ESRD PPS Outpatient Maintenance Billing Guide - JE Part A
End Stage Renal Disease (ESRD) Prospective Payment System (PPS) Outpatient Maintenance Billing Guide
Unique Identifying Provider Number Ranges
3rd - 6th digits:
- 2300-2499 (Hospital-based)
- 2500-2999 (Independent)
- 3500-3799 (Hospital-based Satellite)
- 721 - Admit to discharge
- 727 - Adjustment
- 728 - Cancel
See Bill Types webpage for details
Condition Codes
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 1 Section 80.3.2.2
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 8, Section 50.3
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 11, Section 30.2.E
CMS Chronic and Acute Comorbidity Categories and Diagnosis Codes
One of the codes 71-76 is applicable for every claim. Codes affecting claim processing/payment are shown.
- 02 - Condition is Employment related
- 04 - Information only bill - Patient is a member of Medicare Advantage plan
- 59 - Non-primary ESRD facility (services not rendered at primary dialysis facility)
- 71 - Full care in unit
- 72 - Self-care in unit
- 73 - Self-care in training
- 74 - Home
- 75 - Home - 100 percent reimbursement
- 76 - Back-up in-facility dialysis
- 84 - Acute Kidney Injury (AKI)
- 87 - Self-care retraining (must be within training certificate dates)
- H3 - Gastrointestinal (GI) bleeding (eligible for comorbidity adjustment)
- H4 - Pneumonia (not eligible for comorbidity adjustment)
- H5 - Pericarditis (eligible for comorbidity adjustment)
See ESRD Condition Codes webpage See Acute Kidney Injury (AKI) Coverage and Billing webpage
Occurrence Codes and Dates
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 8, Section 50.3
All ESRD claims must indicate applicable Kt/V reading for dialysis patients
- 24 - Date Insurance Denied - Code indicates the date of receipt of a denial of coverage by a higher priority payer
- 33 - First day of coordination period covered by EGHP
- Must be used in combination with value code 13
- 51 - Date of Last Kt/V Reading
- In-center hemodialysis, date during the billing period
- Peritoneal and home, date before current billing period or four (4) month with date of service
Value Codes and Amount
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 8, Section 50.3
These codes and dollar amount(s) identify monetary data necessary for claim processing.
- 06 - Medicare blood deductible
- Do not use this code if deductible pints have been replaced
- 13 - Amount of EGHP payment
- 37 - Pints of Blood Furnished
- 38 - Blood Deductible Pints
- 39 - Pints of Blood Replaced
- 44 - Amount Provider Agreed To Accept From Primary Payer When This Amount is Less Than Charges But Higher than Payment Received
- 47 - Any Liability Insurance
- 48 - Hemoglobin reading, latest before billing period
- If hemoglobin value not available, report value 99.99
- 49 - Hematocrit reading, latest before billing period
- If hematocrit value not available, report value 99.99
- A8 - Patient weight in kilograms
- A9 - Patient height in centimeters
- D5 - Last Kt/V reading results
Revenue Codes
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 8
Definitions Relating to ESRD
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 10
ESRD facilities are required to report composite rate drugs identified on consolidated billing list. Drugs and biologicals reported are included in ESRD PPS. Report only tests related to dialysis and performed by ESRD facility, not separately payable.
- 250 - Part D drugs equivalent to injectables
- National Drug Code (NDC) is required
- 300 - Laboratory
- 381-392 - Blood storage and processing
- See Blood and Blood Products Billing Guide webpage
- 634 - Erythropoietin (EPO), less than 10,000 units
- 635 - EPO, more than 10,000 units
- 636 - Drugs requiring detailed coding (special pricing when applicable)
- 821-829 - Hemodialysis sessions
- 831-839 - Peritoneal sessions
- 841-849 - Continuous Ambulatory Peritoneal Dialysis (CAPD)
- 851-859 - Continuous Cycling Peritoneal Dialysis (CCPD)
- 881 - Ultrafiltration, performed separately from dialysis treatment
Modifiers
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 8, Section 50.3
Erythropoietin Stimulating Agents (ESA) Claims Monitoring Policy
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 8, Section 60.4.1
Nocturnal Hemodialysis and Modifier CG
CMS IOM, Publication 100-20, One-time Notification, Change Request (CR)9609 and 9989
Transitional Drug Add-On Payment Adjustment (TDAPA)
CMS IOM, Publication 100-20, One-time Notification, CR10065
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 8, Section 20
Report modifiers on hemodialysis in-facility and home dialysis services. Peritoneal dialysis modifier reporting when applicable.
