Independent Renal Dialysis Facility Cost Report and Supporting Regulations 42 CFR 413.20 and 42 CFR 413.24

03-05 FORM CMS 265-94 3495

E LECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-94

T ABLE OF CONTENTS

	Topic	Page(s)
T able 1:	Record Specifications	34-503 - 34-509
T able 2:	Worksheet Indicators	34-510 - 34-511
T able 3:	List of Data Elements With Worksheet, Line, and Column Designations	34-512 - 34-520
T able 3A:	Worksheets Requiring No Input	34-521
T able 3B:	Tables to Worksheet S	34-521
T able 3C:	Tables to Worksheet S-1	34-521
T able 3D:	Lines That Cannot Be Subscripted	34-521
T able 4:	Reserved for future use
T able 5:	Cost Center Coding	34-522 - 34-524
T able 6:	Edits:
	Level I Edits	34-525 - 34-527
	Level II Edits	34-528 - 34-530

Rev. 7 34-501

12-05 FORM CMS-265-94 3495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-94

TABLE 1 - RECORD SPECIFICATIONS

Table 1 specifies the standard record format to be used for electronic cost reporting. Each electronic cost report submission (file) has three types of records. The first group (type one records) contains information for identifying, processing, and resolving problems. The text used throughout the cost report for variable line labels (e.g., Worksheet A) and variable column headers (Worksheet B‑1) is included in the type two records. Refer to Table 5 for cost center coding. The data detailed in Table 3 are identified as type three records. The encryption coding at the end of the file, records 1, 1.01, and 1.02, are type 4 records.

The medium for transferring cost reports submitted electronically to fiscal intermediaries is 3½" diskette. These disks must be in IBM format. The character set must be ASCII. You must seek approval from your fiscal intermediary regarding alternate methods of submission to ensure that the method of transmission is acceptable.

The following are requirements for all records:

1. All alpha characters must be in upper case.

2. For micro systems, the end of record indicator must be a carriage return and line feed, in that sequence.

3. No record may exceed 60 characters.

Below is an example of a set of type 1 records with a narrative description of their meaning.

 1  2  3 4 5  6

123456789012345678901234567890123456789012345678901234567890

1 1 250000200400120043666A99P00120050312004366

Record #1: This is a cost report file submitted by Provider 279999 for the period from January 1, 2004 (2004001) through December 31, 2004 (2004366). It is filed on FORM CMS-265-94. It is prepared with vendor number A99's PC based system, version number 1. Position 38 changes with each new test case and/or approval and is alpha. Positions 39 and 40 remain constant for approvals issued after the first test case. This file is prepared by the independent renal dialysis facility on January 31, 2005 (2005031). The electronic cost report specification dated December 31, 2004 (2004366) is used to prepare this file.

FILE NAMING CONVENTION

Name each cost report file in the following manner:

RDNNNNNN.YYL, where

1. RD (Independent Renal Dialysis Facility Electronic Cost Report) is constant;

2. NNNNNN is the 6 digit Medicare independent renal dialysis facility provider number;

3. YY is the year in which the provider's cost reporting period ends; and

4. L is a character variable (A‑Z) to enable separate identification of files from independent renal dialysis facility with two or more cost reporting periods ending in the same calendar year.

Rev. 9 34-503

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ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-94

TABLE 1 - RECORD SPECIFICATIONS

RECORD NAME: Type 1 Records ‑ Record Number 1

		Size	Usage	Loc.	Remarks
1.	Record Type	1	X	1	Constant "1"
2.	NPI	10	9	2-11	Numeric only
3.	Spaces	1	X	12
4.	Record Number	1	X	13	Constant "1"
5.	Spaces	3	X	14-16
6.	ESRD Provider Number	6	9	17-22	Field must have 6 numeric characters.
7.	Fiscal Year Beginning Date	7	9	23-29	YYYYDDD - Julian date; first day covered by this cost report
8.	Fiscal Year Ending Date	7	9	30-36	YYYYDDD - Julian date; last day covered by this cost report
9.	MCR Version	1	X	37	Constant "6" (for FORM CMS-265-94)
10.	Vendor Code	3	X	38-40	To be supplied upon approval. Refer to page 32-503.
11.	Vendor Equipment	1	X	41	P = PC; M = Main Frame
12.	Version Number	3	X	42-44	Version of extract software, e.g., 001=1st, 002=2nd, etc. or 101=1st, 102=2nd. The version number must be incremented by 1 with each recompile and release to client(s).
13.	Creation Date	7	9	45-51	YYYYDDD – Julian date; date on which the file was created (extracted from the cost report)
14.	ECR Spec. Date	7	9	52-58	YYYYDDD – Julian date; date of electronic cost report specifications used in producing each file. Valid for cost reporting periods ending on or after 2005091 (4/1/2005). Prior approval(s) 2004366.

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T ABLE 1 - RECORD SPECIFICATIONS

R ECORD NAME: Type 1 Records ‑ Record Numbers 2 - 99

		Size	Usage	Loc.	Remarks
1 .	Record Type	1	9	1	Constant "1"
2 .	Spaces	10	X	2-11
3 .	Record Number	2	9	12-13	#2-99 - Reserved for future use.
4 .	Spaces	7	X	14-20	Spaces (optional)
5 .	ID Information	40	X	21-60	Left justified to position 21.

