evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
 Medically necessary home dialysis equipment (see 20.4.A of this chapter);    Home dialysis support  services (see below), which include but is not limited to the delivery, installation, maintenance, repair and testing of home dialysis equipment and support equipment;    Procurement and delivery of all necessary home dialysis supplies;    Renal dialysis laboratory tests;   Renal dialysis drugs and biologicals; and    All dialysis services furnished by the ESRD facilitys staff.   Some examples (but not an all -inclusive list) of renal dialysis items and services included in the ESRD PPS and may not  be billed s eparately when furnished by an ESRD facility are:    Staff time used to administer blood;  Declotting of shunts and any supplies used to declot shunts;   Oxygen and the administration of oxygen; and   Staff time used to administer separately billable items.   For additional information regarding conditions for coverage for home dialysis services, refer to 42 CFR 494.  A.  Home Dialysis Hemodialysis and Peritoneal Support Services   Home dialysis support services identified at 42 CFR 494.100 may be furnished in the home or in the ESRD facility.  Support services may be provided directly or via an agreement or arrangement with another approved ESRD facility.  Support services include (but are not limited to):   1. Periodic monitoring of a patients adaptation to home dial ysis and performance of dialysis, including provisions for visits to the home or the ESRD facility;   2. Emergency visits by qualified ESRD facility personnel;  3. Services provided by a qualified social worker and a qualified dietitian, made in accordance with a plan prepared and periodically reviewed by a professional team which includes the physician;   4. Individuals unscheduled visits to an ESRD facility made on an as -needed basis; e.g., assistance with difficult access situations;   5. Renal dialysis laboratory tes ts covered under the ESRD PPS;   6. Providing, installing, repairing, testing, and maintaining home dialysis equipment, including appropriate water testing and treatment;   7. Ordering of supplies on an ongoing basis;   8. Maintaining and submitting all required docum entation to the ESRD network;   9. A record keeping system that ensures continuity of care;   10. Changing necessary tubing;
(Medicare Benefit Policy Manual)
7. Ordering of supplies on an ongoing basis;   8. Maintaining and submitting all required docum entation to the ESRD network;   9. A record keeping system that ensures continuity of care;   10. Changing necessary tubing;   11. Watching the patient perform dialysis to assure that it is done correctly and to review any aspects of the technique that may require modif ication; and   12. Inspecting the access site and document any access site infections that may require a physician intervention or hospitalization.  The full range of home dialysis support services required by home patients are included in the ESRD PPS.  ESRD support services must be furnished periodically.  These services will usually be furnished during a periodic follow -up visit, but they may be furnished at separate times.  They may be furnished in the ESRD facility or in the home.   NOTE:  For additional inf ormation on  renal dialysis services furnished on or after  January 1, 2011, and paid under the ESRD PPS, refer to 20 of this chapter.  B.  In -facility Dialysis Sessions Furnished to Home Patients Who Are Traveling  Patients who are normally home dialysis  patients may be dialyzed by a Medicare certified ESRD facility on an in -facility basis when traveling away from home.  Patients who normally dialyze in an ESRD facility may wish to dialyze temporarily in another facility or as home dialysis patients while  they travel or vacation.  See Medicare Claims Processing Manual, Chapter 8, Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, 100, for billing services when traveling.   C.  Staff Assisted Home Dialysis   Effective January 1,  2011, renal dialysis services for patients receiving home dialysis may only be billed under Method I.  Staff -assisted home dialysis using nurses to assist ESRD beneficiaries is not included in the ESRD PPS and is not a Medicare covered service.   If an ent ity wishes to bill Medicare for a non- covered renal dialysis service they provide to Medicare beneficiaries, they must first enroll with the appropriate Medicare contractor (assuming that Medicare recognizes such type of provider/supplier for billing purposes).  Providers/suppliers must enroll in the jurisdiction(s) where they intend to provide services and follow the jurisdiction rules specified in Pub. 100-04, chapter 1, 10.
