Renal Dialysis Facility Cost Report

CHAPTER 42
INDEPENDENT RENAL DIALYSIS FACILITY COST REPORT
FORM CMS-265-11
Section
General
General ...................................................................................................................................4200
Rounding Standards .........................................................................................................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 an Officer or Administrator of Facility ....................................4204.3
Worksheet S-1 - Independent Renal Dialysis Facility Statistical Data..................................4205
Worksheet S-2 - Independent Renal Dialysis Facility Reimbursement Questionnaire .........4205.1
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 A-4 - Statement of Compensation ...................................................................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 - Balance Sheet and F-1 Statement of Revenues and Expenses .......................4216
Exhibit 1 - Form CMS-265-11 Worksheets ..........................................................................4290
Electronic Reporting Specifications .....................................................................................4295

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4200.

FORM CMS-265-11

4200

GENERAL

Form CMS-265-11 must be completed by all independent end stage renal dialysis (ESRD)
facilities that are not hospital-based for cost reporting periods ending on or after January 1, 2011.
The Medicare Improvements for Patients and Providers Act (MIPPA) §153(b) required the
implementation of a bundled ESRD prospective payment system (ESRD PPS) for services
furnished on or after January 1, 2011. The ESRD PPS provides a single payment to ESRD
facilities that covers all of the resources used in providing outpatient dialysis treatment, including
supplies and equipment used to administer dialysis (in the ESRD facility or at a patient’s home),
drugs, biologicals, laboratory tests, training, and support services. Submit the form to your fiscal
intermediary (FI)/Medicare administrative contractor (MAC) (hereafter referred to as contractor)
no later than the last day of the fifth month following the close of your cost reporting year. Round
all reported amounts to the nearest dollar (unless specifically stated otherwise in the instructions)
with negative figures or reductions in expenses shown in parentheses ( ).
Effective for cost reporting periods ending on and after December 31, 2004, the electronic cost
report (ECR) file is the official means of cost report submission.
NOTE: This form is not used by ESRD facilities that are hospital-based. Hospital-based ESRD
facilities continue to use Form CMS-2552.
In addition to completing Form CMS-265-11, submit a copy of your facility’s audited (if
available) or unaudited financial statement for the accounting period as specified in this cost
report.
All facilities providing ESRD services to Medicare patients must meet conditions for coverage
before they can qualify for Medicare reimbursement. These criteria are contained in
42 CFR §494.
The final cost report of a facility that voluntarily or involuntarily ceases to participate in the
health insurance program is due no later than 150 days following the effective date of the
termination of the facility agreement. The final cost report required from a facility that undergoes
a change of ownership is due no later than 150 days following the effective date of the change of
ownership.
Failure to submit this cost report may result in suspension of future payments until it is submitted,
or revocation of your facility’s certification to participate in the program.
If your costs have been determined on the cash basis of accounting, make adjustments to conform
to the Medicare program requirement that the accrual method of accounting be used.
You are required to report the necessary accounting data in accordance with the Medicare
principles of reimbursement. These principles are contained in the Provider Reimbursement
Manual (CMS Pub. 15-1).
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-0236. The expiration date of this information
collection is 09/30/2020. The time required to complete this information collection is estimated
to average 65 hours per response, including the time to review instructions, search existing data
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resources, gather the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop
C4-26-05, Baltimore, Maryland 21244-1850. Please do not send applications, claims, payments,
medical records, or any other documents containing sensitive information to the PRA Reports
Clearance Office. Please note that any correspondence not pertaining to the information collection
burden approved under the associated OMB control number listed on this form will not be
reviewed, forwarded, or retained. If you have any questions or concerns regarding where to submit
your documents, please contact 1-800-Medicare.
4200.1 Rounding Standards.--Throughout the ESRD cost report, where computations result in
fractions, use the following rounding standards:
1.

Round to two decimal places:
a. Percentages (e.g., percent ownership of facility, percent of customary work week
devoted to business); (see 2b. below for exception)
b. Averages;
c. Full time equivalents;
d. Payment rate; and
e. Average cost per treatment.

2.

Round to six decimal places:
a. Ratios (e.g., unit cost multipliers)
b. Facility specific composite cost percentage

If a residual exists as a result of computing costs using a fraction, adjust the residual in the largest
amount resulting from the computation. For example, in cost finding, a unit cost multiplier is
applied to the statistics in determining costs. After rounding each computation, the sum of the
allocation may be more or less than the total cost allocated. This residual is adjusted to the largest
amount resulting from the allocation so that the sum of the allocated amounts equals the amount
allocated.
4200.2 Acronyms and Abbreviations.--Throughout the ESRD cost report and instructions, a
number of acronyms and abbreviations are used. For your convenience, commonly used acronyms
and abbreviations are summarized below:
CAPD
CBSA
CCN
CCPD
CFR
CMS
CMS Pub.
ESA
ESRD
FTE
IPD
MAC
MCP
NPR
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Continuous Ambulatory Peritoneal Dialysis
Core Based Statistical Area
CMS Certification Number
Continuous Cycling Peritoneal Dialysis
Code of Federal Regulations
Centers for Medicare and Medicaid Services
Centers for Medicare and Medicaid Services’ Publication
Erythropoiesis Stimulating Agent
End Stage Renal Disease
Full Time Equivalent
Intermittent Peritoneal Dialysis
Medicare Administrative Contractor
Monthly Capitation Method
Notice of Program Reimbursement
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RECOMMENDED SEQUENCE FOR COMPLETING FORM CMS-265-11

Step
No.

Worksheet

Instructions

1

S, Parts I & II

Read §4204.1.

2

S-1

Read §4205. Complete the entire worksheet.

3

S-2

Read §4205.1 Complete the entire worksheet.

4

A

Read §4206. Complete columns 1 through 4.

5

A-1

Read §4207. Complete entire worksheet if applicable.

6

A

Read §4206. Complete columns 5 and 6.

7

A-2

Read §4208. Complete entire worksheet.

8

A

Read §4206. Complete columns 7 and 8.

9

A-3

Read §4209. Complete entire worksheet if applicable.

10

A-4

Read §4210. Complete entire worksheet if applicable.

11

B and B-1

Read §4211. Complete entire worksheets.

12

C

Read §4212. Complete entire worksheet.

13

D

Read §4213. Complete entire worksheet.

14

E, Parts I & II

Read §4214. Complete entire worksheet.

15

E-1, Part II

Read §4215.

16

F & F-1

Read §4216. Complete entire worksheet.

17

S, Part III

Read §4204.2.

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FORM CMS-265-11

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SEQUENCE OF ASSEMBLY

The following list of assembly of worksheets is provided so all facilities are consistent in the order
of submission of their annual cost report. All facilities using Form CMS-265-11 are to adhere to
this sequence. When worksheets are not completed because they are not applicable, blank
worksheets are not included in the assembly of the cost report.
Worksheet

Part(s)

S

I, II & III

S-1
S-2
A
A-1
A-2
A-3
A-4

I & II

B
B-1
C
D
E

I & II

E-1

I & II

F
F-1

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4203.

FORM CMS-265-11

4203.2

METHOD OF PAYMENT

4203.1 Payment for Physician Services.--Physician services are paid differently depending upon
whether the service is an administrative service, routine professional service, or a service rendered
to patients undergoing self-dialysis and home dialysis training. For a definition of these services
and a description of the methods of payment for these services, see 42 CFR §§414.313, 414.314,
and 414.316.
A. Administrative Services.--Administrative services are physician services that benefit the
facility generally and are supervisory in nature. The services are not directly related to the care of
an individual patient, but are supportive of the facility as a whole and of benefit to patients in
general. Examples of administrative services include supervision of staff, staff training,
participation in staff conferences and in the management of the facility, and advising staff on the
procurement of supplies.
B. Physician Routine Professional Services.--Physician routine professional services for
outpatient maintenance dialysis are services furnished to individual patients. Physician routine
professional services are reimbursed under the monthly capitation payment (MCP) method
(see 42 CFR §414.314) unless an election is made by all of the physicians in the facility to be paid
under the initial payment method.
Under the MCP method, the physician is paid an amount for each patient to cover all professional
services rendered by the physician. The associated costs are not included as part of your cost.
They are, however, reported on the cost report as a separate line item.
Under the initial method of payment, the contractor pays the provider for physicians’ routine
professional services. Payment under this method is in the form of an add-on to the composite rate
and is included as part of your costs.
Certain services are not included in either the add-on under the initial method or in the MCP
amount under the MCP method. These services are paid under the physician fee schedule and,
therefore, are not included in your costs. These services are explained in 42 CFR §§414.313(b)
and 414.314(b) respectively.
C. Physician Payment for Self-Dialysis and Home Dialysis Training.-- Payment for
physician services rendered to dialysis patients undergoing self-dialysis training is a flat amount
per patient. The payment is made in addition to any amounts payable under the initial or MCP
methods. It is paid directly to the physician by the carrier and not included in your cost.
4203.2 Facility Payment for Self-Dialysis Training.--The base composite rate applies to
outpatient maintenance dialysis furnished in the facility. A higher rate, consisting of the base plus
a specified add-on, is paid for self-dialysis training sessions.

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The Medicare program pays you for training both the patient and his/her dialysis partner if a partner
is required. However, payment does not include travel to the facility or lost wages of the attendant
during the training period. (See CMS Pub. 100-04, chapter 8, §50.8 for specific instructions
regarding payment for training services.)
4203.3 Facility Payment for Laboratory Services Included in Composite Rate.--The costs of
certain ESRD laboratory services performed by either the ESRD facility or an independent
laboratory (as defined in CMS Pub. 100-04, chapter 8, §50.1) are included in the composite rate
calculations. Therefore, payment for all of these tests is included in the composite rate and may
NOT be billed separately to the Medicare program. This means that even though these laboratory
tests may be furnished one time per month, you are paid for such services over the course of the
month through the composite rate.
4203.4 Facility Payment for Home Dialysis.--For rules that apply to Medicare beneficiaries
dialyzing at home, see CMS Pub. 100-04, chapter 8, §70.1.
4204.

WORKSHEET S - INDEPENDENT RENAL DIALYSIS FACILITY COST REPORT
CERTIFICATION

4204.1 Part I – Cost Report Status.--This section is to be completed by the provider and
contractor as indicated on the worksheet.
Lines 1 through 3, column 1.--The provider must check the appropriate box to indicate on line 1
or 2, whether this cost report is being filed electronically or manually. For electronic filing,
indicate on line 1, columns 2 and 3 respectively, the date and time corresponding to the creation
of the electronic file. This date and time remains as an identifier for the file by the contractor and
is archived accordingly. This file is your original submission and is not to be modified. If this is
an amended cost report, enter on line 3 the number of times the cost report has been amended.
Line 4, Column 1.--Enter the Independent Renal Dialysis Information System (IRDIS) cost report
status code on line 4, column 1 of worksheet S that corresponds to the filing status of the cost
report: 1=As submitted; 2=Settled without audit; 3=Settled with audit; 4=Reopened; or
5=Amended.
Line 5, Column 1.--Enter the date (mm/dd/yyyy) an accepted cost report was received from the
provider.
Line 6, Column 1.--Enter the 5-position Contractor Number.
Lines 7 and 8, Column 1.--If this is an initial cost report, enter “Y” for yes in the box on line 7. If
this is a final cost report, enter “Y” for yes in the box on line 8. If neither, leave both lines 7 and
8 blank. An initial report is the very first cost report for a particular provider CCN. A final cost
report is a terminating cost report for a particular provider CCN.
Line 9, Column 1.--Enter the Notice of Program Reimbursement (NPR) date (mm/dd/yyyy). The
NPR date must be present if the cost report status code is 2, 3 or 4.
Line 10, Column 1.--If this is a reopened cost report (response to line 4, column 1 is “4”), enter
the number of times the cost report has been reopened.
Line 11, Column 1.--Enter the software vendor code for the software used by the contractor to
process this cost report. Use the format “X99”, where X is the alpha character representing a
specific cost report transmittal and 99 is the two digit software vendor code.
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4204.2

Part II - General.--

Line 1.--Enter the name of the facility.
Line 2.--Enter the street address and P.O. Box (if applicable).
Line 3.--Enter the city, State, and ZIP code.
Line 4.--Enter the county where the facility is located and the Core Based Statistical Area (CBSA).
Line 5.--Enter the provider CCN.
Line 6.--Enter the date the provider was certified.
Line 7.--Enter the name and phone number of the person to be contacted if any questions arise
regarding the information in this report.
Line 8.--Enter the inclusive dates covered by this cost report. Generally, a cost reporting period
consists of 12 consecutive calendar months or 13 four-week periods with an additional day (two
in a leap year) added to the last week in the period to make it coincide with the end of the calendar
year or month. See CMS Pub. 15-2, chapter 1, section 110 for situations where a short period cost
report may be filed. A new facility may select an initial cost reporting period of at least one month,
but not in excess of 13 months. (See CMS Pub. 15-2, §102.1(B).)
Line 9.--Indicate in column 1 the type of control. Indicate the ownership or auspices of the facility
by entering the number below that corresponds to the type of control of the facility.
Voluntary Non Profit
1=Corporation
2=Other (specify)

Proprietary
3=Individual
4=Corporation
5=Partnership
6=Other (specify)

Government
7=Federal
8=State
9=County
10=City
11=Other (specify)

If item 2, 6, or 11 is selected (Other (specify) category), specify the type of control in column 2.
Line 10.--Indicate whether your facility qualified and was approved as a low-volume facility for
this cost reporting period. CMS adjusts the base rate for low-volume ESRD facilities. In order to
receive this low-volume adjustment, a facility must attest in accordance with 42 CFR §413.232(f).
Line 11.--Indicate whether the physicians providing outpatient maintenance dialysis and other
physician services for ESRD patients are paid under the initial method or the MCP method.
Indicate the date of election of the initial method if applicable.
Column 1.--Enter the number 1 for the initial method and number 2 for the MCP method.
Column 2.--If the initial method is selected, enter the date of election of the initial method.

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Line 12.--Indicate whether you were previously certified as a hospital-based unit. Enter “Y" for
yes or “N” for no.
Line 13.--Indicate if your facility elected 100 percent PPS effective January 1, 2011. Enter “Y”
for yes or “N” for no. This election must have been received by the ESRD facility’s contractor by
November 1, 2010. Requests received after this date will not be accepted regardless of postmark
or delivery date.
New providers: ESRD facilities certified for Medicare participation on or after January 1, 2011,
are paid based on 100 percent of the ESRD PPS payment. ESRD facilities certified for Medicare
participation on or after January 1, 2011, must enter “Y” for yes.
Line 14.--If your facility did not elect to be paid based on 100 percent of the ESRD PPS payment
and your cost reporting period is a December 31 fiscal year end, enter the transition period in
column 2 as follows: For the fiscal year ending December 31, 2011, enter 1; for the fiscal year
ending December 31, 2012, enter 2; for the fiscal year ending December 31, 2013, enter 3; and,
for the fiscal year ending December 31, 2014, enter 4 for 100 percent ESRD PPS payment.
If your cost reporting period ends on a date other than December 31, indicate in column 1 the
transition period effective for the portion of the cost reporting period prior to January 1. Indicate
in column 2 the transition period effective for the portion of the cost reporting period on and after
January 1. For example, a cost reporting period with a fiscal year ending October 31 would
indicate the applicable transition periods as follows:
Fiscal year ending October 31, 2011: Leave column 1 blank as this would be prebundled ESRD PPS, and enter 1 in column 2 for the period of January 1, 2011, through
October 31, 2011.
Fiscal year ending October 31, 2012: Enter 1 in column 1 for the period of
November 1, 2011 through December 31, 2011, and enter 2 in column 2 for the period of
January 1, 2012 through October 31, 2012.
Fiscal year ending October 31, 2013: Enter 2 in column 1 for the period of
November 1, 2012 through December 31, 2012 and enter 3 in column 2 for the period of
January 1, 2013 through October 31, 2013.
Fiscal year ending October 31, 2014: Enter 3 in column 1 for the period of
November 1, 2013 through December 31, 2013 and enter 4 in column 2 for the period of
January 1, 2014 through October 31, 2014.
For all cost reporting periods beginning on or after January 1, 2014, enter 4 in column 2 for 100
percent ESRD PPS payment.
Payments during the transition period 1 are a blend of 25 percent case-mix adjusted ESRD PPS
and 75 percent basic case-mix adjusted composite rate (25/75). Payments during the transition
period 2 are a blend of 50 percent case-mix adjusted ESRD PPS and 50 percent basic case-mix
adjusted composite rate (50/50). Payments during the transition period 3 are a blend of 75 percent
case-mix adjusted ESRD PPS and 25 percent basic case-mix adjusted composite rate (75/25).
Payments for services rendered on and after January 1, 2014 are 100 percent ESRD PPS.
Line 15 through 17.--Enter the amount of malpractice insurance premiums, paid losses and/or self
insurance premiums, respectively.

