Medicare Claims Processing Manual 
Chapter 8 - Outpatient ESRD Hospital, Independent 
Facility, and Physician/Supplier Claims 
 
Table of Contents 
(Rev. 10640, 08-06-21) 
 
Transmittals for Chapter 8 
 
10 - General Description of  the End Stage Renal Disease Prospective Payment System 
(ESRD PPS) 
10.1 - Billing for Additional Treatments  
10.2 - Uncompleted Treatments 
10.3 - No-Shows 
10.4 - Deductible and Coinsurance 
10.5 - Hospital Services 
10.6 - Amount of Payment 
10.7 - ESRD Services Not Provided Within the United States 
10.8 - Transportation Services 
10.9 - Dialysis Provider Number Series 
20 - Calculation of the End Stage Renal Disease Prospective Payment System (ESRD 
PPS) Per Treatment Payment Amount  
20.1 - Calculation of the Basic Case-Mix Adjusted Composite Rate and the ESRD 
Prospective Payment System Rate 
20.1.1 - Calculation for Double Amputee Dialysis Patients 
20.2 - Pediatric Payment Model for ESRD PPS  
       20.3 - End Stage Renal Disease Quality Incentive Program (QIP) 
30 - Publication of the Prospective Payment System (PPS) Base Rate  
40 - Acute Kidney Injury (AKI) Claims  
50 - In-Facility Dialysis Bill Processing Procedures 
50.1  Lab Service Included in the End Stage Renal Disease Prospective Payment System 
(ESRD PPS) 
  50.1.1 - Laboratory Services Performed During Emergency Room Service 
50.1.5 - Lab Services Included in the Prospective Payment System 
50.1.6 - Laboratory Services Performed During Emergency Room Service 
50.2 - Drugs and Biologicals Included in the End Stage Renal Disease  
50.2.5 - Drugs and Biologicals Included in the PPS  50.3 - Required Information for In-Facility Claims Paid Under  the End Stage Renal   
Disease Prospective Payment System (ESRD PPS)  
50.3.1 - Submitting Corrected Bills 
50.4 - Line Item Detail Billing and Automated Claim Adjustments 
50.5 - Intermittent Peritoneal Dialysis (IPD) in the Facility  
50.6- In-Facility Back-Up Dialysis 
50.6.1 - Payment for In-Facility Maintenance Dialysis Sessions Furnished to 
Continuous Ambulatory Peritoneal Dialysis (CAPD) Continuous Cycling 
Peritoneal Dialysis (CCPD) Home Dialysis Patients 
50.6.2 - Payment for Hemodialysis Sessions 
50.7 - Ultrafiltration 
50.8 - Training and Retraining 
50.9 - Coding for Adequacy of Dialysis, Vascular Access and Infection  
60 - Separately Billable ESRD Items and Services 
60.1 - Lab Services 
60.2 - Drugs Furnished in Dialysis Facilities 
60.2.1 - Billing Procedures for Drugs for Facilities  
60.2.1.1 - Separately Billable ESRD Drugs 
60.2.1.2 - Facilities Billing for ESRD Oral Drugs as Injectable Drug 
Equivalents 
60.2.2 - Drug Payment Amounts for Facilities 
               60.2.3 - Facility Billing Requirements to the A/B MAC (A) 
60.2.4 - Physician Billing Requirements to the A/B MAC (B) 
60.2.4.1 - Facility Billing Requirements to the A/B MAC (A) 
60.2.4.2 - Physician Billing Requirements to the A/B MAC (B) 
60.3 - Blood and Blood Products Furnished in Hospital Based and Independent 
Dialysis Facilities 
60.4 - Erythropoietin Stimulating Agents (ESAs) 
60.4.1 - ESA Claims Monitoring Policy 
60.4.2 - Facility Billing Requirements for ESAs 
60.4.2.1 - Other Information Required on the Form CMS-1500 for Epoetin 
Alfa (EPO 
60.4.2.2 - Completion of Subsequent Form CMS-1500 Claims for Epoetin 
Alfa (EPO) 
60.4.3.1 - Other Information Required on the Form CMS-1500 for Epoetin 
Alfa (EPO) 
60.4.3.2 - Completion of Subsequent Form CMS-1500 Claims for Epoetin 
Alfa (EPO) 
              60.4.3 Reserved for Future Use 
60.4.4 - Payment Amount for ESAs  60.4.4.1 - Payment for Epoetin Alfa (EPO) in Other Settings 
60.4.4.2 - Epoetin Alfa (EPO) Provided in the Hospital Outpatient 
Departments 
60.4.5.1 - Self Administered ESA Supply 
60.4.6.1 -  Reserved for Future Use 
60.4.6.2 -  Reserved for Future Use 
60.4.6.3 - Payment for Darbepoetin Alfa (Aranesp) 
60.4.6.4 - Payment for Darbepoetin Alfa (Aranesp) in Other Settings 
60.4.6.5 - Payment for Darbepoetin Alfa (Aranesp) in the Hospital 
Outpatient Department 
60.4.7 - Payment for Peginesatide in the Hospital Outpatient Department 
60.5- Intradialytic Parenteral/Enteral Nutrition (IDPN) 
60.6 - Vaccines Furnished to ESRD Patients 
60.7- Reserved for Future Use 
60.8- Shared Systems Changes for Medicare Part B Drugs for ESRD Independent 
Dialysis Facilities 
70 - Payment for Home Dialysis 
70.1 - Method Selection for Home Dialysis Payment 
70.1.1 - Change in Method 
70.2 - - Prevention of Double Billing Under Method I and II 
70.3 - Overpayments 
80 - Home Dialysis Method I Billing to the A/B MAC (A) 
80.1 - Items and Services Included in the ESRD PPS payment for Home Dialysis 
80.2 - General A/B MAC (A) Bill Processing Procedures for Method I Home 
Dialysis Services 
80.2.1 - Required Billing Information for Method I Claims 
80.3 - Calculating Payment for Intermittent Peritoneal Dialysis (IPD) for Method I 
Claims Submitted to the A/B MAC (A) 
80.3.1 - IPD at Home for Method I Claims Submitted to the A/B MAC (A)  
80.4 - Calculating Payment for Continuous Ambulatory Peritoneal Dialysis (CAPD) 
and Continuous Cycling Peritoneal Dialysis (CCPD) Under the ESRD PPS   
90 - Reserved for Future Use  
90.1 - DME MAC Denials for Beneficiary Submitted Claims Under Method II 
90.2 - Requirements for Payment by the DME MAC 
90.2.1 - Supplier Documentation Required 
90.2.2 - DME MAC Letter Explaining Requirements to Method II Supplier 
90.3- Amount of Payment by the DME MAC 
90.3.1 - Billing Instructions for Method II to DME MACs 
90.3.2 - Home Dialysis Supplies and Equipment HCPCS Codes Used to Bill the 
DME MAC  90.3.3 - DME MAC Claims Processing Instructions 
90.4 - Equipment and Equipment Related Services Provided to Direct Dealing 
Beneficiary 
90.5- Method II Support Services Billed to the A/B MAC (A) by the Facility 
90.5.1 - Billable Revenue Codes Under Method II 
90.5.1.1 - Unbillable Revenue Codes Under Method II  
100 - Dialysis Sessions Furnished to Patients Who Are Traveling 
100.1 - Traveling Patients Who Are Normally In-Facility Dialysis Patients 
100.2 - Traveling Patients Who are Normally Home Dialysis 
100.3 - Physicians Services Furnished to a Dialysis Patient Away From Home or 
Usual Facility 
110 - Reduction in Medicare Program Payment to Fund ESRD Networks  
120 - Renal Transplantation and Related Services 
120.1 - Payment for Immunosuppressive Drugs Furnished to Transplant Patients  
130 - Physicians and Supplier (Nonfacility) Billing for ESRD Services - General 
130.1 - Initial Method for Physicians Services to Maintenance Dialysis Patients 
140 - Monthly Capitation Payment Method for Physicians Services Furnished to Patients 
on Maintenance Dialysis 
140.1 - Payment for ESRD-Related Services Under the Monthly Capitation Payment 
(Center Based Patients) 
140.1.1 - Payment for Managing Patients on Home Dialysis 
140.1.2 - Patients That Switch Modalities (Center to Home and Vice Versa) 
140.2 - Payment for ESRD-Related Services (Per Diem) 
140.2.1 - Guidelines for Physician or Practitioner Billing (Per Diem) 
140.3- Data Elements Required on Claim for Monthly Capitation Payment 
140.4 - Controlling Claims Paid Under the Monthly Capitation Payment Method  
150 - Physicians Self-Dialysis Training Services 
160 - Payment for Physicians Services Furnished to Dialysis Inpatients 
160.1 - Determining Whether Physician Services Furnished on Day of Dialysis 
160.2 - Physicians Services Furnished on Day of Dialysis 
160.3 - Physicians Services Furnished on Non-Dialysis Days 
160.4 - Requirements for Payment 
170 - Billing Physician Dialysis Services (codes 90935 - 90999) and Related Payment  
180 - Noninvasive Studies for ESRD Patients - Facility and Physician Services 
190 - Appeal Rights for Denied Claims 
200 - Utilization of REMIS for A/B MAC (B) Claims Adjudication 
  10 - General Description of the End Stage Renal Disease Prospective 
Payment System (ESRD (PPS)                                                                   
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
See the Medicare Benefit Policy Manual, Chapter 11, for a general description of 
coverage policies and definitions relating to the ESRD benefit. 
 
Effective January 1, 2011 Section 153b of the Medicare Improvements for Patients and 
Providers (MIPPA) requires the implementation of End Stage Renal Disease Prospective 
Payment System (ESRD PPS).  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 patients home), drugs, biologicals, laboratory tests, training, and support 
services. 
 
All ESRD related services and supplies are paid to the ESRD facility through the 
ESRDPPS. Other entities providing ESRD related services, including laboratories, 
suppliers and physicians billing for ESRD related drugs must look to the ESRD facility 
for payment. Consolidated Billing edits established with the implementation of the ESRD 
PPS will deny or reject claims to other providers and suppliers billing for ESRD related 
labs, drugs and supplies. 
 
Information related to the lab tests, drugs and supplies subject to the ESRD consolidated 
billing requirement can be found at the following website: 
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ESRDpayment/Consolidated_Billing.html  
 
The list of items and services subject to consolidated billing may be updated quarterly in 
January, April, July and October of each year. 
 
10.1 - Billing for Additional Treatments                                                    
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
  The End Stage Renal Disease (ESRD) Prospective Payment System (PPS) provides a 
per treatment unit of payment. The per treatment unit of payment is the same base rate 
that is paid for all dialysis treatment modalities furnished by an ESRD facility.  The 
policy allows for 3 PPS payments per week.  When a beneficiarys plan of care requires 
more than three weekly dialysis treatments, whether HD or daily PD, claim edits are 
applied to ensure that Medicare payment on the monthly claim is consistent with the 3-
times weekly dialysis treatment payment limit. Thus, for a 30-day month, payment is 
limited to 13 treatments, and for a 31-day month, payment is limited to 14 treatments, 
with exceptions made for medical justification. 
    ESRD facilities billing for more than 13 or 14 treatments per month must provide 
medical justification as required by the Medicare Administrative Contractor in order to 
receive payment for the additional treatments. Additional treatments provided without 
meeting the medical justification required must include the modifier CG on the claim 
line. This modifier indicates that the facility attests the additional treatment does not meet 
medical justification requirements.  Additional treatments billed without medical 
justification do not receive payment.  Non-covered treatments are not considered in the 
outlier payment calculation.  
 
  This policy does not apply for training and retraining treatments billed within the 
allowable limits.  See section 50.8 of this chapter for training and retraining treatments. 
 
10.2 - Uncompleted Treatments 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
 A dialysis treatment is started, when a patient is connected to the machine and a dialyzer 
and bloodlines are used. However, if the is not completed for some unforeseen, but valid 
reason such as a medical emergency when the patient must be rushed to an emergency 
room, the facility is paid based on the full Prospective Payment System (PPS) base rate   
This is a rare occurrence and must be fully documented to the A/B MAC (A)s 
satisfaction. 
 
10.3 - No-Shows 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
If a facility sets up in preparation for a dialysis treatment, but the treatment is never 
started because the patient never arrives, no payment is made. In this case, no service has 
been furnished to a Medicare beneficiary even though staff time and supplies may have 
been used.  Furthermore, the facility may not bill the patient or the patients private 
insurance for these services.  This is because the program is already paying the cost of 
pre-dialysis services through the PPS base rate.  In setting that rate, CMS has included 
the salaries of facility personnel and the cost of supplies used for furnishing pre-dialysis 
services. 
 
Therefore, these costs (e.g., salaries for staff time, overhead, supply costs) are included in 
the facilitys costs and reported on its cost report, and they are included in the allowable 
costs used to set future reimbursement rates under the End Stage Renal Disease 
Prospective Payment System (ESRD PPS) for ESRD facilities.  However, these costs may 
not be used as the basis for a facility to be reimbursed as Medicare bad debts. 
 
10.4 - Deductible and Coinsurance                                                          
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
The beneficiary is responsible for any unmet deductible and for coinsurance.   
  Eighty percent of the total End Stage Renal Disease Prospective Payment System (ESRD 
PPS) payment amount for renal dialysis services furnished by ESRD facilities to ESRD 
beneficiaries is paid by Medicare. ESRD beneficiaries are responsible for the remaining 
twenty percent after the deductible. Therefore, the beneficiary coinsurance amount under 
the ESRD PPS is twenty percent of the total ESRD PPS payment, which includes the 
ESRD PPS base rate, all applicable adjustments, any applicable training add-on 
amounts and any applicable outlier payments. 
 
10.5 - Hospital Services 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
Outpatient dialysis services for a patient with acute kidney failure or chronic kidney 
failure but not eligible for Medicare under the ESRD provisions at the time services are 
rendered must be billed by the hospital and cannot be billed by a Medicare certified renal 
dialysis facility on bill type 72x. 
 
Hospitals with a Medicare certified renal dialysis facility should have outpatient ESRD 
related services billed by the hospital-based renal dialysis facility on bill type 72x.  
Hospitals that do not have a Medicare certified renal dialysis facility may bill for 
outpatient emergency or unscheduled dialysis services.  The Prospective Payment System 
(PPS) base rate is not paid. For more information regarding the outpatient hospital billing 
policy for ESRD related services, see chapter 4 section 210 of this manual. 
 
When an individual is furnished outpatient hospital services and is thereafter admitted as 
an inpatient of the same hospital due to renal failure - within 24 hours for non PPS 
hospitals and within 72 hours for PPS hospitals - the outpatient hospital services 
furnished are treated as inpatient services unless the patient does not have Part A 
coverage.  Charges are reported on the ASC X12 837 institutional claim format or on 
Form CMS-1450.  The day on which the patient is formally admitted as an inpatient is 
counted as the first inpatient day.  The PPS base rate is not paid. 
 
10.6 - Amount of Payment 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
Effective for dates of service beginning January 1, 2011, after the beneficiarys Part B 
deductible is met, the A/B MACs (A) pay 80 percent of the ESRD PPS base rate and all 
applicable adjustments (or the blended payment amount if the facility chooses to 
transition), for each outpatient maintenance dialysis treatment furnished to the ESRD 
beneficiary in the ESRD facility or at the beneficiarys home. 
 
10.7 - ESRD Services Not Provided Within the United States 
(Rev. 1, 10-01-03) 
 
Services (except for certain inpatient hospital services and related physicians and 
ambulance services in specified situations) that are not provided within the United States 
are not covered. United States includes the 50 States, the District of Columbia, the  Commonwealth of Puerto Rico, the Virgin Islands, Guam, and American Samoa.  See 
Chapter 1 for additional information concerning specified situations that may be covered, 
billing and payment procedures and jurisdiction for payment. 
 
10.8 - Transportation Services 
(Rev. 1, 10-01-03) 
 
In general, transportation services to obtain ESRD services are not covered. However, see 
the Medicare Benefit Policy Manual, Chapter 10, for coverage of ambulance services to 
renal dialysis facilities located on hospital premises and for coverage of ambulance 
services to nonhospital based dialysis facilities.  Billing and payment instructions are 
provided in Chapter 15 of this manual. 
 
10.9  Dialysis Provider Number Series 
(Rev. 771, Issued: 12-02-05, Effective: 01-03-06, Implementation: 01-03-06) 
 
There are multiple facilities that provide dialysis services to ESRD beneficiaries.  To 
ensure that provider data is correct, facilities are required to use a Provider Number based 
on facility type issued by CMS. 
 
The Provider Number Series for Dialysis Providers are as follows (for CMS use only, 
effective May 23, 2007, providers are required to submit only their National Provider 
Identifier (NPI).  The dialysis provider numbers will be mapped to the NPI): 
 
2300-2499  Chronic Renal Dialysis Facilities (Hospital  Based) 
2500-2899  Non  Hospital Renal Facilities 
2900-2999  Independent Special Purpose Renal Dialysis Facility 
3300-3399  Childrens Hospitals (Excluded from PPS) 
3500-3699  Renal Disease Treatment Centers (Hospital Satellites) 
3700-3799  Hospital Based Special Purpose Renal Dialysis Facilities 
 
All facilities should use their appropriately assigned provider numbers on the 72x type of 
bill.  In the event that a facility changes from one type to another, the provider number 
must reflect the facilitys present provider type. 
 
20 - End Stage Renal Disease Prospective Payment System (ESRD PPS) 
Per Treatment Payment Amount                                                               
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
A case mix methodology adjusts the Prospective Payment System (PPS) base rate based 
on a limited number of patient characteristics.  Variables for which adjustments will be 
applied to the PPS base rate include age, body surface area (BSA), and low body mass 
index (BMI).  These variables are determined in the ESRD PRICER to calculate the End 
Stage Renal Disease Prospective Payment System (ESRD PPS per treatment payment 
amount (including all other adjustments).   
The following table contains claim data required to calculate the ESRD PPS per 
treatment payment amount.   
 
Form CMS-1450   ASC X12 837 institutional claim 
Through Date  2300 | DTP segment | 434 qualifier 
Date of Birth  2010BA | DMG02 
Condition Codes (73, 74, 87)  2300 | HI segment | BG qualifier 
Value Codes (A8 and A9) / Amounts  2300 | HI segment | BE qualifier 
Revenue Code (0821, 0831, 0841,  2400 | SV201 
0851, 0880, or 0881) 
 
For claims with dates of service on or after January 1, 2011, Medicare systems must pass 
the line item date of service dialysis revenue code lines when the onset of dialysis 
adjustment is applicable to one or more of the dialysis sessions reported on the claim. 
 
Form CMS-1450   ASC X12 837 institutional claim 
Line Item Date of Service for  2400 | DTP Segment | D8 qualifier 
Revenue Code (0821, 0831, 0841, 
0851 
 
In addition to the above claim data, the following payer only codes are required on claims 
with dates of service on or after January 1, 2011 to calculate the ESRD PPS per treatment 
payment amount:   
 
Form CMS-1450   Payer Only Format 
Payer Only Condition Codes  (MA,  X(2)    
MB, MC, MD, ME, MF) 
(Identifies comorbid conditions for 
adjustments) 
Payer Only Value Code (79) 
(Identifies dollar amount for 
services applicable for the    X(2) V(9) 
calculation for determining outlier)   
Payer Only Value Code (Q8) 
(Identifies dollar amount for 
services applicable for the 
calculation of the transitional drug    X(2) V(9) 
add-on payment)    Form CMS-1450   Payer Only Format 
Payer Only Value Code (QG) 
(Identifies dollar amount for 
services applicable for the 
calculation of the transitional  
payment for new innovative    X(2) V(9) 
equipment and supplies)   
 
Note: The payer only codes above are assigned by the Medicare standard systems and are 
not submitted on the claim by the provider.   
 
The following provider data must also be passed to the ESRD PRICER to make provider-
specific calculations that determine the ESRD PPS per treatment payment amount: 
 
Field  Format 
Actual Geographic Location MSA  X(4) 
Actual Geographic Location CBSA   X(5) 
Special Wage Index   9(2)V9(4) 
Supplemental Wage Index  9(2)V9(4) 
Provider Type  X(2) 
Special Payment Indicator   X(1) 
 
In addition to the above provider data, the following is required to calculate the final 
ESRD PPS rate effective January 1, 2011: 
 
Field  Format 
Blended Payment Indicator  X(1) 
Low-Volume Indicator  X (1) 
 
Effective January 1, 2012 the following is required to calculate the Quality Incentive 
Program adjustment for ESRD facilities: 
 
Field  Format 
Quality Indicator Field  X(1) 
 
Based on the claim and provider data shown above, the ESRD PRICER makes 
adjustments to the PPS base rate to determine the ESRD PPS per treatment payment 
amount. The following factors are used to adjust and make calculations to the ESRD PPS 
per treatment payment amount.    Provider Type 
  Drug add-on 
  Budget Neutrality Factor 
  Patient Age 
  Patient Height 
  Patient Weight 
  Patient BSA 
  Patient BMI 
  BSA factor 
  BMI factor 
  Condition Code 73 adjustment (if applicable) 
  Condition Code 74 adjustment (if applicable) 
  Condition Code 84 for AKI patients (if applicable) 
  Condition Code 87 adjustment (if applicable) 
 
In addition to the above adjustments, the following adjustments may be applicable to the 
ESRD PPS base rate for adult patient claims with dates of service on or after January 1, 
2011: 
 
  Onset of Dialysis 
  Patient Comorbidities 
  Low-Volume ESRD Facility 
 
Onset of Dialysis: 
 
Providers will receive an adjustment to the ESRD PPS base rate for patients within the 
initial 120 calendar days from when an ESRD beneficiary began their maintenance 
dialysis.  The provider does not report anything on the claim for this adjustment.  The 
adjustment is determined by the start date of dialysis in the Common Working File as 
reported on the patients 2728 form.  When the onset of dialysis adjustment is provided, 
the claim is not entitled to a comorbidity adjustment or a training add-on adjustment. 
 
Patient Comorbidities: 
 
The ESRD PPS will provide adjustments for each category of chronic and acute 
comorbidity conditions, 3 categories of chronic conditions and 3 categories of acute 
conditions.  In the event that more than one of the comorbidity categories is present 
on the claim, the claim will be adjusted for the highest paying comorbidity category. 
 
Chronic Comorbidities  
 
When chronic comorbidity codes are reported on the claim an adjustment may be made 
for as long as the chronic condition remains applicable to the patient care provided and 
is reported on the claim. 
  Acute Comorbidities  
 
Acute comorbidity category adjustments will be eligible for a payment for the first month 
reported and then for the next three consecutive months, regardless of whether or not the 
diagnosis code is on the claim after the first month. This adjustment applies for no more 
than four consecutive months for any reported acute comorbidity category. Acute 
comorbidity conditions reported for more than four consecutive months will not receive 
additional payment.   
 
In the event that the comorbidity condition was resolved and later reoccurred, the 
provider may submit a condition code to indicate the diagnosis is a reoccurrence. The 
adjustment will be applicable for an additional four months. 
 
For a list of specific acute and chronic comorbid conditions eligible for adjustment, refer 
to the following website: 
 
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ESRDpayment/Patient-Level-Adjustments 
 
This list may be updated as often as quarterly in January, April, July and October of each 
year. 
 
Low-Volume ESRD Facilities: 
 
ESRD facilities will receive an adjustment to their ESRD PPS base rate when the facility 
furnished less than 4,000 treatments in each of the three cost report years preceding the 
payment year and has not open, closed, or received a new provider number due to a 
change in ownership during the 3 years preceding the payment year.  The ESRD facility 
must notify their A/B MAC (A) if they believe they are eligible for the low-volume 
adjustment.  The A/B MAC (A) must validate the eligibility and update the provider 
specific file.  Pediatric patient claims are not eligible for the low-volume adjustment. 
 
