SNFData - 135065 - 06/2013 - Worksheet A-8-2

409 KND NRSG & REHAB-MOUNTAIN VALLEY
KELLOGG, ID 83837

Medicare Provider Number: 135065

Cost report status: Settled Without Audit

[Record Code 1054685 - 2010]

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PROVIDER - BASED PHYSICIAN ADJUSTMENTS												Provider CCN: 135065		PERIOD: FROM 07/01/2012 TO 06/30/2013		WORKSHEET A-8-2
	Wkst. A Line No.	Cost Center / Physician Identifier	Total Remuneration	Professional Component	Provider Component	R C E Amount	Physician / Provider Component Hours	Unadjusted R C E Limit	5 Percent of Unadjusted R C E Limit	Cost of Memberships & Continuing Education	Provider Component Share of Col. 12	Physician Cost of Malpractice Insurance	Provider Component Share of Col. 14	Adjusted R C E Limit	R C E Disallowance	Adjustment
	1	2	3	4	5	6	7	8	9	12	13	14	15	16	17	18
1	###	###	###		###	###	###	###	###					###	###	###	1
2																	2
3																	3
4																	4
5																	5
6																	6
7																	7
8																	8
9																	9
10																	10
11																	11
12																	12
100		TOTAL	###		###		###	###	###					###	###	###	100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4118)
08-16																Rev. 7