evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
B. Uncompleted Dialysis Treatment  Generally, CMS only pays for one treatment per day across all settings. However, similar to the policy applied under the ESRD PPS for treatments for patients with ESRD, in the interest of fairness and in accordance with Chapter 8, section 10.2 of the Medicare Claims Processing Manual, if a dialysis  treatment is started, that is, a patient is connected to the machine and a dialyzer and blood lines are used, but the treatment is not completed for some unforeseen, but valid reason, for example, a medical emergency when the patient must be rushed to an emergency room, both the ESRD facility and the hospital would be paid. This is considered to be a rare occurrence that must be fully documented to the A/B MAC's satisfaction.  C. Home and Self -Dialysis  Due to the nature of AKI, dialysis treatments at home or s elf-dialysis in the dialysis facility are not permitted.  Specifically, these patients require supervision by qualified staff during their dialysis and close monitoring through laboratory tests to ensure that they are receiving the necessary care to improve their condition and get off of dialysis.  Therefore, the home dialysis benefit does not extend to beneficiaries with AKI.  D. Vaccines and Their Administration   Section 1881(b)(14)(B) of the Act specifically excludes vaccines covered under section 1861(s)(10)  of the Act from the ESRD PPS. However, ESRD facilities are identified as an entity that can bill Medicare for vaccines and their administration. Therefore, ESRD facilities may furnish vaccines to beneficiaries with AKI and bill Medicare in accordance with  billing requirements in the Medicare Claims Processing Manual (Pub. 100- 04, Chapter 18 Preventive and Screening Services, section 10.2). The staff time associated with vaccine administration is covered in the AKI dialysis payment rate. E. Telehealth  Since telehealth dialysis services are limited to renal dialysis services for home dialysis patients telehealth related to renal dialysis services is not available for beneficiaries with AKI.  F. ESRD Conditions for Coverage (CfCs)  The ESRD CfCs at 42 CFR part 494 a re health and safety standards that all Medicare participating dialysis facilities must meet. These standards set baseline requirements for patient safety, infection control, care planning, staff qualifications, record
(Medicare Benefit Policy Manual)
The ESRD CfCs at 42 CFR part 494 a re health and safety standards that all Medicare participating dialysis facilities must meet. These standards set baseline requirements for patient safety, infection control, care planning, staff qualifications, record keeping, and other matters to ensure that all patients, including ESRD and AKI patients, receive safe and appropriate care.  Payment for Erythropoietin Stimulating Agents (ESAs) and the ESA Monitoring Policy for AKI Patients  ESAs are included in the bundled payment amount for treatments admini stered to patients with AKI. The Non -ESRD HCPCS codes should be used (J0881, J0883, J0885, J0888, Q0138, Q5106) and reported using revenue code 0636.  The ESA monitoring policy has not yet been extended to AKI patients receiving treatment in an ESRD facilit y. Since this policy is not applicable to these treatments, the value codes used to report hemoglobin and hematocrit levels are not required when billing for ESAs.
