evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
 Medical or surgical supplies used to administer drugs and biologicals used for  the treatment of ESRD that were or would have been, prior to January 1, 2011, separately billable under Medicare Part B;  and   Drugs and biologicals used for the treatment of ESRD that were or would have been, prior to January 1, 2011, separately billable under Part D. Implementation of renal dialysis service oral -only drugs has been delayed until January 1,  2025.   The list of renal dialysis services that are included as outlier services may be found at http://www.cms.gov/ESRDPayment/30_Outlier_Services.asp#TopOfPage.  NOTE : All renal dialysis service Part B drugs and biologicals reported with a HCPCS code that is on the ASP List are included for outlier payments (with the exception of composite rate drugs). The laboratory tests that comprise the AMCC panel do not qualify for an outlier, see 20.2.A for information regarding the 50/50 rule.   ESRD facilities may receive o utlier payments for the treatment of both adult and pediatric dialysis patients.  An ESRD facility is eligible for an outlier payment if its actual or imputed MAP amount per treatment for ESRD outlier services exceeds a threshold. The MAP amount represents  the average incurred amount per treatment for services that were or would have been considered separately billable services prior to January 1, 2011. The threshold is equal to the ESRD facilitys predicted ESRD outlier services MAP amount per treatment (w hich is case- mix adjusted) plus the fixed dollar loss amount. In accordance with 42 CFR 413.237(c), facilities are paid 80 percent of the per treatment amount by which the imputed MAP amount for outlier services (that is, the actual incurred amount) exceeds this  threshold.
(Medicare Benefit Policy Manual)
For example, the average outlier services MAP amount per treatment for pediatric and adult dialysis patients for CY 2016 were $39.20 and $50.81, respectively. After multiplication by applicable patient and facility specific adjusters to  yield a predicted outlier services MAP amount, a fixed amount is added (the fixed dollar loss amount) to determine the outlier threshold. The fixed dollar loss amounts for CY 2016 were $62.19 for pediatric patients and $86.97 for adult patients. The CY 2016 values of the average outlier services MAP amount and the fixed dollar loss amount are used below for the purpose of following the outlier payment computation. These values may be revised as a result of subsequent rulemaking.    In computing the MAP amount, the adjusters used are:   Adult  Characteristics  Adjustment  Value   CY 2011 - 2015  Beginning CY 2016  Age: 18 -44 0.996  1.044  Age: 45 -59 0.992  1.000  Age: 60 -69 1.000  1.005  Age: 70 -79 0.963  1.000  Age: 80+  0.915  0.961  Body Surface Area  1.014  1.000  Low Body Mass Index (BMI <18.5)  1.078  1.090   Onset of Dialysis  1.450  1.409  Pericarditis  1.354  1.209  Bacterial pneumonia  1.422  --- Gastro -intestinal tract bleeding  1.571  1.426  Hereditary hemolytic or sickle cell anemia  1.225  1.999  Myelodysplastic syndrome  1.309  1.494  Monoclonal gammopathy  1.074  --- Low-volume facility adjustment  0.975  0.955  Rural facility adjustment  --- 0.978   Pediatric  Characteristics  Adjustment  Value   CY 2011 - 2015  Beginning CY 2016  Age: <13, Modality: PD  0.319  0.410  Age: <13, Modality: Hemo  1.185  1.406  Age: 13 -17, Modality: PD  0.476  0.569  Age: 13 -17, Modality: Hemo  1.459  1.494   Both the adult and pediatric CY 2016 separately billable case -mix adjusters are presented for the purpose of following the outlier payment computations shown below and may be revised as a result of subsequent rulemaking.   1. Outlier Payment  Calculation
(Medicare Benefit Policy Manual)
Both the adult and pediatric CY 2016 separately billable case -mix adjusters are presented for the purpose of following the outlier payment computations shown below and may be revised as a result of subsequent rulemaking.   1. Outlier Payment  Calculation   The outlier payment computations use the case -mix adjusters for separately billable services. These adjusters are applied to the relevant outlier services MAP amount for either adult or pediatric patients discussed above to obtain the predicted MAP amount for outlier services, reflecting all patient- specific and any facility -specific adjustments.   