(Medicare Claims Processing Manual)

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.  Height should be reported under value code A9 as pre -amputation height.  Where feasible this measurement may be obtained from For m 2728.  20.2 - Pediatric Payment Model for ESRD PPS                                         (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  The pediatric payment model applies to all dialysis patients that are under the age of 18.  The model uses the ESRD PPS base rate applicable to adult dialysis patients which is then adjusted by separate adjusters based on two age groups (<13, 13- 17), and dialysis modality (HD, PD).   20.3 -End Stage Renal Disease  Quality Incentive Program ( ESRD QIP)  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)   153c of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) required The Centers for Medicare & Medicaid Services (CMS) to implement a quality based p ayment program for dialysis services with payment consequences effective January 1, 2012.  The measures are defined in the annual dialysis facility report (DFR) that each provider receives in addition to the final rule.  Contractors are notified annually through a Technical Direction Letter from CMS identifying ESRD facilities subject to QIP payment reduction.  Medicare contractors shall update the outpatient provider specific file (OPSF) as indicated for the payment year specified.   See chapter 4 of this manual for appropriate OPSF fields to update.   Valid values for ESRD facilities:  Blank = no reduction  1 =  percent payment reduction  2 = 1 percent payment reduction  3 = 1  percent payment reduction  4 = 2 percent pa yment reduction  30 - Publication of the Prospective Payment System (PPS) Base Rate     (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  The End Stage Renal Disease Prospective Payment System (ESRD PPS)  regulations require Centers  for Medicare & Medicaid Services  (CMS) to publish the  Prospective Payment System (PPS) base rate  in a Federal Register notice when CMS incorporates new cost data or wage index. When the PPS base rate  is updated, a listing of the new payment rates are  published via Recurring Update Notifications .  These rates are updated and published as needed and are used when issuing a PPS base rate  to a new or an existing facility .  40 - Acute Kidney Injury (AKI) Claims                                                      (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)   Effective January 1, 2017, ESRD facilities, both hospital based and freestanding are able to furnish dialysis to AKI patients and receive payment under the ESRD PPS. Medicare will pay ESRD facilities for the dialysis treatment using the ESRD PPS base rate adjusted by the applicable ESRD PPS wage index. In addition to the dialysis treatment, the ESRD PPS base rate pays ESRD facilities for other items and services considered to be renal dialysis services as defined in 42 CFR 413.171.  No separate payment is made for those services considered to be renal dialysis services as payment is included in the ESRD PPS base rate. Other items and services that are furnished to beneficiaries  with AKI that are not considered to be renal dialysis services but are related to their dialysis as a result of their AKI, would be separately payable, this includes 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.  AKI claims are billed on the 072X type of bill with condition code 84.  ESRD facilities are required to include revenue code 082X, 083x, or 088x for the modality of dialysis furnished with the Current Procedural Terminology (CPT) code G0491 (Dialysis procedure at a Medicare certified ESRD facility for Acute Kidney Injury without ESRD).  AKI claims do not receive payment adjustments for comorbidities, TDAPA, TPNIES or outlier.  The ESRD network reduction is not applicable to AKI claims.  More information on dialysis provided for AKI patients including the required diagnosis codes for billing AKI is available on the CMS website at:  https://www.cms.gov/Medicare/Medicare -Fee-for-Service- Payment/ESRDpayment/AKI -and-ESRD -Facilities .  50 - In-Facility Dialysis Bill Processing Procedures  (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)  General instructions for completing the claim are in Chapter 25. The following instructions a pply to facility reporting of ESRD services and to A/B MAC (A) processing of in-facility dialysis claims.   The shared system checks the Common Working File (CWF) to determine if there is Employer Group Health Plan (EGHP) insurance. Where the beneficiary is  covered under the EGHP insurance, see the Medicare Secondary Payer Manual.   50.1 - Laboratory Services Included in the End Stage Renal Disease Prospective Payment System  ESRD PPS                                                    (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  With the implementation of the End Stage Renal Disease Prospective Payment System ESRD PPS, effective for claims with dates of service on or after January 1, 2011, all ESRD -related laboratory services are i ncluded in the ESRD PPS base rate.   f the renal dialysis facility needs to report a lab service that was not related to the treatment of ESRD, they must include the modifier AY to indicate the item or service is not for the treatment of ESRD.   