evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
6. Pediatric case -mix adjusters: Age and dialysis  modality   Pediatric patients are beneficiaries with ESRD who are under the age of 1 8. The same base rate is used for adult and pediatric patients, which is also adjusted by the area wage index. However, the base rate for pediatric patients is not adjusted for case -mix as adjustments used for adult patients. The pediatric payment adjustme nts use only two age categories (<13, age 13- 17) and dialysis modality (PD or HD).   The pediatric case -mix adjusters, applicable for CY 2011, are shown below. These values are presented for the purpose of demonstrating the computations shown in the examples in the following sections. Any revisions to the case -mix adjusters will be published in subsequent rulemaking.   Based on the two classification categories for age and modality, there are four pediatric classification groups.   Pediatric  Patient -Level  Characteristics  Adjustment  Value   CY 2011 - 2015  Beginning CY 2016  Age: <13, Modality: PD  1.033  1.063  Age:<13, Modality: Hemo  1.219  1.306  Age:13 -17, Modality: PD  1.067  1.102  Age:13 -17, Modality: Hemo  1.277  1.327   ESRD facilities do not receive the low -volume adjustment, described in 60.B.1, or the rural adjustment, described in 60.B.3, for pediatric beneficiaries. However, they are eligible for training add -on and outlier payments (described in 60.C and 60.D, of this chapter respectively).   The following example demonstrates the calculation of the payment rate for a pediatric patient who receives dialysis at an ESRD facility and is located in an urban area with a wage index of 1.10. The example also shows the application of the training add- on for eligible training treatments. Before giving the particulars of the pediatric dialysis patient, shown first is the calculation of the labor -adjusted base rate of $242.06, which is the starting point for the computation of the case -mix adjusted base rate.
(Medicare Benefit Policy Manual)
 Base rate:  $230.39   Labor -related share of base rate: $230.39 * 0.50673 =  $116.75   Wage index adjusted labor -related share: $116.75 * 1.1000 =  $128.42   Non labor -related share of base rate: $230.39 * (1 -0.50673) =  $113.64   Wage index adjusted base rate: $128.42 + $113.64 =  $242.06  Provided next is the characteristics of the pediatric patient and continue with the example.    Andrew, a 12 year old male, has been on CCPD since June 2010. His mother, who assists him with his dialysis at home, is no longer abl e to assist with dialysis beginning May 10, 2016. His aunt, who lives nearby, has agreed to be the caregiver and assist him with his dialysis. The aunt required 17 training sessions at an ESRD facility in order to become knowledgeable and skilled sufficiently to perform this role. These training sessions began May 16 and ended June 10. The above pediatric classification table reveals that Andrews pediatric dialysis classification group is cell 1, with an associated patient multiplier of 1.063. During the m onths of May and June 2016, the ESRD payment rate per HD - equivalent treatment would  be:  $242.06 * 1.063 = $257.31   However, the ESRD facility is entitled to receive payment for a maximum of 15 training treatments furnished in connection with a new caregiver. Because the amount of the training add -on is adjusted by the ESRD facilitys wage index (1.10), the amount of the training add -on is calculated as  follows:   Training rate: $50.16 Wage index: 1.10 Training payment: $50.16 * 1.10 = $55.18   For the  maximum number of 15 training treatments for which the training adjustment may be provided in connection with a PD patient, the payment rate, including the training add -on, would be:  ($242.06 * 1.063 + $55.18) = $312.49   NOTE: This example is computed wi thout regard to other adjustments (e.g., outlier payments.)     B. Facility -level  adjustments
(Medicare Benefit Policy Manual)
NOTE: This example is computed wi thout regard to other adjustments (e.g., outlier payments.)     B. Facility -level  adjustments   There are three facility -level adjustments in the ESRD PPS.  The first adjustment accounts for ESRD facilities furnishing a low -volume of dialysis treatments. The second adjustment reflects urban and rural differences in area wage levels using an area wage index developed from Core Based Statistical Areas (CBSAs). The third is a rural adjustment beginning in CY 2016.   1. Low -Volume  Adjustment   ESRD facilities that qualify as being low -volume can receive the low -volume payment adjustment (LVPA) applied to each dialysis treatment they furnish beginning on or after January 1, 2011. For CY 2011 the payment adjustment was 18.9 percent, and beginning January 1, 2016, the paym ent adjustment is 23.9 percent.   a. Low -Volume  Criteria   To be eligible for the low -volume adjustment, an ESRD facility must meet specific criteria:    The ESRD facility must have furnished less than 4,000 dialysis treatments in each of the 3 cost reporting years preceding its payment year. This 3 year eligibility period is based on the ESRD facilitys as -filed or final settled 12 - consecutive month cost  reports.  o The term payment year is the period of time that is used for determining payment to ESRD facilities, which is a calendar year. The ESRD PPS is based on a calendar year which begins January 1 of each  year.   o The eligibility years are defined as the 3 years preceding the payment year and are based on cost reporting periods. Specifically, the cost  reporting periods that end in the 3 years immediately preceding the payment year. The cost reporting periods must report costs for 12 consecutive  months.
