Worksheet A-8
- Return to Cost Report Summary
- Form A800
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3519, REV 4
CHATEAU DE NOTRE DAME
NEW ORLEANS, LA 70125
NEW ORLEANS, LA 70125
Medicare Provider Number: 195589
Cost report status: Settled Without Audit
[Record Code 1212159 - 2010]
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ADJUSTMENTS TO EXPENSES | Provider CCN: 195589 | PERIOD: FROM 07/01/2016 TO 06/30/2017 |
WORKSHEET A-8 | |||
Description (1) | Basis for Adjustment (2) | Amount | Expense Classification on Wkst. A to/from which the amount is to be adjusted |
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Cost Center | Line No. | |||||
0 | 1 | 2 | 3 | 4 | ||
1 | Investment income on restricted funds (Chapter 2) | ### | ### | ### | ### | 1 |
2 | Trade, quantity and time discounts on purchases (Chapter 8) | 2 | ||||
3 | Refunds and rebates of expenses Chapter 8) | 3 | ||||
4 | Rental of provider space by suppliers Chapter 8) | 4 | ||||
5 | Telephone services (pay stations excluded) (Chapter 21) | 5 | ||||
6 | Television and radio service (Chapter 21) | ### | ### | ### | ### | 6 |
7 | Parking lot (Chapter 21) | 7 | ||||
8 | Remuneration applicable to provider-based physician adjustment | Worksheet A-8-2 | 8 | |||
9 | Home office costs (Chapter 21) | 9 | ||||
10 | Sale of scrap, waste, etc. (Chapter 23) | 10 | ||||
11 | Nonallowable costs related to certain Capital expenditures (Chapter 24) | 11 | ||||
12 | Adjustment resulting from transactions with related organizations (Chapter 10) | Worksheet A-8-1 | ### | 12 | ||
13 | Laundry and Linen service | 13 | ||||
14 | Revenue - Employee meals | 14 | ||||
15 | Cost of meals - Guests | 15 | ||||
16 | Sale of medical supplies to other than patients | 16 | ||||
17 | Sale of drugs to other than patients | 17 | ||||
18 | Sale of medical records and abstracts | 18 | ||||
19 | Vending machines | ### | ### | ### | ### | 19 |
20 | Income from imposition of interest, finance or penalty charges (Chapter 21) | 20 | ||||
21 | Interest expense on Medicare overpayments and borrowings to repay Medicare overpayments | 21 | ||||
22 | Utilization review--physicians' compensation (Chapter 21) | Utilization Review- SNF | 82 | 22 | ||
23 | Depreciation--buildings and fixtures | Capital Related Cost- Building | 1 | 23 | ||
24 | Depreciation--movable equipment | Capital Related Cost-Movable | 2 | 24 | ||
25 | Other Adjustment specify - PROVIDER TAX | ### | ### | ### | ### | 25 |
25.01 | MKTG: ADVERTISING: PUBLICAT | ### | ### | ### | ### | 25.01 |
25.02 | MKTG: ADVERTISING: INTERNET | ### | ### | ### | ### | 25.02 |
25.03 | ADMIN: MISS INT: DONATIONS | ### | ### | ### | ### | 25.03 |
25.04 | MKTG: ADVERTISING: PROMO MAT | ### | ### | ### | ### | 25.04 |
25.05 | MKTG: ADVERTISING: TELEVISION | ### | ### | ### | ### | 25.05 |
25.06 | DIET: WAGES: GENERAL | ### | ### | ### | ### | 25.06 |
25.07 | OTHER INCOME: EMPLOYEE MEALS | ### | ### | ### | ### | 25.07 |
