(Medicare Benefit Policy Manual)

a. Duration of Acute Comorbidity  Adjustment   Payment for an acute comorbidity adjustment begins in the month in which the diagnosis is established, and lasts for the next 3 consecutive patient months. A patient month is any month in which a dialysis treatment is furnished, and an acute comorbidity applies.   The acute diagnosis comorbidity adjustment is applied to each dialysis treatment for 4 patient months. If a second comorbidity is diagnosed during that period (either acute or chronic), then the adjustment is made using the higher adjustment factor. At no time is an adjustment applied for more than one comorbidity.  When there is a recurrence of an acute comorbidity within the 4 patient month period, there will not be an extension of the 4 patient month adjustment. A recurrence is defined as a new episode of a comorbidity that was previously experienced by an individual beneficiary.  However, if the recurrence happens after the completion of the 4 month period, t hen a new comorbidity adjustment for 4 months would start.   Example  A male patient has been receiving hemodialysis since January 2010. He had a 2-week hospitalization due to a fracture in mid- January 2016. During his stay in the hospital, he was diagnose d with gastro -intestinal tract bleeding with hemorrhage on January 20, 2016. He resumed his outpatient maintenance dialysis on January 29, 2016. The 4 patient months in which the patients ESRD facility would be eligible to have the comorbidity adjustment applied to each dialysis treatment are January through April  2016.  b. Duration of Chronic Comorbidity  Adjustment   The chronic diagnosis comorbidity adjustment is applicable only when the comorbidity has an effect on the cost of dialysis care and when that chronic diagnosis comorbidity appears on the claim. The adjustment does not automatically continue each month. When an acute diagnosis comorbidity with a higher adjustment value is applicable at the same time a chronic comorbidity applies, then the higher adjustment will be applied for 4 patient months, and then revert to the lower chronic comorbidity payment adjustment factor.   6. Pediatric case -mix adjusters: Age and dialysis  modality   Pediatric patients are beneficiaries with ESRD who are under the age of 1 8. The same base rate is used for adult and pediatric patients, which is also adjusted by the area wage index. However, the base rate for pediatric patients is not adjusted for case -mix as adjustments used for adult patients. The pediatric payment adjustme nts use only two age categories (<13, age 13- 17) and dialysis modality (PD or HD).   The pediatric case -mix adjusters, applicable for CY 2011, are shown below. These values are presented for the purpose of demonstrating the computations shown in the examples in the following sections. Any revisions to the case -mix adjusters will be published in subsequent rulemaking.   Based on the two classification categories for age and modality, there are four pediatric classification groups.   Pediatric  Patient -Level  Characteristics  Adjustment  Value   CY 2011 - 2015  Beginning CY 2016  Age: <13, Modality: PD  1.033  1.063  Age:<13, Modality: Hemo  1.219  1.306  Age:13 -17, Modality: PD  1.067  1.102  Age:13 -17, Modality: Hemo  1.277  1.327   ESRD facilities do not receive the low -volume adjustment, described in 60.B.1, or the rural adjustment, described in 60.B.3, for pediatric beneficiaries. However, they are eligible for training add -on and outlier payments (described in 60.C and 60.D, of this chapter respectively).   The following example demonstrates the calculation of the payment rate for a pediatric patient who receives dialysis at an ESRD facility and is located in an urban area with a wage index of 1.10. The example also shows the application of the training add- on for eligible training treatments. Before giving the particulars of the pediatric dialysis patient, shown first is the calculation of the labor -adjusted base rate of $242.06, which is the starting point for the computation of the case -mix adjusted base rate.    Base rate:  $230.39   Labor -related share of base rate: $230.39 * 0.50673 =  $116.75   Wage index adjusted labor -related share: $116.75 * 1.1000 =  $128.42   Non labor -related share of base rate: $230.39 * (1 -0.50673) =  $113.64   Wage index adjusted base rate: $128.42 + $113.64 =  $242.06  Provided next is the characteristics of the pediatric patient and continue with the example.    Andrew, a 12 year old male, has been on CCPD since June 2010. His mother, who assists him with his dialysis at home, is no longer abl e to assist with dialysis beginning May 10, 2016. His aunt, who lives nearby, has agreed to be the caregiver and assist him with his dialysis. The aunt required 17 training sessions at an ESRD facility in order to become knowledgeable and skilled sufficiently to perform this role. These training sessions began May 16 and ended June 10. The above pediatric classification table reveals that Andrews pediatric dialysis classification group is cell 1, with an associated patient multiplier of 1.063. During the m onths of May and June 2016, the ESRD payment rate per HD - equivalent treatment would  be:  $242.06 * 1.063 = $257.31   However, the ESRD facility is entitled to receive payment for a maximum of 15 training treatments furnished in connection with a new caregiver. Because the amount of the training add -on is adjusted by the ESRD facilitys wage index (1.10), the amount of the training add -on is calculated as  follows:   Training rate: $50.16 Wage index: 1.10 Training payment: $50.16 * 1.10 = $55.18   For the  maximum number of 15 training treatments for which the training adjustment may be provided in connection with a PD patient, the payment rate, including the training add -on, would be:  ($242.06 * 1.063 + $55.18) = $312.49   NOTE: This example is computed wi thout regard to other adjustments (e.g., outlier payments.)     