evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Services which are provided but which are not included in the composite rate may be billed as described in sections that address those specific services.   The last revenue code entered in as 000l represents the total of all charges billed.   Principal Diagnosis Code   Hospital -based and independent renal facilities must complete this item and it should include a diagnosis of end stage renal disease for patients with ESRD. For patients with AKI see section 40 of this chapter.  Other Diagnosis Code(s)   For claims with dates of service on or after January 1, 2011 rena l dialysis facilities report the appropriate diagnosis code(s) for comorbidity conditions eligible for an adjustment.  50.3.1 - Submitting Corrected Bills  (Rev. 1, 10- 01-03)  Claimants must submit a corrected claim if any of the following apply to a previously processed claim:    A change in provider number;   A change in coinsurance involves an amount greater than $1.99; or   A change in visits (decrease or increase).   Claimants must follow procedures for submitting corrected bills in Chapter 26.  50.4 - Line Item Detail Billing and Automated Claim Adjustments (Rev. 1364, Issued:  11- 02-07: Effective:  04- 01-08; Implantation:  04- 07-08)
(Medicare Claims Processing Manual)
The implementation of line item detail billing for ESRD claims effective on April 1, 2007 requires that each service be submitted on a separate line with the appropriate line item date of service.  The Medicare standard systems perform line item date of service compare for RDFs claims with statement billing periods overlapping the statement billing period of another proc essed claim.  This prevents monthly claims from receiving overlapping edits based on the statement billing period dates but rather, only when the RDF claim has a line item that duplicates another processed claim or falls within the dates of an inpatient hospital stay.  Standard systems reject only those overlapping line items while any line items not overlapping another claim continue to process for payment.  As a result of this logic, the RDFs no longer have to submit the occurrence span code 74 on the mon thly dialysis claim when an inpatient stay occurred during the same month.  The initial line item detail billing instruction did not implement a process for rejecting services on the RDF claim overlapping an inpatient stay when the RDF claim is received before the inpatient hospital claim.  A subsequent instruction implemented for April 1, 2008 requires the Medicare Common Working File (CWF) to create an informational unsolicited response prompting the standard system to perform an automated adjustment of the processed 72x claim that contains line item dates of service that are overlapping dates of an incoming inpatient hospital claim.  The admission and discharge dates of an inpatient stay are not considered overlapping dates and may be payable to the RDF.   50.5 - Intermittent Peritoneal Dialysis (IP D) in the Facility (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  Payment for Intermittent Peritoneal Dialysis (IPD)  in the facility is subject to the same payment rules as hemodialysis.   50.6 - In-Facility Back -Up Dialysis  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)
(Medicare Claims Processing Manual)
50.6 - In-Facility Back -Up Dialysis  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)   Back -up dialysis is an in- facility dialysis treatment furnished to a home dialysis patient. Condition code 76 must appear as one  entry in Form Locators ( FLs) 24-30. The facility must explain why any in -facility backup dialysis sessions (furnished on either an inpatient or outpatient basis) are furnished to home dialysis patients who are covered under the Prospective Payment System (PPS) base rate . If a backup session is furnished because of a failure to furnish any of the required items or services, then it will be covered only to the extent of a home dialysis session and reimbursed at the facilitys  PPS base rate . If the backup dia lysis is furnished by an institution other than the home patients End Stage Renal Disease (ESRD)  facility, then the ESRD facility must assume financial liability for any cost or charge in excess of the ESRD  facilitys PPS base  rate except where the patien t is traveling away from home.    50.6.1 - Payment for In -Facility Maintenance Dialysis Sessions Furnished to Continuous Ambulatory Peritoneal Dialysis (CAPD) /Continuous Cycling Peritoneal Dialysis (CCPD  Home Dialysis Patients          (Rev. 10640, Issued:08 -06-21, Effective:09- 07-21, Implementation:09- 07-21)  Although Continuous Ambulatory Peritoneal Dialysis  (CAPD ) and Continuous Cycling Peritoneal Dialysis  (CCPD ) patients are home dialysis patients, it may be necessary at times to dialyze them in -facility as a substitute.  In this case, the total weekly reimbursement to the facility remains the same regardless of the type and frequency of in -facility dialysis involved.   In order to furnish covered CAPD services, a facility must be a Medicare approv ed ESRD facility and must meet additional standards established by CMS.
