100-04 Medicare Claims Processing Manual: Chapter 8 - Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims

Medicare Claims Processing Manual
Chapter 8 - Outpatient ESRD Hospital, Independent
Facility, and Physician/Supplier Claims
Table of Contents
(Rev. 13740; Issued: 04-17-26)
Transmittals for Chapter 8
10 - General Description of the End Stage Renal Disease Prospective Payment System
(ESRD PPS)
10.1 - Billing for Additional Treatments
10.2 - Uncompleted Treatments
10.3 - No-Shows
10.4 - Deductible and Coinsurance
10.5 - Hospital Services
10.6 - Amount of Payment
10.7 - ESRD Services Not Provided Within the United States
10.8 - Transportation Services
10.9 - Dialysis Provider Number Series
20 - Calculation of the End Stage Renal Disease Prospective Payment System (ESRD
PPS) Per Treatment Payment Amount
20.1 - Calculation of the Basic Case-Mix Adjusted Composite Rate and the ESRD
Prospective Payment System Rate
20.1.1 - Calculation for Double Amputee Dialysis Patients
20.2 - Pediatric Payment Model for ESRD PPS
20.3 - End Stage Renal Disease Quality Incentive Program (QIP)
30 - Publication of the Prospective Payment System (PPS) Base Rate
40 - Acute Kidney Injury (AKI) Claims
50 - Dialysis Bill Processing Procedures
50.1 – Lab Service Included in the End Stage Renal Disease Prospective Payment System
(ESRD PPS)
50.1.1 - Laboratory Services Performed During Emergency Room Service
50.1.5 - Lab Services Included in the Prospective Payment System
50.1.6 - Laboratory Services Performed During Emergency Room Service
50.2 - Drugs and Biologicals Included in the End Stage Renal Disease
50.2.5 - Drugs and Biologicals Included in the PPS

50.3 - Required Information for Claims Paid Under the End Stage Renal 	Disease
Prospective Payment System (ESRD PPS)
50.3.1 - Submitting Corrected Bills
50.4 - Line Item Detail Billing and Automated Claim Adjustments
50.5 - Intermittent Peritoneal Dialysis (IPD) in the Facility
50.6- In-Facility Back-Up Dialysis
50.6.1 - Payment for In-Facility Maintenance Dialysis Sessions Furnished to
Continuous Ambulatory Peritoneal Dialysis (CAPD) Continuous Cycling
Peritoneal Dialysis (CCPD) Home Dialysis Patients
50.6.2 - Payment for Hemodialysis Sessions
50.7 - Ultrafiltration
50.8 - Training and Retraining
50.9 - Coding for Adequacy of Dialysis, Vascular Access and Infection
60 - Separately Billable ESRD Items and Services
60.1 - Lab Services
60.2 - Drugs Furnished in Dialysis Facilities
60.2.1 - Billing Procedures for Drugs for Facilities
60.2.1.1 - Separately Billable ESRD Drugs
60.2.1.2 - Facilities Billing for ESRD Oral Drugs as Injectable Drug
Equivalents
60.2.2 - Drug Payment Amounts for Facilities
60.2.3 - Facility Billing Requirements to the A/B MAC (A)
60.2.4 - Physician Billing Requirements to the A/B MAC (B)
60.2.4.1 - Facility Billing Requirements to the A/B MAC (A)
60.2.4.2 - Physician Billing Requirements to the A/B MAC (B)
60.3 - Blood and Blood Products Furnished in Hospital Based and Independent
Dialysis Facilities
60.4 - Erythropoietin Stimulating Agents (ESAs)
60.4.1 - ESA Claims Monitoring Policy
60.4.2 - Facility Billing Requirements for ESAs
60.4.2.1 - Other Information Required on the Form CMS-1500 for Epoetin
Alfa (EPO
60.4.2.2 - Completion of Subsequent Form CMS-1500 Claims for Epoetin
Alfa (EPO)
60.4.3.1 - Other Information Required on the Form CMS-1500 for Epoetin
Alfa (EPO)
60.4.3.2 - Completion of Subsequent Form CMS-1500 Claims for Epoetin
Alfa (EPO)
60.4.3 Reserved for Future Use
60.4.4 - Payment Amount for ESAs

