Worksheet S-7, Part III
- Return to Cost Report Summary
- Form S703
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3514.3, REV 7
WHEELER CARE CENTER
WHEELER, TX 79096
WHEELER, TX 79096
Medicare Provider Number: 675534
Cost report status: As Submitted
[Record Code 66047 - 1996]
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PPS STATISTICAL DATA | PROVIDER NO: 675534 |
PERIOD: FROM 07/15/2000 TO 12/31/2000 |
WORKSHEET S-7 Part III |
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TRANSITION PERIOD: [ ] YEAR # 1 [ ] YEAR # 2 [ ] YEAR # 3 [ ] YEAR # 4 - 100% Federal Case Mix Rate | |||||||||||
HIPPS CODE GROUP | FACILITY SPECIFIC RATE | SERVICES PRIOR TO 10/01 | SERVICES AFTER 9/30 | SUBTOTAL |
YR 1: Col. 9 = Col. 7 X 25%
Col. 10 = Col. 8 X 75% |
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FEDERAL CASE MIX RATE |
DAYS | FEDERAL CASE MIX RATE |
DAYS | FEDERAL CASE MIX (Col. 3 X 4, PLUS Col . 5 X 6) |
FACILITY SPECIFIC (Col. 4 + 6 X Col. 2) |
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YR 2: Col. 9 = Col. 7 X 50%
Col. 10 = Col. 8 X 50% |
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YR 3: Col. 9 = Col. 7 X 75%
Col. 10 = Col. 8 X 25% |
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1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | ||
1 | RUC | ### | ### | ### | ### | ### | ### | 1 | |||
2 | RUB | 2 | |||||||||
3 | RUA | ### | ### | ### | ### | 3 | |||||
4 | RVC | ### | ### | ### | ### | 4 | |||||
5 | RVB | ### | ### | ### | ### | ### | ### | 5 | |||
6 | RVA | ### | ### | ### | ### | ### | ### | 6 | |||
7 | RHC | ### | ### | ### | ### | ### | 7 | ||||
8 | RHB | ### | ### | ### | ### | 8 | |||||
9 | RHA | ### | ### | ### | ### | ### | ### | 9 | |||
10 | RMC | ### | ### | ### | ### | ### | ### | 10 | |||
11 | RMB | ### | ### | ### | ### | ### | 11 | ||||
12 | RMA | ### | ### | ### | ### | ### | ### | 12 | |||
13 | RLB | 13 | |||||||||
14 | RLA | 14 | |||||||||
15 | SE3 | ### | ### | 15 | |||||||
16 | SE2 | ### | ### | 16 | |||||||
17 | SE1 | ### | ### | 17 | |||||||
18 | SSC | ### | ### | ### | ### | ### | 18 | ||||
19 | SSB | ### | ### | 19 | |||||||
20 | SSA | ### | ### | ### | ### | ### | ### | 20 | |||
21 | CC2 | ### | ### | 21 | |||||||
22 | CC1 | ### | ### | 22 | |||||||
23 | CB2 | ### | ### | 23 | |||||||
24 | CB1 | ### | ### | ### | ### | ### | 24 | ||||
25 | CA2 | ### | ### | ### | ### | ### | ### | 25 | |||
26 | CA1 | ### | ### | ### | ### | ### | 26 | ||||
27 | IB2 | 27 | |||||||||
28 | IB1 | 28 | |||||||||
29 | IA2 | 29 | |||||||||
30 | IA1 | 30 | |||||||||
31 | BB2 | 31 | |||||||||
32 | BB1 | 32 | |||||||||
33 | BA2 | 33 | |||||||||
34 | BA1 | 34 | |||||||||
35 | PE2 | 35 | |||||||||
36 | PE1 | 36 | |||||||||
37 | PD2 | 37 | |||||||||
38 | PD1 | 38 | |||||||||
39 | PC2 | 39 | |||||||||
40 | PC1 | 40 | |||||||||
41 | PB2 | 41 | |||||||||
42 | PB1 | 42 | |||||||||
43 | PA2 | 43 | |||||||||
44 | PA1 | ### | ### | ### | ### | ### | ### | 44 | |||
45 | Default Rate | 45 | |||||||||
46 | TOTAL | ### | ### | ### | ### | 46 |