(Medicare Claims Processing Manual)

 The End Stage Renal Disease (ESRD) Prospective Payment System (PPS) provides a per treatment unit of payment. The per treatment unit of payment is the same base rate that is paid for all dialysis treatment modalities furnished by an ESRD facility.  The policy allows for 3 PPS payments per week.  When a beneficiarys plan of care requires more than three weekly dialysis treatments, whether HD or daily PD, claim edits are applied to ensure that Medicare payment on the monthly claim is consistent with the 3-times weekly dialysis treatment payment limit. Thus, for a 30 -day month, payment is limited to 13 treatments, and for a 31- day month, payment is limited to 14 treatments, with exceptions made for medical justification.    ESRD facilities billing for more than 13 or 14 treatments per month must provide medical justification as required by the Medicare Administrative Contractor in order to receive payment for the additional treatments. Additional treatments provided without meeting the medical justification required must include the modifier CG on the claim line. This modifier indicates that the facility  attests the additional treatment does not meet medical justification requirements.  Additional treatments billed without medical justification do not receive payment.  Non- covered treatments are not considered in the outlier payment calculation.    This policy does not apply for training and retraining treatments billed within the allowable limits.  See section 50.8 of this chapter for training and retraining treatments.  10.2 - Uncompleted Treatments  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implem entation:09- 07-21)   A dialysis treatment is started, when  a patient is connected to the machine and a dialyzer and bloodlines are used. However, if the is not completed for some unforeseen, but valid reason  such as  a medical emergency when the patient must be rushed to an emergency room, the facility is paid based on the full Prospective Payment System (PPS) base rate   This is a rare occurrence and must be fully documented to the A/B MAC (A)s satisfaction.   10.3 - No-Shows  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  If a facility sets up in preparation for a dialysis treatment, but the treatment is never started  because the patient never arrives, no payment is made. In this case, no service has been furnished to a Medicare beneficiary even though staff time and supplies may have been used.  Furthermore, the facility may not bill the patient or the patients private insura nce for these services.  This is because the program is already paying the cost of pre-dialysis services through the PPS base rate .  In setting that rate, CMS has included the salaries of facility personnel and the cost of supplies used for furnishing pre -dialysis services.   Therefore, these costs (e.g., salaries for staff time, overhead, supply costs) are included in the facilitys costs and reported on its cost report, and they are included in the allowable costs used to set future reimbursement rates under the End Stage Renal Disease Prospective Payment System (ESRD PPS)  for ESRD facilities.  However, these costs may not be used as the basis for a facility to be reimbursed as Medicare bad debts.  10.4 - Deductible and Coinsurance                                                           (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  The beneficiary is responsible for any unmet deductible and for coinsurance.    Eighty percent of the total End Stage Renal Disease Prospective Paym ent System (ESRD PPS) payment amount for renal dialysis services furnished by ESRD facilities to ESRD beneficiaries is paid by Medicare. ESRD beneficiaries are responsible for the remaining twenty percent after the deductible. Therefore, the beneficiary co insurance amount under the ESRD PPS is twenty percent of the total ESRD PPS payment, which includes the ESRD PPS base rate, all applicable adjustments, any applicable training add- on amounts and any applicable outlier payments.   10.5 - Hospital Services  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  Outpatient dialysis services for a patient with acute kidney failure or chronic kidney failure but not eligible for Medicare under the ESRD provisions at the time services are render ed must be billed by the hospital and cannot be billed by a Medicare certified renal dialysis facility on bill type 72x.   Hospitals with a Medicare certified renal dialysis facility should have outpatient ESRD related services billed by the hospital- based renal dialysis facility on bill type 72x.  Hospitals that do not have a Medicare certified renal dialysis facility may bill for outpatient emergency or unscheduled dialysis services.  The Prospective Payment System (PPS) base rate  is not paid. For more inf ormation regarding the outpatient hospital billing policy for ESRD related services, see chapter 4 section 210 of this manual.  