A/B MACs (A) are instructed to validate the facilitys eligibility for the low volume 
adjustment.  If an A/B MAC (A) determines that an ESRD facility has received the low 
volume adjustment in error, the A/B MAC (A) is required to adjust all of the ESRD 
facilitys affected claims to remove the adjustment within 6 months of finding the error. 
 
In addition to the above adjustments, the following adjustments may be applicable to the 
ESRD PPS base rate for adult and pediatric patient claims with dates of service on or 
after January 1, 2011: 
 
Training Adjustment:  The ESRD PPS provides a training add-on of $33.44 adjusted by 
the geographic area wage index that accounts for an hour of nursing time for training 
treatments.  The add-on applies to both PD and HD training treatments. 
 
ESRD PPS Outlier Payments:   
The ESRD Prospective Payment System (PPS) includes a payment adjustment for high 
cost outliers when there are unusual variations in the type or amount of medically 
necessary care.   
 
Outlier consideration is provided for the following: 
 
  ESRD-related drugs and biologicals that were or would have been prior to 
January 1, 2011, separately billable under Medicare Part B;  
  ESRD-related laboratory tests that were or would have been, prior to January 1, 
2011 separately billable under Part B;  
  Medical/surgical supplies, including syringes, used to administer ESRD-related 
drugs that were or would have been prior to January 1, 2011, separately billable 
under Medicare Part B; and  
  Renal dialysis service drugs that were or would have been, prior to January 1, 
2011 covered under Medicare Part D.   
  For new injectable renal dialysis drugs and biologicals that are eligible outlier 
services, ESRD facilities should report J3591 with the National Drug Code 
(NDC) in the 11-digit format 5-4-2.  The MAC will set the payment rate based on 
pricing methodologies under 1847A of the Act using the guidance in the Medicare 
Claims Processing Manual, Chapter 17 - Drugs and Biologicals, Section 20.1.3 - 
Exceptions to Average Sales Price (ASP) Payment Methodology.  
 
Statute requires the delay of the implementation of the oral-only renal dialysis service 
policy until January 1, 2025. Services not included in the PPS that remain separately 
payable are not considered outlier services. 
 
When the ESRD PRICER returns an outlier payment, the standard systems shall display 
the total applicable outlier payment on the claim with value code 17. 
 
Information related to the outlier services eligible for adjustment can be found at the 
following website:   
 
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ESRDpayment/Outlier_Services.html  
 
This list may be updated as often as quarterly in January, April, July and October of each 
year. 
 
For claims submitted with dates of service on or after January 1, 2012, all drugs reported 
on the ESRD claim under revenue codes 0634, 0635 and 0636 with a rate available on the 
ASP file will be considered in the Medicare allowed payment (MAP) amount for outlier 
consideration with the exception of any drugs reported with the AY modifier and drugs 
included in the original composite rate payment system. 
 
  Transitional Drug Add-On Payment Adjustment (TDAPA) 
Effective January 1, 2016 under the ESRD PPS drug designation process, CMS provides 
payment using a Transitional Drug Add-on Payment Adjustment (TDAPA) for new renal 
dialysis new injectable or intravenous drugs and biologicals that qualify under 42 CFR 
413.234(c)(1).  
CMS will pay for the drug or biological using a transitional drug add-on payment 
adjustment, if the new injectable or intravenous drug or biological is used to treat or 
manage a condition for which there is not an existing ESRD PPS functional category. 
CMS bases the TDAPA on payment methodologies under section 1847A of the Social 
Security Act which are discussed in Pub. 100-04, Chapter 17, Section 20. The MAC will 
set the payment rate based on pricing methodologies under 1847A of the Act using the 
guidance in the Medicare Claims Processing Manual, Chapter 17 - Drugs and 
Biologicals, Section 20.1.3 - Exceptions to Average Sales Price (ASP) Payment 
Methodology.  This payment is applicable for a period of 2 years.  
While the TDAPA applies to a new injectable or intravenous drug or biological, the drug 
or biological is not considered an outlier service, is not separately payable with the AY 
modifier and does not apply to acute kidney injury claims (AKI). 
Drugs eligible for the TDAPA must billed with revenue code 0636 and modifier AX must 
be appended to the HCPCS.  
  The TDAPA claim lines are shown as covered line items but no payment will be 
included on the line item.  The TDAPA is included in the prospective payment 
amount on the dialysis revenue code lines. 
  Q8 payer only value code captures the total allowable payment for the TDAPA. 
The ESRD pricer divides the Q8 amount by the total number of dialysis 
treatments and the per treatment amount is added to PPS rate and included in 
each dialysis line payment. 
Additional information on the TDAPA is available on the CMS website located at:  
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ESRDpayment/ESRD-Transitional-Drug 
 
Transitional Add-on Payment Adjustment for New and Innovative Equipment and 
Supplies (TPNIES) 
Beginning January 1, 2020, the ESRD PPS provides the Transitional Add-on Payment 
Adjustment for New and Innovative Equipment and Supplies (TPNIES) for new and 
innovative renal dialysis equipment and supplies that qualify under  413.236. 
 
The TPNIES payment is based on 65 percent of the Medicare Administrative Contractor 
(MAC) determined price. The MACs, on behalf of CMS, establish prices for new and 
innovative renal dialysis equipment and supplies that meet the TPNIES eligibility criteria 
using verifiable information from the following sources of information, if available:  
    the invoice amount, facility charges for the item, discounts, allowances, and 
rebates;   
  the price established for the item by other MACs and the sources of information 
used to establish that price;  
  payment amounts determined by other payers and the information used to 
establish those payment amounts; 
  charges and payment amounts required for other equipment and supplies that 
may be comparable or otherwise relevant.  
The TPNIES is paid for 2 calendar years, beginning on January 1 and ending on 
December 31. While the TPNIES applies to a new and innovative equipment or supply, 
the equipment or supply is not considered an outlier service.  
Items eligible for the TPNIES must billed with revenue code 027X and modifier AX must 
be appended to the HCPCS. Until TPNIES items receive a HCPCS the TPNIES supplies 
are reported with HCPCS A4913 for miscellaneous dialysis supply not otherwise 
specified and for TPNIES equipment HCPCS E1699 is reported for miscellaneous 
dialysis equipment not otherwise specified.  
  The TPNIES claim lines are shown as covered line items but no payment will be 
included on the line item.  The TPNIES is included in the prospective payment 
amount on the dialysis revenue code lines. 
  QG payer only value code captures the total allowable price for the TPNIES. The 
ESRD pricer calculates the 65 percent of the MAC determined price and divides 
the amount by the total number of dialysis treatments and the per treatment 
amount is added to PPS rate and included in each dialysis line payment. 
 
20.1  Calculation of the Basic Case-Mix Adjusted Composite Rate and 
the ESRD Prospective Payment System Rate 
(Rev. 3053, Issued: 08-28-14, Effective: ICD-10: Upon Implementation of ICD-10; 
ASC X12: 01-01, 12, Implementation ICD-10: Upon Implementation of ICD-10; 
ASC X12: 09-30-14) 
 
A case mix methodology adjusts the composite payment rate based on a limited number 
of patient characteristics.  Variables for which adjustments will be applied to each 
facilitys composite rate include age, body surface area (BSA), and low body mass index 
(BMI).  These variables are determined in the ESRD PRICER to calculate the final 
composite rate (including all other adjustments). 
 
The following table contains claim data required to calculate a final ESRD composite rate 
and the ESRD PPS rate: 
 
Form CMS-1450   ASC X12 837 institutional claim 
Through Date  2300 | DTP segment | 434 qualifier 
Date of Birth  2010BA | DMG02  Form CMS-1450   ASC X12 837 institutional claim 
Condition Code (73 or 74)  2300 | HI segment | BG qualifier 
Value Codes (A8 and A9) / Amounts  2300 | HI segment | BE qualifier 
Revenue Code (0821, 0831, 0841,  2400 | SV201 
0851, 0880, or 0881) 
 
For claims with dates of service on or after January 1, 2011, Medicare systems must pass 
the line item date of service dialysis revenue code lines when the onset of dialysis 
adjustment is applicable to one or more of the dialysis sessions reported on the claim. 
 
Form CMS-1450   ASC X12 837 institutional claim 
Line Item Date of Service for  2400 | DTP Segment | D8 qualifier 
Revenue Code (0821, 0831, 0841, 
0851 
 
In addition to the above claim data, the following payer only codes are required on claims 
with dates of service on or after January 1, 2011 to calculate the final ESRD PPS rate: 
 
Form CMS-1450   ASC X12 837 institutional claim 
Payer Only Condition Codes  (MA,  2300 | HI segment | BG qualifier 
MB, MC, MD, ME, MF) 
Payer Only Value Code (79)  2300 | HI segment | BE qualifier 
 
Note:  These payer only codes above are assigned by the Medicare standard systems and 
are not submitted on the claim by the provider.  Payer only condition codes are only 
applicable when the appropriate corresponding diagnosis code(s) appears on the claim. 
 
See information below in this section on co-morbidity diagnostic categories.  The payer 
only value code 79 represents the dollar amount for services applicable for the calculation 
in determining an outlier payment. 
 
The following provider data must also be passed to the ESRD PRICER to make provider-
specific calculations that determine the final ESRD rate: 
 
Field  Format 
Actual Geographic Location MSA  X(4) 
Actual Geographic Location CBSA   X(5) 
Special Wage Index   9(2)V9(4) 
Provider Type  X(2)  Field  Format 
Special Payment Indicator   X(1) 
 
In addition to the above provider data, the following is required to calculate the final 
ESRD PPS rate effective January 1, 2011: 
 
Field  Format 
Blended Payment Indicator  X(1) 
Low-Volume Indicator  X (1) 
 
Effective January 1, 2012 the following is required to calculate the Quality Incentive 
Program adjustment for ESRD facilities: 
 
Field  Format 
Quality Indicator Field  X(1) 
 
ESRD facilities may elect to be reimbursed 100 percent by ESRD PPS no later than 
November 1, 2010.  Facilities that do not elect to be reimbursed 100 percent by the ESRD 
PPS will be reimbursed by a blended payment rate which is composed of the current 
basic case-mix adjusted composite rate payment system and the new ESRD PPS. 
 
Blended payment schedule: 
 
Calendar year 2011  75 percent of the old payment methodology and 25 percent of new 
ESRD PPS payment 
 
Calendar year 2012  50 percent of the old payment methodology and 50 percent of the 
new ESRD PPS payment 
 
Calendar year 2013  25 percent of the old payment methodology and 75 percent of the 
new ESRD PPS payment 
 
Calendar year 2014  100 percent of the ESRD PPS payment 
 
Based on the claim and provider data shown above, the ESRD PRICER makes 
adjustments to the facility specific base rate to determine the final composite payment 
rate.  The following factors are used to adjust and make calculations to the final payment 
rate: 
 
  Provider Type 
  Drug add-on 
  Budget Neutrality Factor    Patient Age 
  Patient Height 
  Patient Weight 
  Patient BSA 
  Patient BMI 
  BSA factor 
  BMI factor 
  Condition Code 73 adjustment (if applicable) 
  Condition Code 74 adjustment (if applicable) 
 
In addition to the above adjustments, the following adjustments may be applicable to the 
ESRD PPS base rate for adult patient claims with dates of service on or after January 1, 
2011: 
 
  Onset of Dialysis 
  Patient Co-morbidities 
  Low-Volume ESRD Facility 
 
Onset of Dialysis: 
 
Providers will receive an adjustment to the ESRD PPS base rate for patients within the 
initial 120 calendar days from when an ESRD beneficiary began their maintenance 
dialysis.  The provider does not report anything on the claim for this adjustment.  The 
adjustment is determined by the start date of dialysis in the Common Working File as 
reported on the patients 2728 form.  When the onset of dialysis adjustment is provided, 
the claim is not entitled to a co-morbidity adjustment or a training add-on adjustment. 
 
Co-morbidity Adjustment Categories 
 
The ESRD PPS will provide adjustments for 6 categories of co-morbidity conditions, 3 
categories of chronic conditions and 3 categories of acute conditions.  In the event that 
more than one of the co-morbidity categories is present on the claim, the claim will 
be adjusted for the highest paying co-morbidity category. 
 
Acute Co-morbidity Diagnostic Categories: 
 
The acute co-morbidity categories will be eligible for a payment for the first month 
reported and the following 3 consecutive months.  Acute co-morbidity conditions 
reported for more than 4 consecutive months will not receive additional payment.  In the 
event that the co-morbidity condition was resolved and later reoccurred, the provider may 
submit a condition code to indicate the diagnosis is a reoccurrence.  The adjustment will 
be applicable for an additional 4 months. 
 
Acute Categories are: 
 
  Gastro-intestinal tract bleeding    Bacterial pneumonia 
  Pericarditis 
 
Chronic Co-morbidity Diagnostic Categories: 
 
When chronic co-morbidity codes are reported on the claim an adjustment may be made 
for as long as the chronic condition remains applicable to the patient care provided and is 
reported on the claim. 
 
Chronic Categories are: 
 
  Hereditary hemolytic or sickle cell anemia 
  Monoclonal gammopathy  
  Myelodysplastic syndrome 
 
Information related to the comorbid conditions eligible for adjustment can be found at the 
following website: 
 
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ESRDpayment/Comorbidity_Conditions.html  
 
This list may be updated as often as quarterly in January, April, July and October of each 
year. 
 
Low-Volume Facilities: 
 
ESRD facilities will receive an adjustment to their ESRD PPS base rate when the facility 
furnished less than 4,000 treatments in each of the three cost report years preceding the 
payment year and has not open, closed, or received a new provider number due to a 
change in ownership during the 3 years preceding the payment year.  The ESRD facility 
must notify their A/B MAC (A) if they believe they are eligible for the low-volume 
adjustment.  The A/B MAC (A) must validate the eligibility and update the provider 
specific file.  Pediatric patient claims are not eligible for the low-volume adjustment. 
 
A/B MACs (A) are instructed to validate the facilitys eligibility for the low volume 
adjustment.  If an A/B MAC (A) determines that an ESRD facility has received the low 
volume adjustment in error, the A/B MAC (A) is required to adjust all of the ESRD 
facilitys affected claims to remove the adjustment within 6 months of finding the error. 
 
In addition to the above adjustments, the following adjustments may be applicable to the 
ESRD PPS base rate for adult and pediatric patient claims with dates of service on or 
after January 1, 2011: 
 
Training Adjustment:  The ESRD PPS provides a training add-on of $33.44 adjusted by 
the geographic area wage index that accounts for an hour of nursing time for training 
treatments.  The add-on applies to both PD and HD training treatments.   
ESRD PPS Outlier Payments: 
 
Outlier payments may be applied to the payment.  ESRD outlier services are the 
following items and services that are included in the ESRD PPS bundle: (1) ESRD-
related drugs and biologicals that were or would have been prior to January 1, 2011, 
separately billable under Medicare Part B; (2) ESRD-related laboratory tests that were or 
would have been, prior to January 1, 2011 separately billable under Part B; (3) 
medical/surgical supplies, including syringes, used to administer ESRD-related drugs that 
were or would have been prior to January 1, 2011, separately billable under Medicare 
Part B; and (4) renal dialysis service drugs that were or would have been, prior to January 
1, 2011 covered under Medicare Part D.  ESRD-related oral only drugs are delayed until 
January 1, 2014.  Services not included in the PPS that remain separately payable are not 
considered outlier services. 
 
When the ESRD PRICER returns an outlier payment, the standard systems shall display 
the total applicable outlier payment on the claim with value code 17. 
 
Information related to the outlier services eligible for adjustment can be found at the 
following website:   
 
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ESRDpayment/Outlier_Services.html  
 
This list may be updated as often as quarterly in January, April, July and October of each 
year. 
 
For claims submitted with dates of service on or after January 1, 2012, all drugs reported 
on the ESRD claim under revenue codes 0634, 0635 and 0636 with a rate available on the 
ASP file will be considered in the Medicare allowed payment (MAP) amount for outlier 
consideration with the exception of any drugs reported with the AY modifier and drugs 
included in the original composite rate payment system. 
 
Value Codes and Amounts 
 
48 - Hemoglobin Reading - Code indicates the most recent hemoglobin reading taken 
before the start of this billing period.  This is usually reported in three positions with a 
decimal.  Use the right of the delimiter for the third digit. 
 
The blood sample for the hemoglobin reading must be obtained before the dialysis 
treatment.  If a hemoglobin value is not available facilities must report the value 99.99. 
 
49 - Hematocrit Reading - Code indicates the most recent hematocrit reading taken 
before the start of this billing period.  This is usually reported in two positions (a 
percentage) to the left of the dollar/cents delimiter.  If the reading is provided with a 
decimal, use the position to the right of the delimiter for the third digit.   
The blood sample for the hematocrit reading must be obtained before the dialysis 
treatment.  If a hematocrit value is not available facilities must report the value 99.99. 
 
The blood sample for the hematocrit reading must be obtained before the dialysis 
treatment.  If a hematocrit value is not available facilities must report the value 99.99. 
 
20.1.1 - Calculation for Double Amputee Dialysis Patients 
(Rev. 1389; Issued:  12-07-07; Effective:  01-01-08; Implementation:  01-07-08) 
 
For dialysis treatments on or after January 1, 2006, we are revising the reporting 
requirements for value codes A8 and A9 for double amputee dialysis patients. 
 
Weight should be calculated based on pre-amputation weight using the following 
formula:  Pre-amputation weight = Actual weight x 1.15 
 
  Example:  Current weight for double amputee patient = 75.5 kg. 
 
Pre-Amputation weight = 75.5 x 1.15 = 89kg. 
 
  The results should be reported under value code A8. 
 
Height should be reported under value code A9 as pre-amputation height.  Where feasible 
this measurement may be obtained from Form 2728. 
 
20.2 - Pediatric Payment Model for ESRD PPS                                        
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
The pediatric payment model applies to all dialysis patients that are under the age of 18.  
The model uses the ESRD PPS base rate applicable to adult dialysis patients which is 
then adjusted by separate adjusters based on two age groups (<13, 13-17), and dialysis 
modality (HD, PD). 
 
20.3 -End Stage Renal Disease Quality Incentive Program (ESRD QIP) 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)  
 
153c of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) 
required The Centers for Medicare & Medicaid Services (CMS) to implement a quality 
based payment program for dialysis services with payment consequences effective 
January 1, 2012.  The measures are defined in the annual dialysis facility report (DFR) 
that each provider receives in addition to the final rule. 
 
Contractors are notified annually through a Technical Direction Letter from CMS 
identifying ESRD facilities subject to QIP payment reduction.  Medicare contractors shall  update the outpatient provider specific file (OPSF) as indicated for the payment year 
specified.  
 
See chapter 4 of this manual for appropriate OPSF fields to update. 
 
Valid values for ESRD facilities:  
Blank = no reduction  
1 = 12 percent payment reduction  
2 = 1 percent payment reduction  
3 = 1 12 percent payment reduction  
4 = 2 percent payment reduction 
 
30 - Publication of the Prospective Payment System (PPS) Base Rate    
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
The End Stage Renal Disease Prospective Payment System (ESRD PPS) regulations 
require Centers for Medicare & Medicaid Services (CMS) to publish the Prospective 
Payment System (PPS) base rate in a Federal Register notice when CMS incorporates 
new cost data or wage index. When the PPS base rate is updated, a listing of the new 
payment rates are published via Recurring Update Notifications.  These rates are updated 
and published as needed and are used when issuing a PPS base rate to a new or an 
existing facility. 
 
40 - Acute Kidney Injury (AKI) Claims                                                     
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)  
 
Effective January 1, 2017, ESRD facilities, both hospital based and freestanding are able 
to furnish dialysis to AKI patients and receive payment under the ESRD PPS. 
Medicare will pay ESRD facilities for the dialysis treatment using the ESRD PPS base 
rate adjusted by the applicable ESRD PPS wage index. In addition to the dialysis 
treatment, the ESRD PPS base rate pays ESRD facilities for other items and services 
considered to be renal dialysis services as defined in 42 CFR 413.171.  No separate 
payment is made for those services considered to be renal dialysis services as payment is 
included in the ESRD PPS base rate. 
Other items and services that are furnished to beneficiaries with AKI that are not 
considered to be renal dialysis services but are related to their dialysis as a result of their 
AKI, would be separately payable, this includes drugs, biologicals, laboratory services, 
and supplies that ESRD facilities are certified to furnish and that would otherwise be 
furnished to a beneficiary with AKI in a hospital outpatient setting. 
AKI claims are billed on the 072X type of bill with condition code 84.  ESRD facilities 
are required to include revenue code 082X, 083x, or 088x for the modality of dialysis  furnished with the Current Procedural Terminology (CPT) code G0491 (Dialysis 
procedure at a Medicare certified ESRD facility for Acute Kidney Injury without ESRD).  
AKI claims do not receive payment adjustments for comorbidities, TDAPA, TPNIES or 
outlier.  The ESRD network reduction is not applicable to AKI claims. 
More information on dialysis provided for AKI patients including the required diagnosis 
codes for billing AKI is available on the CMS website at: 
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/AKI-
and-ESRD-Facilities. 
 
50 - In-Facility Dialysis Bill Processing Procedures 
(Rev. 3053, Issued: 08-28-14, Effective: ICD-10: Upon Implementation of ICD-10; 
ASC X12: 01-01, 12, Implementation ICD-10: Upon Implementation of ICD-10; 
ASC X12: 09-30-14) 
 
General instructions for completing the claim are in Chapter 25. The following 
instructions apply to facility reporting of ESRD services and to A/B MAC (A) processing 
of in-facility dialysis claims. 
 
The shared system checks the Common Working File (CWF) to determine if there is 
Employer Group Health Plan (EGHP) insurance. Where the beneficiary is covered under 
the EGHP insurance, see the Medicare Secondary Payer Manual. 
 
50.1 - Laboratory Services Included in the End Stage Renal Disease 
Prospective Payment System ESRD PPS                                                   
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
With the implementation of the End Stage Renal Disease Prospective Payment System 
ESRD PPS, 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. 
 
f the renal dialysis facility needs to report a lab service that was not related to the 
treatment of ESRD, they must include the modifier AY to indicate the item or service is 
not for the treatment of ESRD. 
 
ESRD-related lab services that were separately paid under the basic case-mix composite 
rate payment system are considered in the calculation of any applicable outlier payment 
under the ESRD PPS. 
 
 
 
 
  50.1.1 - Laboratory Services Performed During Emergency Room 
Service 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
For claims with dates of service on or after January 1, 2012, the consolidated billing edit 
for laboratory services will be bypassed when billed in conjunction with an emergency 
room service on a hospital outpatient claim and the AY modifier will not be necessary.  
Allowing laboratory testing to bypass consolidated billing edits in the emergency room or 
department does not mean that End Stage Renal Disease (ESRD) facilities should send 
patients to the emergency room or department for routine laboratory testing or for the 
provision of renal dialysis services that should be provided by ESRD facilities.  The 
intent of the bypass is to acknowledge that there are emergency circumstances where the 
reason for the patients illness is unknown and the determination of a laboratory test as 
being ESRD-related is not known. 
 
For hospital claims with dates of service on or after April 1, 2012, that include an 
emergency room service with revenue code 045x on a line item date that differs from the 
line item date of service for the related laboratory test(s) the hospital must include the 
modifier ET to attest that the laboratory test(s) were ordered in conjunction with the 
emergency services.  This is necessary to recognize that emergency services often span 
two calendar days. 
 
50.2 - Drugs and Biologicals Included in the End Stage Renal Disease 
Prospective Payment System (ESRD (PPS)                                              
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
With the implementation of the End Stage Renal Disease Prospective Payment System 
(ESRD PPS), effective for claims with dates of service on or after January 1, 2011, all 
ESRD-related injectable drugs and biologicals and oral equivalents of those injectable 
drugs and biologicals are included in the ESRD PPS. 
 
