Medicare Claims Processing Manual

1 Medicare Claims Processing Manual Chapter 8 - Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims Table of Contents (Rev. 3650, 11-10-16) Transmittals for Chapter 8 10 - General Description of ESRD Payment and Consolidated Billing Requirements - General Description of ESRD Facility Composite Rates - Uncompleted Treatments - No-Shows - Deductible and Coinsurance - Hospital Services - Amount of Payment - ESRD Services Not Provided Within the United States - Transportation Services - dialysis Provider Number Series 20 - Definitions Related to Calculating the Composite Rate and the ESRD Prospective Payment System Rate - Calculation of the Basic Case-Mix Adjusted Composite Rate and the ESRD

2 Prospective Payment System Rate - Calculation for Double Amputee dialysis Patients - ESRD Quality Incentive Program (QIP) 30 - Determination and Publication of Composite Rate - Publication of Composite Rates - Determining Individual Facility Composite Rate - Transition Period - Record-Keeping and Reporting Requirements Under Composite Rate System - Facility Preparation and A/B MAC (A) Review of Cost Reports - Issuance of Notice of Program Reimbursement 40 - Processing Requests for Composite Rate Exceptions - General Instructions for Processing Exceptions Under the Composite Rate Reimbursement System - Criteria for Approval of ESRD Exception Requests - Procedures for Requesting Exceptions to ESRD Payment Rates - Period of Approval: Payment Exception Requests - Criteria for Refiling a Denied Exception Request - Responsibility of A/B MACs (A) - Payment Exception: Pediatric Patient Mix - Payment Exception.

3 Self- dialysis Training Costs in Pediatric Facilities - Pediatric Payment Model for ESRD PPS 50 - In-Facility dialysis Bill Processing Procedures - Laboratory Services Included in the Composite Rate - Lab Services Included in the Prospective Payment System - Laboratory Services Performed During Emergency Room Service - Drugs and Biologicals Included in the Composite Rate - Drugs and Biologicals Included in the PPS - Required Information for In-Facility Claims Paid Under the Composite Rate and the ESRD PPS - Submitting Corrected Bills - Line Item Detail Billing and Automated claim Adjustments - IPD in the Facility In-Facility Back-Up dialysis - Payment for In-Facility Maintenance dialysis Sessions Furnished to CAPD/CCPD Home dialysis Patients - Payment for Hemodialysis Sessions - Ultrafiltration - Training and Retraining - Coding for Adequacy of dialysis .

4 Vascular Access and Infection 60 - Separately Billable ESRD Items and Services - Lab Services - Drugs Furnished in dialysis Facilities - Billing Procedures for Drugs for Facilities - Separately Billable ESRD Drugs - Facilities Billing for ESRD Oral Drugs as Injectable Drug Equivalents - Drug Payment Amounts for Facilities - Use of Additional Codes by Facilities to Report Drugs - Intravenous Iron Therapy - Facility Billing Requirements to the A/B MAC (A) - Physician Billing Requirements to the A/B MAC (B) - Blood and Blood Services Furnished in Hospital Based and Independent dialysis Facilities - Erythropoietin Stimulating Agents (ESAs) - ESA Claims Monitoring Policy - Facility Billing Requirements for ESAs - Other Information Required on the Form CMS-1500 for Epoetin Alfa (EPO - Completion of Subsequent Form CMS-1500 Claims for Epoetin Alfa (EPO) - Other Information Required on the Form CMS-1500 for Epoetin Alfa (EPO) - Completion of Subsequent Form CMS-1500 Claims for Epoetin Alfa (EPO) - Payment Amount for Epoetin Alfa (EPO) - Payment for Epoetin Alfa (EPO))

