Form CMS-265-94 Independent Renal Dialysis Facility Cost Report

CHAPTER 34

INDEPENDENT RENAL DIALYSIS FACILITY COST REPORT

FORM CMS-265-94

Section

General

General 3400

Rounding Standards for Fractional Computations 3400.1

Acronyms and Abbreviations 3400.2

Recommended Sequence for Completing Form CMS-265-94 3401

Sequence of Assembly 3402

Method of Payment 3403

Payment for Physician Services 3403.1

Facility Payment for Self-Dialysis Training 3403.2

Facility Payment for Laboratory Services Included in Composite Rate 3403.3

Facility Payment for Home Dialysis 3403.4

Worksheet S - Independent Renal Dialysis Facility Cost Report Certification 3404

Part I - General 3404.1

Part II - Certification by Officer or Administrator of Facility 3404.2

Worksheet S-1 - Independent Renal Dialysis Facility Statistical Data 3405

Worksheet A - Reclassification and Adjustment of Trial Balance of Expenses 3406

Worksheet A-1 - Reclassifications 3407

Worksheet A-2 - Adjustments to Expenses 3408

Worksheet A-3 - Statement of Costs of Services From Related Organizations 3409

Worksheet A-4 - Statement of Total Compensation to Owners and Statement of

Total Compensation to Administrators, Assistant Administrators, and/or

Medical Directors or Others Performing These Duties (Other Than Owners) 3410

Worksheet B - Cost Allocation - General Service Costs and Worksheet B

-1 - Cost Allocation - Statistical Basis 3411

Worksheet C - Computation of Average Cost Per Treatment 3412

Worksheet D - Calculation of Reimbursable Bad Debts - Title XVIII, Part B 3413

Exhibit 1-Form CMS-265-94 Worksheets 3490

E lectronic Reporting Specifications 3495

Rev. 7 34-1