(Medicare Claims Processing Manual)

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 Dis ease 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 Hem odialysis 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 Requi red 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 f or 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 Servic es 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 t o 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 Dia lysis 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 D enied 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 sing le 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 ESRD PPS. 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 rela ted to the lab tests, drugs and supplies subject to the ESRD consolidated billing requirement can be found at the following website:  http://w ww.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.