Crosswalk

Revisions to Form CMS-265-11 ESRD Cost Report Application/Update Form

The forms are revised in accordance with the End-Stage Renal Disease Prospective Payment System Final Rule published August 12, 2010 which implemented statutory requirements of the Medicare Improvements for Patients and Providers Act (MIPPA), enacted July 15, 2008. Additionally, the forms are revised to incorporate data previously reported on the Provider Cost Report Reimbursement Questionnaire, Form CMS-339.

Changes

Issue #	Instructions Page #	Form Page #	Section	Old Package Form CMS -265-94	New Package Form CMS - 265-11	Reason for the Change Application of the instructions and accompanying worksheets	Burden Effect
1	42-8 – 42-10	42-303	4204	S	S	Added additional questions regarding low volume, ESRD PPS elections, transition periods and malpractice premiums.	N/A
2	42-11 – 42-14	42-304	4205	S-1	S-1	Added a line to capture Aranesp units separately from Epoetin and added a line number to report hours in a normal work week.	N/A
3	42-14 – 42-17	42-305	4205.1		S-2	Included the Provider Cost Report Reimbursement Questionnaire Form CMS-339 (OMB NO. 0938-0301) into CMS-265-11.	Increase
4	42-18 – 42-21	42-306	4206	A	A	Changed the order of lines 9 through 12.	N/A
5	42-28 – 42-33	42-311 – 42-312	4211	B, B-1	B, B-1	Subscripted ESRD modalities to separately cost adult and pediatric treatments. Added columns to properly step down drug allocations.	Increase
6	42-34	42-313	4212	C	C	Revised Worksheet C to compute average ESRD PPS bundled payment cost/treatment for all payor types.	Increase
7	42-35 – 42-36	42-314	4213	D	D	Replaced Worksheet D to compute average Medicare basic composite rate cost per treatment and capture average payment per treatment during the ESRD PPS transition.	Increase

Issue #	Instructions Page #	Form Page #	Section	Old Package Form CMS -265-94	New Package Form CMS – 265-11	Reason for the Change Application of the instructions and accompanying worksheets	Burden Effect
8	42-37 – 42-40	42-315	4214	-	E part I & II	Created a bad debt reimbursement worksheet.	Increase
9	42-40	42.316 – 42.317	4215	-	F & F-1	Created a worksheet to capture balance sheet and income statement information.	Increase

2