evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Data Elements Required on Claim for Monthly Capitation Payment  140.4 -  Controlling Claims Paid Under the Monthly Capitation Payment Method  150 -  Physicians Self -Dialysis Training Services  160 -  Payment for Physicians Services Furnished to Dialysis Inpatients  160.1 -  Determining Whether Physician Services Furnished on Day of Dialysis  160.2 -  Physicians Services Furnished on Day of Dialysis  160.3 -  Physicians Services Furnished on Non- Dialysis Days  160.4 -  Requirements for Payment  170 -  Billing Physician Dialysis Services (codes 90935 -  90999) and Related Payment  180 -  Noninvasive Studies for ESRD Patients -  Facility and Physician Services  190 -  Appeal Rights for D enied Claims  200 -  Utilization of REMIS for A/B MAC (B) Claims Adjudication
(Medicare Claims Processing Manual)
10 - General Description of the End Stage Renal Disease Prospective Payment System (ESRD (PPS)                                                                   (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  See the Medicare Benefit Policy Manual, Chapter 11, for a general description of coverage policies and definitions  relating to the ESRD benefit.   Effective January 1, 2011 Section 153b of the Medicare Improvements for Patients and Providers (MIPPA) requires the implementation of End Stage Renal Disease  Prospective Payment System (ESRD PPS).  The ESRD PPS provides a sing le payment to ESRD facilities that will cover all of the resources used in furnishing an outpatient dialysis treatment, including supplies and equipment used to administer dialysis (in the ESRD facility or at a patients home), drugs, biologicals, laboratory tests, training, and support services.   All ESRD related services and supplies are paid to the ESRD facility through the ESRD PPS. Other entities providing ESRD related services, including laboratories, suppliers and physicians billing for ESRD related drugs must look to the ESRD facility for payment. Consolidated Billing edits established with the implementation of the ESRD PPS will deny or reject claims to other providers and suppliers billing for ESRD related labs, drugs and supplies.   Information rela ted to the lab tests, drugs and supplies subject to the ESRD consolidated billing requirement can be found at the following website:  http://w ww.cms.gov/Medicare/Medicare- Fee-for-Service-Payment/ESRDpayment/Consolidated_Billing.html    The list of items and services subject to consolidated billing may be updated quarterly in January, April, July and October of each year.   10.1 - Billing for Additional Treatments                                                    (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)
(Medicare Claims Processing Manual)
10.1 - Billing for Additional Treatments                                                    (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)   The End Stage Renal Disease (ESRD) Prospective Payment System (PPS) provides a per treatment unit of payment. The per treatment unit of payment is the same base rate that is paid for all dialysis treatment modalities furnished by an ESRD facility.  The policy allows for 3 PPS payments per week.  When a beneficiarys plan of care requires more than three weekly dialysis treatments, whether HD or daily PD, claim edits are applied to ensure that Medicare payment on the monthly claim is consistent with the 3-times weekly dialysis treatment payment limit. Thus, for a 30 -day month, payment is limited to 13 treatments, and for a 31- day month, payment is limited to 14 treatments, with exceptions made for medical justification.    ESRD facilities billing for more than 13 or 14 treatments per month must provide medical justification as required by the Medicare Administrative Contractor in order to receive payment for the additional treatments. Additional treatments provided without meeting the medical justification required must include the modifier CG on the claim line. This modifier indicates that the facility  attests the additional treatment does not meet medical justification requirements.  Additional treatments billed without medical justification do not receive payment.  Non- covered treatments are not considered in the outlier payment calculation.    This policy does not apply for training and retraining treatments billed within the allowable limits.  See section 50.8 of this chapter for training and retraining treatments.  10.2 - Uncompleted Treatments  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implem entation:09- 07-21)   A dialysis treatment is started, when  a patient is connected to the machine and a dialyzer and bloodlines are used. However, if the is not completed for some unforeseen, but valid reason  such as  a medical emergency when the patient must be rushed to an emergency room, the facility is paid based on the full Prospective Payment System (PPS) base rate   This is a rare occurrence and must be fully documented to the A/B MAC (A)s satisfaction.