(Medicare Benefit Policy Manual)
100.7 Billing for Physicians Services for Individuals with AKI  (Rev. 240, Issued: 01- 19-18, Effective: 01- 01-17, Implementation: 02-  20-18)  Physicians are able to bill separately for services provided to individuals with AKI. CMS expects providers to follow correct coding guidelines and use the appropriate HCPCS or CPT codes for the items and services provided to the patient.     The following CPT codes are available for ESRD facilities and physicians offices to use when billing for physicians services provided in either an ESRD facility (place of service 65) or a physicians office (place of  service 11):    90935 -  Hemodialysis procedure with single evaluation by a physician or other qualified health care professional;    90937 -  Hemodialysis procedure requiring repeated evaluation(s) with or without substantial revision of dialysis prescription;    90945 -  Dialysis procedure other than hemodialysis (eg, peritoneal dialysis, hemofiltration, or other continuous replacement therapies), with single evaluation by a physician or other qualified health care professional;    90947 -  Dialysis  procedure other than hemodialysis (eg, peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies) requiring repeated evaluations by a physician or other qualified health care professional, with or without substantial revision of  dialysis prescription.   Please note: this is not an exhaustive list  as indicated above, CMS expects facilities and physicians offices to bill the appropriate codes.    110 - Reserved  (Rev. 171, Issued: 06 -07-13, Effective: 01- 01-11, Implementation: 09- 09-13)  120 - Reserved  (Rev. 171, Issued: 06 -07-13, Effective: 01- 01-11, Implementation: 09- 09-13)  130 - Reserved  (Rev. 171, Issued: 06 -07-13, Effective: 01- 01-11, Implementation: 09- 09-13)  Appendix A  (Rev. 171, Issued: 06 -07-13, Effective: 01- 01-11, Implementation: 09 -09-13)  Composite Rate Tests for Hemodialysis, IPD, CCPD, and Hemofiltration (Items in bold are non composite rate test)
(Medicare Benefit Policy Manual)
Composite Rate Tests for Hemodialysis, IPD, CCPD, and Hemofiltration (Items in bold are non composite rate test)   Chemistry  CPT Code  Monthly  Weekly  13 x Quarter  Albumin  82040  X   Alkaline Phosphates  84075  X   ALT (SGPT)  84460     AST (SGOT)  84450  X   Bilirubin, total  82247     Bilirubin, direct  82248     Calcium  82310  X   Calcium ionized (billed with modifier CD or CE)  82330 X   Calcium ionized (billed with modifier CF) 82330 X   Chloride  82435  X   Cholesterol  82465     CK, CPK  82550     CO2 (bicarbonate)  82374  X   Creatinine  82565   X  GGT  82977     Glucose  82947     LDH  83615  X   Phosphorus  84100  X   Potassium  84132  X   Protein, total  84155  X   Sodium  84295     Triglycerides  84478     Urea nitrogen (BUN)  84520    X Uric Acid  84550      Appendix B  (Rev. 171, Issued: 06 -07-13, Effective: 01- 01-11, Implementation: 09- 09-13)  Composite Rate Tests for CAPD (Items in bold are non composite rate test)   Chemistry  CPT Code  Monthly  Weekly  13 x Quarter  Albumin  82040  X   Alkaline Phosphatase  84075  X   ALT (SGPT)  84460     AST (SGOT)  84450  X   Bilirubin, total  82247     Bilirubin, direct  82248     Calcium  82310  X   Calcium ionized (billed with modifier CD or CE)  82330  X   Calcium ionized (billed with modifier CF) 82330  X   Chloride  82435     Cholesterol  82465     CK, CPK  82550     CO2 (bicarbonate)  82374  X   Creatinine  82565  X   GGT  82977     Glucose  82947     LDH  83615  X   Phosphorus  84100  X   Potassium  84132  X   Protein, total  84155  X   Sodium  84295  X   Triglycerides  84478     Urea nitrogen (BUN)  84520  X   Uric Acid  84550      Appendix C  (Rev. 171, Issued: 06 -07-13, Effective: 01- 01-11, Implementation: 09- 09-13)
(Medicare Benefit Policy Manual)
Brief History of ESRD Composite Payment Rates for Outpatient Maintenance Dialysis   Effective January 1, 2005, section 623 of the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) amended section 1881(b)(7) of the Act to require a 1.6 percent increase to the ESRD composite payment rate.  The MMA also required a drug add- on adjustment to the composite payment rate to account for the difference between pre- MMA payments for separately billable drugs and payments based on revised drug pricing for 2005 which used average acquisition costs.  For CY 2005, CMS computed a drug add -on adjustment of 8.7 percent.  Effective January 1, 2006, section 5106 of the Deficit Reduction Act of 2005 amended section 1881(b)(12) of the Act to require a 1.6 percent increase to the ESRD composite payment rate.  In addition, because the drug add -on adjustment is determined as a percentage of the composite payment rate, CMS must adjust the drug add -on adjustment to account for the 1.6 percent increase to the composite payment rate in order to ensure that the total dollars allocated from the dru g add -on adjustment remains constant.  The growth update to the drug add -on adjustment of 1.4 percent was unchanged; therefore the total drug add -on adjustment to the composite payment rate for 2006 was 14.5 percent.   For dialysis services furnished on or after January 1, 2007 through March 31, 2007, the growth update to the drug add -on adjustment to the composite payment rate was 0.5 percent.  As a result, the drug add- on adjustment to the composite payment rate for 2007 increased from 14.5 percent to 15.1 percent.   For dialysis services furnished on or after April 1, 2007, section 103 of the Tax Relief and Health Care Act of 2006 amended section 1881(b)(12) of the Act to require a 1.6 percent increase to the ESRD composite payment rate.  The effect of the 1.6 percent increase to the composite payment rate was a reduction in the drug add- on adjustment from 15.1 percent to 14.9 percent.
