Form C "New Jersey Acute Care Hospitals Cost Reports - Cost Center Data" - New Jersey

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C
NEW JERSEY ACUTE CARE HOSPITALS
Page 1 of 2
2020
Hospital: __________________________________________
COST REPORTS
Do not change any preprinted
Hospital Number: |_____|_____|_____|_____|
COST CENTER DATA
wording on this form.
Hours (Whole Numbers (1, 2)
Costs ($000’s)
A
B
C
D
E
F
G
H
I
J
K
L
M
Cost Center
Salaries (2)
Phys.
Phys.
Phys.
Supplies
Contract
Other
Dep.&Fac
Lease
Expense
TOTAL
Employee
Salaries
Fees
Fees (2)
(3)
Services
Expense
Int. (4)
Costs
Rec. (5)
COSTS
Employee
Phys.
1
MSA
Med/Surg Acute Care Units
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
MSA
2
PED
Pediatric Acute Care Units
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
PED
3
OBS
Obstetric Acute Care Units
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
OBS
4
PSA
Psych. Acute Care Units
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
PSA
5
ICU
Intensive Care Units (6)
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
ICU
6
CCU
Coronary Care Units
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
CCU
7
NNI
Neo-Natal Int. Care Units
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
NNI
8
NBN
Newborn Nursery
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
NBN
9
SNF
Skilled Nursing Facility
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
SNF
10
SAC
Sub Acute Care
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
SAC
11
CLN
Clinics
CLN
12
EMR
Emergency Room
EMR
13
OHS
Off-site Health Services
OHS
14
ANS
Anesthesiology
ANS
15
BBK
Blood Bank (7)
BBK
16
CCA
Cardiac Catheterization
CCA
17
CSS
Central Sterile Supply
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
CSS
18
MSS
Med/Surg Supplies Sold (8)
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
MSS
19
DEL
Delivery Room/Labor Room
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
DEL
20
DIA
Dialysis (9)
DIA
21
EDG
Electrodiagnosis
EDG
22
LAB
Laboratory
LAB
23
NMD
Nuclear Medicine
NMD
24
ORR
Operating & Recovery Room
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
ORR
25
OPM
Other Physical Medicine
OPM
26
PHM
Pharmacy
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
PHM
27
DRU
Drugs Sold to Patients
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
DRU
28
PHT
Physical Therapy
PHT
29
RAD
Radiology
RAD
30
RSP
Respiratory Therapy
RSP
31
THR
Therapeutic Radiology
THR
32
PHY
Physicians Coverage (6)
/ / / / / / /
PHY
33
RSD
Residents
/ / / / / / /
RSD
34
A&G
Administrative & General (10)
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
A&G
35
DTY
Dietary
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
DTY
36
FIS
Fiscal
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
FIS
Footnotes 1 through 13 – See Page 2 of 2.
C
NEW JERSEY ACUTE CARE HOSPITALS
Page 1 of 2
2020
Hospital: __________________________________________
COST REPORTS
Do not change any preprinted
Hospital Number: |_____|_____|_____|_____|
COST CENTER DATA
wording on this form.
Hours (Whole Numbers (1, 2)
Costs ($000’s)
A
B
C
D
E
F
G
H
I
J
K
L
M
Cost Center
Salaries (2)
Phys.
Phys.
Phys.
Supplies
Contract
Other
Dep.&Fac
Lease
Expense
TOTAL
Employee
Salaries
Fees
Fees (2)
(3)
Services
Expense
Int. (4)
Costs
Rec. (5)
COSTS
Employee
Phys.