(Medicare Benefit Policy Manual)
 For purposes of determining eligibility for the low -volume  adjustment, the number of treatments is  the total number of treatments furnished to Medicare and non- Medicare patients. For peritoneal dialysis (PD) patients, 1 week of PD is considered equivalent to 3 hemodialysis (HD) treatments.  For example, a patient on PD for 21 days would have (21/7) x 3 or 9 HD -equivalent treatments. See 50.A.4 of this chapter for more information on hemodialysis equivalent  treatments.  The ESRD facility must not have opened, closed, or received a new provider number due to a change in ownership, (see Pub. 100- 07, chapt er 3, 3210), in the 3 years preceding the payment year.    o This 3 year period is based on the ESRD facilitys as -filed or final settled 12 -consecutive month cost reports that end in the 3 years immediately preceding the ESRD PPS payment year.    o An ESRD fac ility is determined to be opened when the ESRD facility is a new establishment newly surveyed by the state and Medicare, is certified for Medicare participation, receives a provider number, and begins furnishing Medicare certified outpatient maintenance dialysis treatments.    o If there is a change in ownership that does not result in a change in provider number but does cause a change in the fiscal year reporting to that of the new provider, the A/B MAC (A) should combine the reporting periods for determining eligibility to the  LVPA.
(Medicare Benefit Policy Manual)
For example, prior to a change of ownership (CHOW), Facility A had a cost reporting period that spanned January 1 through December 31. Facility A had a CHOW mid -year that did not result in a new provider transaction ac cess number (PTAN) but caused a break in the cost reporting period.  The A/B MAC (A) would add Facility As cost report that spanned January 1 through May 31 to its cost report that spanned June 1 through December 31 to verify the total treatment count.  T he other situation that could occur is when a CHOW results in a change of the original fiscal period. For example, prior to a CHOW, Facility B had a cost reporting period that spanned January 1 through December 31 and, based on its cost reports for 2012 and 2013, it met the LVPA eligibility criteria. Then, Facility B had a CHOW in the beginning of 2014 that did not result in a new PTAN, but changed its cost reporting period to that of its new owner, October 1, 2014, through September 30, 2015. This scenario would create a short and a long cost report that would not total 12 months that the A/B MAC (A) would need to review for verification. That is, Facility B would have a cost report that spanned January 1, 2014, through July 31, 2014 (7 months) and a cost r eport that  spanned August 1, 2014 through September 30, 2015 (14 months). In this situation, the A/B MAC (A) should combine the two non- standard cost reporting periods that in combination may exceed 12 -consecutive months and prorate the data to equal a full 12-consecutive month period.  o Beginning January 1, 2019, if there is a CHOW that results in a change in provider number due to a facility -type change (for example, hospital based dialysis facility to independent dialysis facility) and the new owner accepts the Medicare agreement, the ESRD facility can qualify for the LVPA if they otherwise meet the LVPA eligibility criteria.  This policy does not extend to CHOWs where a new PTAN is issued for any other reason.