60.4.4.1 - Payment for Epoetin Alfa (EPO) in Other Settings
60.4.4.2 - Epoetin Alfa (EPO) Provided in the Hospital Outpatient
Departments
60.4.5.1 - Self Administered ESA Supply
60.4.6.1 - Reserved for Future Use
60.4.6.2 - Reserved for Future Use
60.4.6.3 - Payment for Darbepoetin Alfa (Aranesp)
60.4.6.4 - Payment for Darbepoetin Alfa (Aranesp) in Other Settings
60.4.6.5 - Payment for Darbepoetin Alfa (Aranesp) in the Hospital
Outpatient Department
60.4.7 - Payment for Peginesatide in the Hospital Outpatient Department
60.5- Intradialytic Parenteral/Enteral Nutrition (IDPN)
60.6 - Vaccines Furnished to ESRD Patients
60.7- Reserved for Future Use
60.8- Shared Systems Changes for Medicare Part B Drugs for ESRD Independent
Dialysis Facilities
70 - Payment for Home Dialysis
70.1 - Method Selection for Home Dialysis Payment
70.1.1 - Change in Method
70.2 - - Prevention of Double Billing Under Method I and II
70.3 - Overpayments
80 - Home Dialysis Method I Billing to the A/B MAC (A)
80.1 - Items and Services Included in the ESRD PPS payment for Home Dialysis
80.2 - General A/B MAC (A) Bill Processing Procedures for Method I Home
Dialysis Services
80.2.1 - Required Billing Information for Method I Claims
80.3 - Calculating Payment for Intermittent Peritoneal Dialysis (IPD) for Method I
Claims Submitted to the A/B MAC (A)
80.3.1 - IPD at Home for Method I Claims Submitted to the A/B MAC (A)
80.4 - Calculating Payment for Continuous Ambulatory Peritoneal Dialysis (CAPD)
and Continuous Cycling Peritoneal Dialysis (CCPD) Under the ESRD PPS
90 - Reserved for Future Use
90.1 - DME MAC Denials for Beneficiary Submitted Claims Under Method II
90.2 - Requirements for Payment by the DME MAC
90.2.1 - Supplier Documentation Required
90.2.2 - DME MAC Letter Explaining Requirements to Method II Supplier
90.3- Amount of Payment by the DME MAC
90.3.1 - Billing Instructions for Method II to DME MACs
90.3.2 - Home Dialysis Supplies and Equipment HCPCS Codes Used to Bill the
DME MAC

90.3.3 - DME MAC Claims Processing Instructions
90.4 - Equipment and Equipment Related Services Provided to Direct Dealing
Beneficiary
90.5- Method II Support Services Billed to the A/B MAC (A) by the Facility
90.5.1 - Billable Revenue Codes Under Method II
90.5.1.1 - Unbillable Revenue Codes Under Method II
100 - Dialysis Sessions Furnished to Patients Who Are Traveling
100.1 - Traveling Patients Who Are Normally In-Facility Dialysis Patients
100.2 - Traveling Patients Who are Normally Home Dialysis
100.3 - 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
120.1 - Payment for Immunosuppressive Drugs Furnished to Transplant Patients
130 - Physicians and Supplier (Nonfacility) Billing for ESRD Services - General
130.1 - Initial Method for Physician’s Services to Maintenance Dialysis Patients
140 - Monthly Capitation Payment Method for Physicians’ Services Furnished to Patients
on Maintenance Dialysis
140.1 - Payment for ESRD-Related Services Under the Monthly Capitation Payment
(Center Based Patients)
140.1.1 - Payment for Managing Patients on Home Dialysis
140.1.2 - Patients That Switch Modalities (Center to Home and Vice Versa)
140.2 - Payment for ESRD-Related Services (Per Diem)
140.2.1 - Guidelines for Physician or Practitioner Billing (Per Diem)
140.3- Data Elements Required on Claim for Monthly Capitation Payment
140.4 - 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
160.1 - Determining Whether Physician Services Furnished on Day of Dialysis
160.2 - Physicians’ Services Furnished on Day of Dialysis
160.3 - Physicians’ Services Furnished on Non-Dialysis Days
160.4 - 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 the End Stage Renal Disease Prospective
Payment System (ESRD (PPS)
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
See the Medicare Benefit Policy Manual, Chapter 11, for a general description of
coverage policies and definitions relating to the ESRD benefit.
Effective January 1, 2011 Section 153b of the Medicare Improvements for Patients and
Providers (MIPPA) requires the implementation of End Stage Renal Disease 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
ESRDPPS. 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
PPS will deny or reject claims to other providers and suppliers billing for ESRD related
labs, drugs and supplies.
Information related to the lab tests, drugs and supplies subject to the ESRD consolidated
billing requirement can be found at the following website:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ESRDpayment/Consolidated_Billing.html
The list of items and services subject to consolidated billing may be updated quarterly in
January, April, July and October of each year.
10.1 - Billing for Additional Treatments
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
• 	The End Stage Renal Disease (ESRD) Prospective Payment System (PPS) provides a
per treatment unit of payment. The per treatment unit of payment is the same base rate
that is paid for all dialysis treatment modalities furnished by an ESRD facility. The
policy allows for 3 PPS payments per week. When a beneficiary’s plan of care requires
more than three weekly dialysis treatments, whether HD or daily PD, claim edits are
applied to ensure that Medicare payment on the monthly claim is consistent with the 3-
times weekly dialysis treatment payment limit. Thus, for a 30-day month, payment is
limited to 13 treatments, and for a 31-day month, payment is limited to 14 treatments,
with exceptions made for medical justification.