The following example shows how outlier payments are calculated under the ESRD PPS. For further information on the calculation of a patients BSA, see 60.A.1. The pricing amounts for laboratory services qualifying as outlier services are based on the clinical   laboratory fee schedule. For injectable drugs and biologicals, pricing is based on the latest available quarterly average sales price plus 6 percent (ASP + 6) methodology. For formerly Part D drugs with an injectable version, pricing is based on national average drug prices based on t he Medicare Prescription Drug Plan Finder. For medical/surgical supplies, pricing is based on prices established by the local A/B MAC (A). For further information regarding A/B MAC (A) pricing of medical/surgical supplies, see Pub. 100-  04, chapter 8, 20.1.   2. Example of Outlier  Payment   Ms. Brown is a 66 year old ESRD patient and is 167.64 cm. tall, weighs 105 kg., and has a recent diagnosis of GI bleeding.  She does not qualify for a low BMI adjustment.  Ms. Browns BSA is 2.1284.  The list of adjusters in D reveals that the separately billable multiplier for BSA is 1.000.   Ms. Browns case -mix adjustment based on her BSA of 2.1284 is 1.000.  Step 1: Determine the predicted, ESRD outlier services MAP amount using the product of all  applicable case- mix adjusters .  The patient -level outlier services case- mix adjusters are identified in the list in D:  66 years old: 1.005, BSA: 1.000, and GI bleeding: 1.426:  = 1.005 * 1.000 * 1.426 = 1.4331
(Medicare Benefit Policy Manual)
66 years old: 1.005, BSA: 1.000, and GI bleeding: 1.426:  = 1.005 * 1.000 * 1.426 = 1.4331  The adjusted, average, ESRD outlier services MAP amount  = $50.81  The adjusted, average ESRD outlier services MAP amount * product of the outlier services case- mix adjusters: = $50.81 * 1.4331 = $72.82  Step 2: Determine the imputed average, per treatment, ESRD outlier services MAP amount ba sed on utilization of all separately billable services on the monthly ESRD facility bill  Assume the imputed monthly ESRD outlier services amount = $4,000 and that the corresponding total number of treatments in the month = 10  The imputed, average, per treatment, outlier services MAP amount = $4,000/10 = $400   Step 3: Add the fixed dollar loss amount to the predicted, ESRD outlier services MAP  amount   The fixed dollar loss amount = $86.97. The predicted ESRD outlier services MAP amount = $72.82 = $72.82 + $86.97 = $159.79  Step 4: Calculate outlier payment per treatment   Outlier payment = imputed average, per treatment, outlier services MAP amount minus (predicted ESRD outlier services MAP amount plus the fixed dollar loss amount) * loss sharing percentag e: = ($400.00- $159.79) * .80 = $240.21 * .80 = $192.17  The outlier payments for Ms. Browns 10 treatments would be: 10 * $192.17 = $1,921.70  E. Co-Insurance
(Medicare Benefit Policy Manual)
The outlier payments for Ms. Browns 10 treatments would be: 10 * $192.17 = $1,921.70  E. Co-Insurance   Eighty percent of the total 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 20 percent after the deductible. Therefore, the beneficiary co -insurance amount under the ESRD PPS is 20 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. For example, under the ESRD PPS the patients co- insurance liability is based on the payment made to the ESRD facilit y and NOT on specific renal dialysis items and services. Therefore, any renal dialysis service drug or biological or laboratory service furnished to a beneficiary would NOT require a co -insurance amount because the renal dialysis service drug or biological  or laboratory service is included in the payment made to the ESRD  facility.   In the event a claim is reprocessed and the amount that was paid to the ESRD facility changes, the ESRD facility is responsible for reconciling with the ESRD patient any overpaym ent or underpayment of co- insurance or deductible amounts paid to the ESRD facility.   70 - ESRD PPS Transition Period  (Rev. 171, Issued: 06 -07-13, Effective: 01- 01-11, Implementation: 09- 09-13)  The ESRD PPS provides ESRD facilities a 4 -year transition per iod under which the ESRD facilities receive a blend of payments comprised of the ESRD PPS and the basic case- mix adjusted composite payment system.  For CY 2011 through 2013, CMS will continue to update the basic case -mix composite payment system for purpo ses of determining the composite rate portion of the blended payment amount, including adjusting payments for geographic differences in area wage levels.  CMS continues to apply the budget neutrality adjustment to the wage index values for the composite ra te portion of the ESRD PPS during the transition.