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Line 18.--If malpractice premiums are reported in other than the A&G cost center, enter “Y” for
yes and submit a supporting schedule listing the cost centers and amounts contained therein.
Otherwise enter “N” for no.
Line 19.--If you are part of a chain organization, enter a “Y” for yes in column 1 and enter the
name and address of the organization on lines 20 through 22. Otherwise enter “N” for no in column
1. See CMS Pub. 15-1, §2150 for a definition of a chain organization.
Line 20.--Enter the name of the home office.
Line 21.--Enter the street address and P. O. Box (if applicable) of the home office.
Line 22.--Enter the city, State and ZIP code of the home office.
4204.3 Part III - Certification by an Officer or Administrator.--Complete and sign this
certification after the cost report has been prepared.
Section 1128B(a) of the Act states that, "Whoever knowingly and willfully makes or causes to be
made any false statement or representation of a material fact in any application for any benefit or
payment under a Federal health care program…--shall (i) in the case of such a statement,
representation, concealment, failure or conversion by any person in connection with the furnishing
(by that person) of items or service for which payment is or may be made under the program, be
guilty of a felony and upon conviction thereof fined not more than $25,000 or imprisoned for not
more than five years or both, or (ii) in the case of such a statement, representation, concealment,
failure, conversion or provision of council or assistance by any other person be guilty of a
misdemeanor and upon conviction thereof fined not more than $10,000 or imprisoned for not more
than one year or both…"
4205

WORKSHEET S-1 STATISTICAL DATA

INDEPENDENT

RENAL

DIALYSIS

FACILITY

In accordance with 42 CFR §§413.24(a) and 413.24(c), you are required to maintain statistical
records for proper determination of costs payable under the Medicare program. The statistics
reported on this worksheet pertain to the renal dialysis department. The required data includes
patient data, the number of treatments, number of machines, and home program data. In addition,
full time equivalent (FTE) data is required for staff employees and contract employees.
Column Descriptions
Column 1--Enter the statistics for Outpatient Hemodialysis patients on lines 1 through 11.
Column 2--Enter the statistics for Outpatient Peritoneal Dialysis patients on lines 1 through 11.
Column 3--Enter the statistics for Training Hemodialysis patients on lines 1 through 11.
Column 4--Enter the statistics for Training Peritoneal Dialysis patients on lines 1 through 11.

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Line Descriptions
Report the statistics on lines 1 through 11 for services furnished by you to patients that are in your
facility or some other institution. Do not include services furnished to patients in their homes.
Identify information as being either maintenance dialysis or training dialysis for either
hemodialysis or peritoneal dialysis.
Line 1.--Enter the number of treatments furnished directly at the facility and which were not billed
to the Medicare program.
Line 2.--Enter the number of treatments furnished under arrangements and which were not billed
directly to the Medicare program by you. An arrangement is an agreement between you and
another institution in which you agree to furnish specified services to patients of the other
institution, but the other institution retains responsibility for those services and for obtaining
reimbursement for services furnished to them.
Line 3.--Enter the number of patients in the dialysis program at the end of the cost reporting period.
The statistics reported in lines 4 through 8 are used to calculate your utilization rate.
Line 4.--Enter the average number of times per week a patient received dialysis at the facility.
This is computed by reporting your standard medical practice, if there was one (e.g., if you
commonly dialyzed hemodialysis patients 3 times per week, report 3), or by counting the number
of patient-weeks in the reporting period and dividing that number into the number of treatments
by mode of dialysis.
Line 5.--Enter the average number of days that you furnished dialysis in an average week. This is
computed by counting the number of days you were open for business during the period covered
by the cost report and dividing this amount by the number of weeks in that period. Normally, the
cost reporting period is 12 months, so the number of weeks in the denominator is 52.
Line 6.--Enter the average time of a typical patient dialysis session, including setup time in hours,
rounded to the nearest half-hour.
Line 7.--Enter the number of machines regularly available for use.
Line 8.--Enter the number of standby machines held in reserve for patient overflow, emergency,
and machine breakdown.
Line 9.--Enter in each column the number of staff shifts in a typical week during the cost reporting
period.
Line 10.--Enter in each column the hours per shift in a typical week during the cost reporting
period for the first shift on line 10.01, second shift on line 10.02, and the third shift on line 10.03.
Line 11.--Enter on lines 11.01 through 11.04 the total number of treatments (by type of treatment)
furnished to patients and the frequency of the treatment. Enter on line 11.01 the total number of
treatments (by type of treatment) furnished to patients who received dialysis one time per week.
Enter on line 11.02 the total number of treatments (by type of treatment) furnished to patients who
received dialysis two times per week. Enter on line 11.03 the total number of treatments (by type
of treatment) furnished to patients who received dialysis three times per week. Enter on line 11.04
the

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total number of treatments (by type of treatment) furnished to patients who received dialysis more
than three times per week. Enter in each column of line 11.05 the sum of the amounts entered on
lines 11.01 through 11.04.
Line 12.-Column 1.--Indicate the type of dialyzers used by entering the number below that
corresponds to the type.
1=Hollow Fiber, 2=Parallel Plate, 3=Coil, 4=Other
Column 2.--If the dialyzers were reused, indicate the number of times. If none
were reused, enter zero.
Column 3.--If “4, Other” is indicated in column 1, then indicate the type of
dialyzer used.
Line 13.--Enter the number of backup sessions furnished to home patients. A backup session is a
maintenance dialysis session furnished in the facility to a home patient. A patient who receives
backup dialysis is considered a home patient if there is a reasonable expectation that the need for
in-facility backup dialysis is only temporary and that the patient will return to home dialysis within
a reasonable period of time.
Column 1--Enter the number of back up sessions for CAPD patients.
Column 2--Enter the number of back up sessions for other patients.
Column 3--Enter the number of back up sessions for CCPD patients.
ESA STATISTICS--Effective January 1, 2005 and prior to January 1, 2011, Medicare paid for
erythropoiesis stimulating agents (ESAs) based on the Average Sales Price Drug Pricing File.
Effective January 1, 2011, payment for ESAs is included in the ESRD PPS payment.
Line 14.--Enter the total units of epoetin (EPO) furnished by the facility during its cost reporting
period divided by 1,000. For example, if a facility furnished 10,255,751 units, it reports 10,256
units on line 14. Round all numbers to whole numbers. Effective for cost reporting periods ending
after December 31, 2012, do not use this line; report ESAs on line 15.01.
Line 15.--Enter the total units of Aranesp furnished by the facility during its cost reporting
period. One unit is equal to 1 microgram (mcg). For example, if a facility furnished 1200 mcg, it
reports 1200 units on line 15. Round all numbers to whole numbers. Effective for cost reporting
periods ending after December 31, 2012, do not use this line; report ESAs on line 15.01.
Line 15.01.--Effective for cost reporting periods ending after December 31, 2012, identify the ESA
furnished to patients during the cost reporting period in column 1 and enter the total units furnished
in column 2. If more than one ESA was administered during the cost reporting period, continue
subscripting line 15 beginning with line 15.02 to identify each additional ESA and the units
furnished.
Line 16.--Enter the number of patients awaiting transplants at the end of this reporting period.
Line 17.--Indicate the number of patients who received transplants during this reporting period.

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Home Program
The data requested on lines 18 and 19 pertain to a home dialysis program.
Line 18.--Enter the number of patients that began home dialysis training during this reporting
period.
Line 19.--Enter the number of patients in the home program on the last day of your cost reporting
period.
Line 20.-Column 1.--Type of dialyzers used--Indicate the type of dialyzers used by entering the
number below that corresponds to the type.
1=Hollow Fiber, 2=Parallel Plate, 3=Coil, 4=Other
Column 2.--If the dialyzers were reused, indicate the number of times. If none were reused,
enter zero.
Column 3.--If column 1 is 4, indicate the type of dialyzer used.
Line 21.--Enter the number of hours in a normal work week in the space provided.
Lines 22 through 31.--The items in this part provide statistical data related to the facility’s human
resources. The human resource statistics are required for each of the job categories specified in
lines 22 through 31. Enter any additional category as needed on line 31.
Column Descriptions
Column 1.--Enter the FTE employees on the payroll. These are staff for which you issued an IRS
Form W-2. Staff FTEs are computed as the sum of all hours for which employees were paid during
the year divided by 2080 hours, rounded to two decimal places.
Column 2.--Enter the FTEs contracted and consultant staff worked during the year and divide by
2080 hours.
If employees were paid for unused vacation, unused sick leave, etc., exclude hours so paid from
the numerator in the calculations.
Personnel involved in more than one activity must have their time prorated among those activities.
For example, physicians who provided professional services and administrative services are
counted in both the physicians line and the administrative line according to the number of hours
spent in each activity (See 42 CFR §414.310). To make this allocation, use the time log records if
available, then use the results of time logs kept for a sample period (e.g., for 1 week per quarter,
have all employees keep a time log), or use estimates based on personal interviews.

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4205.1

4205.1 WORKSHEET S-2 - INDEPENDENT RENAL DIALYSIS FACILITY REIMBURSEMENT QUESTIONNAIRE
The information required on this worksheet (formerly Form CMS-339) must be completed by all
ESRD facilities submitting cost reports to the Medicare contractor under Title XVIII of the Social
Security Act (hereafter referred to as “the Act”). Its purpose is to assist you in preparing an
acceptable cost report, to minimize the need for direct contact between you and your contractor,
and to expedite review and settlement of cost reports. It is designed to gather pertinent information
about key reimbursement concepts as well as to support certain financial and statistical entries on
the cost report.
Where the instructions for this worksheet direct you to submit documentation/information, mail or
otherwise transmit to the contractor immediately, after submission of the ECR. The contractor has
the right under §§1815(a) and 1883(e) of the Act to request any missing documentation required
to complete the desk review.
To the degree that the information in the questionnaire constitutes commercial or financial
information that is confidential and/or is of a highly sensitive personal nature, the information will
be protected from release under the Freedom of Information Act. If there is any question about
releasing information, the contractor consults the CMS Regional Office.
NOTE: The responses on all lines are Yes or No unless otherwise indicated. If, in accordance
with the following instructions, you are requested to submit documentation, indicate the line
number for each set of documents you submit.
Line Descriptions
Lines 1 through 14 are required to be completed by all ESRD facilities.
Line 1.--Indicate whether the provider changed ownership. Enter “Y” for yes or “N” for no in
column 1. If column 1 is “Y”, enter the date the change of ownership occurred in column 2. Also,
submit the name and address of the new owner and a copy of the sales agreement with the cost
report.
Line 2.--Indicate whether the provider terminated participation in the Medicare program. Enter
“Y” for yes or “N” for no in column 1. If column 1 is “Y”, enter the date of termination in column
2, and “V” for voluntary or “I” for involuntary in column 3.
Line 3.--Indicate whether the provider was involved in business transactions, including
management contracts, with individuals or entities (e.g., chain home offices, drug or medical
supply companies) that were related to the provider or its officers, medical staff, management
personnel, or members of the board of directors through ownership, control, or family and other
similar relationships. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a
list of the individuals, the organizations involved, and a description of the transactions with the
cost report.
NOTE: A related party transaction occurs when services, facilities, or supplies are furnished to
the provider by organizations related to the provider through common ownership or control. (See
CMS Pub. 15-1, Chapter 10 and 42 CFR §413.17.)

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Line 4.--Indicate whether the financial statements were prepared by a Certified Public Accountant.
Enter “Y” for yes or “N” for no in column 1. If you answer “Y” in column 1, enter “A” for audited,
“C” for compiled, or “R” for reviewed in column 2. Submit a complete copy of the financial
statements (i.e., the independent public accountant’s opinion, the statements themselves, and the
footnotes) with the cost report. If the financial statements are not available for submission with
the cost report enter the date they will be available in column 3.
If you do not engage public accountants to prepare your financial statements, submit a copy of the
financial statements you prepared, and written statements of significant accounting policy and
procedure changes affecting Medicare reimbursement that occurred during the cost reporting
period. You may submit the changed accounting or administrative procedures manual in lieu of
written statements.
Line 5.--Indicate whether the total expenses and total revenues reported on the cost report differ
from those on the filed financial statements. Enter “Y” for yes or “N” for no in column 1. If you
answer “Y” in column 1, submit a reconciliation with the cost report.
Line 6.--Indicate whether you are seeking reimbursement for bad debts resulting from Medicare
deductible and coinsurance amounts that are uncollectible from Medicare beneficiaries. (See
42 CFR §§413.89(e), 413.89(h)(3), and CMS Pub. 15-1, §§306 - 324 for the criteria for an
allowable bad debt.) Enter “Y” for yes or “N” for no. If you answer “Y”, submit a completed
Exhibit 1 or schedules duplicating the documentation requested on Exhibit 1 to support the bad
debts claimed. Complete a separate Exhibit 1, as applicable, for bad debts for dates of service
prior to January 1, 2011, and each subsequent calendar year.
Exhibit 1 displayed at the end of this section requires the following documentation:
Columns 1, 2, 3 and 4.--Patient Names, Health Insurance Claim (HIC) Number, Dates of Service
(From) and (To)--The documentation required for these columns is derived from the beneficiary’s
bill. Furnish the patient’s name, health insurance claim number, and dates of service that correlate
to the claimed bad debt. (See CMS Pub. 15-1, §314 and 42 CFR §413.89.)
Columns 5 and 6.--Indigency/Welfare Recipient--If the patient was deemed indigent, place a check
in column 5 and include a valid Medicaid number, where applicable, in column 6. See the criteria
in CMS Pub. 15-1, §§312 and 322 and 42 CFR §413.89 for guidance on the billing requirements
for indigent patients and welfare recipients.
Columns 7 and 8.--Date First Bill Sent to Beneficiary and Date Collection Efforts Ceased--This
information is obtained from the provider’s files and must correlate with the beneficiary name,
HIC number, and dates of service shown in columns 1, 2 and 3 of this exhibit. The date in column
8 represents the date that the unpaid account was deemed worthless, whereby all collection efforts,
both internal and by an outside entity, ceased and there is no likelihood of recovery of the unpaid
account. (See 42 CFR §413.89(f), and CMS Pub. 15-1, §§308, 310, and 314.)
Column 9.--Remittance Advice Dates--Enter in this column the remittance advice dates that
correlate with the beneficiary name, HIC No., and dates of service shown in columns 1, 2, and 3
of this exhibit.
Columns 10 and 11.--Deductibles & Coinsurance--Record in these columns the beneficiary’s
unpaid deductible and coinsurance amounts that relate to covered services.

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Column 12.--Total Medicare Bad Debts--Enter on each line of this column, the sum of the amounts
in columns 10 and 11. Calculate the total bad debts amounts on all lines of column 12. This total
must agree with the bad debts claimed on the cost report. Attach additional supporting schedules,
if necessary, for bad debt recoveries.
NOTE: The information on Exhibit 1 (or the provider’s schedules) is not captured in the ECR
file. The exhibit/schedule may be submitted either manually (hard copy), or electronically (e.g.
CD).
Line 7.--Indicate whether your bad debt collection policy changed during the cost reporting period.
Enter “Y” for yes or “N” for. If you answer “Y”, submit a copy of the policy with the cost report.
Line 8.--Indicate whether patient deductibles and/or coinsurance were waived. Enter “Y” for yes
or “N” for no. If you answer “Y”, ensure the deductibles and/or coinsurance were not included on
the bad debt listings (i.e., Exhibit 1 or your schedules) submitted with the cost report.
Line 9.--Indicate whether the cost report was prepared using the Provider Statistical &
Reimbursement Report (PS&R) only. Enter “Y” for yes or “N” for no in column 1. If column 1
is “Y”, enter the paid-through-date of the PS&R in column 2. Also, submit a crosswalk between
revenue codes and charges found on the PS&R to the cost center groupings on the cost report.
Line 10.--Indicate whether the cost report was prepared using the PS&R for totals and provider
records for allocation. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, enter the
paid-through-date of the PS&R in column 2. Also, submit a detailed crosswalk between revenue
codes, departments and charges on the PS&R to the cost center groupings on the cost report. This
crosswalk must include which revenue codes were allocated to each cost center.
Line 11.--If you entered “Y” on either line 9 or 10, column 1, indicate whether adjustments were
made to the PS&R data for additional claims that were billed but not included on the PS&R used
to file this cost report. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a
schedule of claims not included on the PS&R. This schedule must include claims that are
unprocessed or unpaid and must be identified by revenue codes consistent with those reported on
the PS&R.
Line 12.--If you entered “Y” on either line 9 or 10, column 1, indicate whether adjustments were
made to the PS&R data for corrections of other PS&R information. Enter “Y” for yes or “N” for
no in column 1. If column 1 is “Y”, submit a detailed explanation and documentation that provides
an audit trail from the PS&R to the cost report.
Line 13.--If you entered “Y” on either line 9 or 10, column 1, indicate whether other adjustments
were made to the PS&R data. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”,
enter a description of the other adjustments and documentation that provides an audit trail from
the PS&R to the cost report.