(Medicare Claims Processing Manual)
In order to furnish covered CAPD services, a facility must be a Medicare approv ed ESRD facility and must meet additional standards established by CMS.   However, in rare instances an ESRD patient may require a combination of dialysis techniques, on the same day, in order to achieve satisfactory results.  In these situations, Medicare pays for both types of dialysis services furnished on the same day.  Medicare A/B MACs (A) determine the medical necessity.  In each case the A/B MAC (A) obtains medical documentation from the facility that supports the use of back- up dialysis with another  treatment modality.  If a CAPD patient frequently requires back- up sessions, the A/B MAC (A)s medical staff may request medical records to determine if this is the appropriate mode of treatment to meet medical necessity requirement for payment purposes a nd/or whether a different mode of treatment is more advantageous to the beneficiary.   50.6.2 - Payment for Hemodialysis Sessions  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  Hemodialysis is typically furnished three times per  week in sessions of three to five hours duration. Each hemodialysis session equals one PPS base  rate payment.  Therefore, three sessions per week is three PPS base rate payments.  Dialysis furnished at this frequency is paid without the need for a secondary diagnosis to justify payment.  The justification must support the medical necessity of the service(s) being rendered.   50.7 - Ultrafiltration  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)   Ultrafiltration (revenue co de 0881) is a process for removing excess fluid from the blood through the dialysis membrane by means of pressure. It is not a substitute for dialysis. Ultrafiltration is used in cases where excess fluid cannot be removed easily during the regular course o f hemodialysis. It is commonly done during the first hour or two of hemodialysis on patients who, for example, have refractory edema.
(Medicare Claims Processing Manual)
Pre-dialysis Ultrafiltration -  While the need, if any, for pre -dialysis ultrafiltration varies from patient to patient, the facilitys PPS rate  covers the full range of complicated and uncomplicated outpatient dialysis treatments. Therefore, no additional charge is recognized for pre -dialysis ultrafiltration.   Separate Ultrafiltration -  Occasionally, medical complications require that ultrafiltration be performed at a time other than when a dialysis treatment is given, and in these cases an additional payment may be made. However, the need for separate ultrafiltration must be documented in the medical record and a supporting other diagnosis must be included on the claim.   50.8 - Training and Retraining  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  See Pub. 100- 02 Medicare Benefit Policy Manual, Chapter 11, for coverage rules for dialysis training.   Training services and supplies that are covered under the Prospective Payment System (PPS) base rate includes personnel services, dialysis supplies and parenteral items used in dialysis, written training manuals, material and laboratory tests.    End Stage Renal Disease Prospective Payment System (ESRD PPS)  claims with dates of service on or after January 1, 2011, billing for dialysis training sessions will receive a home dialysis training add -on payment.    The home dialysis training add- on paym ent  is adjusted by the geographic area wage index  and added to the PPS base rate. The home dialysis training add- on payment that accounts for nursing time for training treatments. The home dialysis training add -on payment applies to both peritoneal dialys is (PD) and hemodialysis ( HD) training treatments.  Updates to the home dialysis training add- on payment are published through rulemaking .  Hemodialysis (HD)  Training (082X):  An ESRD facility may bill a maximum of 25 training sessions per patient for hemodialysis training.
