ESRD Inquiries and Solutions

Q1. Are routine diagnostic laboratory services furnished to End Stage Renal Disease (ESRD patients in the emergency room included in the ESRD PPS rate?
A1. Emergency situations were diagnostic laboratory testing is ordered according to the illness the patient is presenting and it may not be feasible for the ordering physician to know at the time the laboratory test is being ordered for reasons of treating the patient's ESRD. Hospital providers billing for emergency department or emergency room services will bill non-ESRD related laboratory tests (that is, laboratory tests used to determine the cause of the illness) using the AY modifier to receive separate payment.

Additionally, CR 7593, states, "For hospital claims with dates of service on or after April 1, 2012, that include an emergency room service with revenue code 045x on a line item date that differs from the line item date of service for the related laboratory test(s) the hospital must include the modifier ET to attest that the laboratory test(s) were ordered in conjunction with the emergency services. This is necessary to recognize that emergency services often span two calendar days."

Q2. How are the automated multi-channel chemistry tests (AMCC) calculated?
A2. The system (FISS) will calculate the number of AMCC tests provided for any given date of service. These laboratory tests are included in the outlier calculation. Refer to Attachment 3: Outlier Services of CMS Change Request (CR) 7064

Q3. When a hospital-based laboratory provides services for an ESRD beneficiary for the dialysis facility who should bill Medicare?
A3. If the laboratory test is ESRD related and therefore, meets the definition of a renal dialysis service, payment to the laboratory is the responsibility of the ESRD facility.

Q4. How should the patient's weight and height be reported on the dialysis claims?
A4. Use the appropriate value code. These factors and as well as others are used to adjust and make calculations to the final payment rate. A8 - Weight of Patient - Code indicates the weight of the patient in kilograms. The weight of the patient should be measured after the last dialysis session of the month. A9 - Height of Patient - Code indicates the height of the patient in centimeters. The height of the patient should be measured during the last dialysis session of the month. This height is as the patient presents.

Q5. How is erythropoiesis stimulating agents (ESA) reimbursed when given to an ESRD patient in a renal dialysis facility?
A5. For details refer to CR 5251

Q6. What are the qualifications for End-stage Renal Disease Quality Incentive Program (ESRD QIP)?
A6. CMS developed the ESRD QIP to be the nation's first pay-for-performance (also known as "value-based purchasing") quality incentive program as mandated by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) section 153(c). For more details refer to the CMS End-Stage Renal Disease (ESRD) Quality Initiative webpage.


Last Updated Dec 16 , 2022