(Medicare Benefit Policy Manual)

I.  Nutritional Services   ESRD facilities are required, in ac cordance with 42 CFR 494.80(a)(6) and 494.90(a)(2), to evaluate a patients nutritional status and expected to assist the patient in achieving their nutritional goals by providing education, counseling, and encouragement.  These services are included in the ESRD PPS.  Nutritional items, such as nutritional supplements, are not considered related to the treatment of ESRD and are not included in the ESRD PPS as renal dialysis services.   50 - ESRD Prospective Payment System (PPS) Base Rate  (Rev. 200, Issued:  12-02-14, Effective: 01- 01-15, Implementation: 01- 05-15)  Updates to the provisions under the ESRD PPS are discussed through rulemaking on a yearly basis.  The updates are implemented through Recurring Update Notifications.  A.  Per Treatment Unit of Payment   Under the ESRD PPS payment is made on a per treatment basis.  The ESRD PPS base rate is the per treatment unit of payment that applies to both adult and pediatric patients. ESRD facilities furnishing dialysis treatments in -facility are paid for up  to 3 treatments per week.  ESRD facilities treating patients at home regardless of modality receive payment for 3 hemodialysis (HD) equivalent treatments per week.  Payment for additional treatments may be considered when there is medical justification fo r more than 3 weekly treatments.  For more information regarding home dialysis, see 30 of this chapter.  ESRD facilities furnishing dialysis in- facility or in a patients home are paid for a maximum of 13 treatments during a 30 day month and 14 treatments  during a 31 day month unless there is medical justification for additional treatments.   Frequency of Dialysis Sessions by Dialysis Modality and Treatment Setting*    In-Facility  Home  Hemodialysis  3 per week  Maximum  of 3 per week regardless of frequency  Hemofiltration  3 per week  3 per week  Ultrafiltration  3 per week  Maximum of 3 per week, regardless of frequency  Peritoneal Dialysis (e.g., CAPD and CCPD)  HD-equivalent sessions  HD-equivalent sessions  Intermittent Peritoneal Dialysis (IPD)  3 per week  HD-equivalent sessions   * Regardless of dialysis modality or treatment setting, payments for additional treatments may be made when they are medically justified.  The A/B MAC (A) reviews the medical justification and is responsible for making the decision on the appropriateness of the extra treatment.   1.  Hemodialysis: Payment Based on Standard of Three Treatments per Week   Hemodialysis is typically furnished 3 times per week in sessions of 3 to 5 hours in duration.  If the ESRD facility bills for any treatments in excess of this frequency, medical justification is required to be furnished to the A/B MAC (A) and must be based upon an individual patients need.  The A/B MAC (A) reviews the medical justification for each additional treatment and is respon sible for making the decision on the appropriateness of the extra treatment(s) and payments for these additional treatments.   2.  Hemofiltration   Hemofiltration is an alternative to peritoneal dialysis and hemodialysis.  Hemofiltration may be routinely performed either in an ESRD facility or at home in 3 weekly sessions.  See 10.A.3 of this chapter.   3.  Ultrafiltration   When ultrafiltration is performed the same day as the dialysis treatment; there is no separate payment.  When ultrafiltration is performe d on a day other than the day of a dialysis treatment, the ESRD facility must document in the medical record why the ultrafiltration could not have been performed at the time of the dialysis treatment.  For the ESRD facility to be paid for the ultrafiltration, the ESRD facility must report the appropriate diagnosis code and the A/B MAC (A) must verify the medical justification to determine appropriate payment.  If the A/B MAC (A) considers the medical justification appropriate, the ESRD facility will receiv e the ESRD PPS base rate.  For more information regarding ultrafiltration, see Pub. 100- 04, Chapter 8, 50.7.   4.  Peritoneal Dialysis: Payment Based on Hemodialysis Equivalent Sessions   For home patients undergoing peritoneal dialysis (PD), the number of days of PD regardless of the number of dialysate exchanges performed each day, is converted to HD -equivalent sessions.  This is accomplished by dividing the number of days of PD by 7, and multiplying the result by 3.   Example:   Joe is a home CCPD patient w ho undergoes PD for 24 days.  The number of HD -equivalent sessions is 24/7 x 3 or 10.28571.  The number of HD -equivalent sessions or treatments for which case -mix adjusted prospective payments are applicable, is 10.28571.   Although CAPD and CCPD patients a re home dialysis patients, occasionally it may be necessary to perform dialysis in -facility.  The number of HD -equivalent sessions for PD performed in- facility is limited to 3 weekly, regardless of the number of days PD is furnished in- facility.  However, each day of in -facility PD is treated as one HD -equivalent session, up to a maximum of 3 per week.   Example:  Mary is a home CCPD patient.  After 21 days on CCPD in a month, Marys cycler required repair.  Mary received CCPD in -center for 4 consecutive day s before returning to home CCPD.  The number of HD -equivalent sessions for which payments under the ESRD PPS may be made is 12, determined as follows:   Home CCPD HD- equivalent sessions    21/7 x 3 = 9  In-center PD HD -equivalent sessions (limited to 3)        3 Total HD -equivalent sessions         12  Marys ESRD facility would receive the case- mix adjusted ESRD PPS base rate for 12 treatments in the month.  