06-01,,,FORM CMS 1728-94,,,,, 3290 (Cont.)
CALCULATION OF PER DIEM COST,,,PROVIDER NO:,,PERIOD:,, WORKSHEET  K-6,
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,,,HOSPICE NO.:,,TO: _______________,,,
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,COMPUTATION OF PER DIEM COST,,,TITLE XVIII,TITLE XIX,OTHER,TOTAL,
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1,"Total cost (Worksheet K-5, Part I, col. 8, line 29 less col. 8, line 28",,,,,,,1
,"plus Worksheet K-5, Part III, col. 6, line 7)  (see instructions)",,,,,,,
2,"Total Unduplicated Days (Worksheet S-5, line 5, col. 4)",,,,,,,2
3,Average cost per diem (line 1 divided by line 2),,,,,,,3
4,"Unduplicated Medicare Days (Worksheet S-5, line 5, col. 1)",,,,,,,4
5,Aggregate Medicare cost (line 3 times line 4),,,,,,,5 
6,Unduplicated Medicaid Days (Not Applicable),,,,,,,6 
7,Aggregate Medicaid cost (Not Applicable),,,,,,,7
8,"Unduplicated SNF days (Worksheet S-5, line 5, col. 2)",,,,,,,8
9 ,Aggregate SNF cost (line 3 times line 8),,,,,,,9 
10 ,Unduplicated NF days (Not Applicable),,,,,,,10 
11 ,Aggregate NF cost (Not Applicable),,,,,,,11 
12 ,"Other unduplicated days (Worksheet S-5, line 5, col. 3)",,,,,,,12 
13 ,Aggregate cost for other days (line 3 times line 12),,,,,,,13 
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NOTE:  The data for the SNF on line 8 & 9 are included in the Medicare lines 4 & 5. ,,,,,,,,
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"FORM  CMS-1728-94 (6-2001) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3246)",,,,,,,,
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Rev. 10,,,,,,,,32-331.10