3290 (Cont.),,,,,FORM CMS 1728-94,,,,,,,05-07
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES,,,,,,,PROVIDER NO:,,PERIOD:,,WORKSHEET K,
,,,,,,,_,,FROM: ____________,,,
,,,,,,,HOSPICE NO.:,,TO: _______________,,,
,,,,,,,_,,,,,
,,,,,CON-,,,,,,,
,,,EMPLOYEE,,TRACTED,,,,,,,
,,SALARIES,BENEFITS,TRANSPOR-,SERVICES,,,,SUBTOTAL,,TOTAL,
,COST CENTER DESCRIPTIONS,(From,(From,TATION,(From,,TOTAL,RECLAS-,(col. 6,ADJUST-,(col. 8,
,,Wkst.K-1),Wkst. K-2),(See inst.),Wkst. K-3),OTHER,(cols. 1-5),SIFICATION,± col. 7),MENTS,± col. 9),
,,1,2,3,4,5,6,7,8,9,10,
,GENERAL SERVICE COST CENTERS,, , , ,,,,, ,,
1 ,Capital Related Costs-Bldg and Fixt.,, , , ,,,,,,,1 
2 ,Capital Related Costs-Movable Equip.,, , , ,,,,,,,2 
3 ,Plant Operation and Maintenance,,,,,,,,,,,3 
4 ,Transportation - Staff,,,,,,,,,,,4 
5 ,Volunteer Service Coordination,,,,,,,,,,,5 
6 ,Administrative and General,,,,,,,,,,,6 
,INPATIENT CARE SERVICE,,,,,,,,,,,
7 ,Inpatient - General Care,,,,,,,,,,,7 
8 ,Inpatient - Respite Care,,,,,,,,,,,8 
,VISITING SERVICES,,,,,,,,,,,
9 ,Physician Services,,,,,,,,,,,9 
10 ,Nursing Care,,,,,,,,,,,10 
10.20,Nursing Care - Continuous Home Care,,,,,,,,,,,10.20
11 ,Physical Therapy,,,,,,,,,,,11 
12 ,Occupational Therapy,,,,,,,,,,,12 
13 ,Speech/ Language Pathology,,,,,,,,,,,13 
14 ,Medical Social Services ,,,,,,,,,,,14 
15 ,Spiritual Counseling,, , , ,,,,, ,,15 
16 ,Dietary Counseling,,,,,,,,,,,16 
17 ,Counseling - Other,,,,,,,,,,,17 
18 ,Home Health Aide and Homemaker,,,,,,,,,,,18 
18.20,Home Health Aide and Homemaker-Cont Home Care,,,,,,,,,,,18.20
19 ,Other,,,,,,,,,,,19 
,OTHER HOSPICE SERVICE COSTS,,,,,,,,,,,
20 ,"Drugs, Biological and Infusion Therapy",,,,,,,,,,,20 
20.30,Analgesics,,,,,,,,,,,20.30
20.31,Sedatives/Hypnotics,,,,,,,,,,,20.31
20.32,Other - specify,,,,,,,,,,,20.32
21 ,Durable Medical Equipment/Oxygen,,,,,,,,,,,21 
22 ,Patient Transportation,,,,,,,,,,,22 
23 ,Imaging Services,,,,,,,,,,,23 
24 ,Labs and Diagnostics,,,,,,,,,,,24 
25 ,Medical Supplies,,,,,,,,,,,25 
26 ,Outpatient Services (incl. E/R Dept.),,,,,,,,,,,26 
27 ,Radiation Therapy,,,,,,,,,,,27 
28 ,Chemotherapy,,,,,,,,,,,28 
29 ,Other,,,,,,,,,,,29 
,HOSPICE NONREIMBURSABLE SERV.,,,,,,,,,,,
30 ,Bereavement Program Costs,,,,,,,,,,,30 
31 ,Volunteer Program Costs,,,,,,,,,,,31 
32 ,Fundraising,,,,,,,,,,,32 
33 ,Other Program Costs,,,,,,,,,,,33 
34 ,Total (sum of line 1 thru 33),,,,,,,,,,,34 
,"The net expenses for cost allocation on Worksheet A for the Hospice cost center line must equal the total facility costs in column 10, line 34 of this worksheet.",,,,,,,,,,,
,,,,,,,,,,,,
"FORM CMS-1728-94-K (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3240)",,,,,,,,,,,,
,,,,,,,,,,,,
32-331.1,,,,,,,,,,,,Rev. 13