R ECORD NAME: Type 2 Records for Labels

		Size	Usage	Loc.	Remarks
1 .	Record Type	1	9	1	Constant "2"
2 .	Wkst. Indicator	7	X	2-8	Alphanumeric. Refer to Table 2.
3 .	Spaces	2	X	9-10
4 .	Line Number	3	9	11-13	Numeric
5 .	Subline Number	2	9	14-15	Numeric
6 .	Column Number	3	X	16-18	Alphanumeric
7 .	Subcolumn Number	2	9	19-20	Numeric
8 .	Cost Center Code	4	9	21-24	Numeric. Refer to Table 5 for appropriate cost center codes.
9 .	Labels/Headings
	a. Line Labels	36	X	25-60	Alphanumeric, left justified
	b. Column Headings Statistical Basis & Code	10	X	21-30	Alphanumeric, left justified

T he type 2 records contain both the text that appears on the pre‑printed cost report and any labels added by the preparer. Of these, there are three groups: (1) Worksheet A cost center names (labels); (2) column headings for stepdown entries; and (3) other text appearing in various places throughout the cost report.

A Worksheet A cost center label must be furnished for every cost center with cost or charge data anywhere in the cost report. The line and subline numbers for each label must be the same as the line and subline numbers of the corresponding cost center on Worksheet A. The columns and subcolumn numbers are always set to zero.

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T ABLE 1 - RECORD SPECIFICATIONS

C olumn headings for the General Service cost centers on Worksheets B and B-1 are supplied once. They consist of one to three records. Each statistical basis shown on Worksheet B‑1 is also to be reported. The statistical basis consists of one or two records (lines 4-5). Statistical basis code is supplied only to Worksheet B‑1 columns and is recorded as line 6. The statistical code must agree with the statistical bases indicated on lines 4 and 5, i.e., code 1 = square footage, code 2 = dollar value, and code 3 = all others. Refer to Table 2 for the special worksheet identifier to be used with column headings and statistical basis and to Table 3 for line and column references.

T he following type 2 cost center descriptions are to be used for all Worksheet A standard cost center lines.

Line 1 2 3 4 6 7 8 9 10 11 12 13 14 15 16 19 20 21 22 23 24

Description CAP REL COSTS-BLDG & FIXT CAP REL COSTS-MVBLE EQUIP OPERATION & MAINTENANCE OF PLANT HOUSEKEEPING MACHINE CAP-REL OR RENTAL & MAINT SALARIES FOR DIRECT PATIENT CARE EMP HEALTH & WELFARE BENEFITS DRUGS SUPPLIES LABORATORY ADMINISTRATIVE & GENERAL INTEREST EXPENSE LAUNDRY AND LINEN MEDICAL RECORDS PHY ROUT PRO SERVICES-INITIAL METHOD PHY ROUT PRO SERVICES-MCP METHOD WHOLE BLOOD & PACKED RED BLOOD CELLS HEPATITIS B VACCINE PHYSICIANS’ PRIVATE OFFICES EPOETIN METHOD II PATIENTS (DIRECT DEALING)

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TABLE 1 - RECORD SPECIFICATIONS

Type 2 records for Worksheet B-1, columns 2-8, for lines 1-6 are listed below. The numbers running vertical to line 1 descriptions are the general service cost center line designations.

LINE

	1 ­­­­­	2 ­­­­­	3 ­­­­­	4 ­­­­­	5 ­­­­­	6
2 3 4 5 6 7 8	CAP REL OP MACH CAP SALARIES EMP H&W DRUGS SUPPLIES LABORATORY	OF MAINT REL OR REN FOR DIRECT BENEFITS	& HOUSE & MAINT PAT CARE DIR PAT CR	SQUARE PERCENT OF HRS OF GROSS CHARGES CHARGES CHARGES	FEET TIME SPENT SERVICE SALARIES	1 3

Examples of type 2 records are below. Either zeros or spaces may be used in the line, subline, column, and subcolumn number fields (positions 11‑20). However, spaces are preferred. Refer to Table 5 and 6 for additional cost center code requirements.

Examples:

Worksheet A line labels with embedded cost center codes:

2A000000 1 0100CAP REL COSTS-BLDG & FIXT

2A000000 2 0200CAP REL COSTS-MVBLE EQUIP

2A000000 9 0900DRUGS

2A000000 15 1500MEDICAL RECORDS

2A000000 19 1900PHY ROUT PRO SERVICES-MCP METHOD

2A000000 23 2300EPOETIN

Examples of column headings for Worksheets B‑1 and B; statistical bases used in cost allocation on Worksheet B-1; and statistical codes used for Worksheet B‑1 (line 6) are displayed below.

2B10000* 1 2 CAP REL OP

2B10000* 2 2 OF MAINT

2B10000* 3 2 & HOUSE

2B10000* 4 2 SQUARE

2B10000* 5 2 FEET

2B10000* 6 2 1

2B10000* 1 3 MACH CAP

2B10000* 2 3 REL OR REN

2B10000* 3 3 & MAINT

2B10000* 4 3 PERCENT OF

2B10000* 5 3 TIME SPENT

2B10000* 6 3 3

Rev. 9 34-507

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ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-94

TABLE 1 - RECORD SPECIFICATIONS

RECORD NAME: Type 3 Records for Nonlabel Data

		Size	Usage	Loc.	Remarks
1.	Record Type	1	9	1	Constant "3"
2.	Wkst. Indicator	7	X	2-8	Alphanumeric. Refer to Table 2.
3.	Spaces	2	X	9-10
4.	Line Number	3	9	11-13	Numeric
5.	Subline Number	2	9	14-15	Numeric
6.	Column Number	3	X	16-18	Alphanumeric
7.	Subcolumn Number	2	9	19-20	Numeric
8.	Field Data
	a. Alpha Data	36	X	21-56	Left justified. (Y or N for yes/no answers; dates must use MM/DD/YYYY format - slashes, no hyphens.) Refer to Table 6 for additional requirements for alpha data.
		4	X	57-60	Spaces (optional).
	b. Numeric Data	16	9	21-36	Right justified. May contain embedded decimal point. Leading zeros are suppressed; trailing zeros to the right of the decimal point are not. Positive values are presumed; no A+@ signs are allowed. Use leading minus to specify negative values. Express percentages as decimal equivalents, i.e., 8.75% is expressed as .087500. All records with zero values are dropped. Refer to Table 6 for additional requirements regarding numeric data.