• 	ESRD facilities billing for more than 13 or 14 treatments per month must provide
medical justification as required by the Medicare Administrative Contractor in order to
receive payment for the additional treatments. Additional treatments provided without
meeting the medical justification required must include the modifier CG on the claim
line. This modifier indicates that the facility attests the additional treatment does not meet
medical justification requirements. Additional treatments billed without medical
justification do not receive payment. Non-covered treatments are not considered in the
outlier payment calculation.
• 	This policy does not apply for training and retraining treatments billed within the
allowable limits. See section 50.8 of this chapter for training and retraining treatments.
10.2 - Uncompleted Treatments
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
A dialysis treatment is started, when a patient is connected to the machine and a dialyzer
and bloodlines are used. However, if the is not completed for some unforeseen, but valid
reason such as a medical emergency when the patient must be rushed to an emergency
room, the facility is paid based on the full Prospective Payment System (PPS) base rate
This is a rare occurrence and must be fully documented to the A/B MAC (A)’s
satisfaction.
10.3 - No-Shows
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
If a facility sets up in preparation for a dialysis treatment, but the treatment is never
started because the patient never arrives, no payment is made. In this case, no service has
been furnished to a Medicare beneficiary even though staff time and supplies may have
been used. Furthermore, the facility may not bill the patient or the patient’s private
insurance for these services. This is because the program is already paying the cost of
pre-dialysis services through the PPS base rate. In setting that rate, CMS has included
the salaries of facility personnel and the cost of supplies used for furnishing pre-dialysis
services.
Therefore, these costs (e.g., salaries for staff time, overhead, supply costs) are included in
the facility’s costs and reported on its cost report, and they are included in the allowable
costs used to set future reimbursement rates under the End Stage Renal Disease
Prospective Payment System (ESRD PPS) for ESRD facilities. However, these costs
may not be used as the basis for a facility to be reimbursed as Medicare bad debts.
10.4 - Deductible and Coinsurance
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
The beneficiary is responsible for any unmet deductible and for coinsurance.

