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Federal Register / Vol. 86, No. 129 / Friday, July 9, 2021 / Proposed Rules
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stakeholders have suggested the following changes: 1 Add separate columns differentiating composite rate from separately billable supplies Worksheet B/B1, Column 78; 2 add separate columns differentiating composite rate from separately billable laboratory services Worksheet B/B1, Column 910.
3. Request for Information on Independent Facility Cost Report CMS invites comments on the suggested changes to the Independent Facility Cost Report CMS Form 265
11, as described earlier in this section of the proposed rule. In addition to any other input the public wants to provide on modifying the Independent Facility Cost Report, we are requesting responses to the following questions.
What challenges, including operational difficulties, do ESRD
facilities currently face in reporting capital costs:
++ In general.
++ Due to inadequate instructions:
Which instructions should be revised for clarity?
Of those above, which are most problematic?
++ In responding, please indicate whether you are representing the views of a Large dialysis organization.
Regional organization.
Independent and/or rural facility or another entity.
++ What level of expertise do personnel typically filling out cost reports have:
With cost accounting principles and practices?
With health care cost accounting principles and practices?
With operational details of how capital equipment is used in their ESRD
facility?
++ Are accounting record-keeping systems currently used by ESRD
facilities adequate to the task of responding to current and contemplated in this RFI cost reporting requirements?
What challenges, including operational difficulties, would ESRD
facilities face:
++ In reporting dialysis-related machine costs by modality and location?
++ In determining the facility level distribution of direct patient labor FTE
across modalities for each type of direct patient labor?
++ In reporting separate costs for composite rate supplies and separately billable supplies?
++ In reporting separate costs for composite rate laboratory services and separately billable laboratory services?

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What categories of direct patient care labor, such as registered nurses North American Classification System NAICS 291141 and dieticians NAICS 291031, are routinely employed by your dialysis facility and which can be documented in cost reports? Please provide the specific Bureau of Labor Statistics NAICS code associated with each labor category for outpatient care centers found at this website: https www.bls.gov/oes/
current/naics4_621400.htm.
Please detail the specific categories of administrative and management personnel currently employed by your ESRD facility and which can be reported on CMS Form 26511. Please provide the specific Bureau of Labor Statistics NAICS code associated with each labor category for management https
www.bls.gov/oes/current/naics4_
541600.htm11-0000 and administrative https www.bls.gov/oes/
2018/may/naics3_561000.htm. Please indicate if relevant labor categories are not represented here and how these categories can be documented and reported on CMS Form 26511.
Stakeholders have commented on other categorical costs that are not reported on the cost report. These include missed treatments and use of isolation rooms.
++ Specifically, please comment on adding reporting of 1 missed treatments, and 2 maintenance of isolation rooms.
++ Where on CMS Form 26511
should these items be inserted if at all?
What challenges would hospitalbased facilities face were the hospitalbased cost report to be revised to harmonize with the changes suggested for the independent facility cost report?
How can the two cost reporting forms be brought into congruence as related to:
Dialysis related equipment, direct patient care, administrative labor, drugs, laboratory services, and supplies?
Costing accuracy is difficult to achieve for home dialysis. The suggested revisions described above strive to differentiate costs among the different modalities. Are there other means for facilities to report more accurate cost data for home dialysis modalities? Specifically, how can staff time dedicated to home dialysis treatment be better reported?
What other changes might be made to the cost report to better differentiate costs across modalities and patient risk groups?
H. Modifying the Pediatric Cost Report 1. Background Pediatric composite rate costs are not differentiated from adult costs on
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hospital cost reports, while some pediatric-specific costs are itemized on the existing free-standing cost report.
Using CY 2019 cost report data, CMS
data contractor computed total and component specific cost per treatment for hemodialysis-equivalent treatments, stratified by modality, and obtained the ratio of pediatric to adult cost per treatment for each dialysis facility that reported both adult and pediatric treatments. The results indicate that there is variation in costs across composite rate cost components for pediatric and adult treatments. Overall the cost ratio of pediatric to adult treatment costs is 1.58,302 indicating that pediatric treatments are more expensive to administer than adult treatments. For one cost component in particular, supplies, the ratio is 7.30,303
indicating much higher costs for pediatric dialysis supplies than for adult supplies. Further analysis, however, revealed that a substantial portion of facilities does not differentiate between adult and pediatric costs in their cost report accounting. Overall, we found that 13 percent of facilities that treat both pediatric and adult dialysis patients do not differentiate costs between the two age groups.
2. Suggestions for the Pediatric Cost Report In response, CMS is considering that two types of changes be made to the hospital and free-standing ESRD facility cost report that would facilitate the separate reporting of adult and pediatric treatment costs: 1 Changes that differentiate pediatric from adult composite rate component costs, and 2
changes that allow for further differentiation of component costs by modality and age group within the pediatric population. The potential revisions for which stakeholder input is being sought include the addition of select direct patient care labor categories, which correspond to the type of labor typically employed by pediatric dialysis facilities, and the differentiation of pediatric supplies and equipment.
Specifically, CMS is considering adding the following staff categories to CMS Form 26511, Worksheet S1, Lines 2131 Renal Dialysis Facility Number of Employees Full Time Equivalents: Pediatric dialysis nurses and nurse practitioners, pediatric social workers, pediatric dieticians, child life specialists, teachers, and pediatric 302 The fraction would be 158/100, that is $1.58
is spent overall on pediatric dialysis treatments for every $1.00 spent for adult patients.
303 $7.30 is spent, overall, on supplies for a pediatric dialysis treatment for every $1.00 spent on supplies for an adult treatment.

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