If the renal dialysis facility needs to report a drug that was furnished to an ESRD 
beneficiary that was not related to the treatment of ESRD, they must include the modifier 
AY to indicate the item or service is not for the treatment of ESRD. 
 
ESRD-related drugs and biologicals that were separately paid under the basic case-mix 
composite rate payment system are considered in the calculation of any applicable outlier 
payment under the ESRD PPS. 
 
 
 
  50.3 - Required Information for In-Facility Claims Paid Under the End 
Stage Renal Disease Prospective Payment System ESRD PPS                      
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
The term Medicare beneficiary identifier (Mbi) is a general term describing a 
beneficiarys Medicare identification number. For purposes of this manual, Medicare 
beneficiary identifier references both the Health Insurance Claim Number (HICN) and 
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition 
period and after for certain business areas that will continue to use the HICN as part of 
their processes. 
 
The electronic form required for billing ESRD claims is the ASC X12 837 institutional 
claim transaction.  The paper form, where permissible, is Form CMS-1450. 
 
The coding and related descriptions for the following items are identical for the ASC X12 
837 institutional claim format and Form CMS-1450.  See the related X12 implementation 
guide or Chapter 25, respectively, for where the information is reported. 
 
Type of Bill 
 
Acceptable codes for Medicare are: 
 
721 - Admit Through Discharge Claim - This code is used for a bill encompassing an 
entire course of outpatient treatment for which the provider expects payment from the 
payer. 
 
722 - Interim - First Claim - This code is used for the first of an expected series of 
payment bills for the same course of treatment. 
 
723 - Interim - Continuing Claim - This code is used when a payment bill for the same 
course of treatment is submitted and further bills are expected to be submitted later. 
 
724 - Interim - Last Claim - This code is used for a payment bill which is the last of a 
series for this course of treatment. The Through date of this bill (FL 6) is the discharge 
date for this course of treatment. 
 
727 - Replacement of Prior Claim - This code is used when the provider wants to correct 
(other than late charges) a previously submitted bill.  The previously submitted bill needs 
to be resubmitted in its entirety, changing only the items that need correction.  This is the 
code used for the corrected or new bill. 
 
728 - Void/Cancel of a Prior Claim - This code indicates this bill is a cancel-only 
adjustment of an incorrect bill previously submitted.  Cancel-only adjustments should be 
used only in cases of incorrect provider identification numbers, incorrect Medicare 
beneficiary identifier, duplicate payments and some OIG recoveries.  For incorrect  provider numbers or Medicare beneficiary identifier, a corrected bill is also submitted 
using a code 721. 
 
Statement Covers Period (From-Through) - Hospital-based and independent renal 
dialysis facilities: 
 
The beginning and ending service dates of the period included on this bill.  Note:  ESRD 
services are subject to the monthly billing requirements for repetitive services. 
 
Condition Codes 
 
Hospital-based and independent renal facilities complete these items.  Note that one of 
the codes 71-76 is applicable for every bill.  Special Program Indicator codes A0-A9 are 
not required. 
 
Condition Code Structure (only codes affecting Medicare payment/processing are 
shown). 
 
02 - Condition is Employment Related - Providers enter this code if the patient alleges 
that the medical condition causing this episode of care is due to environment/events 
resulting from employment. 
 
04 - Information Only Bill - Providers enter this code to indicate the patient is a member 
of a Medicare Advantage plan. 
 
59  Non-Primary ESRD Facility  Providers enter this code to indicate that ESRD 
beneficiary received non-scheduled or emergency dialysis services at a facility other than 
his/her primary ESRD dialysis facility. 
 
71 - Full Care in Unit - Providers enter this code to indicate the billing is for a patient 
who received staff-assisted dialysis services in a hospital or renal dialysis facility. 
 
72 - Self-Care in Unit - Providers enter this code to indicate the billing is for a patient 
who managed his own dialysis in a hospital or renal dialysis facility. 
 
73 - Self-Care in Training - Providers enter this code to indicate the billing is for special 
dialysis services where a patient and his/her helper (if necessary) were learning to 
perform dialysis. 
 
76 - Back-up In-facility Dialysis - Providers enter this code to indicate the billing is for a 
home dialysis patient who received back-up dialysis in a facility. 
 
84  Acute Kidney Injury- Provider enters this code to indicate the claim is for an AKI 
patient. 
  87  Retraining  Provider enters this code to indicate the billing is for retraining of the 
patient and his/her helper (if necessary) to perform self-care dialysis. 
 
H3  Reoccurrence of GI Bleed comorbid category  
 
H4  Reoccurrence of Pneumonia comorbid category  
 
H5  Reoccurrence of Pericarditis comorbid Category 
 
Occurrence Codes and Dates 
 
Codes(s) and associated date(s) defining specific events(s) relating to this billing period 
are shown.  Event codes are two alpha-numeric digits, and dates are shown as six 
numeric digits (MM-DD-YY).  When occurrence codes 01-04 and 24 are entered, make 
sure the entry includes the appropriate value code, if there is another payer involved. 
 
Occurrence and occurrence span codes are mutually exclusive.  Occurrence codes have 
values from 01 through 69 and A0 through L9.  Occurrence span codes have values from 
70 through 99 and M0 through Z9. 
 
24 - Date Insurance Denied - Code indicates the date of receipt of a denial of coverage by 
a higher priority payer. 
 
33 - First Day of Medicare Coordination Period for ESRD Beneficiaries Covered by an 
EGHP - Code indicates the first day of the Medicare coordination period during which 
Medicare benefits are payable under an EGHP.  This is required only for ESRD 
beneficiaries. 
 
51  Date of last Kt/V reading.  For in-center hemodialysis patients, this is the date of the 
last reading taken during the billing period.  For peritoneal dialysis patients and home 
hemodialysis patients, this date may be before the current billing period but should be 
within 4 months of the claim date of service.  
 
Occurrence Span Code and Dates 
 
Code(s) and associated beginning and ending dates(s) defining a specific event relating to 
this billing period are shown.  Event codes are two alpha-numeric digits and dates are 
shown numerically as MM-DD-YY. 
 
74 - Noncovered Level of Care - This code is used for repetitive Part B services to show a 
period of inpatient hospital care or of outpatient surgery during the billing period.  Use of 
this code will not be necessary for ESRD claims with dates of service on or after April 1, 
2007 due to the requirement of ESRD line item billing. 
 
Document Control Number (DCN) 
  Required for all provider types on adjustment requests.  (Bill Type/FL=XX7).  All 
providers requesting an adjustment to a previous processed claim insert the DCN of the 
claims to be adjusted. 
 
Value Codes and Amounts 
 
Code(s) and related dollar amount(s) identify monetary data that are necessary for the 
processing of this claim.  The codes are two alphanumeric digits and each value allows 
up to nine numeric digits (0000000.00).  Negative amounts are not allowed.  Whole 
numbers or non-dollar amounts are right justified to the left of the dollars and cents 
delimiter.  Some values are reported as cents, so refer to specific codes for instructions.  
If more than one value code is shown for a billing period, show the codes in ascending 
alphanumeric sequence. 
 
Value Code Structure (Only codes used to bill Medicare are shown.): 
 
06 - Medicare Blood Deductible - Code indicates the amount the patient paid for un-
replaced deductible blood. 
 
13 - ESRD Beneficiary in the 30- Month Coordination Period with an EGHP - Code 
indicates that the amount shown is that portion of a higher priority EGHP payment on 
behalf of an ESRD beneficiary that applies to covered Medicare charges on this bill.  If 
the provider enters six zeros (0000.00) in the amount field, it is claiming a conditional 
payment because the EGHP has denied coverage or there has been a substantial delay in 
its payment.  Where the provider received no payment or a reduced payment because of 
failure to file a proper claim, this is the amount that would have been payable had it filed 
a proper claim. 
 
17  Not submitted by the provider.  The Medicare shared system will display this payer 
only code on the claim when an outlier payment is being made.  The value is the total 
claim outlier payment. 
 
19  Not submitted by the provider.  The Medicare shared system will display this payer 
only code on the claim for low volume providers to identify the amount of the low 
volume adjustment being included in the providers reimbursement. 
 
37 - Pints of Blood Furnished - Code indicates the total number of pints of blood or units 
of packed red cells furnished, whether or not replaced.  Blood is reported only in terms of 
complete pints rounded upwards, e.g., 1 1/4 pints is shown as 2 pints.  This entry serves a 
basis for counting pints towards the blood deductible.  Hospital-based and independent 
renal facilities must complete this item. 
 
38 - Blood Deductible Pints - Code indicates the number of un-replaced deductible pints 
of blood supplied.  If all deductible pints furnished have been replaced, no entry is made.  
Hospital-based and independent renal facilities must complete this item. 
  39 - Pints of Blood Replaced - Code indicates the total number of pints of blood donated 
on the patients behalf.  Where one pint is donated, one pint is replaced.  If arrangements 
have been made for replacement, pints are shown as replaced.  Where the provider 
charges only for the blood processing and administration, i.e., it does not charge a 
replacement deposit fee for un-replaced pints, the blood is considered replaced for 
purposes of this item.  In such cases, all blood charges are shown under the 039x revenue 
code series, Blood Administration.  Hospital-based and independent renal facilities must 
complete this item. 
 
44 - Amount Provider Agreed To Accept From Primary Payer When This Amount is 
Less Than Charges But Higher than Payment Received - Code indicates the amount 
shown is the amount the provider was obligated or required to accept from a primary 
payer as payment in full when that amount is less than the charges but higher than 
amount actually received.  A Medicare secondary payment is due. 
 
47 - Any Liability Insurance - Code indicates amount shown is that portion from a higher 
priority liability insurance made on behalf of a Medicare beneficiary that the provider is 
applying to Medicare covered services on this bill.  If six zeros (0000.00) are entered in 
the amount field, the provider is claiming conditional payment because there has been 
substantial delay in the other payers payment. 
 
48 - Hemoglobin Reading - Code indicates the most recent hemoglobin reading taken 
before the start of this billing period.  This is usually reported in three positions with a 
decimal. Use the right of the delimiter for the third digit.  The blood sample for the 
hemoglobin reading must be obtained before the dialysis treatment. If a hemoglobin value 
is not available facilities must report the value 99.99. 
 
49 - Hematocrit Reading - Code indicates the most recent hematocrit reading taken 
before the start of this billing period.  This is usually reported in two positions (a 
percentage) to the left of the dollar/cents delimiter.  If the reading is provided with a 
decimal, use the position to the right of the delimiter for the third digit.  The blood 
sample for the hemoglobin reading must be obtained before the dialysis treatment. If a 
hematocrit value is not available facilities must report the value 99.99 
 
71 - Funding of ESRD Networks - Code indicates the amount of Medicare payment 
reduction to help fund the ESRD networks.  This amount is calculated by the A/B MAC 
(A) and forwarded to CWF.  (See 120 for discussion of ESRD networks). 
 
79  Not submitted by the provider.  The Medicare shared system will display this payer 
only code on the claim.  The value represents the dollar amount for Medicare allowed 
payments applicable for the calculation in determining an outlier payment. 
 
A8  Weight of Patient  Code indicates the weight of the patient in kilograms.  The 
weight of the patient should be measured after the last dialysis session of the month. 
  A9  Height of Patient  Code indicates the height of the patient in centimeters.  The 
height of the patient should be measured during the last dialysis session of the month.  
The measurement is required no less frequently than once per year but must be reported 
on every claim. This height is as the patient presents. 
 
D5  Result of last Kt/V reading.  For in-center hemodialysis patients this is the last 
reading taken during the billing period.  For peritoneal dialysis patients and home 
hemodialysis this may be before the current billing period but should be within 4 months 
of the claim date of service. 
 
Q8  Not submitted by the provider.  The Medicare shared system will display this payer 
only code on the claim.  The value represents the dollar amount for the services 
applicable to the calculation of the transitional drug add-on adjustment (TDAPA). 
 
QG  Not submitted by the provider.  The Medicare shared system will display this payer 
only code on the claim.  The value represents the dollar amount for the services 
applicable to the calculation of the new innovative equipment and supplies add-on 
adjustment (TPNIES). 
 
Revenue Codes 
 
The revenue code for the appropriate treatment modality is billed (e.g., 0821 for 
hemodialysis).  Effective January 1, 2015, ESRD facilities are required to report on the 
claim the drugs identified on the consolidated billing list provided at  
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ESRDpayment/Consolidated_Billing.html  
 
082X - Hemodialysis - Outpatient or Home Dialysis - A waste removal process 
performed in an outpatient or home setting, necessary when the bodys own kidneys have 
failed.  Waste is removed directly from the blood.  Detailed revenue coding is required.  
Therefore, services may not be summed at the zero level. 
 
0 - General Classification  HEMO/OP OR HOME 
1  Hemodialysis/Composite or other rate  HEMO/COMPOSITE 
2 - Home Supplies  HEMO/HOME/SUPPL 
3 - Home Equipment  HEMO/HOME/EQUIP 
4 - Maintenance 100%  HEMO/HOME/100% 
5 - Support Services  HEMO/HOME/SUPSERV 
9 - Other Hemodialysis Outpatient  HEMO/HOME/OTHER 
 
083X - Peritoneal Dialysis - Outpatient or Home - A waste removal process performed in 
an outpatient or home setting, necessary when the bodys own kidneys have failed.  
Waste is removed indirectly by instilling a special solution into the abdomen using the 
peritoneal membrane as a filter. 
 
0 - General Classification  PERITONEAL/OP OR HOME  1 - Peritoneal/Composite or other rate  PERTNL/COMPOSITE 
2 - Home Supplies  PERTNL/HOME/SUPPL 
3 - Home Equipment  PERTNL/HOME/EQUIP 
4 - Maintenance 100%  PERTNL/HOME/100% 
5 - Support Services  PERTNL/HOME/SUPSERV 
9 -Other Peritoneal Dialysis  PERTNL/HOME/OTHER 
 
084X - Continuous Ambulatory Peritoneal Dialysis (CAPD) - Outpatient - A continuous 
dialysis process performed in an outpatient or home setting, which uses the patients 
peritoneal membrane as a dialyzer. 
 
0 - General Classification  CAPD/OP OR HOME 
1 - CAPD/Composite or other rate  CAPD/COMPOSITE 
2 - Home Supplies  CAPD/HOME/SUPPL 
3 - Home Equipment  CAPD/HOME/EQUIP 
4 - Maintenance 100%  CAPD/HOME/100%  
5 - Support Services  CAPD/HOME/SUPSERV 
9 -Other CAPD Dialysis  CAPD/HOME/OTHER 
 
085X - Continuous Cycling Peritoneal Dialysis (CCPD) - Outpatient. - A continuous 
dialysis process performed in an outpatient or home setting, which uses the patients 
peritoneal membrane as a dialyzer. 
 
0 - General Classification  CCPD/OP OR HOME 
1 - CCPD/Composite or other rate  CCPD/COMPOSITE 
2 - Home Supplies  CCPD/HOME/SUPPL 
3 - Home Equipment  CCPD/HOME/EQUIP 
4 - Maintenance 100%  CCPD/HOME/100% 
5 - Support Services  CCPD/HOME/SUPSERV 
9 -Other CCPD Dialysis  CCPD/HOME/OTHER 
 
088X - Miscellaneous Dialysis - Charges for Dialysis services not identified elsewhere. 
 
0 - General Classification  DAILY/MISC 
1  Ultrafiltration  DAILY/ULTRAFILT 
2  Home dialysis aid visit  HOME DIALYSIS AID VISIT 
9 -Other misc. Dialysis  DAILY/MISC/OTHER 
 
HCPCS/Rates 
 
All ESRD hemodialysis claims must include HCPCS 90999 on the line reporting revenue 
code 082x. All AKI claims must include HCPCS G0491. 
 
Modifiers 
  Modifiers are required with ESRD Billing for reporting the adequacy of dialysis and the 
vascular access.  For information on modifiers required for these quality measures see 
50.9 of this chapter. 
 
For information on reporting modifiers applicable to the Erythropoietin Stimulating 
Agents refer to section 60.4 of this chapter. 
 
Route of administration modifiers required are JA, JB and JE. 
 
For information on reporting the AY modifier for services not related to the treatment of 
ESRD, see sections 60.2.1.1 - Separately Billable ESRD Drugs and 60.1 - Lab Services. 
 
For information on reporting the CG modifier for additional treatments provided without 
medical justification, see section 10.1 of this chapter. 
 
Service Date 
 
Report the line item date of service for each dialysis session and each separately payable 
item or service. 
 
Service Units 
 
Hospital-based and independent renal facilities must complete this item.  The entries 
quantify services by revenue category, e.g., number of dialysis treatments. Units are 
defined as follows: 
 
0634 - Erythropoietin (EPO) - Administrations, i.e., the number of times an injection of 
less than 10,000 units of EPO was administered.  For claims with dates of service on or 
after January 1, 2008, facilities use the units field as a multiplier of the dosage description 
in the HCPCS to arrive at the dosage amount per administration. 
 
0635 - Erythropoietin (EPO) - Administrations, i.e., the number of times an injection of 
10,000 units or more of EPO was administered.  For claims with dates of service on or 
after January 1, 2008, facilities use the units field as a multiplier of the dosage description 
in the HCPCS to arrive at the dosage amount per administration. 
 
082X - (Hemodialysis) - Sessions 
 
083X - (Peritoneal) - Sessions 
 
084X - (CAPD)  Per Day 
 
085X - (CCPD)  Per Day 
 
Effective April 1, 2007, the implementation of ESRD line item billing requires that each 
dialysis session be billed on a separate line.  As a result, claims with dates of service on  or after April 1, 2007 should not report units greater than 1 for each dialysis revenue code 
line billed on the claim. 
 
Total Charges 
 
Hospital-based and independent renal facilities must complete this item.  Hospital-based 
facilities must show their customary charges that correspond to the appropriate revenue 
code.  They must not enter their composite or the EPO` rate as their charge. Independent 
facilities may enter their composite and/or EPO rates. 
 
Neither revenue codes nor charges for services included in the composite rate may be 
billed separately (see 90.3 for a description).  Hospitals must maintain a log of these 
charges in their records for cost apportionment purposes. 
 
Services which are provided but which are not included in the composite rate may be 
billed as described in sections that address those specific services. 
 
The last revenue code entered in as 000l represents the total of all charges billed. 
 
Principal Diagnosis Code 
 
Hospital-based and independent renal facilities must complete this item and it should 
include a diagnosis of end stage renal disease for patients with ESRD. For patients with 
AKI see section 40 of this chapter. 
 
Other Diagnosis Code(s) 
 
For claims with dates of service on or after January 1, 2011 renal dialysis facilities report 
the appropriate diagnosis code(s) for comorbidity conditions eligible for an adjustment. 
 
50.3.1 - Submitting Corrected Bills 
(Rev. 1, 10-01-03) 
 
Claimants must submit a corrected claim if any of the following apply to a previously 
processed claim: 
 
  A change in provider number; 
  A change in coinsurance involves an amount greater than $1.99; or  
  A change in visits (decrease or increase). 
 
Claimants must follow procedures for submitting corrected bills in Chapter 26. 
 
50.4 - Line Item Detail Billing and Automated Claim Adjustments 
(Rev. 1364, Issued:  11-02-07: Effective:  04-01-08; Implantation:  04-07-08) 
  The implementation of line item detail billing for ESRD claims effective on April 1, 2007 
requires that each service be submitted on a separate line with the appropriate line item 
date of service.  The Medicare standard systems perform line item date of service 
compare for RDFs claims with statement billing periods overlapping the statement billing 
period of another processed claim.  This prevents monthly claims from receiving 
overlapping edits based on the statement billing period dates but rather, only when the 
RDF claim has a line item that duplicates another processed claim or falls within the 
dates of an inpatient hospital stay.  Standard systems reject only those overlapping line 
items while any line items not overlapping another claim continue to process for 
payment.  As a result of this logic, the RDFs no longer have to submit the occurrence 
span code 74 on the monthly dialysis claim when an inpatient stay occurred during the 
same month. 
 
The initial line item detail billing instruction did not implement a process for rejecting 
services on the RDF claim overlapping an inpatient stay when the RDF claim is received 
before the inpatient hospital claim.  A subsequent instruction implemented for April 1, 
2008 requires the Medicare Common Working File (CWF) to create an informational 
unsolicited response prompting the standard system to perform an automated adjustment 
of the processed 72x claim that contains line item dates of service that are overlapping 
dates of an incoming inpatient hospital claim.  The admission and discharge dates of an 
inpatient stay are not considered overlapping dates and may be payable to the RDF. 
 
50.5 - Intermittent Peritoneal Dialysis (IPD) in the Facility 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
Payment for Intermittent Peritoneal Dialysis (IPD) in the facility is subject to the same 
payment rules as hemodialysis. 
 
50.6 - In-Facility Back-Up Dialysis 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)  
 
Back-up dialysis is an in-facility dialysis treatment furnished to a home dialysis patient. 
Condition code 76 must appear as one entry in Form Locators (FLs) 24-30. The facility 
must explain why any in-facility backup dialysis sessions (furnished on either an 
inpatient or outpatient basis) are furnished to home dialysis patients who are covered 
under the Prospective Payment System (PPS) base rate. If a backup session is furnished 
because of a failure to furnish any of the required items or services, then it will be 
covered only to the extent of a home dialysis session and reimbursed at the facilitys PPS 
base rate. If the backup dialysis is furnished by an institution other than the home 
patients End Stage Renal Disease (ESRD) facility, then the ESRD facility must assume 
financial liability for any cost or charge in excess of the ESRD facilitys PPS base rate 
except where the patient is traveling away from home. 
 
  50.6.1 - Payment for In-Facility Maintenance Dialysis Sessions 
Furnished to Continuous Ambulatory Peritoneal Dialysis (CAPD) 
/Continuous Cycling Peritoneal Dialysis (CCPD Home Dialysis Patients          
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
Although Continuous Ambulatory Peritoneal Dialysis (CAPD) and Continuous Cycling 
Peritoneal Dialysis (CCPD) patients are home dialysis patients, it may be necessary at 
times to dialyze them in-facility as a substitute.  In this case, the total weekly 
reimbursement to the facility remains the same regardless of the type and frequency of in-
facility dialysis involved. 
 
In order to furnish covered CAPD services, a facility must be a Medicare approved 
ESRD facility and must meet additional standards established by CMS. 
 
However, in rare instances an ESRD patient may require a combination of dialysis 
techniques, on the same day, in order to achieve satisfactory results.  In these situations, 
Medicare pays for both types of dialysis services furnished on the same day.  Medicare 
A/B MACs (A) determine the medical necessity.  In each case the A/B MAC (A) obtains 
medical documentation from the facility that supports the use of back-up dialysis with 
another treatment modality.  If a CAPD patient frequently requires back-up sessions, the 
A/B MAC (A)s medical staff may request medical records to determine if this is the 
appropriate mode of treatment to meet medical necessity requirement for payment 
purposes and/or whether a different mode of treatment is more advantageous to the 
beneficiary. 
 
50.6.2 - Payment for Hemodialysis Sessions 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
Hemodialysis is typically furnished three times per week in sessions of three to five hours 
duration. Each hemodialysis session equals one PPS base rate payment.  Therefore, three 
sessions per week is three PPS base rate payments.  Dialysis furnished at this frequency 
is paid without the need for a secondary diagnosis to justify payment.  The justification 
must support the medical necessity of the service(s) being rendered. 
 
50.7 - Ultrafiltration 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
  
Ultrafiltration (revenue code 0881) is a process for removing excess fluid from the blood 
through the dialysis membrane by means of pressure. It is not a substitute for dialysis. 
Ultrafiltration is used in cases where excess fluid cannot be removed easily during the 
regular course of hemodialysis. It is commonly done during the first hour or two of 
hemodialysis on patients who, for example, have refractory edema. 
 