Eighty percent of the total End Stage Renal Disease Prospective Payment System (ESRD
PPS) payment amount for renal dialysis services furnished by ESRD facilities to ESRD
beneficiaries is paid by Medicare. ESRD beneficiaries are responsible for the remaining
twenty percent after the deductible. Therefore, the beneficiary coinsurance amount under
the ESRD PPS is twenty percent of the total ESRD PPS payment, which includes the
ESRD PPS base rate, all applicable adjustments, any applicable training add-on amounts
and any applicable outlier payments.
10.5 - Hospital Services
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
Outpatient dialysis services for a patient with acute kidney failure or chronic kidney
failure but not eligible for Medicare under the ESRD provisions at the time services are
rendered must be billed by the hospital and cannot be billed by a Medicare certified renal
dialysis facility on bill type 72x.
Hospitals with a Medicare certified renal dialysis facility should have outpatient ESRD
related services billed by the hospital-based renal dialysis facility on bill type 72x.
Hospitals that do not have a Medicare certified renal dialysis facility may bill for
outpatient emergency or unscheduled dialysis services. The Prospective Payment System
(PPS) base rate is not paid. For more information regarding the outpatient hospital billing
policy for ESRD related services, see chapter 4 section 210 of this manual.
When an individual is furnished outpatient hospital services and is thereafter admitted as
an inpatient of the same hospital due to renal failure - within 24 hours for non PPS
hospitals and within 72 hours for PPS hospitals - the outpatient hospital services
furnished are treated as inpatient services unless the patient does not have Part A
coverage. Charges are reported on the ASC X12 837 institutional claim format or on
Form CMS-1450. The day on which the patient is formally admitted as an inpatient is
counted as the first inpatient day. The PPS base rate is not paid.
10.6 - Amount of Payment
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
Effective for dates of service beginning January 1, 2011, after the beneficiary’s Part B
deductible is met, the A/B MACs (A) pay 80 percent of the ESRD PPS base rate and all
applicable adjustments (or the blended payment amount if the facility chooses to
transition), for each outpatient maintenance dialysis treatment furnished to the ESRD
beneficiary in the ESRD facility or at the beneficiary’s home.
10.7 - ESRD Services Not Provided Within the United States
(Rev. 1, 10-01-03)
Services (except for certain inpatient hospital services and related physicians and
ambulance services in specified situations) that are not provided within the United States
are not covered. United States includes the 50 States, the District of Columbia, the

Commonwealth of Puerto Rico, the Virgin Islands, Guam, and American Samoa. See
Chapter 1 for additional information concerning specified situations that may be covered,
billing and payment procedures and jurisdiction for payment.
10.8 - Transportation Services
(Rev. 1, 10-01-03)
In general, transportation services to obtain ESRD services are not covered. However, see
the Medicare Benefit Policy Manual, Chapter 10, for coverage of ambulance services to
renal dialysis facilities located on hospital premises and for coverage of ambulance
services to nonhospital based dialysis facilities. Billing and payment instructions are
provided in Chapter 15 of this manual.
10.9 – Dialysis Provider Number Series
(Rev. 771, Issued: 12-02-05, Effective: 01-03-06, Implementation: 01-03-06)
There are multiple facilities that provide dialysis services to ESRD beneficiaries. To
ensure that provider data is correct, facilities are required to use a Provider Number based
on facility type issued by CMS.
The Provider Number Series for Dialysis Providers are as follows (for CMS use only,
effective May 23, 2007, providers are required to submit only their National Provider
Identifier (NPI). The dialysis provider numbers will be mapped to the NPI):
2300-2499 	Chronic Renal Dialysis Facilities (Hospital – Based)
2500-2899 	Non – Hospital Renal Facilities
2900-2999 	Independent Special Purpose Renal Dialysis Facility
3300-3399 	Children’s Hospitals (Excluded from PPS)
3500-3699 	Renal Disease Treatment Centers (Hospital Satellites)
3700-3799 	Hospital Based Special Purpose Renal Dialysis Facilities
All facilities should use their appropriately assigned provider numbers on the 72x type of
bill. In the event that a facility changes from one type to another, the provider number
must reflect the facility’s present provider type.
20 - End Stage Renal Disease Prospective Payment System (ESRD PPS)
Per Treatment Payment Amount
(Rev. 13740; Issued: 04-17-26; Effective: 07-01-26; Implementation: 07-06-26)
A case mix methodology adjusts the Prospective Payment System (PPS) base rate based
on a limited number of patient characteristics. Variables for which adjustments will be
applied to the PPS base rate include age, body surface area (BSA), and low body mass
index (BMI). These variables are determined in the ESRD PRICER to calculate the End
Stage Renal Disease Prospective Payment System (ESRD PPS per treatment payment
amount (including all other adjustments).

