(Medicare Claims Processing Manual)

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 separat e 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 cover ed 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, Im plementation: 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 i n 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 eligibl e 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 facilit y, 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 impleme ntation 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 as sociated 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 ES RD 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 arra ngements) 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 paym ent  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 t he 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 accomplish ed 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 s chedules. The total weekly dialysis time varies from 50 to 80 hours. For example, home IPD may b e 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 d ialysis 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.