Pre-dialysis Ultrafiltration - While the need, if any, for pre-dialysis ultrafiltration varies 
from patient to patient, the facilitys PPS rate covers the full range of complicated and  uncomplicated outpatient dialysis treatments. Therefore, no additional charge is 
recognized for pre-dialysis ultrafiltration. 
 
Separate Ultrafiltration - Occasionally, medical complications require that 
ultrafiltration be performed at a time other than when a dialysis treatment is given, and in 
these cases an additional payment may be made. However, the need for separate 
ultrafiltration must be documented in the medical record and a supporting other diagnosis 
must be included on the claim.  
 
50.8 - Training and Retraining 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
See Pub. 100-02 Medicare Benefit Policy Manual, Chapter 11, for coverage rules for 
dialysis training. 
 
Training services and supplies that are covered under the Prospective Payment System 
(PPS) base rate includes personnel services, dialysis supplies and parenteral items used 
in dialysis, written training manuals, material and laboratory tests.   
 
End Stage Renal Disease Prospective Payment System (ESRD PPS) claims with dates of 
service on or after January 1, 2011, billing for dialysis training sessions will receive a 
home dialysis training add-on payment.   
 
The home dialysis training add-on payment  is adjusted by the geographic area wage 
index and added to the PPS base rate. The home dialysis training add-on payment that 
accounts for nursing time for training treatments. The home dialysis training add-on 
payment applies to both peritoneal dialysis (PD) and hemodialysis (HD) training 
treatments.  Updates to the home dialysis training add-on payment are published through 
rulemaking. 
 
Hemodialysis (HD) Training (082X): 
An ESRD facility may bill a maximum of 25 training sessions per patient for hemodialysis 
training. 
 
Intermittent Peritoneal Dialysis (IPD) Training (083X): 
An ESRD facility is not reimbursed for more three IPD treatments in a single week, for a 
total duration longer than 3 months. 
 
Continuous Ambulatory Peritoneal Dialysis (CAPD) Training (84X): 
An ESRD facility may bill a maximum of 15 training sessions per patient for CAPD 
training.  The A/B MAC (A) will make a determination whether or not to permit training 
sessions in excess of 15. 
 
Continuous Cycling Peritoneal Dialysis (CCPD) Training (085X):  An ESRD facility may bill a maximum of 15 training sessions per patient for CCPD 
training. The A/B MAC (A) will determine whether or not training sessions over 15 are 
medically necessary.  
 
Retraining 
 
A.  General - Occasionally, it is necessary to furnish additional training to an ESRD 
self-dialysis beneficiary after the initial training course is completed.  Retraining 
sessions are paid under the following conditions: 
 
  The patient changes from one mode of dialysis to another, e.g., from 
hemodialysis to CAPD; 
  The patients home dialysis equipment changes; 
  The patients dialysis setting changes; 
  The patients dialysis partner changes; or 
  The patients medical condition changes e.g., temporary memory loss due 
to stroke, physical impairment.  
 
The patient must continue to be an appropriate patient for self-dialysis. 
 
B.  Payment Rates - Retraining sessions are reimbursed at the same rate as the 
facilitys training rate. 
 
C.  Duplicate Payments - No home dialysis training add-on payment is made for a 
home dialysis treatment furnished on the same day as a retraining session.  In the case 
of a CAPD patient, the facilitys equivalent CAPD daily rate is not paid on the day(s) 
of retraining. 
 
50.9 - Coding for Adequacy of Dialysis, Vascular Access and Infection 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
A.   Reporting the Urea Reduction Ratio (URR) for End Stage Renal Disease (ESRD) 
Hemodialysis Claims 
 
All hemodialysis claims must indicate the most recent Urea Reduction Ratio (URR) for 
the dialysis patient.  Code all claims using HCPCS code 90999 along with the appropriate 
G modifier listed in section B. 
 
Claims for dialysis treatments must include the adequacy of hemodialysis data as 
measured by URR.  Dialysis facilities must monitor the adequacy of dialysis treatments 
monthly for facility patients.  Home hemodialysis and peritoneal dialysis patients may be 
monitored less frequently, but not less than quarterly.  If a home hemodialysis patient is 
not monitored during a month, the last, most recent URR for the dialysis patient must be 
reported. 
  HCPCS code 90999 (unlisted dialysis procedure, inpatient or outpatient) must be reported 
in field location 44 for all bill types 72X.  The appropriate G-modifier in field location 44 
(HCPCS/RATES) is used, for patients that received seven or more dialysis treatments in 
a month.  Continue to report revenue codes 0820, 0821, 0825, and 0829 in field location 
43. 
 
G1 - Most recent URR of less than 60% 
G2 - Most recent URR of 60% to 64.9% 
G3 - Most recent URR of 65% to 69.9% 
G4 - Most recent URR of 70% to 74.9% 
G5 - Most recent URR of 75% or greater 
 
For patients that have received dialysis 6 days or less in a month, facilities use the 
following modifier: 
 
G6 - ESRD patient for whom less than seven dialysis sessions have been provided in a 
month. 
 
For services beginning January 1, 2003, and after, if the modifier is not present, 
A/B/MACs (A) must return the claim to the provider for the appropriate modifier.  
Effective April, 2007 due to the requirement of line item billing, at least one revenue 
code line for hemodialysis on the claim must contain one of the URR modifiers shown 
above.  The URR modifier is not required on every hemodialysis line on the claim. 
 
The techniques to be used to draw the pre- and post-dialysis blood urea Nitrogen samples 
are listed in the National Kidney Foundation Dialysis Outcomes Quality Initiative 
Clinical Practice Guidelines for Hemodialysis Adequacy, Guideline 8, Acceptable 
Methods for BUN sampling, New York, National Kidney Foundation, 2000, pp.53-60. 
 
B.   Reporting the Vascular Access for End Stage Renal Disease (ESRD) 
Hemodialysis Claims 
 
ESRD claims for hemodialysis with dates of service on or after July 1, 2010 must 
indicate the type of vascular access used for the delivery of the hemodialysis at the last 
hemodialysis session of the month.  One of the following codes is required to be reported 
on the latest line item date of service billing for hemodialysis revenue code 0821.  It may 
be reported on all revenue code 0821 lines at the discretion of the provider. 
 
Note:  Modifier V5 must be entered if a vascular catheter is present even if it is not being 
used for the delivery of the hemodialysis.  In this instance 2 modifiers should be entered, 
V5 for the vascular catheter and either V6 or V7 for the access that is being used for the 
delivery of hemodialysis. 
 
Modifier V5 - Any Vascular Catheter (alone or with any other vascular access), 
  Modifier V6 - Arteriovenous Graft (or other Vascular Access not including a vascular 
catheter in use with two needles) 
 
Modifier V7 - Arteriovenous Fistula Only (in use with two needles) 
 
C.   Reporting the Kt/V for ALL End Stage Renal Disease (ESRD) Claims 
 
All End Stage Renal Disease (ESRD) claims with dates of service on or after July 1, 2010 
must indicate the applicable Kt/V reading for the dialysis patient.  The reading result and 
the date of the reading must be reported on the claim using the following claim codes: 
 
Value Code D5  Result of last Kt/V reading.  For in-center hemodialysis patients this is 
the last reading taken during the billing period.  For peritoneal dialysis patients and home 
hemodialysis this may be before the current billing period but should be within 4 months 
of the claim date of service. 
 
  Hemodialysis: For in-center and home-hemodialysis patients prescribed for three 
or fewer treatments per week, the last Kt/V obtained during the month must be 
reported.  Facilities must report single pool Kt/V using the preferred National 
Quality Forum (NQF) endorsed methods for deriving the single pool Kt/V value: 
Daugirdas II or Urea Kinetic Modeling (UKM). The reported Kt/V should not 
include residual renal function.  
 
A value of 8.88 shall be entered on the claim if the situation exists that a patient is 
prescribed and receiving greater than three hemodialysis treatments per week for a 
medically justified and documented clinical need.  The 8.88 value is not to be used for 
patients who are receiving extra treatments for a temporary clinical need (e.g. fluid 
overload).  A medical justification must be submitted for patients receiving greater than 
13 treatments per month.  
 
  Peritoneal Dialysis:  When measured the delivered weekly total Kt/V (dialytic 
and residual) should be reported. 
 
This code is effective and required on all ESRD claims with dates of service on or after 
July 1, 2010.  In the event that no Kt/V reading was performed providers must report the 
D5 with a value of 9.99. 
 
Occurrence Code 51  Date of last Kt/V reading.  For in-center hemodialysis patients, 
this is the date of the last reading taken during the billing period.  For peritoneal dialysis 
patients and home hemodialysis patients, this date may be before the current billing 
period but should be within 4 months of the claim date of service.  This code is effective 
for ESRD claims with dates of service on or after July 1, 2010.  This code not required 
when reporting value code D5 with a value of 9.99 indicating no Kt/V reading is 
available for reporting or value 8.88 to indicate the patient is prescribed and receiving 
greater than 3 hemodialysis treatments per week for a medically justified and documented 
clinical need.   
D.   Reporting of Infection for End Stage Renal Disease (ESRD) Claims 
Effective April 1, 2012, the infection modifiers V8 and V9 were terminated. All End Stage 
Renal Disease (ESRD) claims with dates of service on or after April 1, 2012, no longer 
require reporting of infection modifiers V8 and V9. 
 
60 - Separately Billable ESRD Items and Services 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
Payment for all items and services provided for the treatment of ESRD are included in 
the ESRD PPS.  ESRD facilities are required to itemize the ESRD related services 
provided including drugs, laboratory tests and supplies that are eligible for outlier 
consideration. 
 
60.1 - Lab Services 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
See the Medicare Benefit Policy Manual, Chapter 11, for a description of lab services 
included in the PPS rate. 
 
Renal dialysis facilities must bill all lab tests provided for the treatment of ESRD.  This is 
true whether the tests were provided directly or under arrangements with an independent 
lab.  When lab tests are billed by providers other than the ESRD facility and the lab test is 
provided for the treatment of ESRD, the claim will be rejected or denied.  In the event 
that a lab test usually provided for the treatment of ESRD was furnished to an ESRD 
beneficiary for reasons other than for the treatment of ESRD, the provider may submit a 
claim for separate payment using modifier AY. 
 
ESRD facilities should only bill for lab tests related to the treatment of ESRD or other lab 
tests performed by the dialysis facility (i.e. CLIA waived lab tests).  Lab tests that are not 
for the treatment of ESRD and are not performed by the ESRD facility are not to be 
reported on the ESRD facility claim. 
 
60.2 - Drugs Furnished in Dialysis Facilities 
(Rev. 10640, Issued:08-06-21, Effective:09-07-2021, Implementation:09-07-21) 
 
Effective January 1, 2011, section 153b of the MIPPA requires that all drugs and 
biologicals used in the treatment of ESRD are included in the ESRD PPS payment 
amount and must be billed by the ESRD facility. 
 
60.2.1 - Billing Procedures for Drugs for Facilities 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
The following billing procedures apply to independent and hospital based ESRD 
facilities. 
  Facilities identify and bill for drugs by HCPCS code, along with revenue code 0636, 
Drugs Requiring Specific Information.  Example below includes the HCPCS code and 
indicates the dosage amount specified in the descriptor of that code.  Facilities use the 
units field as a multiplier to arrive at the dosage amount. 
 
EXAMPLE: 
 
HCPCS  Drug  Dosage (lowest denominator)  Amount 
J3360  Valium  5 mg  $2.00 
 
Actual dosage, 10 mg 
 
On the bill, the facility shows J3360 and 2 in the units field (2 x 5 mg = 10 mg). For 
independent facilities, A/B MACs (A) compare the price of $4.00 (2 x $2.00) to the billed 
charge and pay the lower, subject to coinsurance and deductible.  Effective January 1, 
2006 payment is not subject to the lower of charges or fee.  All separately payable drugs 
for both hospital-based and independent facilities are paid at ASP+6% except vaccines.  
For information on billing and payment for vaccines see section 60.6 of this chapter. 
 
NOTE:  When the dosage amount is greater than the amount indicated for the HCPCS 
code, the facility rounds up to determine units.  When the dosage amount is less than the 
amount indicated for the HCPCS code, use one as the unit of measure.  In the example 
above, if the dosage were 7 mg, the facility would show 2 in the unit field, if the dosage 
were 3 mg, the facility would show 1 in the unit field. 
 
Facilities bill for supplies used to administer drugs with revenue code 0270, 
Medical/Surgical Supplies.  The number of administrations is shown in the units field. 
 
EXAMPLE: 
 
Revenue Code  Units 
0270  3 
 
The number of units for supply codes billed should match the number of injections billed 
on the claim form. 
 
Appropriate HCPCS codes for administration-supply of separately billable drugs would 
include: 
 
A4657: Injection Administration-supply Charge: include the cost of alcohol swab, 
syringe, and gloves.  Reimbursement for all ESRD facilities is based on a fee of 
$0.50 per unit billed for A4657. 
 
A4913: IV Administration-supply Charge: include the cost of IV solution 
administration set, alcohol swab, syringe, and gloves.  This code should only be  used when an IV solution set is required for a drug to be given.  This rate will not 
be paid for drugs that only require a syringe for administration.   
 
60.2.1.1  Separately Billable ESRD Drugs 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)  
 
Effective January 1, 2011, section 153b of the MIPPA requires that all drugs and 
biologicals that are used in the treatment of ESRD be provided and billed by the ESRD  
facility.  When a drug or biological is billed by providers other than the ESRD facility 
and the drug or biological furnished is designated as a drug or biological that is included 
in the ESRD PPS ( renal dialysis service), the claim will be rejected or denied.  In the 
event that a drug or biological generally used in the treatment of ESRD was furnished to 
an ESRD beneficiary for reasons other than for the treatment of ESRD, the provider may 
report the drug on the claim with modifier AY and receive separate payment.  For claims 
with dates of service on or after July 1, 2013, when these drugs are administered through 
the dialysate the provider must append the modifier JE (Administered via Dialysate). 
  
All drugs reported on the renal dialysis facility claim are considered included in the 
ESRD PPS, unless they are covered by an exception as discussed below. The list of drugs 
and biologicals for consolidated billing are designated as always ESRD-related and 
therefore no separate payment is made to ESRD facilities.  However, CMS has 
determined that some of these drugs warrant separate payment when they are used to treat 
conditions other than ESRD. 
  
  Exceptions to Always ESRD Related Drugs: 
The following drugs have been approved for separate payment consideration 
when billed with the AY modifier attesting to the drug not being used for the 
treatment of ESRD.  The ESRD facility is required to indicate (in accordance with 
ICD coding guidelines) the diagnosis code for which the drug is indicated. 
 
  Vancomycin, effective January 1, 2012 
  Daptomycin, effective January 1, 2013 
 
Items and services subject to the consolidated billing requirements for the ESRD 
PPS can be found on the CMS website at:  
http://www.cms.gov/ESRDPayment/50_Consolidated_Billing.asp#TopOfPage 
 
Other drugs and biologicals  are separately payable to the dialysis facility if the drug was 
not used  for the treatment of ESRD.  The facility must include the modifier AY to 
indicate it was not for the treatment of ESRD. 
 
Drugs are assigned HCPCS codes.  If no HCPCS code is listed for a drug (e.g., a new 
drug) the facility bills using HCPCS code J3490, Unclassified Drugs, and submits 
documentation identifying the drug. To establish a code for the drug, the A/B MAC (A) 
checks HCPCS to verify that there is no acceptable HCPCS code for billing and if a code 
is not found checks with the local A/B MAC (B), which may have a code and price that is  appropriate. If no code is found the drug is processed under HCPCS code J3490. See 
Chapter 17 for a complete description of drug pricing. 
 
60.2.1.2  Facilities Billing for ESRD Drugs and Biologicals Equivalent 
to Injectable Drugs 
(Rev. 10640, Issued:08-06-21, Effective:09-07-2021, Implementation:09-07-21) 
 
The ESRD PPS includes some injectable drugs and biologicals that have oral equivalent   
These drugs should be reported on the renal dialysis facility claim for consideration of 
outlier payments.  For the drugs and biologicals used in the treatment of ESRD that do 
not have an assigned HCPCS, effective for dates of services on or after January 1, 2011, 
ESRD facilities should bill using revenue code 0250 and report the national drug code 
(NDC).  The NDC is reported on the 837i claim transaction in loop 2410 line 03. 
 
CMS will price these oral drugs based on a plan comparison for consideration in the 
outlier payment.  CMS will maintain a list of these drug categories by NDC and will post 
the list on the CMS.gov website.  Payment includes a mean dispensing fee and this 
amount is updated via Recurring Update Notifications.  This amount is applied to each 
NDC included on the monthly claim.  CMS limits 1 dispensing fee per NDC per month.  
Providers should report the quantity in the smallest available unit.  This is necessary 
because Medicare is using the mean per unit cost in calculating the outlier.  For example, 
if the provider reports NDC 00054312041 Calcitriol 1 mcg/ml oral solution 
(15/ml/bottle) and uses the full 15 ml bottle, the quantity is reported as 15, not 1.  This 
allows for the most accurate calculation for the outlier policy. 
 
60.2.2 - Drug Payment Amounts for Facilities 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
Effective for claims with dates of service on or after January 1, 2011 all drugs and 
biologicals used in the treatment of ESRD are reimbursed under the ESRD PPS payment 
amount. For more information, please refer to Chapter 11 Benefit Policy Manual, section 
20.3 Drugs and Biologicals.  
 
60.2.3 - Facility Billing Requirements to the A/B MAC (A)                   
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
  
See Medicare Benefit Policy Manual, Chapter 11 for coverage and effective dates 
applicable to intravenous iron therapy services. 
 
For claims with dates of service on or after December 1, 2000, sodium ferric gluconate 
complex in sucrose injection is covered by Medicare for first line treatment of iron 
deficiency anemia in patients undergoing chronic hemodialysis who are receiving 
supplemental erythropoeitin therapy.  Payment is made on a reasonable cost basis for 
claims with dates of service on or after December 1, 2000 in renal dialysis centers  (freestanding facilities).  Payment is made pursuant to 42 CFR 405.517 for claims with 
dates of service on or after January 1, 2001. 
 
For claims with dates of service on or after October 1, 2001, Medicare also covers iron 
sucrose injection as a first line treatment of iron deficiency anemia when furnished 
intravenously to patients undergoing chronic hemodialysis who are receiving 
supplemental erythropoeitin therapy.  Payment is made under the outpatient prospective 
payment system for hospital outpatient departments.  Payment is made on a reasonable 
cost basis in CAHs and in renal dialysis centers (freestanding facilities). See Chapter 17. 
Deductible and coinsurance apply. 
 
Facilities bill the A/B MAC (A) using type of bill 72X and revenue code 0636. For 
claims with dates of service on or after December 1, 2000, report HCPCS code J3490 
(Unclassified drugs) for sodium ferric gluconate complex in sucrose injection.  For 
claims with dates of service on or after January 1, 2001, facilities report HCPCS code 
J2915 for sodium ferric gluconate complex in sucrose injection.  Until a specific code is 
developed for iron sucrose injection, report HCPCS code J3490 (Unclassified drugs). 
 
60.2.4 - Physician Billing Requirements to the A/B MAC (B)               
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
A.   Sodium Ferric Gluconate Complex in Sucrose Injection 
 
Sodium Ferric Gluconate Complex in sucrose injection may be payable for claims with 
dates of service on or after December 1, 2000 when furnished intravenously, for first line 
treatment of iron deficiency anemia in patients undergoing chronic hemodialysis who are 
receiving supplemental erythropoeitin therapy.  Physicians bill and A/B MACs (B) pay 
for HCPCS code J1756 when submitted with a primary diagnosis for chronic renal failure 
and a secondary diagnosis for iron deficiency anemia.  
 
These diagnoses are listed below.  Use ICD-9-CM or ICD-10-CM as applicable for the 
service date. 
 
Chronic Renal Failure (Primary Diagnosis) 
  ICD-9-CM  585 
  ICD-10-CM  N18.3, N18.4, N18.5, N18.6, 
 
Iron Deficiency Anemia (Secondary Diagnosis) 
  ICD-9-CM  280.0, 280.1, 280.8, or 280.9 
  ICD-10-CM  D50.0, D50.1, D50.8, D50.9, or D63.1 
 
This benefit is subject to the Part B deductible and coinsurance and should be paid per 
current Medicare drug payment reimbursement rules. 
 
B.   Iron Sucrose Injection   
Iron Sucrose injections are payable for claims with dates of service on or after October 1, 
2001, when furnished intravenously, for first line treatment of iron deficiency anemia in 
patients undergoing chronic hemodialysis who are receiving supplemental erythropoeitin 
therapy.  Until a specific code for iron sucrose injection is developed, providers must 
submit HCPCS code J1756, with the appropriate explanation of drug name and dosage 
entered on the claim.  The primary diagnosis code for chronic renal failure and one of the 
following secondary diagnosis codes for iron deficiency must be entered. 
 
These diagnoses are listed below.  Use ICD-9-CM or ICD-10-CM as applicable for the 
service date. 
 
Chronic Renal Failure (Primary Diagnosis) 
  ICD-9-CM - 585 
  ICD-10-CM - N18.3, N18.4, N18.5, N18.6, 
 
Iron Deficiency Anemia (Secondary Diagnosis) 
  ICD-9-CM  280.0, 280.1, 280.8, or 280.9 
  ICD-10-CM  D50.0, D50.1, D50.8, D50.9,D63.1 
 
Iron sucrose injection is subject to the Part B deductible and coinsurance and should be 
paid per current Medicare drug payment reimbursement rules. A/B MACs (B) may cover 
other uses of this drug at their discretion. 
 
C.   Messages for Use with Denials 
 
The contractor shall deny claims for sodium ferric gluconate complex in sucrose injection 
or iron sucrose injection due to a missing diagnosis code. 
 
The contractor shall use the following remittance advice messages and associated codes 
when rejecting/denying claims under this policy.  This CARC/RARC combination is 
compliant with CAQH CORE Business Scenario Two. 
 
Group Code: CO 
CARC: 16 
RARC: M76 
MSN: 9.2 
 
60.3 - Blood and Blood Products Furnished in Hospital Based and 
Independent Dialysis Facilities                                                                
(Rev. 10640, Issued:08-06-2021, Effective:09-07-2021, Implementation:09-07-2021) 
  Effective January 1, 2011,blood and blood products remain separately payable under the 
ESRD PPS. However, the staff time associated with administering blood and blood 
products is included in the ESRD PPS payment amount. 
 
60.4 - Erythropoietin Stimulating Agents (ESAs) 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
Coverage rules for ESAs are explained in the Medicare Benefit Policy Manual, 
Publication 100-02, Chapter 11. 
 
ESAs and their administration supplies and staff are included in the payment for the 
ESRD PPS effective January 1, 2011.  Providers must continue to report ESAs on the 
claim.  ESAs are eligible for outlier payment consideration.  The Medicare allowed 
payment (MAP) amounts for the outlier policy include the ESA rate provided on the 
Average Sale Price (ASP) list.  
 
60.4.1 - ESA Claims Monitoring Policy 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
Effective for services provided on or after April 1, 2006, Medicare has implemented a 
national claims monitoring policy for ESAs administered in Medicare renal dialysis 
facilities. This policy does not apply to claims for ESAs for patients who receive their 
dialysis at home and self-administer their ESA. 
 
While Medicare is not changing its coverage policy on erythropoietin use to maintain a 
target hematocrit level between 30% and 36%, we believe the variability in response to 
ESAs warrants postponing requiring monitoring until the hematocrit reaches higher 
levels.  For dates of services April 1, 2006, and later, the Centers for Medicare & 
Medicaid Services (CMS) claims monitoring policy applies when the hematocrit level 
exceeds 39.0% or the hemoglobin level exceeds 13.0g/dL.  This does not preclude the 
contractors from performing medical review at lower levels. 
 
