Form Cms-216-94 - Organ Procurement Organization-Histo-Compatibility Lab Statement Of Reimbursable Costs Page 13
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1811-05
Form CMS-216-94
3390 (Cont.)
COMPUTATION OF MEDICARE COST
MEDICARE NUMBER
REPORTING PERIOD
WORKSHEET C
FROM_____________
TO________________
Part I - KIDNEY ACQUISITION
1
Total Number of Viable Kidneys Procured (W/S S-1,Part 1, Line 3, Column 3)
1
2
Total Number of Medicare Kidneys (See Instructions)
2
3
Ratio of Medicare Kidneys to Total Kidneys (Line 2/line 1)
3
4
Total Cost Applicable to Kidney Acquisition from W/S B, Col. 11, Line 3 or W/S A,
4
Col. 7, Line 26
5
Total Medicare Kidney Acquisition Costs (Line 3 x Line 4) (1)
5
(1) Transfer amount on line 5 to Worksheet D, Column 1, Line 1
Part II - TISSUE TYPING LABORATORY
1
Gross Revenues-Tissue Typing Laboratory-All Tests
1
2
Gross Revenues-Tissue Typing Laboratory-Kidney Transplant Related Tests Only (2)
2
3
Ration of Kidney Transplant to Total (Line 2/Line 1)
3
4
Total Cost Applicable to Tissue Typing Lab. From W/S-B, Col. 11, Line 4 or W/S-A,
4
Col.7, Line 26
5
Reimbursable Kidney Transplant Related Costs (Line 3 x Line 4) (3)
5
(2) If the cost report is a partial year under the program, show only the kidney related revenue earned since
the participation date
(3) Transfer Line 5 to Worksheet D, Column 2, Line 1.
Form CMS-216-94 (11-2005) (INSTRUCTION FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, Section 3312)
33-314
Rev. 4
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