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Line 14.--Indicate whether the cost report was prepared using provider records only. Enter “Y”
for yes or “N” for no in column 1. If column 1 is “Y”, submit detailed documentation of the system
used to support the data reported on the cost report. If detailed documentation was previously
supplied, submit only necessary updated documentation with the cost report.
The minimum requirements are:
•
Internal records supporting program utilization statistics, charges, prevailing rates and
payment information broken into each Medicare bill type in a consistent manner with the PS&R.
•

Reconciliation of remittance totals to the provider’s internal records.

•
Include the name of the system used and indicate how the system was maintained (vendor
or provider). If the provider maintained the system, include date of last software update.
NOTE: Additional information may be supplied such as narrative documentation, internal flow
charts, or outside vendor informational material to further describe and validate the reliability of
your system.

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4205.1(Cont.)

EXHIBIT 1
LISTING OF MEDICARE BAD DEBTS AND APPROPRIATE SUPPORTING DATA
Provider Name
Prepared by

Provider CCN
Date prepared
Indigency / Welfare
Recipient

Yes

Medicaid
Number

Date First
Bill Sent
to Beneiciary

Date
Collection
Effort
Ceased

Remittance
Advice
Dates

Deductibles*

CoInsurance*

Total

5

6

7

8

9

10

11

12

(Check if applicable)

Patient Name

HIC No.

1

2

Dates of Service
From
To
3

4

FYE

* These amounts must not be claimed unless the provider bills for these services with the intention of payment. See instructions
for Indigency/Welfare Recipient, columns 5 and 6, for possible exception.
Rev. 3

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4206.
WORKSHEET A - RECLASSIFICATION AND ADJUSTMENT OF TRIAL
BALANCE OF EXPENSES
This worksheet provides for recording the trial balance of expense accounts from your accounting
books and records. It also provides for the necessary reclassifications and adjustments to certain
accounts.
The cost centers on this worksheet are listed in a manner that facilitates the combination of the
various groups of cost centers for purposes of cost finding. All of the cost centers listed do not
apply to all facilities using these forms. Complete only those lines that are applicable.
Where the cost elements of a cost center were separately maintained on your books, a
reconciliation of the costs per the accounting books and records to those on this worksheet must
be maintained by you and is subject to review by the contractor.
Do not change standard (i.e., preprinted) CMS line numbers and cost center descriptions. If you
need to use additional or different cost center descriptions, do so by adding additional lines to the
cost report. Do this in such a manner that the entries bear a logical relationship to the standard line
description preceding the added line. Identify the line added as a numeric subscript of the
immediately preceding line. That is, if two lines are added between lines 3 and 4, identify them
as lines 3.01 and 3.02. If you add additional lines for reimbursable cost centers, add corresponding
columns on Worksheets B and B-1 for each additional cost center.
Columns 1, 2, 3, and 4.--The expenses listed in these columns must be in accordance with your
accounting books and records. List on the appropriate lines in columns 1, 2, 3, and 4 the total
expenses incurred during the cost reporting period. The expenses must be detailed between
salaries (columns 1 and 2) and other than salaries (column 3). The sum of columns 1, 2, and 3
must equal column 4. Any needed reclassifications and adjustments must be recorded in columns
5 and 7, as appropriate.
Column 5.--Enter any reclassifications among the cost center expenses that are needed to effect
proper cost allocation.
Worksheet A-1 is provided to compute the reclassifications affecting the expenses specified
therein. This worksheet need not be completed by all facilities but must be completed only to the
extent that the reclassifications are needed and are appropriate in the particular facility’s
circumstances. Show reductions to expenses in parentheses ( ).
The net total of the entries in column 5 must equal zero on line 27.
Column 6.--Adjust the amounts entered in column 4 by the amounts entered in column 5 (increase
or decrease) and extend the net balances to column 6. Column 6 line 27 must equal column 4 line
27.
Column 7.--Enter on the appropriate lines in column 7 the amounts of any adjustments to expenses
indicated on Worksheet A-2, column 2. Indicate those adjustments to expenses that are reductions
in the expense by showing the figure in parentheses ( ). The total on Worksheet A, column 7, line
27, must equal Worksheet A-2, column 2, line 23. The amounts entered on Worksheet A, column
7, lines 13, 19, and 23 must equal the amounts entered on Worksheet A, column 6, lines 13, 19,
and 23 respectively.

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4206 (Cont.)

Column 8.--Adjust the amounts in column 6 by the amounts in column 7 (increase or decrease)
and extend the net balances to column 8.
The amounts in column 8 marked with an asterisk (*) in the left and right margins are transferred
to the appropriate columns and lines on Worksheets B and B-1. See the instructions for
Worksheets B and B-1.
Line Descriptions
Line 1.--This cost center includes capital-related costs on buildings and fixtures and expenses
pertaining to buildings and fixtures such as depreciation, insurance, interest, rent, and property
taxes.
Line 2.--This cost center includes capital-related costs on movable equipment and expenses
pertaining to moveable equipment, such as depreciation, insurance, interest, personal property
taxes, and rent. It includes items such as office furniture and equipment. Moveable equipment
does not refer to dialysis machines or support equipment. The costs related to depreciation and/or
rental and maintenance on the dialysis machines and support equipment is reported on line 6.
Line 3.--This cost center includes the direct expenses incurred in the operation and maintenance
of the plant and equipment and protecting employees, visitors, and facility property. Operation
and maintenance of plant includes the maintenance and service of utility systems, such as heat,
light, water (excluding water treatment for dialysis purposes), air conditioning, and air treatment;
the maintenance and repair of buildings, parking facilities, and equipment; painting; elevator
maintenance; and performance of minor renovation of buildings and equipment. The utility cost
of water is included on this line. The cost of water treatment for dialysis purposes is not entered
on this line, but rather is included in line 6, machine capital-related or rental and maintenance.
Line 6.--This cost center includes capital-related costs for moveable equipment other than those
included on line 2. Enter only the capital-related costs of moveable equipment, rented and/or
purchased, and maintenance on the dialysis machine and any support equipment. Include the costs
of water treatment for dialysis purposes on this line.
Water treatment for dialysis includes the equipment and associated maintenance and repair and
installation costs necessary to render the water acceptable for use in dialysis. Examples of such
equipment are water softener (resin or deionizer type) and reverse osmosis machines. This
equipment prepares the water that is fed directly into the dialysis machine.
Line 7.--This cost center includes direct salaries of all personnel who furnished direct care to
dialysis patients. Direct salaries include gross salaries and wages of all such personnel, e.g.,
registered and licensed practical nurses, nursing aides, technicians, social workers, and dieticians.
Salaries paid to physicians are not included in this cost center but are allocated to cost centers on
line 11 and either line 16 or line 19. Administrative costs are reported on line 11 and routine
professional costs related to costs of direct patient care are reported on line 16 or 19. To compute
this allocation, first separate the costs of physician administrative services versus direct patient
care services. Separate these costs by the time spent in each activity. The remainder, costs of
direct patient care, is split between routine professional services, line 16 or line 19, and other
medical services which may be billed for separately by the physician to the Medicare carrier. If
you pay malpractice insurance premiums applicable to physicians, see instructions for malpractice
cost adjustments on Worksheet A-2, line 19.

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Line 8.--This cost center includes the cost of employee health and wellness benefits for direct
patient care.
Line 9.--This cost center includes the direct cost of total dialysis supplies used in furnishing
dialysis services. It includes the cost of supplies that are covered under the composite rate payment
and separately billable supplies. Exclude the costs of meals served to patients. If these costs are
included, adjust them out on Worksheet A-2, line 9.
Line 10.--This cost center includes the cost of all laboratory services (i.e., laboratory services that
are either included or not included in the composite rate payment) performed either by your staff
or an independent laboratory. Effective for claims with dates of service on or after January 1,
2011, all ESRD-related laboratory services are included in the ESRD PPS base rate. (See CMS
Pub. 100-04, chapter 8, §50.1.)
Line 11.--This cost center is used to record the expenses of several costs incurred in maintaining
the facility. Examples are fiscal services, legal services, accounting, recordkeeping, data
processing, purchasing, taxes, telephone, home office costs, malpractice costs, and physicians’
administrative services. The physicians’ administrative services are services rendered by
physicians that are directly related to the support of the facility and not directly related to the care
of individual patients. (See §4203.1A.) Malpractice costs include allowable insurance premiums,
direct losses, and expenses related to direct losses. The cost of malpractice insurance premiums
paid by the facility, applicable to physicians, is adjusted out in column 7. If you pay malpractice
insurance premiums applicable to physicians, see instructions for malpractice cost adjustments on
Worksheet A-2, line 19.
Line 12.--This cost center includes the direct cost of total drugs used in furnishing dialysis services.
It includes the costs of parenteral drugs used in the dialysis procedure that are covered under the
composite rate payment (see CMS Pub. 100-04, Chapter 8, §50.2). In addition to drugs included
in the composite rate, this cost center includes separately billable injectable drugs provided to the
facility’s patients. Effective for claims with dates of service on or after January 1, 2011, ESRDrelated injectable drugs and biologicals and oral equivalents of those injectable drugs and
biologicals are included and are no longer separately billable. Report all drugs, ESRD related and
non-ESRD related (including approved ESAs), on this line (see CMS Pub. 100-04, chapter 8,
§50.2). Do not include on this line any ESA drug cost for dates of service prior to January 1, 2011,
as these costs must be reported on line 23.
Line 16.--Enter the cost of physician routine professional services covered under the initial method
of physician payment. See 42 CFR §414.310 for a definition of these services.
Line 17.--Use this line to record the cost applicable to any reimbursable cost center not provided
for on this worksheet.
Line 18.--Enter the sum of lines 11 and 13 through 17.
Line 19.--This cost center includes compensation (i.e., direct salaries, fringe benefits, etc.) of
physicians for professional services that are related to the care of the patient and medical
management over the period of time the patient is on dialysis. These costs are adjusted out on
Worksheet A-2, line 10, and are not transferred in the cost report because they are not included in
the composite rate.

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Line 20.--This cost center includes the direct expenses incurred in obtaining blood directly from
donors and whole blood and packed red blood cells from suppliers. Include in this cost center in
column 3 (Other) the processing fee charged by suppliers. These items are billed separately and
reimbursement is not included in the composite rate.
Line 21.--This cost center includes the direct costs associated with hepatitis B, influenza virus and
pneumococcal pneumonia virus (PPV) vaccines and their administration when furnished to eligible
beneficiaries in accordance with coverage rules. Vaccines remain separately payable under the
ESRD PPS. (See CMS Pub. 100-04, chapter 8, §60.6)
Line 22.--This non-reimbursable cost center accumulates the cost incurred by you for services
related to the physicians’ private practices. Examples of such costs are depreciation costs for the
space occupied, moveable equipment used by the physicians’ offices, administrative services,
medical records, housekeeping, maintenance and repairs, operation of plant, drugs, medical
supplies, and nursing services.
Line 23.--This cost center includes the cost of approved ESAs furnished to both in-facility and
home-program ESRD patients for services prior to January 1, 2011. These costs are adjusted out
on Worksheet A-2, lines 15 through 18 respectively, and are not transferred to any worksheets in
the cost report.
Effective January 1, 2011, these costs are reimbursed through the ESRD PPS payment system and
are reported on line 12.
Line 24.--This cost center includes the direct cost of support services provided to Method II home
patients. Under this option, the patient elects to make his/her own arrangements for securing the
necessary supplies and equipment to dialyze at home through a Method II supplier. (See
CMS Pub. 100-04, chapter 8, §90). Effective January 1, 2011, §153b of the Medicare
Improvements for Patients and Providers Act (MIPPA) eliminates Method II and all home dialysis
claims must be billed by a renal dialysis facility and paid under the ESRD PPS.
Lines 25 and 26.--Use these lines to record the cost applicable to any nonreimbursable cost centers
not provided for on this worksheet, e.g., Supplementary Medical Insurance premiums paid by the
facility on behalf of beneficiaries financially unable to pay the premiums. Label the lines used to
indicate the purpose of their use.
Line 27.--Enter the sum of the amounts on lines 5, 12, 18, and 19 through 26.

Rev. 2

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4207.

FORM CMS-265-11

06-13

WORKSHEET A-1 - RECLASSIFICATIONS

This worksheet provides for the reclassification of certain amounts to effect proper cost allocation
under cost finding. Specifically identify the cost centers affected in your accounting records. If
more lines are needed than provided on this worksheet, submit additional copies of this worksheet
and enter the additional information on them. The following are some examples of costs which
are reclassified on this worksheet.
1. If the total employee health and welfare benefits are included in administrative and
general on Worksheet A, column 4, line 11, then reclassify these costs to Worksheet A, column 5,
line 8. Reclassify employee health and welfare benefits relating to physicians’ routine professional
services to Worksheet A, column 5, line 16 or 19.
2. Reclassify the insurance expense applicable to the building and/or fixtures, moveable
equipment, dialysis machines, and supportive equipment included in administrative and general
on Worksheet A, column 4, line 11, to Worksheet A, column 5, lines 1, 2, and 6, respectively.
3. Reclassify any interest expense applicable to funds borrowed for administrative and
general purposes (operating expenses, etc.) or for the purchase of buildings and/or fixtures,
moveable equipment, dialysis machines, or supportive equipment included in interest on
Worksheet A, column 4, line 13, to Worksheet A, column 5, lines 11, 1, 2, and 6, respectively.
4. Reclassify rent expenses applicable to the rental of buildings and fixtures and to
moveable equipment included in administrative and general from Worksheet A, column 5, line 11,
to Worksheet A, column 5, lines 1 and 2, respectively. See instructions for Worksheet A-3 for
treatment of rental expense for related organizations. Reclassify expenses (such as insurance,
interest and taxes) applicable to machine depreciation or rental and maintenance of dialysis
machines and supportive equipment to Worksheet A, column 5, line 6.
5. Reclassify any taxes (real property taxes and/or personal property taxes) applicable to
buildings, fixtures, moveable equipment, dialysis machines, and support equipment included in
administrative and general on Worksheet A, column 4, line 11, to Worksheet A, column 5, lines
1, 2, and 6, respectively.
Transfer the amount of increase (column 4) and decrease (column 7) of Worksheet A-1, applicable
to the various cost centers, to Worksheet A, column 5.
You may have charged some of these amounts to the proper cost center before the end of the
accounting period. Therefore, complete Worksheet A-1 only to the extent that expenses differ
from the result that would be obtained using the instructions in the preceding paragraphs.

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4208.

FORM CMS-265-11

4208

WORKSHEET A-2 - ADJUSTMENTS TO EXPENSES

This worksheet provides for the adjustments to the expenses listed on Worksheet A, column 6.
These adjustments, which are required under the Medicare principles of reimbursement, are to be
made on the basis of cost, or amount received. Enter the total amount received (revenue) only if
the cost (including direct cost and all applicable overhead) cannot be determined. If the total direct
and indirect cost can be determined, enter the cost. Once an adjustment to an expense is made on
the basis of cost, you may not in future cost reporting periods determine the required adjustment
to the expense on the basis of revenue. The following symbols are to be entered in column 1 to
indicate the basis for adjustment: "A" for costs and "B" for amount received. Line descriptions
indicate the more common activities which affect allowable costs or result in costs incurred for
reasons other than patient care and, thus, require adjustments.
Types of items to be entered on Worksheet A-2 are (1) those needed to adjust expenses to reflect
actual expenses incurred; (2) those items which constitute recovery of expenses through sales,
charges, fees, etc. and (3) those items needed to adjust expenses in accordance with the Medicare
principles of reimbursement. (See CMS Pub. 15-1, chapter 23, §2328.)
Where an adjustment to an expense affects more than one cost center, you must record the
adjustment to each cost center on a separate line on Worksheet A-2.
Line Descriptions
Line 1.--Investment income on restricted and unrestricted funds which are commingled with other
funds must be applied together against, but should not exceed, the total interest expense included
in allowable costs. (See CMS Pub. 15-1, chapter 2.)
Apply the investment income on restricted and unrestricted funds which are commingled with
other funds against the administrative and general, the capital-related - buildings and fixtures, the
capital-related - moveable equipment and any other appropriate cost centers on the basis of the
ratio that interest expense charged to each cost center bears to the total interest expense charged to
all of your cost centers.
Line 5.--Enter any adjustments to the various cost centers which have been included as costs paid
directly by the carrier for physician’s services which are separately billable, i.e., declotting of
shunts for facilities whose physicians are paid under the MCP method.
Line 6.--Enter allowable home office costs which have been allocated to you and which are not
already included in your cost report. Use additional lines to the extent that various facility cost
centers are affected. (See CMS Pub. 15-1, chapter 21.)
Line 7.--The amount entered is obtained from Worksheet A-3, Part B, column 6, line 5. Note that
Worksheet A-3, Part B, lines 1through 4 represent the detail of the various cost centers to be
adjusted on Worksheet A.
Line 8.--Remove the direct cost plus applicable overhead of operating vending machines from
allowable cost. If cost cannot be calculated, then income received may be used.