Effective for services provided on or after April 1, 2006, for claims reporting hematocrit 
or hemoglobin levels exceeding the monitoring threshold, the dose shall be reduced by 
25% over the preceding month.  Providers may report that a dose reduction did occur in 
response to the reported elevated hematocrit or hemoglobin level by adding a GS 
modifier on the claim.  The definition of the GS modifier is defined as: Dosage of ESA 
has been reduced and maintained in response to hematocrit or hemoglobin level.  Thus, 
for claims reporting a hematocrit level or hemoglobin level exceeding the monitoring 
threshold without the GS modifier, CMS will reduce the covered dosage reported on the 
claim by 25%.  The excess dosage is considered to be not reasonable and necessary.  
Providers are reminded that the patients medical records should reflect 
hematocrit/hemoglobin levels and any dosage reduction reported on the claim during the 
same time period for which the claim is submitted. 
  Effective for dates of service provided on and after January 1, 2008, requests for 
payments or claims for ESAs for ESRD patients receiving dialysis in renal dialysis 
facilities reporting a hematocrit level exceeding 39.0% (or hemoglobin exceeding 
13.0g/dL) shall also include modifier ED or EE.  Claims reporting neither modifier or 
both modifiers will be returned to the provider for correction. 
 
The definition of modifier ED is The hematocrit level has exceeded 39.0% (or 
hemoglobin 1evel has exceeded 13.0g/dL) 3 or more consecutive billing cycles 
immediately prior to and including the current billing cycle.  The definition of modifier 
EE is The hematocrit level has exceeded 39.0% (or hemoglobin level has exceeded 
13.0g/dL) less than 3 consecutive billing cycles immediately prior to and including the 
current billing cycle.  The GS modifier continues to be defined as stated above. 
 
Providers may continue to report the GS modifier when the reported hematocrit or 
hemoglobin levels exceed the monitoring threshold for less than 3 months and a dose 
reduction has occurred.  When both modifiers GS and EE are included, no reduction in 
the covered dose will occur.  Claims reporting a hematocrit or hemoglobin level 
exceeding the monitoring threshold and the ED modifier shall have an automatic 50% 
reduction in the covered dose applied, even if the claim also reports the GS modifier. 
 
Below is a chart illustrating the resultant claim actions under all possible reporting 
scenarios: 
 
Hct Exceeds  ED  EE Modifier?  GS  Claim Action 
39.0% or  Modifier?  (Hct >39% or  Modifier? 
Hgb Exceeds  (Hct >39%  Hgb >13g/dL  (Dosage 
13.0g/dL  or Hgb  <3 cycles)  reduced and 
>13g/dL 3  maintained) 
cycles) 
Do not reduce 
No  N/A  N/A  N/A 
reported dose. 
Return to provider 
for correction. Claim 
Yes  No  No  No 
must report either 
modifier ED or EE. 
Return to provider 
for correction. Claim 
Yes  No  No  Yes 
must report either 
modifier ED or EE. 
Do not reduce 
Yes  No  Yes  Yes 
reported dose. 
Reduce reported 
Yes  No  Yes  No 
dose 25%. 
Reduce reported 
Yes  Yes  No  Yes 
dose 50%.  Hct Exceeds  ED  EE Modifier?  GS  Claim Action 
39.0% or  Modifier?  (Hct >39% or  Modifier? 
Hgb Exceeds  (Hct >39%  Hgb >13g/dL  (Dosage 
13.0g/dL  or Hgb  <3 cycles)  reduced and 
>13g/dL 3  maintained) 
cycles) 
Reduce reported 
Yes  Yes  No  No 
dose 50%. 
 
In some cases, physicians may believe there is medical justification to maintain a 
hematocrit above 39.0% or hemoglobin above 13.0g/dL.  Beneficiaries, physicians, 
and/or renal facilities may submit additional medical documentation to justify this belief 
under the routine appeal process.  You may reinstate any covered dosage reduction 
amounts under this first level appeal process when you believe the documentation 
supports a higher hematocrit/hemoglobin level. 
 
Providers are reminded that, in accordance with FDA labeling, CMS expects that as the 
hematocrit approaches 36.0% (hemoglobin 12.0g/dL), a dosage reduction occurs.  
Providers are expected to maintain hematocrit levels between 30.0 to 36.0% (hemoglobin 
10.0-12.0g/dL).  Hematocrit levels that remain below 30.0% (hemoglobin levels below 
10.0g/dL)) despite dosage increases, should have causative factors evaluated.  The 
patients medical record should reflect the clinical reason for dose changes and 
hematocrit levels outside the range of 30.0-36.0% (hemoglobin levels 10.0-12.0g/dL). 
Medicare contractors may review medical records to assure appropriate dose reductions 
are applied and maintained and hematological target ranges are maintained. 
 
These hematocrit requirements apply only to ESAs furnished as an ESRD benefit under 
1881(b) of the Social Security Act. 
 
Effective January 1, 2020, the EMP is discontinued under the ESRD PPS. Prescribing 
practitioners should continue to prescribe ESAs in accordance with ESA dosing 
guidelines and ESRD facilities should continue to report what they furnish.  
 
The type of bill 72X will no longer be subject to dose reductions or ESA dose limitations.  
ESRD facilities are not required to report the following modifiers:  
1. GS - Dosage of erythropoietin stimulating agent has been reduced and maintained in 
response to hematocrit or hemoglobin level  
2. ED - Hematocrit level has exceeded 39% (or hemoglobin level has exceeded 13.0 g/dl) 
for 3 or more consecutive billing cycles immediately prior to and including the current 
cycle  
3. EE - Hematocrit level has not exceeded 39% (or hemoglobin level has not exceeded 
13.0 g/dl) for 3 or more consecutive billing cycles immediately prior to and including the 
current cycle  
 
 
  Medically Unlikely Edits (MUE) 
 
For dates of service on and after January 1, 2008, the MUE for claims billing for 
Epogen is reduced to 400,000 units from 500,000. The MUE for claims for Aranesp 
is reduced to 1200 mcg from 1500 mcg. 
 
It is likely that claims reporting doses exceeding the threshold reflect typographical errors 
and will be returned to providers for correction. 
 
Effective January 1, 2020 the medically unlikely edits for ESAs exceeding the threshold 
limits above are discontinued under the ESRD PPS. 
 
60.4.2 - Facility Billing Requirements for ESAs 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
Hematocrit and Hemoglobin Levels 
Renal dialysis facilities are required to report hematocrit or hemoglobin levels for their 
Medicare patients receiving erythropoietin products.  Hematocrit levels are reported in 
value code 49 and reflect the most recent reading taken before the start of the billing 
period.  Hemoglobin readings before the start of the billing period are reported in value 
code 48. 
 
To report a hemoglobin or hematocrit reading for a new patient on or after January 1, 
2006, the provider should report the reading that prompted the treatment of epoetin alfa.  
The provider may use results documented on form CMS 2728 or the patient's medical 
records from a transferring facility. 
 
Effective January 1, 2012, ESRD facilities are required to report hematocrit or 
hemoglobin levels on all ESRD claims.  Reporting the value 99.99 is not permitted when 
billing for an ESA. 
 
The revenue codes for reporting Epoetin Alfa are 0634 and 0635.  All other ESAs are 
reported using revenue code 0636.  The HCPCS code for the ESA must be included: 
HCPCS  HCPCS Description  Dates of Service  
Q4055  Injection, Epoetin Alfa,  1/1/2004 through 12/31/2005 
1,000 units (for ESRD on 
Dialysis)  HCPCS  HCPCS Description  Dates of Service  
J0886  Injection, Epoetin Alfa,  1/1/2006 through 12/31/2006 
1,000 units (for ESRD on 
Dialysis) 
Q4081  Injection, Epoetin alfa, 100  1/1/2007 to present 
units (for ESRD on 
Dialysis) 
Q4054  Injection, Darbepoetin Alfa,  1/1/2004 through 12/31/2005 
1mcg (for ESRD on 
Dialysis) 
J0882  Injection, Darbepoetin Alfa,  1/1/2006 to present 
1mcg (for ESRD on 
Dialysis) 
J0890  Injection, Peginesatide,  0.1  1/1/2013 through 7/1/2015 
mg (for ESRD on Dialysis) 
Q5105  Injection, epoetin alfa,  7/1/2018  to present 
biosimilar, (Retacrit) (For 
ESRD on Dialysis), 100 
units 
 
Each administration of an ESA is reported on a separate line item with the units reported 
used as a multiplier by the dosage description in the HCPCS to arrive at the dosage per 
administration. 
Route of Administration Modifiers 
Patients with ESRD) receiving administrations of ESA for the treatment of anemia may 
receive intravenous administration or subcutaneous administrations of the ESA.  Effective for 
claims with dates of services on or after January 1, 2012, all facilities billing for injections of 
ESA for ESRD beneficiaries must include the modifier JA on the claim to indicate an 
intravenous administration or modifier JB to indicate a subcutaneous administration. ESRD 
claims containing ESA administrations that are submitted without the route of administration 
modifiers will be returned to the provider for correction. Renal dialysis facility claims 
including charges for administrations of the ESA by both methods must report separate lines 
to identify the number of administration provided using each method. 
  Effective July 1, 2013, providers must identify when a drug is administered via the dialysate 
by appending the modifier JE (administered via dialysate).   
Maximum Allowable Administrations 
The maximum number of administrations of EPO for a billing cycle is 13 times in 30 
days and 14 times in 31 days. 
The maximum number of administrations of Aranesp for a billing cycle is 5 times in 30/ 
31days. 
Number of Units Administered - Subsequent claims may be submitted electronically. 
 
Number of Units Administered - Subsequent claims may be submitted electronically. 
 
60.4.4 - Payment Amount for Epoetin Alfa (EPO) 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
Payment for ESRD-related EPO is included in the ESRD PPS for claims with dates of 
service on or after January 1, 2011. 
 
60.4.4.1 - Payment for Epoetin Alfa (EPO) in Other Settings 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
With the implementation of the ESRD PPS, ESRD-related EPO is included in ESRD PPS 
payment amount and is not separately payable on Part B claims with dates of service on 
or after January 1, 2011 for other providers with the exception of a hospital billing for an 
emergency or unscheduled dialysis session. 
In the hospital inpatient setting, payment under Part A is included in the DRG. 
 
In the hospital inpatient setting, payment under Part B is made on bill type 12x. Hospitals 
report the drug units based on the units defined in the HCPCS description.  Hospitals do 
not report value code 68 for units of EPO.  For dates of service prior to April 1, 2006, 
report EPO under revenue code 0636.  For dates of service from April 1, 2006 report 
EPO under the respective revenue code 0634 for EPO less than 10,000 units and revenue 
code 0635 for EPO over 10,000 units. Payment will be based on the ASP Pricing File.   
 
In a skilled nursing facility (SNF), payment for EPO covered under the Part B EPO 
benefit is not included in the prospective payment rate for the residents Medicare-
covered SNF stay. 
 
In a hospice, payment is included in the hospice per diem rate when treatment is related 
to the terminal illness. 
 
For a service furnished by a physician or incident to a physicians service, payment is 
made to the physician by the A/B MAC (B) in accordance with the rules for incident to 
services.  When EPO is administered in the renal facility, the service is not an incident 
to service and not under the incident to provision.   
60.4.4.2 - Epoetin Alfa (EPO) Provided in the Hospital Outpatient 
Departments 
(Rev. 2582, Issued: 11-02-12, Effective: 04-01-13, Implementation: 04-01-13) 
 
When ESRD patients come to the hospital for an unscheduled or emergency dialysis 
treatment they may also require the administration of EPO.  Effective January 1, 2005, 
EPO will be paid based on the ASP Pricing File. 
 
Hospitals use type of bill 13X (or 85X for Critical Access Hospitals) and report charges 
under the respective revenue code 0634 for EPO less than 10,000 units and revenue code 
0635 for EPO over 10,000 units.  Hospitals report the drug units based on the units 
defined in the HCPCS description.  Hospitals do not report value code 68 for units of 
EPO.  Value code 49 must be reported with the hematocrit value for the hospital 
outpatient visits prior to January 1, 2006, and for all claims with dates of service on or 
after January 1, 2008. 
 
60.4.5.1 - Self Administered ESA Supply 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
Initially, facilities may bill for up to a 2-month supply of an ESA for home dialysis 
beneficiaries who meet the criteria for selection for self-administration. After the initial 
two months supply, the facility will bill for one months supply at a time. Condition 
code 70 is used to indicate payment requested for a supply of an ESA furnished a 
beneficiary. Usually, revenue code 0635 would apply to EPO since the supply would be 
over 10,000 units. Facilities leave FL 46, Units of Service, blank since they are not 
administering the drug. 
For claims with dates of service on or after January 1, 2008, supplies of an ESA for self-
administration should be billed according to the pre-determined plan of care schedule 
provided to the beneficiary.  Submit a separate line item for each date an administration is 
expected to be performed with the expected dosage.  In the event that the schedule was 
changed, the provider should note the changes in the medical record and bill according to 
the revised schedule.  For patients beginning to self-administer an ESA at home receiving 
an extra month supply of the drug, bill the one month reserve supply on one claim line 
and include modifier EM defined as Emergency Reserve Supply (for ESRD benefit 
only). 
 
When billing for drug wastage in accordance with the policy in chapter 17 of this manual, 
section 40.1 the provider must show the wastage on a separate line item with the modifier 
JW.  The line item date of service should be the date of the last covered administration 
according to the plan of care or if the patient dies use the date of death. 
 
Condition code 70 should be reported on claims billing for home dialysis patients who   
self-administer anemia management drugs including ESAs. 
  60.4.6.1 - Reserved for Future Use                                                      
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
60.4.6.2 - Reserved for Future Use                                                        
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
60.4.6.3 - Payment Amount for Darbepoetin Alfa (Aranesp) 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
Payment for ESRD-related Aranesp is included in the ESRD PPS for claims with dates of 
service on or after January 1, 2011. 
 
60.4.6.4 - Payment for Darbepoetin Alfa (Aranesp) in Other Settings 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
In the hospital inpatient setting, payment under Part A for Aranesp is included in the 
DRG. 
 
In the hospital inpatient setting, payment under Part B is made on bill type 12x when 
billed with revenue code 0636.  The total number of units as a multiple of 1mcg is placed 
in the unit field.  Reimbursement is based on the payment allowance limit for Medicare 
Part B drugs as found in the ASP pricing file. 
 
In a skilled nursing facility (SNF), payment for Aranesp covered under the Part B EPO 
benefit is not included in the prospective payment rate for the residents Medicare-
covered SNF stay. 
 
In a hospice, payment is included in the hospice per diem rate when treatment is related 
to the terminal illness. 
 
For a service furnished by a physician or incident to a physicians service, payment is 
made to the physician by the A/B MAC (B) in accordance with the rules for incident to 
services. When Aranesp is administered in the renal facility, the service is not an 
incident to service and not under the incident to provision. 
 
With the implementation of the ESRD PPS, ESRD-related Aranesp is included in the 
ESRD PPS payment amount and is not separately payable on Part B claims with dates of 
service on or after January 1, 2011 for other providers, with the exception of a hospital 
billing for an emergency or unscheduled dialysis session. 
 
60.4.6.5 - Payment for Darbepoetin Alfa (Aranesp) in the Hospital 
Outpatient Department 
(Rev. 2582, Issued: 11-02-12, Effective: 04-01-13, Implementation: 04-01-13) 
  When ESRD patients come to the hospital for an unscheduled or emergency dialysis 
treatment they may also require the administration of Aranesp.  For patients with ESRD 
who are on a regular course of dialysis, Aranesp administered in a hospital outpatient 
department is paid the MMA Drug Pricing File rate.  Effective January 1, 2005, Aranesp 
will be paid based on the ASP Pricing File. 
 
Hospitals use bill type 13X (or 85X for Critical Access Hospitals) and report charges 
under revenue code 0636. The total number of units as a multiple of 1mcg is placed in the 
unit field.  Value code 49 must be reported with the hematocrit value for the hospital 
outpatient visits prior to January 1, 2006, and for all claims with dates of service on or 
after January 1, 2008. 
 
60.5 - Intradialytic Parenteral/Enteral Nutrition (IDPN) 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
A.  General 
 
Parenteral/enteral nutrition (PEN) administered during dialysis may be covered under 
Medicare, but it is not part of the Medicare ESRD benefit. Therefore, an ESRD facility or 
PEN supplier may bill Medicare separately for PEN solution if the patient meets all of the 
requirements for PEN coverage. (See Medicare Benefit Policy Manual for PEN coverage 
requirements.) If the ESRD facility bills, it does so as a PEN supplier and bills the 
appropriate DME MAC. 
 
B.  Staff Time 
 
The ESRD facility staff time used to administer PEN solution is not covered by 
Medicare, and, therefore, not included in the ESRD PPS. (PEN is considered a self-
administered therapy and generally administered in the patients home.) Since it is not 
covered under Medicare, it is not part of the ESRD PPS nor may a facility bill Medicare 
separately for it. 
 
60.6 - Vaccines Furnished to ESRD Patients 
(Rev. 10640, Issued:08-06-21, Effective:09-07-2021, Implementation:09-07-2021) 
 
The Medicare program covers hepatitis B, influenza virus and Pneumococcal pneumonia 
virus (PPV) vaccines and their administration when furnished to eligible beneficiaries in 
accordance with coverage rules.  Payment may be made for both the vaccine and the 
administration.  The costs associated with the syringe and supplies are included in the 
administration fee: HCPCS code A4657 should not be billed for these vaccines. 
 
Vaccines and their administration are reported using separate codes. See Chapter 18 of 
this manual for the payment and codes required for billing vaccines and the 
administration of the vaccine. 
 
Vaccines remain separately payable under the ESRD PPS.   
60.7  Reserved For Future Use                                                                 
(Rev. 10640, Issued:08-06-21, Effective:09-07-2021, Implementation:09-07-21) 
 
70 - Payment for Home Dialysis 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
Home dialysis is dialysis performed by an appropriately trained dialysis patient at home.  
Hemodialysis, CCPD, IPD and CAPD may be performed at home. For renal all dialysis 
services furnished by an ESRD facility, the facility must accept assignment, and only the 
facility may be paid by the Medicare program.  
 
For purposes of home dialysis, a skilled nursing facility (SNF) may qualify as a 
beneficiarys home.  The services are excluded from SNF consolidated billing for its 
inpatients. The home dialysis services are billed by the ESRD facility.  
 
With the implementation of the ESRD PPS on January 1, 2011, payment for all home 
dialysis services furnished to the ESRD beneficiary is made to an ESRD   dialysis facility 
whether services are  provided directly or under arrangements. 
 
70.1  Overpayments                                                                                  
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
Any overpayments that occur are subject to recovery following the usual Medicare 
program rules and procedures. 
 
80 - Home Dialysis Method I Billing to the A/B MAC (A) 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
If an ESRD patient chooses home dialysis, the ESRD dialysis facility with which the 
Medicare home patient is associated assumes responsibility for providing all home 
dialysis equipment and supplies, and home support services. For these services, the 
facility receives the same Medicare dialysis payment rate as it would receive for an in-
facility patient under the ESRD PPS. The beneficiary is responsible for paying any unmet 
Part B deductible and the 20-percent coinsurance.  
 
80.1 - Items and Services Included in the ESRD PPS payment for Home 
Dialysis 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
The following items are paid for and must be furnished under the PPS. The facility may 
furnish them directly under arrangements, to all of its home dialysis patients. If the 
facility fails to furnish (either directly or under arrangements) any part of the items and  services covered under the rate, then the facility cannot be paid any amount for the part of 
the items and services that the facility does furnish. 
 
  Medically necessary dialysis equipment and dialysis support equipment;  
 
  Home dialysis support services including the delivery, installation, maintenance, 
repair, and testing of home dialysis equipment, and home support equipment; 
 
  Purchase and delivery of all necessary dialysis supplies; 
 
  Routine ESRD related laboratory tests; and 
 
  All dialysis services furnished by the facilitys staff. 
 
The following items and services are included in the ESRD PPS and may not be billed 
separately when furnished by a dialysis facility: 
 
  Staff time used to administer blood; 
 
  Declotting of shunts and any supplies used to declot shunts by facility staff in the 
dialysis unit; 
 
  Oxygen and the administration of oxygen furnished in the dialysis unit;  
 
  Staff time used to administer separately billable parenteral items; 
 
  Bicarbonate dialysate; 
 
  Cardiac monitoring; 
 
  Catheter changes (Ideal Loop); 
 
  Suture removal; 
 
  Dressing changes; 
 
  Crash cart usage for cardiac arrest; or 
 
  Staff time used to collect specimens for all laboratory tests. 
 
Sometimes services that are not renal dialysis services  (e.g., declotting of shunts, suture 
removal, injecting separately billable ESRD related drugs) are furnished in a department 
of the hospital other than the dialysis unit (e.g., the emergency room). These services may 
be paid in addition to the ESRD PPS payment  only if the services could not be furnished 
in a dialysis facility or the dialysis unit of the hospital, due to the absence of specialized 
equipment or staff, which can be found only in the other department. In the case of  emergency services furnished in the hospital emergency room (ER), the services are paid 
separately subject to the additional requirement that there is a sudden onset of a medical 
condition manifesting itself by acute symptoms of sufficient severity (including severe 
pain) such that the absence of immediate medical attention in the ER could reasonably be 
expected to result in either: 
 
  Placing the patients health in serious jeopardy; 
 
  Causing serious impairment to bodily functions; or 
 
  Causing serious dysfunction of any bodily organ or part. 
 
These situations are rare and, in the absence of documentation to the contrary, these 
conditions are deemed to be not met. 
 
80.3 - Calculating Payment for Intermittent Peritoneal Dialysis (IPD)  
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
The value of a typical week of dialysis services generally serves as the maximum weekly 
payment;. 
 
While maintenance IPD is usually accomplished in sessions of 10-12 hours duration, 
three times per week, it is sometimes accomplished in fewer sessions of longer duration.  
Regardless of the particular regimen used, under the ESRD PPS IPD is paid based on a 
weekly equivalence of three ESRD PPS payments rates per week. 
  
IPD in the home is accomplished according to any one of several schedules. The total 
weekly dialysis time varies from 50 to 80 hours. For example, home IPD may be 
furnished every day for 10 hours per day, every other day for 15 hours per dialysis day, 
every night for 8 hours per night, etc. Regardless of the particular regimen used, under 
the ESRD PPS home IPD is paid based on a weekly equivalence of three ESRD PPS rates 
per week. 
 
Line item billing is required for all dialysis sessions.  For intermittent home dialysis the 
facility submits a separate line item for each dialysis session using the dates in the pre-
determined plan of care and the units reported on each line should be one.  In the event 
that the schedule was changed, the provider should note the changes in the medical 
record and bill according to the revised schedule. 
 
80.4 - Calculating Payment for Continuous Ambulatory Peritoneal 
Dialysis (CAPD) and Continuous Cycling Peritoneal Dialysis (CCPD) 
Under the ESRD PPS                                                                                              
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
  CAPD and CCPD are furnished on a continuous basis, not in discrete sessions and, 
therefore, are paid on a weekly or daily basis, not on a per treatment basis. Facilities are 
required to report the number of days in the units field. A facilitys daily payment rate is 
1/7 of three times the composite rate for a single hemodialysis treatment. 
 
The equivalent weekly or daily IPD or CAPD/CCPD payment does not depend upon the 
number of exchanges of dialysate fluid per day (typically 3-5) or the actual number of 
days per week that the patient undergoes dialysis. The weekly (or daily) rate is based on 
the equivalency of one week of IPD or CAPD/CCPD to one week of hemodialysis, 
regardless of the actual number of dialysis days or exchanges in that week. 
 