- AX - Furnished in conjunction with dialysis, TDAPA services, effective January 1, 2018
- AY - Service(s) not related to ESRD
- CG - hemodialysis treatments more than monthly allowable, attests added treatments do not meet medical necessity, effective October 1, 2017
Effective for dates of service on or after January 1, 2020 modifier ED, EE and GS are not required on ESRD claims.
- ED - Hematocrit level exceeds 39 percent
- EE - Hematocrit level does not exceed 39 percent
Urea reduction ration (URR) modifier must be used when seven or more dialysis treatments are performed in a month
- G1-G6
- GS - Reduced dosage of EPO or darbepoetin alfa, in response to hematocrit or hemoglobin level
- JA - Intravenous administration
- JB - Subcutaneous administration
- JE - Dialysate administration
- KX - Medical policy requirements met for extra session
- UJ - Services provided at night, effective January 1, 2017
- V5-V7 - report one type of vascular access used
See ESRD ESA modifiers webpage
All hemodialysis claims must include, not an all-inclusive list:
- 90999 - report URR for hemodialysis patients, modifier required
- G0491 - Dialysis procedure at a Medicare certified ESRD facility for AKI without ESRD
- J3490 - Unclassified drugs, only when no other code for the drug is listed
- J0604 or J0606 - Bone and mineral metabolism, modifier AX required
ESRD Billable Sessions
CMS IOM, Medicare Claims Processing Manual, Publication 100-04, Chapter 8, Section 10.1
Two commonly used treatment for ESRD is hemodialysis and peritoneal dialysis. Each dialysis session performed should be reported on a separate line. Report one unit of service for each date dialysis was performed. ESRD facilities furnishing dialysis in-facility or in a patient's 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.
Services In-facility or Home
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 10
Renal dialysis services are all items and services used to furnish outpatient maintenance dialysis in ESRD facility or in a patient's home
- Services include but not limited to (not an all-inclusive list)
- All items and services included under the composite rate as of December 31, 2010
- ESAs
- Injectable drugs and biologicals
- Laboratory tests
- Equipment, supplies and support services
- Home and self-dialysis training
ESRD PPS Adjustments
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 8, Section 20
ESRD PPS Pricer will factor billed items:
- Body Surface Area (BSA)
- Low Body Mass Index (BMI)
- Onset of dialysis - determined by start date in Common Working File (CWF)
- Within 120 days of date in Item 24 on Form CMS 2728-U3
- See ESRD Claims Processing Affected by Dates Latest Updates Article
- Patient co-morbidities
- Low-volume dialysis treatments in the ESRD facility
- Reflects the Core-based statistical area (CBSA)
- Training add-on using national average hourly wage for nurses, adjusted by geographic are wage index
- Outlier policy for unusual variation in medically necessary care
- ESRD PPS payment is per treatment, dialysis in-facility or home
- 80% of ESRD PPS base rate and applicable adjustments after Part B deductible is met
- ESRD PPS rate updates annually by
- Market basket minus a productivity adjustment
- Current wage index budget neutrality adjustment factor
- Any applicable budget neutrality adjustment factor
Frequency of Billing
ESRD services are subject to the monthly billing requirements for repetitive services.
Non-ESRD PPS Services
Preventive and Screening Services
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 18
Telehealth Services
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 270
The below items are not ESRD PPS services and are paid according to Medicare provisions for each type of service.
- Blood and blood process
- Preventive vaccines
- Telehealth services
- Items and services reported with AY modifier
Beneficiary Coinsurance
See Annual Benefits webpage
Beneficiary Deductible
See Annual Benefits webpage
