evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
Updates to the provisions under the ESRD PPS are discussed through rulemaking on a yearly basis.  The updates are implemented through Recurring Update Notifications.  A.  Per Treatment Unit of Payment   Under the ESRD PPS payment is made on a per treatment basis.  The ESRD PPS base rate is the per treatment unit of payment that applies to both adult and pediatric patients. ESRD facilities furnishing dialysis treatments in -facility are paid for up  to 3 treatments per week.  ESRD facilities treating patients at home regardless of modality receive payment for 3 hemodialysis (HD) equivalent treatments per week.  Payment for additional treatments may be considered when there is medical justification fo r more than 3 weekly treatments.  For more information regarding home dialysis, see 30 of this chapter.  ESRD facilities furnishing dialysis in- facility or in a patients home are paid for a maximum of 13 treatments during a 30 day month and 14 treatments  during a 31 day month unless there is medical justification for additional treatments.   Frequency of Dialysis Sessions by Dialysis Modality and Treatment Setting*    In-Facility  Home  Hemodialysis  3 per week  Maximum  of 3 per week regardless of frequency  Hemofiltration  3 per week  3 per week  Ultrafiltration  3 per week  Maximum of 3 per week, regardless of frequency  Peritoneal Dialysis (e.g., CAPD and CCPD)  HD-equivalent sessions  HD-equivalent sessions  Intermittent Peritoneal Dialysis (IPD)  3 per week  HD-equivalent sessions   * Regardless of dialysis modality or treatment setting, payments for additional treatments may be made when they are medically justified.  The A/B MAC (A) reviews the medical justification and is responsible for making the decision on the appropriateness of the extra treatment.   1.  Hemodialysis: Payment Based on Standard of Three Treatments per Week   Hemodialysis is typically furnished 3 times per week in sessions of 3 to 5 hours in duration.  If the ESRD facility bills for any treatments in excess of this frequency, medical justification is required to be furnished to the A/B MAC (A) and must be based upon an individual patients need.  The A/B MAC (A) reviews the medical justification for each additional treatment and is respon sible for making the decision on the appropriateness of the extra treatment(s) and payments for these additional treatments.   2.  Hemofiltration
(Medicare Benefit Policy Manual)
2.  Hemofiltration   Hemofiltration is an alternative to peritoneal dialysis and hemodialysis.  Hemofiltration may be routinely performed either in an ESRD facility or at home in 3 weekly sessions.  See 10.A.3 of this chapter.   3.  Ultrafiltration   When ultrafiltration is performed the same day as the dialysis treatment; there is no separate payment.  When ultrafiltration is performe d on a day other than the day of a dialysis treatment, the ESRD facility must document in the medical record why the ultrafiltration could not have been performed at the time of the dialysis treatment.  For the ESRD facility to be paid for the ultrafiltration, the ESRD facility must report the appropriate diagnosis code and the A/B MAC (A) must verify the medical justification to determine appropriate payment.  If the A/B MAC (A) considers the medical justification appropriate, the ESRD facility will receiv e the ESRD PPS base rate.  For more information regarding ultrafiltration, see Pub. 100- 04, Chapter 8, 50.7.   4.  Peritoneal Dialysis: Payment Based on Hemodialysis Equivalent Sessions   For home patients undergoing peritoneal dialysis (PD), the number of days of PD regardless of the number of dialysate exchanges performed each day, is converted to HD -equivalent sessions.  This is accomplished by dividing the number of days of PD by 7, and multiplying the result by 3.   Example:   Joe is a home CCPD patient w ho undergoes PD for 24 days.  The number of HD -equivalent sessions is 24/7 x 3 or 10.28571.  The number of HD -equivalent sessions or treatments for which case -mix adjusted prospective payments are applicable, is 10.28571.   Although CAPD and CCPD patients a re home dialysis patients, occasionally it may be necessary to perform dialysis in -facility.  The number of HD -equivalent sessions for PD performed in- facility is limited to 3 weekly, regardless of the number of days PD is furnished in- facility.  However, each day of in -facility PD is treated as one HD -equivalent session, up to a maximum of 3 per week.