(Medicare Benefit Policy Manual)
 As of January 1, 2011, the blended amount consists of 25 percent based on the ESRD PPS payment and 75 percent of the basic case -mix adjusted composite payment system.    For CY 2012, payment will be based on 50 percent of the payment rate under the ESRD PPS and 50 percent of the payment rate under the basic case -mix adjusted composite payment system.    For CY 2013, payment will be based on 75 percent of the payment rate under the ESRD PPS and 25 percent of the  payment rate under the basic case -mix adjusted composite payment system.    For renal dialysis services furnished on or after January 1, 2014, payments to ESRD facilities will be based on 100 percent of the payment amount under the ESRD PPS.  See 60 of thi s chapter for examples of how the ESRD PPS payment amount is calculated and see 50 of this chapter for more information to the ESRD PPS base rate.   Calendar Year  ESRD PPS Portion  During Transition  Basic Case -Mix Adjusted  Composite Payment System Portion   During Transition  2011  25% 75% 2012  50% 50% 2013  75% 25% 2014 and beyond  100 0%  A.  ESRD PPS Portion of the Blended Payment   The ESRD PPS portion of the blended payment is comprised of the ESRD PPS base rate (which is adjusted by any applicable patient -level and facility -level case -mix adjusters and a wage index), any applicable training add- ons, and any applicable outlier payments.  See 10.F.1of this chapter for more on the ESRD PPS.   For CY 2011, the ESRD PPS base rate was adjusted by an ESRD market basket.  For CY 2012 and all subsequent years, the ESRD PPS base rate is updated by an ESRD market basket minus a productivity adjustment.  See 50.B of this chapter for more on the market basket.   The following table summarizes the features of the ESRD PPS portion of the blended payment rates for two different scenarios (adult and pediatric) in CY 2011.
(Medicare Benefit Policy Manual)
The following table summarizes the features of the ESRD PPS portion of the blended payment rates for two different scenarios (adult and pediatric) in CY 2011.   Feature  Adult Scenario  Pediatric Scenario  ESRD PPS base rate  Yes Yes  Wage index adjustments  Yes, reflecting current wage data, including any applicable floor  Yes, reflecting current wage data, including any applicable floor  Patient -level case -mix adjustments  Yes, Adult  Yes, Pediatric  Low-volume adjustment  Yes, if applicable  No Training add -on Yes, if applicable  Yes, if applicable  Outlier payment  Yes, if applicable  Yes, if applicable   B.  Composite Rate Portion of the Blended Payment   Under the composite rate, hemodialysis is paid for at 3 treatments per week and peritoneal dialysis is paid based on hemodialysis equivalent sessions (see 50.A.1 and 50.A.4, respectively, of this chapter).  For per treatment unit of payment information for hemofiltration, ultrafiltration, and IPD, respectively, see 50.A.2, 50.A.3, and 50.A.5.  Additional composite rate payments may be made when they are m edically justified.  The FI or A/B MAC reviews the medical justification and is responsible for making the decision on the appropriateness of the extra treatment.  Additional information regarding home dialysis can be found in 30.  ESRD facilities furnishing dialysis in -facility or in a patients home  are paid for up to 13 treatments during a 30 day month and 14 treatments during a 31 day month unless there is medical justification for additional treatments.   The composite rate portion of the blended payment rate is based on the payment amount under the basic case -mix adjusted composite payment system.  It is comprised of the composite payment rate, which is adjusted by both the basic case -mix adjustments and a wage index.   The composite rate portion of the blended payment may include adjustments for:    A drug add- on amount,    Applicable home training add- ons for ESRD facilities going through the transition will continue to be paid the current training add- on rates of $12 for CAPD and $20 for CCPD and home hemodialysis for the portion of the blended payment that is based on the basic case -mix adjusted composite payment system.  For more information on training and retraining, see 60.C.