1
MSA
Med/Surg Acute Care Units
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
MSA
2
PED
Pediatric Acute Care Units
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
PED
3
OBS
Obstetric Acute Care Units
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
OBS
4
PSA
Psych. Acute Care Units
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
PSA
5
ICU
Intensive Care Units (6)
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
ICU
6
CCU
Coronary Care Units
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
CCU
7
NNI
Neo-Natal Int. Care Units
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
NNI
8
NBN
Newborn Nursery
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
NBN
9
SNF
Skilled Nursing Facility
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
SNF
10
SAC
Sub Acute Care
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
SAC
11
CLN
Clinics
CLN
12
EMR
Emergency Room
EMR
13
OHS
Off-site Health Services
OHS
14
ANS
Anesthesiology
ANS
15
BBK
Blood Bank (7)
BBK
16
CCA
Cardiac Catheterization
CCA
17
CSS
Central Sterile Supply
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
CSS
18
MSS
Med/Surg Supplies Sold (8)
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
MSS
19
DEL
Delivery Room/Labor Room
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
DEL
20
DIA
Dialysis (9)
DIA
21
EDG
Electrodiagnosis
EDG
22
LAB
Laboratory
LAB
23
NMD
Nuclear Medicine
NMD
24
ORR
Operating & Recovery Room
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
ORR
25
OPM
Other Physical Medicine
OPM
26
PHM
Pharmacy
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
PHM
27
DRU
Drugs Sold to Patients
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
DRU
28
PHT
Physical Therapy
PHT
29
RAD
Radiology
RAD
30
RSP
Respiratory Therapy
RSP
31
THR
Therapeutic Radiology
THR
32
PHY
Physicians Coverage (6)
/ / / / / / /
PHY
33
RSD
Residents
/ / / / / / /
RSD
34
A&G
Administrative & General (10)
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
A&G
35
DTY
Dietary
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
DTY
36
FIS
Fiscal
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
FIS
Footnotes 1 through 13 – See Page 2 of 2.
NEW JERSEY ACUTE CARE HOSPITALS
C
Page 2 of 2
2020
Hospital: __________________________________________
COST REPORTS
Do not change any preprinted
Hospital Number: |_____|_____|_____|_____|
COST CENTER DATA
wording on this form.
Hours (Whole Numbers (1, 2)
Costs ($000’s)
A
B
C
D
E
F
G
H
I
J
K
L
M
Cost Center
Salaries (2)
Phys.
Phys.
Phys.
Supplies
Contract
Other
Dep.&Fac
Lease
Expense
TOTAL
Employee
Salaries
Fees
Fees (2)
(3)
Services
Expense
Int. (4)
Costs
Rec. (5)
COSTS
Employee
Phys.
37
HKP
Housekeeping
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
HKP
38
L&L
Laundry and Linen
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
L&L
39
MAL
Malpractice Insurance
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
MAL
40
MRD
Medical Records
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
MRD
41
OGS
Other General Services
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
OGS
42
PCC
Patient Care Coordination
PCC
43
PLT
Plant
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
PLT
44
BLD
Building & Fixed Equipment
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
(11)
BLD
45
UTC
Utilities
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
UTC
46
EDR
Education and Research
EDR
47
INT
Interest
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
(12)
/ / / / / / /
INT
48
LFB
Legal Fringe Benefits
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
LFB
49
PEN
Pensions
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
PEN
50
PFB
Policy Fringe Benefits
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
PFB
51
Subtotal (13)
52
Reconciling Items (C-4 Totals)
53
Total Institution (Lines 51 & 52)
54
Total Operational Costs
(A) (Total Institution Cost Plus Expense Recovery Reported on Line 53) - - - - - - - - - ->
Total Operational Cost Per Audited
55
- - - - - - - - - - - >
Financial)
(B) (Attach an itemized detailed description if Line 56 is other than zero.) - - - - - - - - - - - ->
56
Difference (Line 54 minus 55) (B)
(1)
FTE = 2080 hours per annum.
(7)
Report Blood Processing Costs in Blood Bank Contract Services.
(2)
Hours must be reported if salaries or fees are reported and vice versa.
(8)
Report Pacemakers in the MSS Cost Center.
(3)
Supplies, net of supplies sold to patients.
(9)
Report total costs inclusive of inpatient and outpatient.
(4)
Report Major Moveable Equipment Depreciation Expense.
(10)
Report Outside Collection Costs in Contract Service Column in A&G Cost Center.
(5)
This Column should include only the expense recoveries associated
(11)
Report Building and Fixed Equipment Depreciation Expense.
with other operating income and should equal C-5, Line 20, Revenue Column.
Report all grant income offsets related to C Form costs.
(12)
Include short-term interest in the Interest Cost Center in the Other Expense Column.
(6)
Report Burn Care non-physician costs in ICU and physician costs in PHY
(13)
Report Rebundled Service Costs in the above using cost centers, Lines 1 through 31,
Provide detailed listing.
and not in Reconciling Items Form C-4 or Line 51.
Page of 2