(Medicare Benefit Policy Manual)
Effective January 1, 2008, there was no increase to the composite payment rate however; the drug add- on adjustment to the c omposite payment rate was increased by a growth update of 0.5 percent.  As a result, the drug add -on adjustment to the composite payment rate for CY 2008 increased from 14.9 percent to 15.5 percent.   Effective January 1, 2009, section 153 of the Medicare Improvements for Patients and Providers Act of 2008 amended section 1881(b)(12) of the Social Security Act to require a 1 percent increase to the ESRD composite payment rate and that hospital -based ESRD facilities are paid the same composite payment rate as independent ESRD facilities.  The effect of the 1 percent increase in the composite payment rate is a reduction in the drug add-on adjustment from 15.5 percent to 15.2 percent.   Effective January 1, 2010, CMS continued to apply the growth update to the drug add -on adjustment to the composite payment rate, which was 0.percent.  As a result, the drug add-on adjustment to the composite payment rate for 2010 was reduced from 15.2 to 15.0 percent. Also, as required by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), CMS applied a 1.0 increase to the ESRD composite payment rate.   Section 153 of the MIPPA amended section 1881(b)(12) of the Social Security Act to require a 4 -year transition (phase -in) from the current composite payment sys tem to the ESRD Prospective Payment System (PPS).  Effective January 1, 2011, CMS continued to apply the growth update to the drug add- on adjustment to the composite payment rate portion of the blended payment rate, which was 0.percent.  As a result, the drug add- on adjustment to the composite payment rate portion of the blended payment for 2010 is reduced from 15.0 to 14.7 percent.  For a detailed description of the transition period, see 70 of this chapter.   For further information on the drug add on amounts for CY 2012 and 2013, see the respective ESRD final rules.   Effective 2014, the drug add- on will no longer be applied.  Future updates will be issued via Recurring Update Notifications.   140 - Transplantation  (Rev. 1, 10- 01-03)  A3-3178, PR 1- 2770, RD F-230  Introduction
(Medicare Benefit Policy Manual)
Future updates will be issued via Recurring Update Notifications.   140 - Transplantation  (Rev. 1, 10- 01-03)  A3-3178, PR 1- 2770, RD F-230  Introduction  Renal transplantation is a principal form of treatment for patients with ESRD.  Medicare has developed a method of reimbursement for the variety of medical services required to support a transplant program, including payment for Medica res share of the costs of organ procurement.   In addition, Medicare has developed coverage and reimbursement criteria for necessary medical services provided to potential donors and recipients.  In some situations, these services are provided before the e ffective date of Medicare entitlement for the potential transplant recipient.   Medicare pays for the covered services provided a Medicare patient who receives a living or cadaveric transplant.  A certified transplant centers (CTC) or organ procurement organizations (OPO) expenses in providing kidneys are included in the transplant providers living or cadaveric kidney acquisition cost center.  To participate in the Medicare program, any CTC or OPO must be a member of the Organ Procurement and Transplantat ion Network (OPTN).  The CTC is required to notify the OPO designated for  its service area of potential donors.  (See the Medicare Provider Reimbursement Manual, Part 1, 2771, for rules in developing a living and cadaveric acquisition charge.)   See the O PTN Web site at http://www.optn.org/members/search.asp  or a search facility for various transplant centers, including kidney transplant centers.   140.1 - Identifying Candidates for Transplantation  (Rev. 1, 10- 01-03)  A3-3178.1, RDF -231  After a patient is diagnosed as having ESRD, the physician should determine if the patient is suitable for transplantation.  If the patient is a suitable transplant candidate, a live donor transplant is considered fi rst because of the high success rate in comparison to a cadaveric transplant.  Whether one or multiple potential donors are available, the following sections provide a general description of the usual course of events in preparation for a live -donor transplant.   140.2 - Identifying Suitable Live Donors  (Rev. 1, 10- 01-03)  A3-3178.2, RDF -231