(Medicare Benefit Policy Manual)
Once the ESRD facility is enrolled with the appropriate Medicare contractor(s),  they should work with the contractor(s) to determine the appropriate code to bill for the service, if any.  Finally, entities enrolled in Medicare as Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS) suppliers may not bill the DME MAC s for professional or quasi -professional services, including but not limited to nurse caregiver staff -assistance services.  Instead, if a DMEPOS supplier is permitted under State law to furnish such services under its licensure and wishes to bill Medicare for such services, it must enroll with the appropriate Medicare contractor under such professional or quasi -professional service category as Medicare may recognize for Medicare billing purposes, if any.   For additional information, contact your appropriate  Medicare contractor.   30.2 - Home Dialysis Training  (Rev. 200, Issued: 12- 02-14, Effective: 01- 01-15, Implementation: 01- 05-15)  Self-dialysis and home dialysis training are programs provided by Medicare certified ESRD facilities that educate ESRD patient s and their caregivers to perform self -dialysis in the ESRD facility or home dialysis (including CAPD and CCPD) with little or no professional assistance.  Self -dialysis training can occur in the patients home or the in- facility when it is provided by the  qualified staff of the ESRD facility.  CMS expects that the patients who elect for home dialysis are good candidates for home dialysis training, and therefore, will successfully complete their method of training before reaching the maximum number of sessi ons allotted.  Dialysis training services are reimbursed in accordance with Pub. 100- 04, Medicare Claims Processing Manual, chapter 8, 50.8.   Home dialysis training services and supplies may include but are not limited to personnel services; dialysis supplies, parenteral items used in dialysis, written training manuals and materials, and renal dialysis laboratory tests.  For more information on the requirements for ESRD facilities, see 42 CFR Part 494.  An ESRD facility may bill a maximum of 25 trainin g sessions per patient for hemodialysis training and 15 sessions for CCPD and CAPD.  For information on how home dialysis training treatments are paid, see 60.C of this chapter.
(Medicare Benefit Policy Manual)
NOTE:   ESRD facilities that are certified for home dialysis training and sup port services are expected to provide training throughout the home dialysis experience.  Information regarding home dialysis training certification may be found at the following link: http://www.cms.gov/Medicare/Provider -Enrollment -and-Certification/GuidanceforLawsAndRegulations/Dialysis.html .  A.  Hemodialysis Training  The average training time for hemodialysis patients is based upon 5- hour sessions given 3 times per week.  In some dialysis programs, the dialysis partner is trained to perform the dialysis treatment in its entirety.  The patient plays a secondary role.  In other programs, the patient performs most of the treatment an d is only aided by a helper.   B.  Intermittent Peritoneal Dialysis Training (IPD)   The IPD patients can be trained in approximately 4 weeks.  IPD is usually accomplished in sessions of 10- 12 hours.  It is sometimes accomplished in fewer sessions of longer duration.  In the IPD program, the patients partner is usually trained to carry out the dialytic care.  The patient plays a secondary or minimal role, as most are unable to perform self -care dialysis.  IPD patients are usually unable to perform self -care dialysis because of other debilitating conditions.  C.  Continuous Ambulatory Peritoneal Dialysis (CAPD) Training  The CAPD training is furnished in sessions that can last up to 8 hours (one session per day) 5 - 6 days per week.  Typically, 6 - 8 CAPD exch anges can be performed per day for the purpose of teaching the patient the CAPD technique; however, no specific number of exchanges is required.  Normally patients are trained within 2 weeks (5 -  6 training sessions per week); however, up to 15 sessions (i .e., 15 training days) may be covered routinely.  Additional CAPD training sessions are covered only when documented for medical necessity.  Extra training sessions raise questions about either the adequacy of CAPD for the patient or the patients capacity  to learn or perform the CAPD technique.  The patients physician should address these questions in the explanation of the need for extra training sessions.  The A/B MAC (A) will make a determination whether or not to permit training sessions in excess of 15.
(Medicare Benefit Policy Manual)
Once the patient is trained, CAPD is primarily a home service because the patient performs CAPD 24 hours a day.  Therefore, renal dialysis services that are specifically CAPD services are training services and include associated services that are furn ished in the ESRD facility during training.  Persons who are primarily treated by CAPD may also require in -facility dialysis, either intermittent peritoneal or hemodialysis, occasionally.   Prior to the implementation of the ESRD PPS, there were specific fr equency coverage requirements of the routine laboratory services furnished for CAPD.  The CAPD laboratory tests that were included under the composite rate are those monthly tests listed in (20.2.E.1.b of this chapter) and they are covered during training .  The coverage frequency screens for these laboratory tests did not apply during training, as these tests were commonly given during each training session.  All of these tests were included in the training screen, regardless of how frequently they were gi ven, and may have been billed separately.  Under the composite rate, separately billable laboratory tests must have been documented for medical necessity.  However, under the ESRD PPS all renal dialysis laboratory services are included in the bundle regardless of the frequency they are furnished.  Supplemental Dialysis during CAPD Training   It may be necessary to supplement the patients dialysis during CAPD training with intermittent peritoneal dialysis because the patient has not yet mastered the CAPD technique.  Generally, no more than three supplemental intermittent peritoneal dialysis sessions are required during the course of CAPD training, and these may be covered routinely.  If more than three sessions are billed during training, the claims must be documented for medical necessity.  Under certain circumstances, the form of supplemental dialysis may be hemodialysis.   D.  Continuous Cycling Peritoneal Dialysis (CCPD) Training  Continuous cycling peritoneal dialysis training is furnished in sessions of 8  hours per day 5 days per week.  Typically, five exchanges can be performed per day to teach the patient the technique; however, no specific number of exchanges is required.  Most patients are trained within 2 weeks; however, up to 15 sessions may be cover ed routinely.  The A/B MAC (A) will determine whether or not training sessions over 15 are medically necessary.   E.  Retraining