A sample of type 3 records are below.

3A000000 12 1 36000

3A000000 15 2 12064

3A000000 19 1 144000

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T ABLE 1 - RECORD SPECIFICATIONS

T he line numbers are numeric. In several places throughout the cost report (see list below), the line numbers themselves are data. The placement of the line and subline numbers as data must be uniform.

W orksheet A-1, columns 3 and 6

W orksheet A-2, column 4

W orksheet A-3, Part B, column 1

E xamples of records (*) with a Worksheet A line number as data are below.

3 A100010 1 0 EMP. HEALTH & WELFARE BENE

3 A100010 1 1 A

* 3A100010 1 3 8.00

3 A100010 1 4 61743

* 3A100010 1 6 12.00

3 A100010 1 7 82263

3 A100010 2 0 EMP HEALTH & WELFARE BENE

3 A100010 2 1 A

* 3A100010 2 3 19.00

3 A100010 2 4 20520

3 A200000 17 0 MIS INCOME

3 A200000 17 1 B

3 A200000 17 2 -1993

* 3A200000 17 4 12.00

* 3A30000B 1 1 11.00

3 A30000B 1 3 LABORATORY

3 A30000B 1 4 23121

3 A30000B 1 5 18000

R ECORD NAME: Type 4 Records - File Encryption

T his type 4 record consists of 3 records: 1, 1.01, and 1.02. These records are created at the point in which the ECR file has been completed and saved to disk and insures the integrity of the file.

Rev. 7 34-509

3495 (Cont.)

FORM CMS-265-94

03-05

E LECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-94

T ABLE 2 - WORKSHEET INDICATORS

T his table contains the worksheet indicators that are used for electronic cost reporting. A worksheet indicator is provided for only those worksheets for which data are to be provided.

T he worksheet indicator consists of seven digits in positions 2‑8 of the record identifier. The first two digits of the worksheet indicator (positions 2 and 3 of the record identifier) always show the worksheet. The third digit of the worksheet indicator (position 4 of the record identifier) is always 0. For Worksheets A-1 and A-2, if there is a need for extra lines on multiple worksheets, the fifth and sixth digits of the worksheet indicator (positions 6 and 7 of the record identifier) identify the page number. The seventh digit of the worksheet indicator (position 8 of the record identifier) represents the worksheet or worksheet part.

W orksheets That Apply to the Independent Renal Dialysis Facility Cost Report

	Worksheet	Worksheet Indicator
	S, Part I	S000001
	S-1	S100000
	A	A000000
	A-1	A100010	(a)
	A-2	A200000
	A-3, Part A	A30000A
	A-3, Part B	A30000B
	A-3, Part C	A30000C
	A-4, Part I	A400001
	A-4, Part II	A400002
	B-1 (For use in column headings)	B10000*
	B	B000000
	B-1	B100000
	C	C000010	(b)
	D	D000000

34-510 Rev. 7

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ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-94

TABLE 2 - WORKSHEET INDICATORS

FOOTNOTES:

(a) Multiple Worksheets for Reclassifications and Adjustments Before Stepdown

The fifth and sixth digits of the worksheet indicator (positions 6 and 7 of the record) are numeric from 01‑99 to accommodate reports with more lines on Worksheets A-1. For reports that do not need additional worksheets, the default is 01. For reports that do need additional worksheets, the first page is numbered 01. The number for each additional page of the worksheet is incremented by 1.

b) Multiple ESRD Payment Rates

The sixth digit of the worksheet indicator (position 7 of the record) is numeric from 1 to 9 to accommodate two or more payment rates in effect during one cost reporting period. If there is only a single payment rate, the default is 1. This applies only to Worksheet C. NOTE: For cost reporting periods beginning on or after April 1, 2005, the sixth digit of the worksheet indicator (position 7 of the record) will always default to 1, as Worksheet C is no longer subscriptable.

Rev. 9 34-511

3495 (Cont.) FORM CMS-265-94 12-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-94

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

This table identifies those data elements necessary to calculate a independent renal dialysis cost report. It also identifies some figures from a completed cost report. These calculated fields (e.g., Worksheet B, column 8) are needed to verify the mathematical accuracy of the raw data elements and to isolate differences between the file submitted by the independent renal dialysis facility and the report produced by the fiscal intermediary. Where an adjustment is made, that record must be present in the electronic data file. For explanations of the adjustments required, refer to the cost report instructions.

Table 3 "Usage" column is used to specify the format of each data item as follows:

9 Numeric, greater than or equal to zero.

-9 Numeric, may be either greater than, less than, or equal to zero.

9(x).9(y) Numeric, greater than zero, with x or fewer significant digits to the left of the decimal point, a decimal point, and exactly y digits to the right of the decimal point.

