(Medicare Benefit Policy Manual)

100.1 Definition of AKI  (Rev.  240, Issued: 01- 19-18, Effective: 01 -01-17, Implementation: 02-  20-18) Section 1834(r)(2) of the Act defines individual with acute kidney injury'' to mean an individual who has acute loss of renal function and does not receive renal dialysis services for which payment is made under section 1881(b)(14) of the Act.   100.2 Payment Rate for AKI Dialysis  (Rev.  240, Issued: 01- 19-18, Effective: 01- 01-17, Implementation: 02-  20-18) The payment rate for AKI Dialysis is the ESRD PPS per treatment base rate updated annually by the market  basket, less the productivity adjustment and adjusted by any other adjustment factor applied to the ESRD PPS base rate.     100.3 Geographic Adjustment Factor  (Rev.  240, Issued: 01- 19-18, Effective: 01- 01-17, Implementation: 02-  20-18)  The payment rate for  AKI dialysis is adjusted by the geographic adjustment factor that is applied to the ESRD PPS base rate for a particular facility, which is the same wage index applied under the ESRD PPS.   100.4 Other Adjustments to the AKI Payment Rate  (Rev.  240, Issued: 01- 19-18, Effective: 01- 01-17, Implementation: 02-  20-18)  There are currently no other adjustments applied to the AKI Payment Rate   A. ESRD Network Fee   The ESRD Network Fee reduction is not applicable to claims for beneficiaries with AKI.   B. ESRD Quality Incentive Program (QIP)   The ESRD QIP is not applicable for beneficiaries with AKI at this time.   C. Sequestration Adjustments   The 2 percent sequestration adjustment is applicable to claims for beneficiaries with AKI.   100.5 Renal Dialysis Services Included in the AKI Payment Rate  (Rev.  240, Issued: 01- 19-18, Effective: 01- 01-17, Implementation: 02-  20-18) Drugs, biologicals, laboratory services, and supplies that are considered to be renal dialysis services under the ESRD PPS as defined in 42 CFR 413.171, ar e considered to be renal dialysis services for patients with AKI. As such, no separate payment would be made for renal dialysis drugs, biologicals, laboratory services, and supplies that are included in the ESRD PPS base rate when they are furnished by an ESRD facility to an individual with AKI.  Other items and services furnished to beneficiaries with AKI that are not considered to be renal dialysis services as defined in 42 CFR 413.171, but that are related to their dialysis treatment as a result of their AKI and that an ESRD facility might furnish to a beneficiary with AKI, would be separately payable. In particular, an ESRD facility could seek separate payment for 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. Items and services included on the consolidated billing list are not separately payable for patients with AKI.  All dialysis treatments, that is, hemod ialysis and peritoneal dialysis, furnished to individuals with AKI in an ESRD facility will be paid the AKI payment rate.  This includes any treatments that exceed the three times -weekly limitation applied to treatments furnished to ESRD beneficiaries.  CM S expects that individuals with AKI will need renal dialysis services for a finite number of days since the intent of the dialysis for these patients is curative.     100.6 Applicability of Specific ESRD PPS Policies to AKI Dialysis (Rev.  245, Issued: 08- 03-18, Effective: 01- 01-19, Implementation: 01-  07-19)  A. Dialysis Modality  Beneficiaries with AKI can receive their dialysis via the most clinically appropriate in- facility modality.   B. Uncompleted Dialysis Treatment  Generally, CMS only pays for one treatment per day across all settings. However, similar to the policy applied under the ESRD PPS for treatments for patients with ESRD, in the interest of fairness and in accordance with Chapter 8, section 10.2 of the Medicare Claims Processing Manual, if a dialysis  treatment is started, that is, a patient is connected to the machine and a dialyzer and blood lines are used, but the treatment is not completed for some unforeseen, but valid reason, for example, a medical emergency when the patient must be rushed to an emergency room, both the ESRD facility and the hospital would be paid. This is considered to be a rare occurrence that must be fully documented to the A/B MAC's satisfaction.  C. Home and Self -Dialysis  Due to the nature of AKI, dialysis treatments at home or s elf-dialysis in the dialysis facility are not permitted.  Specifically, these patients require supervision by qualified staff during their dialysis and close monitoring through laboratory tests to ensure that they are receiving the necessary care to improve their condition and get off of dialysis.  Therefore, the home dialysis benefit does not extend to beneficiaries with AKI.  