All home dialysis support services, equipment and supplies necessary for home IPD or 
CAPD/CCPD are included in the ESRD PPS payment. No support services, equipment or 
supplies may be paid in addition to the ESRD PPS. 
 
Line item billing is required for all dialysis sessions.  For claims billing for Continuous 
Ambulatory Peritoneal Dialysis (CAPD) and Continuous Cycling Peritoneal Dialysis 
(CCPD), the provider may submit a separate dialysis line for each day of the month.  If 
the provider is aware of an inpatient stay for the beneficiary within the month, the  ESRD 
facility may include the date of admission and date of discharge as a billable day for the 
dialysis but should omit the dates within the inpatient stay.  In the event that the  ESRD 
facility  is unaware of an inpatient stay during the month, the Medicare system shall 
detect the overlapping dates and reject only the line item dates within the inpatient stay 
but pay the remainder of the claim for any dates that are not within the inpatient stay. 
 
90  Reserved for Future Use                                                                    
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
100 - Dialysis Sessions Furnished to Patients Who are Traveling 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
A. Dialysis at Another Facility 
 
All in-facility dialysis treatments furnished by and in a facility are billed by and paid to 
that facility under the ESRD PPS. This is true even if the patient is only temporary at a 
particular facility while traveling. 
 
B. Temporary Home Dialysis 
 
Patients who normally dialyze in a facility may wish to dialyze temporarily as home 
dialysis patients while they travel or vacation.  
 
Training services furnished to temporary home dialysis patients are covered and paid at 
the training rate subject to the usual rules for reimbursement of training services.   100.1 - Physicians Services Furnished to a Dialysis Patient Away From 
Home or Usual Facility                                                                             
(Rev. 10640, Issued:08-06-21, Effective:09-07-2021, Implementation:09-07-21) 
 
When a dialysis patient whose attending physician receives a monthly payment receives 
maintenance dialysis services of any kind outside the usual setting from any physician 
who is neither the attending physician nor that physicians substitute, the following 
procedures apply: 
 
  The physician who furnished the service submits a claim to the local A/C MAC 
(B) of jurisdiction; 
 
  The A/B MAC (B) will process the claim and send an MSN to the patient; 
 
  The A/B MAC (B) that has jurisdiction over the usual dialysis setting adjusts the 
MCP to the usual attending physician to account for the time the patient was 
absent from the usual dialysis setting. 
 
  The A/B MAC (B) that has jurisdiction over the usual dialysis setting adjusts the 
MCP to the usual attending physician per 140.3.E below to account for the time 
the patient was absent from the usual dialysis setting. 
 
A/B MACs (B) must notify physicians that claims for services furnished to temporary 
patients must be identified as a claim for a temporary patient.  The physician must 
indicate temporary patient on the claim. 
 
110 - Reduction in Medicare Program Payment to Fund ESRD 
Networks 
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) 
 
A. General 
 
Section 9335(j) of OBRA 1986 requires the Secretary to reduce the amount of each 
payment for each treatment by 50 cents and to allocate these amounts to ESRD network 
activities. This applies to all dialysis treatments furnished on or after January 1, 1987 for 
all treatment modalities, including training treatments. All Medicare hospital-based and 
independent ESRD facilities paid under the  ESRD PPS are affected. 
 
The ESRD network reduction is $.50 per covered treatment when the full ESRD PPS rate 
is applicable. For ESRD claims billing for continuous modalities of dialysis performed in 
the beneficiarys home, the ESRD PPS rate is calculated at a daily per diem rate by 
taking the full ESRD PPS rate multiplied by 3 for the weekly allowable total and dividing 
by 7 to provide a daily treatment rate. The ESRD network reduction is also calculated at 
a daily rate by multiplying the $.50 by 3 for the weekly total network reduction and 
dividing by 7 for a daily network reduction of $.21.   
The reduction amount is reported in the Provider Statistics and Reimbursement Report 
(PS&R) and CWF using value code 71 to identify monies withheld to fund ESRD 
networks. 
 
The Medicare payment reduction allocated toward funding the ESRD networks for the 
individual claims will be indicated on the remittance record to the facility. 
 
Facilities may not claim the 50-cent reduction as an expense on their Medicare cost 
reports. 
 
C. Application of ESRD Network Funding to MSP Claims 
 
The ESRD offset for network funding on MSP claims will be applied as follows: 
 
  Where another payer, primary to Medicare, pays the claim in full, no ESRD offset 
is applicable; 
 
  Where another payer, primary to Medicare, makes a partial payment, the ESRD 
offset is deducted for each treatment as described in subsection C2 from the 
Medicare secondary payment; and  
 
  Where the ESRD offset amount is greater that the secondary payment amount, the 
entire Medicare secondary payment amount is applied towards the ESRD network 
funding. No Medicare secondary payment is made to the facility in this situation 
and no further ESRD offset is applicable. No additional ESRD offset for 
treatments on this claim will be made against other payments to the facility on the 
same remittance or on future payments for the same beneficiary. 
 
120 - Renal Transplantation and Related Services 
(Rev. 1341, Issued: 09-21-07, Effective: 06-28-07, Implementation: 10-22-07) 
 
Renal transplantation is a principal form of treatment available to patients with end-stage 
renal disease. See Medicare Provider Reimbursement Manual, Part I, 2771, for a 
description of related payment policies.  For a list of approved facilities, refer to the 
following Web site:   
 
http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/Transplant.html 
 
120.1 - Payment for Immunosuppressive Drugs Furnished to 
Transplant Patients 
(Rev. 1, 10-01-03) 
 
A. General 
  Effective January 1, 1987, Medicare pays for FDA approved self-administered 
immunosuppressive drugs. Generally, under this benefit, payment is made for self-
administered immunosuppressive drugs that are specifically labeled and approved for 
marketing as such by the FDA, as well as those prescription drugs, such as prednisone, 
that are used in conjunction with immunosuppressive drugs as part of a therapeutic 
regimen reflected in FDA approved labeling for immunosuppressive drugs. This benefit 
is subject to the Part B deductible and coinsurance provision. There is no time limitation 
on the coverage of these drugs; however, if a beneficiary loses Medicare coverage as a 
result of the transplant, the drugs are no longer covered. When the beneficiary reaches the 
age of 65 and becomes entitled, that person can have the drugs covered again. The 
hospital pharmacy must ask the physician to furnish the patient with a non-refillable 30-
day prescription for the immunosuppressive drugs. This is because the dosage of these 
drugs frequently diminishes over a period of time, and it is not uncommon for the 
physician to change the prescription from one drug to another because of the patients 
needs. Also, these drugs are expensive, and the coinsurance liability on unused drugs 
could be a financial burden to the beneficiary. Unless there are special circumstances, the 
A/B MAC (A) and A/B MAC (B) do not consider a supply of drugs in excess of 30 days 
to be reasonable and necessary and limits payment accordingly. 
 
B. Payment 
 
Payment is made on a reasonable cost basis if the beneficiary is the outpatient of a 
participating hospital. In all other cases, payment is made on an allowable charge basis. 
 
C. FDA Approved Drugs 
 
Some of the most commonly prescribed immunosuppressive drugs are: 
 
  Sandimmune (cyclosporine), Sandoz Pharmaceutical (oral or parenteral), 
  Imuran (azathioprine), Burroughs Wellcome Vial (oral), 
  Atgam (antithymocyte/globulin), Upjohn (parenteral); and  
  Orthoclone OKT3 (muromonab - CD3) Ortho Pharmaceutical (parenteral). 
 
Also covered are prescription drugs used in conjunction with immunosuppressive drugs 
as part of a therapeutic regimen reflected in FDA approved labeling for 
immunosuppressive drugs. 
 
The payment for the drug is limited to the cost of the most frequently administered 
dosage of the drug (adjusted for medical factors as determined by the physician). 
 
Consult such sources as the Drug Topics Red Book, American Druggists Blue Book, and 
Medispan, realizing that substantial discounts are available. 
 
 
  130 - Physicians and Supplier (Nonfacility) Billing for ESRD Services - 
General 
(Rev. 3053, Issued: 08-28-14, Effective: ICD-10: Upon Implementation of ICD-10; 
ASC X12: 01-01, 12, Implementation ICD-10: Upon Implementation of ICD-10; 
ASC X12: 09-30-14) 
 
Payment for renal-related physicians services to ESRD patients is made in either of the 
following ways: 
 
  Under the Monthly Capitation Payment (MCP) (see 140 below for an 
explanation of the MCP); or 
 
  Using the daily codes for ESRD services (CPT codes 90922-90925) with units 
that represent the number of days services were furnished. 
 
  Under the Initial method (IM)  
 
The A/B MAC (B) receives bills from physicians for services furnished ESRD 
beneficiaries.  
 
The A/B MAC (A) receives bills from ESRD facilities. 
 
Lab bills from CLIA certified independent dialysis facilities were billed to the A/B MAC 
(B) before September 1, 1997, and to the A/B MAC (A) beginning on that date. Other 
certified labs bill the A/C MAC (B). 
 
130.1 - Initial Method for Physicians Services to Maintenance Dialysis 
Patients 
(Rev. 1, 10-01-03) 
 
Under the Initial Method (IM), do not pay for physicians routine professional dialysis 
services. Instead, the dialysis facilitys A/B MAC (A) pays the dialysis facility for them 
as part of the facilitys composite rate. Physicians professional services that are not 
routine professional dialysis services are billed to the contractor and paid in the same way 
as any other Medicare covered physician professional service. 
 
1.   For the physician to be paid under the IM, the following requirements must be 
met: 
 
All physicians of the facility must choose the IM with respect to all of the patients treated 
at the facility and all of the facilitys Method I home dialysis patients. (See 70.1 for a 
description of Method I). All of the facilitys physicians must file a written statement 
with their A/B MAC (B) and the facilitys A/B MAC (A) to this effect. For example: 
 
The physicians practicing at ________________ dialysis facility are listed 
below. The signature of each physician indicates the physicians election  to be paid for their routine professional dialysis services under the Initial 
Method. This election is effective for services furnished beginning with 
the second month after the month in which this statement is filed with the 
A/B MAC (B) and the facilitys A/B MAC (A). 
 
This written statement must be signed and dated by each physician. 
 
2.   The physician may bill the A/B MAC (B) only those physicians professional 
services that are not routine professional dialysis services. (See paragraph 3 below). 
 
The election of the IM is effective for services furnished beginning with the second 
calendar month after the month in which all the physicians of a facility elect it. A 
physician may terminate the election by written notice to the A/B MAC (B) and to the 
facilitys A/B MAC (A) that the physician thereby terminates the IM. If the A/B MAC 
(B) and the A/B MAC (A) receive the termination notice on or before November 1, it is 
effective the following January 1. If the A/B MAC (B) or the A/B MAC (A) receives it 
after November 1, it is effective January 1 of the second year after the calendar year in 
which the notice of termination is received. Note that if the IM is terminated by one 
physician, it is thereby terminated for all physicians at the same facility with respect to 
the patients treated through that facility. 
 
3.   Definitions 
 
A.   Administrative Services 
 
Physician services that are differentiated from routine professional services and other 
physician services. They include supervision, as described in the definition of 
supervision of staff, are not related directly to the care of an individual patient and 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.   Dialysis Session 
 
The period of time that begins when the patient arrives at the facility and ends when the 
patient departs from the facility. In the case of home dialysis, the period begins when the 
patient prepares for dialysis and generally ends when the patient is disconnected from the 
machine. In this context, a dialysis facility includes only those parts of the building used 
as a facility. It does not include any areas used as a physicians private office. 
 
C.   Medical Direction 
 
Routine professional service that entails substantial direct involvement and the physical 
presence of the physician in the delivery of services directly to the patient. 
  D.   Routine Professional Services 
 
Physicians services furnished during a dialysis session and all services listed under 
Types of routine professional services that:  
 
  Are personally furnished by a physician to an individual patient. 
  Contribute directly to the diagnosis or treatment of an individual patient. 
  Ordinarily must be performed by a physician. 
 
E.   Supervision of Staff 
 
Administrative services that do not necessarily require the physician to be present at the 
dialysis session. It is a general activity primarily concerned with monitoring performance 
of and giving guidance to other health care personnel (such as nurses and dialysis 
technicians) who deliver services to patients. 
 
F.   Types of Routine Professional Services 
 
Routine professional services include at least the following services when medically 
appropriate: 
 
  Visits to the patient during dialysis, and in conjunction with review of 
laboratory test results, 
 
  Nurses notes and any other medical documentation, as a basis for: 
 
  Adjustment of the patients medication, diet or the dialysis 
o
procedure; 
 
  Prescription of medical supplies; and 
o
 
  Evaluation of the patients psychosocial status and the 
o
appropriateness of the modality, 
 
  Medical direction of staff in delivering services to a patient during 
o
a dialysis session, and 
 
  Pre-dialysis and post-dialysis examinations or examinations that 
o
could have been furnished on a pre-dialysis or post-dialysis basis. 
 
140 - Monthly Capitation Payment Method for Physicians Services 
Furnished to Patients on Maintenance Dialysis 
(Rev. 1456, Issued: 02-22-08, Effective: 03-24-08, Implementation: 03-24-08) 
 
Physicians and practitioners managing patients on dialysis (center based) are paid a 
monthly capitation payment (MCP) for most outpatient dialysis-related physician  services furnished to a Medicare end stage renal disease (ESRD) beneficiary.  The 
payment amount varies based on the number of visits provided within each month and the 
age of the ESRD beneficiary.  Physicians and practitioners managing ESRD patients who 
dialyze at home are paid a single monthly rate based on the age of the ESRD beneficiary, 
regardless of the number of face-to-face physician or practitioner visits.  The MCP is 
reported once per month for services performed in an outpatient setting that are related to 
the patients ESRD. 
 
Physicians and practitioners may receive payment for managing patients on dialysis for 
less than a full month of care in specific circumstances as discussed in section 140.2.  
Payment for ESRD related services, less than a full month, is made on a per diem bases. 
 
Payment for ESRD-related services is made at 80 percent of the Medicare approved 
amount (lesser of the actual charge or applicable Medicare fee schedule amount) after the 
beneficiarys Part B deductible is met. The beneficiary is responsible for the Part B 
deductible and the 20 percent coinsurance for physician and practitioner ESRD-related 
services. 
 
A.  Services Included in Monthly Capitation Payment 
 
The following physician services are included in the MCP: 
 
  Assessment of the need for a specified diet and the need for nutritional 
supplementation for the control of chronic renal failure. Specification of the 
quantity of total protein, high biologic protein, sodium, potassium, and amount of 
fluids to be allowed during a given time period. For diabetic patients with chronic 
renal failure, the prescription usually specifies the number of calories in the diet. 
 
  Assessment of which mode(s) of chronic dialysis (types of hemodialysis or 
peritoneal dialysis) are suitable for a given patient and recommendation of the 
type(s) of therapy for a given patient. 
 
  Assessment and determination of which type of dialysis access is best suited for a 
given patient and arrangement for creation of dialysis access. 
 
  Assessment of whether the patient meets preliminary criteria as a renal transplant 
candidate and presentation of this assessment to the patient and family. 
 
  Prescription of the parameters of intradialytic management. For chronic 
hemodialysis therapies, this includes the type of dialysis access, the type and 
amount of anticoagulant to be employed, blood flow rates, dialysate flow rate, 
ultrafiltration rate, dialysate temperature, type of dialysate (acetate versus 
bicarbonate) and composition of the electrolytes in the dialysate, size of 
hemodialyzer (surface area) and composition of the dialyzer membrane 
(conventional versus high flux), duration and frequency of treatments, the type 
and frequency of measuring indices of clearance, and intradialytic medications to  be administered. For chronic peritoneal dialysis therapies, this includes the type of 
peritoneal dialysis, the volume of dialysate, concentration of dextrose in the 
dialysate, electrolyte composition of the dialysate, duration of each exchange, and 
addition of medication to the dialysate, such as heparin, and the type and 
frequency of measuring indices of clearance. For diabetics, the quantity of insulin 
to be added to each exchange is prescribed. 
 
  Assessment of whether the patient has significant renal failure-related anemia, 
determination of the etiology(ies) for the anemia based on diagnostic tests, and 
prescription of therapy for correction of the anemia, such as vitamins, oral or 
parenteral iron, and hormonal therapy such as erythropoietin. 
 
  Assessment of whether the patient has hyperparathyroidism and/or renal 
osteodystrophy secondary to chronic renal failure and prescription of appropriate 
therapy, such as calcium and phosphate binders for control of hyperphosphatemia. 
Based upon assessment of parahormone levels, serum calcium levels, and 
evaluation for the presence of metabolic bone disease, the physician determines 
whether oral or parenteral therapy with vitamin D or its analogs is indicated and 
prescribes the appropriate therapy. Based upon assessment and diagnosis of bone 
disease, the physician may prescribe specific chelation therapy with deferoxamine 
and the use of hemoperfusion for removal of aluminum and the chelation. 
 
  Assessment of whether the patient has dialysis-related arthropathy or neuropathy 
and adjustment of the patients prescription accordingly. Referral of the patient 
for any additional needed specialist evaluation and management of these end-
organ problems. 
 
  Assessment of whether the patient has fluid overload resulting from renal failure 
and establishment of an estimated ideal (dry) weight. The physician determines 
the need for fluid removal independent of the dialysis prescription and 
implements these measures when indicated. 
 
  Determination of the need for and prescription of antihypertensive medications 
and their timing relative to dialysis when the patient is hypertensive in spite of 
correction of fluid overload. 
 
  Periodic review of the dialysis records to ascertain whether the patient is receiving 
the prescribed amount of dialysis and ordering of indices of clearance, such as 
urea kinetics, in order to ascertain whether the dialysis prescription is producing 
adequate dialysis. If the indices of clearance suggest that the prescription requires 
alteration, the physician orders changes in the hemodialysis prescription, such as 
blood flow rate, dialyzer surface area, dialysis frequency, and/or dialysis duration 
(length of treatment). For peritoneal dialysis patients, the physician may order 
changes in the volume of dialysate, dextrose concentration of the dialysate, and 
duration of the exchanges. 
    Periodic visits (at least one per month) to the patient during dialysis to ascertain 
whether the dialysis is working well and whether the patient is tolerating the 
procedure well (physiologically and psychologically). During these visits, the 
physician determines whether alteration in any aspect of a given patients 
prescription is indicated, such as changes in the estimate of the patients dry 
weight. Review of the treatment with the nurse or technician performing the 
therapy is also included. The frequency of these visits will vary depending upon 
the patients medical status, complicating conditions, and other determinants. 
 
  Performance of periodic physical assessments, based upon the patients clinical 
stability, in order to determine the necessity for alterations in various aspects of 
the patients prescription. Similarly, the physician reviews the results of periodic 
laboratory testing in order to determine the need for alterations in the patients 
prescription, such as changes in the amount and timing of phosphate binders or 
dose of erythropoietin. 
 
  Periodic assessment of the adequacy and function of the patients dialysis access 
appropriate tests and antibiotic therapy. 
 
  Interpretations of the following tests: 
 
o  Bone mineral density studies (CPT codes 76070, 76075, 78350, and 
78351); 
 
o  Noninvasive vascular diagnostic studies of hemodialysis access (CPT 
codes 93925, 93926, 93930, 93931, and 93990); 
 
o  Nerve conduction studies (CPT codes 95900, 95903, 95904, 95925, 
95926, 95927, 95934, 95935, and 95936); 
 
o  Electromyography studies (CPT codes 95860, 95861, 95863, 95864, 
95867, 95867, 95869, and 95872). 
 
  Periodic review and update of the patients short-term and long-term care plans 
with staff. 
 
  Coordination and direction of the care of patients by other professional staff, such 
as dieticians and social workers. 
 
  Certification of the need for items and services such as durable medical 
equipment and home health care services. Care plan oversight services described 
by CPT code 99375 are included in the MCP and may not be separately reported. 
 
B.  Services Excluded from Monthly Capitation Payment 
  The following physician services furnished to the physicians ESRD patients are 
excluded from the MCP and should be paid in accordance with the physician fee 
schedule: 
 
1.  Administration of hepatitis B vaccine. 
 
2.  Surgical services such as: 
 
  Temporary or permanent hemodialysis catheter placement; 
  Temporary or permanent peritoneal dialysis catheter placement; 
  Repair of existing dialysis accesses; 
  Placement of catheter(s) for thrombolytic therapy; 
  Thrombolytic therapy (systemic, regional, or access catheter only; 
hemodialysis or peritoneal dialysis); 
  Thrombectomy of clotted cannula; 
  Arthrocentesis; 
  Bone marrow aspiration; and 
  Bone marrow biopsy. 
 
3.  Interpretation of tests that have a professional component such as: 
 
  Electrocardiograms (12 lead, Holter monitor, stress tests, etc.); 
  Echocardiograms; 
  24-hour blood pressure monitor; 
  Biopsies; and 
  Spirometry and complete pulmonary function tests. 
 
4.  Complete evaluation for renal transplantation. While the physician assessment of 
whether the patient meets preliminary criteria as a renal transplant candidate is included 
under the MCP, the complete evaluation for renal transplantation is excluded from the 
MCP 
 
5.  Evaluation of potential living transplant donors. 
 
6.  The training of patients to perform home hemodialysis, self hemodialysis, and the 
various forms of self peritoneal dialysis. 
 
7.  Non-renal related physicians services. These services may be furnished by the 
physician providing renal care or by another physician. They may not be incidental to 
services furnished during a dialysis session or office visit necessitated by the renal 
condition. The physician must provide documentation that the illness is not related to the 
renal condition and that the added visits are required.  The contractors medical staff 
determines whether additional reimbursement is warranted for treatment of the unrelated 
illness. For example, the medical management of diabetes mellitus that is not related to 
the dialysis or furnished during a dialysis session is excluded. 
  8.  Covered physician services furnished to hospital inpatients. 
 
9.  All physician services that antedate the initiation of outpatient dialysis. 
 
10.  Covered physician services furnished by another physician when the patient is not 
available to receive the outpatient services as usual; for example, when the patient is 
traveling out of town. 
 
140.1 - Payment for ESRD-Related Services Under the Monthly 
Capitation Payment (Center Based Patients) 
(Rev. 2269, Issued: 08-05-11, Effective: 01-01-11, Implementation: 11-07-11) 
 
Physicians and practitioners managing center based patients on dialysis are paid a 
monthly rate for most outpatient dialysis-related physician services furnished to a 
Medicare ESRD beneficiary.  The payment amount varies based on the number of visits 
provided within each month and the age of the ESRD beneficiary.  Under this 
methodology, separate codes are billed for providing one visit per month, two to three 
visits per month and four or more visits per month.  The lowest payment amount applies 
when a physician provides one visit per month; a higher payment is provided for two to 
three visits per month.  To receive the highest payment amount, a physician or 
practitioner would have to provide at least four ESRD-related visits per month.  The 
MCP is reported once per month for services performed in an outpatient setting that are 
related to the patients ESRD. 
 
The physician or practitioner who provides the complete assessment, establishes the 
patients plan of care, and provides the ongoing management is the physician or 
practitioner who submits the bill for the monthly service. 
 
a.  Month defined. 
 
For purposes of billing for physician and practitioner ESRD related services, the term 
month means a calendar month.  The first month the beneficiary begins dialysis 
treatments is the date the dialysis treatments begin through the end of the calendar month.  
Thereafter, the term month refers to a calendar month. 
 
b.  Determination of the age of beneficiary. 
 
The beneficiarys age at the end of the month is the age of the patient for determining the 
appropriate age related ESRD-related services code. 
 
c.  Qualifying Visits Under the MCP 
 
  General policy. 
 
Visits must be furnished face-to-face by a physician, clinical nurse specialist, nurse 
practitioner, or physicians assistant.   
  Visits furnished by another physician or practitioner (who is not the MCP 
physician or practitioner). 
 
