ESRD PPS Outpatient Maintenance Billing Guide - JF Part A

End Stage Renal Disease (ESRD) Prospective Payment System (PPS) Outpatient Maintenance Billing Guide

Requirement	Description
Unique Identifying Provider Number Ranges	3rd - 6th digits: 2300-2499 (Hospital-based) 2500-2999 (Independent) 3500-3799 (Hospital-based Satellite)
Bill Type CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 80.3.2.2	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 CMS Consolidated Billing List 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
HCPCS CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 8, Section 50.3	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 CMS Outlier Services	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
Reimbursement CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 8, Section 20	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

Last Updated Dec 09 , 2023

© 2024 Noridian Healthcare Solutions, LLC Terms & Privacy

Noridian Medicare Chat