(Medicare Claims Processing Manual)

20.1  Calculation o f the Basic Case -Mix Adjusted Composite Rate  and the ESRD Prospective Payment System Rate  (Rev. 3053, Issued: 08- 28-14, Effective: ICD -10: Upon Implementation of ICD -10; ASC X12: 01 -01, 12, Implementation ICD -10: Upon Implementation of ICD -10; ASC X12: 09 -30-14)  A case mix methodology adjusts the composite payment rate based on a limited number of patient characteristics.  Variables for which adjustments will be applied to each facilitys composite rate include age, body surface area (BSA), and low body mass index (BMI).  These variables are determined in the ESRD PRICER to calculate the final composite rate (including all other adjustments).   The following table contains claim data required to calculate a final ESRD composite rate and the ESRD PPS rate:   Form CMS -1450  ASC X12 837 institutional claim  Through Date  2300 | DTP segment | 434 qualifier  Date of Birth  2010 BA | DMG02  Form CMS -1450  ASC X12 837 institutional claim  Condition Code (73 or 74)  2300 | HI segment  | BG qualifier  Value Codes (A8 and A9) / Amounts  2300 | HI segment | BE qualifier  Revenue Code (0821, 0831, 0841, 0851, 0880, or 0881)  2400 | SV201   For claims with dates of service on or after January 1, 2011, Medicare systems must pass the line item date of service dialysis revenue code lines when the onset of dialysis adjustment is applicable to one or more of the dialysis sessions reported on the claim.  Form CMS -1450  ASC X12 837 institutional claim  Line Item Date of Service for Revenue Code (0821, 0831, 0841, 0851  2400 | DTP Segment | D8 qualifier   In addition to the above claim  data, the following payer only codes are required on claims with dates of service on or after January 1, 2011 to calculate the final ESRD PPS rate:   Form CMS -1450  ASC X12 837 institutional claim  Payer Only Condition Codes  (MA, MB, MC, MD, ME, MF)  2300 | HI segment  | BG qualifier  Payer Only Value Code (79)  2300 | HI segment | BE qualifier   Note:  These payer  only codes above are assigned by the Medicare standard systems and are not submitted on the claim by the provider.  Payer only condition codes are only applicable when the appropriate corresponding diagnosis code(s) appears on the claim.  See information below in this section on co- morbidity diagnostic categories.  The payer only value code 79 represents the dollar amount for services applicable for the calculation in determining an outlier payment.  The following provider data must also be passed to the E SRD PRICER to make provider -specific calculations that determine the final ESRD rate:   Field  Format  Actual Geographic Location MSA  X(4)  Actual Geographic Location CBSA  X(5)  Special Wage Index  9(2)V9(4)  Provider Type  X(2)  Field  Format  Special Payment Indicator  X(1)   In addition to the above provider data, the following is required to calculate the final ESRD PPS rate effective January 1, 2011:   Field  Format  Blended Payment Indicator  X(1)  Low-Volume Indicator  X (1)   Effective January 1, 2012 the following is required to calculate the Quality Incentive Program adjustment for ESRD facilities:  Field  Format  Quality Indicator Field  X(1)   ESRD facilities may elect to be reimbursed 100 percent by ESRD PPS no later than November 1, 2010.  Facilities that do not elect to be reimbursed 100 percent by the ESRD PPS will be reimbursed by a blended payment rate which is composed of the current basic case- mix adjusted composite rate payment system and the new ESRD PPS.   Blended payment schedule:   Calendar year 2011  75 percent of the old payment methodology and 25 percent of new ESRD PPS payment   Calendar year 2012  50 percent of the old payment methodology and 50 percent of the new ESRD PPS payment   Calendar year 2013  25 percent of the old payment methodology and 75 percent of the new ESRD PPS payment   Calendar year 2014  100 percent of the ESRD PPS payment   Based on the claim and provider data shown above, the ESRD PRICER makes adjustments to the facility specific base rate to determine the final composite payment rate.  The following factors are used to adjust and make calculations to the final payment rate:   Provider Type   Drug add -on  Budget Neutrality Factor   Patient Age   Patient Height   Patient Weight  Patient BSA   Patient BMI   BSA factor   BMI factor   Condition Code 73 adjustment (if applicable)   Condition Code 74 adjustment (if applicable)   In addition to the above adjustments, the following adjustments may be applicable to the ESRD PPS base rate for adult  patient claims with dates of service on or after January 1, 2011:    Onset of Dialysis   Patient Co -morbidities   Low-Volume ESRD Facility   Onset of Dialysis:   Providers will receive an adjustment to the ESRD PPS base rate for patients within the initial 120 calendar days from when an ESRD beneficiary began their maintenance dialysis.  The provider does not report anything on the claim for this adjustment.  The adjustment is determined by the start date of dialysis in the Common Working File as reported on the patients 2728 form.  When the onset of dialysis adjustment is provided, the claim is not entitled to a co -morbidity adjustment or a training add -on adjustment.   Co-morbidity Adjustment Categories   The ESRD PPS will provide adjustments for 6 categories of co -morbidity conditions, 3 categories of chronic conditions and 3 categories of acute conditions.  In the event that more than one of the co -morbidity categories is present on the claim, the claim w ill be adjusted for the highest paying co -morbidity category.   Acute Co -morbidity Diagnostic Categories:   The acute co -morbidity categories will be eligible for a payment for the first month reported and the following 3 consecutive months.  Acute co- morbid ity conditions reported for more than 4 consecutive months will not receive additional payment.  