The MCP physician or practitioner may use other physicians or qualified nonphysician 
practitioners to provide some of the visits during the month.  The MCP physician or 
practitioner does not have to be present when these other physicians or practitioners 
provide visits.  In this instance, the rules are consistent with the requirements for hospital 
split/shared evaluation and management visits.  The non-MCP physician or practitioner 
must be a partner, an employee of the same group practice, or an employee of the MCP 
physician or practitioner.  For example, the physician or practitioner furnishing visits 
under the MCP may be either a W-2 employee or 1099 independent contractor. 
 
When another physician is used to furnish some of the visits during the month, the 
physician who provides the complete assessment, establishes the patients plan of care, 
and provides the ongoing management should bill for the MCP service. 
 
If the nonphysician practitioner is the practitioner who performs the complete assessment 
and establishes the plan of care, then the MCP service should be billed under the PIN of 
the clinical nurse specialist, nurse practitioner, or physician assistant. 
 
  Residents, interns and fellows. 
 
Patient visits by residents, interns and fellows enrolled in an approved Medicare graduate 
medical education (GME) program may be counted towards the MCP visits if the 
teaching MCP physician is present during the visit. 
 
  Patients designated/admitted as hospital observation status. 
 
ESRD-related visits furnished to patients in hospital observation status that occur on or 
after January 1, 2005, should be counted for purposes of billing the MCP codes.   Visits 
furnished to patients in hospital observation status are included when submitting MCP 
claims for ESRD-related services. 
 
  ESRD-related visits furnished to beneficiaries residing in a SNF. 
 
ESRD-related visits furnished to beneficiaries residing in a SNF should be counted for 
purposes of billing the MCP codes.  
 
  SNF residents admitted as an inpatient. 
 
Inpatient visits are not counted for purposes of the MCP service.  If the beneficiary 
residing in a SNF is admitted to the hospital as an inpatient, the appropriate inpatient visit 
code should be billed. 
 
140.1.1 - Payment for Managing Patients on Home Dialysis  (Rev. 2269, Issued: 08-05-11, Effective: 01-01-11, Implementation: 11-07-11) 
 
Physicians and practitioners managing ESRD patients who dialyze at home are paid a 
single monthly rate based on the age of the beneficiary.  The MCP physician (or 
practitioner) must furnish at least one face-to-face patient visit per month for the home 
dialysis MCP service.  Documentation by the MCP physician (or practitioner) should 
support at least one face-to-face encounter per month with the home dialysis patient. 
Medicare contractors may waive the requirement for a monthly face-to-face visit for the 
home dialysis MCP service on a case by case basis, for example, when the nephrologists 
notes indicate that the physician actively and adequately managed the care of the home 
dialysis patient throughout the month.  The management of home dialysis patients who 
remain a home dialysis patient the entire month should be coded using the ESRD-related 
services for home dialysis patients HCPCS codes. 
 
a.  Month defined. 
 
For purposes of billing for physician and practitioner ESRD related services, the term 
month means a calendar month.  The first month the beneficiary begins dialysis 
treatments is the date the dialysis treatments begin through the end of the calendar month.  
Thereafter, the term month refers to a calendar month. 
 
b.  Qualifying Visits under the MCP 
 
  General policy. 
 
Visits must be furnished face-to-face by a physician, clinical nurse specialist, nurse 
practitioner, or physicians assistant. 
 
  Visits furnished by another physician or practitioner (who is not the MCP 
physician or practitioner). 
 
The MCP physician or practitioner may use other physicians or qualified nonphysician 
practitioners to provide the visit(s) during the month.  The MCP physician or practitioner 
does not have to be present when these other physicians or practitioners provide visit(s).  
The non-MCP physician or practitioner must be a partner, an employee of the same group 
practice, or an employee of the MCP physician or practitioner.  For example, the 
physician or practitioner furnishing visits under the MCP may be either a W-2 employee 
or 1099 independent contractor. 
 
When another physician is used to furnish some of the visits during the month, the 
physician who provides the complete assessment, establishes the patients plan of care, 
and provides the ongoing management should bill for the MCP service. 
 
If the nonphysician practitioner is the practitioner who performs the complete assessment 
and establishes the plan of care, then the MCP service should be billed under the PIN of 
the clinical nurse specialist, nurse practitioner, or physician assistant.   
  Residents, interns and fellows. 
Patient visits by residents, interns and fellows enrolled in an approved Medicare graduate 
medical education (GME) program may be counted towards the MCP visits if the 
teaching MCP physician is present during the visit. 
 
140.1.2 - Patients Who Switch Modalities (Center to Home and Vice 
Versa) 
(Rev. 1999, Issued: 07-09-10, Effective: 01-01-11, Implementation: 01-03-11) 
 
If a home dialysis patient receives dialysis in a dialysis center or other outpatient facility 
during the month, the MCP physician or practitioner is paid the management fee for the 
home dialysis patient and cannot bill the ESRD-related services codes for managing 
center based patients. 
 
This situation should be coded using the ESRDrelated services codes for a home 
dialysis patient per full month. Physicians and practitioners should use the ESRDrelated 
services codes for a home dialysis patient per full month when billing for outpatient 
ESRD-related services when a home dialysis patient receives dialysis in a dialysis center 
or other outpatient facility during the month. 
 
Physicians and practitioners should use the ESRDrelated services codes for a home 
dialysis patient per full month for patients that switch modalities regardless of whether 
the ESRD beneficiary went from home dialysis to center-based dialysis, or vice versa, 
and regardless of the proportion of the month that the beneficiary was receiving each 
modality. 
 
140.2 - Payment for ESRD-related services (Per Diem) 
(Rev. 1456, Issued: 02-22-08, Effective: 03-24-08, Implementation: 03-24-08) 
 
Physicians and practitioners may receive payment for managing patients on dialysis for 
less than a full month of care in specific circumstances as discussed in this section.  
Payment for ESRD related services, less than a full month, is paid on a per diem basis. 
 
Per diem ESRD-related services should be coded using the ESRD related services (less 
than full month), per day HCPCS codes for ESRD-related services furnished in the 
situations described below. 
 
  Home dialysis patients (less than full month); 
 
  Transient patients  Patients traveling away from home (less than full month); 
 
  Partial month where there was one or more face-to-face visits without a complete 
assessment of the patient and the patient was either hospitalized before a complete 
assessment was furnished, dialysis stopped due to death, or the patient had a 
transplant.   
  Patients who have a permanent change in their MCP physician during the month. 
 
The ESRD-related services (less than full month), per day HCPCS codes should only be 
used for the circumstances described above.  The per diem codes may not be used for a 
full month when a complete monthly assessment is not furnished. 
 
140.2.1 - Guidelines for Physician or Practitioner Billing -- (Per Diem) 
(Rev. 3311, Issued: 08-06-15, Effective: 01-01-15, Implementation: 09-08-15) 
 
A.  Home dialysis, transient patient and partial month 
 
When submitting claims for ESRD-related services (less than full month) per day, the 
physician or practitioner should specify the number of days he or she was responsible for 
the beneficiarys outpatient ESRD-related services during the month. 
 
Only one code should be used to report the daily management of home dialysis patients, 
transient patients, and for partial month scenarios.  For example, if a home dialysis 
patient receives dialysis at home for two weeks and is hospitalized for the remainder of 
the month, then 14 units of the age appropriate ESRD-related per day code is billed.  The 
MCP service is not billed. 
 
For transient patients, the physician or practitioner responsible for the transient patients 
ESRD-related care should bill the appropriate ESRD-related services, per day code.  Only 
the physician or practitioner responsible for the traveling ESRD patients care is 
permitted to bill for ESRD-related services using the per diem ESRD-related services 
HCPCS codes. 
 
For home dialysis patients (less than full month) if the MCP physician or practitioner 
furnishes a complete monthly assessment of the ESRD beneficiary and at least one face-
to-face patient visit during the month, he or she should bill for the age appropriate home 
dialysis MCP service.  For example, if a home dialysis patient was hospitalized during 
the month and at least one face-to-face outpatient visit and complete monthly assessment 
was furnished, the MCP physician or practitioner should bill for the full home dialysis 
MCP service. 
 
For partial month scenarios resulting from hospitalization, kidney transplant, or the 
patient expired, if the MCP physician or practitioner furnished a complete monthly 
assessment of the patient, he or she should bill using the age appropriate MCP service 
that reflects the number of visits furnished during the month. 
 
Example #1: An ESRD beneficiary was hospitalized on the tenth through the twentieth 
day of the month.  On the third day of the month, the MCP physician or practitioner 
furnished a face-to-face visit including a complete assessment and a subsequent 
outpatient visit on the twenty-fifth day of the month.  While the patient was hospitalized, 
an inpatient ESRD-related visit was furnished.   
In this scenario, the MCP physician or practitioner may bill for the appropriate outpatient 
MCP service based on the age of the beneficiary and number of visits furnished during 
the month.  The physician or practitioner who furnished the inpatient visit may bill for the 
appropriate inpatient ESRD-related service code. 
 
Example #2: An ESRD beneficiary vacationing in Florida is away from his or her home 
dialysis site from August fifteenth through September seventh.  On August tenth, the 
MCP physician furnishes a face-to-face visit.  For the month of September, the MCP 
physician furnishes a visit on the ninth and a subsequent visit on the twenty-fifth of the 
month.  A physician in Florida is responsible for the beneficiarys ESRD-related care 
from August fifteenth through September seventh. 
 
In this scenario, the physician or practitioner responsible for the transient patients 
ESRD-related care bills sixteen units of the age appropriate ESRD-related services for 
dialysis less than full month, per day code for the month of August and seven units of the 
per day code for the month of September.  The MCP physician bills the MCP service 
with one visit for the month of August and the MCP service with two to three visits for 
the month of September. 
 
If the transient beneficiary is under the care of a physician or practitioner other than his or 
her regular MCP physician for an entire calendar month, the physician or practitioner 
responsible for the transient patients ESRD-related care must furnish a complete 
assessment and bill for ESRD-related services under the MCP. 
 
B.  Patient has a permanent change in their MCP physician during the month 
 
ESRD-related services (less than full month) per day HCPCS codes should be billed in 
situations where an ESRD beneficiary permanently changes their MCP physician during 
the month.  For example, the new MCP physician has the ongoing responsibility for the 
evaluation and management of the patients ESRD-related care and is not part of the 
same group practice or an employee of the first MCP physician.  The new MCP physician 
should use the appropriate per diem HCPCS code when submitting claims for ESRD-
related services for the remainder of the month, when the first MCP physician furnishes a 
complete assessment of the beneficiary during the month. 
 
If the first MCP physician does not furnish a complete assessment of the patient during 
the month the patient permanently changes their MCP physician, the new MCP physician 
may bill for the appropriate MCP service based on the age of the patient and number of 
visits furnished and the first MCP physician may bill the appropriate per day HCPCS 
code as discussed above. 
 
Example: An ESRD patient residing in Virginia Beach, Virginia for the first 20 days of 
the month, moves to Atlanta, Georgia.  As a result, a different physician or practitioner is 
now responsible for the ongoing management of the beneficiarys ESRD-related care.  
Both the first and second MCP physician furnishes a visit with a complete assessment of  the patient and establishes a monthly plan of care.  In this situation, the first MCP 
physician should bill the MCP service that reflects the number of visits he or she 
furnished during the month and the second MCP physician should bill the age appropriate 
per day ESRD-related services code.  Thereafter, the new MCP physician would bill for 
the MCP service. 
 
In this example, if the first MCP physician does not provide a complete assessment of the 
patient, he or she should bill 20 units of the per day ESRD-related services code, but may 
not bill for the MCP during the month the beneficiary permanently changes his or her 
MCP physician.  The second MCP physician may bill for the MCP service after 
furnishing a complete monthly assessment of the ESRD beneficiary that includes 
establishing the patients plan of care and at least one face-to-face visit. 
 
140.3 - Data Elements Required on Claim for Monthly Capitation 
Payment 
(Rev. 10236, Issued: 07-31-2020, Effective: 08-31-2020, Implementation: 08-31-2020) 
 
 
On Form CMS-1500 
 
A. Elements 1 through 13 of the Form CMS-1500 are completed in accordance with the 
regular instructions 
 
B. Elements 14 through 20 of the Form CMS-1500 are omitted. 
 
C. Element 32 must contain the name and address of the facility involved with the 
patients maintenance care or training, and 32a must contain the facility NPI. 
 
D. Element 21 must show the diagnosis.  Indicate in Element 19 whether the patient is in 
training for self-dialysis.  
 
E. Element 24A must show the dates of service during the month that are included in the 
MCP.  The period includes the full calendar month the MCP physician or practitioner 
was responsible for the beneficiary's ESRD related care. 
 
For the first month the beneficiary begins dialysis treatments, the first date the dialysis 
treatments begin through the end of the calendar month should be used as the dates of 
service. 
 
For outpatient ESRD-related services furnished for less than a full month, per day as 
discussed in 140.2 (e.g. transient patients, partial month due to hospitalization, transplant, 
or death), the first and last date the physician or practitioner was responsible for the 
beneficiarys ESRD-related care during the month should be used as the dates of service.  
Non-continuous dates should be billed on separate claim lines, (e.g. 1/1/08  1/7/08 and 
1/20/08  1/31/08).  A separate monthly claim should be submitted when the duration of  ESRD-related services, per day, overlaps two different months as discussed in 140.21 
(e.g. August 15 -  September 7). 
 
F. The remainder of the Form CMS-1500 is completed in accordance with the general 
instructions. 
 
On ASC X12 Professional Format 
 
Instructions for completing the ASC X12 837 professional claim format are in the related 
implementation guide, available on the official Washington Publishing Company 
website. 
 
140.4 - Controlling Claims Paid Under the Monthly Capitation Payment 
Method 
(Rev. 1456, Issued: 02-22-08, Effective: 03-24-08, Implementation: 03-24-08) 
 
Contractors must be able to identify dialysis patient history records and physicians who 
furnish services related to dialysis. 
 
In processing claims reimbursed under this method, contractors must assure that: 
 
  Only one monthly payment is made for any renal disease patient per month; 
 
  The MCP payment is made after the month has passed; i.e., do not pay the MCP 
in advance of the services actually furnished; 
 
  The payment amount is based on the age of the beneficiary and the number of 
visits furnished during a calendar month (center based patients); 
 
  Duplicate charges billed as a duplicate MCP or as separate charges for services 
covered by the monthly payment are denied; 
 
  Where several physicians or practitioners form a team to provide the monthly 
continuity of services to a group of patients, make only one monthly payment for 
each patient. 
 
  Concurrent services by another physician or practitioner who is part of the MCP 
practice team are covered and reimbursed separately only for services not 
included in the MCP (e.g. a visit not related to managing the patients ESRD); and 
 
  If payment for inpatient hospital services is claimed in addition to the MCP, and 
assignment is taken only with respect to the MCP, follow the instructions in Pub. 
100-04, chapter 1, 30.3.12.3. 
 
Contractors must conduct periodic review of a randomly selected sample of patients 
histories with reimbursement under the MCP method, to evaluate whether the number of  and types of services billed separately from the MCP are appropriate considering the 
individual patients medical condition. 
 
Make separate payments for medically necessary services that are included or bundled 
into the MCP (e.g., test interpretations) when furnished by physicians other than the 
monthly capitation payment physician. According to the Renal Physicians Association, 
these test interpretations are billed separately only in rare circumstances. 
 
150 - Physicians Self-Dialysis Training Services 
(Rev. 1, 10-01-03) 
 
Pay physicians for physician training services furnished to dialysis patients undergoing 
training by a flat fee of $500 (subject to the deductible and coinsurance requirements) for 
each patient under the physicians supervision during the training course. Pay this upon 
completion of the training course in addition to the monthly capitation payment for 
physicians maintenance dialysis services. If the training period is not completed, such as 
in instances where the patient can no longer be trained, prorate the training rate in 
proportion to the number of training treatments completed, but not to exceed $500. For 
purposes of this pro-ration, consider 25 training treatments as a complete course of 
training. Therefore, for an incomplete training course, pay the physician for the training 
services based on an amount of $20 per treatment times the number of treatments 
completed. This rule applies to all modes of treatment, including CAPD. 
 
Occasionally, it is necessary to furnish additional training to an ESRD self-dialysis 
beneficiary after the initial training course is completed; e.g., because of a change from 
hemodialysis to peritoneal dialysis, a change in equipment. The amount of additional 
training required depends upon the transferability of the skills the patient has already 
learned; subsequent training would normally be very limited. Physicians training 
services furnished during subsequent training of an ESRD beneficiary are covered and 
reimbursed in addition to the initial training fee. 
 
Subsequent training sessions that are reimbursable under this rule must be distinguished 
from the ongoing services for which the original training fee is considered payment in 
full; e.g., answering the patients questions arising after home dialysis has begun about 
the machine the patient has already been trained to use. No additional payment is made 
after the initial training course unless the subsequent training is required because of a 
change from the patients treatment machine to a machine that he had not been trained to 
use in the initial training course, a change in the type of dialysis, or a change in setting or 
dialysis partner. 
 
160 - Payment for Physicians Services Furnished to Dialysis Inpatients 
(Rev. 1, 10-01-03) 
 
The following instructions cover physicians services to inpatients for all types of dialysis 
patients; e.g., hemodialysis, intermittent peritoneal dialysis (IPD), continuous ambulatory  peritoneal dialysis (CAPD), and continuous cycling peritoneal dialysis (CCPD). Note that 
the hospitalization need not be related to dialysis. 
 
Payment is made on the claim only if the place of service on the claims is inpatient 
hospital.  See 170 for proper HCPCS coding. 
 
160.1 - Determining Whether Physician Services Furnished on Day of 
Dialysis 
(Rev. 1, 10-01-03) 
 
If the patient is admitted to a hospital to receive dialysis for a reason not related to the 
patients ESRD condition (e.g., there was no space available in the dialysis unit), the 
dialysis is covered as an outpatient service.  In this case, A/B MACs (B) do not pay 
separately for any physicians ESRD services because these services are covered under 
the physicians MCP or under the add-on to the hospitals composite rate for physicians 
under the initial method.  (See 130.1 for a description of the initial method.) 
 
160.2 - Physicians Services Furnished on Day of Dialysis 
(Rev. 1, 10-01-03) 
B3-15062.1 
 
Supervision or direction of a dialysis treatment by a physician does not ordinarily meet 
the requirements for physicians services and, therefore, is not paid for as such under the 
fee schedule. However, physicians are responsible for the medical care and treatment of 
the dialysis patients. Physicians services furnished to those patients that meet the 
requirements and are medically necessary are covered. The hospital medical record must 
document the services furnished and the medical reasons for them. 
 
Generally, claims from the physician receiving a procedure code payment for additional 
services furnished to the same patient on the day of dialysis must be reviewed by medical 
staff prior to payment. Follow 170.B for dialysis and evaluation and management 
services performed on the same day. 
 
Payment in addition to the procedure code payment is made only if the service is not 
related to the treatment of the patients ESRD, and the service was not, and could not 
have been, furnished during the dialysis treatment. However, an exception to this rule is 
physicians surgical services; e.g., catheter insertion. Physicians surgical services are 
generally billed under the appropriate procedure code for payment. If more than one 
physician furnishes care to the same dialysis patient, follow the usual coverage rules on 
concurrent care. 
 
160.3 - Physicians Services Furnished on Non-Dialysis Days 
(Rev. 1, 10-01-03) 
 
Physicians services furnished on non-dialysis days are coded and paid under the same 
rules as any other physicians services when non-renal related services are furnished.  Renal-related services may also be paid if the physician chooses to prorate the MCP 
payment. Generally, these services are the physicians hospital visits and are coded and 
paid as such. 
 
160.4 - Requirements for Payment 
(Rev. 1, 10-01-03) 
 
A.   General 
 
When paying for physicians services furnished to dialysis inpatients, whether they are 
ESRD patients or acute dialysis patients, there are several factors to consider. 
 
  The payment must be for covered physicians services; 
 
  The services must be medically necessary; and 
 
  The payment for the services must be reasonably related to the nature of the 
services actually furnished. 
 
B.   Physicians Services - Criteria for Procedure Codes 
 
The procedure code covers the full range of physicians renal-related services furnished 
during an inpatient dialysis treatment. 
 
In order to be paid on the basis of a procedure code, the physician must have been 
physically present with the patient at some time during the course of the dialysis, and the 
medical record (e.g., the physicians progress note or the nurses notes in the patients 
hospital medical record) must document this. 
 
If the physician visits the dialysis inpatient on a dialysis day, but not during the dialysis 
treatment, do not pay the physician on the basis of a procedure code. The nature of these 
services is the same as physicians services furnished to any inpatient during a hospital 
visit. Therefore, use the same hospital visit codes that apply to any other physicians 
treating hospital inpatients. 
 
Physicians services furnished to patients who are dialyzed as inpatients because there is 
no room in the outpatient dialysis units are covered under the MCP, and physicians are 
not paid amounts in addition to or in place of the MCP. 
 
Effective January 1, 1995, all evaluation and management services provided on the same 
day as inpatient dialysis codes should be denied without review with the exception of 
CPT codes 99221-99223, 99251-99255, and 99238. These codes may be billed with 
modifier -25 and reviewed for possible allowance if the evaluation and management 
service is unrelated to the treatment of ESRD and was not and could not have been 
furnished during the dialysis treatment. 
  C.   Peritoneal Dialysis 
 
Peritoneal dialysis is typically furnished in extended periods. For example, CAPD is 
continuous, and the patient may actually be dialyzed seven days per week. IPD may be 
furnished in extended periods of 30 hours or more. The fact that a patient is dialyzed 
continuously for an extended period does not justify payment in excess of the average 
weekly allowance made for hemodialysis services. Payment in excess of this amount is 
made only if it is determined that the same kind and intensity of physicians hemodialysis 
treatment beyond the number ordinarily furnished in a 7-day period, and the patients 
condition was similar to that of a hemodialysis patient who would have required these 
additional services. 
 
170 - Billing Physician Dialysis Services (codes 90935 - 90999) and 
Related Payment 
(Rev. 1, 10-01-03) 
 
Except when the MCP applies claims for physicians inpatient dialysis services furnished 
to ESRD or acute dialysis patients are processed using physicians inpatient dialysis 
services procedure codes 90935, 90937, 90945, and 90947. All A/B MACs (B) must use 
these codes for these services. 
 
A/B MACs (B) make payment on the basis of ESRD procedure codes, i.e., codes 90935, 
90937, 90945, or 90947, only if the place of service on the claim is inpatient hospital. 
This is because all physicians outpatient renal-related services are included in payment 
made under the monthly capitation payment. 
 
A. ESRD Monthly Capitation Payments 
 
Effective January 1, 1995, monthly capitation payments are made under the physician fee 
schedule. For their adult patients, physicians may bill either the monthly code (CPT code 
90921) or the daily code (CPT code 90922) with units that represent the number of days 
in a single month, but may not bill both. 
 
To bill for a month of services for pediatric patients, providers should bill the appropriate 
monthly code (CPT codes 90919, 90920, or 90921). To bill for less than a month of 
service, providers bill the appropriate daily code (CPT codes 90923-90925) and units that 
represent the number of days. Providers may bill either the monthly code or the daily 
code, but not both. Since billing is done at the conclusion of the month, the patients age 
at the end of month is the age of the patient for billing purposes. 
 