(Medicare Benefit Policy Manual)
E.  Retraining   Payment is made for retraining self -dialysis education after a patient or caregiver has completed the initial program if the pa tient continues to be an appropriate candidate for home dialysis.  Most patients receive additional training on the use of new equipment, a change in their caregiver, or a change in modality.  The ESRD facility may not bill for retraining services when the y install home dialysis equipment or furnish monitoring services.  For example, an ESRD facility nurse may not bill for retraining sessions to update treatment records, order new supplies, or add additional medicine for the treatment of infection.  NOTE:   When retraining and educational services are furnished to a patient or caregiver already knowledgeable in some other form of self -dialysis or if training is being done for a change of equipment, fewer sessions are necessary because of the transferability o f certain basic skills.   Criteria for retraining are explained in greater detail in Pub. 100 -04, Medicare Claims Processing Manual, chapter 8, 50.8.   40 - Other Services  (Rev. 200, Issued: 12- 02-14, Effective: 01- 01-15, Implementation: 01- 05-15)  ESRD beneficiaries may receive other services that may be related to their ESRD diagnosis but are excluded from the ESRD PPS payment.  A.  Coverage under the Home Health Benefit for ESRD Patients   Services that are covered under the ESRD PPS are excluded from coverage under the Medicare home health benefit.   Services can be provided to dialysis patients under the home health benefit as long as the condition that necessitates home health care is not a renal dialysis service.  A beneficiary, entitled to Medicare u nder the ESRD program, is eligible for home health benefits as is any other Medicare beneficiary if coverage conditions are met provided the patients condition is not covered by the ESRD PPS.  This is true even where the primary condition is related to ki dney failure.  For example, Medicare will pay for home health care, such as decubitus care or for severe hypotension that is not included in the ESRD PPS.
(Medicare Benefit Policy Manual)
Medicare patients can receive care under both the ESRD benefit and the home health benefit.  The key  is whether or not the services are being furnished for the treatment of the patients ESRD.  Surgical dressing changes that are furnished for the treatment of ESRD are to be provided by the ESRD facility, but dressing changes furnished for reasons other t han for the treatment of ESRD may be provided under the home health benefit provided all eligibility criteria have been met.  See 42 CFR 409.49(e) .  B.  Coverage under the Hospice Benefit   If the patients terminal condition is not related to ESRD, the patient may receive covered services under both the ESRD benefit and the hospice benefit.  Hospice agencies can provide hospice services to patients who wish to continue dialysis treatment.   C.  Skil led Nursing Facility (SNF) Patients Needing Dialysis Services   Section 4432(b) of the Balanced Budget Act (BBA) requires consolidated billing for SNFs.  Dialysis and certain dialysis -related services including covered ambulance transportation to obtain the  dialysis services are excluded from SNF consolidated billing and the services may be billed separately.  For more information regarding ESRD patients also receiving services in a SNF, see Pub. 100- 02, chapter 8, 10.2 and Pub. 100-04, chapter 6, 20.2.1.   D.  Nursing Homes and/or Long Term Care Facility (LTC) Patients Needing Dialysis Services   Medicare ESRD beneficiaries who permanently reside in a nursing home or LTC facilities and who meet the home dialysis requirements set forth under 42 CFR 494.100 a re considered home dialysis patients.  All home dialysis items and services will be paid under the ESRD PPS and no separate payment will be made to the facility.   E.  Physicians Services for ESRD Beneficiaries
(Medicare Benefit Policy Manual)
E.  Physicians Services for ESRD Beneficiaries   Physician services are excluded from the ESR D PPS.  Payment for physicians services is subject to the guidelines in Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 15, 30.  Medicare pays physicians services furnished in connection with dialysis sessions for outpatients who are on maintenance  dialysis in an ESRD facility or at home by the monthly capitation payment method or the initial method.  See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 8, for payment instructions.  For physician responsibilities, refer to 42 CFR 414.310.  F.  The Sudden Onset of Acute Symptoms During Renal Dialysis Services   Renal dialysis services furnished in other settings, such as declotting of shunts, suture removal, or furnishing renal dialysis drugs may be paid separately only if the services could not have been furnished in the ESRD facility.   Emergency renal dialysis services furnished in a hospital emergency room are separately paid when medical justification is submitted on the claim and when the absence of immediate medical attention in the emergency room could reasonably be expected to result in either:    Placing the patients health in serious jeopardy;   Serious impairment to bodily functions; or   Serious dysfunction of any bodily organ or part.   G.  Renal Dialysis Services Furnished During the Crea tion or Revision of a Vascular Access   The creation or revision of an ESRD patients vascular access is usually performed in hospital outpatient departments.  Laboratory services, drugs and biologicals, and equipment and supplies furnished to ESRD benefici aries for the treatment of ESRD on the day a procedure is performed to create or revise a vascular access site is not considered to be renal dialysis services.  Providers furnishing renal dialysis services that are subject to the ESRD PPS consolidated bill ing requirements during the creation or revision of a vascular access for an ESRD beneficiary should bill those services separately with an AY modifier.  The appropriate HCPCS or CPT code indicating the creation or revision of an access site is required on the claim.  Items and services that are subject to the ESRD PPS consolidated billing requirements may be found at http://www.cms.gov/ESRDPayment/50_Consolidated_Bill ing.asp#TopOfPage .
