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FORM CMS-265-11 INDEPENDENT RENAL DIALYSIS FACILITY COST REPORT
WORKSHEETS AND INSTRUCTIONS
The Form CMS-265-11, Independent Renal Dialysis Facility Cost Report, updates the existing Form CMS-265-11. The overall burden for the Independent Renal
Dialysis Facility Cost Report increased to 66 hours. Changes to the revised cost report forms, effective for reporting periods beginning on or after
January 1, 2022, include:
1.
2.
3.
4.
5.

Revising Worksheet S-1 and instructions
Revising Worksheet A and instructions
Added Worksheet A-7 and instructions
Revising Worksheets B and Worksheet B-1 and instructions
Revising Worksheet E-1 and instructions

FORM
CMS-265-11
CURRENTLY
APPROVED
Worksheet S,
Parts I, II, & III
Worksheet S-1

PROPOSED FORM CMS-265-11
WORKSHEET
INSTRUCTIONS
WORKSHEET
Worksheet S,
Parts I, II, & III
Worksheet S-1

PAGE #
42-303

SECTION #
§4204 - 4204.3

PAGE #
42-8 - 42-11

42-304 - 42-304.2

§4205

42-11 - 42-14

Worksheet S-2
Worksheet A

Worksheet S-2
Worksheet A

42-305
42-306

§4205.1
§4206

42-15 - 42-19
42-20 - 42-24

Worksheet A-1
Worksheet A-2
Worksheet A-3
Worksheet A-4
N/A

Worksheet A-1
Worksheet A-2
Worksheet A-3
Worksheet A-4
Worksheet A-7

42-307
42-308
42-309
42-310
42-310.1 - 2-310.2

§4207
§4208
§4209
§4210
§4210.50

42-24
42-25 - 42-26
42-27 - 42-28
42-29
42-29.1 - 42-29.2

Worksheets B
and B-1
Worksheet C
Worksheet D
Worksheet E

Worksheets B
and B-1
Worksheet C
Worksheet D
Worksheet E

42-311 - 42-313.4

§4211

42-30 - 42-42.35

42-314
42-315
42-316

§4212
§4213
§4214 - §4214.2

42-36
42-36 - 42-38
42-39 - 42-42

Worksheet E-1

Worksheet E-1

42-317

§4215 - §4215.2

43

Worksheet F
Worksheet F-1

Worksheet F
Worksheet F-1

42-318
42-319 - 42-320

§4216, 4216.1
§4216, §4216.2

43
43

REASON FOR THE CHANGE /
APPLICATION OF THE INSTRUCTIONS
AND ACCOMPANYING WORKSHEETS
Revised disclosure statement to reflect updated
burden hours.
Revising worksheet and instructions to add labor
categories.
N/A
Revising the instructions for line 9 and added line
9.01 to report pediatric supplies.
N/A
N/A
N/A
N/A
Added Worksheet A-7 and instructions to report
the analysis of capital cost centers.
Revising the worksheet and instructions to report
pediatric supplies.
N/A
N/A
Revising the instructions to reflect the suspension
of the sequestration adjustment.
Added lines 5, 6, and 7 to report TDAPA,
TPNIES, and HDPA for informational purposes.
N/A
N/A

BURDEN
EFFECT
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Increase
N/A
N/A
N/A
N/A
N/A
N/A
N/A