X Character.

Consistency in line numbering (and column numbering for general service cost centers) for each cost center is essential. The sequence of some cost centers does change among worksheets.

Table 3 refers to the data elements needed from a standard cost report. When a standard line is subscripted, the subscripted lines must be numbered sequentially with the first subline number displayed as "01" or " 1" (with a space preceding the 1) in field locations 14‑15. It is unacceptable to format in a series of 10, 20, or skip subline numbers (i.e., 01, 03), except for skipping subline numbers for prior year cost center(s) deleted in the current period or initially created cost center(s) no longer in existence after cost finding. Exceptions are specified in this manual. For Other (specify) lines, i.e., Worksheet settlement series, all subscripted lines should be in sequence and consecutively numbered beginning with subscripted line number 01. Automated systems should reorder these numbers where providers skip or delete a line in the series.

Drop all records with zero values from the file. Any record absent from a file is treated as if it were zero.

All numeric values are presumed positive. Leading minus signs may only appear in data with values less than zero that are specified in Table 3 with a usage of "-9". Amounts that are within preprinted parentheses on the worksheets, indicating the reduction of another number, are reported as positive values.

34-512 Rev. 9

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ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-94

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET S

Name	1	1	36	X
Street	1.01	1	36	X
P.O. Box	1.01	2	9	X
City	1.02	1	36	X
State	1.02	2	2	X
Zip Code	1.02	3	10	X
County	1.03	1	36	X
Facility Number (xxxxxx)	2	1	6	X
Date Certified (MM/DD/YYYY)	3	1	10	X
Name	4	1	36	X
Phone number (xxx-xxx-xxxx)	4	2	12	X
Cost reporting period beginning date	5	1	10	X
(MM/DD/YYYY)
Cost reporting period ending date	5	2	10	X
(MM/DD/YYYY)
Type of control: (See Table 3B)	6	1	2	9
Other(Specify)	6	2	36	X
Type of physicians’ reimbursement:	7	1	1	9
(See Table 3B)
Date of election of initial method	7	2	10	X
(MM/DD/YYYY)
Was this facility previously certified as a	8	1	1	X
Hospital-based unit/ (y/n)
If you are part of a chain organization check	9	1	1	X
“yes”, otherwise check “no”. (y/n)
If you checked “yes”, enter the
Name	9.01	1	36	X
Street	9.02	1	36	X
P.O. Box	9.02	2	9	X
City	9.03	1	36	X
State	9.03	2	2	X
Zip code of the organization	9.03	3	10	X

Rev. 9

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ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-94

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET S-1

Renal Dialysis Statistics
Number of treatments not billed to Medicare and furnished directly	1	1-4	11	9
Number of treatments not billed to Medicare and furnished under arrangement	2	1-4	11	9
Number of patients currently in dialysis program	3	1-4	11	9
Average time per week patient receives dialysis	4	1-4	5	9(2).99
Number of days in average week for patient dialysis treatments	5	1-4	4	9.99
Average time of patient dialysis treatment including set up time	6	1-4	5	9(2).99
Number of machines regularly available for use	7	1-4	11	9
Number of standby machines	8	1-4	11	9
Number of shifts in typical week during regular reporting period	9	1-4	11	9
Hours per shift in typical week during regular reporting period:
First shift	10.01	1-4	9	9
Second shift	10.02	1-4	9	9
Third shift	10.03	1-4	9	9
Number of treatments provided:

One (1) time per week	11.01	1-4	11	9
Two (2) times per week	11.02	1-4	11	9
Three (3) times per week	11.03	1-4	11	9
More than three (3) times per week	11.04	1-4	11	9
Total Treatments	11.05	1-4	11	9
Type of dialyzers used: (See Table 3C)	12	1	1	9

34-514 Rev. 9

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T ABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

D ESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

W ORKSHEET S-1 (Continued)

I f dialyzers are reused, indicate the number of times	12	2	11	9
I f other is selected, specify type	12	3	36	X
N umber of back-up sessions furnished to home patients:
C APD	13	1	11	9
O ther	13	2	11	9
CCPD	13	3	11	9
N umber of units of epoetin furnished during cost reporting period	14	1	11	9
T ransplant Statistics:
N umber of patients who are awaiting transplants	15	1	11	9
N umber of patients who received transplants during this period	16	1	11	9
H ome Program:
N umber of patients commencing home dialysis training during this period	17	1	11	9
N umber of patients currently in home program	18	1	11	9
T ypes of dialyzers used: (See Table 3C)	19	1	1	9

Rev. 7 34-515

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T ABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

D ESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

W ORKSHEET S-1(Continued)

I f dialyzers are reused, indicate the number of times:	19	2	11	9
I f other is selected, specify type	19	3	36	X
N umber of hours in a normal work week	20	0	6	9(3).99
T ext as needed for blank line	29	0	36	X
N umber of full time equivalent employees
Staff	20-29	1	6	9(3).99
Contract	20-29	2	6	9(3).99

W ORKSHEET A

P hysicians salaries by department	9-12,14-17,19-26	1	9	-9
T otal physicians salaries	27	1	9	9
O ther salaries by department	3-4,6-12,14-17,20-26	2	9	-9
T otal other salaries	27	2	9	9
O ther direct costs by department	1-4,6,8-17,19-26	3	9	-9
T otal other direct costs	27	3	9	9
N et expenses for allocation by department	1-4,6-17,19-26	8	9	-9
Total expenses for allocation	27	8	9	9

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TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET A-1