(Medicare Benefit Policy Manual)
Example:  Mary is a home CCPD patient.  After 21 days on CCPD in a month, Marys cycler required repair.  Mary received CCPD in -center for 4 consecutive day s before returning to home CCPD.  The number of HD -equivalent sessions for which payments under the ESRD PPS may be made is 12, determined as follows:   Home CCPD HD- equivalent sessions    21/7 x 3 = 9  In-center PD HD -equivalent sessions (limited to 3)        3 Total HD -equivalent sessions         12  Marys ESRD facility would receive the case- mix adjusted ESRD PPS base rate for 12 treatments in the month.  5.  Intermittent Peritoneal Dialysis (IPD)   Maintenance Intermittent Peritoneal Dialysis (IPD) is usually accomplished in sessions of 10 to 12 hours in duration.  Sometimes it is accomplished in fewer weekly sessions of longer duration.  The payment applicable for maintenance IPD, as well as the ESRD facilitys actual payment for maintenance IPD, depen ds on the treatment setting (in -facility or at home).  Payment for in -facility IPD follows the same payment rules as hemodialysis, i.e., 3 sessions per week (see Pub. 100- 04, chapter 8, 50.5 and 50.6.2).  Payment for home IPD is based on a weekly equival ence of 3 sessions per week (see Pub. 100- 04, chapter 8, 80.3, 80.3.1, and 80.4).  If additional dialysis beyond the usual weekly maintenance dialysis is required because of special circumstances, the ESRD facilitys claim for these extra services must be accompanied by a medical justification for payment to be made.   6.  Uncompleted Dialysis Treatments under the ESRD PPS
(Medicare Benefit Policy Manual)
6.  Uncompleted Dialysis Treatments under the ESRD PPS   If a dialysis treatment is started, (i.e., a patient is connected to the machine and a dialyzer and blood lines are used), but the tr eatment is not completed for some unforeseen, but valid reason, (e.g., a medical emergency when the patient must be rushed to an emergency room), the ESRD facility is paid based on the ESRD PPS base rate.  This is a rare occurrence and must be medically ju stified.  If the patient returns the same day and completes the treatment, the facility is only paid for one treatment.   If a patient was taken to a hospital and was furnished a dialysis treatment while in the emergency room, then the ESRD facility will no t receive payment for the treatment and only the hospital will be paid.  See Pub.100- 04, chapter 4, section 200.2 for additional information.  B.  Market Basket   For renal dialysis services furnished on or after January 1, 2011 and before January 1, 2012, CMS adjusts the composite rate portion of the basic case -mix adjusted composite payment system described in 42 CFR 413.220 by the ESRD bundled market basket percentage increase factor.  For renal dialysis services furnished on or after January 1, 2012, CMS  updates on an annual basis, the ESRD PPS base rate and the composite rate portion of the basic case -mix adjusted composite payment described in 42 CFR 413.220 by the ESRD bundled market basket percentage increase factor minus a productivity adjustment fac tor.  Effective for renal dialysis services furnished on or after January 1, 2014, there is no longer a transition, therefore only the ESRD PPS base rate would be updated by the ESRD bundled market basket percentage increase factor minus a productivity adj ustment factor.   60 - ESRD PPS Case -Mix Adjustments  (Rev. 254, Issued: 12- 13-18, Effective: 01- 01-19, Implementation: 01- 07-19)
(Medicare Benefit Policy Manual)
60 - ESRD PPS Case -Mix Adjustments  (Rev. 254, Issued: 12- 13-18, Effective: 01- 01-19, Implementation: 01- 07-19)  The ESRD PPS includes patient -level adjustments (also known as the case -mix adjustments), facility -level adjustments, and training adjustments, as well as an outlier payment. Under the ESRD PPS, the beneficiary co-insurance amount is 20 percent of the total ESRD PPS payment, after the deductible (see 60.E of this chapter).   A. Patient -level case- mix adjustments   The ESRD PPS ba se rate is adjusted for characteristics of both adult and pediatric patients to account for case- mix variability. The adult case -mix adjusters include variables (age, body surface area (BSA), and low body mass index (BMI)) that were part of the basic case -mix adjusted composite rate payment system. In addition, the ESRD PPS implemented in CY 2011 includes adult case -mix adjustments for six comorbidity categories (three acute and three chronic) as well as the onset of renal dialysis. Pediatric patient -level adjusters (see 60.A.6 of this chapter), consist of combinations of two age categories and two dialysis modalities. Based on the refinement of the ESRD PPS, effective January 1, 2016, adult case -mix payment adjustments are made for four comorbidity categor ies (two acute and two chronic) as discussed below.  1. Adult case -mix adjusters   This section presents a list of the ESRD PPS case- mix adjusters for adults and provides several examples using the adult case -mix adjusters implemented in CY 2011 and refined in CY 2016. Any revisions to the case- mix adjusters will be published in subsequent rulemaking.   Adult  Patient -Level  Characteristics  Adjustment  Value