The following table contains claim data required to calculate the ESRD PPS per
treatment payment amount.
Form CMS-1450 	ASC X12 837 institutional claim
Through Date 	2300 | DTP segment | 434 qualifier
Date of Birth 	2010BA | DMG02
Condition Codes (73, 74, 87) 	2300 | HI segment | BG qualifier
Value Codes (A8 and A9) / Amounts 	2300 | HI segment | BE qualifier
Revenue Code (0821, 0831, 0841,
0851, 0880, or 0881)
2400 | SV201
For claims with dates of service on or after January 1, 2011, Medicare systems must pass
the line item date of service dialysis revenue code lines when the onset of dialysis
adjustment is applicable to one or more of the dialysis sessions reported on the claim.
Form CMS-1450 	ASC X12 837 institutional claim
Line Item Date of Service for
Revenue Code (0821, 0831, 0841,
0851
2400 | DTP Segment | D8 qualifier
In addition to the above claim data, the following payer only codes are required on claims
with dates of service on or after January 1, 2011 to calculate the ESRD PPS per treatment
payment amount:
Form CMS-1450 	Payer Only Format
Payer Only Condition Codes (MA,
MB, MC, MD, ME, MF)
(Identifies comorbid conditions for
adjustments)
X(2)
Payer Only Value Code (79)
(Identifies dollar amount for
services applicable for the
calculation for determining outlier)
• 	X(2) V(9)
Payer Only Value Code (Q8)
(Identifies dollar amount for
services applicable for the
calculation of the transitional drug
add-on payment)
• 	X(2) V(9)

Form CMS-1450 	Payer Only Format
Payer Only Value Code (QG)
(Identifies dollar amount for
services applicable for the
calculation of the transitional
payment for new innovative
equipment and supplies)
• 	X(2) V(9)
Payer Only Value Code (QH)
(Identifies dollar amount for
services applicable for the
calculation of the transitional
payment for capital related assets for
new innovative equipment
• 	X(2) V(9)
Note: The payer only codes above are assigned by the Medicare standard systems and are
not submitted on the claim by the provider.
The following provider data must also be passed to the ESRD PRICER to make provider-
specific calculations that determine the ESRD PPS per treatment payment amount:
Field 	Format
Actual Geographic Location MSA 	X(4)
Actual Geographic Location CBSA 	X(5)
Special Wage Index 	9(2)V9(4)
Supplemental Wage Index 	9(2)V9(4)
Provider Type 	X(2)
Special Payment Indicator 	X(1)
In addition to the above provider data, the following is required to calculate the final
ESRD PPS rate effective January 1, 2011:
Field 	Format
Blended Payment Indicator 	X(1)
Low-Volume Indicator 	X (1)
Effective January 1, 2012 the following is required to calculate the Quality Incentive
Program adjustment for ESRD facilities:

Field 	Format
Quality Indicator Field 	X(1)
Based on the claim and provider data shown above, the ESRD PRICER makes
adjustments to the PPS base rate to determine the ESRD PPS per treatment payment
amount. The following factors are used to adjust and make calculations to the ESRD PPS
per treatment payment amount.
• 	Provider Type
• 	Drug add-on
• 	Budget Neutrality Factor
• 	Patient Age
• 	Patient Height
• 	Patient Weight
• 	Patient BSA
• 	Patient BMI
• 	BSA factor
• 	BMI factor
• 	Condition Code 73 adjustment (if applicable)
• 	Condition Code 74 adjustment (if applicable)
• 	Condition Code 84 for AKI patients (if applicable)
• 	Condition Code 87 adjustment (if applicable)
In addition to the above adjustments, the following adjustments may be applicable to the
ESRD PPS base rate for adult patient claims with dates of service on or after January 1,
2011:
• 	Onset of Dialysis
• 	Patient Comorbidities
• 	Low-Volume ESRD Facility
Onset of Dialysis:
Providers will receive an adjustment to the ESRD PPS base rate for patients within the
initial 120 calendar days from when an ESRD beneficiary began their maintenance
dialysis. The provider does not report anything on the claim for this adjustment. The
adjustment is determined by the start date of dialysis in the Common Working File as
reported on the patient’s 2728 form. When the onset of dialysis adjustment is provided,
the claim is not entitled to a comorbidity adjustment or a training add-on adjustment.
Patient Comorbidities:
The ESRD PPS will provide adjustments for each category of chronic and acute
comorbidity conditions, 3 categories of chronic conditions and 3 categories of acute

