evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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)  A case mix methodology adjusts the composite payment rate based on a limited number of patient characteristics.  Variables for which adjustments will be applied to each facilitys composite rate include age, body surface area (BSA), and low body mass index (BMI).  These variables are determined in the ESRD PRICER to calculate the final composite rate (including all other adjustments).   The following table contains claim data required to calculate a final ESRD composite rate and the ESRD PPS rate:   Form CMS -1450  ASC X12 837 institutional claim  Through Date  2300 | DTP segment | 434 qualifier  Date of Birth  2010 BA | DMG02  Form CMS -1450  ASC X12 837 institutional claim  Condition Code (73 or 74)  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 final ESRD PPS rate:   Form CMS -1450  ASC X12 837 institutional claim  Payer Only Condition Codes  (MA, MB, MC, MD, ME, MF)  2300 | HI segment  | BG qualifier  Payer Only Value Code (79)  2300 | HI segment | BE qualifier
(Medicare Claims Processing Manual)
Note:  These payer  only codes above are assigned by the Medicare standard systems and are not submitted on the claim by the provider.  Payer only condition codes are only applicable when the appropriate corresponding diagnosis code(s) appears on the claim.  See information below in this section on co- morbidity diagnostic categories.  The payer only value code 79 represents the dollar amount for services applicable for the calculation in determining an outlier payment.  The following provider data must also be passed to the E SRD PRICER to make provider -specific calculations that determine the final ESRD rate:   Field  Format  Actual Geographic Location MSA  X(4)  Actual Geographic Location CBSA  X(5)  Special Wage Index  9(2)V9(4)  Provider Type  X(2)  Field  Format  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)   ESRD facilities may elect to be reimbursed 100 percent by ESRD PPS no later than November 1, 2010.  Facilities that do not elect to be reimbursed 100 percent by the ESRD PPS will be reimbursed by a blended payment rate which is composed of the current basic case- mix adjusted composite rate payment system and the new ESRD PPS.   Blended payment schedule:   Calendar year 2011  75 percent of the old payment methodology and 25 percent of new ESRD PPS payment   Calendar year 2012  50 percent of the old payment methodology and 50 percent of the new ESRD PPS payment   Calendar year 2013  25 percent of the old payment methodology and 75 percent of the new ESRD PPS payment   Calendar year 2014  100 percent of the ESRD PPS payment   Based on the claim and provider data shown above, the ESRD PRICER makes adjustments to the facility specific base rate to determine the final composite payment rate.  The following factors are used to adjust and make calculations to the final payment rate:   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)
(Medicare Claims Processing Manual)
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 Co -morbidities   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 adjustment is provided, the claim is not entitled to a co -morbidity adjustment or a training add -on adjustment.   Co-morbidity Adjustment Categories   The ESRD PPS will provide adjustments for 6 categories of co -morbidity conditions, 3 categories of chronic conditions and 3 categories of acute conditions.  In the event that more than one of the co -morbidity categories is present on the claim, the claim w ill be adjusted for the highest paying co -morbidity category.   Acute Co -morbidity Diagnostic Categories:   The acute co -morbidity categories will be eligible for a payment for the first month reported and the following 3 consecutive months.  Acute co- morbid ity conditions reported for more than 4 consecutive months will not receive additional payment.  In the event that the co -morbidity condition was resolved and later reoccurred, the provider may submit a condition code to indicate the diagnosis is a reoccur rence.  The adjustment will be applicable for an additional 4 months.   Acute Categories are:    Gastro -intestinal tract bleeding   Bacterial pneumonia   Pericarditis   Chronic Co -morbidity Diagnostic Categories:   When chronic co- morbidity 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.   Chronic Categories are:    Hereditary hemolytic or sickle cell anemia   Monoclonal gammopathy   Myelodysplastic  syndrome