25.08 | DEPR/INT: INTEREST: LATE FEES | ### | ### | ### | ### | 25.08 |
25.09 | DIR CARE: PROF: DENTIST | ### | ### | ### | ### | 25.09 |
25.10 | DIR CARE: RES REL: HEARING AID | ### | ### | ### | ### | 25.10 |
25.11 | DIR CARE: RES REL: DENTURES | ### | ### | ### | ### | 25.11 |
25.12 | DIR CARE: RES REL: EYE GLASSES | ### | ### | ### | ### | 25.12 |
25.13 | MKTG: FICA EXPENSE | ### | ### | ### | ### | 25.13 |
25.14 | ADMIN: PROF FEES: LEGAL FEES | ### | ### | ### | ### | 25.14 |
25.15 | ADMIN: ADVERTISING: GENERAL | ### | ### | ### | ### | 25.15 |
25.16 | ADMIN: TAXES & LIC: FINES | ### | ### | ### | ### | 25.16 |
25.17 | DIET: ALLOC: GENERAL | ### | ### | ### | ### | 25.17 |
25.18 | BUS OFF: WAGES: GENERAL | ### | ### | ### | ### | 25.18 |
25.19 | FACILTS: WAGES: GENERAL | ### | ### | ### | ### | 25.19 |
25.20 | NON-RECURRING: INS PROCEEDS | ### | ### | ### | ### | 25.20 |
25.21 | PASTORAL: WAGES: GENERAL | ### | ### | ### | ### | 25.21 |
25.22 | MKTG: ADVERTISING: GENERAL | ### | ### | ### | ### | 25.22 |
25.23 | ADMIN: BAD DEBT: CO-PAY | ### | ### | ### | ### | 25.23 |
25.24 | ADMIN: BAD DEBT: ALLOWANCE | ### | ### | ### | ### | 25.24 |
25.25 | MKTG: EMPL BENE: RETIREMENT | ### | ### | ### | ### | 25.25 |
25.26 | ADMIN: PROF FEES: MARKETING | ### | ### | ### | ### | 25.26 |
25.27 | MKTG: WAGES: MARKETING | ### | ### | ### | ### | 25.27 |
25.28 | MKTG: EMPL REL: RECRUITING | ### | ### | ### | ### | 25.28 |
25.29 | PASTORAL: ALLOC: GENERAL | ### | ### | ### | ### | 25.29 |
25.30 | ADMIN: MISC: INVESTMENT FEES | ### | ### | ### | ### | 25.30 |
25.31 | NRSG ADMIN: RES REL: EYE GLSS | ### | ### | ### | ### | 25.31 |
25.32 | IOI PAY REFUND | ### | ### | ### | ### | 25.32 |
25.33 | VOID CHECK | ### | ### | ### | ### | 25.33 |
25.34 | FEMA REIMB. - CONSTRUCTION ($465 77 | ### | ### | ### | ### | 25.34 |
25.35 | FLOOD RECONCILING ADJUSTMENT TO AGR | ### | ### | ### | ### | 25.35 |
25.36 | FEMA REIMB. - CONSTRUCTION ($320 78 | ### | ### | ### | ### | 25.36 |
25.37 | DISCOUNTS EARNED OFFSETS | ### | ### | ### | ### | 25.37 |
25.38 | DISCOUNTS EARNED OFFSETS | ### | ### | ### | ### | 25.38 |
25.39 | DISCOUNTS EARNED OFFSETS | ### | ### | ### | ### | 25.39 |
25.40 | DISCOUNTS EARNED OFFSETS | ### | ### | ### | ### | 25.40 |
25.41 | DISCOUNTS EARNED OFFSETS | ### | ### | ### | ### | 25.41 |
25.42 | DISCOUNTS EARNED OFFSETS | ### | ### | ### | ### | 25.42 |
25.43 | DISCOUNTS EARNED OFFSETS | ### | ### | ### | ### | 25.43 |
100 | TOTAL (sum of lines 1 through 99) (transfer to Wkst. A, col. 6, line 100) |
### | 100 | |||
(1) Description - all chapter references in this column pertain to CMS Pub. 15-1 (2) Basis for adjustment (see instructions) |
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A. Costs - if cost, including applicable overhead, can be determined B. Amount Received - if cost cannot be determined |
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FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4116) | ||||||
41-320 | Rev. 1 |