(Medicare Benefit Policy Manual)
Adult  Patient -Level  Characteristics  Adjustment  Value   CY 2011 -2015  Beginning  CY 2016  Age: 18 -44 1.171  1.257  Age: 45 -59 1.013  1.068  Age: 60 -69 1.000  1.070  Age: 70 -79 1.011  1.000  Age: 80+  1.016  1.109  Body Surface Area  1.020  1.032  Low Body Mass Index (BMI <18.5)  1.025  1.017  Onset of Dialysis  1.510  1.327  Pericarditis  1.114  1.040  Bacterial pneumonia  1.135  --- Gastro -intestinal tract bleeding  1.183  1.082  Hereditary hemolytic or sickle cell anemia  1.072  1.192  Myelodysplastic syndrome  1.099  1.095  Monoclonal gammopathy  1.024  ---  Calculating the ESRD PPS Adjusted Payment   The following example demonstrates the calculation of the  ESRD PPS payment in an urban area with a wage index of 1.10. Before giving the particulars of the dialysis patient for the example, shown first is how to calculate the labor -adjusted base rate, which is the starting point for the computation of the case -mix adjusted base rate.    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 - .50673) =  $113.64   Wage index adjusted base rate: $128.42 + $113.64 =  $242.06  Provided next is the continuation of the example with the inclusion of the patient characteristics portion of the payment.   A 45 year old male Medicare beneficiary is 187.96 cm. (1.8796 m.) in height and weighs 95 kg.  He receives dialysis in an ESRD facility on January 1, 2016.  725 425 Using the formula for BMI, note that the patient is not underweight, having a BMI of  26.89 kg/m2, which is greater than the threshold value of 18.5 kg/m2.
(Medicare Benefit Policy Manual)
BMI Patient = weight kg /height (m2) = 95/1.87962 = 95/3.5329 = 26.89  The formula for calculation of a patients BSA is:    0.007184 multiplied by height in meters 0.725 multiplied by weight in kg.  0.425  or BSA = 0.007184 * height cm * weight kg  The BSA for the patient in this example is calculated as:   BSA Patient = 0.007184 * 187.96.725 * 95.425 = 0.007184 * 44.5346 * 6.9268 = 2.2161  Using the adult case- mix adjusters table shown above, the BSA multiplier of 1.032 is used. The patients case -mix adjustment or payment multiplier (PM) based on his BSA of 2.2161 is computed as follows:   PM BSA = 1.032(2.2161 -1.90)/0.1  = 1.0323.161 = 1.1047  The example patients PM would reflect the applicable case- mix adjustments from the adult case- mix adjusters table above for both age and BSA and may be expressed as:   PM Patient = PM age * PM BSA  = 1.068 * 1.1047 = 1.1798  The example patients ESRD payment rate for treatments furnished in his ESRD facility would be:   $242.06* 1.1798 = $285.58  NOTE: This example is computed without regard to other adjustments (e.g., outlier payments, training add- on, low -volume adjustment, etc.).   2. Patient  Age
(Medicare Benefit Policy Manual)
NOTE: This example is computed without regard to other adjustments (e.g., outlier payments, training add- on, low -volume adjustment, etc.).   2. Patient  Age  There are 5 age categories for adults (18 -44; 45- 59; 60- 69; 70- 79; and 80 and above) in the ESRD PPS and each category has a separate case- mix adjuster.  Note that, when a  beneficiary reaches a birthday that results in a different age category, the age change is effective from the first day of the birthday month, regardless of the date the birthday occurs in that month. The case -mix adjustment factor corresponding to the age of the dialysis patient is multiplied by the wage index adjusted base rate as a step in the calculation of the ESRD PPS per treatment payment amount. The examples shown below draw on values from the table  of the CY 2016 adult case -mix adjusters as well as the discussion of the wage adjusted ESRD PPS base rate found in the section above.   Example 1: Mr. Taylor is 38 years of age and is classified in the 18- 44 age group with an associated case- mix adjuster o f 1.257.  Applying the case -mix adjuster  of 1.257 to the wage index adjusted base rate of $242.06 yields the age adjusted base rate amount of $304.27 ($242.06 x 1.257 = $304.27).   Example 2: Mrs. Williams was born on July 4, 1936. On June 15, 2016, she is 79 years old and is classified in the 70 -79 age category with a case- mix adjustment of 1.000 (the reference group). However, beginning with dialysis treatments occurring on and after July 1, 2016, she will move into the 80+ age group with an associated cas e-mix multiplier of 1.109.   Example 3: Mr. Davis was born on September 29, 1971. For dialysis treatments occurring in August 2016, he is 44 years old and would be classified in the 18- 44 age group with an associated case- mix adjuster of 1.257. Beginning with dialysis treatments occurring on and after September 1, 2016, he is classified in the 45- 59 age category with a case -mix adjuster of 1.068 because he is considered to have attained age 45 on September  1.