conditions. In the event that more than one of the comorbidity categories is present
on the claim, the claim will be adjusted for the highest paying comorbidity category.
Chronic Comorbidities
When chronic comorbidity codes are reported on the claim an adjustment may be made
for as long as the chronic condition remains applicable to the patient care provided and is
reported on the claim.
Acute Comorbidities
Acute comorbidity category adjustments will be eligible for a payment for the first month
reported and then for the next three consecutive months, regardless of whether or not the
diagnosis code is on the claim after the first month. This adjustment applies for no more
than four consecutive months for any reported acute comorbidity category. Acute
comorbidity conditions reported for more than four consecutive months will not receive
additional payment.
In the event that the comorbidity condition was resolved and later reoccurred, the
provider may submit a condition code to indicate the diagnosis is a reoccurrence. The
adjustment will be applicable for an additional four months.
For a list of specific acute and chronic comorbid conditions eligible for adjustment, refer
to the following website:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ESRDpayment/Patient-Level-Adjustments
This list may be updated as often as quarterly in January, April, July and October of each
year.
Low-Volume ESRD Facilities:
ESRD facilities will receive an adjustment to their ESRD PPS base rate when the facility
furnished less than 4,000 treatments in each of the three cost report years preceding the
payment year and has not open, closed, or received a new provider number due to a
change in ownership during the 3 years preceding the payment year. The ESRD facility
must notify their A/B MAC (A) if they believe they are eligible for the low-volume
adjustment. The A/B MAC (A) must validate the eligibility and update the provider
specific file according to the ESRD facility’s low-volume payment tier. Pediatric patient
claims are not eligible for the low-volume adjustment.
A/B MACs (A) are instructed to validate the facility’s eligibility for the low volume
adjustment. If an A/B MAC (A) determines that an ESRD facility has received the low
volume adjustment in error, the A/B MAC (A) is required to adjust all of the ESRD
facility’s affected claims to remove the adjustment within 6 months of finding the error.

In addition to the above adjustments, the following adjustments may be applicable to the
ESRD PPS base rate for adult and pediatric patient claims with dates of service on or
after January 1, 2011:
Training Adjustment: The ESRD PPS provides a training add-on of $33.44 adjusted by
the ESRD PPS wage index that accounts for an hour of nursing time for training
treatments. The add-on applies to both PD and HD training treatments.
ESRD PPS Outlier Payments:
The ESRD Prospective Payment System (PPS) includes a payment adjustment for high
cost outliers when there are unusual variations in the type or amount of medically
necessary care.
Outlier consideration is provided for the following:
• 	ESRD-related drugs and biologicals that were or would have been prior to
January 1, 2011, either included under the case-mix adjusted composite payment
system or separately billable under Medicare Part B;
• 	ESRD-related laboratory tests that were or would have been, prior to January 1,
2011 separately billable under Part B;
• 	Medical/surgical supplies, including syringes, used to administer ESRD-related
drugs that were or would have been prior to January 1, 2011, separately billable
under Medicare Part B; and
• 	Renal dialysis service drugs that were or would have been, prior to January 1,
2011 covered under Medicare Part D.
• 	For new injectable renal dialysis drugs and biologicals that are eligible outlier
services, ESRD facilities should report J3591 with the National Drug Code
(NDC) in the 11-digit format 5-4-2. The MAC will set the payment rate based on
pricing methodologies under 1847A of the Act using the guidance in the Medicare
Claims Processing Manual, Chapter 17 - Drugs and Biologicals, Section 20.1.3 -
Exceptions to Average Sales Price (ASP) Payment Methodology.
Statute requires the delay of the implementation of the oral-only renal dialysis service
policy until January 1, 2025. Services not included in the PPS that remain separately
payable are not considered outlier services.
When the ESRD PRICER returns an outlier payment, the standard systems shall display
the total applicable outlier payment on the claim with value code 17.
Information related to the outlier services eligible for adjustment can be found at the
following website:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ESRDpayment/Outlier_Services.html