B. Facility -level  adjustments   There are three facility -level adjustments in the ESRD PPS.  The first adjustment accounts for ESRD facilities furnishing a low -volume of dialysis treatments. The second adjustment reflects urban and rural differences in area wage levels using an area wage index developed from Core Based Statistical Areas (CBSAs). The third is a rural adjustment beginning in CY 2016.   1. Low -Volume  Adjustment   ESRD facilities that qualify as being low -volume can receive the low -volume payment adjustment (LVPA) applied to each dialysis treatment they furnish beginning on or after January 1, 2011. For CY 2011 the payment adjustment was 18.9 percent, and beginning January 1, 2016, the paym ent adjustment is 23.9 percent.   a. Low -Volume  Criteria   To be eligible for the low -volume adjustment, an ESRD facility must meet specific criteria:    The ESRD facility must have furnished less than 4,000 dialysis treatments in each of the 3 cost reporting years preceding its payment year. This 3 year eligibility period is based on the ESRD facilitys as -filed or final settled 12 - consecutive month cost  reports.  o The term payment year is the period of time that is used for determining payment to ESRD facilities, which is a calendar year. The ESRD PPS is based on a calendar year which begins January 1 of each  year.   o The eligibility years are defined as the 3 years preceding the payment year and are based on cost reporting periods. Specifically, the cost  reporting periods that end in the 3 years immediately preceding the payment year. The cost reporting periods must report costs for 12 consecutive  months.   For purposes of determining eligibility for the low -volume  adjustment, the number of treatments is  the total number of treatments furnished to Medicare and non- Medicare patients. For peritoneal dialysis (PD) patients, 1 week of PD is considered equivalent to 3 hemodialysis (HD) treatments.  For example, a patient on PD for 21 days would have (21/7) x 3 or 9 HD -equivalent treatments. See 50.A.4 of this chapter for more information on hemodialysis equivalent  treatments.  The ESRD facility must not have opened, closed, or received a new provider number due to a change in ownership, (see Pub. 100- 07, chapt er 3, 3210), in the 3 years preceding the payment year.    o This 3 year period is based on the ESRD facilitys as -filed or final settled 12 -consecutive month cost reports that end in the 3 years immediately preceding the ESRD PPS payment year.    o An ESRD fac ility is determined to be opened when the ESRD facility is a new establishment newly surveyed by the state and Medicare, is certified for Medicare participation, receives a provider number, and begins furnishing Medicare certified outpatient maintenance dialysis treatments.    o If there is a change in ownership that does not result in a change in provider number but does cause a change in the fiscal year reporting to that of the new provider, the A/B MAC (A) should combine the reporting periods for determining eligibility to the  LVPA.   For example, prior to a change of ownership (CHOW), Facility A had a cost reporting period that spanned January 1 through December 31. Facility A had a CHOW mid -year that did not result in a new provider transaction ac cess number (PTAN) but caused a break in the cost reporting period.  The A/B MAC (A) would add Facility As cost report that spanned January 1 through May 31 to its cost report that spanned June 1 through December 31 to verify the total treatment count.  T he other situation that could occur is when a CHOW results in a change of the original fiscal period. For example, prior to a CHOW, Facility B had a cost reporting period that spanned January 1 through December 31 and, based on its cost reports for 2012 and 2013, it met the LVPA eligibility criteria. Then, Facility B had a CHOW in the beginning of 2014 that did not result in a new PTAN, but changed its cost reporting period to that of its new owner, October 1, 2014, through September 30, 2015. This scenario would create a short and a long cost report that would not total 12 months that the A/B MAC (A) would need to review for verification. That is, Facility B would have a cost report that spanned January 1, 2014, through July 31, 2014 (7 months) and a cost r eport that  spanned August 1, 2014 through September 30, 2015 (14 months). In this situation, the A/B MAC (A) should combine the two non- standard cost reporting periods that in combination may exceed 12 -consecutive months and prorate the data to equal a full 12-consecutive month period.  o Beginning January 1, 2019, if there is a CHOW that results in a change in provider number due to a facility -type change (for example, hospital based dialysis facility to independent dialysis facility) and the new owner accepts the Medicare agreement, the ESRD facility can qualify for the LVPA if they otherwise meet the LVPA eligibility criteria.  This policy does not extend to CHOWs where a new PTAN is issued for any other reason.   o Effective January 1, 2019, ESRD facilities t hat change their fiscal year end for cost reporting purposes, outside of a CHOW, qualify for the LVPA if they otherwise meet the LVPA eligibility criteria.  When this occurs, the MACs will combine the two nonstandard cost reporting periods of less than 12 months to equal a full 12-  consecutive month period or combine the two non- standard cost reporting periods, that in combination may exceed 12- consecutive months, and prorate the data to equal a full 12 -consecutive month period. This does not impact or chan ge requirements for reporting, as established by the MACs, or those set forth in  413.24(f)(3).