(Medicare Claims Processing Manual)

Note: The  payer only codes above are assigned by the Medicare standard systems and are not submitted on the claim by the provider.    The following provider data must also be passed to the ESRD PRICER to make provider -specific calculations that determine the ESRD PPS per treatment payment amount:   Field  Format  Actual Geographic Location MSA  X(4)  Actual Geographic Location CBSA  X(5)  Special Wage Index  9(2)V9(4)  Supplemental Wage Index  9(2)V9(4)  Provider Type  X(2)  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)   Based on the claim and provider data shown above, the ESRD PRICER makes adjustments to the  PPS  base rate to determine the ESRD PPS per treatment payment amount . The following factors are used to adjust and make calculations to the  ESRD PPS per treatment payment amount .  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)   Condition Code 84 for AKI patients (if applicable)   Condition Code 87 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 Comorbidities   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 adjus tment is provided, the claim is not entitled to a comorbidity adjustment or a training add -on adjustment.   Patient Comorbidities:   The ESRD PPS will provide adjustments for each category of chronic and acute  comorbidity conditions, 3 categories of chronic conditions and 3 categories of acute conditions.  In the event that more than one of the comorbidity categories is present on the claim, the claim will be adjusted for the highest paying comorbidity category.   Chronic Comorbidities    When chronic comorbidity 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.  Acute Comorbidities    Acute comorbidity category adjustments will be eligible for a payment for the first month reported and then for the next three consecutive months, regardless of whether or not the diagnosis code is on the claim after the first month. This adjustment applie s for no more than four consecutive months for any reported acute comorbidity category. Acute comorbidity conditions reported for more than four consecutive months will not receive additional payment.    In the event that the comorbidity condition was resolved and later reoccurred, the provider may submit a condition code to indicate the diagnosis is a reoccurrence. The adjustment will be applicable for an additional four months.  For a list of specific acute and chronic  comorbid conditions eligible for adj ustment, refer  to the following website:   https://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/ESRDpayment/Patient- Level -Adjustments   This list may be updated as often as quarterly in January, April, July and October of each year.   Low -Volume ESRD  Facilities:   ESRD facilities will receive an adjustment to their 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 preceding the payment year.  The ESRD facility must notify their A/B MAC (A) if th ey 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 not 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 t he 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:   Trai ning 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 P ayments:   The ESRD Prospective Payment System (PPS) includes a payment adjustment for high cost outliers when there are unusual variations in the type or amount of medically necessary care.    Outlier consideration is provided for the following:    ESRD -related drugs and biologicals that were or would have been prior to January 1, 2011, separately billable under Medicare Part B;   ESRD -related laboratory tests that were or would have been, prior to January 1, 2011 separately billable under Part B;   Medical/surgical 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   Renal dialysis service drugs that were or would have been, prior to January 1, 2011 covered under Medicare Part D.    For new injectable renal dialysis drugs and biologicals that are eligible outlier services, ESRD facilities should report J3591 with the National Drug Code (NDC) in the 11 -digit format 5 -4-2.  The MAC will set  the payment rate based on pricing methodologies under 1847A of the Act using the guidance in the Medicare Claims Processing Manual, Chapter 17 -  Drugs and Biologicals, Section 20.1.3 -  Exceptions to Average Sales Price (ASP) Payment Methodology.   Statute  requires the delay of the implementation of the oral -only renal dialysis service policy until January 1, 2025. Services not included in the PPS that remain separately payable are not considered outlier services.   When the ESRD PRICER returns an outlier pa yment, 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.    Transitional Drug Add- On Payment Adjustment (TDAPA)  Effec tive January 1, 2016 under the ESRD PPS drug designation process, CMS provides payment using a Transitional Drug Add- on Payment Adjustment (TDAPA) for new renal dialysis new injectable or intravenous drugs and biologicals that qualify under 42 CFR 413.234( c)(1).  CMS will pay for the drug or biological using a transitional drug add- on payment adjustment, if the new injectable or intravenous drug or biological is used to treat or manage a condition for which there is not an existing ESRD PPS functional category. CMS bases the TDAPA on payment methodologies under section 1847A of the Social Security Act which are discussed in Pub. 100- 04, Chapter 17, Section 20. The MAC will set the payment rate based on pricing methodologies under 1847A of the Act using the guidance in the Medicare Claims Processing Manual, Chapter 17 -  Drugs and Biologicals, Section 20.1.3 -  Exceptions to Average Sales Price (ASP) Payment Methodology.  This payment is applicable for a period of 2 years.  While the TDAPA applies to a new injec table or intravenous drug or biological, the drug or biological is not considered an outlier service, is not separately payable with the AY modifier and does not apply to acute kidney injury claims (AKI).  Drugs eligible for the TDAPA must billed with revenue code 0636 and modifier AX must be appended to the HCPCS.   The TDAPA claim lines are shown as covered line items but no payment will be included on the line item.  The TDAPA is included in the prospectiv e payment amount on the dialysis revenue code lines.   Q8 payer only value code captures the total allowable payment for the TDAPA. The ESRD pricer divides the Q8 amount by the total number of dialysis treatments and the per treatment amount is added to PPS rate and included in each dialysis line payment. Additional information on the TDAPA is available on the CMS website located at:  https://www.c ms.gov/Medicare/Medicare -Fee-for-Service-Payment/ESRDpayment/ESRD -Transitional -Drug   Transitional Add -on Payment Adjustment for New and Innovative Equipment and Supplies (TPNIES)  Beginning January 1, 2020, the ESRD PPS provides the Transitional Add- on Payment Adjustment for New and Innovative Equipment and Supplies (TPNIES) for new and innovative renal dialysis equipment and supplies that qualify under  413.236.  The TPNIES payment is based on 65 percent of the Medicare Administrative Contractor (MAC) determined price. The MACs, on behalf of CMS, establish prices for new and innovative renal dialysis equipment and supplies that meet the TPNIES eligibility criteria using verifiable information from the following sources of information, if available:    the invoice amount, facility charges for the item, discounts, allowances, and rebates;    the price established for the item by other MACs and the sources of information used to establish that price;   payment amounts determined by other payers and the information used to establish those payment amounts;  charges and payment amounts required for other equipment and supplies that may be comparable or otherwise relevant.  The TPNIES is paid for 2 calendar years, beginning on January 1 and ending on December 31. While the TPNIES applies to a new and innovative equipment or supply, the equipment or supply is not considered an outlier service.  Items eligible for the TPNIES must billed with revenue code 027X and modifier AX must be appended to the HCPCS. Until TPNIES items receive a HCPCS the TPNIES supplies are reported with HCPCS A4913 for miscellaneous dialysis supply not otherwise specified and for TPNIES equipment HCPCS E1699 is reported for miscellaneous dialysis equipment not otherwise specified.   The TPNIES cla im lines are shown as covered line items but no payment will be included on the line item.  The TPNIES is included in the prospective payment amount on the dialysis revenue code lines.   QG payer only value code captures the total allowable price for the TPN IES. The ESRD pricer calculates the 65 percent of the MAC determined price and divides the amount by the total number of dialysis treatments and the per treatment amount is added to PPS rate and included in each dialysis line payment.  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)