For each expense reclassification:
Explanation	1-35	0	36	X
Reclassification identification code	1-35	1	2	X
Increases:
Worksheet A line number	1-35	3	6	9(3).99
Reclassification amount	1-35	4	9	9
Decreases:
Worksheet A line number	1-35	6	6	9(3).99
Reclassification amount	1-35	7	9	9

WORKSHEET A-2

Description of adjustment	17-20	0	36	X
Basis (A or B)	1,3-6,8-20	1	1	X
Amount	1-6,8-20,	2	9	-9
Worksheet A line number	1,3-6, 8-9,11,12, 17-20	4	6	9(3).99

WORKSHEET A-3

Part A - Are there any related organization costs included on Worksheet A? (Y/N)	1	1	1	X
Part B - For costs incurred and adjustments required as a result of transactions with related organization(s):
Worksheet A line number	1-4	1	6	9(3).99
Expense item(s)	1-4	3	36	X
Amount included in Worksheet A	1-4	4	9	-9

Rev. 9 34-517

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TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET A-3 (Continued)

Amount allowable in reimbursable cost	1-4	5	9	-9
Part C - For each related organization:
Type of interrelationship (A through G)	1-4	1	1	X
If type is G, specify description of relationship	1-4	0	36	X
Name of related individual or organization	1-4	2	36	X
Percentage of ownership	1-4	3	6	9(3).99
Name of related individual or organization	1-4	4	36	X
Percentage of ownership of provider	1-4	5	6	9(3).99
Type of business	1-4	6	36	X

WORKSHEET A-4

Owners Compensation-Part I
Title	1-10	1	36	X
Function	1-10	2	36	X
Sole proprietorship
Percentage of work week devoted to business	1-10	3	6	9(3).99
Partners
Percent share of operating profit (loss)	1-10	4A	6	9(3).99
Percentage of week devoted to business	1-10	4B	6	9(3).99

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TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET A-4 (Continued)

Corporation
Percent of provider’s stock owned	1-10	5A	6	9(3).99
Percentage of work week devoted to business	1-10	5B	6	9(3).99
Total compensation included in allowable cost	1-10	6	11	9
Part II
Title	1-10	1	36	X
Percentage of work week devoted to business	1-10	2	6	9(3).99
Total compensation	1-10	3	11	9

WORKSHEETS B and B-1

Column heading (cost center name)	1-3 +	2-9	10	X
Statistical basis	4, 5 +	2-9	10	X

+ Refer to Table 1 for specifications and Table 2 for the worksheet identifier for column headings. There may be up to five type 2 records (3 for cost center name and 2 for the statistical basis) for each column. However, for any column that has less than five type 2 record entries, blank records or the word blank is not required to maximize each column record count.

WORKSHEET B

Costs after cost finding by department	2-20 (excluding line 16.01)	11	9	-9
Total costs after cost finding	21	11	9	9

WORKSHEET B-1

All cost allocation statistics

2-20

2-8

9

9

Rev. 9 34-519

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ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-94

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET C

Total number of treatments	1-8,11	1	11	9
Total CAPD patient weeks	9	1	11	9
Total CCPD patient weeks	10	1	11	9
Number of treatments-Medicare	1-8,11	4 & 4.01	11	9
CAPD patient weeks-Medicare	9	4 & 4.01	11	9
CCPD patient weeks-Medicare	10	4 & 4.01	11	9
Payment Rates	1-10	6 & 6.01	6	9(3).99

WORKSHEET D

Total expenses related to care of Medicare beneficiaries	1	1	11	9
Total Payment Due	2	1	11	9
Part B deductibles & coinsurance billed	5	1	11	9
Reimbursable bad debts	6	1	11	9
Reimbursable bad debts for dual eligible beneficiaries	9.01	1	11	9

34-520 Rev. 9

12-05 FORM CMS-265-94 3495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-94

TABLE 3A ‑ WORKSHEETS REQUIRING NO INPUT

Worksheet B

TABLE 3B-TABLES TO WORKSHEET S

Type of Control Type of Reimbursement

1 = Voluntary Non Profit, Corporation 1 = Initial Method

2 = Voluntary Non Profit, Other 2 = MCP Method

3 = Proprietary, Individual

4 = Proprietary, Corporation

5 = Proprietary, Partnership

6 = Proprietary, Other

7 = Government, Federal

8 = Government, State

9 = Government, County

10 = Government, City

11 = Government, Other

TABLE 3C-TABLES TO WORKSHEET S-1

Type of Dialyzers Used

1. = Hollow Fiber

2. = Parallel Plate

3. = Coil

4. = Other

TABLE 3D‑ LINES THAT CANNOT BE SUBSCRIPTED

(BEYOND THOSE PREPRINTED)

	Worksheet	Lines
	S	1-9
	S-1	1-11, 13-18, 20-28
	A	5,18,27
	A-1	1-36
	A-2	1-16,21
	A-3-Part A	All
	A-3, Part B	1-3,5
	A-3, Part C	1-3
	A-4, Part I	1-9
	A-4, Part II	1-9
	B	1-19, 21
	B-1	1-19,21-23
	C	ALL
	D	1-8

Rev. 9 34-521

3495 (Cont.) FORM CMS 265-94 12-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-94

TABLE 5 - COST CENTER CODING

INSTRUCTIONS FOR PROGRAMMERS

Cost center coding is required because there are thousands of unique cost center names in use by providers. Many of these names are peculiar to the reporting provider and give no hint as to the actual function being reported. Using codes to standardize meanings makes practical data analysis possible. The method to accomplish this must be rigidly controlled to assure accuracy.

