evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
With the implementation of the ESRD PPS, ESRD -related EPO is included in ESRD PPS payment amount and is not separately payable on Part B cl aims with dates of service on or after January 1, 2011 for other providers with the exception of a hospital billing for an emergency or unscheduled dialysis session.  In the hospital inpatient setting, payment under Part A is included in the DRG.  In the hospital inpatient setting, payment under Part B is made on bill type 12x. Hospitals report the drug units based on the units defined in the HCPCS description.  Hospitals do not report value code 68 for units of EPO.  For dates of service prior to April 1, 2006, report EPO under revenue code 0636.  For dates of service from April 1, 2006 report EPO under the respective revenue code 0634 for EPO less than 10,000 units and revenue code 0635 for EPO over 10,000 units. Payment will be based on the ASP Pricing Fil e.    In a skilled nursing facility (SNF), payment for EPO covered under the Part B EPO benefit is not included in the prospective payment rate for the residents Medicare -covered SNF stay.   In a hospice, payment is included in the hospice per diem rate when treatment is related to the terminal illness .  For a service furnished by a physician or incident to a physicians service, payment is made to the physician by the A/B MAC (B) in accordance with the rules for incident to services.  When EPO is administered in the renal facility, the service is not an incident to service and not under the incident to provision.  60.4.4.2 - Epoetin Alfa (EPO) Provided in the  Hospital Outpatient Departments  (Rev. 2582, Issued: 11- 02-12, Effective: 04- 01-13, Implementation: 04 -01-13)  When ESRD patients come to the hospital for an unscheduled or emergency dialysis treatment they may also require the administration of EPO.  Effective January 1, 2005, EPO will be paid based on the ASP Pricing File.
(Medicare Claims Processing Manual)
When ESRD patients come to the hospital for an unscheduled or emergency dialysis treatment they may also require the administration of EPO.  Effective January 1, 2005, EPO will be paid based on the ASP Pricing File.   Hospitals us e type of bill 13X (or 85X for Critical Access Hospitals) and report charges under the respective revenue code 0634 for EPO less than 10,000 units and revenue code 0635 for EPO over 10,000 units.  Hospitals report the drug units based on the units defined in the HCPCS description.  Hospitals do not report value code 68 for units of EPO.  Value code 49 must be reported with the hematocrit value for the hospital outpatient visits prior to January 1, 2006, and for all claims with dates of service on or after J anuary 1, 2008.   60.4.5.1 - Self Administered ESA Supply  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  Initially, facilities may bill for up to a 2 -month supply of an ESA for  home dialysis  beneficiaries who meet the criteria f or selection for self -administration. After the initial two months supply, the facility will bill for one months supply at a time. Condition code 70 is used to indicate payment requested for a supply of an ESA furnished a beneficiary. Usually, revenue co de 0635 would apply to EPO since the supply would be over 10,000 units. Facilities leave FL 46, Units of Service, blank since they are not administering the drug.  For claims with dates of service on or after January 1, 2008, supplies of an ESA for self -administration  should be billed according to the pre -determined plan of care schedule provided to the beneficiary.  Submit a separate line item for each date an administration is expected to be performed with the expected dosage.  In the event that the schedule was changed, the provider should note the changes in the medical record and bill according to the revised schedule.  For patients beginning to self -administer an ESA at home receiving an extra month supply of the drug, bill the one month reserve supply on one claim line and include modifier EM defined as Emergency Reserve Supply (for ESRD benefit only).
(Medicare Claims Processing Manual)
When billing for drug wastage in accordance with the policy in chapter 17 of this manual, section 40.1 the provider must show the wastage on a separat e line item with the modifier JW.  The line item date of service should be the date of the last covered administration according to the plan of care or if the patient dies use the date of death.   Condition code 70 should be reported on claims billing for home dialysis patients who   self-administer  anemia management drugs including ESAs.   60.4.6.1 - Reserved for Future Use                                                       (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21) 60.4.6.2 - Reserved for Future Use                                                         (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21) 60.4.6.3 - Payment Amount for Darbepoetin Alfa (Aranesp)  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  Payment for ESRD -related Aranesp is included in the ESRD PPS for claims with dates of service on or after January 1, 2011.   60.4.6.4 - Payment for Darbepoetin Alfa (Aranesp) in Other Settings  (Rev. 10640, Issued:08- 06-21, Effective:09 -07-21, Implementation:09- 07-21)  In the hospital inpatient setting, payment under Part A for Aranesp is included in the DRG.   In the hospital inpatient setting, payment under Part B is made on bill type 12x when billed with revenue code 0636.  The total number of units as a multiple of 1mcg is placed in the unit field.  Reimbursement is based on the payment allowance limit for Medicare Part B drugs as found in the ASP pricing file.   In a skilled nursing facility (SNF), payment for Aranesp cover ed under the Part B EPO benefit is not included in the prospective payment rate for the residents Medicare -covered SNF stay.   In a hospice, payment is included in the hospice per diem rate when treatment is related to the terminal illness .