When an individual is furnished outpatient hospital services and is thereafter admitted as an inpatient of the same hospital due  to renal failure -  within 24 hours for non PPS hospitals and within 72 hours for PPS hospitals -  the outpatient hospital services furnished are treated as inpatient services unless the patient does not have Part A coverage.  Charges are reported on the AS C X12 837 institutional claim format or on Form CMS -1450.  The day on which the patient is formally admitted as an inpatient is counted as the first inpatient day.  The PPS base rate  is not paid.  10.6 - Amount of Payment  (Rev. 10640, Issued:08- 06-21, Effe ctive:09 -07-21, Implementation:09- 07-21)  Effective for dates of service beginning January 1, 2011, after the beneficiarys Part B deductible is met, the A/B MACs (A) pay 80 percent of the ESRD PPS base rate and all applicable adjustments (or the blended payment amount if the facility chooses to transition), for each outpatient maintenance dialysis treatment furnished to the ESRD beneficiary in the ESRD facility or at the beneficiarys home.   10.7 - ESRD Services Not Provided Within the United States (Rev.  1, 10- 01-03)  Services (except for certain inpatient hospital services and related physicians and ambulance services in specified situations) that are not provided within the United States are not covered. United States includes the 50 States, the Distric t of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, and American Samoa.  See Chapter 1 for additional information concerning specified situations that may be covered, billing and payment procedures and jurisdiction for payment.   10.8 - Transportation Services  (Rev. 1, 10- 01-03)  In general, transportation services to obtain ESRD services are not covered. However, see the Medicare Benefit Policy Manual, Chapter 10, for coverage of ambulance services to renal dialysis facilities located on hospital premises and for coverage of ambulance services to nonhospital based dialysis facilities.  Billing and payment instructions are provided in Chapter 15 of this manual.  10.9  Dialysis Provider Number Series (Rev. 771, Issued: 12- 02-05, Effective: 01 -03-06, Implementation: 01- 03-06)  There are multiple facilities that provide dialysis services to ESRD beneficiaries.  To ensure that provider data is correct, facilities are required to use a Provider Number based on facility type issued by CMS.   The Provider Number Series for Dialysis Providers are as follows (for CMS use only, effective May 23, 2007, providers are required to submit only their National Provider Identifier (NPI).  The dialysis provider numbers will be mapped to the NPI):   2300- 2499 Chronic Renal Dialysis Facilities (Hospital  Based)  2500- 2899 Non  Hospital Renal Facilities  2900- 2999 Independent Special Purpose Renal Dialysis Facility  3300- 3399 Childrens Hospitals (Excluded from PPS)  3500- 3699 Renal Disease Treatment Centers (Hospi tal Satellites)  3700- 3799 Hospital Based Special Purpose Renal Dialysis Facilities   All facilities should use their appropriately assigned provider numbers on the 72x type of bill.  In the event that a facility changes from one type to another, the provider number must reflect the facilitys present provider type.   20 - End Stage Renal Disease Prospective Payment System (ESRD PPS)  Per Treatment Payment Amount                                                               (Rev. 10640, Issued:08- 06-21, Effective:09 -07-21, Implementation:09- 07-21)  A case mix methodology adjusts the  Prospective Payment System (PPS) base rate based on a limited number of patient characteristics.  Variables for which adjustments will be applied to the PPS base rate  include age, body surface area (BSA), and low body mass index (BMI).  These variables are determined in the ESRD PRICER to calculate the End Stage Renal Disease Prospective Payment System (ESRD PPS  per treatment payment amount (including all other adjustments).   The following table contains claim data required to calculate the ESRD PPS  per treatment payment amount .    Form CMS -1450  ASC X12 837 institutional claim  Through Date  2300 | DTP segment | 434 qualifier  Date of Birth  2010 BA | DMG02  Condition Codes (73, 74, 87) 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 ESRD PPS per treatment payment amount:     Form CMS -1450  Payer Only Format  Payer Only Condition C odes  (MA, MB, MC, MD, ME, MF)  (Identifies comorbid conditions for adjustments)  X(2)    Payer Only Value Code (79)  (Identifies dollar amount for services applicable for the calculation for determining outlier)   X(2) V(9)   Payer Only Value Code (Q8)  (Identifies dollar amount for services applicable for the calculation of the transitional drug add-on payment)   X(2) V(9)   Form CMS -1450  Payer Only Format  Payer Only Value Code (QG)  (Identifies dollar amount for services applicable for the calculation of the transitional  payment for new  innovative equipment and supplies)   X(2) V(9)    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)