For any added cost center names (the preprinted cost center labels must be precoded), preparers must be presented with the allowable choices for that line or range of lines from the lists of standard and nonstandard descriptions. They then select a description that best matches their added label. The code associated with the matching description, including increments due to choosing the same description more than once, will then be appended to the user’s label by the software.

Additional guidelines are:

• Do not allow any pre-existing codes for the line to be carried over.

• Do not precode all Other lines.

• For cost centers, the order of choice must be standard first, then specific nonstandard, and finally the nonstandard “Other . . ."

• For the nonstandard "Other . . .", prompt the preparers with, “Is this the most appropriate choice?," and then offer the chance to answer yes or to select another description.

• Allow the preparers to invoke the cost center coding process again to make corrections.

• For the preparers’ review, provide a separate printed list showing their added cost center names on the left with the chosen standard or nonstandard descriptions and codes on the right.

• On the screen next to the description, display the number of times the description can be selected on a given report, decreasing this number with each usage to show how many remain. The numbers are shown on the cost center tables.

• Do not change standard cost center lines, descriptions and codes. The acceptable formats for these items are listed on page 34-524 of the Standard Cost Center Descriptions and Codes. The proper line number is the first two digits of the cost center code.

INSTRUCTIONS FOR PREPARERS

Coding of Cost Center Labels

Cost center coding standardized the meaning of cost center labels used by health care providers on the Medicare cost reporting forms. The use of this coding methodology allows providers to continue to use their labels for cost centers that have meaning within the individual institution.

The four digit codes that are required to be associated with each label provide standardized meaning for data analysis. Normally, it is necessary to code only added labels because the preprinted standard labels are automatically coded by CMS approved cost report software.

Additional cost center descriptions have been identified. These additional descriptions are hereafter referred to as the nonstandard labels. Included with the nonstandard descriptions is an "Other . . ." designation to provide for situations where no match in meaning can be found. Refer to Worksheet A, line 17 or 26.

34-522 Rev. 9

03-05 FORM CMS 265-94 3495 (Cont.)

E LECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-94

T ABLE 5 - COST CENTER CODING

B oth the standard and nonstandard cost center descriptions along with their cost center codes are shown on Table 5. The "use" column on that table indicates the number of times that a given code can be used on one cost report. You are required to compare your added label to the descriptions shown on the standard and nonstandard tables for purposes of selecting a code. Most CMS approved software provides an automated process to present you with the allowable choices for the line/column being coded and automatically associates the code for the selected matching description with your label.

A dditional Guidelines

C ategories

M ake a selection from the proper category such as general service description for general service lines, nonreimbursable cost center descriptions for nonreimbursable cost center lines, etc.

U se of a Cost Center Coding Description More Than Once

O ften a description from the "standard" or "nonstandard" tables applies to more than one of the labels being added or changed by the preparer. In the past, it was necessary to determine which code was to be used and then increment the code number upwards by one for each subsequent use. This was done to provide a unique code for each cost center label. Now, most approved software associate the proper code, including increments as required, once a matching description is selected. Remember to use your label. You are matching to CMS’s description only for coding purposes.

C ost Center Coding and Line Restrictions

U se cost center codes only in designated lines in accordance with the classification of cost center(s), e.g., lines 22 through 26 may only contain cost center codes within the nonreimbursable services cost center category of both standard and nonstandard coding. Refer to Table 1 for Type 2 cost center descriptions.

S TANDARD COST CENTER DESCRIPTIONS AND CODES

	CODE	USE
G ENERAL SERVICE COST CENTERS
C apital Related - Buildings and Fixtures	0100	(01)
C apital Related - Movable Equipment	0200	(01)
O peration and Maintenance of Plant	0300	(01)
H ousekeeping	0400	(01)
M achine Capital-Related or Rental and Maintenance	0600	(01)
S alaries for Direct Patient Care	0700	(01)
E mp. Health & Welfare Benefits for Direct Patient Care	0800	(01)
D rugs	0900	(01)

Rev. 7 34-523

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E LECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-94

T ABLE 5 - COST CENTER CODING

STANDARD COST CENTER DESCRIPTIONS AND CODES (Continued)

S upplies	1000	(01)
L aboratory	1100	(01)
A dministrative and General	1200	(01)
I nterest Expense	1300	(01)
L aundry and Linen	1400	(01)
M edical Records	1500	(01)
P hysicians’ Routine Professional Services-Initial Method	1600	(01)
P hysicians’ Routine Professional Services-MCP Method	1900	(01)
W hole Blood and Packed Red Blood Cells	2000	(01)
H epatitis B Vaccine	2100	(01)
NON REIMBURSABLE COST CENTER
P hysicians’ Private Offices	2200	(01)
E poetin	2300	(01)
M ethod II Patients (Direct Dealing)	2400	(01)

NONSTANDARD COST CENTER DESCRIPTIONS AND CODES

	CODE	USE
G ENERAL SERVICE COST CENTERS
O ther	1700	(10)
N ONREIMBURSABLE COST CENTERS
O ther Nonreimbursable	2500	(01)
Other Nonreimbursable	2600	(10)

34-524 Rev. 7

12-05 FORM CMS-265-94 3495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-94

TABLE 6 - EDITS

Medicare cost reports submitted electronically must be subjected to various edits, which are divided into two categories: Level I and level II edits. These include mathematical accuracy edits, certain minimum file requirements, and other data edits. Any vendor software that produces an electronic cost report file for Medicare ESRD must automate all of these edits. Failure to properly implement these edits may result in the suspension of a vendor's system certification until corrective action is taken. The vendor’s software should provide meaningful error messages to notify the home health agency of the cause of every exception. The edit message generated by the vendor systems must contain the related 4 digit and 1 alpha character, where indicated, reject/edit code specified below. Any file containing a level I edit will be rejected by your fiscal intermediary without exception.