(Medicare Claims Processing Manual)
In a hospice, payment is included in the hospice per diem rate when treatment is related to the terminal illness .  For a service furnished by a physician or incident to a physicians service, payment is made to the physician by the A/B MAC (B) in accordance with the rules for incident to services. When Aranesp is administered in the renal facility, the service is not an incident to service and not under the incident to provision.  With the implementation of the ESRD PPS, ESRD -related Aranesp is included in the ESRD PPS payment amount and is not separately payable on Part B claims with dates of service on or after January 1, 2011 for other providers, with the exception of a hospital billing for an emergency or unscheduled dialysis session.  60.4.6.5 - Payment for Darbepoetin Alfa (Aranesp) in the Hospital Outpatient Department  (Rev. 2582, Issued: 11- 02-12, Effective: 04- 01-13, Im plementation: 04 -01-13)  When ESRD patients come to the hospital for an unscheduled or emergency dialysis treatment they may also require the administration of Aranesp.  For patients with ESRD who are on a regular course of dialysis, Aranesp administered i n a hospital outpatient department is paid the MMA Drug Pricing File rate.  Effective January 1, 2005, Aranesp will be paid based on the ASP Pricing File.   Hospitals use bill type 13X (or 85X for Critical Access Hospitals) and report charges under revenue code 0636. The total number of units as a multiple of 1mcg is placed in the unit field.  Value code 49 must be reported with the hematocrit value for the hospital outpatient visits prior to January 1, 2006, and for all claims with dates of service on or after January 1, 2008.   60.5 - Intradialytic Parenteral/Enteral Nutrition (IDPN)  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  A.  General
(Medicare Claims Processing Manual)
A.  General   Parenteral/enteral nutrition (PEN) administered during dialysis may be covered under Medicare, but it is not part of the Medicare ESRD benefit. Therefore, an ESRD facility or PEN supplier may bill Medicare separately for PEN solution if the patient meets all of the requirements for PEN coverage. (See Medicare Benefit Policy Manual for PEN coverage requirements.) If the ESRD facility bills, it does so as a PEN supplier and bills the appropriate DME MAC.  B.  Staff Time   The ESRD facility staff time used to administer PEN solution is not covered by Medicare, and, therefore, not included in the ESRD PPS . (PEN is considered a self -administered therapy and generally administered in the patients home.) Since it is not covered under Medicare, it is not part of the ESRD PPS  nor may a facility bill Medicare separately for it.   60.6 - Vaccines Furnished to ESRD Patients (Rev. 10640, Issued:08- 06-21, Effective:09- 07-2021, Implementation:09- 07-2021)   The Medicare program covers hepatitis B, influenza virus and Pneumococcal pneumonia virus ( PPV) vaccines and their administration when furnished to eligibl e beneficiaries in accordance with coverage rules.  Payment may be made for both the vaccine and the administration.  The costs associated with the syringe and supplies are included in the administration fee: HCPCS code A4657 should not be billed for these  vaccines.   Vaccines and their administration are reported using separate codes. See Chapter 18 of this manual for the payment  and codes required for billing vaccines and the administration of the vaccine.   Vaccines remain separately payable under the ESRD  PPS.   60.7  Reserved  For Future Use                                                                  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-2021, Implementation:09- 07-21)  70 - Payment for Home Dialysis  (Rev. 10640, Issued:08- 06-21, Effective:09 -07-21, Implementation:09- 07-21)  Home dialysis is dialysis performed by an appropriately trained dialysis patient at home.  Hemodialysis, CCPD, IPD and CAPD may be performed at home. For renal all dialysis services furnished by an ESRD facilit y, the facility must accept assignment, and only the facility may be paid by the Medicare program.
