMENT OF PATIENT SERVICE COSTS,,,,,,,,,,PROVIDER NO.: ,, PERIOD:,,,WORKSHEET C, ,,,,,,,,,,,,From: ______________,,,PARTS I & II, ,,,,,,,,,,______________,,To: ______________,,,, PART I - AGGREGATE AGENCY COST PER VISIT COMPUTATION,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,Average, Cost Per Visit Computation,,,,,,,,,,,,From Wkst ,,,Cost, ,,,,,,,,,,,,"B, Col. 6,",Total,,Per Visit, , Patient Services,,,,,,,,,,,Line:,Cost,Visits,(Cols 2 ÷ 3) (1), ,,,,,,,,,,,,1,2,3,4, 1, Skilled Nursing,,,,,,,,,,,6,,,, 1 2, Physical Therapy,,,,,,,,,,,7,,,, 2 3, Occupational Therapy,,,,,,,,,,,8,,,, 3 4, Speech Pathology,,,,,,,,,,,9,,,, 4 5, Medical Social Services,,,,,,,,,,,10,,,, 5 6, Home Health Aide Services,,,,,,,,,,,11,,,, 6 7, Total (Sum of lines 1-6),,,,,,,,,,,,,,, 7 ,,,,,,,,,,,,,,,, PART II - COMPUTATION OF THE AGGREGATE MEDICARE COST AND THE AGGREGATE OF THE MEDICARE LIMITATION (2),,,,,,,,,,,,,,,, ,,,,,,,,,Medicare Program Visits,,,Cost of Medicare Services,,,, ,MSA/CBSA CODE: ,,,,,,,,,Part B,,,Part B,,, ,,,,,,,"From Wkst. C,",Average,,Not Subject,Subject,,Not Subject,Subject,Total, ,,,,,,,"Part I, Col. 4,",Cost,,to Deductibles,to Deductibles,,to Deductibles,to Deductibles,(Sum of, , Total Medicare Patient Service Cost Computation,,,,,,Line:,Per Visit,Part A,& Coinsurance,& Coinsurance,Part A,& Coinsurance,& Coinsurance,Cols 8 & 9), ,,,,,,,,4,5,6,7,8,9,10,11, 1, Skilled Nursing,,,,,,1,,,,,,,,, 1 2, Physical Therapy,,,,,,2,,,,,,,,, 2 3, Occupational Therapy,,,,,,3,,,,,,,,, 3 4, Speech Pathology,,,,,,4,,,,,,,,, 4 5, Medical Social Services,,,,,,5,,,,,,,,, 5 6, Home Health Aide Services,,,,,,6,,,,,,,,, 6 7, Total (Sum of lines 1-6),,,,,,,,,,,,,,, 7 ,,,,,,,,,,,,,,,, ,,,,,,,,,Medicare Program Visits,,,Cost of Medicare Services,,,, ,,,,,,,,,,Part B,,,Part B,,, ,,,,,,,,Program,,Not Subject,Subject,,Not Subject,Subject,Total, ,,,,,,,,Cost,,to Deductibles,to Deductibles,,to Deductibles,to Deductibles,(Sum of, , Total Medicare Patient Service Cost Limitation Computation,,,,,,,Limits,Part A,& Coinsurance,& Coinsurance,Part A,& Coinsurance,& Coinsurance,Cols 8 & 9, ,,,,,,,,4,5,6,7,8,9,10,11, 8, Skilled Nursing,,,,,,,,,,,,,,, 8 9, Physical Therapy,,,,,,,,,,,,,,, 9 10, Occupational Therapy,,,,,,,,,,,,,,,10 11, Speech Pathology ,,,,,,,,,,,,,,,11 12, Medical Social Services,,,,,,,,,,,,,,,12 13, Home Health Aide Services,,,,,,,,,,,,,,,13 14," Total (Sum of lines 8-13 plus the subscripts of lines 1-6, respectively)",,,,,,,,,,,,,,,14 ,"(1) Compute the average cost per visit one time for each discipline (column 4, lines 1 through 6) for the entire home health agency. ",,,,,,,,,,,,,,, ,"(2) Complete Worksheet C, Part II once for each MSA where Medicare covered services were furnished during the cost reporting period.",,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,, "FORM CMS-1728-94-C (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3215 - 3215.5)",,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,, 32-320,,,,,,,,,,,,,,,,Rev. 13 05-07,,,,,,,,,FORM CMS 1728-94,,,,,,,3290 (Cont.) APPORTIONMENT OF PATIENT SERVICE COSTS,,,,,,,,,,PROVIDER NO.: ,, PERIOD:,,,WORKSHEET C, ,,,,,,,,,,,,From: ______________,,,"PARTS III, IV & V", ,,,,,,,,,,______________,,To: ______________,,,, PART III - SUPPLIES AND DRUGS COST COMPUTATION,,,,,,,,,,,,,,,, ,,,,,,,,,,Medicare Covered Charges ,,,Cost of Services ,,, ,,,,,,,,Total,,,Part B,,,Part B,, ,,,,,,From Wkst ,,Charges,,,Not Subject,Subject,,Not Subject,Subject, ,,,,,,"B, Col. 6,",Total,from HHA,Ratio,,to Deductibles,to Deductibles,,to Deductibles,to Deductibles, , Other Patient Services,,,,,Line:,Cost,Record),(Col 2 ÷ 3),Part A,& Coinsurance ,& Coinsurance,Part A,& Coinsurance,& Coinsurance, ,,,,,,1,2,3,4,5,6,7,8,9,10, 15, Cost of Medical Supplies,,,,,12,,,,,,,,,,15 16, Cost of Drugs,,,,,13,,,,,,,,,,16 16.20, Cost of Drugs,,,,,13.20,,,,,,,,,,16.20 ,,,,,,,,,,,,,,,, "PART IV - COMPARISON OF THE LESSER OF THE AGGREGATE MEDICARE COST, THE AGGREGATE OF THE MEDICARE COST PER VISIT LIMITATION AND THE AGGREGATE PER BENEFICIARY COST LIMITATION",,,,,,,,,,,,,,,, ,,,,,,,,,,Medicare Program,Per Beneficiary,,,,, ,,,,,,,,,,Unduplicated,Annual,Cost of Medicare Services,,,, ,,,,,,,,,,Census Count,Limitation Per,,Part B,,, ,,,,,,,,,,For Each MSA,MSA/Non-MSA,,Not Subject,Subject,Total, ,,,,,,,,,,Pre 10/1/2000,(From Your,,to Deductibles,to Deductibles,(Sum of, ,,,,,,,,,,(4),Intermediary),Part A,& Coinsurance,& Coinsurance,Cols 3 & 4, ,,,,,,,,,,1,2,3,4,5,6, 17,"Total Cost of Medicare Services (Sum of the amounts from each Wkst. C, Pt. II, cols. 8, 9 & 11, respectively, lines",,,,,,,,,,,,,,,17 ,1-6 (exculsive of subscripts)),,,,,,,,,,,,,,, 18,"Cost of Medical Supplies (from Part III, columns 8 and 9, line 15 (exclusive of line 15.01))",,,,,,,,,,,,,,,18 19,Total (Sum of lines 17 and 18),,,,,,,,,,,,,,,19 ,,,,,,,,,,,,,,,, 20,"Total Cost Per Visit Limitation for Medicare Services (Sum of the amounts from each Wkst. C, Pt. II, cols. 8, 9 &11, respectively, line 14)",,,,,,,,,,,,,,,20 21,"Cost of Medical Supplies (from Part III, columns 8 and 9, line 15 (exclusive of line 15.01))",,,,,,,,,,,,,,,21 22,Total (Sum of lines 20 and 21),,,,,,,,,,,,,,,22 ,,,,,,,,,,,,,,,, ,,,,,,,,,MSA Code (3),,,,,,(Col 1 x 2), ,,,,,,,,,0 ,1,2,3,4,5,6, 23,Per Beneficiary Cost Limitation for MSA:,,,,,,,,,,,,,,,23 23.01,Per Beneficiary Cost Limitation for MSA:,,,,,,,,,,,,,,,23.01 23.02,Per Beneficiary Cost Limitation for MSA:,,,,,,,,,,,,,,,23.02 23.03,Per Beneficiary Cost Limitation for MSA:,,,,,,,,,,,,,,,23.03 23.04,Per Beneficiary Cost Limitation for MSA:,,,,,,,,,,,,,,,23.04 23.05,Per Beneficiary Cost Limitation for MSA:,,,,,,,,,,,,,,,23.05 23.06,Per Beneficiary Cost Limitation for MSA:,,,,,,,,,,,,,,,23.06 23.07,Per Beneficiary Cost Limitation for MSA:,,,,,,,,,,,,,,,23.07 23.08,Per Beneficiary Cost Limitation for MSA:,,,,,,,,,,,,,,,23.08 23.09,Per Beneficiary Cost Limitation for MSA:,,,,,,,,,,,,,,,23.09 24,Aggregate Per Beneficiary Cost Limitation (Sum of lines 23 and subscripts thereof),,,,,,,,,,,,,,,24 ,,,,,,,,,,,,,,,, PART V - OUTPATIENT THERAPY REDUCTION COMPUTATION,,,,,,,,,,,,,,,, ,,,,,,,,Part B,,,,,,,, ,,,,,,,,Subject to Deductibles and Coinsurance,,,,,,,, ,,,,,,,,Medicare,Medicare,Medicare,Medicare,Medicare,Medicare,,, ,,,,,,"From Wkst. C,",Average,Program Visits,Program Costs,Program Visits,Program Visits,Program Visits,Program Costs,Application of,Reasonable, ,,,,,,"Part I, Col. 4,",Cost,for Services,for Services,for Services,for Services,for Services on ,for Services,the Reasonable ,Costs Net of , , Patient Services,,,,,Line:,Per Visit,Before 1/1/98,Before 1/1/98,1/1/98-12/31/98,1/1/99-9/30/00,or after 10/1/00,1/1/98-12/31/98,Cost Reduction,Adjustments, ,,,,,,1,2,3,4,5,5.01,5.02,6,7,8, 25, Physical Therapy,,,,,2,,,,,,,,,,25 26, Occupational Therapy,,,,,3,,,,,,,,,,26 27, Speech Pathology,,,,,4,,,,,,,,,,27 28, Total (Sum of lines 25-27),,,,,,,,,,,,,,,28 ,"(3) The MSA/CBSA codes flow from Worksheet S-3, Part III, line 29 and subscripts as indicated.",,,,,,,,,,,,,,, ,"(4) The sum of column 1, line 24 must equal Worksheet S-3, Part I, column 2, line 10.01.",,,,,,,,,,,,,,, "FORM CMS-1728-94-C (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3215 - 3215.5)",,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,, Rev. 13,,,,,,,,,,,,,,,,32-321