(Medicare Benefit Policy Manual)
 Payment amounts for renal dialysis services furnished to dialysis pa tients that were separately paid under Part B.    Under the blended payment rate, the composite rate includes a $0.49 per treatment amount to account for oral and other forms of injectable drugs that had previously been paid under Part D.  Beginning in CY 2012, the composite payment rate is updated annually by applying a market basket minus a productivity adjustment factor.    As of January 1, 2011, CMS will not accept any new applications for composite rate exceptions.  Those facilities with existing exception s will continue with those exceptions, which do not include any case -mix adjustments.  Any existing exceptions will terminate effective for ESRD treatments on or after January 1, 2014.  In the event that an ESRD facility elects to receive full payment on o r after January 1, 2011, any current exception will terminate.  In the event that an ESRD facility receives payment under the transition period, any exceptions would be recognized for purposes of the basic case -mix adjusted composite payment system portion of the blended payment through the transition.   The following table presents the features of the composite rate portion of the blended payment rates for three different scenarios (adult, pediatric, and exception), using CY 2011 as the timeframe.   Feature  Adult Scenario  Pediatric Scenario  Exception Scenario  Rate Type  Composite payment rate  Composite payment rate  Exception rate (type and dollar amount unique to the ESRD facility)  Rate updated by an ESRD market basket  Yes Yes No Drug add -on adjustment  Yes Yes No Case- mix adjustment(s)  Age, BSA, and BMI  Single pediatric adjustment factor  No Wage index adjustments  Yes, reflecting current wage data, including any applicable floor  Yes, reflecting current wage data, including any applicable floor  No Adjustment for ESRD -related drugs and biologicals previously paid under Part D  Yes Yes No Training add- ons Yes, if applicable  Yes, if applicable  Yes, but only applies to ESRD facilities that have exceptions for reasons other than training  Payment amounts for renal dialysis services furnished to dialysis patients that had been Yes Yes Yes  separately paid under Part B   C.  Transition Budget Neutrality Factor
(Medicare Benefit Policy Manual)
C.  Transition Budget Neutrality Factor  An adjustment to payments for renal dialysis services provided by ESRD facilities d uring the transition will be made so that the estimated total amount of payments under the ESRD PPS, including payments under the transition, equals the estimated total amount of payments that would otherwise occur under the ESRD PPS without such a transition.  The transition budget neutrality adjustment factor is applied to the blended payment amount if the ESRD facility is going through the transition.  If the ESRD facility is not going through the transition, then the transition budget neutrality adjustm ent factor is applied to the ESRD PPS payment.  The adjustment factor is addressed in the ESRD PPS through rulemaking during the transition period.  After the transition period, the transition budget neutrality adjustment factor no longer applies.  80 - Bad Debt  (Rev. 171, Issued: 06 -07-13, Effective: 01-01-11, Implementation: 09-09-13)  Bad debt payments will continue to be made for the unpaid Medicare deductibles and co-insurance amounts for only those items and services associated with the composite rate.  For payments made under the ESRD PPS for items and services included in the composite rate and for drugs and laboratory tests, only the bad debt amounts associated with the composite rate portion of the single ESRD payment rate will be used to determine  an ESRD facilitys allowable bad debt payments.  A facility -specific composite cost percentage will be applied to the total bad debt amount associated with the ESRD PPS payment to compute the bad debt amount for only the composite rate services.   Bad debt payments for ESRD facilities will continue to be made in accordance with 42CFR413.89 and 413.178.  However, effective January 1, 2013, the cap on bad debt reimbursement is no longer applied.  General requirements and policies for payment of bad debts attributable to unpaid Medicare deductibles and co-insurance are found in chapter 3 of the Provider Reimbursement Manual, Part 1(PRM)(CMS Pub. 15-1) and cost reporting worksheets and instructions in the PRM Part 2 (CMS Pub. 15- 2).  90  Medicare as a Secondary Payer (MSP)  (Rev. 171, Issued: 06 -07-13, Effective: 01-01-11, Implementation: 09-09-13)
(Medicare Benefit Policy Manual)
90  Medicare as a Secondary Payer (MSP)  (Rev. 171, Issued: 06 -07-13, Effective: 01-01-11, Implementation: 09-09-13)  The implementation of the ESRD PPS does not have an effect on the 30 month coordination period and MSP rules.  See Pub. 100-05, Chapter 2, 20 for the MSP and coordination of benefit provisions that are applicable to ESRD beneficiaries.
(Medicare Benefit Policy Manual)
100 - Payment for Renal Dialysis Services Furnished to Individuals with Acute Kidney Injury (AKI)  (Rev. 240, Issued: 01- 19-18, Effective: 01- 01-17, Implement ation: 02-  20-18) On June 29, 2015, the Trade Preferences Extension Act of 2015 (TPEA) (Pub. L. 114- 27) was enacted. In the TPEA, Congress amended the Act to include coverage and provide for payment for dialysis furnished by an ESRD facility to an individual with AKI. Specifically, section 808(a) of the TPEA amended section 1861(s)(2)(F) of the Social Security Act (the Act by including coverage for renal dialysis services furnished on or after January 1, 2017 by a renal dialysis facility or provider of services currently paid under section 1881(b)(14) of the Act to an individual with AKI. In addition, section 808(b) of TPEA amended section 1834 of the Act by adding a new subsection (r). Subsection (r)(1) of section 1834 of the Act provides that in the case o f renal dialysis services (as defined in subparagraph (B) of section 1881(b)(14) of the Act) furnished under Part B by a renal dialysis facility or a provider of services paid under such section during a year (beginning with 2017) to an individual with AKI , the amount of payment under Part B for such services shall be the base rate for renal dialysis services determined for such year under such section, as adjusted by any applicable geographic adjustment applied under subparagraph (D)(iv)(II) of such section and may be adjusted by the Secretary (on a budget neutral basis for payments under section 1834(r) of the Act) by any other adjustment factor under subparagraph (D) of section 1881(b)(14) of the Act.   100.1 Definition of AKI  (Rev.  240, Issued: 01- 19-18, Effective: 01 -01-17, Implementation: 02-  20-18) Section 1834(r)(2) of the Act defines individual with acute kidney injury'' to mean an individual who has acute loss of renal function and does not receive renal dialysis services for which payment is made under section 1881(b)(14) of the Act.
