(Medicare Benefit Policy Manual)

C. Training and Retraining Add -On Payment   A training add- on payment adjustment is available under the ESRD PPS. The training add-on payment is computed by using the national average hourly wage for nurses from the Bureau of Labor Statistics. The payment accounts for 1.5 hours of nursing time for each training treatment that is furnished and is adjusted by the geographic area wage index. The training add- on payment applies to both peritoneal dialysis and hemodialysis training treatments, and added to the ESRD PPS payment, when a training treatment is provided by a Medicare c ertified training ESRD facility. An ESRD facility may bill a maximum of 25 training sessions per patient for hemodialysis training, and 15 sessions for CCPD and CAPD training. ESRD facilities should not expect additional reimbursement beyond the maximum se ssions.  CMS expects that ESRD patients who opt for home dialysis are good candidates for home dialysis training, and will successfully complete their method of training before reaching the maximum number of allotted training treatments. For more information regarding dialysis training, see 30.2 of this chapter.  For more information regarding retraining, see 30.2.E of this chapter.   D. Outlier  Policy   The ESRD PPS provides additional payment for high cost outliers due to unusual variations in the type or amount of medically necessary care when applicable. Outlier payments are based on a comparison of the predicted Medicare allowable payment (MAP) per treatment to actual incurred expenditure per treatment for services which  were or would have been considere d separately billable prior to the implementation of the ESRD PPS.  ESRD outlier services  include:    Drugs and biologicals used for the treatment of ESRD that were or would have been, prior to January 1, 2011, separately billable under Medicare Part  B;   Laboratory tests used for the treatment of ESRD that were or would have been, prior to January 1, 2011, separately billable under Medicare Part  B;   Medical or surgical supplies used to administer drugs and biologicals used for  the treatment of ESRD that were or would have been, prior to January 1, 2011, separately billable under Medicare Part B;  and   Drugs and biologicals used for the treatment of ESRD that were or would have been, prior to January 1, 2011, separately billable under Part D. Implementation of renal dialysis service oral -only drugs has been delayed until January 1,  2025.   The list of renal dialysis services that are included as outlier services may be found at http://www.cms.gov/ESRDPayment/30_Outlier_Services.asp#TopOfPage.  NOTE : All renal dialysis service Part B drugs and biologicals reported with a HCPCS code that is on the ASP List are included for outlier payments (with the exception of composite rate drugs). The laboratory tests that comprise the AMCC panel do not qualify for an outlier, see 20.2.A for information regarding the 50/50 rule.   ESRD facilities may receive o utlier payments for the treatment of both adult and pediatric dialysis patients.  An ESRD facility is eligible for an outlier payment if its actual or imputed MAP amount per treatment for ESRD outlier services exceeds a threshold. The MAP amount represents  the average incurred amount per treatment for services that were or would have been considered separately billable services prior to January 1, 2011. The threshold is equal to the ESRD facilitys predicted ESRD outlier services MAP amount per treatment (w hich is case- mix adjusted) plus the fixed dollar loss amount. In accordance with 42 CFR 413.237(c), facilities are paid 80 percent of the per treatment amount by which the imputed MAP amount for outlier services (that is, the actual incurred amount) exceeds this  threshold.  For example, the average outlier services MAP amount per treatment for pediatric and adult dialysis patients for CY 2016 were $39.20 and $50.81, respectively. After multiplication by applicable patient and facility specific adjusters to  yield a predicted outlier services MAP amount, a fixed amount is added (the fixed dollar loss amount) to determine the outlier threshold. The fixed dollar loss amounts for CY 2016 were $62.19 for pediatric patients and $86.97 for adult patients. The CY 2016 values of the average outlier services MAP amount and the fixed dollar loss amount are used below for the purpose of following the outlier payment computation. These values may be revised as a result of subsequent rulemaking.    In computing the MAP amount, the adjusters used are:   Adult  Characteristics  Adjustment  Value   CY 2011 - 2015  Beginning CY 2016  Age: 18 -44 0.996  1.044  Age: 45 -59 0.992  1.000  Age: 60 -69 1.000  1.005  Age: 70 -79 0.963  1.000  Age: 80+  0.915  0.961  Body Surface Area  1.014  1.000  Low Body Mass Index (BMI <18.5)  1.078  1.090   Onset of Dialysis  1.450  1.409  Pericarditis  1.354  1.209  Bacterial pneumonia  1.422  --- Gastro -intestinal tract bleeding  1.571  1.426  Hereditary hemolytic or sickle cell anemia  1.225  1.999  Myelodysplastic syndrome  1.309  1.494  Monoclonal gammopathy  1.074  --- Low-volume facility adjustment  0.975  0.955  Rural facility adjustment  --- 0.978   Pediatric  Characteristics  Adjustment  Value   CY 2011 - 2015  Beginning CY 2016  Age: <13, Modality: PD  0.319  0.410  Age: <13, Modality: Hemo  1.185  1.406  Age: 13 -17, Modality: PD  0.476  0.569  Age: 13 -17, Modality: Hemo  1.459  1.494   Both the adult and pediatric CY 2016 separately billable case -mix adjusters are presented for the purpose of following the outlier payment computations shown below and may be revised as a result of subsequent rulemaking.   