(Medicare Benefit Policy Manual)
o Effective January 1, 2019, ESRD facilities t hat change their fiscal year end for cost reporting purposes, outside of a CHOW, qualify for the LVPA if they otherwise meet the LVPA eligibility criteria.  When this occurs, the MACs will combine the two nonstandard cost reporting periods of less than 12 months to equal a full 12-  consecutive month period or combine the two non- standard cost reporting periods, that in combination may exceed 12- consecutive months, and prorate the data to equal a full 12 -consecutive month period. This does not impact or chan ge requirements for reporting, as established by the MACs, or those set forth in  413.24(f)(3).    Effective January 1, 2016, the ESRD facility must not be located within 5 road miles of another ESRD facility under common ownership. The geographic proximity  criterion is applicable to all ESRD facilities that are Medicare certified to furnish outpatient maintenance dialysis treatments. For the purpose of determining the number of treatments furnished by the ESRD facility, the number of treatments considered f urnished by the ESRD facility would be equal to the aggregate number of treatments furnished by the other ESRD facilities that are both under common ownership, and 5 road miles or less from the ESRD facility in  question.  For example, ESRD facility A received its Medicare certification on February 1, 2011, allowing them to bill and receive payment for outpatient maintenance dialysis that they furnish to Medicare beneficiaries.  ESRD facility A will need to meet the low -volume criteria for 3 years. When  the ESRD facility A submits its attestation to the A/B MAC (A), the A/B MAC (A) will need to consider ESRD facility As ownership and the ownership of all of the ESRD facilities located within a 5 road mile radius or less when determining total treatments . A/B MACs (A) shall use the Provider Enrollment, Chain, and Ownership System (PECOS) (or the most recent available Medicare enrollment system) to locate the ESRD facilitys ownership information. A/B MACs (A) shall refer to 42 CFR 421.404(a) when determi ning common ownership.   Prior to January 1, 2016, ESRD facilities that were Medicare certified prior to January 1, 2011, were grandfathered into the geographic proximity criterion.
(Medicare Benefit Policy Manual)
Prior to January 1, 2016, ESRD facilities that were Medicare certified prior to January 1, 2011, were grandfathered into the geographic proximity criterion.   NOTE: The low -volume adjustment does not apply to dialysis treatments provided to pediatric patients.   b. ESRD Facility Attestation Instruction for Low -Volume  Adjustment   In order to receive the low -volume adjustment under the ESRD PPS, each individual ESRD facility must submit an attestation statement each year to its A/B MAC (A).  The attestation must state that the ESRD facility qualifies as a low -volume facility in accordance with 42 CFR 413.232 as described above. Specifically, the attestation states that the ESRD facility was low -volume for the first 2 eligibility years and th at they will be for the third eligibility year, that is, the cost reporting period ending in the year that immediately precedes the payment year.  In most cases, the A/B MACs  (A) will not have received the third eligibility years cost report and will rely on the attestation in order to allow the application of the adjustment. November 1st of each year is the mandatory deadline for the submission of attestations for ESRD facili ties that believe they are eligible to receive the low -volume payment adjustment.   Beginning January 1, 2019, ESRD facilities may request an extraordinary circumstance exception to the November 1 deadline.  In order to request an extraordinary circumstanc e exception, the facility is required to submit a narrative explaining the rationale for the exception to their MAC. The MAC will evaluate the narrative to determine if an exception is justified.  The determination will be final, with no appeal.