(Medicare Benefit Policy Manual)
100.2 Payment Rate for AKI Dialysis  (Rev.  240, Issued: 01- 19-18, Effective: 01- 01-17, Implementation: 02-  20-18) The payment rate for AKI Dialysis is the ESRD PPS per treatment base rate updated annually by the market  basket, less the productivity adjustment and adjusted by any other adjustment factor applied to the ESRD PPS base rate.     100.3 Geographic Adjustment Factor  (Rev.  240, Issued: 01- 19-18, Effective: 01- 01-17, Implementation: 02-  20-18)  The payment rate for  AKI dialysis is adjusted by the geographic adjustment factor that is applied to the ESRD PPS base rate for a particular facility, which is the same wage index applied under the ESRD PPS.   100.4 Other Adjustments to the AKI Payment Rate  (Rev.  240, Issued: 01- 19-18, Effective: 01- 01-17, Implementation: 02-  20-18)  There are currently no other adjustments applied to the AKI Payment Rate   A. ESRD Network Fee   The ESRD Network Fee reduction is not applicable to claims for beneficiaries with AKI.   B. ESRD Quality Incentive Program (QIP)   The ESRD QIP is not applicable for beneficiaries with AKI at this time.   C. Sequestration Adjustments   The 2 percent sequestration adjustment is applicable to claims for beneficiaries with AKI.
(Medicare Benefit Policy Manual)
The ESRD QIP is not applicable for beneficiaries with AKI at this time.   C. Sequestration Adjustments   The 2 percent sequestration adjustment is applicable to claims for beneficiaries with AKI.   100.5 Renal Dialysis Services Included in the AKI Payment Rate  (Rev.  240, Issued: 01- 19-18, Effective: 01- 01-17, Implementation: 02-  20-18) Drugs, biologicals, laboratory services, and supplies that are considered to be renal dialysis services under the ESRD PPS as defined in 42 CFR 413.171, ar e considered to be renal dialysis services for patients with AKI. As such, no separate payment would be made for renal dialysis drugs, biologicals, laboratory services, and supplies that are included in the ESRD PPS base rate when they are furnished by an ESRD facility to an individual with AKI.  Other items and services furnished to beneficiaries with AKI that are not considered to be renal dialysis services as defined in 42 CFR 413.171, but that are related to their dialysis treatment as a result of their AKI and that an ESRD facility might furnish to a beneficiary with AKI, would be separately payable. In particular, an ESRD facility could seek separate payment for drugs, biologicals, laboratory services, and supplies that ESRD facilities are certified to furnish and that would otherwise be furnished to a beneficiary  with AKI in a hospital outpatient setting. Items and services included on the consolidated billing list are not separately payable for patients with AKI.  All dialysis treatments, that is, hemod ialysis and peritoneal dialysis, furnished to individuals with AKI in an ESRD facility will be paid the AKI payment rate.  This includes any treatments that exceed the three times -weekly limitation applied to treatments furnished to ESRD beneficiaries.  CM S expects that individuals with AKI will need renal dialysis services for a finite number of days since the intent of the dialysis for these patients is curative.     100.6 Applicability of Specific ESRD PPS Policies to AKI Dialysis (Rev.  245, Issued: 08- 03-18, Effective: 01- 01-19, Implementation: 01-  07-19)
(Medicare Benefit Policy Manual)
100.6 Applicability of Specific ESRD PPS Policies to AKI Dialysis (Rev.  245, Issued: 08- 03-18, Effective: 01- 01-19, Implementation: 01-  07-19)  A. Dialysis Modality  Beneficiaries with AKI can receive their dialysis via the most clinically appropriate in- facility modality.