09-11,,,,,,FORM CMS-1984-99,,,,,,,3890 (Cont.) RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE EXPENSES,,,,,PROVIDER NO:,,PERIOD:,,,,,, ,,,,,,,FROM,,,,,WORKSHEET A, ,,,,,,,TO,,,,,, ,,,,,,,,,,,ADJUST-,, ,,,,,,CON-,,,RECLAS-,,MENTS,, ,,,,EMPLOYEE,,TRACTED,,,SIFICATION,,(Increase/,, ,,,SALARIES,BENEFITS,TRANSPOR-,SERVICES,,,(Increase/,,Decrease),, ,,COST CENTER DESCRIPTIONS,(From,(From,TATION,(From,,TOTAL,Decrease),,(Fr Wkst A-8,TOTAL, ,,,Wkst A-1),Wkst A-2),(See inst.),Wkst A-3),OTHER,(col. 1-5),(Fr Wkst A-6),SUBTOTAL,& A-8-1),(col.8ącol.9), ,,,1,2,3,4,5,6,7,8,9,10, ,,GENERAL SERVICE COST CENTERS,, , , ,,,,, ,, 1 ,0100,Capital Related Costs-Bldg and Fixtures,,,,,,,,,,,1 2 ,0200,Capital Related Costs-Movable Equipment,,,,,,,,,,,2 3 ,0300,Plant Operation and Maintenance,,,,,,,,,,,3 4 ,0400,Transportation - Staff,,,,,,,,,,,4 5 ,0500,Volunteer Service Coordination,,,,,,,,,,,5 6 ,0600,Administrative and General ,,,,,,,,,,,6 ,,INPATIENT CARE SERVICE,,,,,,,,,,, 10 ,1000,Inpatient - General Care,,,,,,,,,,,10 11 ,1100,Inpatient - Respite Care,,,,,,,,,,,11 ,,VISITING SERVICES,,,,,,,,,,, 15 ,1500,Physician Services,,,,,,,,,,,15 16 ,1600,Nursing Care,,,,,,,,,,,16 16.20 ,1620,Nursing Care -- Continuous Home Care,,,,,,,,,,,16.20 17 ,1700,Physical Therapy,,,,,,,,,,,17 18 ,1800,Occupational Therapy,,,,,,,,,,,18 19 ,1900,Speech/ Language Pathology,,,,,,,,,,,19 20 ,2000,Medical Social Services ,,,,,,,,,,,20 21 ,2100,Spiritual Counseling,,,,,,,,,,,21 22 ,2200,Dietary Counseling,,,,,,,,,,,22 23 ,2300,Counseling - Other,,,,,,,,,,,23 24 ,2400,Home Health Aide and Homemaker,,,,,,,,,,,24 24.20 ,2420,HH Aide & Homemaker -- Cont Home Care,,,,,,,,,,,24.20 25 ,,Other,,,,,,,,,,,25 ,,,,,,,,,,,,, ,,HH Aide & Homemaker -- Cont Hm Care,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, "FORM CMS-1984-99 (9/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3810)",,,,,,,,,,,,, ,,,,,,,,,,,,, Rev. 9,,,,,,,,,,,,,38-105 3890 (Cont.),,,,,,FORM CMS-1984-99,,,,,,,09-11 RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE EXPENSES,,,,,PROVIDER NO:,,PERIOD:,,,,,, ,,,,,,,FROM,,,,,WORKSHEET A, ,,,,,,,TO,,,,,, ,,,,,,,,,,,,, ,,,,,,CONT-,,,RECLAS-,,ADJUST-,, ,,,,EMPLOYEE,,RACTED,,,SIFICATION,,MENTS,, ,,,SALARIES,BENEFITS,TRANSPOR-,SERVICES,,,(Increase/,,(Increase/,, ,,COST CENTER DESCRIPTIONS,(From,(From,TATION,(From,,TOTAL,Decrease),,Decrease),TOTAL, ,,,Wkst A-1),Wkst A-2),(See inst.),Wkst A-3),OTHER,(col. 1-5),(Fr Wkst A-6),SUBTOTAL,(Fr Wkst A-8),(col.8ącol.9), ,,,1,2,3,4,5,6,7,8,9,10, ,,OTHER HOSPICE SERVICE COSTS,,,,,,,,,,, 30 ,3000,"Drugs, Biological and Infusion Therapy",,,,,,,,,,,30 30.30 ,3030,Analgesics,,,,,,,,,,,30.30 30.31 ,3031,Sedatives / Hypnotics,,,,,,,,,,,30.31 30.32 ,3032,Other -- Specify,,,,,,,,,,,30.32 31 ,3100,Durable Medical Equipment/Oxygen,,,,,,,,,,,31 32 ,3200,Patient Transportation,,,,,,,,,,,32 33 ,3300,Imaging Services,,,,,,,,,,,33 34 ,3400,Labs and Diagnostics,,,,,,,,,,,34 35 ,3500,Medical Supplies,,,,,,,,,,,35 36 ,3600,Outpatient Services (incl. E/R Dept.),,,,,,,,,,,36 37 ,3700,Radiation Therapy,,,,,,,,,,,37 38 ,3800,Chemotherapy,,,,,,,,,,,38 39 ,,Other,,,,,,,,,,,39 ,,HOSPICE NONREIMBURSABLE SERV.,,,,,,,,,,, 50 ,5000,Bereavement Program Costs,,,,,,,,,,,50 51 ,5100,Volunteer Program Costs,,,,,,,,,,,51 52 ,5200,Fundraising,,,,,,,,,,,52 53 ,,Other Program Costs,,,,,,,,,,,53 100 ,,Total,,,,,,,,,,,100 ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, ,,,,,,,,,,,,, "FORM CMS-1984-99 (9/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3810)",,,,,,,,,,,,, ,,,,,,,,,,,,, 38-106,,,,,,,,,,,,,Rev. 9