(Medicare Claims Processing Manual)

The value of a typical week of dialysis services generally serves as the maximum weekly payment;.  While maintenance IPD is usually accomplished in sessions of 10- 12 hours duration, three times per week, it is sometimes accomplish ed in fewer sessions of longer duration.  Regardless of the particular regimen used, under the ESRD PPS  IPD is paid based on a weekly equivalence of three ESRD PPS payments rates per week.    IPD in the home is accomplished according to any one of several s chedules. The total weekly dialysis time varies from 50 to 80 hours. For example, home IPD may b e furnished every day for 10 hours per day, every other day for 15 hours per dialysis day, every night for 8 hours per night, etc. Regardless of the particular regimen used, under the ESRD PPS home IPD is paid based on a weekly equivalence of three ESRD PPS rates per week.   Line item billing is required for all dialysis sessions.  For intermittent home dialysis the facility submits a separate line item for each d ialysis session using the dates in the pre -determined plan of care and the units reported on each line should be one.  In the event that the schedule was changed, the provider should note the changes in the medical record and bill according to the revised schedule.   80.4 - Calculating Payment for Continuous Ambulatory Peritoneal Dialysis (CAPD) and Continuous Cycling Peritoneal Dialysis (CCPD) Under the ESRD PPS                                                                                               (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  CAPD and CCPD are furnished on a continuous basis, not in discrete sessions and, therefore, are paid on a weekly or daily basis, not on a per treatment basis. Facilities are require d to report the number of days in the units field. A facilitys daily payment rate is 1/7 of three times the composite rate for a single hemodialysis treatment.   The equivalent weekly or daily IPD or CAPD/CCPD payment does not depend upon the number of exc hanges of dialysate fluid per day (typically 3 -5) or the actual number of days per week that the patient undergoes dialysis. The weekly (or daily) rate is based on the equivalency of one week of IPD or CAPD/CCPD to one week of hemodialysis, regardless of t he actual number of dialysis days or exchanges in that week.   All home dialysis support services, equipment and supplies necessary for home IPD or CAPD/CCPD are included in the ESRD PPS payment. No support services, equipment or supplies may be paid in addition to the ESRD PPS .  Line item billing is required for all dialysis sessions.  For claims billing for Continuous Ambulatory Peritoneal Dialysis (CAPD) and Continuous Cycling Peritoneal Dialysis (CCPD), the provider may submit a separate dialysis line for each day of the month.  If the provider is aware of an inpatient stay for the beneficiary within the month, the  ESRD facility may include the date of admission and date of discharge as a billable day for the dialysis but should omit the dates within the  inpatient stay.  In the event that the  ESRD facility   is unaware of an inpatient stay during the month, the Medicare system shall detect the overlapping dates and reject only the line item dates within the inpatient stay but pay the remainder of the clai m for any dates that are not within the inpatient stay.   90  Reserved for Future Use                                                                     (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  100 - Dialysis Sessions Furnished to Patients Who are Traveling (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  A. Dialysis at Another Facility   All in -facility dialysis treatments furnished by and in a facility are billed by and paid to that facility under the ESRD PPS . This is true even if the patient is only temporary at a particular facility while traveling .  B. Temporary Home Dialysis   Patient s who normally dialyze in a facility may wish to dialyze temporarily as home dialysis patients while they travel or vacation.   Training services furnished to temporary home dialysis patients are covered and paid at the training rate subject to the usual r ules for reimbursement of training services.  100.1 - Physicians Services Furnished to a Dialysis Patient Away From Home or Usual Facility                                                                             (Rev. 10640, Issued:08- 06-21, Effective: 09-07-2021, Implementation:09- 07-21)  When a dialysis patient whose attending physician receives a monthly payment receives maintenance dialysis services of any kind outside the usual setting from any physician who is neither the attending physician nor that physicians substitute, the following procedures apply:    The physician who furnished the service submits a claim to the local A/C MAC (B) of jurisdiction;   The A/B MAC (B) will process the claim and send an MSN to the patient;    The A/B MAC (B) that has jurisdiction over the usual dialysis setting adjusts the MCP to the usual attending physician to account for the time the patient was absent from the usual dialysis setting.    The A/B MAC (B) that has jurisdiction over the usual dialysis setting adjusts the  MCP to the usual attending physician per 140.3.E  below to account for the time the patient was absent from the usual dialysis setting.   A/B MACs (B) must notify physicians that claims for services furnished to temporary patients must be identified as a claim for a temporary patient.  The physician must indicate temporary patient on the claim.   110 - Reduction in Medicare Program Payment to Fund ESRD Networks  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  A. General   Section 9335(j) of OBRA 1986 requires the Secretary to reduce the amount of each payment for each treatment by 50 cents and to allocate these amounts to ESRD network activities. This applies to all dialysis treatments furnished on or after January 1, 1987 for all treatment modalities, including training treatments. All Medicare hospital- based and independent ESRD facilities paid under the  ESRD PPS are affected.   