Proposed ESRD Payment System
The Centers for Medicare & Medicaid Services (CMS) on June 21, 2022, issued a proposed rule that proposes to update payment rates and policies under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to Medicare beneficiaries on or after January 1, 2023. This rule also proposes an update to the Acute Kidney Injury (AKI) dialysis payment rate for renal dialysis services furnished by ESRD facilities for calendar year (CY) 2023.
In order to explore options regarding payment under the ESRD PPS, the CY 2023 ESRD PPS proposed rule includes requests for information regarding (1) a potential add-on payment adjustment for certain new renal dialysis drugs and biological products, and (2) health equity issues under the ESRD PPS, with a focus on pediatric dialysis payment. The ESRD PPS provides a bundled, per-treatment payment to ESRD facilities that includes all renal dialysis services furnished for outpatient maintenance dialysis, including drugs and biological products (with the exception of oral-only ESRD drugs until 2025). Additionally, the bundled payment includes all other renal dialysis items and services that were formerly separately payable under previous payment methodologies.
CMS is expanding eligibility for the Transitional Add-on Payment Adjustment for New and Innovative Equipment and Supplies (TPNIES) to include certain capital-related assets that are home dialysis machines when used in the home for a single patient. As with other renal dialysis equipment and supplies potentially eligible for the TPNIES, CMS would evaluate the application to determine whether the home dialysis machine represents an advance that substantially improves, relative to renal dialysis services previously available, the diagnosis or treatment of Medicare beneficiaries, and meets the other requirements under § 413.236(b).
CMS is finalizing additional steps the Medicare Administrative Contractors (MACs) would follow to establish the basis payment of the TPNIES for these home dialysis machines. CMS would pay 65 percent of the MAC-determined pre-adjusted reduced by an average per treatment offset amount of $9.32 for 2 calendar years. CMS is finalizing that after the 2-year TPNIES period ends, the home dialysis machines would not become eligible outlier services and no change would be made to the ESRD PPS base rate.
Renal Dialysis Services
Renal dialysis services are all items and services used to furnish outpatient maintenance dialysis in the ESRD facility or in a patient’s home. Renal dialysis services include but are not limited to:
- All items and services included under the composite rate as of December 31, 2010;
- Erythropoiesis stimulating agents (ESAs) and their oral or other forms of administration that are for the treatment of ESRD;
- Injectable drugs and biologicals and their oral or other forms of administration that are for the treatment of ESRD;
- Oral or other forms of non-injectable drugs and biologicals that are for the treatment of ESRD;
- Diagnostic laboratory tests that are for the treatment of ESRD;
- Home and self-dialysis training; and
- All supplies, equipment, and self-dialysis support services necessary for the effective performance of a patient’s dialysis furnished in the ESRD facility or in a patient’s home. Support services may include:
- Visits by trained hospital or dialysis facility workers to check on the patient’s self-dialysis, to help in emergencies when needed, and to check dialysis equipment and water supply;
- Monitoring access and related declotting or referring the patient; or
- Direct nursing services include registered nurses, licensed practical nurses, technicians, social workers, and dietitian
For detailed understanding of billing updates for renal dialysis services, you can refer to CMS page End Stage Renal Disease (ESRD) Prospective Payment System (PPS). Medisys Data Solutions is a leading medical billing company providing complete billing and coding services for various medical billing specialties. Our team of expert medical billers and coders are well versed with Medicare guidelines and coverages for various medical procedures. We can assist you in receiving accurate and timely Medicare reimbursement for delivered services. To know more about our Medicare billing services, contact us at firstname.lastname@example.org / 302-261-9187