MACs to Reprocess ESRD Claims Containing Incorrect Onset Adjustments

CMS has instructed the Medicare Administrative Contractors (MACs) to reprocess End Stage Renal Disease (ESRD) claims for beneficiaries where the onset adjustment was not applied correctly for dates of service prior to June 13, 2023. This error occurred in the transmission of data from the Eligibility Database (EDB) to the Common Working File (CWF) that resulted in a change in the date of first dialysis. The error resulted in some beneficiary records reflecting the ESRD eligibility date in the date of first dialysis field rather than the initial date of first dialysis. In addition, when the date of first dialysis was after the eligibility date, it was defaulting to the first of the month.

The initial date of first dialysis that is stored in the CWF is used for determining if ESRD claims, type of bill (TOB) 72X paid through the ESRD Prospective Payment System (PPS), should include a payment adjustment for new ESRD beneficiaries. The onset adjustment is applicable when the line-item date of service for dialysis on the 72X TOB is within 120 days of the initial date of first dialysis. As a result of the coding error, some ESRD claims did not get the onset adjustment applied correctly; therefore, MACs shall adjust affected ESRD claims when brought to their attention by the provider.

Providers should contact the Noridian Provider Contact Center at 877-908-8431 to have any affected claims reprocessed. Noridian will bypass timely filing requirements and apply condition code 15 as necessary to correct payments. Adjustments will be completed within 120 days of the request.

Last Updated Oct 04 , 2023