B - Inpatient and Outpatient Dialysis Services On Same Date As An Evaluation and 
Management Service 
 
CPT codes 90935 and 90937 are used to report inpatient ESRD hemodialysis and 
outpatient hemodialysis performed on non-ESRD patients (e.g., patients in acute renal 
failure requiring a brief period of dialysis prior to recovery). CPT codes 90945 and 90947  are used to report all non-hemodialysis procedures. All four of these codes include 
payment for any evaluation and management services related to the patients renal disease 
that are provided on the same date as the dialysis service. Therefore, payment for all 
evaluation and management services is bundled into the payment for 90935, 90937, 
90945, and 90947, except for the following evaluation and management services which 
may be reported on the same date as a dialysis service with the use of the 25 modifier 
and they are significant and separately identifiable and met any medical necessity 
requirements: 
 
99201-99205  Office or Other Outpatient Visit for a New Patient 
99211-99215  Office or Other Outpatient Visit for an Established Patient 
99221-99223  Initial Hospital Care for a New or Established Patient 
99238-99239  Hospital Discharge Day Management Services 
99241-99245  Office or Other Outpatient Consultations, New or Established 
Patient 
99251-99255  Initial Inpatient Consultations, New or Established Patient 
99291-99292  Critical Care Services 
 
In the absence of one of these codes being reported with the 25 modifier and meeting 
the other requirements listed above, pay only the dialysis service and deny the evaluation 
and management service. Furthermore, payment is not allowed for more than one dialysis 
service per day. 
 
180 - Noninvasive Studies for ESRD Patients - Facility and Physician 
Services 
(Rev. 3650, Issued: 11-10-16, Effective: 02-10-17, Implementation: 02-10-17) 
 
For Medicare coverage of noninvasive vascular studies, see the Medicare Benefit Policy 
Manual, Chapter 11. 
 
For dialysis to take place there must be a means of access so that the exchange of waste 
products may occur.  As part of the dialysis treatment, ESRD facilities are responsible for 
monitoring access, and when occlusions occur, either declot the access or refer the patient 
for appropriate treatment.  Procedures associated with monitoring access involve taking 
venous pressure, aspirating thrombus, observing elevated recirculation time, reduced urea 
reduction ratios, or collapsed shunt, etc.  All such procedures are covered under the 
composite rate. 
 
ESRD facilities may not monitor access through noninvasive vascular studies such as 
duplex and Doppler flow scans and bill separately for these procedures.  Noninvasive 
vascular studies are not covered as a separately billable service if used to monitor a 
patients vascular access site. 
 
Medicare pays for the technical component of the procedure in the composite payment 
rate. 
  Where there are signs and symptoms of vascular access problems, Doppler flow studies 
may be used as a means to obtain diagnostic information to permit medical intervention 
to address the problem.  Doppler flow studies may be considered medically necessary in 
the presence of signs or symptoms of possible failure of the ESRD patients vascular 
access site, and when the results are used in determining the clinical course of the 
treatment for the patient. 
 
The only Current Procedural Terminology (CPT) billing code for noninvasive vascular 
testing of a hemodialysis access site is 93990.  A/B MACs (B) must deny separate billing 
of the technical component of this code if it is performed on any patient for whom the 
ESRD composite rate for dialysis is being paid, unless there is appropriate medical 
indication of the need for a Doppler flow study. 
 
When a dialysis patient exhibits signs and symptoms of compromise to the vascular 
access site, Doppler flow studies may provide diagnostic information that will determine 
the appropriate medical intervention.  Medicare considers a Doppler flow study medically 
necessary when the beneficiarys dialysis access site manifests signs or symptoms 
associated with vascular compromise, and when the results of this test are necessary to 
determine the clinical course of treatment. 
 
Examples supporting the medical necessity for Doppler flow studies include: 
 
a.  Elevated dynamic venous pressure >200mm HG when measured during dialysis 
with the blood pump set on a 200cc/min., 
 
b.  Access recirculation of 12 percent or greater, 
 
c.  An otherwise unexplained urea reduction ration <60 oercebtm abd 
 
d.  An access with a palpable water hammer pulse on examination, (which implies 
venous outflow obstruction). 
 
Unless the documentation is provided supporting the necessity of more than one study, 
Medicare will limit payment to either a Doppler flow study or an arteriogram 
(fistulogram, venogram), but not both. 
 
An example of when both studies may be clinically necessary is when a Doppler flow 
study demonstrates reduced flow (blood flow rate less than 800cc/min or a decreased 
flow of 25 percent or greater from previous study) and the physician requires an 
arteriogram to further define the extent of the problem.  The patients medical record(s) 
must provide documentation supporting the need for more than one imaging study. 
 
This policy is applicable to claims from ESRD facilities and all other sources, such as 
independent diagnostic testing facilities, and hospital outpatient departments. 
  A/B MACs (B) shall develop LMRP for Doppler flow studies if this service meets the 
criteria listed in the Medicare Program Integrity Manual, Chapter 1.  This provides 
guidance to contractors on the scope, purpose, and meaning of LMRP. 
 
The professional component of the procedure is included in the monthly capitation 
payment (MCP) (See 140 above.) The professional component should be denied for 
code 93990 if billed by the MCP physician.  Medically necessary services that are 
included or bundled into the MCP (e.g., test interpretations) are separately payable when 
furnished by physicians other than the MCP physician. 
 
The contractor shall use the following remittance advice messages and associated codes 
when rejecting/denying claims under this policy.  This CARC/RARC combination is 
compliant with CAQH CORE Business Scenario Four. 
 
Group Code: CO 
CARC: 24 
RARC: N/A 
MSN:16.32 
 
Billing for monitoring of hemodialysis access using CPT codes for noninvasive vascular 
studies other than 93990 is considered a misrepresentation of the service actually 
provided and contractors will consider this action for fraud investigation.  They will 
conduct data analysis on a periodic basis for noninvasive diagnostic studies of the 
extremities (including CPT codes 93922, 93923, 93924, 93925, 93926, 93930, 93931, 
93965, 93970, 93971).  Contractors should handle aberrant findings under normal 
program safeguard processes by taking whatever corrective action is deemed necessary. 
 
190 - Appeal Rights for Denied Claims 
 
For appeal rights if the claim is denied see Chapter 29. 
 
200  Utilization of REMIS for A/B MAC (B) Claims Adjudication 
(Rev. 82, 02-06-04) 
 
Renal Management Information System (REMIS) determines the Medicare coverage 
periods for ESRD patients and serves as the primary mechanism to store and access 
information in the ESRD Program Management and Medical Information System 
Database.  REMIS is used by CMS and the renal community to monitor the Medicare 
status, transplant activities, dialysis activities, and Medicare utilization of ESRD patients 
and their Medicare provider. 
 
The following fields are contained in the (Dialysis) auxiliary file: 
 
  ESRD Coverage Start Date (The date on which the beneficiary is entitled to 
Medicare, in some part, because of a diagnosis of End Stage Renal Disease.) 
    ESRD Coverage Source Code (The source of the information that establishes 
Medicare-based End-Stage Renal Disease Coverage; A= Part A and Dialysis 
Training, B= Part A and Dialyzing (No 3 month wait), C= Part A and 3 months 
after Dialysis, D= Part A and Functioning Transplant, E= Part A and Month of 
Pre-Transplant Stay, F= Part A and ESRD (Verified Source), Blank= No ESRD 
Involvement.) 
 
  ESRD Coverage Termination Date (The date on which the beneficiary is no 
longer entitled to Medicare under ESRD Provisions.) 
 
  ESRD Coverage Termination Reason (A code that indicates the reason 
Medicare-based End-Stage Renal Disease Coverage was terminated; codes: A= 
Month of transplant plus 36 months, B=Last month of chronic dialysis, C= Part A 
termination, D=Death, E=ESRD ended: other verified source.) 
 
  ESRD Dialysis Start Date (A date that indicates when ESRD dialysis started.) 
 
  ESRD Dialysis Stop Date (A date that indicates when ESRD dialysis ended.) 
 
  ESRD Transplant Start Date (A date that indicates when a kidney transplant 
operation occurred.) 
 
  ESRD Transplant Stop Date (A date that indicates when a kidney transplant 
failed.)  
 
The above data elements are in CWF and stored in the dialysis auxiliary file, which can 
be used to identify a beneficiarys ESRD eligibility.  This data source will assist carriers 
in reviewing overpayment determination and accurately processing claims.  Transmittals Issued for this Chapter 
Rev #  Issue Date  Subject  Impl  CR # 
Date 
R10640CP  08/06/2021  Update of Internet Only Manual (IOM),  09/07/2021  12079 
Pub. 100-04, Chapter 8 - Outpatient ESRD 
Hospital, Independent Facility, and 
Physician/Supplier Claims 
R10236CP  07/31/2020  Update to the IOM Publication (Pub) 100- 08/31/2020  11857 
04, Medicare Claims Processing Manual, 
Chapters 1, 6, 8, 17, 20, 22, 24, and 31 
Referencing the Active Universal Resource 
Locators (URLs) for the Washington 
Publishing Company (WPC) and the ASC 
X12 Organizations, and Updates to the 
HIPAA Eligibility Transaction System 
(HETS) 
R4202CP  01/18/2019  Update to Pub. 100-04 Chapters 8, 20, and  02/19/2019  10964 
24 to Provide Language-Only Changes for 
the New Medicare Card Project 
R4105CP  08/03/2018  System Changes to Implement Epoetin Alfa  01/07/2019  10839 
Biosimilar, Retacrit for End Stage Renal 
Disease (ESRD) and Acute Kidney Injury 
(AKI) Claims 
R4010CP  03/23/2018  Revisions to Medicare Claims Processing  06/26/2018        10541 
Manual for End Stage Renal Disease   
R3650CP  11/10/2016  Updates to Pub. 100-04, Chapters 8, 13 and  02/10/2016  9841 
14 to Correct Remittance Advice Messages 
R3311CP  08/06/2015  End Stage Renal Disease (ESRD) Home  09/08/2015  9265 
Dialysis Policy 
R3139CP  12/02/2014  Implementation of Changes in the End- 01/05/2015  8978 
Stage Renal Disease Prospective Payment 
System (ESRD PPS) for Calendar Year 
(CY) 2015 
R3125CP  11/14/2014  Implementation of Changes in the End- 01/05/2015  8978 
Stage Renal Disease Prospective Payment 
System (ESRD PPS) for Calendar Year  Rev #  Issue Date  Subject  Impl  CR # 
Date 
(CY) 2015  Rescinded and replaced by 
Transmittal 3139 
R3116CP  11/06/2014  Elimination of the 50/50 Payment Rule for  04/06/2015  8957 
Laboratory Services on End Stage Renal 
Disease (ESRD) Claims 
R3053CP  08/28/2014  Update to Pub. 100-04, Chapters 7 and 8 to  09/30/2014  8579 
Provide Language-Only Changes for 
Updating ICD-10 and ASC X12 
R2905CP  03/14/2014  Update to Pub. 100-04, Chapters 7 and 8 to  10/01/2014  8579 
Provide Language-Only Changes for 
Updating ICD-10 and ASC X12  
Rescinded and replaced by Transmittal 3053 
R2839CP  12/13/2013  Implementation of Changes in the End- 01/06/2014  8472 
Stage Renal Disease Prospective Payment 
System (ESRD PPS) for Calendar Year 
(CY) 2014 
R2831CP  11/29/2013  Implementation of Changes in the End- 01/06/2014  8472 
Stage Renal Disease Prospective Payment 
System (ESRD PPS) for Calendar Year 
(CY) 2014  Rescinded and replaced by 
Transmittal 2839 
R2688CP  04/26/2013  Reporting End Stage Renal Disease (ESRD)  07/01/2013  8256 
Drugs Administered Through the Dialysate 
R2545CP  01/31/2013  Changes Applicable to the Billing of Drugs  07/012013  8174 
on ESRD Claims 
R2582CP  11/02/2012  New Erythropoietin Stimulating Agent  04/01/2013  8050 
(ESA) Peginesatide Requirements for End 
Stage Renal Disease (ESRD) 
R2577CP  11/01/2012  Update to the Fiscal Intermediary Shared  04/01/2013  8066 
Systems (FISS) for the End Stage Renal 
Disease (ESRD) Quality Incentive Program 
(QIP) Adjustments for Childrens Hospitals 
R2588CP  11/05/2012  Implementation of Changes to the End- 01/07/2013  7869 
Stage Renal Disease (ESRD) Prospective 
Payment System (PPS) Consolidated Billing  Rev #  Issue Date  Subject  Impl  CR # 
Date 
Requirements and a Clarification of Outlier 
Services for Calendar Year 2013 
R2504CP  08/02/2012  Implementation of Changes to the End- 01/07/2013  7869 
Stage Renal Disease (ESRD) Prospective 
Payment System (PPS) Consolidated Billing 
Requirements and a Clarification of Outlier 
Services for Calendar Year 2013  
Rescinded and replaced by Transmittal 2588 
R2361CP  11/25/2011  Clarification and Revisions for Claims  04/02/2012  7593 
Submitted for End Stage Renal Disease 
(ESRD) Patients 
R2347CP  11/18/2011  Recoupment of Incorrect Payments Made  01/03/2012  7626 
Under the End Stage Renal Disease (ESRD) 
Prospective Payment System (PPS) for 
Low-Volume Payment Adjustment 
R2335CP  10/28/2011  Clarification and Revisions for Claims  04/02/2012  7593 
Submitted for End Stage Renal Disease 
(ESRD) Patients  Rescinded and replaced 
by Transmittal 2361 
R2311CP  09/23/2011  Implementation of the MIPPA 153c End  01/03/2012  7460 
Stage Renal Disease (ESRD) Quality 
Incentive Program (QIP) and Other 
Requirements for ESRD Claims 
R2281CP  08/19/2011  Implementation of Changes to the End  01/03/2012  7471 
Stage Renal Disease (ESRD) Prospective 
Payment System (PPS) Outlier Payment 
Policy and Changes to the ESRD PPS 
Consolidated Billing Requirements for 
Laboratory Services Furnished in a Hospital 
Emergency Room or Department 
R2269CP  08/05/2011  Clarification of Payment for ESRD-Related  11/07/2011  7520 
Services Under the Monthly Capitation 
Payment 
R2266CP  07/29/2011  Implementation of Changes to the End  01/03/2012  7471 
Stage Renal Disease (ESRD) Prospective 
Payment System (PPS) Outlier Payment 
Policy and Changes to the ESRD PPS  Rev #  Issue Date  Subject  Impl  CR # 
Date 
Consolidated Billing Requirements for 
Laboratory Services Furnished in a Hospital 
Emergency Room or Department  
Rescinded and replaced by Transmittal 
2281. 
R2262CP  07/29/2011  Implementation of the MIPPA 153c End  01/03/2012  7460 
Stage Renal Disease (ESRD) Quality 
Incentive Program (QIP) and Other 
Requirements for ESRD Claims  
Rescinded and replaced by Transmittal 2311 
R2195CP  04/22/2011  End Stage Renal Disease (ESRD) Low  10/03/2011  7388 
Volume Adjustment and Establishing 
Quarterly Updates to the ESRD Prospective 
Payment System (PPS) 
R2134CP  01/14/2011  End Stage Renal Disease (ESRD)  01/03/2011  7064 
Prospective Payment System (PPS) and 
Consolidated Billing for Limited Part B 
Services 
R2094CP  11/17/2010  End Stage Renal Disease (ESRD)  01/03/2011  7064 
Prospective Payment System (PPS) and 
Consolidated Billing for Limited Part B 
Services  Rescinded and replaced by 
Transmittal 2134 
R2033CP  08/20/2010  End Stage Renal Disease (ESRD)  01/03/2011  7064 
Prospective Payment System (PPS) and 
Consolidated Billing for Limited Part B 
Services - Rescinded and replaced by 
Transmittal 2094 
R1999CP  07/09/2010  ESRD Home Dialysis MCP  01/03/2011  7003 
R1932CP  03/17/2010  Dialysis Adequacy, Infection and Vascular  07/06/2010  6782 
Access Reporting 
R1898CP  01/29/2010  Dialysis Adequacy, Infection and Vascular  07/06/2010  6782 
Access Reporting - Rescinded and replaced 
by Transmittal 1932  Rev #  Issue Date  Subject  Impl  CR # 
Date 
R1655CP  12/31/2008  End Stage Renal Disease (ESRD) Medicare  02/02/2009  6245 
Claims Processing Manual Clarification 
R1648CP  12/12/2008  Implementation of Changes in End Stage  01/05/2009  6216 
Renal Disease (ESRD) Payment for 
Calendar Year 2009 
R1581CP  08/29/2008  Discarded Erythropoietin Stimulating  12/01/2008  6133 
Agents for Home Dialysis 
R1503CP  05/16/2008  Revisions to the Billing Requirements for  10/06/2008  6047 
ESRD-Related Epoetin Alfa (EPO) and 
Darbepoetin Alfa (Aranesp) Administration 
Provided During Unscheduled or 
Emergency Dialysis Treatments in the 
Outpatient Hospital Setting 
R1472CP  03/06/2008  Update of Institutional Claims References  04/07/2008  5893 
R1456CP  02/22/2008  Manualization of Payment for Outpatient  03/24/2008  5931 
ESRD-Related Services 
R1421CP  01/25/2008  Update of Institutional Claims References -  04/07/2008  5893 
Rescinded and Replaced by Transmittal 
1472 
R1412CP  01/11/2008  Reporting of Hematocrit or Hemoglobin  04/07/2008  5699 
Levels on All Claims for the Administration 
of Erythropoiesis Stimulating Agents 
(ESAs), Implementation of New Modifiers 
for Non-ESRD Indications, and Reporting 
of Hematocrit/Hemoglobin Levels on all 
Non-ESRD, Non-ESA Claims Requesting 
Payment for Anti-Anemia Drugs 
R1389CP  12/07/2007  Implementation of Change in End Stage  01/07/2008  5827 
Renal Disease (ESRD) Payment for 
Calendar Year 2008 
R1364CP  11/02/2007  Common Working File (CWF)  04/07/2008  5768 
Informational Unsolicited Responses for 
RDF Claims Overlapping Patient Hospital 
Stays  Rev #  Issue Date  Subject  Impl  CR # 
Date 
R1341CP  09/21/2007  New Web Site for Approved Transplant  10/22/2007  5724 
Centers 
R1307CP  07/20/2007  Modification to the National Monitoring  01/07/2008  5700 
Policy for Erythropoietic Stimulating 
Agents (ESAs) for End-Stage Renal Disease 
(ESRD) Patients Treated in Renal Dialysis 
Facilities 
R1285CP  07/13/2007  Renal Dialysis Facility Line Item Billing  01/07/2008  5545 
Requirements for Epoetin Alfa (EPO) 
Submitted on End Stage Renal Disease 
(ESRD) Claims 
R1212CP  03/30/2007  Requirements for Providing Route of  06/29/2007  5480 
Administration Codes for Erythropoiesis 
Stimulating Agents (ESAs) 
R1043CP  08/25/2006  Revisions to the EPO/ Aranesp Monitoring  10/02/2006  5251 
Policy 
R1041CP  08/25/2006  (HCPCS) for Renal Dialysis Facilities and  01/01/2007  5216 
Hospitals Billing for End Stage Renal 
Disease (ESRD) Related Epoetin Alfa 
(EPO) 
R1007CP  07/28/2006  (HCPCS) for Renal Dialysis Facilities and  01/02/2007  5216 
Hospitals Billing for End Stage Renal 
Disease (ESRD) Related Epoetin Alfa 
(EPO) 
R849CP  02/10/2006  Update to the ESRD Composite Payment  02/13/2006  4291 
Rates 
R797CP  12/30/2005  Full Replacement of CR 4095, Diagnosis  01/30/2006  4227 
Code Requirements for Method II Home 
Dialysis Claims 
R781CP  12/16/2005  Revised Manual Instructions for Processing  01/17/2006  4188 
End Stage Renal Disease Exceptions Under 
the Composite Rate Reimbursement System  Rev #  Issue Date  Subject  Impl  CR # 
Date 
R774CP  12/02/2005  Implementation of Change in End Stage  01/03/2006  4196 
Renal Disease Payment for Calendar Year 
2006 
R771CP  12/02/2005  Revisions to Pub. 100-04, Medicare Claims  01/03/2006  4181 
Processing Manual in Preparation for the 
National Provider Identifier 
R751CP  11/10/2005  National Monitoring Policy for EPO and  04/03/2006  4135 
Aranesp for End Stage Renal Disease 
Patients Treated in Renal Dialysis Facilities 
R737CP  10/31/2005  New ICD-9-CM Code for Beneficiaries with  04/03/2006  4108 
Chronic Kidney Disease and new HCPCS 
for Reporting Epoetin Alfa and Darbepoetin 
Alfa 
R736CP  10/31/2005  Clarification and Update to Hospital Billing  04/03/2006  4103 
Instructions and Payment for Epoetin Alfa 
and Darbepoetin Alfa for Beneficiaries with 
End Stage Renal Disease 
R725CP  10/21/2005  New ICD-9-CM Code for Beneficiaries with  04/03/2006  4108 
Chronic Kidney Disease 
R721CP  10/21/2005  Use of Value Codes 48 and 49 on End Stage  01/03/2006  4087 
Renal Disease Bills 
R719CP  10/21/2005  Clarification and Update to Hospital Billing  04/03/2006  4103 
Instructions and Payment for Epoetin Alfa 
and Darbepoetin Alfa (Aranesp) for 
Beneficiaries with End Stage Renal Disease 
R701CP  10/07/2005  New Diagnosis Code Requirements for  11/07/2005  4095 
Method II Home Dialysis Claims 
R634CP  08/03/2005  Guidelines for Payment of Vaccines  01/03/2006  3936 
(Pneumococcal Pneumonia Virus, Influenza 
Virus, and Hepatitis B Virus) and their 
Administration at Renal Dialysis Facilities 
R610CP  07/22/2005  Guidelines for Payment of Vaccines  01/03/2006  3936 
(Pneumococcal Pneumonia Virus, Influenza  Rev #  Issue Date  Subject  Impl  CR # 
Date 
Virus, and Hepatitis B Virus) and their 
Administration at Renal Dialysis Facilities 
R598CP  06/27/2005  Implementation of Carrier Guidelines for  01/01/2006  3890 
End Stage Renal Disease Reimbursement 
For Automated Multi-Channel Chemistry 
Test Supplemental To Change Request 2813 
R595CP  06/24/2005  Implementation of Carrier Guidelines for  07/25/3005  3890 
End Stage Renal Disease Reimbursement 
For Automated Multi-Channel Chemistry 
Tests Supplemental To Change Request 
2813 
R477CP  02/18/2005  New Case-Mix Adjusted End Stage Renal  04/04/2005  3720 
Disease Composite Payment Rates and New 
Composite Rate Exceptions Window for 
Pediatric ESRD Facilities 
R447CP  01/21/2005  CWF Editing for Method Selection on  07/05/2005  3547 
DMERC Claims for EPO and Aranesp 
R373CP  11/19/2004  New ESRD Composite Payment Rates  01/03/2005  3554 
Effective January 1, 2005 
R370CP  11/19/2004  New Case-Mix Adjusted End Stage Renal  04/04/2005  3572 
Disease Composite Payment Rates and New 
Composite Rate Exceptions Window for 
Pediatric ESRD Facilities 
R257CP  07/30/2004  Informs the FISS to carry at least two  01/03/2005  3332 
Payments Limits for ESRD 
R197CP  06/04/2004  Epoetin Alfa  10/04/2004  3184 
R146CP  04/23/2004  Dialysis Provider Number Series  10/04/2004  3176 
R118CP  03/05/2004  Epoetin Alfa  04/05/2004  2984 
R116CP  03/05/2004  DMERC Claims Processing Instructions  04/05/2004  3019 
R110CP  02/27/2004  Drugs Furnished in Dialysis  03/29/2004  3078 
R101CP  02/20/2004  Processing Requests for Composite Rate  04/01/2004  3119 
Exception  Rev #  Issue Date  Subject  Impl  CR # 
Date 
R082CP  02/06/2004  Utilization of REMIS for Carrier Claims  07/06/2004  3066 
Adjudication 
R031CP  11/21/2003  Dialysis Provider Number Series  N/A  2877 
R001CP  10/01/2003  Initial Publication of Manual  NA  NA 
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