D. Vaccines and Their Administration   Section 1881(b)(14)(B) of the Act specifically excludes vaccines covered under section 1861(s)(10)  of the Act from the ESRD PPS. However, ESRD facilities are identified as an entity that can bill Medicare for vaccines and their administration. Therefore, ESRD facilities may furnish vaccines to beneficiaries with AKI and bill Medicare in accordance with  billing requirements in the Medicare Claims Processing Manual (Pub. 100- 04, Chapter 18 Preventive and Screening Services, section 10.2). The staff time associated with vaccine administration is covered in the AKI dialysis payment rate. E. Telehealth  Since telehealth dialysis services are limited to renal dialysis services for home dialysis patients telehealth related to renal dialysis services is not available for beneficiaries with AKI.  F. ESRD Conditions for Coverage (CfCs)  The ESRD CfCs at 42 CFR part 494 a re health and safety standards that all Medicare participating dialysis facilities must meet. These standards set baseline requirements for patient safety, infection control, care planning, staff qualifications, record keeping, and other matters to ensure that all patients, including ESRD and AKI patients, receive safe and appropriate care.  Payment for Erythropoietin Stimulating Agents (ESAs) and the ESA Monitoring Policy for AKI Patients  ESAs are included in the bundled payment amount for treatments admini stered to patients with AKI. The Non -ESRD HCPCS codes should be used (J0881, J0883, J0885, J0888, Q0138, Q5106) and reported using revenue code 0636.  The ESA monitoring policy has not yet been extended to AKI patients receiving treatment in an ESRD facilit y. Since this policy is not applicable to these treatments, the value codes used to report hemoglobin and hematocrit levels are not required when billing for ESAs.   100.7 Billing for Physicians Services for Individuals with AKI  (Rev. 240, Issued: 01- 19-18, Effective: 01- 01-17, Implementation: 02-  20-18)  Physicians are able to bill separately for services provided to individuals with AKI. CMS expects providers to follow correct coding guidelines and use the appropriate HCPCS or CPT codes for the items and services provided to the patient.     The following CPT codes are available for ESRD facilities and physicians offices to use when billing for physicians services provided in either an ESRD facility (place of service 65) or a physicians office (place of  service 11):    90935 -  Hemodialysis procedure with single evaluation by a physician or other qualified health care professional;    90937 -  Hemodialysis procedure requiring repeated evaluation(s) with or without substantial revision of dialysis prescription;    90945 -  Dialysis procedure other than hemodialysis (eg, peritoneal dialysis, hemofiltration, or other continuous replacement therapies), with single evaluation by a physician or other qualified health care professional;    90947 -  Dialysis  procedure other than hemodialysis (eg, peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies) requiring repeated evaluations by a physician or other qualified health care professional, with or without substantial revision of  dialysis prescription.   Please note: this is not an exhaustive list  as indicated above, CMS expects facilities and physicians offices to bill the appropriate codes.    110 - Reserved  (Rev. 171, Issued: 06 -07-13, Effective: 01- 01-11, Implementation: 09- 09-13)  120 - Reserved  (Rev. 171, Issued: 06 -07-13, Effective: 01- 01-11, Implementation: 09- 09-13)  130 - Reserved  (Rev. 171, Issued: 06 -07-13, Effective: 01- 01-11, Implementation: 09- 09-13)  Appendix A  (Rev. 171, Issued: 06 -07-13, Effective: 01- 01-11, Implementation: 09 -09-13)  Composite Rate Tests for Hemodialysis, IPD, CCPD, and Hemofiltration (Items in bold are non composite rate test)   Chemistry  CPT Code  Monthly  Weekly  13 x Quarter  Albumin  82040  X   Alkaline Phosphates  84075  X   ALT (SGPT)  84460     AST (SGOT)  84450  X   Bilirubin, total  82247     Bilirubin, direct  82248     Calcium  82310  X   Calcium ionized (billed with modifier CD or CE)  82330 X   Calcium ionized (billed with modifier CF) 82330 X   Chloride  82435  X   Cholesterol  82465     CK, CPK  82550     CO2 (bicarbonate)  82374  X   Creatinine  82565   X  GGT  82977     Glucose  82947     LDH  83615  X   Phosphorus  84100  X   Potassium  84132  X   Protein, total  84155  X   Sodium  84295     Triglycerides  84478     Urea nitrogen (BUN)  84520    X Uric Acid  84550      Appendix B  (Rev. 171, Issued: 06 -07-13, Effective: 01- 01-11, Implementation: 09- 09-13)  Composite Rate Tests for CAPD (Items in bold are non composite rate test)   Chemistry  CPT Code  Monthly  Weekly  13 x Quarter  Albumin  82040  X   Alkaline Phosphatase  84075  X   ALT (SGPT)  84460     AST (SGOT)  84450  X   Bilirubin, total  82247     Bilirubin, direct  82248     Calcium  82310  X   Calcium ionized (billed with modifier CD or CE)  82330  X   Calcium ionized (billed with modifier CF) 82330  X   Chloride  82435     Cholesterol  82465     CK, CPK  82550     CO2 (bicarbonate)  82374  X   Creatinine  82565  X   GGT  82977     Glucose  82947     LDH  83615  X   Phosphorus  84100  X   Potassium  84132  X   Protein, total  84155  X   Sodium  84295  X   Triglycerides  84478     Urea nitrogen (BUN)  84520  X   Uric Acid  84550      Appendix C  (Rev. 171, Issued: 06 -07-13, Effective: 01- 01-11, Implementation: 09- 09-13)  Brief History of ESRD Composite Payment Rates for Outpatient Maintenance Dialysis