Level I edits (1000 series reject codes) test that the file conforms to processing specifications, identifying error conditions that would result in a cost report rejection. These edits also test for the presence of some critical data elements specified in Table 3. Level II edits (2000 series edit codes) identify potential inconsistencies and/or missing data items that may have exceptions and should not automatically cause a cost report rejection. Resolve these items and submit appropriate worksheets and/or data supporting the exceptions with the cost report. Failure to submit the appropriate data with your cost report may result in payments being withheld pending resolution of the issue(s).

The vendor requirements (above) and the edits (below) reduce both intermediary processing time and unnecessary rejections. Vendors should develop their programs to prevent their client home health agencies from generating either a hard copy substitute cost report or electronic cost report file where level I edits exist. Ample warnings should be given to the provider where level II edit conditions are violated.

NOTE: Dates in brackets [ ] at the end of an edit indicate the effective date of that edit for cost reporting periods ending on or after that date. Dates followed by a “b” are for cost reporting periods beginning on or after the specified date. Dates followed by an “s” are for services rendered on or after the specified date unless otherwise noted. [10/31/2000]

I. Level I Edits (Minimum File Requirements)

Reject Code	Condition
1000	The first digit of every record must be either 1, 2, 3, or 4 (encryption code only). [12/31/2004]
1005	No record may exceed 60 characters. [12/31/2004]
1010	All alpha characters must be in upper case. This is exclusive of the encryption code, type 4 record, record numbers 1, 1.01, and 1.02. [12/31/2004]
1015	For micro systems, the end of record indicator must be a carriage return and line feed, in that sequence. [12/31/2004]
1020	The independent renal dialysis facility provider number (record #1, positions 17-22) must be valid and numeric. [12/31/2004]
1025	All dates (record #1, positions 23-29, 30-36, 45-51, and 52-58) must be in Julian format and legitimate. [12/31/2004]
1030	The fiscal year beginning date (record #1, positions 23-29) must be less than the fiscal year ending date (record #1, positions 30-36). [12/31/2004]

Rev. 9 34-525

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ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-94

TABLE 6 - EDITS

Reject Code	Condition
1035	The vendor code (record #1, positions 38-40) must be a valid code. [12/31/2004]
1050	The type 1 record #1 must be correct and the first record in the file. [12/31/2004]
1055	All record identifiers (positions 1-20) must be unique. [12/31/2004]
1060	Only a Y or N is valid for fields which require a Yes/No response. [12/31/2004]
1075	Cost center integrity must be maintained throughout the cost report. For subscripted lines, the relative position must be consistent throughout the cost report. [12/31/2004]
1080	For every line used on Worksheets A, there must be a corresponding type 2 record. [12/31/2004]
1090	Fields requiring numeric data (charges, treatments, costs, FTEs, etc.) may not contain any alpha character. [12/31/2004]
1100	In all cases where the file includes both a total and the parts that comprise that total, each total must equal the sum of its parts. [12/31/2004]
1005S	The cost report ending date (Worksheet S, column 2, line 4) must be on or after December 31, 2004. [12/31/2004]
1015S	The cost report period beginning date (Worksheet S, column 1, line 5) must precede the cost report ending date (Worksheet S, column 2, line 5). [12/31/2004]
1020S	The independent renal dialysis facility name, address, provider number, and certification date (Worksheet S, line 1, column 1; line 1.01, column 1; line 1.02, columns 1, 2, & 3; and line 1.03, column 1) must be present and valid. [12/31/2004]
1021S	The type of control (Worksheet S, line 6, column 1) must be present and a valid code of 1 thru 11. [4/1/2005]
1025S	The independent renal dialysis total number of hours per work week must be greater than zero (0) (Worksheet S-1, line 20, column 0). [12/31/2004]
1030S	The total number FTEs for Social Workers must be greater than zero (0) (Worksheet S-1, line 25, sum of columns 1 and 2). [12/31/2004]
1000A	All amounts reported on Worksheet A, columns 1-3, line 27, must be greater than or equal to zero. [3/31/1997]
1020A	For reclassifications reported on Worksheet A-1 the sum of all increases (column 4) must equal the sum of all decreases (column 7). [12/31/2004]
1025A	For each line on Worksheet A-1, if there is an entry in columns 3, 4, 6, or 7, there must be an entry in column 1. There must be an entry on each line of column 4 for each entry in column 3 (and vice versa), and there must be an entry on each line of column 7 for each entry in column 6 (and vice versa). [12/31/2004]
1040A	For Worksheet A-2 adjustments on lines 1,3-6,8,9,11, and 12, and if either columns 2 or 4 has an entry, then both columns 2 and 4 must have entries, and if any one of columns 0, 1, 2, or 4 for lines 17-20 and subscripts thereof has an entry, then all columns 0, 1, 2, and 4 must have entries. Only valid line numbers may be used in column 4. [12/31/2004]

526. Rev. 9

12-05 FORM CMS-265-94 3495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-94