(Medicare Benefit Policy Manual)
However, for new or resubmitted attestations applicable to payment years 2011 to 2015, to allow A/B MACs (A) and facilities adequate time to review policy clarifications related to the low volume adjustment, the attestation deadline was extended to December 31, 2014.  For attestations applicable to payment year 2016, the attestation deadline is extended to December 31, 2015, to allow A/B MACs (A) and facilities adequate time to review policy changes finalized in the CY 2016 ESRD PPS final rule. A/B MACs (A) have a m aximum of 60 days to verify attestations for implementation of the low -volume adjustment beginning January 1 of the following payment year.  A/B MACs (A) shall notify the ESRD facilities no later than September 1 of each year that they need to submit the lo w-volume attestation no later than November 1st of each year in order to receive the adjustment the following payment year.  A/B  MACs (A) may not accept attestations submitted after the mandatory deadline. If an ESRD facility is receiving the low -volume payment adjustment and will qualify for the adjustment in the subsequent payment year they must submit another attestation.  If the ESRD facility does not submit an attestation, the A/B MAC (A) should no longer apply the low -volume payment adjustment beginning January 1st of the next payment year and the ESRD facility cannot receive the low -volume payment adjustment until the following payment year.   An ESRD facility should notify its A/B MAC if it determines that it did not maintain low -volume status for it s cost reporting period ending immediately preceding the payment year or if it finds that it will not remain low -volume for any subsequent cost reporting year. The A/B MAC (A) is responsible to reconcile incorrect payments made to ESRD facilities retroactively, if needed, to ensure overpayments have not been made. 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.   The A/B MAC (A) shall:
(Medicare Benefit Policy Manual)
The A/B MAC (A) shall:    Recoup low -volume adjustment payments made to an ESRD facility that failed to meet the low-volume adjustment criteria defined in 42 CFR 413.232(b)(1). Recoupment shall occur when the  A/B MAC (A) receives the as -filed cost report for the third eligibility year and finds that the ESRD facility did not meet the eligibility criteria. Recoupment shall also occur if any cost reports used for eligibility are subsequently found to have not me t the low-volume criteria, for example, reopening or appeals. A/B MACs (A) shall reprocess claims paid during the payment year in which the ESRD facility incorrectly received the low-volume payment  adjustment.   Recoup low -volume adjustment payments made to  an ESRD facility that failed to meet the low-volume adjustment criteria defined in 42 CFR 413.232(b)(2). A/B MACs (A) shall use PECOS (or most recent Medicare enrollment system) to locate the ESRD facilitys ownership information at the time of verificat ion to determine if the ESRD facility is in the process of a CHOW.  A/B  MACs  (A) shall use the current owner provided in PECOS. If the ESRD facility was in the process of a CHOW, recoupment shall occur when the CHOW is effective and the new owner is assign ed a new provider number.  A/B MACs  (A) shall reprocess claims paid during the payment year in which the ESRD facility incorrectly received the low -volume payment adjustment.   If an ESRD facility does not remain low -volume for each of the 3 years (describe d above in 60.B.1.a) immediately preceding the payment year, the ESRD facility cannot be eligible for the adjustment until it can demonstrate again that for 3 years it has met the low-volume criteria.   Example -  Provider 21- 25XX is an independent ESRD fac ility that has a June 30th cost report year end.
(Medicare Benefit Policy Manual)
Example -  Provider 21- 25XX is an independent ESRD fac ility that has a June 30th cost report year end.   The ESRD facility concluded in October 2010 that it met the criteria of a low - volume facility. For its cost reporting periods, 7/1/2007  6/30/2008, 7/1/2008  6/30/2009, and 7/1/2009  6/30/2010, it did not open, close, or have a change of ownership and furnished less than 4,000 dialysis treatments in each of those cost reporting periods. In October 2010, the ESRD facility sent its A/B MAC (A) an attestation stating that it believes that it meets the low -volume criteria and would like to begin to receive the low -volume adjustment. The A/B MAC (A) receives the attestation on November 1st and then has 60 days (that is, until December 30th) to verify if the ESRD facility qualifies as a low -volume facility. On December 28th the A/B MAC (A) was able to verify that provider 21- 25XX met the criteria and allowed for the adjustment to be applied to each dialysis treatment the ESRD facility furnished beginning January 1, 2011.  Determining Low -Volume Eligibility in Ho spitals with Multiple Subunits and Satellites   A hospital may be affiliated with multiple hospital -based ESRD facilities. In addition, an individual hospital -based ESRD facility may have several locations that are subsumed under it, billing under the same ESRD facility provider number.