(Medicare Claims Processing Manual)
For purposes of home dialysis, a skilled nursing facility (SNF) may qualify as a beneficiarys home.  The services are excluded from SNF consolidated billing for its inpatients. The home dialysis services are billed by the ESRD facility.   With the impleme ntation of the ESRD PPS on January 1, 2011, payment for all home dialysis services furnished to the ESRD beneficiary is made to an ESRD   dialysis facility whether services are  provided directly or under arrangements.   70.1  Overpayments                                                                                   (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  Any overpayments that occur are subject to recovery following the usual Medicare program rules and procedures.   80 - Home Dialysis Method I Billing to the A/B MAC (A)  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  If an ESRD patient chooses home dialysis, the ESRD dialysis facility with which the Medicare home patient is as sociated assumes responsibility for providing all home dialysis equipment and supplies, and home support services. For these services, the facility receives the same Medicare dialysis payment rate as it would receive for an in -facility patient under the ES RD PPS. The beneficiary is responsible for paying any unmet Part B deductible and the 20- percent coinsurance.   80.1 - Items and Services Included in the ESRD PPS payment  for Home Dialysis (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  The following items are paid for and must be furnished under the PPS . The facility may furnish them directly under arrangements, to all of its home dialysis patients. If the facility fails to furnish (either directly or under arra ngements) any part of the items and services covered under the rate, then the facility cannot be paid any amount for the part of the items and services that the facility does furnish.    Medically necessary dialysis equipment and dialysis support equipment;    Home dialysis support services including the delivery, installation, maintenance, repair, and testing of home dialysis equipment, and home support equipment;
(Medicare Claims Processing Manual)
 Medically necessary dialysis equipment and dialysis support equipment;    Home dialysis support services including the delivery, installation, maintenance, repair, and testing of home dialysis equipment, and home support equipment;    Purchase and delivery of all necessary dialysis supplies;    Routine ESRD related laboratory tests; and    All dialysis services furnished by the facilitys staff.   The following items and services are included in the ESRD PPS and may not be billed separately when furnished by a dialysis facility:    Staff time used to administer blood;   Declotting of  shunts and any supplies used to declot shunts by facility staff in the dialysis unit;   Oxygen and the administration of oxygen furnished in the dialysis unit;    Staff time used to administer separately billable parenteral items;   Bicarbonate dialysate;    Cardiac monitoring;    Catheter changes (Ideal Loop);    Suture removal;    Dressing changes;    Crash cart usage for cardiac arrest; or    Staff time used to collect specimens for all laboratory tests.   Sometimes services that are not renal dialysis services  ( e.g., declotting of shunts, suture removal, injecting separately billable ESRD related drugs) are furnished in a department of the hospital other than the dialysis unit (e.g., the emergency room). These services may be paid in addition to the ESRD PPS paym ent  only if the services could not be furnished in a dialysis facility or the dialysis unit of the hospital, due to the absence of specialized equipment or staff, which can be found only in the other department. In the case of emergency services furnished  in the hospital emergency room (ER), the services are paid separately subject to the additional requirement that there is a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that t he absence of immediate medical attention in the ER could reasonably be expected to result in either:    Placing the patients health in serious jeopardy;    Causing serious impairment to bodily functions; or    Causing serious dysfunction of any bodily organ or  part.
(Medicare Claims Processing Manual)
 Placing the patients health in serious jeopardy;    Causing serious impairment to bodily functions; or    Causing serious dysfunction of any bodily organ or  part.   These situations are rare and, in the absence of documentation to the contrary, these conditions are deemed to be not met.  80.3 - Calculating Payment for Intermittent Peritoneal Dialysis (IPD)  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  The value of a typical week of dialysis services generally serves as the maximum weekly payment;.  While maintenance IPD is usually accomplished in sessions of 10- 12 hours duration, three times per week, it is sometimes accomplish ed in fewer sessions of longer duration.  Regardless of the particular regimen used, under the ESRD PPS  IPD is paid based on a weekly equivalence of three ESRD PPS payments rates per week.    IPD in the home is accomplished according to any one of several s chedules. The total weekly dialysis time varies from 50 to 80 hours. For example, home IPD may b e furnished every day for 10 hours per day, every other day for 15 hours per dialysis day, every night for 8 hours per night, etc. Regardless of the particular regimen used, under the ESRD PPS home IPD is paid based on a weekly equivalence of three ESRD PPS rates per week.   Line item billing is required for all dialysis sessions.  For intermittent home dialysis the facility submits a separate line item for each d ialysis session using the dates in the pre -determined plan of care and the units reported on each line should be one.  In the event that the schedule was changed, the provider should note the changes in the medical record and bill according to the revised schedule.   80.4 - Calculating Payment for Continuous Ambulatory Peritoneal Dialysis (CAPD) and Continuous Cycling Peritoneal Dialysis (CCPD) Under the ESRD PPS                                                                                               (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)
(Medicare Claims Processing Manual)
