Independent Renal Dialysis Facility Cost Report and Supporting Regulations 42 CFR 413.20, 42 CFR 413.24 and 42 CFR 413.178

CHAPTER 42

INDEPENDENT RENAL DIALYSIS FACILITY COST REPORT

FORM CMS-265-11

Section

General

General 4200

Rounding Standards for Fractional Computations 4200.1

Acronyms and Abbreviations 4200.2

Recommended Sequence for Completing Form CMS-265-11 4201

Sequence of Assembly 4202

Method of Payment 4203

Payment for Physician Services 4203.1

Facility Payment for Self-Dialysis Training 4203.2

Facility Payment for Laboratory Services Included in Composite Rate 4203.3

Facility Payment for Home Dialysis 4203.4

Worksheet S - Independent Renal Dialysis Facility Cost Report Certification 4204

Part I – Cost Report Status 4204.1

Part II – General 4204.2

Part II - Certification by Officer or Administrator of Facility 4204.3

Worksheet S-1 - Independent Renal Dialysis Facility Statistical Data 4205

Worksheet A - Reclassification and Adjustment of Trial Balance of Expenses 4206

Worksheet A-1 - Reclassifications 4207

Worksheet A-2 - Adjustments to Expenses 4208

Worksheet A-3 - Statement of Costs of Services of Related Organizations 4209

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) 4210

Worksheet B - Cost Allocation - General Service Costs and

Worksheet B-1 - Cost Allocation - Statistical Basis 4211

Worksheet C - Computation of the Average Cost Per Treatment for

ESRD PPS Payment System 4212

Worksheet D - Computation of the Average Cost Per Treatment under

Basic Composite Rate 4213

Worksheet E – Calculation of Bad Debt Reimbursement 4214

Part I – Calculation of Reimbursable Bad Debt Title XVIII 4214.1

Part II – Calculation of Facility Specific Composite Cost Percentage 4214.2

Worksheet E-1 - Analysis of Payments to Providers for Services Rendered 4215

Part I – Tentative Settlements (Contractor Use) 4215.1

Part II – Low Volume Payment 4215.2

Worksheet F and F-1, Financial Statements 4216

Exhibit 1-Form CMS-265-11 Worksheets 4290

Electronic Reporting Specifications 4295

Rev. 1 42-1