ESRD -related  lab services that were separately paid under the basic case -mix composite rate payment system are considered in the calculation of any applicable outlier payment under the ESRD PPS.       50.1.1  - Laboratory Services Performed During Emergency Room Service  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  For claims with dates of service on or after January 1, 2012, the consolidated billing edit for laboratory services will be bypassed when billed in conjunction with an emergency room service on a hospital outpatient claim and the AY modifier will not be necessary.  Allowing laboratory testing to bypass consolidated billing edits in the emergency room or department does not mean that  End Stage Renal Disease (ESRD)  facilities should send patients to the emergency room or department for routine laboratory testing or for the provision of renal dialysis services that should be provided by ESRD facilities.  The intent of the bypass is to acknowledge that there are emergency circumstances where the reason for the patients illness is unknown and the determination of a laboratory test as being ESRD -related is not known.  For hospital claims with dates of service on or after April 1, 2012, that include an emergency room service with revenue code 045x on a line item date that differs from the line item date of service for the related laboratory test(s) the hospital must include the modifier ET to attest that the laboratory test(s) were ordered in conjunction with the emergency services.  This i s necessary to recognize that emergency services often span two calendar days.   50.2 - Drugs and Biologicals Included in the End Stage Renal Disease Prospective Payment System  (ESRD (PPS)                                              (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  With the implementation of the End Stage Renal Disease Prospective Payment System  (ESRD PPS), effective for claims with dates of service on or after January 1, 2011, all ESRD -related injectable drugs and  biologicals and oral equivalents of those injectable drugs and biologicals are included in the ESRD PPS.   If the renal dialysis facility needs to report a drug that was furnished to an ESRD beneficiary that was not related to the treatment of ESRD, they must include the modifier AY to indicate the item or service is not for the treatment of ESRD.   ESRD -related drugs and biologicals that were separately paid under the basic case- mix composite rate payment system are considered in the calculation of any appl icable outlier payment under the ESRD PPS.      50.3 - Required Information for In -Facility Claims Paid Under the End Stage Renal Disease Prospective Payment System  ESRD PPS                       (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Nu mber (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   The electronic form required for billing ESRD claims is the ASC X12 837 institutional claim transaction.  The paper form, where permissible, is Form CMS -1450.  The coding and related descriptions for the following items are identical for the ASC X12 837 institutional claim format and Form CMS -1450.  S ee the related X12 implementation guide or Chapter 25, respectively, for where the information is reported.   Type of Bill   Acceptable codes for Medicare are:   721 -  Admit Through Discharge Claim -  This code is used for a bill encompassing an entire course of outpatient treatment for which the provider expects payment from the payer.   722 -  Interim -  First Claim -  This code is used for the first of an expected series of payment bills for the same course of treatment.   723 -  Interim -  Continuing Claim -  This code is used when a payment bill for the same course of treatment is submitted and further bills are expected to be submitted later.   724 -  Interim -  Last Claim -  This code is used for a payment bill which is the last of a series for this course of treatment. The Through date of this bill (FL 6) is the discharge date for this course of treatment.  727 -  Replacement of Prior Claim -  This code is used when the provider wants to correct (other than late charges) a previously submitted bill.  The previously s ubmitted bill needs to be resubmitted in its entirety, changing only the items that need correction.  This is the code used for the corrected or new bill.   728 -  Void/Cancel of a Prior Claim -  This code indicates this bill is a cancel- only adjustment of an incorrect bill previously submitted.  Cancel -only adjustments should be used only in cases of incorrect provider identification numbers, incorrect Medicare beneficiary identifier, duplicate payments and some OIG recoveries.  For incorrect provider numbe rs or Medicare beneficiary identifier, a corrected bill is also submitted using a code 721.   Statement Covers Period (From -Through)  - Hospital- based and independent renal dialysis facilities:  The beginning and ending service dates of the period included on this bill.  Note:  ESRD services are subject to the monthly billing requirements for repetitive services.   Condition Codes