TABLE 6 - EDITS

Reject Code	Condition
1045A	If there are any transactions with related organizations or home offices as defined in CMS Pub. 15-I, chapter 10 (Worksheet A-3, Part A, column 1, line 1 is "Y"), Worksheet A-3, Part B, columns 4 or 5, sum of lines 1-4 must be greater than zero; and Part C, column 1, any one of lines 1-4 must contain any one of alpha characters A through G. Conversely, if Worksheet A-3, Part A, column 1, line 1 is "N", Worksheet A-3, Parts B and C must not be completed. [12/31/2004]
1000B	On Worksheet B-1, all statistical amounts must be greater than or equal to zero. [4/1/2005]
1010B	Edit 1010B - For each overhead cost center with a net expense for cost allocation greater than zero (Worksheet A, column 8, lines 1-4 & 6-11, respectively), the corresponding total cost allocation statistics (Worksheet B-1, columns 2-8, respectively, sum of lines 2-20) must also be greater than zero. Exclude from this edit any column that uses accumulated cost as its basis for allocation and any reconciliation column. [4/1/2005]
1005B	Worksheet B, column 11, line 21 must be greater than zero. [12/31/2004]

Rev. 9 34-527

3495 (Cont.) FORM CMS-265-94 12-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-94

TABLE 6 – EDITS

II. Level II Edits (Potential Rejection Errors)

These conditions are usually, but not always, incorrect. These edit errors should be cleared when possible through the cost report. When corrections on the cost report are not feasible, provide additional information in schedules, note form, or any other manner as may be required by your fiscal intermediary (FI). Failure to clear these errors in a timely fashion, as determined by your FI, may be grounds for withholding payments.

Edit	Condition
2000	All type 3 records with numeric fields and a positive usage must have values equal to or greater than zero (supporting documentation may be required for negative amounts). [12/31/2004]
2005	Only elements set forth in Table 3, with subscripts as appropriate, are required in the file . [12/31/2004]
2010	The cost center codes (positions 21-24) (type 2 records) must be a code from Table 5, and each cost center code must be unique. [12/31/2004]
2015	Standard cost center lines, descriptions, and codes should not be changed. (See Table 5.) This edit applies to the standard line only and not subscripts of that code. [12/31/2004]
2020	All standard cost center codes must be entered on the designated standard cost center line and subscripts thereof as indicated in Table 5. [12/31/2004]
2025	Only nonstandard cost center codes within a cost center category may be placed on standard cost center lines of that cost center category. [12/31/2004]
2030	The standard cost centers listed below must be reported on the lines as indicated and the corresponding cost center codes may only appear on the lines as indicated. No other cost center codes may be placed on these lines or subscripts of these lines, unless indicated herein. [12/31/2004]

	Cost Center	Line	Code
	Cap Rel-Bldg & Fixt	1	0100
	Cap Rel-Mvble Equip	2	0200
	Operation and Maintenance of Plant	3	0300
	Housekeeping	4	0400
	Machine Cap-Rel or Rental and Maintenance	6	0600
	Salaries for Direct Patient Care	7	0700
	Emp. Health and wel Bene for Direct Pat Care	8	0800
	Drugs	9	0900
	Supplies	10	1000
	Laboratory	11	1100
	Administrative and General	12	1200

34-528

Rev. 9

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E LECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-94

T ABLE 6 – EDITS

E dit

Condition

	Cost Center	Line	Code
	Interest Expense	13	1300
	Laundry and Linen	14	1400
	Medical Records	15	1500
	Phy Routine Pro Services-Initial Method	16	1600
	Phy Routine Pro Services-MCP Method	19	1900
	Whole Blood and Packed Red Blood Cells	20	2000
	Hepatitis B Vaccine	21	2100
	Physicians’ Private Offices	22	2200
	Epoetin	23	2300
	Method II Patients (Direct Dealing)	24	2400

2 035	The administrative and general standard cost center code (1200) may appear only on line 12. [12/31/2004]
2 040	All calendar format dates must be edited for 10 character format, e.g., 01/01/2004 (MM/DD/YYYY). [12/31/2004]
2 045	All dates must be possible, e.g., no "00", no "30", or "31" of February. [12/31/2004]
2 015S	The independent renal dialysis facility certification date (Worksheet S, column 1, line 3) should be on or before the cost report beginning date (Worksheet S, column 1, line 5). [12/31/2004]
2 020S	The length of the cost reporting period should be greater than 27 days and less than 459 days. [12/31/2004]
2 100S	The following statistics from Worksheet S-1, should be greater than zero:
	a. Total treatments for the independent renal dialysis facility (column 1-4, line 11.05) [12/31/2004]

Rev. 7 34-529

3495 (Cont.) FORM CMS 265-94 03-05

E LECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-94

T ABLE 6 - EDITS

E dit	Condition
2 000A	Worksheet A-1, column 1 (reclassification code) must be alpha characters. [12/31/2004]
2 020A	Worksheet A-3, Part A, must contain a "Y" or "N" response. [12/31/2004]
2 000B	At least one cost center description (lines 1-3), at least one statistical basis label (lines 4-5), and one statistical basis code (line 6) must be present for each general service cost center. This edit applies to all general service cost centers required and/or listed. [12/31/2004]
2 005B	The column numbering among these worksheets must be consistent. For example, data in capital related costs - buildings and fixtures is identified as coming from column 1 on all applicable worksheets. [12/31/2004]
NOTE:	CMS reserves the right to require additional edits to correct deficiencies that become evident after processing the data commences and, as needed, to meet user requirements.

34-530 Rev. 7