CAPD and CCPD are furnished on a continuous basis, not in discrete sessions and, therefore, are paid on a weekly or daily basis, not on a per treatment basis. Facilities are require d to report the number of days in the units field. A facilitys daily payment rate is 1/7 of three times the composite rate for a single hemodialysis treatment.   The equivalent weekly or daily IPD or CAPD/CCPD payment does not depend upon the number of exc hanges of dialysate fluid per day (typically 3 -5) or the actual number of days per week that the patient undergoes dialysis. The weekly (or daily) rate is based on the equivalency of one week of IPD or CAPD/CCPD to one week of hemodialysis, regardless of t he actual number of dialysis days or exchanges in that week.   All home dialysis support services, equipment and supplies necessary for home IPD or CAPD/CCPD are included in the ESRD PPS payment. No support services, equipment or supplies may be paid in addition to the ESRD PPS .  Line item billing is required for all dialysis sessions.  For claims billing for Continuous Ambulatory Peritoneal Dialysis (CAPD) and Continuous Cycling Peritoneal Dialysis (CCPD), the provider may submit a separate dialysis line for each day of the month.  If the provider is aware of an inpatient stay for the beneficiary within the month, the  ESRD facility may include the date of admission and date of discharge as a billable day for the dialysis but should omit the dates within the  inpatient stay.  In the event that the  ESRD facility   is unaware of an inpatient stay during the month, the Medicare system shall detect the overlapping dates and reject only the line item dates within the inpatient stay but pay the remainder of the clai m for any dates that are not within the inpatient stay.   90  Reserved for Future Use                                                                     (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  100 - Dialysis Sessions Furnished to Patients Who are Traveling (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  A. Dialysis at Another Facility
(Medicare Claims Processing Manual)
100 - Dialysis Sessions Furnished to Patients Who are Traveling (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  A. Dialysis at Another Facility   All in -facility dialysis treatments furnished by and in a facility are billed by and paid to that facility under the ESRD PPS . This is true even if the patient is only temporary at a particular facility while traveling .  B. Temporary Home Dialysis   Patient s who normally dialyze in a facility may wish to dialyze temporarily as home dialysis patients while they travel or vacation.   Training services furnished to temporary home dialysis patients are covered and paid at the training rate subject to the usual r ules for reimbursement of training services.  100.1 - Physicians Services Furnished to a Dialysis Patient Away From Home or Usual Facility                                                                             (Rev. 10640, Issued:08- 06-21, Effective: 09-07-2021, Implementation:09- 07-21)  When a dialysis patient whose attending physician receives a monthly payment receives maintenance dialysis services of any kind outside the usual setting from any physician who is neither the attending physician nor that physicians substitute, the following procedures apply:    The physician who furnished the service submits a claim to the local A/C MAC (B) of jurisdiction;   The A/B MAC (B) will process the claim and send an MSN to the patient;    The A/B MAC (B) that has jurisdiction over the usual dialysis setting adjusts the MCP to the usual attending physician to account for the time the patient was absent from the usual dialysis setting.    The A/B MAC (B) that has jurisdiction over the usual dialysis setting adjusts the  MCP to the usual attending physician per 140.3.E  below to account for the time the patient was absent from the usual dialysis setting.   A/B MACs (B) must notify physicians that claims for services furnished to temporary patients must be identified as a claim for a temporary patient.  The physician must indicate temporary patient on the claim.   110 - Reduction in Medicare Program Payment to Fund ESRD Networks  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  A. General
(Medicare Claims Processing Manual)
110 - Reduction in Medicare Program Payment to Fund ESRD Networks  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  A. General   Section 9335(j) of OBRA 1986 requires the Secretary to reduce the amount of each payment for each treatment by 50 cents and to allocate these amounts to ESRD network activities. This applies to all dialysis treatments furnished on or after January 1, 1987 for all treatment modalities, including training treatments. All Medicare hospital- based and independent ESRD facilities paid under the  ESRD PPS are affected.   The ESRD network reduction is $.50 per covered treatment when the full ESRD PPS rate is applicable. For ESRD claims billing for continuous modalities of dialysis performed in the beneficiarys home, the ESRD PPS rate is calculated at a daily per diem rate by taking the full ESRD PPS rate multiplied by 3 for the weekly allowable total and dividing by 7 to provide a daily treatment rate. The ESRD network reduction is also calculated at a daily rate by multiplying the $.50 by 3 for the weekly total network reduction and dividing by 7 for a daily network reduction of  $.21.  The reduction amount is reported in the Provider Statistics and Reimbursement Report (PS&R) and CWF using value code 71 to identify monies withheld to fund ESRD networks.   The Medicare payment reduction allocated toward funding the ESRD networks for the individual claims will be indicated on the remittance record to the facility.   Facilities may not claim the 50 -cent reduction as an expense on their Medicare cost reports.   C. Application of ESRD Network Funding to MSP Claims   The ESRD offset for net work funding on MSP claims will be applied as follows:    Where another payer, primary to Medicare, pays the claim in full, no ESRD offset is applicable;    Where another payer, primary to Medicare, makes a partial payment, the ESRD offset is deducted for each treatment as described in subsection C2 from the Medicare secondary payment; and