(Medicare Claims Processing Manual)
Chronic Categories are:    Hereditary hemolytic or sickle cell anemia   Monoclonal gammopathy   Myelodysplastic  syndrome   Information related to the comorbid conditions eligible for adjustment can be found at the following website:  http://www.cms.go v/Medicare/Medicare- Fee-for-Service-Payment/ESRDpayment/Comorbidity_Conditions.html    This list may be updated as often as quarterly in January, April, July and October of each year.   Low -Volume Facilities:   ESRD facilities will receive an adjustment to th eir 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 prec eding the payment year.  The ESRD facility must notify their A/B MAC (A) if they 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 no t 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 the 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:   Training 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 Payments:
(Medicare Claims Processing Manual)
Outlier payments may be applied to the payment.  ESRD outlier services are the following items and services that are included in the ESRD PPS bundle: (1) ESRD -related d rugs and biologicals that were or would have been prior to January 1, 2011, separately billable under Medicare Part B; (2) ESRD -related laboratory tests that were or would have been, prior to January 1, 2011 separately billable under Part B; (3) medical/su rgical 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 (4) renal dialysis service drugs that were or would have been, prior to January  1, 2011 covered under Medicare Part D.  ESRD -related oral only drugs are delayed until January 1, 2014.  Services not included in the PPS that remain separately payable are not considered outlier services.  When the ESRD PRICER returns an outlier payment, 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.   Value Codes and Amounts   48 - Hemoglobin Reading -  Code indicates the most recent hemoglobin reading taken before the start of this billing period.  This is usually reported in three positions with a decimal.  Use the right of the delimiter for the third digit.   The blood sample for the hemoglobin reading must be obtained before the dialysis treatment.  If a hemoglobin value is not available facilities must report the value 99.99.
(Medicare Claims Processing Manual)
The blood sample for the hemoglobin reading must be obtained before the dialysis treatment.  If a hemoglobin value is not available facilities must report the value 99.99.   49 - Hematocrit Reading - Code indicates the most recent hematocrit reading taken before the start of this billing period.  This is usually reported in two positions (a percentage) to the left of the dollar/cents delimiter.  If the reading is provided with a decimal, use the position to the right of the delimiter for the third digit.   The blood sample for the hematocrit reading must be  obtained before the dialysis treatment.  If a hematocrit value is not available facilities must report the value 99.99.   The blood sample for the hematocrit reading must be obtained before the dialysis treatment.  If a hematocrit value is not available fa cilities must report the value 99.99.  20.1.1 - Calculation for Double Amputee Dialysis Patients  (Rev. 1389; Issued:  12- 07-07; Effective:  01- 01-08; Implementation:  01 -07-08)  For dialysis treatments on or after January 1, 2006, we are revising the repor ting requirements for value codes A8 and A9 for double amputee dialysis patients.  Weight should be calculated based on pre -amputation weight using the following formula:  Pre -amputation weight = Actual weight x 1.15    Example:  Current weight for double amputee patient = 75.5 kg.   Pre-Amputation weight = 75.5 x 1.15 = 89kg.   The results should be reported under value code A8.  Height should be reported under value code A9 as pre -amputation height.  Where feasible this measurement may be obtained from For m 2728.  20.2 - Pediatric Payment Model for ESRD PPS                                         (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  The pediatric payment model applies to all dialysis patients that are under the age of 18.  The model uses the ESRD PPS base rate applicable to adult dialysis patients which is then adjusted by separate adjusters based on two age groups (<13, 13- 17), and dialysis modality (HD, PD).
