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Did You Know? – End Stage Renal Disease

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For some of our patients, the nephrologists order acute outpatient hemodialysis, prior to the doctor deeming their clinical status end stage and signing a CMS-2728 form. Can acute dialysis treatments performed in the dialysis facility be billed?
- The AKI provision provides payment beginning on dates of service January 1, 2017, and after to ESRD facilities, that is, hospital-based and freestanding, for renal dialysis services furnished to beneficiaries with AKI (both adult and pediatric). Medicare will pay ESRD facilities for the dialysis treatment using the ESRD Prospective Payment System (PPS) base rate adjusted by the applicable geographic adjustment factor, that is, wage index. In addition to the dialysis treatment, the ESRD PPS base rate pays ESRD facilities for the items and services considered to be renal dialysis services as defined in 42 CFR 413.171 and there will be no separate payment for those services.
  
  CMS MLN Matters® article, "Changes to the ESRD Facility Claim (Type of Bill 72X) to Accommodate Dialysis Furnished to Beneficiaries with Acute Kidney Injury"
  
  Reviewed 09/22/2021
How do we report administration of erythropoiesis stimulating agents (ESAs)?
- Each administration of an ESA is reported on a separate line item with the units reported used as a multiplier by the dosage description in the HCPCS to arrive at the dosage per administration. Renal dialysis facilities claims including charges for administration of the ESA by both methods must report separate lines to identify the number of administrations provided using each method.
  - As of January 1, 2012 all facilities billing for injections of ESA for ESRD beneficiaries must include:
    - HCPCS modifier JA on the claim to indicate an intravenous administration or
    - HCPCS modifier JB to indicate a subcutaneous administration
  - As of July 1, 2013 when billing for drugs administered via the dialysate append:
    - HCPCS modifier JE
  Note: ESRD claims containing ESA administrations that are submitted without the route of administration modifier will be returned to the provider for correction.
  - Reference: CMS Claims Processing Manual, (Pub. 100-04), chapter 8, section 60.4.2
  Reviewed 09/22/2021
Since our facility is also a hospital, many dialysis patients come here for other services. We have one patient in particular that dialyzes at a community center, and we completed a medical procedure for the patient at this hospital. He did not receive a one-time outpatient dialysis treatment; however, we administered Epogen to him. How should we submit this administration of Epogen? This is a 131 claim, not a 721 claim. We have billed the Epogen with revenue code 636 and HCPCS code/modifier J0886-EC, and the claim was returned. We submitted it again with revenue code 634 and HCPCS code Q4081 â€“ again, the claim was returned.
- CGS will return to provider (RTP) any claim with erythropoiesis stimulating agent (ESA) HCPCS code J0886 when value code 48 (Hemoglobin reading) or 49 (Hematocrit reading) is not present on the claim. If your claim includes one of these value codes, please call us at 866.590.6703 so we can review the specifics of your claim.
  
  Reference:
  - CMS MLN Matters® article MM5699, "Reporting of Hematocrit or Hemoglobin Levels on All Claims for the Administration of Erythropoiesis Stimulating Agents"
  Reviewed 09/22/2021
If a patient is within his or her 30-month ESRD Coordination of Benefit (COB) period with COBRA coverage with a prior employer, and the employer group insurance refuses payment when the COBRA coverage began (stating Medicare is primary or the employer group insurance is not compliant with the MSP ESRD guidelines), do we have the option to file a conditional claim? If not, what is our recourse? Our prior contractor advised we do not have this option; however, we have the option to sue for double pay and damages due to noncompliance of federal regulations. Please advise.
- There are two scenarios under which a provider may file for conditional payment:
  - No payment received from Group Health Plan (GHP), or
  - No prompt payment received from the Liability Insurer ("prompt" means that payment is not received within 120 days)
  Background information and definitions:
  - A provider may file for conditional payment from Medicare for services for which another payer is responsible.
  - If payment has not been made or cannot be expected to be made promptly by the other payer, Medicare may make conditional payment.
  - Conditional payments are subject to repayment when the primary plan makes payment.
  Providers can request conditional payment for a GHP situation if one of the following applies:
  - Primary benefits exhausted
  - Services not covered under primary plan
  - Services applied to deductible or coinsurance
  Note: If there is a primary GHP, Medicare may not pay conditionally on the liability, no-fault, or workers' compensation (WC) claim if the claim is not billed to the GHP first. The GHP insurer must be billed first and the primary payer payment information must appear on the claim submitted to Medicare.
  