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Line 9.--Enter any adjustments to the cost for meals served to patients. Under Part B of Medicare,
only medical services are covered in an outpatient setting. Therefore, food costs must be excluded
from the total costs.
Line 10.--Enter the total compensation of physician routine professional services which are paid
under the MCP method and related to the care of patients. This must equal the amount on
Worksheet A, column 7, line 19.
Line 11.--Enter the direct cost including applicable overhead of dialysis services furnished to a
hospital under arrangements.
Lines 13 and 14.--Where capital-related expenses computed in accordance with the Medicare
principles of reimbursement differ from capital-related expenses per your books, enter the
difference on lines 13 and 14. (See CMS Pub. 15-1, chapter 1.)
Line 15.--Enter rebates taken on epoetin purchases prior to January 1, 2011.
Line 16.--Enter the cost of the approved drug epoetin (EPO) furnished to both in-facility and home
ESRD patients. This amount must equal the amount on Worksheet A, column 7, line 23 less the
amount, if any, entered on line 15 of this worksheet. For services rendered on or after
January 1, 2011, do not complete this line as EPO will be paid as part of the ESRD PPS payment.
Line 17.--Enter rebates taken on aranesp purchases prior to January 1, 2011.
Line 18.--Enter the cost of the approved drug aranesp furnished to both in-facility and home ESRD
patients. This amount must equal the amount on Worksheet A, column 7, line 23 less the amount,
if any, entered on line 17 of this worksheet. For services rendered on or after January 1, 2011, do
not complete this line as Aranesp will be paid as part of the ESRD PPS payment.
Line 19.--Enter rebates taken on epoetin purchases on or after January 1, 2011. Do not use for
purchases on or after January 1, 2012; use line 20.01.
Line 20.--Enter rebates taken on aranesp purchases on or after January 1, 2011. Do not use for
purchases on or after January 1, 2012; use line 20.01.
Line 20.01.--Enter rebates taken on ESA drug purchases on or after January 1, 2012.
Line 21.--Enter the cost of malpractice insurance premiums paid by the facility specifically
identified as physicians’ malpractice premiums on this line.
Lines 22 through 99.--Enter any additional adjustments which are required under the Medicare
principles of reimbursement. Appropriately label the line to indicate the nature of the required
adjustments.
Line 100.--Enter the sum of lines 1 through 99. Transfer the amounts in column 2 to Worksheet
A, column 7.

42-26

Rev. 3

12-11
4209.

FORM CMS-265-11

4209

WORKSHEET A-3 - STATEMENT OF COSTS OF SERVICES FROM RELATED
ORGANIZATIONS

In accordance with 42 CFR §413.17, costs applicable to services, facilities, and supplies furnished
to you by organizations related to you by common ownership or control are includable in your
allowable cost at the cost to the related organization except for the exceptions outlined in
42 CFR §413.17(d). This worksheet provides for the computation of any needed adjustments to
costs applicable to services, facilities, and supplies furnished to you by organizations related to
you by common ownership or control. In addition, certain information concerning the related
organizations with which you transacted business is required. (See CMS Pub. 15-1, chapter 10.)
Part A.--If any costs included on Worksheet A resulted from transactions with related
organizations as defined in CMS Pub. 15-1, chapter 10, check "Yes" and complete Parts B and C.
If there are no costs included in Worksheet A which resulted from transactions with related
organizations as defined in CMS Pub. 15-1, chapter 10, check "No" and do not complete the
remainder of this form.
Part B.--Costs incurred and adjustments required for services, facilities, and supplies furnished to
you by organizations related to you by common ownership or control are includable in your
allowable cost at the cost to the related organizations. Such cost must not exceed the amount a
prudent and cost conscious buyer would pay for comparable services, facilities, or supplies that
could be purchased elsewhere.
Complete each line as necessary and complete all columns for each of those lines.
Column 1.--Enter the line number from Worksheet A that corresponds to the cost center for which
the adjustment is being made.
Column 2.--Enter the cost center from Worksheet A for which the adjustment is being made.
Column 3.--Enter the item of service, facility, or supply that you obtained from the related
organization.
Column 4.--Enter the allowable cost to your organization for the service, facility, or supply that
was obtained from the related organization. The allowable cost is the lesser of the amount a
prudent and cost conscious buyer pays for a comparable service, facility, or supply purchased
elsewhere or the actual cost incurred by the related party. (See CMS Pub. 15-1, chapter 10.)
Column 5.--Enter the cost charged to your organization by the related organization for the service,
facility, or supply that was obtained from the related organization.
Column 6.--Enter the amount in column 4 less the amount in column 5. Transfer the(se) amount(s)
to the corresponding line of Worksheet A, column 7.

Rev. 1

42-27

4209 (Cont.)

FORM CMS-265-11

12-11

Part C.--This part is used to report your interrelationship to organizations furnishing services,
facilities, or supplies to you. The requested data relative to all individuals, partnerships,
corporations, or other organizations having either a financial interest in the facility, a common
ownership of the facility, or control over the facility as defined in CMS Pub. 15-1, chapter 10,
must be shown in columns 1 through 6, as appropriate.
Complete only those columns which are pertinent to the type of relationship which existed.
Column 1.--Enter the appropriate symbol which describes your interrelationship to the related
organization.
Column 2.--If the symbol A, D, E, F, or G is entered in column 1, enter the name of the related
individual in column 2.
Column 3.--If the individual in column 2 or the organization in column 4 has a financial interest
in your facility, enter the percent of ownership in the facility.
Column 4.--Enter the name of the related corporation, partnership, or other organization.
Column 5.--If the individual in column 2 or your facility had a financial interest in the related
organization, enter the percent of ownership in such organization.
Column 6.--Enter the type of business in which the related organization engaged (e.g., laboratory
drugs and/or supplies).

42-28

Rev. 1

05-14
4210.

FORM CMS-265-11

4210.2

WORKSHEET A-4 - STATEMENT OF COMPENSATION

Administrative services are those services directly related to the support of your facility and are
not related directly to the dialysis patients’ care. When listing the percent of work devoted to the
business by a person who performed more than one duty, the person’s combined percentage may
not total over 100 percent. For example, if one person was both an administrator and a medical
director, and spent 60 percent the workweek as an administrator, then a maximum of 40 percent
can be reported as time spent as the medical director. Use a separate line per person per function.
When one person performed more than one function, indicate this in column 1 by entering "same
as line."
4210.1 Part I – Statement of Total Compensation to Owners.--Include the title, function, and
percentage of time devoted to the business for the owners and employees related to the owners. In
addition, show the total compensation (including fringe benefits, perquisites, and maintenance)
included in allowable cost that was earned by sole proprietors, partners, and corporation officers,
as owner(s) of your organization. Compensation is the total benefit received and receivable by the
owner for the services rendered to the institution. It includes salary amounts earned for managerial,
administrative, professional, and other services; the amounts paid by the institution for the personal
benefit of the owner; the cost of the assets and services that the owner received from the institution;
and deferred compensation.
4210.2 Part II – Statement of Total Compensation to Administrators, Assistant Administrators,
and/or Medical Directors or Others Performing These Duties (Other than Owners).--Include the
title, percent of time devoted to the business and total compensation (including fringe benefits,
perquisites, and maintenance) earned by employed administrators, assistant administrators,
medical directors, or others who performed these duties. (See 100-04, Chapter 8, §40.6.)

Rev. 3

42-29

4211

FORM CMS-265-11

05-14

4211.
WORKSHEET B - COST ALLOCATION - GENERAL SERVICE COSTS and
WORKSHEET B-1 - COST ALLOCATION – STATISTICAL BASIS
Worksheet B provides for cost finding by using a combined methodology of cost centers and
apportioning the costs to those cost centers that receive the services. The cost centers that are
serviced include all cost centers within your organization; that is, separately billable, reimbursable
cost centers, and nonreimbursable cost centers. Obtain the total direct expenses from Worksheet
A, column 8.
Worksheet B-1 provides for the statistics necessary to allocate the cost to the revenue producing
and nonreimbursable cost centers on Worksheet B.
To facilitate the allocation process, the general format of Worksheets B and B-1 are identical for
columns 1 through 8. The column and line numbers for columns 1 through 8 are identical on the
two worksheets.
The statistical bases shown at the top of each column on Worksheet B-1 are the recommended
bases of allocation of the cost centers indicated. Use these statistical bases of allocation unless
you have contractor approval in writing to use different bases. (See CMS Pub. 15-1, §2313.)
Certain cost centers are combined on Worksheet B-1 for cost allocation purposes. These
combinations are not optional; that is, facilities must combine and allocate these costs as shown
on the worksheet. The total costs of each combined group of cost centers are allocated in one
process to the revenue producing and nonreimbursable cost centers.
Column Descriptions
Columns 2 and 3.--These columns are used to allocate costs reported on Worksheet A, lines 1
through 4, to the various cost centers. Column 2 allocates costs to the various cost centers and
Column 3 further allocates these costs by modality between Adults and Pediatrics. On
Worksheet B-1 enter in column 2 the square footage statistics for cost centers 8, 9, 10, 11, 12, 13,
14, 15, 16, 17, and 19 through 22. On Worksheet B-1 enter in column 3, the total number of
treatments for Adults and Pediatrics, by modality on subscripted lines 8 through 17.
Enter on Worksheet B, column 2, the costs allocated for cost centers 8, 9, 10, 11, 12, 13, 14, 15,
16, 17, and 19 through 22. On Worksheet B, column 3, enter on the subscripted lines 8 through
17, the costs allocated in column 2 to their respective modalities between Adults and Pediatrics
based on a percentage of treatments to total treatments for each modality multiplied by the costs
allocated on the respective lines on Worksheet B, column 2.
Columns 7 and 8.--These columns allocate supplies and laboratory services, (i.e., ESRD related
and Non-ESRD related) provided to both Medicare and non-Medicare patients, that were furnished
by, billed by, and reimbursed to your facility. Do not include any items and services that were
billed by physicians as such costs are not part of your facility’s costs. To determine the costs
allocated to the various cost centers, report actual costs if separate expense accounts are
maintained, or allocate these costs based on the supplier’s charges as reported on the costed
requisitions. The cost or costed requisitions used for allocation purposes must bear a consistent
relationship to the costs of all items and services. (See CMS Pub. 100-04, Chapter 8, §50.1.)

42-30

Rev. 3

06-13

FORM CMS-265-11

4211 (Cont.)

NOTE: Drugs and biologicals are reported in column 10 and subsequently allocated into
columns 11, 12 and 13 in order to determine basic composite rate costs and ESRD PPS costs.
Basic composite rate costs are used in the determination of allowable bad debts.
Column 10.--This column allocates drugs (i.e., ESRD related and non-ESRD related) provided to
both Medicare and non-Medicare patients to lines 2 through 5. These drugs and biologicals include
ESAs and any oral form of such agents as well as other drugs and biologicals that are furnished
by, billed by and reimbursed to your facility. Do not include any drugs that were billed by
physicians as such costs are not part of your facility’s costs. To determine the costs allocated to
lines 2 through 5, use actual costs if separate expense accounts are maintained, or allocate these
costs based on the supplier’s charges as reported on the costed requisitions. The cost or costed
requisitions used for allocation purposes must bear a consistent relationship to the costs of all items
and services. (See CMS Pub. 100-04, chapter 8, §50.2)
Columns 11, 12 and 13.--These columns are used to allocate the costs identified on column 10,
lines 2, 3 and 4 to the various modes of treatment on subscripted lines 8 through 17, based on
actual costs or supplier’s charges.
Line Descriptions
Items and services that are covered under the composite rate are those commonly furnished as part
of a typical dialysis service. These costs are reimbursed through your dialysis rate and may not be
separately billed. The costs of items and services covered under the composite payment rate are
allocated to the various modes of treatment on subscripted lines 8 through 17, Worksheet B. The
costs of separately billable items and services are not allocated to various modes of treatment
because they are not considered one of the dialysis service costs that are used in computing the
composite payment rate.
Effective January 1, 2011, the ESRD PPS provides a single payment to ESRD facilities that will
cover all of the resources used in furnishing an outpatient dialysis treatment, including supplies
and equipment used to administer dialysis (in the ESRD facility or at a patient’s home), drugs,
biologicals, laboratory tests, training, and support services.
Line 2.--Drugs included in basic composite rate are ESRD-related drugs and biologicals that were
paid under the composite rate payment system prior to January 1, 2011, and are considered in the
calculation of the basic case-mix composite rate effective January 1, 2011.
Line 3.--ESAs prior to January 1, 2011, are adjusted on Worksheet A-2. For services rendered on
or after January 1, 2011, ESAs (including oral forms) are included in the ESRD PPS payment and
are included on line 3 for proper allocation.
Line 4.--ESRD related other drugs are drugs that are reimbursed under the ESRD PPS payment
system effective January 1, 2011. DO NOT include oral-only drugs.

Rev. 2

42-31

4211 (Cont.)

FORM CMS-265-11

06-13

Line 5.--Non-ESRD related drugs, supplies and lab services - for dates of service prior to
January 1, 2011, these drugs, supplies and lab services are not reimbursed under the composite
payment rate and are separately billable. For dates of service on or after January 1, 2011, include
on this line drugs and biologicals, supplies, and lab services administered during dialysis for nonESRD related conditions as well as oral-only drugs. Non-ESRD related drugs, supplies and lab
services as well as oral-only drugs, are excluded from the ESRD PPS payment.
Use the following procedures in completing these worksheets.
1. Enter on Worksheet B-1, columns 2 and 4 through 10, line 24, and Worksheet B,
columns 3 through 10, line 1, the following costs to be allocated. Obtain these costs from
Worksheet A as follows:
FROM

TO

Worksheet A, column 8

Worksheet B-1, line 24 and
Worksheet B, line 1

Lines

Column

5

Capital-Related, Operation and Maintenance
of Plant and Housekeeping
Machine Capital-Related or Rental and
Maintenance
Salaries for Direct Patient Care
Employee Health and Welfare Benefits
for Direct Patient Care
Supplies
Laboratory
Administrative and General and Other
Drugs

6
7
8
9
10
18
12
2.

2 on Wkst. B-1 and 3 on Wkst. B
4
5
6
7
8
9
10

On Worksheet B, column 1, line 1, enter the total of columns 8A through 10, line 1.

3. On Worksheet B, column 1, lines 6, 7, and 19 through 22, enter the direct costs of the
revenue producing and nonreimbursable cost centers which are obtained from Worksheet A,
column 8, lines 20 through 22 and 24 through 26 respectively.
4. On Worksheet B, column 1, line 23, enter the total of column 1, lines 1 through 22. This
total must equal the amount on Worksheet A, column 8, line 27.
5. On Worksheet B-1, column 2, enter on lines 8 through 22 the portion of the total
statistical base over which the expenses of the cost center are to be allocated. The statistical base
to be used is cited in the column heading and reflects only those statistics applicable to the revenue
producing and nonreimbursable cost centers. Enter in column 2, line 23, the sum of lines 8 through
22.

42-32

Rev. 2

5-14

FORM CMS-265-11

4211 (Cont.)

6. On Worksheet B-1, column 3, enter on subscripted lines 8 through 17 the portion of the
total statistical base over which the expenses of the cost center are to be allocated. The statistical
base to be used is cited in the column heading and reflects only those statistics applicable to the
revenue producing cost centers.
7. On Worksheet B-1, columns 4 through 8, enter on lines 2 through 7, subscripted lines 8
through 17, and lines 19 through 22 the portion of the total statistical base over which the expenses
of the cost centers are to be allocated. The statistical base to be used in each column is cited in the
column heading and reflects only those statistics applicable to the revenue producing and
nonreimbursable cost centers. Enter in columns 4 through 8, line 23, the sum of lines 2 through
22.
8. On Worksheet B-1, column 10, enter on lines 2 through 5, the portion of the total
statistical base over which the expenses of the cost centers are to be allocated. The statistical base
to be used in column 10 is cited in the column heading and reflects only those statistics applicable
to lines 2 through 5. Enter in column 10, line 23, the sum of lines 2 through 5.
9. On Worksheet B-1, columns 2, 4 through 8, and 10, line 25, determine the unit cost
multiplier by dividing the amount on line 24 by the total statistics on line 23. The unit cost
multiplier is rounded to the nearest six decimal places (e.g., $4,000/15,000 square feet = .2666666
= .266667).
10. On Worksheet B-1, column 3, subscripted lines 8 through 17, determine the percentage
of Adult treatments and Pediatrics treatments to total treatments by modality. (e.g., line 8.01
Adults/(line 8.01 Adults plus 8.02 Pediatrics)). Multiply the percentages calculated for each
modality by their respective costs on Worksheet B, column 2, lines 8 through 17 ((e.g. line 8.01
Adults/(line 8.01 Adults plus 8.02 Pediatrics)) times Worksheet B, column 2, line 8) and enter
each result on Worksheet B, column 3, subscripted lines 8 through 17.
11. On Worksheet B-1, multiply the appropriate unit cost multipliers computed in step 9 by
the individual cost center statistics in columns 2, 4 through 8, and 10. Enter the resulting amounts
in the corresponding columns and lines of Worksheet B.
12. On Worksheet B, columns 3 through 8, and 10, enter on line 23 the sum of the amounts
computed on lines 2 through 22. Do not include in these totals the amounts entered on line 1. For
each column, the amount on line 23 must equal the amount on line 1.
13. On Worksheet B, column 8A, line 1, enter the sum of columns 3 through 8. On
Worksheet B, column 8A, lines 2 through 22, enter the sum of columns 1 through 8.
14. On Worksheet B, column 8A, line 23, enter the total of lines 2 through 22. This total
plus the amounts in columns 9 and 10, line 1, must equal the amount in column 1, line 23.
15. Transfer the total on Worksheet B, column 8A, line 23, to Worksheet B-1, column 9,
line 23.
16. On Worksheet B-1, column 9, line 25, determine the unit cost multiplier by dividing the
amount on line 24 by the amount on line 23.

