SNF MINIMUM DATA SET

10/1/99

Table I: Type of Control: (S13)

FREESTANDINGSNFsHOSPITAL BASED SNFs

VoluntaryVoluntary

1 = Church1 = Church

2 = Other2 = Other

PropietaryPropietary

3 = Individual3 = Individual

4 = Corporation4 = Corportion

5 = Partnership5 = Partnership

6 = Other6 = Other

GovernmentGovernment

7 = Federal7 = Federal

8 = City - County8 = City-County

9 = County9 = County

10 = State 10 = State

11 = Hospital District 11 = Hospital District

12= City 12 = City

13 = Other 13 = Other

Table II: Type of Freestanding SNF (S14)

0 = HCFA Form 2540S-97 (Reimbursed under Prospective Payment System)

1 = Entirely Participating SNF *

2 = Partially Participating SNF *

3 = SNF Unit of Domiciliary Institution *

4 = SNF Unit of Rehabilitation Center *

5 =Other *

* = HCFA Form 2540-96

SNF MINIMUM DATA SET

10/1/99

Table III: FIPS State Codes (S16)

01 = Alabama 02 = Alaska 04 = Arizona

05 = Arkansas 06 = California 08 = Colorado

09 = Connecticut 10 = Delaware 11 = Washington, D. C.

12 = Florida 13 = Georgia 15 = Hawaii

16 = Idaho 17 = Illinois 18 = Indiana

19 = Iowa 20 = Kansas 21 = Kentucky

22 = Louisiana 23 = Maine 24 = Maryland

25 = Massachusetts 26 = Michigan 27 = Minnesota

28 = Mississippi 29 = Missouri 30 = Montana

31 = Nebraska 32 = Nevada 33 = New Hampshire

34 = New Jersey 35 = New Mexico 36 = New York

37 = North Carolina 38 = North Dakota 39 = Ohio

40 = Oklahoma 41 = Oregon 42 = Pennsylvania

43 = Puerto Rico 44 = Rhode Island 45 = South Carolina

46 = South Dakota 47 = Tennessee 48 = Texas

49 = Utah 50 = Vermont 51 = Virginia

53 = Washington 54 = West Virginia 55 = Wisconsin

56 = Wyoming 99 = Other

Table IV: SSA State Codes (S18) (The first two digits of the Medicare Provider Number)

01 = Alabama 02 = Alaska 03 = Arizona

04 = Arkansas 05 = California 06 = Colorado

07 = Connecticut 08 = Delaware 09 = Washington, D. C.

10 = Florida 11 = Georgia 12 = Hawaii

13 = Idaho 14 = Illinois 15 = Indiana

16 = Iowa 17 = Kansas 18 = Kentucky

19 = Louisiana 20 = Maine 21 = Maryland

22 = Massachusetts 23 = Michigan 24 = Minnesota

25 = Mississippi 26 = Missouri 27 = Montana

28 = Nebraska 29 = Nevada 30 = New Hampshire

31 = New Jersey 32 = New Mexico 33 = New York

34 = North Carolina 35 = North Dakota 36 = Ohio

37 = Oklahoma 38 = Oregon 39 = Pennsylvania

40 = Puerto Rico 41 = Rhode Island 42 = South Carolina

43 = South Dakota 44 = Tennessee 45 = Texas

46 = Utah 47 = Vermont 49 = Virginia

50 = Washington 51 = West Virginia 52 = Wisconsin

53 = Wyoming 99 = Other

SNF MINIMUM DATA SET

10/1/99

Table V: Cost Report Status (S21)

1 = As Submitted

2 = Settled Without Audit

3 = Settled With Audit

4 = Reopened

Table VI: Type of Cost Report (S22)

2540-96 2540S-97

L = Low Medicare Utilization * L = Low Medicare Utilization *

N = No Medicare Utilization * F = Full Cost Report

F = Full Cost Report

A = All-Inclusive *

Table VII: Census Divisions (S23)

0 = National

1 = New England

2 = Middle Atlantic

3 = South Atlantic

4 = East North Central

5 = East South Central

6 = West North Central

7 = West South Central

8 = Mountain

9 = Pacific

Table VIII: HCFA Regions (S24)

1 = Boston

2 = New York

3 = Philadelphia

4 = Atlanta

5 = Chicago

6 = Dallas

7 = Kansas City

8 = Denver

9 = San Francisco

10 = Seattle

* For No Medicare Utilization cost reports, only provider identifying data is available. In addition to the provider identifying data, the following fields of data are available for Low Medicare Utilization reports; S26, S38, S43, S46, S50, S336, S337, S348, S349, S364, S365, S375, S376, and S405. All Inclusive cost reports that cannot be processed through the automated system as full cost reports, are received as Low Medicare Utilization reports.

SNF MINIMUM DATA SET

10/1/99

FOR FREE-STANDING AND HOSPITAL BASED COST REPORTS FOR

COST REPORTING PERIODS ENDING ON OR AFTER SEPTEMBER 30, 1996

TABLE OF CONTENTS

Identifying and Informational Data 1

Statistical and Summary Utilization Data 2,3

Total Costs 3,4

Total Costs Before Cost Allocation 4

General Service Costs Allocated to SNF-Participating 5

Total Costs After Cost Allocation 6

Cost Allocation Statistical Bases - HCFA 2540S-876

Old Capital-Related Costs Available for Pass Through 7, 8

New Capital-Related Costs Available for Pass Through 8

Old Capital-Related Costs Allocated to SNF-Participating8

New Capital-Related Costs Allocated to SNF - Participating9

Total Facility Ancillary Charges 9

Ratio of Cost to Charges for Ancillary and Outpatient10

Medicare Part A Inpatient Ancillary Costs and Charges11

Medicare Part B Inpatient Ancillary Costs and Charges 12

Computation of Inpatient Routine Costs in Total and for Medicare 13

Medicare Part A Inpatient Settlement Summary 13, 14

Medicare Part B Inpatient Settlement Summary 14

Medicare Part A PPS Settlement Summary15

Medicare Part B PPS Settlement Summary15

Financial Data 16

Patient Revenues 16

Facility Revenues and Expenses 16

SNF Wage Index Information17 - 19

Tables 20 - 22