(Medicare Benefit Policy Manual)
3. Body Size: Low Body Mass Index (BMI) and/or Body Surface Area  (BSA)  Low BMI and BSA are two measures used to estimate body size. Both measures are strong predictors of variation in costs and are closely associated with the duration and intensity of dialysis necessary to achieve a therapeutic dialysis  target for ESRD patients. Both are objective measures that are computed using height and weight data located on the patient claim. The BMI and BSA are calculated for all beneficiaries. Low BMI is associated with higher costs due to additional resources that may be necessary to address malnutrition or frailty. BSA is associated with higher costs due to more time on the dialysis machine.   Although height and weight are taken at intervals throughout any given month of dialysis treatment, the measurements for the purpose of payment must be taken as follows:    The dry weight of the patient is measured and recorded in kilograms immediately following the last dialysis session of the  month.   The patient height is measured and recorded in centimeters during the last  dialysis session of the month. The measurement is required no less frequently than once per  year.  The formula for the calculation of the BMI is weight in kilograms divided by height in meters squared, or kg/m2.  As an example, the designated low BMI adjustment factor of  1.017 (see 60.A.1 of this chapter) is only applied for those beneficiaries with a BMI value that is less than 18.5kg/m2 which is a clinical measure of being underweight and an indicator of malnutrition.   The formula for the calcul ation of the BSA is BSA = w0.425 * h0.725 * 0.007184 where w and h represent weight in kilograms and height in centimeters. The BSA factor is defined as an exponent equal to the value of the patients BSA minus the reference BSA of 1.90 divided by 0.1.  Us ing the example of adult adjusters above, the BSA adjustment factor of  1.032 is then exponentiated based on the calculated BSA factor as 1.032(BSA -1.90)/0.1. The reference BSA used to calculate the BSA is the national average among Medicare dialysis patien ts.  4. Onset of  Dialysis
(Medicare Benefit Policy Manual)
4. Onset of  Dialysis   An ESRD facility may only receive the onset of dialysis adjustment for adult Medicare ESRD beneficiaries. The onset period is defined as the initial 120 days of outpatient maintenance dialysis, which is designated by the first date of when regular chronic dialysis began as reported on the CMS Form 2728. The onset of dialysis adjustment factor is a multiplier used in the calculation of the ESRD PPS per treatment payment amount for dialysis furnished in either an ESRD facility or home setting. For example, when a dialysis patient is not eligible for the Medicare ESRD benefit at the initiation of their maintenance dialysis, but is Medicare eligible at the end of 85 days, the onset of dialysis adjustment will be applied to the ESRD facilitys ESRD PPS base rate for each treatment furnished in the following 35 days. However, if the patient is not Medicare eligible at any time during the initial 120 days of receiving maintenance dialysis, the onset of dialysis adjustment will not apply.   The onset of dialysis adjustment is a one -time adjustment.  It is not applied when a patient changes ESRD facilities or after a failed transplant. If a patient changes or transfers to another ESRD facility during the initial 120 days, the new ESRD facility will only receive the onset of dialysis adjustment for the remaining time. In other words, the 120 day clock does not start over.   If the onset of dialysis adjustment is being applied to the ESRD PPS base rate, then those treatments would not be eligible f or the comorbidity adjustment nor any applicable training adjustment(s). However, those treatments are eligible for an outlier payment when appropriate.   5. Comorbidity  Categories   The two acute comorbidity categories are pericarditis and gastro -intestinal tr act bleeding with hemorrhage. The two chronic comorbidity categories are myelodysplastic syndrome and hereditary hemolytic anemia (including sickle cell anemia).  The related comorbidity  diagnosis codes can be found at the CMS ESRD Payment Web site located at  https://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/ESRDpayment/Patient- Level -Adjustments.html