Rev. 3

42-33

4211 (Cont.)

FORM CMS-265-11

05-14

17. On Worksheet B-1, multiply the appropriate unit cost multiplier computed in step 16 by
the individual cost center amounts greater than zero in column 8A of Worksheet B. Exclude any
cost centers with negative amounts in column 8A of Worksheet B as the negative amounts will
cause an improper distribution of this overhead cost center. Enter the resulting amounts in the
corresponding lines of Worksheet B, column 9. On Worksheet B, column 9, enter on line 23 the
sum of the amounts computed on lines 2 through 22. The amount on line 23 must equal the amount
on line 1.
18. On Worksheet B, column 10, enter as follows:
FROM
Worksheet B, column 10

Lines
2
3
4

TO
Worksheet B-1, line 24
and Worksheet B, line 1
Column

Drugs Included in Composite Rate
ESAs
ESRD Related Drugs

11
12
13

19. On Worksheet B-1, columns 11, 12, and 13, enter on subscripted lines 8 through 17 the
portion of the total statistical base over which the expenses of the cost centers are to be allocated.
The statistical base to be used in columns 11, 12 and 13 are cited in the column heading and reflects
only those statistics applicable to the revenue producing cost centers. Enter in columns 11, 12,
and 13, line 23, the sum of lines 2 through 22.
20. On Worksheet B-1, columns 11, 12, and 13, determine the unit cost multiplier by
dividing the amount on line 24 by the total statistics on line 23.
21. On Worksheet B-1, multiply the appropriate unit cost multipliers computed in step 20
by the individual cost center statistics in columns 11, 12, and 13. Enter the resulting amounts in
the corresponding columns and lines of Worksheet B.
22. On Worksheet B, column 11A, line 5, enter the total of columns 8A through 11. On
lines 6 through 17.02 and lines 19 through 22, enter the total of columns 8A, 9 and 11.
23. On Worksheet B, column 11A, line 18, enter the subtotal of lines 2 through 17.02.
24. On Worksheet B, column 11A, line 23, enter the total of lines 18 through 22.
25. On Worksheet B, column 13A, lines 2 through 17.02 and lines 19 through 22, enter the
total of columns 11A through 13.
26. On Worksheet B, column 13A, line 18, enter the subtotal of lines 2 through 17.02.
27. On Worksheet B, column 13A, line 23, enter the total of lines 18 through 22. The amount
on line 23 must equal the amount in column 1, line 23.

42-34

Rev. 3

05-14

FORM CMS-265-11

4211 (Cont.)

28. Transfer the expenses from Worksheet B as follows:
From Worksheet B
Column 13A, line 8.01
Column 13A, line 8.02
Column 13A, line 9.01
Column 13A, line 9.02
Column 13A, line 10.01
Column 13A, line 10.02
Column 13A, line 11.01
Column 13A, line 11.02
Column 13A, line 12.01
Column 13A, line 12.02
Column 13A, line 13.01
Column 13A, line 13.02
Column 13A, line 14.01
Column 13A, line 14.02
Column 13A, line 15.01
Column 13A, line 15.02
Column 13A, line 16.01
Column 13A, line 16.02
Column 13A, line 17.01
Column 13A, line 17.02

To
Worksheet C, column 2, line 8.01
Worksheet C, column 2, line 8.02
Worksheet C, column 2, line 9.01
Worksheet C, column 2, line 9.02
Worksheet C, column 2, line 10.01
Worksheet C, column 2, line 10.02
Worksheet C, column 2, line 11.01
Worksheet C, column 2, line 11.02
Worksheet C, column 2, line 12.01
Worksheet C, column 2, line 12.02
Worksheet C, column 2, line 13.01
Worksheet C, column 2, line 13.02
Worksheet C, column 2, line 14.01
Worksheet C, column 2, line 14.02
Worksheet C, column 2, line 15.01
Worksheet C, column 2, line 15.02
Worksheet C, column 2, line 16.01
Worksheet C, column 2, line 16.02
Worksheet C, column 2, line 17.01
Worksheet C, column 2, line 17.02

The totals in column 13A, lines 5 through 7 and lines 19 through 22, are not transferred because
only the amounts for the reimbursable cost centers are transferred to Worksheet C.

Rev. 3

42-35

4212

FORM CMS-265-11

05-14

4212.
WORKSHEET C - COMPUTATION OF AVERAGE COST PER TREATMENT
ESRD PPS PAYMENT SYSTEM
This worksheet records the apportionment of total costs under ESRD PPS. The information on
this worksheet is used in the calculation of the facility specific composite cost ratio computed on
Worksheet E, Part II, and to compute the average cost per treatment under ESRD PPS. This
information is used for overall program evaluation, determining the appropriateness of program
reimbursement rates, and meeting statutory requirements of determining the cost of ESRD PPS
care.
Column 1.--Enter the total number of treatments/patient weeks by type for all renal dialysis
patients from your records. These statistics include all treatments furnished to all patients, both
Medicare and non-Medicare.
Column 2.--Enter the total cost transferred from Worksheet B, column 13A, subscripted lines 8
through 17.
Column 3.--Enter the average cost per treatment determined by dividing the cost entered on each
line in column 2 by the number of treatments/patient weeks entered on each line in column 1.
Line 18.--Transfer the expense from Worksheet C, column 2 to Worksheet E, Part II, line 1.
Line 19.--Report “total provider treatments” on this line. This line is informational only. This line
will be used for contractor verification. Continuous cycling peritoneal dialysis (CCPD) and
continuous ambulatory peritoneal dialysis (CAPD) are daily treatment modalities, and ESRD
facilities are paid the equivalent of three hemodialysis treatments for each week that CCPD and
CAPD treatments are provided.
Compute hemodialysis equivalent treatments for lines 16.01, 16.02, 17.01, and 17.02 by
multiplying the number of weeks reported in column 1 times 3 treatments for each week. Add to
this amount the treatments computed on line 18, column 1.

42-36

Rev. 3

06-13
4213.

FORM CMS-265-11

4213

WORKSHEET D - COMPUTATION OF AVERAGE COST PER TREATMENT
UNDER BASIC COMPOSITE RATE

This worksheet records the apportionment of basic composite rate cost to the various modalities
of Medicare dialysis treatments.
This information is used for overall program evaluation, determining the appropriateness of bad
debt reimbursement, and meeting statutory requirements of determining the cost of ESRD basic
composite rate. For cost reporting periods that straddle January 1, 2011, report the rates for each
modality on Worksheet D as follows: For the portion of the cost reporting period prior to
January 1, 2011, enter the average composite rate for each modality in column 6. For the portion
of the cost reporting period on and after January 1, 2011, enter the average ESRD PPS payment
rate for each modality in column 6.02. For cost reporting periods that straddle January 1, 2012,
January 1, 2013, and January 1, 2014, report the average ESRD PPS payment rate for each
modality on Worksheet D as follows: For the portion of the cost reporting period prior to January
1, enter the average ESRD PPS payment rate for each modality in column 6.01. For the portion
of the cost reporting period on and after January 1, enter the average ESRD PPS payment rate for
each modality in column 6.02.
Column 1.--Enter the total number of treatments/patient weeks by modality for all dialysis patients
reported on Worksheet C, column 1, lines 8.01 through 17.02 (i.e. Worksheet C, column 1, lines
8.01 plus 8.02, report on Worksheet D, column 1, line 1). These statistics include all treatments
furnished to all patients, both Medicare and non-Medicare.
Column 2.--Enter the total cost transferred from Worksheet B, column 11A, by modality, to lines
1 through 10 (i.e., Worksheet B, column 11A, lines 8.01 plus 8.02 report on Worksheet D, column
2, line 1).
Column 3.—Enter the average cost of treatment determined by dividing the cost entered on each
line in column 2 by the number of treatments/patient weeks entered on each line in column 1.
Columns 4 through 7.02.--Report treatments furnished to Medicare beneficiaries that were billed
to, and reimbursed by the program directly.
Column 4.--For cost reporting periods that straddle January 1, 2011, enter on column 4 the total
number of treatments or patient weeks billed to Medicare for services rendered prior to
January 1, 2011.
Column 4.01.--For cost reporting periods that straddle January 1, 2012, January 1, 2013 or
January 1, 2014, enter the total number of treatments or patient weeks billed to Medicare for
services rendered prior to January 1.
Column 4.02.--For cost reporting periods that straddle or begin January 1, 2011, January 1, 2012,
or January 1, 2013, enter the total number of treatments or patient weeks billed to Medicare for
services rendered on and after January 1. For cost reporting periods that straddle January 1, 2014,
enter the total number of treatments or patient weeks billed to Medicare for services rendered on
and after January 1.
For cost reporting periods beginning on or after January 1, 2014, enter the number of ESRD PPS
treatments billed to Medicare in column 4 and eliminate columns 4.01 and 4.02.

Rev. 2

42-37

4213(Cont.)

FORM CMS-265-11

06-13

Column 5.—Enter total expenses determined by multiplying the sum of columns 4, 4.01, and 4.02
by the average cost per treatment entered on each corresponding line in column 3. Transfer the
total from column 5, line 11, to Worksheet E, Part I, line 1.
Column 6.--For cost reporting periods that straddle January 1, 2011, report your Medicare payment
rates for each modality on Worksheets D as follows: For the portion of the cost reporting period
occurring prior to January 1, 2011, enter the average composite rate for each modality in column
6.
Column 6.01--For cost reporting periods that straddle January 1, 2012, January 1, 2013, or
January 1, 2014, report the average ESRD PPS payment rate for each modality in column 6.01 for
the portion of the cost reporting period occurring prior to January 1.
Column 6.02.--For cost reporting periods that straddle or begin January 1, 2011, January 1, 2012,
or January 1, 2013, report the average ESRD PPS payment rate for each modality in column 6.02
for the portion of the cost reporting period occurring on and after January 1. For cost reporting
periods that straddle January 1, 2014, report the average ESRD PPS payment rate for each modality
in column 6.02 for the portion of the cost reporting period occurring on and after January 1.
The ESRD composite payment rates and the ESRD PPS payment rates are average payments
calculated based on the total Medicare payments (by type of treatment) divided by the total
corresponding ESRD treatments per the facility’s PS&R data. For example, the total Medicare
payment for hemodialysis is divided by the total ESRD hemodialysis treatments.
For cost reporting periods beginning on or after January 1, 2014, enter all ESRD PPS payment
rates in column 6, and eliminate columns 6.01 and 6.02.
Column 7.--Enter total payment due amounts determined by multiplying the number of treatments
or patient weeks entered on each line in column 4 by the payment rate entered on each
corresponding line in column 6. Transfer the total from column 7, line 11, to Worksheet E, Part I,
line 2, column 1.
Column 7.01.--Enter total payment due amounts determined by multiplying the number of
treatments or patient weeks entered on each line in column 4.01 by the payment rate entered on
each corresponding line in column 6.01. Transfer the total from column 7.01, line 11, to
Worksheet E, Part I, line 2.01, column 1.
Column 7.02.--Enter total payment due amounts determined by multiplying the number of
treatments or patient weeks entered on each line in column 4.02 by the payment rate entered on
each corresponding line in column 6.02. Transfer the total from column 7.02, line 11, to
Worksheet E, Part I, line 2.02, column 1.
Column 8.--Enter the sum of columns 7, 7.01, and 7.02 into their corresponding line in column 8.
Lines 9 and 10.--Report CAPD and CCPD treatments by patient weeks. Patient weeks are
computed by totaling the number of weeks each patient dialyzed at home by CCPD and/or CAPD.
Obtain this information from your records.
Line 11.--For columns 1, 4, 4.01, and 4.02, enter the sum of lines 1 through 8. For columns 2, 5,
7, 7.01, 7.02, and 8, enter the sum of lines 1 through 10.

42-38

Rev. 2

05-14

FORM CMS-265-11

4214.

WORKSHEET E - CALCULATION OF BAD DEBT REIMBURSEMENT

4214.1

4214.1 Part I – Calculation of Reimbursable Bad Debts Title XVIII – Part B.--Under the
composite rate payment system for services prior to January 1, 2011, the contractor pays the
facility its allowable ESRD bad debts, up to the facility’s unreimbursed reasonable costs as
determined under Medicare principles. Under the ESRD PPS payment system, effective for dates
of service on and after January 1, 2011, the contractor pays the facility for allowable ESRD bad
debts, up to the facility’s unreimbursed reasonable costs for those items and services associated
with the basic case-mix adjusted composite rate portion of the ESRD PPS payment rate. Allowable
bad debts must relate to specific Medicare deductibles and coinsurance amounts.
Determination of bad debt amounts for the basic case-mix adjusted composite rate payment portion
of the ESRD PPS payment, is based on the percentage of basic composite rate payment costs to
total costs on a facility specific basis. The facility specific composite rate percentage is applied to
the facility’s total bad debt amounts associated with the ESRD PPS payment. The resulting bad
debt amount is used to determine the allowable Medicare bad debt payment in accordance with
42 CFR §413.89 of the regulations. During the transition periods, apply the facility specific
composite cost percentage to the bad debt amounts associated with the transition portion of the
ESRD PPS payment.
The resulting bad debt amount will be added to the bad debt amount associated with the transition
portion of the facility’s ESRD reasonable costs to determine the total allowable Medicare bad debt
(For example, a facility that does not elect 100 percent PPS, will be in transition period 1 for
services rendered beginning January 1, 2011 through December 31, 2011. Under transition period
1, services rendered during this period are paid based on 75 percent composite rate and 25 percent
ESRD PPS payment rate. The facility specific composite cost percentage will be applied to 25
percent of the bad debts and the resulting bad debt amount will be added to the transitional 75
percent to determine the total allowable bad debt pertaining to services rendered during this
period).
EXCEPTION: The transition period payment method will not apply to an ESRD for services
rendered on and after January 1, 2011, that (1) elected 100 percent of the payment amount to be
based on the ESRD PPS payment, or (2) was certified for Medicare participation and began
providing dialysis services on or after January 1, 2011.
Column 1.--Enter the total amounts by line description.
Column 2.--This column is used to compute the appropriate reduction to each amount reported in
column 1, based on the facility’s transition period and application of their facility specific
composite cost ratio.
Line 1.--Enter the sum of the amount from Worksheet D, column 5, line 11. The amount reported
is reflective of the provider’s calculated basic composite rate payment cost.
Line 2.--For cost reporting periods that straddle January 1, 2011, enter in column 1, the sum of the
amount from Worksheet D, column 7, line 11, minus any applicable Part B deductibles. Enter in
column 2, the amount reported in column 1. For cost reporting periods beginning on or after
January 1, 2014, enter in column 1, the sum of the amount from Worksheet D, column 7, line 11,
minus any applicable Part B deductibles. Enter in column 2, the amount reported in column 1
times the facility specific composite cost ratio from Worksheet E, Part II, line 3. For cost reporting
periods beginning on or after January 1, 2014, do not complete lines 2.01 and 2.02.
Rev. 3

42-39

4214.1 (Cont.)