5.  Intermittent Peritoneal Dialysis (IPD)   Maintenance Intermittent Peritoneal Dialysis (IPD) is usually accomplished in sessions of 10 to 12 hours in duration.  Sometimes it is accomplished in fewer weekly sessions of longer duration.  The payment applicable for maintenance IPD, as well as the ESRD facilitys actual payment for maintenance IPD, depen ds on the treatment setting (in -facility or at home).  Payment for in -facility IPD follows the same payment rules as hemodialysis, i.e., 3 sessions per week (see Pub. 100- 04, chapter 8, 50.5 and 50.6.2).  Payment for home IPD is based on a weekly equival ence of 3 sessions per week (see Pub. 100- 04, chapter 8, 80.3, 80.3.1, and 80.4).  If additional dialysis beyond the usual weekly maintenance dialysis is required because of special circumstances, the ESRD facilitys claim for these extra services must be accompanied by a medical justification for payment to be made.   6.  Uncompleted Dialysis Treatments under the ESRD PPS   If a dialysis treatment is started, (i.e., a patient is connected to the machine and a dialyzer and blood lines are used), but the tr eatment is not completed for some unforeseen, but valid reason, (e.g., a medical emergency when the patient must be rushed to an emergency room), the ESRD facility is paid based on the ESRD PPS base rate.  This is a rare occurrence and must be medically ju stified.  If the patient returns the same day and completes the treatment, the facility is only paid for one treatment.   If a patient was taken to a hospital and was furnished a dialysis treatment while in the emergency room, then the ESRD facility will no t receive payment for the treatment and only the hospital will be paid.  See Pub.100- 04, chapter 4, section 200.2 for additional information.  B.  Market Basket   For renal dialysis services furnished on or after January 1, 2011 and before January 1, 2012, CMS adjusts the composite rate portion of the basic case -mix adjusted composite payment system described in 42 CFR 413.220 by the ESRD bundled market basket percentage increase factor.  For renal dialysis services furnished on or after January 1, 2012, CMS  updates on an annual basis, the ESRD PPS base rate and the composite rate portion of the basic case -mix adjusted composite payment described in 42 CFR 413.220 by the ESRD bundled market basket percentage increase factor minus a productivity adjustment fac tor.  Effective for renal dialysis services furnished on or after January 1, 2014, there is no longer a transition, therefore only the ESRD PPS base rate would be updated by the ESRD bundled market basket percentage increase factor minus a productivity adj ustment factor.   60 - ESRD PPS Case -Mix Adjustments  (Rev. 254, Issued: 12- 13-18, Effective: 01- 01-19, Implementation: 01- 07-19)  The ESRD PPS includes patient -level adjustments (also known as the case -mix adjustments), facility -level adjustments, and training adjustments, as well as an outlier payment. Under the ESRD PPS, the beneficiary co-insurance amount is 20 percent of the total ESRD PPS payment, after the deductible (see 60.E of this chapter).   A. Patient -level case- mix adjustments   The ESRD PPS ba se rate is adjusted for characteristics of both adult and pediatric patients to account for case- mix variability. The adult case -mix adjusters include variables (age, body surface area (BSA), and low body mass index (BMI)) that were part of the basic case -mix adjusted composite rate payment system. In addition, the ESRD PPS implemented in CY 2011 includes adult case -mix adjustments for six comorbidity categories (three acute and three chronic) as well as the onset of renal dialysis. Pediatric patient -level adjusters (see 60.A.6 of this chapter), consist of combinations of two age categories and two dialysis modalities. Based on the refinement of the ESRD PPS, effective January 1, 2016, adult case -mix payment adjustments are made for four comorbidity categor ies (two acute and two chronic) as discussed below.  1. Adult case -mix adjusters   This section presents a list of the ESRD PPS case- mix adjusters for adults and provides several examples using the adult case -mix adjusters implemented in CY 2011 and refined in CY 2016. Any revisions to the case- mix adjusters will be published in subsequent rulemaking.   Adult  Patient -Level  Characteristics  Adjustment  Value   CY 2011 -2015  Beginning  CY 2016  Age: 18 -44 1.171  1.257  Age: 45 -59 1.013  1.068  Age: 60 -69 1.000  1.070  Age: 70 -79 1.011  1.000  Age: 80+  1.016  1.109  Body Surface Area  1.020  1.032  Low Body Mass Index (BMI <18.5)  1.025  1.017  Onset of Dialysis  1.510  1.327  Pericarditis  1.114  1.040  Bacterial pneumonia  1.135  --- Gastro -intestinal tract bleeding  1.183  1.082  Hereditary hemolytic or sickle cell anemia  1.072  1.192  Myelodysplastic syndrome  1.099  1.095  Monoclonal gammopathy  1.024  ---  Calculating the ESRD PPS Adjusted Payment   The following example demonstrates the calculation of the  ESRD PPS payment in an urban area with a wage index of 1.10. Before giving the particulars of the dialysis patient for the example, shown first is how to calculate the labor -adjusted base rate, which is the starting point for the computation of the case -mix adjusted base rate.