3290 (Cont.),,,,,FORM CMS 1728-94,,,,,05-07
HOME HEALTH AGENCY,,,,,  PROVIDER NO.:,,  PERIOD:,,WORKSHEET S-3,
STATISTICAL DATA,,,,,,,From:  ______________,,PART IV,
,,,,,  ______________,,To: ______________,,,
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"PART IV - PPS ACTIVITY DATA - Applicable for Services Rendered on or After October 1, 2000",,,,,,,Cook,,,
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,,,Full Episodes,Full Episodes,LUPA Episodes,PEP Only,SCIC within a,SCIC Only,Totals,
,     DESCRIPTION,,without Outliers,with Outliers,,Episodes,PEP,Episodes,,
,,,1 ,2 ,3 ,4 ,5 ,6 ,7 ,
30 ,Skilled Nursing Visits,,,,,,,,,30 
31 ,Skilled Nursing Visit Charges,,,,,,,,,31 
32 ,Physical Therapy Visits,,,,,,,,,32 
33 ,Physical Therapy Visit Charges,,,,,,,,,33 
34 ,Occupational Therapy Visits,,,,,,,,,34 
35 ,Occupational Therapy Visit Charges,,,,,,,,,35 
36 ,Speech Pathology Visits,,,,,,,,,36 
37 ,Speech Pathology Visit Charges,,,,,,,,,37 
38 ,Medical Social Service Visits,,,,,,,,,38 
39 ,Medical Social Service Visit Charges,,,,,,,,,39 
40 ,Home Health Aide Visits,,,,,,,,,40 
41 ,Home Health Aide Visit Charges,,,,,,,,,41 
42 ,"Total Visits (Sum of lines 30,32,34,36,38,40)",,,,,,,,,42 
43 ,Other Charges,,,,,,,,,43 
44 ,"Total Charges (Sum of lines 31,33,35,37,39,41,43)",,,,,,,,,44 
45 ,Total Number of Episodes,,,,,,,,,45 
46 ,Total Number of Outlier Episodes,,,,,,,,,46 
47 ,Total Non-Routine Medical Supply Charges,,,,,,,,,47 
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"FORM CMS-1728-94 (6-2001)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3205) ",,,,,,,,,,
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32-305.1,,,,,,,,,,Rev. 13