FORM CMS-265-11

05-14

Line 2.01.--Enter in column 1, the sum of the amount from Worksheet D, column 7.01, line 11,
minus any applicable Part B deductibles. Enter in column 2, the portion of the amount reported in
column 1 as it relates to the ESRD PPS payment times the facility specific composite cost ratio
from Worksheet E, Part II, line 3. Add to this amount the composite cost portion of the payment.
For cost reporting periods beginning on or after January 1, 2014, do not complete this line.
Line 2.02.--Enter in column 1, the sum of the amount from Worksheet D, column 7.02, line 11,
minus any applicable Part B deductibles. Enter in column 2, the portion of the amount reported in
column 1 as it relates to the ESRD PPS payment times the facility specific composite cost ratio
from Worksheet E, Part II, line 3. Add to this amount the composite cost portion of the payment.
For cost reporting periods beginning on or after January 1, 2014, do not complete this line.
Line 2.03.--Enter the sum of lines 2, 2.01, and 2.02 in columns 1 and 2 accordingly.
Line 3.--Enter the amount for outlier payments applicable to Medicare (Part B) patients from your
records. (Informational only)
Line 4.--Reserved for future use.
Line 5.--Enter 80 percent of the amount on line 2.03, column 2.
Line 6.--Enter the amount on line 1 minus the amount on line 5.
Line 7.--Enter in column 1, the amount shown in your records for deductibles and coinsurance
billed to Medicare (Part B) patients. Include only deductibles and coinsurance amounts that are
related to the payments listed on line 2, column 1, and apply to Medicare beneficiaries under the
composite payment rate. Enter in column 2, the amount reported in column 1. For cost reporting
periods beginning on or after January 1, 2014, enter in column 1, the amount shown in your records
for deductibles and coinsurance billed to Medicare (Part B) patients. Enter in column 2, the amount
reported in column 1 times the facility specific composite cost ratio from Worksheet E, Part II,
line 3.
For cost reporting periods beginning on or after January 1, 2014, do not complete lines 7.01 and
7.02.
Line 7.01.--Enter in column 1, the amount shown in your records for deductibles and coinsurance
billed to Medicare (Part B) patients. Include only deductibles and coinsurance amounts that are
related to the payments listed on line 2.01, column 1, and apply to Medicare beneficiaries under
the ESRD PPS payment rate. Enter in column 2, the portion of the amount reported in column 1,
as it relates to the ESRD PPS payment times the facility specific composite cost ratio from
Worksheet E, Part II, line 3.
Line 7.02.--Enter in column 1, the amount shown in your records for deductibles and coinsurance
billed to Medicare (Part B) patients. Include only deductibles and coinsurance amounts that are
related to the payments listed on line 2.02, column 1, and apply to Medicare beneficiaries under
the ESRD PPS payment rate. Enter in column 2, the portion of the amount reported in column 1,
as it relates to the ESRD PPS payment times the facility specific composite cost ratio from
Worksheet E, Part II, line 3.

42-40

Rev. 3

05-14

FORM CMS-265-11

4214.1 (Cont.)

Line 7.03.--Enter the sum of column 2, lines 7, 7.01 and 7.02. If that sum is less than 20 percent
of the amount reported on line 2.03, column 2, enter 20 percent of the amount reported on line
2.03, column 2.
Line 8.--Enter in column 1, the bad debt amount for deductible and coinsurance, net of recoveries,
for services rendered prior to January 1, 2011. Transfer this amount to column 2.
Line 9.--Enter in column 1, the bad debt amount for deductible and coinsurance, net of recoveries
for services rendered on or after January 1, 2011, but before January 1, 2012. Enter in column 2,
75 percent of the amount in column 1, plus 25 percent of the amount in column 1 times the facility
specific composite cost ratio on Worksheet E, Part II, line 3. If the provider indicated “Y” on
Worksheet S, line 13 and elected 100 percent PPS, do not complete this line but complete line 12.
Line 10.--Enter in column 1, the bad debt amount for deductible and coinsurance, net of recoveries,
for services rendered on or after January 1, 2012, but before January 1, 2013. Enter in column 2,
50 percent of the amount in column 1, plus 50 percent of the amount in column 1 times the facility
specific composite cost ratio on Worksheet E, Part II, line 3. If the provider indicated “Y” on
Worksheet S, line 13 and elected 100 percent PPS, do not complete this line but complete line 12.
Line 11.--Enter in column 1, the bad debt amount for deductible and coinsurance, net of recoveries,
for services rendered on or after January 1, 2013, but before January 1, 2014. Enter in column 2,
25 percent of the amount in column 1, plus 75 percent of the amount in column 1 times the facility
specific composite cost ratio on Worksheet E, Part II, line 3. If the provider indicated “Y” on
Worksheet S, line 13 and elected 100 percent PPS, do not complete this line but complete line 12.
Line 12.--Enter in column 1, the bad debt amount for deductible and coinsurance, net of recoveries,
for services rendered on or after January 1, 2014. Enter in column 2, 100 percent of the amount
in column 1, times the facility specific composite cost ratio on Worksheet E, Part II, line 3. If the
provider indicated “Y” on Worksheet S, line 13 and elected 100 percent PPS, DO NOT complete
lines 9, 10 or 11, but enter in column 1, the bad debt amount for deductible and coinsurance, net
of recoveries for all services rendered on or after January 1, 2011. Enter in column 2, 100 percent
of the amount in column 1, times the facility specific composite cost ratio on Worksheet E, Part
II,
line 3.
Line 13.--Enter in column 1, the sum of lines 8 through 12, column 1. This amount should
reconcile to the provider’s bad debt listing(s). Enter in column 2, the sum of lines 8 through 12,
column 2.
Line 14.--Subtract the amount on line 13, column 2, from the amount on line 7.03 and enter the
result.
Line 15.--Subtract the amount on line14 from the amount on line 6 and enter the result. If the
amount on line 14 exceeds the amount on line 6, do not complete line 16. For cost reporting
periods beginning on or after January 1, 2013, do not complete this line.
Line 16.--For cost reporting periods ending on or before September 30, 2012, enter the lesser of
the amount on line 13, column 2, or the amount on line 15. For cost reporting periods beginning
on or after October 1, 2012, enter the lesser of the amount on line 13, column 2 times 88 percent,
or the amount on line 15. For cost reporting periods beginning on or after January 1, 2013, enter
the amount on line 13, column 2 times 88 percent. For cost reporting periods beginning on or after
October 1, 2013, enter the amount on line 13, column 2 times 76 percent. For cost reporting
periods beginning on or after October 1, 2014, enter the amount on line 13, column 2 times 65
percent.

Rev. 3

42-41

4214.2

FORM CMS-265-11

05-14

Line 17.--Enter the gross reimbursable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. This amount must also be included in the amount on line
13, i.e., line 17 is a subset of line 13.
Line 18.--Your contractor will enter the Part A tentative adjustments from Worksheet E-1, column
2, line 1.99.
Line 19.--Enter the sequestration adjustment amount. For cost reporting periods that overlap or
begin on or after April 1, 2013, enter the sequestration adjustment amount as [(2 percent times
(total days in the cost reporting period that occur during the sequestration period beginning on or
after April 1, 2013, divided by total days in the entire cost reporting period), rounded to four
decimal places) times line 16]. If line 16 is less than zero, do not calculate the sequestration
adjustment.
Line 20.--Enter the net of the amount on line 16 minus lines 18 and 19. Enter a negative amount
in parentheses ( ).
4214.2 Part II – Calculation of Facility Specific Composite Cost Percentage.--A facility specific
composite cost percentage is applied to the facility’s total bad debt amounts and associated cost
data necessary to compute the ESRD facility bad debt payments. This percentage is computed by
dividing your facility’s basic composite rate costs by your total allowable expenses.
Line 1.--Enter total allowable expenses from Worksheet C, column 2, line 18.
Line 2.--Enter total composite costs from Worksheet D, column 2, line 11.
Line 3.--Compute the facility specific composite cost percentage (line 2 divided by line 1).
4215.

WORKSHEET E-1 - ANALYSIS OF PAYMENTS TO PROVIDER FOR SERVICES
RENDERED

4215.1

Part I – For Contractor Use Only

Line 1.--List the date and amount of each tentative settlement payment for this cost reporting
period.
Line 2.--Enter the net settlement amount (balance due to the provider or balance due to the
program) for the NPR or, if this settlement is after a reopening of the NPR, for this reopening.
Transfer this amount from Worksheet E,, Part I, line 20.
Line 3.--Enter the contractor name and the contractor number in columns 1 and 2 respectively.
4215.2

Part II – To be completed by Provider

Line 4.--For cost reporting periods that begin or overlap January 1, 2012, if your response on
Worksheet S, Part II, line 10 is “Y”, enter the amount of your low volume payments.
4216.

WORKSHEETS F - BALANCE SHEET and WORKSHEET F-1 - STATEMENT OF
REVENUES AND EXPENSES.

These worksheets are prepared from your accounting books and records. Additional worksheets
may be submitted if necessary.
Complete all worksheets in the "F" series. Worksheets F and F-1 are completed by all providers.
Cost reports that do not include the "F" series worksheets are considered incomplete and
unacceptable.
42-42

Rev. 3

05-14

FORM CMS 265-11

4295

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
TABLE OF CONTENTS
Topic

Page(s)

Table 1:

Record Specifications

42-503 - 42-509

Table 2:

Worksheet Indicators

42-510 - 42-511

Table 3:

List of Data Elements With Worksheet, Line, and
Column Designations

42-512 - 42-520

Table 3A:

Worksheets Requiring No Input

42-521

Table 3B:

Tables to Worksheet S

42-521

Table 3C:

Tables to Worksheet S-1

42-521

Table 3D:

Lines That Cannot Be Subscripted

42-521

Table 4:

Reserved for future use

Table 5:

Cost Center Coding

Table 6:

Edits:

Rev. 3

42-522 - 42-524

Level I Edits

42-525 - 42-527

Level II Edits

42-528 - 42-530

42-501

4295 (Cont.)

FORM CMS-265-11

05-14

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-11
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 four types of records. The first group (type 1 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 2 records. Refer to Table 5 for cost center coding. The
data detailed in Table 3 are identified as type 3 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 contractors is compact disc
(CD), flash drive, or other means (such as electronic mail or a secured website) as approved by the
provider’s contractor. The file must be in IBM format and the character set must be ASCII. A
provider must seek approval from their contractor regarding alternate methods of submission to
ensure that the method of transmission is acceptable. The ECR and PI files sent via electronic
mail or uploaded to a secured website must be compressed or self-extracting files.
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 Type 1 record with a narrative description of its meaning.
1
2
3
4
5
6
123456789012345678901234567890123456789012345678901234567890
1
1
272599201100120113656A99P00120121362011001
Record #1:

42-502

This is a cost report file submitted by Provider CCN 272599 for the period from
January 1, 2011, (2011001) through December 31, 2011, (2011365). It is filed on
Form CMS-265-11. 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 an alpha character. Positions 39 and 40 remain constant for approvals issued
after the first test case. This file is prepared by the ESRD facility on May 15, 2012
(2012136). The electronic cost report specification dated January 1, 2011,
(2011001), is used to prepare this file.

Rev. 3

05-14

FORM CMS-265-11

4295 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-11
TABLE 1 - RECORD SPECIFICATIONS (Cont.)
FILE NAMING CONVENTION
Name each cost report ECR file in the following manner:
RDNNNNNN.YYL, where
1.
2.
3.
4.

RD (ESRD Electronic Cost Report) is constant;
NNNNNN is the 6 digit CMS Certification Number;
YY is the year in which the provider's cost reporting period ends; and
L is a character variable (A through Z) to enable separate identification of files from
ESRD facilities with two or more cost reporting periods ending in the same calendar
year.

Name each cost report PI file in the following manner:

PINNNNNN.YYL, where

1. PI (Print Image) is constant;
2. NNNNNN is the 6 digit CMS Certification Number,
3. YY is the year in which the provider’s cost reporting period ends; and
4.
L is a character variable (A through Z) to enable separate identification of files from
ESRD facilities with two or more cost reporting periods ending in the same calendar
year.
RECORD NAME: Type 1 Records - Record Number 1
Size

Usage

Loc.

1. Record Type

1

X

1

Constant "1"

2. For Future Use

10

9

2-11

Numeric only

3. Spaces

1

X

12

4. Record Number

1

X

13

5. Spaces

3

X

14-16

6. ESRD Provider CCN

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-265-11)

10. Vendor Code

3

X

38-40

To be supplied upon approval. Refer to
page 42-502.

11. Vendor Equipment

1

X

41

Rev. 3

Remark

Constant "1"

P = PC; M = Main Frame

42-503

4295 (Cont.)

FORM CMS 265-11

05-14

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
TABLE 1 - RECORD SPECIFICATIONS (Cont.)
RECORD NAME: Type 1 Records - Record Number 1 (Cont.)
Size

Usage

Loc.

Remark

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
2014090 (March 31, 2014). Prior
approvals 2012275 for cost reports
beginning on or after October 1, 2013,
and 2011001 for cost reporting periods
ending on or after January 1, 2011.

RECORD NAME: Type 1 Records - Record Numbers 2 - 99
Size

Usage

Loc.

Remark

1. Record Type

1

9

1

2. Spaces

10

X

2-11

3. Record Number

2

9

12-13

#2 - Reserved for future use.
#3 - Vendor information; optional; left
justified in positions 21 through 60.
#4 - The time that the cost report is
created. This is represented in military
time as alpha numeric. Use positions
21 through 25. Example 2:30 pm is
expressed as 14:30.
#5 through 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.

Constant "1"

RECORD NAME: Type 2 Records for Labels
Size

Usage

Loc.

1. Record Type

1

9

1

2. Wkst. Indicator

7

X

2-8

3. Spaces

2

X

9-10

42-504

Remark
Constant "2"
Alphanumeric. Refer to Table 2.

Rev. 3

12-11

FORM CMS 265-11

4295 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
TABLE 1 - RECORD SPECIFICATIONS (Cont.)
RECORD NAME: Type 2 Records for Labels (Cont.)
4.

Line Number

3

9

11-13 Numeric

5

Sub-line Number

2

9

14-15 Numeric

6.

Column Number

3

X

16-18 Alphanumeric

7.

Sub-column Number

2

9

8.

Cost Center Code

4

9

19-20 Numeric
Refer to Table 5 for
21-24 Numeric.
appropriate cost center codes.

9.

Labels/Headings
a. Line Labels
b. Column Headings
Statistical Basis &
Code

36

X

25-60 Alphanumeric, left justified

10

X

21-30 Alphanumeric, left justified

The type 2 records contain text that appears on the printed cost report. Of these, there are three
groups: (1) Worksheet A cost center names (labels); (2) column headings for step-down 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 sub-line numbers for each label must be the same as the
line and sub-line numbers of the corresponding cost center on Worksheet A. The columns and
sub-column numbers are always set to zero.
Column 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.

Rev. 1

42-505

4295 (Cont.)

FORM CMS 265-11

12-11

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
TABLE 1 - RECORD SPECIFICATIONS (Cont.)
The 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

42-506

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
EH&W BENEFTIS FOR DIRECT PT. CARE
SUPPLIES
LABORATORY
ADMINISTRATIVE & GENERAL
DRUGS
INTEREST EXPENSE
LAUNDRY AND LINEN
MEDICAL RECORDS
PHY ROUT PROF SVCS-INITIAL METHOD
PHY ROUT PROF SVCS-MCP METHOD
WHOLE BLOOD & PACKED RED BLOOD CELLS
VACCINES
PHYSICIANS PRIVATE OFFICES
ESA’S
METHOD II PATIENTS

Rev. 1

06-13

FORM CMS 265-11

4295 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
TABLE 1 - RECORD SPECIFICATIONS (Cont.)
Type 2 records for Worksheet B-1, columns 2 through 13, for lines 1 through 6 are listed below.
The numbers running vertical to line 1 descriptions are the general service cost center line
designations.
1
CAP REL
STEP DOWN
MACH CAP
SALARIES
EH&W BENE
SUPPLIES
LABORATORY
DRUGS
DRUGS
ESA’S
ESRD

2
3
4
5
6
7
8
10
11
12
13

2
OP & MAINT
OF COL 2
REL OR REN
FOR DIR
FOR DIR

INCLD IN
REL DRUGS

LINE
3
& HOUSE
& MAINT
PT CARE
PT CARE

COMP RATE

4
SQUARE
# OF TREAT
% TIME
HRS OF
GROSS
CHARGES
CHARGES
CHARGES
CHARGES
CHARGES
CHARGES

5
FEET
MENTS
SERVICE
SALARIES

6
1
3
3
3
3
3
3
3
3
3
3

Examples of type 2 records are below. Either zeros or spaces may be used in the line, sub-line,
column, and sub-column number fields (positions 11 through 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
12
1200DRUGS
2A000000
15
1500MEDICAL RECORDS
2A000000
19
1900PHY ROUT PRO SERVICES-MCP METHOD
2A000000
23
2300ESA’S
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 % TIME
2B10000*
6 3 3

Rev. 2

42-507

4295 (Cont.)

FORM CMS 265-11

06-13

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
TABLE 1 - RECORD SPECIFICATIONS (Cont.)
RECORD NAME: Type 3 Records for Non-label Data
Size Usage Loc
1.
2.
3.
4.
5.
6.
7.
8.

Record Type
Wkst. Indicator
Spaces
Line Number
Sub-line Number
Column Number
Sub-column Number
Field Data
a. Alpha Data

1
7
2
3
2
3
2

9
X
X
9
9
X
9

1
2-8
9-10
11-13
14-15
16-18
19-20

36

X

21-56

b. Numeric Data

4
16

X
9

57-60
21-36

Remarks
Constant "3"
Alphanumeric. Refer to Table 2.
Numeric
Numeric
Alphanumeric
Numeric
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.
Spaces (optional).
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 percent is expressed as .087500.
All records with zero values are dropped.
Refer to Table 6 for additional requirements
regarding numeric data.

