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Suggested Citation: "Appendix H: S-3 Worksheet." Institute of Medicine. 2012. Geographic Adjustment in Medicare Payment: Phase I: Improving Accuracy. Washington, DC: The National Academies Press. doi: 10.17226/13138.

Appendix H

S-3 Worksheet

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04-05						FORM CMS-2552-96													3690 (Cont.)
HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX STATISTICAL DATA							PROVIDER NO.:								PERIOD FROM ______ TO ______				WORKSHEET S-3, PART I
Component		No. of Beds	Bed Days Available	I/P Days / O/P Visits / Trips								Interns & Residents FTEs			Full Time Equivalent		Discharges
				Title V	Title XVIII	Title XIX			Total All Patients	Obs. Beds Admittec	Obs. Beds Mot Adm	Total	Less I & R Replacing Non-Phys. Anesthetist	Net	Employees On Payroll	Nonpaid Workers	Title V	Title XVIII	Title XIX	Total All Patients
				Title V	Title XVIII	Total Title XIX	Obs. Beds Admittec	Obs. Beds Not Adm	Total All Patients	Obs. Beds Admittec	Obs. Beds Mot Adm	Total	Less I & R Replacing Non-Phys. Anesthetist	Net	Employees On Payroll	Nonpaid Workers	Title V	Title XVIII	Title XIX	Total All Patients
		1	2	3	4	5	5.01	5.02	6	6.01	602	7	8	9	10	11	12	13	14	15
1	Hospital Adults & Peds. (columns 3, 4, 5 and 6, exclude Swing Bed Observation Bed and Hospice days)																				1
2	HMO																				2
3	Hospital Adults & Peds. Swing Bed SNF																				3
4	Hospital Adults & Peds. Swing Bed NF																				4
5	Total Adults and Peds. (exclude observation beds) (see instructions)																				5
6	Intensive Care Unit																				6
7	Coronary Care Unit																				7
8	Burn Intensive Care Unit																				8
9	Surgical Intensive Care Unit																				9
10	Other Special Care																				10
11	Nursery																				11
12	Total (see instructions)																				12
13	RPCH\CAH visits																				13
14	Subprovider																				14
15	Skilled Nursing Facility																				15
16	Nursing Facility																				16
17	Other Long Term Care																				17
18	Home Health Agency																				18
20	ASC (Distinct Part)																				20
21	Hospice (Distinct Part)																				21
23	Outpatient Rehab. Provider (specify)																				23
24	RHC/FQHC (specify)																				24
25	Total (sum of lines 12-24)																				25
26	Observation Bed Days																				26
27	Ambulance Trips																				27
28	Employee discount days (see instru.)																				28

FORM CMS-2552-96 (4-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3605.1)

Rev. 14

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3690		FORM CMS-2552-96			04-05
HOSPITAL WAGE INDEX INFORMATION			PROVIDER NO.: _________		PERIOD: FROM _________ TO _________		WORKSHEET S-3, PART III
PART II - WAGE DATA
		Amount Reported	Reclass. of Salaries (from Wkst. A-6)	Adjusted Salaries (col. 1 ± col. 2)	Paid Hours Related to Salaries in col. 3	Average Hourly Wage (col. 3 + col. 4)	Data Source
		1	2	3	4	5	6
	SALARIES
1	Total salaries (see instructions)							1
2	Non-physician anesthetist Part A							2
3	Non-physician anesthetist Part B							3
4	Physician-Part A							4
4.01	Teaching physician salaries (see instructions)							4.01
5	Physician-Part B							5
5.01	Non-physician-Part B							5.01
6	Interns & residents (in an approved program)							6
6.01	Contract services, I&R (see instructions)							6.01
7	Home office personnel							7
8	SNF							8
8.01	Excluded area salaries (see instructions)							8.01
	OTHER WAGES & RELATED COSTS
9	Contract labor (see instructions)							9
9.01	Pharmacy services under contract							9.01
9.02	Laboratory services under contract							9.02
9.03	Management and administrative services							9.03
10	Contract labor: physician-Part A							10
10.01	Teaching physician under contract (see instru.)							10.01
11	Home office salaries & wage-related costs							11
12	Home office: physician Part A							12
12.01	Teaching physician salaries (see instructions)							12.01
	WAGE-RELATED COSTS
13	Wage-related costs (core)						CMS 339	13
14	Wage-related costs (other)						CMS 339	14
15	Excluded areas						CMS 339	15
16	Non-physician anesthetist Part A						CMS 339	16
17	Non-physician anesthetist Part B						CMS 339	17
18	Physician Part A						CMS 339	18
18.01	Part A teaching physicians (see instructions)						CMS 339	18.01
19	Physician Part B						CMS 339	19
19.01	Wage-related costs (RHC/FQHC)						CMS 339	19.01
20	Interns & residents (in an approved program)						CMS 339	20

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_______

FORM CMS-2552-96 (5/2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3605.2)

36-506.2 06-03		FORM CMS-2552-96			Rev. 14 3690 (Cont.)
HOSPITAL WAGE INDEX INFORMATION			PROVIDER NO.: _______		PERIOD: FROM ______ TO ______		WORKSHEET S-3, PART III

PART II - WAGE DATA
		Amount Reported	Reclass. of Salaries (from Wkst. A-6)	Adjusted Salaries (col. 1 ± col. 2)	Paid Hours Related to Salaries in col. 3	Average Hourly Wage (col. 3 + col. 4)	Data Source
		1	2	3	4	5	6
	OVERHEAD COST - DIRECT SALARIES
21	Employee Benefits							21
22	Administrative & General							22
22.01	Administrative & General under contract (see inst.)							22.01
23	Maintenance & Repairs							23
24	Operation of Plant							24
25	Laundry & Linen Service							25
26	Housekeeping							26
26.01	Housekeeping under contract (see instructions)							26.01
27	Dietary							27
27.01	Dietary under contract (see instructions)							27.01
28	Cafeteria							28
29	Maintenance of Personnel							29
30	Nursing Administration							30
31	Central Services and Supply							31
32	Pharmacy							32
33	Medical Records & Medical Records Library							33
34	Social Service							34
35	Other General Service							35
PART III - HOSPITAL WAGE INDEX SUMMARY
1	Net salaries (see instructions)							1
2	Excluded area salaries (see instructions)							2
3	Subtotal salaries (line 1 minus line 2)							3
4	Subtotal other wages & related costs (see inst.)							4
5	Subtotal wage-related costs (see inst.)							5
6	Total (sum of lines 3 thru 5)							6
7	Net salaries (see instructions)							7
8	Excluded area salaries							8
9	Subtotal salaries (line 7 minus line 8)							9
10	Subtotal other wages & related costs (see inst.)							10
11	Subtotal wage-related costs (see inst.)							11
12	Total (sum of lines 9 thru 11)							12
13	Total overhead costs (see inst.)							13

Geographic Adjustment in Medicare Payment: Phase I: Improving Accuracy (2012)

Chapter: Appendix H: S-3 Worksheet

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Geographic Adjustment in Medicare Payment: Phase I: Improving Accuracy (2012)

Chapter: Appendix H: S-3 Worksheet