(Medicare Claims Processing Manual)
10.3 - No-Shows  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  If a facility sets up in preparation for a dialysis treatment, but the treatment is never started  because the patient never arrives, no payment is made. In this case, no service has been furnished to a Medicare beneficiary even though staff time and supplies may have been used.  Furthermore, the facility may not bill the patient or the patients private insura nce for these services.  This is because the program is already paying the cost of pre-dialysis services through the PPS base rate .  In setting that rate, CMS has included the salaries of facility personnel and the cost of supplies used for furnishing pre -dialysis services.   Therefore, these costs (e.g., salaries for staff time, overhead, supply costs) are included in the facilitys costs and reported on its cost report, and they are included in the allowable costs used to set future reimbursement rates under the End Stage Renal Disease Prospective Payment System (ESRD PPS)  for ESRD facilities.  However, these costs may not be used as the basis for a facility to be reimbursed as Medicare bad debts.  10.4 - Deductible and Coinsurance                                                           (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  The beneficiary is responsible for any unmet deductible and for coinsurance.    Eighty percent of the total End Stage Renal Disease Prospective Paym ent System (ESRD PPS) payment amount for renal dialysis services furnished by ESRD facilities to ESRD beneficiaries is paid by Medicare. ESRD beneficiaries are responsible for the remaining twenty percent after the deductible. Therefore, the beneficiary co insurance amount under the ESRD PPS is twenty percent of the total ESRD PPS payment, which includes the ESRD PPS base rate, all applicable adjustments, any applicable training add- on amounts and any applicable outlier payments.   10.5 - Hospital Services  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)
(Medicare Claims Processing Manual)
10.5 - Hospital Services  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  Outpatient dialysis services for a patient with acute kidney failure or chronic kidney failure but not eligible for Medicare under the ESRD provisions at the time services are render ed must be billed by the hospital and cannot be billed by a Medicare certified renal dialysis facility on bill type 72x.   Hospitals with a Medicare certified renal dialysis facility should have outpatient ESRD related services billed by the hospital- based renal dialysis facility on bill type 72x.  Hospitals that do not have a Medicare certified renal dialysis facility may bill for outpatient emergency or unscheduled dialysis services.  The Prospective Payment System (PPS) base rate  is not paid. For more inf ormation regarding the outpatient hospital billing policy for ESRD related services, see chapter 4 section 210 of this manual.  When an individual is furnished outpatient hospital services and is thereafter admitted as an inpatient of the same hospital due  to renal failure -  within 24 hours for non PPS hospitals and within 72 hours for PPS hospitals -  the outpatient hospital services furnished are treated as inpatient services unless the patient does not have Part A coverage.  Charges are reported on the AS C X12 837 institutional claim format or on Form CMS -1450.  The day on which the patient is formally admitted as an inpatient is counted as the first inpatient day.  The PPS base rate  is not paid.  10.6 - Amount of Payment  (Rev. 10640, Issued:08- 06-21, Effe ctive:09 -07-21, Implementation:09- 07-21)  Effective for dates of service beginning January 1, 2011, after the beneficiarys Part B deductible is met, the A/B MACs (A) pay 80 percent of the ESRD PPS base rate and all applicable adjustments (or the blended payment amount if the facility chooses to transition), for each outpatient maintenance dialysis treatment furnished to the ESRD beneficiary in the ESRD facility or at the beneficiarys home.   10.7 - ESRD Services Not Provided Within the United States (Rev.  1, 10- 01-03)
(Medicare Claims Processing Manual)
10.7 - ESRD Services Not Provided Within the United States (Rev.  1, 10- 01-03)  Services (except for certain inpatient hospital services and related physicians and ambulance services in specified situations) that are not provided within the United States are not covered. United States includes the 50 States, the Distric t of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, and American Samoa.  See Chapter 1 for additional information concerning specified situations that may be covered, billing and payment procedures and jurisdiction for payment.   10.8 - Transportation Services  (Rev. 1, 10- 01-03)  In general, transportation services to obtain ESRD services are not covered. However, see the Medicare Benefit Policy Manual, Chapter 10, for coverage of ambulance services to renal dialysis facilities located on hospital premises and for coverage of ambulance services to nonhospital based dialysis facilities.  Billing and payment instructions are provided in Chapter 15 of this manual.  10.9  Dialysis Provider Number Series (Rev. 771, Issued: 12- 02-05, Effective: 01 -03-06, Implementation: 01- 03-06)  There are multiple facilities that provide dialysis services to ESRD beneficiaries.  To ensure that provider data is correct, facilities are required to use a Provider Number based on facility type issued by CMS.   The Provider Number Series for Dialysis Providers are as follows (for CMS use only, effective May 23, 2007, providers are required to submit only their National Provider Identifier (NPI).  The dialysis provider numbers will be mapped to the NPI):   2300- 2499 Chronic Renal Dialysis Facilities (Hospital  Based)  2500- 2899 Non  Hospital Renal Facilities  2900- 2999 Independent Special Purpose Renal Dialysis Facility  3300- 3399 Childrens Hospitals (Excluded from PPS)  3500- 3699 Renal Disease Treatment Centers (Hospi tal Satellites)  3700- 3799 Hospital Based Special Purpose Renal Dialysis Facilities   All facilities should use their appropriately assigned provider numbers on the 72x type of bill.  In the event that a facility changes from one type to another, the provider number must reflect the facilitys present provider type.