Samples of type 3 records are below.
3A000000
3A000000
3A000000

42-508

11
15
19

1
2
1

36000
12064
144000

Rev. 2

06-13

FORM CMS 265-11

4295 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
TABLE 1 - RECORD SPECIFICATIONS (Cont.)
The 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 sub-line numbers as data must
be uniform.
Worksheet A-1, columns 3 and 6
Worksheet A-2, column 4
Worksheet A-3, Part B, column 1
Examples of records (*) with a Worksheet A line number as data are below.

*
*

*

*
*

3A1000A0
3A1000A0
3A1000A0
3A1000A0
3A1000A0
3A1000A0
3A1000A0
3A1000A0
3A1000A0
3A1000A0

1
1
1
1
1
1
2
2
2
2

0

3A200000
3A200000
3A200000
3A200000

20
20
20
20

0
1
2
4

MISC INCOME
B
-106896
21.00

3A30000B
3A30000B
3A30000B
3A30000B

1
1
1
1

3
4
5

10.00
LABORATORY
18000
23121

3
4
6
7
0
1
3
4

A

EMP. HEALTH & WELFARE BENE
8.00
61743
11.00
82263
EMP HEALTH & WELFARE BENE
A
19.00
20520

RECORD NAME: Type 4 Records - File Encryption
This 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. 2

42-509

4295 (Cont.)

FORM CMS 265-11

06-13

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
TABLE 2 - WORKSHEET INDICATORS
This 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.
The worksheet indicator consists of seven digits in positions 2 through 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.
Worksheets That Apply to the Independent Renal Dialysis Facility Cost Report
Worksheet
S, Part I

42-510

Worksheet Indicator
S000001

S, Part II

S000002

S-1

S100000

S-2

S200000

A

A000000

A-1

A100?A0

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

C000000

D

D000000

E, Part I

E000001

(a)

Rev. 2

12-11

FORM CMS 265-11

4295 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
TABLE 2 - WORKSHEET INDICATORS (Cont.)

FOOTNOTES:

Worksheet

Worksheet Indicator

E, Part II

E000002

E-1, Part I

E100001

E-1, Part II

E100002

F

F000000

F-1

F100000

(a) Worksheet A-1
For worksheet A-1, include the worksheet identifier reclassification code as the 5th and 6th
digits (positions 6 and 7 in the ECR file). For example, 3A600?A0 or 3A6000A0.

Rev. 1

42-511

4295 (Cont.)

FORM CMS 265-11

12-11

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-11
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
This table identifies those data elements necessary to calculate an ESRD 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 ESRD facility and the report produced by the
contractor. 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 sub-line 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 sub-line numbers (i.e., 01, 03), except for skipping sub-line
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.

42-512

Rev. 1

05-14

FORM CMS 265-11

4295 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION

LINE(S)
WORKSHEET S

Part I: Cost report Status
Provider Use Only
Electronically filed cost report
Manually submitted cost report
If this is an amended cost report enter
the number of times the provider
resubmitted this cost report = (0-9)
Creation Date (MM/DD/YYYY)
Creation Time (XX:XX:XX XX)
Contractor Use Only
Cost Report Status
Date Received
Contractor Number
First Cost Report for Provider CCN
Last Cost Report for Provider CCN
NPR Date: (MM/DD/YYYY)
If line 4, column 1 is “4”, enter number
of times reopened = (0-9)
Enter the Contractor’s vendor code
Part II: General
Name
Street
P.O. Box
City
State
ZIP Code
County
CBSA Code (XXXXX)
Provider CCN (XXXXXX)
Date Certified (MM/DD/YYYY)
Contact Person Name
Phone number (XXX-XXX-XXXX)

Rev. 3

COLUMN(S)

FIELD
SIZE

USAGE

1
2
3

1
1
1

1
1
1

X
X
9

3
3

2
3

10
11

X
X

4
5
6
7
8
9
10

1
1
1
1
1
1
1

1
10
5
1
1
10
1

X
X
X
X
X
X
9

11

1

3

X

1
2
2
3
3
3
4
4
5
6
7
7

1
1
2
1
2
3
1
2
1
1
1
2

36
36
9
36
2
10
36
5
6
10
36
12

X
X
X
X
X
X
X
X
X
X
X
X

42-513

4295 (Cont.)

FORM CMS 265-11

05-14

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION

LINE(S) COLUMN(S)
WORKSHEET S (Cont.)

Cost reporting period beginning date
(MM/DD/YYYY)
Cost reporting period ending date
(MM/DD/YYYY)
Type of control: (See Table 3B)
Other(Specify)
Is this facility approved as a low-volume
facility for this cost reporting period?
(Y/N)
Type of physicians’ reimbursement: (See
Table 3B)
Date of election of initial method
(MM/DD/YYYY)
Was this facility previously certified as a
hospital-based unit? (Y/N)
Did your facility elect 100 percent PPS
effective January 1, 2011? (Y/N)
If you responded “N” to line 13, enter in
col. 1 the year of transition for periods
prior to January 1
And enter in col. 2 the year of transition for
periods after December 31
Malpractice premiums
Malpractice paid losses
Malpractice self insurance
Are malpractice premiums and/or paid
losses reported in other than the A&G
cost center? (Y/N)
If you are part of a chain organization enter
“Y” for yes or “N” for no.
If line 19 is “Y” enter the Name:
Street
P.O. Box
City
State
ZIP code of the organization

42-514

FIELD
SIZE

USAGE

8

1

10

X

8

2

10

X

9
9

1
2

2
36

9
X

10

1

1

X

11

1

1

9

11

2

10

X

12

1

1

X

13

1

1

X

14

1

1

X

14

2

1

X

15
16
17

1
1
1

9
9
9

-9
-9
-9

18

1

1

X

19

1

1

X

20
21
21
22
22
22

1
1
2
1
2
3

36
36
9
36
2
10

X
X
X
X
X
X

Rev. 3

06-13

FORM CMS 265-11

4295 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
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

99

Number of treatments not billed to
Medicare and furnished under arrangement

2

1-4

11

99

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

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

First shift

10.01

1-4

9

9

Second shift

10.02

1-4

9

9

Third shift

10.03

1-4

9

9

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

11.05

1-4

11

9

Hours per shift in typical week during
regular reporting period:

Number of treatments provided:

Total Treatments

Rev. 2

42-515

4295 (Cont.)

FORM CMS 265-11

06-13

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION

LINE(S)

COLUMN(S)

FIELD
SIZE USAGE

WORKSHEET S-1 (Cont.)
Type of dialyzers used: (See Table 3C)

12

1

1

9

If dialyzers are reused, indicate the number of times

12

2

11

9

If other is selected, specify type

12

3

36

X

CAPD

13

1

11

9

Other

13

2

11

9

CCPD

13

3

11

9

Number of units of Epoetin furnished during
cost reporting period

14

1

11

9

Number of units of Aranesp furnished during
cost reporting period

15

1

11

9

ESA furnished during cost reporting period

15.01

1

36

X

Number of units of ESA furnished during cost
reporting period

15.01

2

11

9

Number of patients who are awaiting transplants

16

1

11

9

Number of patients who received transplants
during this period

17

1

11

9

Number of patients commencing home dialysis
training during this period

18

1

11

9

Number of patients currently in home program

19

1

11

9

Types of dialyzers used: (See Table 3C)

20

1

1

9

If dialyzers are reused, indicate the number of times: 20

2

11

9

If other is selected, specify type

20

3

36

X

Number of hours in a normal work week

21

1

6

9(3).99

Number of back-up sessions furnished to
home patients:

Transplant Statistics:

Home Program:

42-516

Rev. 2

12-11

FORM CMS 265-11

4295 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION
LINE(S) COLUMN(S)
WORKSHEET S-1 (Continued)
Text as needed for blank line
Number of full time equivalent employees
Staff
Contract
Total

FIELD
SIZE

USAGE

31

0

36

X

22-31
22-31
22-31

1
2
3

6
6
6

9(3).99
9(3).99
9(3).99

1

1

1

X

1

2

10

X

2

1

1

X

2

2

10

X

2

3

1

X

3

1

1

X

WORKSHEET S-2
Provider Organization and Operation
Has the Provider changed ownership
immediately prior to the beginning of the
cost reporting period?
If column 1 is "Y", enter the date of the
change in column 2. (see instructions)
Has the provider terminated participation in
the Medicare Program? (Y/N)
If column 1 is yes, enter in column 2 the
date of termination
If column 1 (line 2) is yes, enter in column
3, "V" for voluntary or "I" for involuntary.
(V/I)
Is the provider involved in business
transactions, including management
contracts, with individuals or entities (e.g.,
chain home offices, drug or medical supply
companies) that are related to the provider
or its officers, medical staff, management
personnel, or members of the board of
directors through ownership, control, or
family and other similar relationships?
(Y/N)

Rev. 1

42-517

4295 (Cont.)

FORM CMS-265-11

12-11

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-11
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS

DESCRIPTION
LINE(S) COLUMN(S)
WORKSHEET S-2 (Continued)
Financial Data and Reports
Were the financial statements prepared by a
Certified Public Accountant? (Y/N)
If column 1 is "Y" enter "A" for Audited,
"C" for Compiled, or "R" for Reviewed in
column 2.
Submit a complete copy, or enter date
available in column 3. (see instructions) If
column 1 is "N" see instructions.
Are the cost report total expenses and total
revenues different from those on the filed
financial statements? (Y/N)
Bad Debts
Is the provider seeking reimbursement for
bad debts? (Y/N)
If line 6 is "Y", did the provider's bad debt
collection policy change during this cost
reporting period? (Y/N)
If line 6 is "Y", are patient deductibles and
or coinsurance waived? (Y/N)
PS&R Report Data
Was the cost report prepared using the
PS&R report only? (Y/N)
If column 1 is yes, enter paid through date
of the PS&R report
Was the cost report prepared using the
PS&R for totals and the provider's records
for allocation? (Y/N)
If column. 1 is "Y" enter the paid through
date of the PS&R report used to prepare this
cost report in column 2.
If line 9 or 10 is "Y", were adjustments
made to PS&R data for additional claims
that have been billed but are not included on
the PS&R used to file this cost report?
(Y/N)

42-518

FIELD
SIZE

USAGE

4

1

1

X

4

2

1

X

4

3

10

X

5

1

1

X

6

1

1

X

7

1

1

X

8

1

1

X

9

1

1

X

9

2

10

X

10

1

1

X

10

2

10

X

11

1

1

X

Rev. 1

06-13

FORM CMS 265-11

4295 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION

LINE(S)

COLUMN(S)

FIELD
SIZE USAGE

WORKSHEET S-2 (Cont.)
If line 9 or 10 is "Y", were adjustments made
to PS&R data for corrections of other PS&R
information? (Y/N)

12

1

1

X

If line 9 or 10 is "Y", were adjustments made
to PS&R data for Other?(Y/N)

13

1

1

X

If line 13 is "Y", then describe the other adjustments. 13

0

36

X

Was the cost report prepared only using the
provider's records? (Y/N) If yes, see instructions

1

1

X

9-12, 14-17, 19-26

1

9

-9

27

1

9

9

3-4, 6-12, 14-17, 20-26 2

9

-9

14

WORKSHEET A
Physicians salaries by department
Total physicians salaries
Other salaries by department
Total other salaries
Other direct costs by department
Total other direct costs
Net expenses for allocation by department
Total expenses for allocation

Rev. 2

27

2

9

9

1-4, 6, 8-17, 19-26

3

9

-9

27

3

9

9

1-4, 6-17, 19-26

8

9

-9

27

8

9

9

42-519

4295 (Cont.)

FORM CMS-265-11

06-13

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
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

1-99

0

36

X

1-99

1

2

X

Worksheet A line number

1-99

3

6

9(3).99

Reclassification amount

1-99

4

9

9

Worksheet A line number

1-99

6

6

9(3).99

Reclassification amount

1-99

7

9

9

Total Increases

100

4

9

9

Total Decreases

100

7

9

9

0

36

X

1-6, 8-9, 11-15, 17, 19-99 1

1

X

2

9

-9

1-6, 8, 9, 11, 12, 21-99 4

6

9(3).99

Reclassification identification code
Increases:

Decreases:

WORKSHEET A-2
Description of adjustment
Basis (A or B)
Amount
Worksheet A line number

42-520

22-99

1-6, 8-100

Rev. 2

12-11

FORM CMS 265-11

4295 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION

LINE(S)
WORKSHEET A-3

Part A - Are there any related organization
costs included on Worksheet A? (Y/N)
Part B - Costs incurred and adjustments
required as a result of transactions with
related organization(s):
Worksheet A line number
Expense item(s)
Amount included in Worksheet A
Amount allowable in reimbursable
cost
Total
Part C – Interrelationship of facility to
related organization(s):
Type of interrelationship (A through
G)
If type is G, specify description of
relationship
Name of related individual or
organization
Percentage of ownership
Name of related individual or
organization
Percentage of ownership of provider
Type of business

Rev. 1

COLUMN(S)

FIELD
SIZE

USAGE

1

1

1

X

1-4
1-4
1-4

1
3
4

6
36
9

9(3).99
X
-9

1-4

5

9

-9

5

4-6

9

-9

1-4

1

1

X

1-4

0

36

X

1-4

2

36

X

1-4

3

6

9(3).99

1-4

4

36

X

1-4
1-4

5
6

6
36

9(3).99
X

42-521

4295 (Cont.)

FORM CMS-265-11

12-11

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION

LINE(S)
WORKSHEET A-4

Owners Compensation-Part I
Title
Function
Sole proprietorship
Percentage of work week devoted to
business
Partners
Percent share of operating profit (loss)
Percentage of week devoted to
business
Corporation
Percent of provider’s stock owned
Percentage of work week devoted to
business
Total compensation included in allowable
cost
Part II
Title
Percentage of work week devoted to
business
Total compensation

COLUMN(S)

FIELD
SIZE

USAGE

1-10
1-10

1
2

36
36

X
X

1-10

3

6

9(3).99

1-10

4A

6

9(3).99

1-10

4B

6

9(3).99

1-10

5A

6

9(3).99

1-10

5B

6

9(3).99

1-10

6

11

9

1-10

1

36

X

1-10

2

6

9(3).99

1-10

3

11

9

10
10

X
X

WORKSHEETS B and B-1
Column heading (cost center name)
Statistical basis
+

1-3 +
4, 5 +

2-13
2-13

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.

42-522

Rev. 1

05-14

FORM CMS-265-11

4295 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION

LINE(S)
WORKSHEET B

COLUMN(S)

5-7, 8.01-8.02, 9.019.02, 10.01-10.02,
11.01-11.02, 12.0112.02, 13.01-13.02,
14.01-14.02, 15.0115.02, 16.01-16.02,
17.01-17.02, 19-22
23

Costs after cost finding by department

Total costs after cost finding

FIELD
SIZE

USAGE

13A

9

-9

13A

9

9

2-8,
10-13

9

9

1
1
1
1

11
11
11
11

9
9
9
9

11
11
11
11
11
11
6
11

9
9
9
9
9
9
9(3).99
9

WORKSHEET B-1
All cost allocation statistics

2-22
WORKSHEET C

Total number of treatments
Total CAPD patient weeks
Total CCPD patient weeks
Total provider treatments (informational
only)

8.01-15.02, 18
16.01-16.02
17.01-17.02
19

WORKSHEET D
Total number of treatments
Total CAPD patient weeks
Total CCPD patient weeks
Number of treatments-Medicare
CAPD patient weeks-Medicare
CCPD patient weeks-Medicare
Average Payment Rates
Total Payment Due

Rev. 3

1-8,11
9
10
1-8,11
9
10
1-10
1-10

1
1
1
4, 4.01 & 4.02
4, 4.01 & 4.02
4, 4.01 & 4.02
6, 6.01 & 6.02
7, 7.01, 7.02
&8

42-523

4295 (Cont.)