(Medicare Benefit Policy Manual)
NOTE: Prior to the refinement of the ESRD PPS, effective January 1, 2016, the ESRD PPS included payment adjustments for the comorbidity categories of bacterial pneumonia and monoclonal gammopathy.   The ESRD facility is responsible for obtaining documentation of the presence of an acute or chronic comorbidity. If an ESRD facility is unaware of the existence of a comorbidity because it does not impact the facilitys costs, then the ESRD facility should not expect to receive a comorbidity adjustment.  The comorbidity payment adj ustment is only applied if the appropriate diagnosis code, specified under one of the categories above, is identified on the ESRD claim.  Comorbidities other than the two acute and the two chronic conditions identified above do not qualify for a comorbidit y adjustment. Even if an ESRD patient has or has had one of the four conditions that would qualify for a comorbidity payment adjustment, the condition must be currently active and have an effect on the cost of care for the ESRD facility to be eligible to r eceive the adjustment.   To qualify for the comorbidity adjustment there must be adherence to diagnosis coding requirements.  Diagnosis codes are updated annually as stated in Pub. 100- 04, Chapter 23, section 10, are posted at http://www.cms.gov/Medicare/Coding/ICD10/index.html , and are effective each October 1st.   For transfer patients, it is expected that ESRD facilities will work together on the appropriate transfer of information to faci litate appropriate billing for dialysis services. The counting of treatments for an acute comorbidity adjustment is based on the patient and not on the ESRD facility. Therefore, counting does not restart when a beneficiary moves to a new ESRD facility, but  rather continues for the remaining 4 months.  a. Duration of Acute Comorbidity  Adjustment   Payment for an acute comorbidity adjustment begins in the month in which the diagnosis is established, and lasts for the next 3 consecutive patient months. A patient month is any month in which a dialysis treatment is furnished, and an acute comorbidity applies.
(Medicare Benefit Policy Manual)
The acute diagnosis comorbidity adjustment is applied to each dialysis treatment for 4 patient months. If a second comorbidity is diagnosed during that period (either acute or chronic), then the adjustment is made using the higher adjustment factor. At no time is an adjustment applied for more than one comorbidity.  When there is a recurrence of an acute comorbidity within the 4 patient month period, there will not be an extension of the 4 patient month adjustment. A recurrence is defined as a new episode of a comorbidity that was previously experienced by an individual beneficiary.  However, if the recurrence happens after the completion of the 4 month period, t hen a new comorbidity adjustment for 4 months would start.   Example  A male patient has been receiving hemodialysis since January 2010. He had a 2-week hospitalization due to a fracture in mid- January 2016. During his stay in the hospital, he was diagnose d with gastro -intestinal tract bleeding with hemorrhage on January 20, 2016. He resumed his outpatient maintenance dialysis on January 29, 2016. The 4 patient months in which the patients ESRD facility would be eligible to have the comorbidity adjustment applied to each dialysis treatment are January through April  2016.  b. Duration of Chronic Comorbidity  Adjustment   The chronic diagnosis comorbidity adjustment is applicable only when the comorbidity has an effect on the cost of dialysis care and when that chronic diagnosis comorbidity appears on the claim. The adjustment does not automatically continue each month. When an acute diagnosis comorbidity with a higher adjustment value is applicable at the same time a chronic comorbidity applies, then the higher adjustment will be applied for 4 patient months, and then revert to the lower chronic comorbidity payment adjustment factor.   6. Pediatric case -mix adjusters: Age and dialysis  modality