  In this situation, submit the claim with value code 12, 13, or 43 (whichever is appropriate) and six zeroes (0000.00). Include Occurrence Code (OC) 24 along with the date of primary insurer's rejection notice.
  
  Providers can request conditional payment in a Liability Insurance situation when no prompt payment is received from liability insurer (120 days).
  - Submit MSP Value Code 14 or 47 with six zeroes (0000.00) on the claim and report the date of the accident in Occurrence Code 01, 02, or 04.
  - Include Occurrence Code 24 or 25 (date benefits exhaust or 120 days elapsed).
  - Provide any information related to the liability insurer in the Remarks section of the claim.
  Report the name of the primary insurer in Form Locator (FL) 50, on all claims for conditional payment along with payer code "C". Note: PC Ace Pro32 users do not have to enter Payer Codes, these are automatically filled based on the value codes and CAS information on the claim. Indicate the name of the insured policyholder (FL 58) and Medicare beneficiary's relationship to the insured (FL 59). Lastly, providers should state in the remarks field, "Requesting conditional payment because...".
  
  You may NOT file for conditional payment in the following situations:
  - Services were provided under the Black Lung Program
  - Under no-fault, liability, and workers' compensation when:
  - Benefits exhaust: provide the term date or contact COBC to have MSP record closed instead, and include comments in the Remarks section.
  - The claim is not related to the WC diagnosis: provide comments on the claim in Remarks section stating the service is NOT related to the open MSP file.
  Reference:
  - CMS Medicare Secondary Payer Manual (Pub. 100-05), chapter 2
    - Conditional payment and liability insurers: section 40
    - Conditional payment and workers' compensation: section 50.B
    - Conditional payment and no-fault insurers: section 60
  Reviewed 09/22/2021
What condition code should end-stage renal disease facilities report to indicate home dialysis provided in a skilled nursing facility?
- The condition codes 74 and 80 should be reported for dialysis provided to a skilled nursing facility (SNF) resident.
  
  Reviewed 09/22/2021
What is the maximum number of treatments that Medicare will pay for home hemodialysis training?
- Hemodialysis is typically furnished three times per week in sessions of three to five hour durations. A facility is not reimbursed for more than three Intermittent Peritoneal Dialysis (IPD) treatments or for hemodialysis training treatments in a single week, which includes a total duration longer than three months.
  
  Reference:
  - CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 8, sections 50.6.2 and 50.0
  Reviewed 09/22/2021
If a patient's kidney transplant fails, does an ESRD provider get another onset of dialysis adjustment when the patient resumes dialysis?
- No. The onset of dialysis adjustment is only given one time when the patient begins dialysis for the first time.
  
  Reviewed 09/22/2021
When is the CMS Form-2728 required?
- The CMS Form-2728, "Medical Evidence Form Medicare Entitlement and/or Patient Registration," is required for all newly diagnosed End Stage Renal Disease (ESRD) patients, regardless of their Medicare status or the modality of treatment.
  
  This form must be completed within 45 days for all of the following:
  - Dialysis patients new to Medicare
  - Kidney transplant within the first three months of starting dialysis
  - New kidney transplant patients with no previous dialysis
  - Restart of dialysis three years or more after kidney transplant
  - Restart of dialysis one year or more after regaining kidney function or discontinuing dialysis
  - Self-care dialysis training (modality change from in-center hemodialysis to CAPD, CCPD or home hemodialysis) within the first three months of starting in-center hemodialysis
  Note: CMS Form-2728 is not required for an acute dialysis patient.
  
  Once the form is completed, mail the blue copy of the form to the Social Security Administration and the green copy of the form to your ESRD Network. The white copy should be put into the patient's file.
  
  Reviewed 09/22/2021
How often can EPO be administered?
- EPO can be administered 13 times during a 30-day month or 14 times during a 31-day month for ALL types of dialysis.
  
  Reviewed 09/22/2021

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Did You Know? – End Stage Renal Disease

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