FORM CMS-265-11

05-14

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION

LINE(S)

COLUMN(S)

FIELD
SIZE USAGE

WORKSHEET E, Part I
Part I - Calculation of Reimbursable Bad
Debts Title XVIII – Part B
Total expenses related to care of Medicare
beneficiaries
Total payment due net of Part B deductibles
Outlier payments
Program payments (80 percent of line 2.03,
column 2)
Amount of cost to be recovered from
Medicare patients (line 1 minus line 5)
Deductibles & coinsurance billed to
Medicare Part B patients
Total deductibles & coinsurance billed to
Medicare Part B patients for comparison
Bad debts for deductibles & coinsurance net
of bad debt recoveries for services rendered
prior to 1/1/2011
Transition period 1 (75-25 percent) bad
debts for deductibles & coinsurance net of
bad debt recoveries for services on or after
1/1/2011 but before 1/1/2012
Transition period 2 (50-50 percent) bad
debts for deductibles & coinsurance net of
bad debt recoveries for services on or after
1/1/2012 but before 1/1/2013
Transition period 3 (25-75 percent) bad
debts for deductibles & coinsurance net of
bad debt recoveries for services on or after
1/1/2013 but before 1/1/2014
100 percent PPS bad debts for deductibles
& coinsurance net of bad debt recoveries for
services rendered on or after 1/1/2014
Total bad debts (sum of lines 8 through 12)
Net deductibles and coinsurance billed to
Unrecovered from Medicare Part B patients

42-524

1

1

11

9

2-2.03
3
5

1&2
1
1

11
11
11

9
9
9

6

1

11

9

7 - 7.02

1&2

11

9

7.03

1

11

9

8

1&2

11

-9

9

1& 2

11

-9

10

1&2

11

-9

11

1&2

11

-9

12

1& 2

11

-9

13
14
15

1&2
1
1

11
11
11

-9
9
9

Rev. 3

05-14

FORM CMS-265-11

4295 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION

LINE(S)

COLUMN(S)

FIELD
SIZE USAGE

WORKSHEET E, Part I (Cont.)
Reimbursable bad debts
Reimbursable bad debts for dual eligible
beneficiaries
Sequestration adjustment amount
Balance due provider/(program)

16
17

1
1

11
11

-9
9

19
20

1
1

11
11

9
-9

1
1
1

9
9
9

9
9
9.9(6)

1

10

X

2

9

-9

1

10

X

2

9

-9

0
1

39
5

X
X

1

9

9

WORKSHEET E, Part II
Part II - Calculation of Facility Specific
Composite Cost Percentage
Total allowable expenses
Total composite costs
Facility specific composite cost percentage

1
2
3

WORKSHEET E-1 Part I
Part I – TO BE COMPLETED BY CONTRACTOR
Enter the date of the tentative payment
1.01 - 1.49
from program to provider (mm/dd/yyyy)
Enter the amount of the tentative payment
1.01 - 1.49
from program to provider
Enter the date of the tentative payment
1.50 - 1.98
from provider to program (mm/dd/yyyy)
Enter the amount of the tentative payment
1.50 - 1.98
from provider to program
Name of contractor
3
Contractor number
3
WORKSHEET E-1 Part II
Part II - TO BE COMPLETED BY PROVIDER
Low volume payment amount

Rev. 3

4

42-525

4295 (Cont.)

FORM CMS-265-11

05-14

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION

LINE(S)

COLUMN(S)

FIELD
SIZE USAGE

WORKSHEET F
For all ESRD (end stage renal disease) facilities (see note):
Balance sheet account balances
1 - 10,
12 - 26,
28 - 31,
34 - 41,
43 - 47,
50, 51
Other (specify)
47

1

9

-9

0

36

X

NOTE: For contra accounts (reported on lines 6, 14, 16, 18, 20, 22, and 24), the usage is -9.
WORKSHEET F-1
Total patient revenues
Allowances and discounts on patients’ accounts
Blank lines (specify)
Increases to operating expenses reported on
Worksheet A
Decreases to operating expenses reported on
Worksheet A
Other revenues
Blank lines (specify)
Net income or (loss) for the period

1
2
5 - 10,
11 - 16
5 - 10

1
1
0

9
9
36

9
9
X

1

9

9

11 - 16

1

9

9

19 - 31
27 - 31
33

1
0
2

9
36
9

9
X
-9

TABLE 3A - WORKSHEETS REQUIRING NO INPUT
Worksheet B

42-526

Rev. 3

06-13

FORM CMS-265-11

4295 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-11
TABLE 3B - TABLES TO WORKSHEET S
Type of Control
1 = Voluntary Non Profit, Corporation
12/31/2011
2 = Voluntary Non Profit, Other
12/31/2012
3 = Proprietary, Individual
12/31/2013
4 = Proprietary, Corporation
12/31/2014
5 = Proprietary, Partnership
6 = Proprietary, Other
7 = Government, Federal
8 = Government, State
9 = Government, County
10 = Government, City
11 = Government, Other

Type of Reimbursement
1 = Initial Method

Transition Period
1 = FYE

2 = MCP Method

2 = FYE
3 = FYE
4 = FYE

Cost Report Status
1 = As Submitted
2 = Settled without Audit
3 = Settled with Audit
4 = Reopened
5 = Amended

TABLE 3C - TABLES TO WORKSHEET S-1
Type of Dialyzers Used
1
2
3
4

=
=
=
=

Hollow Fiber
Parallel Plate
Coil
Other
TABLE 3D - LINES THAT CANNOT BE SUBSCRIPTED
(BEYOND THOSE PREPRINTED)
Worksheet
S Parts I & II
S-1
S-2
A
A-1
A-2
A-3-Part A
A-3, Part B
A-3, Part C
A-4, Part I
A-4, Part II
B
B-1
C
D
E Parts I & II
E-1, Parts I & II
F
F-1

Rev. 2

Lines
All
1-14, 16-30
1-14
1-16, 18-25, 27
All
1-21, 100
All
1-3,5
1-3
1-9
1-9
1-20, 23
1-20,23-25
All
1-8
All
1.01-1.03, 1.50-1.52, 2-4
All
1-4, 17-27, 32-33

42-527

4295 (Cont.)

FORM CMS-265-11

06-13

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
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 pre-coded), 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 pre-code 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 42-524 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, 25 or 26.

42-528

Rev. 2

12-11

FORM CMS 265-11

4295 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
TABLE 5 - COST CENTER CODING
Both 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.
Additional Guidelines
Categories
Make 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.
Use of a Cost Center Coding Description More Than Once
Often 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’ description only for coding
purposes.
Cost Center Coding and Line Restrictions
Use 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.
STANDARD COST CENTER DESCRIPTIONS AND CODES
GENERAL SERVICE COST CENTERS
Capital Related - Buildings and Fixtures
Capital Related - Movable Equipment
Operation and Maintenance of Plant
Housekeeping
Machine Capital-Related or Rental and Maintenance
Salaries for Direct Patient Care
Emp. Health & Welfare Benefits for Direct Patient Care
Supplies

Rev. 1

CODE

USE

0100
0200
0300
0400
0600
0700
0800
0900

(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)

42-529

4295 (Cont.)

FORM CMS-265-11

12-11

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 265-11
TABLE 5 - COST CENTER CODING
STANDARD COST CENTER DESCRIPTIONS AND CODES (Continued)
Laboratory
Administrative and General
Drugs
Interest Expense
Laundry and Linen
Medical Records
Physicians’ Routine Professional Services-Initial Method

1000
1100
1200
1300
1400
1500
1600

(01)
(01)
(01)
(01)
(01)
(01)
(01)

Physicians’ Routine Professional Services-MCP Method
Whole Blood & Packed Red Blood Cells
Vaccines

1900
2000
2100

(01)
(01)
(01)

NON REIMBURSABLE COST
Physicians’ Private Offices
ESA’S prior to 1/1/2011
Method II Patients (Direct Dealing)

2200
2300
2400

(01)
(01)
(01)

NONSTANDARD COST CENTER DESCRIPTIONS AND CODES
CODE

USE

Other

1700

(10)

NONREIMBURSABLE COST CENTERS
Other Nonreimbursable
Other Nonreimbursable

2500
2600

(01)
(10)

GENERAL SERVICE COST CENTERS

42-530

Rev. 1

05-14

FORM CMS-265-11

4295 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-11
TABLE 6 - EDITS
Medicare cost reports submitted electronically are 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 ESRD 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 contractor 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 contractor processing time and
unnecessary rejections. Vendors should develop their programs to prevent their client ESRD
facilities 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).
[1/1/2011]

1005

No record may exceed 60 characters. [1/1/2011]

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. [1/1/2011]

1015

For micro systems, the end of record indicator must be a carriage return and line
feed, in that sequence. [1/1/2011]

1020

The independent renal dialysis facility provider number (record #1, positions 17
through 22) must be valid and numeric. [1/1/2011]

1025

All dates (record #1, positions 23 through 29, 30 through 36, 45 through 51, and 52
through 58) must be in Julian format and legitimate. [1/1/2011]

1030

The fiscal year beginning date (record #1, positions 23 through 29) must be less
than the fiscal year ending date (record #1, positions 30-36). [1/1/2011]

1035

The vendor code (record #1, positions 38 through 40) must be a valid code.
[1/1/2011]

Rev. 3

42-531

4295 (Cont.)

FORM CMS-265-11

05-14

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-11
TABLE 6 - EDITS
I.

Level I Edits (Minimum File Requirements) (Cont.)

Reject Code

Condition

1050

The type 1 record #1 must be correct and the first record in the file. [1/1/2011]

1055

All record identifiers (positions 1 through 20) must be unique. [1/1/2011]

1060

Only a Y or N is valid for fields that require a Yes/No response. [1/1/2011]

1075

Cost center integrity must be maintained throughout the cost report. For
subscripted lines, the relative position must be consistent throughout the cost report.
[1/1/2011]

1080

For every line used on Worksheets A, there must be a corresponding type 2 record.
[1/1/2011]

1090

Fields requiring numeric data (charges, treatments, costs, FTEs, etc.) may not
contain any alpha character. [1/1/2011]

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. [1/1/2011]

1005S

The cost reporting period ending date (Worksheet S, Part II, column 2, line 8) must
be on or after January 1, 2011. [1/1/2011]

1010S

The cost reporting period beginning date (Worksheet S, Part II, column 1, line 8)
must precede the cost reporting period ending date (Worksheet S, Part II, column
2, line 8). [1/1/2011]

1015S

The independent renal dialysis facility name, address, city, State, ZIP code,
provider CCN, and certification date (Worksheet S, Part II, line 1, column 1; line 2,
column 1; line 3, columns 1, 2, & 3; lines 5 and 6, column 1) must be present and
valid. [1/1/2011]

1020S

The type of control (Worksheet S, Part II, line 9, column 1) must be present and a
valid code of 1 through 11. If code 2, 6, or 11 is entered, there must be an entry in
column 2. [1/1/2011]

1022S

If Worksheet S-1, column 1, line 14 or 15, or column 2, line 15.01 (including all
subscripted lines of line 15.01), is greater than zero, then Worksheet A, column 8,
line 12 must be greater than zero. [1/1/2011]

1025S

The independent renal dialysis total number of hours per work week must be greater
than zero (0) (Worksheet S-1, line 21, column 1). [1/1/2011]

1030S

The total number FTEs for Social Workers must be greater than zero (0)
(Worksheet S-1, line 27, sum of columns 1 and 2). [1/1/2011]

1000A

All amounts reported on Worksheet A, columns 1 through 3, line 27, must be
greater than or equal to zero. [1/1/2011]

1005A

For cost reporting periods beginning on or after January 1, 2011, Worksheet A,
column 8, line 23 must be zero. [1/1/2011b]

1020A

For reclassifications reported on Worksheet A-1 the sum of all increases (column 4)
must equal the sum of all decreases (column 7). [1/1/2011]

42-532

Rev. 3

05-14

FORM CMS-265-11

4295 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-11
TABLE 6 - EDITS
I.

Level I Edits (Minimum File Requirements) (Cont.)

Reject Code

Condition

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). [1/1/2011]

1040A

For Worksheet A-2 adjustments on lines 1 through 6, and 8 through 21, if there is
an amount in column 2, there must be an entry in columns 1 and 4, and if any of
lines 22 through 99 and subscripts has an entry in column 2, then all columns 0, 1,
2, and 4 must have entries. Only valid line numbers may be used in column 4.
[1/1/2011]

1045A

If there are any transactions with related organizations or home offices as defined
in CMS Pub. 15-1, 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 through 4 must be greater
than zero; and Part C, column 1, any one of lines 1 through 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. [1/1/2011]

1000B

On Worksheet B-1, all statistical amounts must be greater than or equal to zero.
[4/1/2005]

1005B

For each overhead cost center with a net expense for cost allocation greater than
zero (Worksheet A, column 8, lines 1 through 4 and 6 through 12,), the
corresponding total cost allocation statistics (Worksheet B-1, columns 2 through
13, sum of lines 2 through 22) 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. [1/1/2011]

1010B

Worksheet B, columns 11A and 13A, line 23 must be greater than zero. [1/1/2011]

1000C

For each line on Worksheet C (lines 8.01 through 17.02), if column 1 is greater than
zero, then Worksheet C, column 2 for that line must also be greater than zero, and
vice versa. [1/1/2011]

1010C

Total treatments on Worksheet C, column 1 must equal total treatments on
Worksheet D, column 1 as noted below. [1/1/2011]
Worksheet C
Line 8.01 plus line 8.02
Line 9.01 plus line 9.02
Line 10.01 plus line 10.02
Line 11.01 plus line 11.02
Line 12.01 plus line 12.02
Line 13.01 plus line 13.02
Line 14.01 plus line 14.02
Line 15.01 plus line 15.02
Line 16.01 plus line 16.02
Line 17.01 plus line 17.02

Rev. 3

Worksheet D
Line 1
Line 2
Line 3
Line 4
Line 5
Line 6
Line 7
Line 8
Line 9
Line 10

42-533

4295 (Cont.)

FORM CMS-265-11

05-14

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-11
TABLE 6 - EDITS
I.

Level I Edits (Minimum File Requirements) (Cont.)

Reject Code

Condition

1000D

Worksheet D, column 1, lines 9, 10, or 11 must be greater than zero. [1/1/2011]

1010D

For each line on Worksheet D, the sum of columns 4, 4.01, and 4.02 must be less
than or equal to the total in column 1 for the same line. [1/1/2011]

1000E

Worksheet E, Part I, line 1 must be greater than zero when the sum of Worksheet D,
line 11, columns 4, 4.01 and 4.02 is greater than 0. [1/1/2011]

1010E

For Worksheet E, Part I, column 1, line 2.03 must be greater than zero and less than
or equal to Worksheet D, column 8, line 11. [1/1/2011]

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
contractor. Failure to clear these errors in a timely fashion, as determined by your contractor, 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). [1/1/2011]

2005

Only elements set forth in Table 3, with subscripts as appropriate, are required in
the file. [1/1/2011]

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. [1/1/2011]

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.
[1/1/2011]

2020

All standard cost center codes must be entered on the designated standard cost
center line and subscripts thereof as indicated in Table 5. [1/1/2011]

2025

Only nonstandard cost center codes within a cost center category may be placed on
standard cost center lines of that cost center category. [1/1/2011]

42-534

Rev. 3

05-14

FORM CMS-265-11

4295 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-11
TABLE 6 - EDITS
II.

Level II Edits (Potential Rejection Errors) (Cont.)

Edit
2030

Condition
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. [1/1/2011]
Cost Center

Rev. 3

Line

Code

Cap Rel-Bldg & Fixt.

1

0100

Cap Rel-Mvble Equip

2

0200

Operation & Maintenance of Plant

3

0300

Housekeeping

4

0400

Machine Cap-Rel or Rental & Maint.

6

0600

Salaries for Direct Patient Care

7

0700

EH&W Benefits for Direct Pt. Care

8

0800

Supplies

9

0900

Laboratory

10

1000

Administrative and General

11

1100

Drugs

12

1200

Interest Expense

13

1300

Laundry and Linen

14

1400

Medical Records

15

1500

Phy Routine Prof Services-Initial Method

16

1600

Phy Routine Prof Services-MCP Method

19

1900

Whole Blood & Packed Red Blood Cells

20

2000

Vaccines

21

2100

Physicians’ Private Offices

22

2200

ESAs

23

2300

Method II Patients (Direct Dealing)

24

2400

42-535

4295 (Cont.)

FORM CMS-265-11

05-14

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-265-11
TABLE 6 - EDITS
II.

Level II Edits (Potential Rejection Errors) (Cont.)

Edit

Condition

2035

The administrative and general standard cost center code (1100) may appear only
on line 11. [1/1/2011]

2040

All calendar format dates must be edited for 10 character format, e.g., 01/01/2011
(MM/DD/YYYY). [1/1/2011]

2045

All dates must be possible, e.g., no "00", no "30" or "31" in February. [1/1/2011]

2005S

If the response on Worksheet S, Part II, line 10 is “Y”, the total treatments on
Worksheet C, column 1, line 19 must be less than 4000. [1/1/2011]

2010S

If the response on Worksheet S, Part II, line 10 is “Y”, effective for cost reporting
periods that overlap 1/1/2012, there should be an amount on Worksheet E-1, Part II,
line 4 and vice versa. [1/1/2012s].

2015S

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). [1/1/2011]

2020S

The length of the cost reporting period should be greater than 27 days and less than
459 days. [1/1/2011]

2100S

The following statistics from Worksheet S-1, should be greater than zero:
a. Total treatments for the independent renal dialysis facility (columns 1
through 4, line 11.05) [1/1/2011]

2000A

Worksheet A-1, column 1 (reclassification code) must be alpha characters.
[1/1/2011]

2020A

Worksheet A-3, Part A, must contain a "Y" or "N" response. [1/1/2011]

2000B

At least one cost center description (lines 1 through 3), at least one statistical basis
label (lines 4 through 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. [1/1/2011]

2005B

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. [1/1/2011]

2000F

Total assets on Worksheet F (line 33) must equal total liabilities and fund balances (line
51). [01/01/2013b]

2010F

Net income or loss (Worksheet F-1, column 2, line 33) should not equal zero.
[01/01/2013b]

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.

42-536

Rev. 3