5 In Other Settings - Epoetin Alfa (EPO) Provided in the Hospital Outpatient Departments - Self Administered ESA Supply - Other Information Required on the Form CMS-1500 for Darbepoetin Alfa (Aranesp) - Completion of Subsequent Form CMS-1500 Claims for Darbepoetin Alfa (Aranesp) - Payment for Darbepoetin Alfa (Aranesp) - Payment for Darbepoetin Alfa (Aranesp) in Other Settings - Payment for Darbepoetin Alfa (Aranesp) in the Hospital Outpatient Department - Payment for Peginesatide in the Hospital Outpatient Department Intradialytic Parenteral/Enteral Nutrition (IDPN) - Vaccines Furnished to ESRD Patients Reserved Shared Systems Changes for Medicare Part B Drugs for ESRD Independent dialysis Facilities 70 - Payment for Home dialysis - Method Selection for Home dialysis Payment - Change in Method - - Prevention of Double Billing Under Method I and II - Overpayments 80 - Home dialysis Method I Billing to the A/B MAC (A)

6 - Items and Services Included in the Composite Rate for Home dialysis - General A/B MAC (A) Bill Processing Procedures for Method I Home dialysis Services - Required Billing Information for Method I Claims - Calculating Payment for Intermittent peritoneal dialysis (IPD) for Method I Claims Submitted to the A/B MAC (A) - IPD at Home for Method I Claims Submitted to the A/B MAC (A) - Calculating Payment for continuous ambulatory peritoneal dialysis (CAPD) and continuous Cycling peritoneal dialysis (CCPD) Under the Composite Rate 90 - Method II Billing - DME MAC Denials for Beneficiary Submitted Claims Under Method II - Requirements for Payment by the DME MAC - Supplier Documentation Required - DME MAC Letter Explaining Requirements to Method II Supplier Amount of Payment by the DME MAC - Billing Instructions for Method II to DME MACs - Home dialysis Supplies and Equipment HCPCS Codes Used to Bill the DME MAC - DME MAC Claims Processing Instructions - Equipment and Equipment Related Services Provided to Direct Dealing Beneficiary Method II Support Services

7 Billed to the A/B MAC (A) by the Facility - Billable Revenue Codes Under Method II - Unbillable Revenue Codes Under Method II 100 - dialysis Sessions Furnished to Patients Who Are Traveling - Traveling Patients Who Are Normally In-Facility dialysis Patients - Traveling Patients Who are Normally Home dialysis - Physician s Services Furnished to a dialysis Patient Away From Home or Usual Facility 110 - Reduction in Medicare Program Payment to Fund ESRD Networks 120 - Renal Transplantation and Related Services - Payment for Immunosuppressive Drugs Furnished to Transplant Patients 130.

8 Physicians and Supplier (Nonfacility) Billing for ESRD Services - General - Initial Method for Physician s Services to Maintenance dialysis Patients 140 - Monthly Capitation Payment Method for Physicians Services Furnished to Patients on Maintenance dialysis - Payment for ESRD-Related Services Under the Monthly Capitation Payment (Center Based Patients) - Payment for Managing Patients on Home dialysis - Patients That Switch Modalities (Center to Home and Vice Versa) - Payment for ESRD-Related Services (Per Diem) - Guidelines for Physician or Practitioner Billing (Per Diem)

9 Data Elements Required on claim for Monthly Capitation Payment - Controlling Claims Paid Under the Monthly Capitation Payment Method 150 - Physician s Self- dialysis Training Services 160 - Payment for Physician s Services Furnished to dialysis Inpatients - Determining Whether Physician Services Furnished on Day of dialysis - Physicians Services Furnished on Day of dialysis - Physicians Services Furnished on Non- dialysis Days - Requirements for Payment 170 - Billing Physician dialysis Services (codes 90935 - 90999) and Related Payment 180 - Noninvasive Studies for ESRD Patients - Facility and Physician Services 190 - Appeal Rights for Denied Claims 200 - Utilization of REMIS for A/B MAC (B) Claims Adjudication 10 - General Description of ESRD Payment and Consolidated Billing Requirements (Rev.)

10 2195, Issued: 04-22-11, Effective: 10-01-11, Implementation: 10-03-11) See the Medicare Benefit Policy Manual , Chapter 11, for a general description of coverage policies relating to the ESRD benefit. ESRD benefits may be paid in several ways at several sites, either in a hospital setting, an independent facility or at home. Depending on the location or the type of dialysis performed, rates may differ. ESRD facilities are paid at a composite rate and for beneficiaries dialyzing at home benefits may be paid under a composite rate (Method I) or as a series of separately billable services (Method II).