(Medicare Claims Processing Manual)
20.3 -End Stage Renal Disease  Quality Incentive Program ( ESRD QIP)  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)   153c of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) required The Centers for Medicare & Medicaid Services (CMS) to implement a quality based p ayment program for dialysis services with payment consequences effective January 1, 2012.  The measures are defined in the annual dialysis facility report (DFR) that each provider receives in addition to the final rule.  Contractors are notified annually through a Technical Direction Letter from CMS identifying ESRD facilities subject to QIP payment reduction.  Medicare contractors shall update the outpatient provider specific file (OPSF) as indicated for the payment year specified.   See chapter 4 of this manual for appropriate OPSF fields to update.   Valid values for ESRD facilities:  Blank = no reduction  1 =  percent payment reduction  2 = 1 percent payment reduction  3 = 1  percent payment reduction  4 = 2 percent pa yment reduction  30 - Publication of the Prospective Payment System (PPS) Base Rate     (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  The End Stage Renal Disease Prospective Payment System (ESRD PPS)  regulations require Centers  for Medicare & Medicaid Services  (CMS) to publish the  Prospective Payment System (PPS) base rate  in a Federal Register notice when CMS incorporates new cost data or wage index. When the PPS base rate  is updated, a listing of the new payment rates are  published via Recurring Update Notifications .  These rates are updated and published as needed and are used when issuing a PPS base rate  to a new or an existing facility .  40 - Acute Kidney Injury (AKI) Claims                                                      (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)
(Medicare Claims Processing Manual)
40 - Acute Kidney Injury (AKI) Claims                                                      (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)   Effective January 1, 2017, ESRD facilities, both hospital based and freestanding are able to furnish dialysis to AKI patients and receive payment under the ESRD PPS. Medicare will pay ESRD facilities for the dialysis treatment using the ESRD PPS base rate adjusted by the applicable ESRD PPS wage index. In addition to the dialysis treatment, the ESRD PPS base rate pays ESRD facilities for other items and services considered to be renal dialysis services as defined in 42 CFR 413.171.  No separate payment is made for those services considered to be renal dialysis services as payment is included in the ESRD PPS base rate. Other items and services that are furnished to beneficiaries  with AKI that are not considered to be renal dialysis services but are related to their dialysis as a result of their AKI, would be separately payable, this includes drugs, biologicals, laboratory services, and supplies that ESRD facilities are certified to furnish and that would otherwise be furnished to a beneficiary with AKI in a hospital outpatient setting.  AKI claims are billed on the 072X type of bill with condition code 84.  ESRD facilities are required to include revenue code 082X, 083x, or 088x for the modality of dialysis furnished with the Current Procedural Terminology (CPT) code G0491 (Dialysis procedure at a Medicare certified ESRD facility for Acute Kidney Injury without ESRD).  AKI claims do not receive payment adjustments for comorbidities, TDAPA, TPNIES or outlier.  The ESRD network reduction is not applicable to AKI claims.  More information on dialysis provided for AKI patients including the required diagnosis codes for billing AKI is available on the CMS website at:  https://www.cms.gov/Medicare/Medicare -Fee-for-Service- Payment/ESRDpayment/AKI -and-ESRD -Facilities .
(Medicare Claims Processing Manual)
50 - In-Facility Dialysis Bill Processing Procedures  (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)  General instructions for completing the claim are in Chapter 25. The following instructions a pply to facility reporting of ESRD services and to A/B MAC (A) processing of in-facility dialysis claims.   The shared system checks the Common Working File (CWF) to determine if there is Employer Group Health Plan (EGHP) insurance. Where the beneficiary is  covered under the EGHP insurance, see the Medicare Secondary Payer Manual.   50.1 - Laboratory Services Included in the End Stage Renal Disease Prospective Payment System  ESRD PPS                                                    (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  With the implementation of the End Stage Renal Disease Prospective Payment System ESRD PPS, effective for claims with dates of service on or after January 1, 2011, all ESRD -related laboratory services are i ncluded in the ESRD PPS base rate.   f the renal dialysis facility needs to report a lab service that was not related to the treatment of ESRD, they must include the modifier AY to indicate the item or service is not for the treatment of ESRD.   ESRD -related  lab services that were separately paid under the basic case -mix composite rate payment system are considered in the calculation of any applicable outlier payment under the ESRD PPS.       50.1.1  - Laboratory Services Performed During Emergency Room Service  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)