(Medicare Benefit Policy Manual)
140.2 - Identifying Suitable Live Donors  (Rev. 1, 10- 01-03)  A3-3178.2, RDF -231  Those who are willing and medically able to donate a kidney are tested to determine whether they are of the same blood type as the recipient.  After blood typing, the r ecipient and the donors are tissue typed.  Only those candidates with blood and tissue types similar to the recipient are considered further.   After tissue typing, those medically suitable donors are evaluated on physical, psychological, and social factors .  Potential donors who remain after the above testing may be hospitalized for about two days for further evaluation using procedures not appropriately performed on outpatients.  These procedures may include intravenous urography and renal arteriography.   If the results of the above tests identify several suitable donors, the most suitable donor is selected, and arrangements are made for the transplant.  At such time, the donor and recipient will enter the hospital to undergo the excision and transplantatio n, respectively.   When tests do not identify an acceptable living donor, the patient is considered for a cadaveric transplant and placed on hemo - or peritoneal dialysis, if this has not already proved necessary.  If the ultimate goal is transplantation, the patient is registered with a kidney transplant registry.  140.3 - Pretransplant Outpatient Services  (Rev. 1, 10- 01-03)   A3-3178.3   All hospital outpatient services provided to live donors and recipients in anticipation of a transplant during the preentit lement period and after entitlement, but prior to admission to the hospital for transplantation, are covered.  Such services would include kidney recipient registration fees, laboratory tests (including tissue typing of recipient and donors), and general m edical evaluations of the recipient and the donor(s). Pretransplant physicians services are also covered.   140.4 - Pretransplant Inpatient Services  (Rev. 1, 10- 01-03)  A3-3178.4
(Medicare Benefit Policy Manual)
140.4 - Pretransplant Inpatient Services  (Rev. 1, 10- 01-03)  A3-3178.4   The following rules apply to kidney transplant inpatient medical evaluations  when the kidney recipient has Medicare entitlement or is in the preentitlement period.  The preentitlement period is that period prior to the patients actual Medicare entitlement, during which services are furnished in anticipation of a transplant, after  the patient has been diagnosed to have end stage renal disease.  If the potential kidney recipient does not have entitlement, or is not in the preentitlement period, no services rendered to the kidney recipient or to the related living donor for kidney tr ansplant the Medicare program will cover medical evaluations.   140.5 - Living Donor Evaluation, Patient Has Entitlement or is in Preentitlement Period  (Rev. 1, 10- 01-03)  A3-3178.5, RDF -233.1   When a living donor is admitted to a hospital (before admission for excising the donor kidney) for a medical evaluation in anticipation of a kidney donation, all hospital and physicians services costs applicable to medical evaluation are considered kidney acquisition service costs.  As such, the hospital statistics ( charges, patient days, etc.) and the physicians charges should be treated in accordance with all other kidney acquisition service statistics and the related costs are included in Medicare costs.   When the live donor subsequently enters the hospital for the actual excision, the hospital costs of services rendered to the donor will continue to be treated as kidney acquisition service costs under Part A.  However, at that point physician services are no longer considered kidney acquisition services and are not reimbursable under Part A.  Instead, during the donors inpatient stay for the excision surgery and during any subsequent donor inpatient stays resulting from a direct complication of the organ donation, physician services are billed under Part B.  They are billed in the normal manner but on the account of the recipient at 100 percent of the fee schedule.  Note that services furnished to kidney donors are covered under the account of the recipient.   Services listed in the following sections are also cover ed.  However, they are not billed as such but become a part of the kidney acquisition costs.  140.6 - Kidney Recipient Admitted for Transplant Evaluation  (Rev. 1, 10- 01-03)