(Medicare Claims Processing Manual)
Hemodialysis (HD)  Training (082X):  An ESRD facility may bill a maximum of 25 training sessions per patient for hemodialysis training.   Intermittent Peritoneal Dialysis (IPD) Training (083X):  An ESRD facility is not reimbursed for more three IPD treatments in a single week, for a total duration longer than 3 months.  Continuous Ambulatory Peritoneal Dialysis (CAPD) Train ing (84X):  An ESRD facility may bill a maximum of 15 training sessions per patient for CAPD training.  The A/B MAC (A) will make a determination whether or not to permit training sessions in excess of 15.   Continuous Cycling Peritoneal Dialysis (CCPD) Training (085X):  An ESRD facility may bill a maximum of 15 training sessions per patient for CCPD training. The A/B MAC (A) will determine whether or not training sessions over 15 are medically necessary.   Retraining   A. General -  Occasionally, it is necessary to furnish additional training to an ESRD self-dialysis beneficiary after the initial training course is completed.  Retraining sessions are paid under the following conditions:    The patient changes from one mode of dialysis to another, e.g., from hemodial ysis to CAPD;   The patients home dialysis equipment changes;   The patients dialysis setting changes;   The patients dialysis partner changes; or   The patients medical condition changes e.g., temporary memory loss due to stroke, physical impairment.   The pa tient must continue to be an appropriate patient for self -dialysis.   B. Payment Rates -  Retraining sessions are reimbursed at the same rate as the facilitys training rate.   C. Duplicate Payments  - No home dialysis training add- on payment is made for a home dialysis treatment furnished on the same day as a retraining session.  In the case of a CAPD patient, the facilitys equivalent CAPD daily rate is not paid on the day(s) of retraining.   50.9 - Coding for Adequacy of Dialysis, Vascular Access and Infection  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)
(Medicare Claims Processing Manual)
50.9 - Coding for Adequacy of Dialysis, Vascular Access and Infection  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  A.   Reporting the Urea Reduction Ratio (URR) for End Stage Renal Disease (ESRD ) Hemodialysis Claims   All hemodialysis claims must indicate the most recent Urea Reduction Ratio (URR) for the dialysis patient.  Code all claims using HCPCS code 90999 along with the appropriate G modifier listed in section B.   Claims for dialysis treatments must include the adequ acy of hemodialysis data as measured by URR.  Dialysis facilities must monitor the adequacy of dialysis treatments monthly for facility patients.  Home hemodialysis and peritoneal dialysis patients may be monitored less frequently, but not less than quarte rly.  If a home hemodialysis patient is not monitored during a month, the last, most recent URR for the dialysis patient must be reported.   HCPCS code 90999 (unlisted dialysis procedure, inpatient or outpatient) must be reported in field location 44 for al l bill types 72X.  The appropriate G -modifier in field location 44 (HCPCS/RATES) is used, for patients that received seven or more dialysis treatments in a month.  Continue to report revenue codes 0820, 0821, 0825, and 0829 in field location 43.  G1 - Most  recent URR of less than 60%  G2 - Most recent URR of 60% to 64.9%  G3 - Most recent URR of 65% to 69.9%  G4 - Most recent URR of 70% to 74.9%  G5 - Most recent URR of 75% or greater   For patients that have received dialysis 6 days or less in a month, facilities use the following modifier:
(Medicare Claims Processing Manual)
For patients that have received dialysis 6 days or less in a month, facilities use the following modifier:   G6 - ESRD patient for whom less than seven dialysis sessions have been provided in a month.  For services beginning January 1, 2003, and after, if the modifier is not present, A/B/MACs (A) must return the claim to the provid er for the appropriate modifier.  Effective April, 2007 due to the requirement of line item billing, at least one revenue code line for hemodialysis on the claim must contain one of the URR modifiers shown above.  The URR modifier is not required on every hemodialysis line on the claim.   The techniques to be used to draw the pre - and post -dialysis blood urea Nitrogen samples are listed in the National Kidney Foundation Dialysis Outcomes Quality Initiative Clinical Practice Guidelines for Hemodialysis Adequacy, Guideline 8, Acceptable Methods for BUN sampling, New York, National Kidney Foundation, 2000, pp.53- 60.  B.   Reporting the Vascular Access for End Stage Renal Disease (ESRD)  Hemodialysis Claims   ESRD claims for hemodialysis with dates of service on or  after July 1, 2010 must indicate the type of vascular access used for the delivery of the hemodialysis at the last hemodialysis session of the month.  