In the event that the co -morbidity condition was resolved and later reoccurred, the provider may submit a condition code to indicate the diagnosis is a reoccur rence.  The adjustment will be applicable for an additional 4 months.   Acute Categories are:    Gastro -intestinal tract bleeding   Bacterial pneumonia   Pericarditis   Chronic Co -morbidity Diagnostic Categories:   When chronic co- morbidity codes are reported on the claim an adjustment may be made for as long as the chronic condition remains applicable to the patient care provided and is reported on the claim.   Chronic Categories are:    Hereditary hemolytic or sickle cell anemia   Monoclonal gammopathy   Myelodysplastic  syndrome   Information related to the comorbid conditions eligible for adjustment can be found at the following website:  http://www.cms.go v/Medicare/Medicare- Fee-for-Service-Payment/ESRDpayment/Comorbidity_Conditions.html    This list may be updated as often as quarterly in January, April, July and October of each year.   Low -Volume Facilities:   ESRD facilities will receive an adjustment to th eir ESRD PPS base rate when the facility furnished less than 4,000 treatments in each of the three cost report years preceding the payment year and has not open, closed, or received a new provider number due to a change in ownership during the 3 years prec eding the payment year.  The ESRD facility must notify their A/B MAC (A) if they believe they are eligible for the low -volume adjustment.  The A/B MAC (A) must validate the eligibility and update the provider specific file.  Pediatric patient claims are no t eligible for the low -volume adjustment.  A/B MACs (A) are instructed to validate the facilitys eligibility for the low volume adjustment.  If an A/B MAC (A) determines that an ESRD facility has received the low volume adjustment in error, the A/B MAC (A ) is required to adjust all of the ESRD facilitys affected claims to remove the adjustment within 6 months of finding the error.   In addition to the above adjustments, the following adjustments may be applicable to the ESRD PPS base rate for adult  and pediatric  patient claims with dates of service on or after January 1, 2011:   Training Adjustment:  The ESRD PPS provides a training add- on of $33.44 adjusted by the geographic area wage index that accounts for an hour of nursing time for training treatments.  The add -on applies to both PD and HD training treatments .  ESRD PPS Outlier Payments:   Outlier payments may be applied to the payment.  ESRD outlier services are the following items and services that are included in the ESRD PPS bundle: (1) ESRD -related d rugs and biologicals that were or would have been prior to January 1, 2011, separately billable under Medicare Part B; (2) ESRD -related laboratory tests that were or would have been, prior to January 1, 2011 separately billable under Part B; (3) medical/su rgical supplies, including syringes, used to administer ESRD -related drugs that were or would have been prior to January 1, 2011, separately billable under Medicare Part B; and (4) renal dialysis service drugs that were or would have been, prior to January  1, 2011 covered under Medicare Part D.  ESRD -related oral only drugs are delayed until January 1, 2014.  Services not included in the PPS that remain separately payable are not considered outlier services.  When the ESRD PRICER returns an outlier payment, the standard systems shall display the total applicable outlier payment on the claim with value code 17.   Information related to the outlier services eligible for adjustment can be found at the following website:    http://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/ESRDpayment/Outlier_Services.html    This list may be updated as often as quarterly in January, April, July and October of each year.   For claims submitted with dates of service on or after January 1, 2012, all drugs reported on the ESRD claim under revenue codes 0634, 0635 and 0636 with a rate available on the ASP file will be considered in  the Medicare allowed payment (MAP) amount for outlier consideration with the exception of any drugs reported with the AY modifier and drugs included in the original composite rate payment system.   Value Codes and Amounts   48 - Hemoglobin Reading -  Code indicates the most recent hemoglobin reading taken before the start of this billing period.  This is usually reported in three positions with a decimal.  Use the right of the delimiter for the third digit.   The blood sample for the hemoglobin reading must be obtained before the dialysis treatment.  If a hemoglobin value is not available facilities must report the value 99.99.   49 - Hematocrit Reading - Code indicates the most recent hematocrit reading taken before the start of this billing period.  This is usually reported in two positions (a percentage) to the left of the dollar/cents delimiter.  If the reading is provided with a decimal, use the position to the right of the delimiter for the third digit.   The blood sample for the hematocrit reading must be  obtained before the dialysis treatment.  If a hematocrit value is not available facilities must report the value 99.99.   The blood sample for the hematocrit reading must be obtained before the dialysis treatment.  If a hematocrit value is not available fa cilities must report the value 99.99.  20.1.1 - Calculation for Double Amputee Dialysis Patients  (Rev. 1389; Issued:  12- 07-07; Effective:  01- 01-08; Implementation:  01 -07-08)  For dialysis treatments on or after January 1, 2006, we are revising the repor ting requirements for value codes A8 and A9 for double amputee dialysis patients.  Weight should be calculated based on pre -amputation weight using the following formula:  Pre -amputation weight = Actual weight x 1.15    Example:  Current weight for double amputee patient = 75.5 kg.   Pre-Amputation weight = 75.5 x 1.15 = 89kg.   The results should be reported under value code A8.