The ESRD network reduction is $.50 per covered treatment when the full ESRD PPS rate is applicable. For ESRD claims billing for continuous modalities of dialysis performed in the beneficiarys home, the ESRD PPS rate is calculated at a daily per diem rate by taking the full ESRD PPS rate multiplied by 3 for the weekly allowable total and dividing by 7 to provide a daily treatment rate. The ESRD network reduction is also calculated at a daily rate by multiplying the $.50 by 3 for the weekly total network reduction and dividing by 7 for a daily network reduction of  $.21.  The reduction amount is reported in the Provider Statistics and Reimbursement Report (PS&R) and CWF using value code 71 to identify monies withheld to fund ESRD networks.   The Medicare payment reduction allocated toward funding the ESRD networks for the individual claims will be indicated on the remittance record to the facility.   Facilities may not claim the 50 -cent reduction as an expense on their Medicare cost reports.   C. Application of ESRD Network Funding to MSP Claims   The ESRD offset for net work funding on MSP claims will be applied as follows:    Where another payer, primary to Medicare, pays the claim in full, no ESRD offset is applicable;    Where another payer, primary to Medicare, makes a partial payment, the ESRD offset is deducted for each treatment as described in subsection C2 from the Medicare secondary payment; and    Where the ESRD offset amount is greater that the secondary payment amount, the entire Medicare secondary payment amount is applied towards the ESRD network funding. No Medicare secondary payment is made to the facility in this situation and no further ESRD offset is applicable. No additional ESRD offset for treatments on this claim will be made against other payments to the facility on the same remittance or on future pa yments for the same beneficiary.   120 - Renal Transplantation and Related Services  (Rev. 1341, Issued: 09- 21-07, Effective: 06- 28-07, Implementation: 10- 22-07)  Renal transplantation is a principal form of treatment available to patients with end -stage renal disease. See Medicare Provider Reimbursement Manual, Part I, 2771, for a description of related payment policies.  For a list of approved facilities, refer to the following Web site:    http://www.cms.gov/Medicare/Provider -Enrollment -and-Certification/CertificationandComplianc/Transplant.html   120.1 - Payment for Immunosuppressive Drugs Furnished to Transplant Patients  (Rev. 1, 10- 01-03)  A. General   Effective January 1, 1987, Medicare pays for FDA approved self -administered immunosuppressive drugs. Generally, under this benefit, payment is made for self -administered immunosuppressive drugs that are specifically labeled and appro ved for marketing as such by the FDA, as well as those prescription drugs, such as prednisone, that are used in conjunction with immunosuppressive drugs as part of a therapeutic regimen reflected in FDA approved labeling for immunosuppressive drugs. This benefit is subject to the Part B deductible and coinsurance provision. There is no time limitation on the coverage of these drugs; however, if a beneficiary loses Medicare coverage as a result of the transplant, the drugs are no longer covered. When the ben eficiary reaches the age of 65 and becomes entitled, that person can have the drugs covered again. The hospital pharmacy must ask the physician to furnish the patient with a non- refillable 30 -day prescription for the immunosuppressive drugs. This is becaus e the dosage of these drugs frequently diminishes over a period of time, and it is not uncommon for the physician to change the prescription from one drug to another because of the patients needs. Also, these drugs are expensive, and the coinsurance liabi lity on unused drugs could be a financial burden to the beneficiary. Unless there are special circumstances, the A/B MAC (A) and A/B MAC (B) do not consider a supply of drugs in excess of 30 days to be reasonable and necessary and limits payment accordingl y.  B. Payment   Payment is made on a reasonable cost basis if the beneficiary is the outpatient of a participating hospital. In all other cases, payment is made on an allowable charge basis.   C. FDA Approved Drugs   Some of the most commonly prescribed immunosuppressive drugs are:    Sandimmune (cyclosporine), Sandoz Pharmaceutical (oral or parenteral),   Imuran (azathioprine), Burroughs Wellcome Vial (oral),   Atgam (antithymocyte/globulin), Upjohn (parenteral); and   Orthoclone OKT3 (muromonab -  CD3) Ortho Pharmaceutical (parenteral).   Also covered are prescription drugs used in conjunction with immunosuppressive drugs as part of a therapeutic regimen reflected in FDA approved labeling for immunosuppressive drugs.  The payment for the drug is limited to the co st of the most frequently administered dosage of the drug (adjusted for medical factors as determined by the physician).   Consult such sources as the Drug Topics Red Book, American Druggists Blue Book, and Medispan, realizing that substantial discounts are  available.     130 - Physicians and Supplier (Nonfacility) Billing for ESRD Services - General  (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)  Payment for renal -related physicians services to ESRD patients is made in either of the following ways:    Under the Monthly Capitation Payment (MCP) (see 140 below for an explanation of the MCP); or    Using the daily codes for ESRD services (CPT codes 90922- 90925) with units that represent the number of days services were furnished.   Under the Initial method (IM)   The A/B MAC (B) receives bills from physicians for services furnished ESRD beneficiaries.   The A/B MAC ( A) receives bills from ESRD facilities.   Lab bills from CLIA certified independent dialysis facilities were billed to the A/B MAC (B) before September 1, 1997, and to the A/B MAC (A) beginning on that date. Other certified labs bill the A/C MAC (B).   130.1 - Initial Method for Physicians Services to Maintenance Dialysis Patients  (Rev. 1, 10- 01-03)