1. Outlier Payment  Calculation   The outlier payment computations use the case -mix adjusters for separately billable services. These adjusters are applied to the relevant outlier services MAP amount for either adult or pediatric patients discussed above to obtain the predicted MAP amount for outlier services, reflecting all patient- specific and any facility -specific adjustments.   The following example shows how outlier payments are calculated under the ESRD PPS. For further information on the calculation of a patients BSA, see 60.A.1. The pricing amounts for laboratory services qualifying as outlier services are based on the clinical   laboratory fee schedule. For injectable drugs and biologicals, pricing is based on the latest available quarterly average sales price plus 6 percent (ASP + 6) methodology. For formerly Part D drugs with an injectable version, pricing is based on national average drug prices based on t he Medicare Prescription Drug Plan Finder. For medical/surgical supplies, pricing is based on prices established by the local A/B MAC (A). For further information regarding A/B MAC (A) pricing of medical/surgical supplies, see Pub. 100-  04, chapter 8, 20.1.   2. Example of Outlier  Payment   Ms. Brown is a 66 year old ESRD patient and is 167.64 cm. tall, weighs 105 kg., and has a recent diagnosis of GI bleeding.  She does not qualify for a low BMI adjustment.  Ms. Browns BSA is 2.1284.  The list of adjusters in D reveals that the separately billable multiplier for BSA is 1.000.   Ms. Browns case -mix adjustment based on her BSA of 2.1284 is 1.000.  Step 1: Determine the predicted, ESRD outlier services MAP amount using the product of all  applicable case- mix adjusters .  The patient -level outlier services case- mix adjusters are identified in the list in D:  66 years old: 1.005, BSA: 1.000, and GI bleeding: 1.426:  = 1.005 * 1.000 * 1.426 = 1.4331  The adjusted, average, ESRD outlier services MAP amount  = $50.81  The adjusted, average ESRD outlier services MAP amount * product of the outlier services case- mix adjusters: = $50.81 * 1.4331 = $72.82  Step 2: Determine the imputed average, per treatment, ESRD outlier services MAP amount ba sed on utilization of all separately billable services on the monthly ESRD facility bill  Assume the imputed monthly ESRD outlier services amount = $4,000 and that the corresponding total number of treatments in the month = 10  The imputed, average, per treatment, outlier services MAP amount = $4,000/10 = $400   Step 3: Add the fixed dollar loss amount to the predicted, ESRD outlier services MAP  amount   The fixed dollar loss amount = $86.97. The predicted ESRD outlier services MAP amount = $72.82 = $72.82 + $86.97 = $159.79  Step 4: Calculate outlier payment per treatment   Outlier payment = imputed average, per treatment, outlier services MAP amount minus (predicted ESRD outlier services MAP amount plus the fixed dollar loss amount) * loss sharing percentag e: = ($400.00- $159.79) * .80 = $240.21 * .80 = $192.17  The outlier payments for Ms. Browns 10 treatments would be: 10 * $192.17 = $1,921.70  E. Co-Insurance   Eighty percent of the total 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 20 percent after the deductible. Therefore, the beneficiary co -insurance amount under the ESRD PPS is 20 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. For example, under the ESRD PPS the patients co- insurance liability is based on the payment made to the ESRD facilit y and NOT on specific renal dialysis items and services. Therefore, any renal dialysis service drug or biological or laboratory service furnished to a beneficiary would NOT require a co -insurance amount because the renal dialysis service drug or biological  or laboratory service is included in the payment made to the ESRD  facility.   In the event a claim is reprocessed and the amount that was paid to the ESRD facility changes, the ESRD facility is responsible for reconciling with the ESRD patient any overpaym ent or underpayment of co- insurance or deductible amounts paid to the ESRD facility.   70 - ESRD PPS Transition Period  (Rev. 171, Issued: 06 -07-13, Effective: 01- 01-11, Implementation: 09- 09-13)  The ESRD PPS provides ESRD facilities a 4 -year transition per iod under which the ESRD facilities receive a blend of payments comprised of the ESRD PPS and the basic case- mix adjusted composite payment system.  For CY 2011 through 2013, CMS will continue to update the basic case -mix composite payment system for purpo ses of determining the composite rate portion of the blended payment amount, including adjusting payments for geographic differences in area wage levels.  CMS continues to apply the budget neutrality adjustment to the wage index values for the composite ra te portion of the ESRD PPS during the transition.    As of January 1, 2011, the blended amount consists of 25 percent based on the ESRD PPS payment and 75 percent of the basic case -mix adjusted composite payment system.    For CY 2012, payment will be based on 50 percent of the payment rate under the ESRD PPS and 50 percent of the payment rate under the basic case -mix adjusted composite payment system.    For CY 2013, payment will be based on 75 percent of the payment rate under the ESRD PPS and 25 percent of the  payment rate under the basic case -mix adjusted composite payment system.