(Medicare Benefit Policy Manual)
H.  Noninvasive Vascular Studies for ESRD Patients   For dialysis to take place there must be a means of access so that the exchange of waste products may occur.  As part of the dialysis treatment, ESRD facilities are responsible for monitoring access to determine if the access site is functioning correctly.   An ESRD facility must furnish all necessary services, equipment, and supplies associated with a dialysis treatment, either directly or under arrangements.  The ESRD facility is fi nancially responsible for the service.  If an ESRD facility or a renal physician decides to monitor the patients access site with a non -invasive vascular study and does not have the equipment to perform the procedure, the ESRD facility or physician may ar range for the service to be furnished by another source.  The alternative source, such as an independent diagnostic testing facility must look to the ESRD facility for payment.   Procedures associated with monitoring access may include activities such as, b ut not limited to, taking venous pressure, aspirating thrombus, observing elevated recirculation time, reduced urea reduction ratios, or collapsed shunt, etc.  All such procedures are included under the ESRD PPS.  Non- invasive vascular studies such as dupl ex and Doppler flow scans are not covered as separately billable services if used to monitor a patients vascular access site.   Doppler flow studies may be considered appropriate in the presence of signs or symptoms of possible failure of the ESRD patient s vascular access site, and when the results are used in determining the clinical course of the treatment for the patient.  Routine monitoring by noninvasive Doppler flow studies is included under the ESRD PPS.   Examples supporting the medical necessity fo r Doppler flow studies include:    Elevated dynamic venous pressure >200mm HG when measured during dialysis with the blood pump set on a 200cc/min.,   Access recirculation of 12 percent or greater,    An otherwise unexplained urea reduction ratio <60 percent, a nd   An access with a palpable water hammer pulse on examination, (which implies venous outflow obstruction).
(Medicare Benefit Policy Manual)
 An otherwise unexplained urea reduction ratio <60 percent, a nd   An access with a palpable water hammer pulse on examination, (which implies venous outflow obstruction).  Unless the documentation is provided supporting the necessity of more than one study, Medicare will limit payment to either a Doppler flow study  or an arteriogram (fistulogram, venogram), but not both.  An example of when both studies may be clinically necessary is when a Doppler flow study demonstrates:    Reduced flow (blood flow rate less than 800cc/min or   A decreased flow of 25 percent or greater from previous study) and   The physician requires an arteriogram to define the problem.   This policy is applicable to claims from ESRD facilities and all other sources, such as independent diagnostic testing facilities and hospital outpatient departments.   The professional component of the procedure is included in the MCP.  The professional component is denied if billed by the MCP physician. Medically necessary services that are included or bundled into the MCP (e.g., test interpretations) are separately p ayable when furnished by physicians other than the MCP physician.  The MCP physician is identified by the performing provider number that billed MCP services identified by the HCPCS code 90995.   I.  Nutritional Services   ESRD facilities are required, in ac cordance with 42 CFR 494.80(a)(6) and 494.90(a)(2), to evaluate a patients nutritional status and expected to assist the patient in achieving their nutritional goals by providing education, counseling, and encouragement.  These services are included in the ESRD PPS.  Nutritional items, such as nutritional supplements, are not considered related to the treatment of ESRD and are not included in the ESRD PPS as renal dialysis services.   50 - ESRD Prospective Payment System (PPS) Base Rate  (Rev. 200, Issued:  12-02-14, Effective: 01- 01-15, Implementation: 01- 05-15)  Updates to the provisions under the ESRD PPS are discussed through rulemaking on a yearly basis.  The updates are implemented through Recurring Update Notifications.  A.  Per Treatment Unit of Payment