(Medicare Benefit Policy Manual)
A hospital may be affiliated with multiple hospital -based ESRD facilities. In addition, an individual hospital -based ESRD facility may have several locations that are subsumed under it, billing under the same ESRD facility provider number.   Verification of an ESRD facilitys low -volume status is based on the A/B MACs (A) review of the total treatment count on an ESRD facilitys (or a hospitals) cost report. In the situation where a hospital has multiple locations of a hospital -based ESRD facility under its governing body, the aggregate cost and treatment data of all of the locations (not just the treatment count of one of the subunits or satellite entities) are reported on the hospitals cost report I series. In the case where a hospital has multiple locations and treatment counts are aggregated in the hospitals cost report, the A/B MAC (A) may consider other supporting documentation which may include individual facility treatment counts, rather than the hospi tals cost report alone. The hospital must provide the documentation to support the total treatment count for all the facilities that make up the total treatment count on the cost report for the A/B MAC (A) to review, even if not all the facilities are app lying for the low volume adjustment.  2. Wage  index   The wage index adjustment is applied when calculating the ESRD PPS payment in order to account for geographic differences in area wage levels. Each ESRD facilitys payment is adjusted using the wage index f or the CBSA in which the ESRD facility is located.  Rural ESRD facilities use the statewide average.   The wage index values and the budget neutrality adjustment factor are updated during rulemaking, are issued via annual Recurring Update Notifications, and are posted on the ESRD Payment Webpage.  3. Rural  adjustment   Beginning January 1, 2016, the ESRD PPS provides a 1.008 percent payment adjustment for ESRD facilities located in a rural CBSA.   C. Training and Retraining Add -On Payment
(Medicare Benefit Policy Manual)
3. Rural  adjustment   Beginning January 1, 2016, the ESRD PPS provides a 1.008 percent payment adjustment for ESRD facilities located in a rural CBSA.   C. Training and Retraining Add -On Payment   A training add- on payment adjustment is available under the ESRD PPS. The training add-on payment is computed by using the national average hourly wage for nurses from the Bureau of Labor Statistics. The payment accounts for 1.5 hours of nursing time for each training treatment that is furnished and is adjusted by the geographic area wage index. The training add- on payment applies to both peritoneal dialysis and hemodialysis training treatments, and added to the ESRD PPS payment, when a training treatment is provided by a Medicare c ertified training ESRD facility. An ESRD facility may bill a maximum of 25 training sessions per patient for hemodialysis training, and 15 sessions for CCPD and CAPD training. ESRD facilities should not expect additional reimbursement beyond the maximum se ssions.  CMS expects that ESRD patients who opt for home dialysis are good candidates for home dialysis training, and will successfully complete their method of training before reaching the maximum number of allotted training treatments. For more information regarding dialysis training, see 30.2 of this chapter.  For more information regarding retraining, see 30.2.E of this chapter.   D. Outlier  Policy   The ESRD PPS provides additional payment for high cost outliers due to unusual variations in the type or amount of medically necessary care when applicable. Outlier payments are based on a comparison of the predicted Medicare allowable payment (MAP) per treatment to actual incurred expenditure per treatment for services which  were or would have been considere d separately billable prior to the implementation of the ESRD PPS.  ESRD outlier services  include:    Drugs and biologicals used for the treatment of ESRD that were or would have been, prior to January 1, 2011, separately billable under Medicare Part  B;   Laboratory tests used for the treatment of ESRD that were or would have been, prior to January 1, 2011, separately billable under Medicare Part  B;   Medical or surgical supplies used to administer drugs and biologicals used for  the treatment of ESRD that were or would have been, prior to January 1, 2011, separately billable under Medicare Part B;  and