(Medicare Benefit Policy Manual)
Services listed in the following sections are also cover ed.  However, they are not billed as such but become a part of the kidney acquisition costs.  140.6 - Kidney Recipient Admitted for Transplant Evaluation  (Rev. 1, 10- 01-03)  A3-3178.6, RDF -233, RDF -233.2   When a potential recipient is admitted to a hospita l (before admission for the actual transplant) solely for a medical evaluation for an anticipated kidney transplant, all hospital and physicians services costs applicable to the anticipated transplant are considered kidney acquisition service costs.   140.7 - Kidney Recipient Evaluated for Transplant During Inpatient Stay (Rev. 1, 10- 01-03)  A3-3178.7, RDF -233.3   When a recipient is admitted to a hospital for a medical reason other than in anticipation of a transplant, but during the stay, a medical evaluation for an anticipated kidney transplant is performed, all hospital and physicians services costs applicable to the medical evaluation are considered kidney acquisition service costs.  Accordingly, those services will be treated the same as the ser vices above.  However, all hospital and physicians services applicable to the nontransplant related services (i.e., related to the medical services for which the patient was actually admitted) must not be included with kidney acquisition services costs; i nstead such services must be billed in the same manner as any other inpatient service on the account of the recipient.  These latter services may be billed to the Medicare program only if the recipient has actual Medicare entitlement.   140.8 - Kidney Recip ient Admitted for Transplantation and Evaluation  (Rev. 1, 10- 01-03)  A3-3178.8, RDF -233.4   When the medical evaluation for a transplant is performed on the recipient or the living donor during the same inpatient stay in which the actual transplant occurs, all such services will be billed, and the costs will be accumulated in the normal manner.  For example, all hospital services rendered to the donor will be considered kidney acquisition services.  However, all physicians services rendered to the living donor and all hospital and physicians services rendered to the recipient will be billed in the same manner as any other inpatient services on the account of the recipient.
(Medicare Benefit Policy Manual)
140.9  Post-transplant Services Provided to Live Donor  (Rev. 257, Issued: 03- 01-19, Effective: 04 - 01-19 Implementation: 04-  01-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the  Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   The donor of an organ fo r a Medicare transplant beneficiary is covered for an unlimited number of days of care in connection with the organ removal operation.  Days of inpatient hospital care used by the donor in connection with the organ removal operation shall not be charged ag ainst either partys utilization record.  However, the programs assumption of liability is limited to those donor expenses that are incurred directly in connection with the organ donation.  Coverage of organ donor services includes postoperative recovery services directly related to the organ donation.  For routine follow -up care the period of postoperative recovery ceases when the donor no longer exhibits symptoms related to the kidney donation.  Claims for services rendered more than 3 months after donat ion surgery will be reviewed.  However, follow -up examinations may be covered up to 6 months after the donation to monitor for possible complications.  The requirement that additional payment cannot be made for services included in the donors organ remova l charge still applies.   Regarding donor follow -up:  Expenses incurred by the transplant center for routine donor follow -up care are included in the transplant centers organ acquisition cost center.  Follow -up services performed by the operating physician  are included in the 90- day global payment for the surgery.  Beyond the 90 -day global payment period, follow -up services are billed using the recipients Medicare beneficiary identifier .  Follow -up services billed by a physician other than the operating physician for up to 3 months following donation surgery should be billed under the recipients Medicare beneficiary identifier .  Regarding donor complications: