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Centers for Medicare and. Medicaid Services (CMS). Provider Reimbursement Manual. Part 2, Provider Cost Reporting Forms and. Instructions, Chapter 40 HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX COST REPORT CERTIFICATION complete Worksheet E, Part A, lines 200 through 218, and Worksheet E-2, instructions for Worksheet E, Part A. Cost Reports Without Dates of Services 4/1/2001 - 9/30/2001 or 4/1/2004 - 9/30/2004. DRG Payments. Line 1. Line 1.01. To find the specifications for “Number of Beds,” navigate to Section 4095, Worksheet S-3, Part 1, Column 2 (Figure 6). Electronic Reporting Specifications for a Transfer the total amount to CMS 2552-96,. Worksheet E-3, Part III, line 59. Schedule 8, Summary of Medi-Cal Psychiatric Inpatient Hospital Services. CompleteSelect the “Hospital” box and complete a separate. Worksheet E, Part A, for the portion of the cost reporting period not included in the demonstration. E, Part A Worksheet S - Hospital and Hospital Health Care Complex Cost Report Certification Throughout the Medicare cost report and instructions, a. Hospitals and Health Care Complex Cost Report (CMS-2552-10) If yes, complete Worksheet E, Part A, lines 200 through 218, and Worksheet E-2, Wkst. E, Part A Inpatient Hospital Services Under. PPS (40/-42/) Cost Report Instructions Worksheet A-8, line 34: “The PA is an employee of the hospital