(Medicare Claims Processing Manual)
All facilities should use their appropriately assigned provider numbers on the 72x type of bill.  In the event that a facility changes from one type to another, the provider number must reflect the facilitys present provider type.   20 - End Stage Renal Disease Prospective Payment System (ESRD PPS)  Per Treatment Payment Amount                                                               (Rev. 10640, Issued:08- 06-21, Effective:09 -07-21, Implementation:09- 07-21)  A case mix methodology adjusts the  Prospective Payment System (PPS) base rate based on a limited number of patient characteristics.  Variables for which adjustments will be applied to the PPS base rate  include age, body surface area (BSA), and low body mass index (BMI).  These variables are determined in the ESRD PRICER to calculate the End Stage Renal Disease Prospective Payment System (ESRD PPS  per treatment payment amount (including all other adjustments).   The following table contains claim data required to calculate the ESRD PPS  per treatment payment amount .    Form CMS -1450  ASC X12 837 institutional claim  Through Date  2300 | DTP segment | 434 qualifier  Date of Birth  2010 BA | DMG02  Condition Codes (73, 74, 87) 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 ESRD PPS per treatment payment amount:
(Medicare Claims Processing Manual)
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 ESRD PPS per treatment payment amount:     Form CMS -1450  Payer Only Format  Payer Only Condition C odes  (MA, MB, MC, MD, ME, MF)  (Identifies comorbid conditions for adjustments)  X(2)    Payer Only Value Code (79)  (Identifies dollar amount for services applicable for the calculation for determining outlier)   X(2) V(9)   Payer Only Value Code (Q8)  (Identifies dollar amount for services applicable for the calculation of the transitional drug add-on payment)   X(2) V(9)   Form CMS -1450  Payer Only Format  Payer Only Value Code (QG)  (Identifies dollar amount for services applicable for the calculation of the transitional  payment for new  innovative equipment and supplies)   X(2) V(9)    Note: The  payer only codes above are assigned by the Medicare standard systems and are not submitted on the claim by the provider.    The following provider data must also be passed to the ESRD PRICER to make provider -specific calculations that determine the ESRD PPS per treatment payment amount:   Field  Format  Actual Geographic Location MSA  X(4)  Actual Geographic Location CBSA  X(5)  Special Wage Index  9(2)V9(4)  Supplemental Wage Index  9(2)V9(4)  Provider Type  X(2)  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)
(Medicare Claims Processing Manual)
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)   Based on the claim and provider data shown above, the ESRD PRICER makes adjustments to the  PPS  base rate to determine the ESRD PPS per treatment payment amount . The following factors are used to adjust and make calculations to the  ESRD PPS per treatment payment amount .  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)   Condition Code 84 for AKI patients (if applicable)   Condition Code 87 adjustment (if applicable)   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 Comorbidities   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 adjus tment is provided, the claim is not entitled to a comorbidity adjustment or a training add -on adjustment.   Patient Comorbidities:   The ESRD PPS will provide adjustments for each category of chronic and acute  comorbidity conditions, 3 categories of chronic conditions and 3 categories of acute conditions.  In the event that more than one of the comorbidity categories is present on the claim, the claim will be adjusted for the highest paying comorbidity category.   Chronic Comorbidities    When chronic comorbidity 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.  Acute Comorbidities
(Medicare Claims Processing Manual)
Chronic Comorbidities    When chronic comorbidity 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.  Acute Comorbidities    Acute comorbidity category adjustments will be eligible for a payment for the first month reported and then for the next three consecutive months, regardless of whether or not the diagnosis code is on the claim after the first month. This adjustment applie s for no more than four consecutive months for any reported acute comorbidity category. Acute comorbidity conditions reported for more than four consecutive months will not receive additional payment.    In the event that the comorbidity condition was resolved and later reoccurred, the provider may submit a condition code to indicate the diagnosis is a reoccurrence. The adjustment will be applicable for an additional four months.  For a list of specific acute and chronic  comorbid conditions eligible for adj ustment, refer  to the following website:   https://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/ESRDpayment/Patient- Level -Adjustments   This list may be updated as often as quarterly in January, April, July and October of each year.   Low -Volume ESRD  Facilities:   ESRD facilities will receive an adjustment to their 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 preceding the payment year.  The ESRD facility must notify their A/B MAC (A) if th ey 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 not 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 t he adjustment within 6 months of finding the error.
(Medicare Claims Processing Manual)
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:   Trai ning 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 P ayments:   The ESRD Prospective Payment System (PPS) includes a payment adjustment for high cost outliers when there are unusual variations in the type or amount of medically necessary care.    Outlier consideration is provided for the following:    ESRD -related drugs and biologicals that were or would have been prior to January 1, 2011, separately billable under Medicare Part B;   ESRD -related laboratory tests that were or would have been, prior to January 1, 2011 separately billable under Part B;   Medical/surgical 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   Renal dialysis service drugs that were or would have been, prior to January 1, 2011 covered under Medicare Part D.    For new injectable renal dialysis drugs and biologicals that are eligible outlier services, ESRD facilities should report J3591 with the National Drug Code (NDC) in the 11 -digit format 5 -4-2.  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.   Statute  requires the delay of the implementation of the oral -only renal dialysis service policy until January 1, 2025. Services not included in the PPS that remain separately payable are not considered outlier services.   When the ESRD PRICER returns an outlier pa yment, the standard systems shall display the total applicable outlier payment on the claim with value code 17.
(Medicare Claims Processing Manual)
When the ESRD PRICER returns an outlier pa yment, 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.