Medicare Claims Processing Manual - Centers for Medicare ...

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 Prospective Payment System Rate - Calculation for Double Amputee Dialysis Patients - ESRD Quality Incentive Program (QIP)

2 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, 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)

4 - 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) 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) - Items and Services Included in the Composite Rate for Home Dialysis - General A/B MAC (A))

5 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 Billed to the A/B MAC (A)

6 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 - 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)

7 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.)

8 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). Home dialysis patients choose between the two methods. Renal dialysis facilities develop a unit charge for the range of services normally provided, taking into account variations among patients (complicated and uncomplicated situations) since it is the overall dialysis service that is covered.

9 Any auxiliary service that cannot be included in the single unit charge for dialysis services as an integral part of a maintenance dialysis must be includable under another specific coverage provision of the Medicare law, or be denied. For example, the Medicare law excludes from coverage out of hospital drugs except when specified conditions are met with respect to the physician s involvement. Furthermore, when the conditions are met, the drug and injection charges must be billed to the A/B MAC (B) by the physician. Medicare benefits are secondary, during a coordination period, to benefits payable under a Group Health Plan (GHP) in the case of individuals entitled to benefits on the basis of ESRD. See the Medicare Secondary Payer (MSP) Manual , Chapter 2, for further information on the coordination period and when Medicare would pay secondary to GHP insurance.

10 Effective January 1, 2011 Section 153b of the Medicare Improvements for Patients and Providers Act (MIPPPA) requires the implementation of an ESRD bundled prospective payment system (ESRD PPS). The ESRD PPS provides a single payment to ESRD facilities that will cover all of the resources used in furnishing an outpatient dialysis treatment, including supplies and equipment used to administer dialysis (in the ESRD facility or at a patient s home), drugs, biologicals, laboratory tests, training, and support services. All ESRD related services and supplies are paid to the ESRD facility through the ESRD prospective payment system. Other entities providing ESRD related services, including laboratories, suppliers and physicians billing for ESRD related drugs must look to the ESRD facility for payment. Consolidated Billing edits established with the implementation of the ESRD prospective payment system will deny or reject Claims to other providers and suppliers billing for ESRD related labs, drugs and supplies.