One of the following codes is required to be reported on the latest line item date of service billing fo r hemodialysis revenue code 0821.  It may be reported on all revenue code 0821 lines at the discretion of the provider.   Note:   Modifier V5 must be entered if a vascular catheter is present even if it is not being used for the delivery of the hemodialysis.  In this instance 2 modifiers should be entered, V5 for the vascular catheter and either V6 or V7 for the access that is being used for the delivery of hemodialysis.   Modifier V5  - Any Vascular Catheter (alone or with any other vascular access),   Modifier V6  - Arteriovenous Graft (or other Vascular Access not including a vascular catheter in use with two needles)   Modifier V7  - Arteriovenous Fistula Only (in use with two needles)   C.   Reporting the Kt/V for ALL End Stage Renal Disease (ESRD ) Claims
(Medicare Claims Processing Manual)
Modifier V7  - Arteriovenous Fistula Only (in use with two needles)   C.   Reporting the Kt/V for ALL End Stage Renal Disease (ESRD ) Claims   All End Stage Renal Disease (ESRD) claims with dates of service on or after July 1, 2010 must indicate the applicable Kt/V reading for the dialysis patient.  The reading result and the date of the reading must be reported on the claim using the following claim  codes:   Value Code D5  Result of last Kt/V reading.  For in -center hemodialysis patients this is the last reading taken during the billing period.  For peritoneal dialysis patients and home hemodialysis this may be before the current billing period but s hould be within 4 months of the claim date of service.    Hemodialysis : For in -center and home -hemodialysis patients prescribed for three or fewer treatments per week, the last Kt/V obtained during the month must be reported.  Facilities must report single p ool Kt/V using the preferred National Quality Forum (NQF) endorsed methods for deriving the single pool Kt/V value: Daugirdas II or Urea Kinetic Modeling (UKM). The reported Kt/V should not include residual renal function.   A value of 8.88 shall be entere d on the claim if the situation exists that a patient is prescribed and receiving greater than three hemodialysis treatments per week for a medically justified and documented clinical need.  The 8.88 value is not to be used for patients who are receiving  extra treatments for a temporary clinical need (e.g. fluid overload).  A medical justification must be submitted for patients receiving greater than 13 treatments per month.    Peritoneal Dialysis :  When measured the delivered weekly total Kt/V (dialytic and residual) should be reported.   This code is effective and required on all ESRD claims with dates of service on or after July 1, 2010.  In the event that no Kt/V reading was performed providers must report the D5 with a value of 9.99.
(Medicare Claims Processing Manual)
This code is effective and required on all ESRD claims with dates of service on or after July 1, 2010.  In the event that no Kt/V reading was performed providers must report the D5 with a value of 9.99.   Occurrence Code 51  Date of last Kt/V reading.  For in -center hemodialysis patients, this is the date of the last reading taken during the billing period.  For peritoneal dialysis patients and home hemodialysis patients, this date may be before the current billing period but should be within 4 months of the claim date of service.  This code is effective for ESRD claims with dates of service on or after July 1, 2010.  This code not required when reporting value code D5 with a value of 9.99 indicating no Kt/ V reading is available for reporting or value 8.88 to indicate the patient is prescribed and receiving greater than 3 hemodialysis treatments per week for a medically justified and documented clinical need.   D.   Reporting of Infection for End Stage Renal Disease (ESRD)  Claims  Effective April 1, 2012, the infection modifiers V8 and V9 were terminated. All End Stage Renal Disease (ESRD) claims with dates of service on or after April 1, 2012, no longer require reporting of infection modifiers V8 and V9.  60 - Separately Billable ESRD Items and Services  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  Payment for all items and services provided for the treatment of ESRD are included in the ESRD PPS.  ESRD facilities are required to it emize the ESRD related services provided including drugs, laboratory tests and supplies that are eligible for outlier consideration.  60.1 - Lab Services  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  See the Medicare Benefit Policy Manual, Chapter 11, for a description of lab services included in the PPS rate.
(Medicare Claims Processing Manual)
See the Medicare Benefit Policy Manual, Chapter 11, for a description of lab services included in the PPS rate.   Renal dialysis facilities must bill all lab tests provided for the treatment of ESRD.  This is true whether the tests were provided directly or  under arrangements with an independent lab.  When lab tests are billed by providers other than the ESRD facility and the lab test is provided for the treatment of ESRD, the claim will be rejected or denied.  In the event that a lab test usually provided f or the treatment of ESRD was furnished to an ESRD beneficiary for reasons other than for the treatment of ESRD, the provider may submit a claim for separate payment using modifier AY.   ESRD facilities should only bill for lab tests related to the treatment of ESRD or other lab tests performed by the dialysis facility (i.e. CLIA waived lab tests).  Lab tests that are not for the treatment of ESRD and are not performed by the ESRD facility are not to be reported on the ESRD facility claim.   60.2 - Drugs Furni shed in Dialysis Facilities (Rev. 10640, Issued:08- 06-21, Effective:09- 07-2021, Implementation:09- 07-21)  Effective January 1, 2011, section 153b of the MIPPA requires that all drugs and biologicals used in the treatment of ESRD are included in the ESRD PPS payment amount and must be billed by the ESRD facility .  60.2.1 - Billing Procedures for Drugs for Facilities  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  The following billing procedures apply to independent and hospital  based ESRD  facilities.   Facilities identify and bill for drugs by HCPCS code, along with revenue code 0636, Drugs Requiring Specific Information.  Example below includes the HCPCS code and indicates the dosage amount specified in the descriptor of that code.  Facilities use the units field as a multiplier to arrive at the dosage amount.   EXAMPLE:   HCPCS  Drug  Dosage (lowest denominator) Amount  J3360 Valium 5 mg $2.00  Actual dosage, 10 mg
(Medicare Claims Processing Manual)
EXAMPLE:   HCPCS  Drug  Dosage (lowest denominator) Amount  J3360 Valium 5 mg $2.00  Actual dosage, 10 mg  On the bill, the facility shows J3360 and 2 in the units field (2 x 5 mg = 10 mg). For independent facilities, A/B MACs (A)  compare the price of $4.00 (2 x $2.00) to the billed charge and pay the lower, subject to coinsurance and deductible.  Effective January 1, 2006 payment is not subject to the lower of char ges or fee.  All separately payable drugs for both hospital- based and independent facilities are paid at ASP+6% except vaccines.  For information on billing and payment for vaccines see section 60.6 of this chapter.  NOTE:   When the dosage amount is greater than the amount indicated for the HCPCS code, the facility rounds up to determine units.  When the dosage amount is less than the amount indicated for the HCPCS code, use one as the unit of measure.  In the example above, if the dosage were 7 mg, the facility would show 2 in the unit field, if the dosage were 3 mg, the facility would show 1 in the unit field.  Facilities bill for supplies used to administer drugs with revenue code 0270, Medical/Surgical Supplies.  The number of administrations is shown in the units field.   EXAMPLE:   Revenue Code Units  0270 3  The number of units for supply codes billed should match the number of injections billed on the claim form.   Appropriate HCPCS codes for administration-supply of separately billable drugs would include:  A4657: Injection Administration-supply Charge: include the cost of alcohol swab, syringe, and gloves.  Reimbursement for all ESRD facilities is based on a fee of $0.50 per unit billed for A4657.  A4913: IV Administration-supply Charge: include the cost of IV solution administration set, alcohol swab, syringe, and gloves.  This code should only be used when an IV solution set is required for a drug to be given.  This rate will not be paid for drugs that only require a syringe for administration.