This list may be updated as often as quarterly in January, April, July and October of each
year.
For claims submitted with dates of service on or after January 1, 2012, all drugs reported
on the ESRD claim under revenue codes 0634, 0635 and 0636 with a rate available on the
ASP file will be considered in the Medicare allowed payment (MAP) amount for outlier
consideration with the exception of any drugs reported with the AY modifier and drugs
included in the original composite rate payment system.
Transitional Drug Add-On Payment Adjustment (TDAPA)
Effective January 1, 2016 under the ESRD PPS drug designation process, CMS provides
payment using a Transitional Drug Add-on Payment Adjustment (TDAPA) for new renal
dialysis new injectable or intravenous drugs and biologicals that qualify under 42 CFR
413.234(c)(1).
CMS will pay for the drug or biological using a transitional drug add-on payment
adjustment, if the new injectable or intravenous drug or biological is used to treat or
manage a condition for which there is not an existing ESRD PPS functional category.
CMS bases the TDAPA on payment methodologies under section 1847A of the Social
Security Act which are discussed in Pub. 100-04, Chapter 17, Section 20. The MAC will
set the payment rate based on pricing methodologies under 1847A of the Act using the
guidance in the Medicare Claims Processing Manual, Chapter 17 - Drugs and
Biologicals, Section 20.1.3 - Exceptions to Average Sales Price (ASP) Payment
Methodology. This payment is applicable for a period of 2 years.
While the TDAPA applies to a new injectable or intravenous drug or biological, the drug
or biological is not considered an outlier service, is not separately payable with the AY
modifier and does not apply to acute kidney injury claims (AKI).
Drugs eligible for the TDAPA must be billed with revenue code 0636 and, for dates of
service before July 1, 2026, modifier AX must be appended to the HCPCS.
• 	The TDAPA claim lines are shown as covered line items but no payment will be
included on the line item. The TDAPA is included in the prospective payment
amount on the dialysis revenue code lines.
• 	Q8 payer only value code captures the total allowable payment for the TDAPA.
The ESRD pricer divides the Q8 amount by the total number of dialysis
treatments and the per treatment amount is added to PPS rate and included in each
dialysis line payment.
Additional information on the TDAPA is available on the CMS website located at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ESRDpayment/ESRD-Transitional-Drug

Transitional Add-on Payment Adjustment for New and Innovative Equipment and
Supplies (TPNIES)
Beginning January 1, 2020, the ESRD PPS provides the Transitional Add-on Payment
Adjustment for New and Innovative Equipment and Supplies (TPNIES) for new and
innovative renal dialysis equipment and supplies that qualify under § 413.236.
The TPNIES payment is based on 65 percent of the Medicare Administrative Contractor
(MAC) determined price. The MACs, on behalf of CMS, establish prices for new and
innovative renal dialysis equipment and supplies that meet the TPNIES eligibility criteria
using verifiable information from the following sources of information, if available:
• 	the invoice amount, facility charges for the item, discounts, allowances, and
rebates;
• 	the price established for the item by other MACs and the sources of information
used to establish that price;
• 	payment amounts determined by other payers and the information used to
establish those payment amounts;
• 	charges and payment amounts required for other equipment and supplies that
may be comparable or otherwise relevant.
The TPNIES is paid for 2 calendar years, beginning on January 1 and ending on
December 31. While the TPNIES applies to a new and innovative equipment or supply,
the equipment or supply is not considered an outlier service.
Items eligible for the TPNIES must be billed with revenue code 027X and, for dates of
service before July 1, 2026, modifier AX must be appended to the HCPCS. Until
TPNIES items receive a HCPCS the TPNIES supplies are reported with HCPCS A4913
for miscellaneous dialysis supply not otherwise specified and for TPNIES equipment
HCPCS E1699 is reported for miscellaneous dialysis equipment not otherwise specified.
• 	The TPNIES claim lines are shown as covered line items but no payment will be
included on the line item. The TPNIES is included in the prospective payment
amount on the dialysis revenue code lines.
• 	QG payer only value code captures the total allowable price for the TPNIES. The
ESRD pricer calculates the 65 percent of the MAC determined price and divides
the amount by the total number of dialysis treatments and the per treatment
amount is added to PPS rate and included in each dialysis line payment.
Transitional Add-on Payment Adjustment for New and Innovative Equipment and
Supplies (TPNIES) for Capital Related Assets (CRA)
Beginning January 1, 2021, the TPNIES policy was expanded to include CRA that are
home dialysis machines when used in the home for a single patient. For CRA for
TPNIES only, CMS includes an offset adjustment to offset the costs already paid for
dialysis machines in the ESRD PPS bundle. Effective January 1, 2022, CMS annually
updates the offset adjustment amount by the ESRD bundled market basket percentage

increase factor minus the productivity adjustment factor. The payment for CRA for
TPNIES is based on 65 percent of the MAC determined price (see below), reduced by the
offset adjustment amount described in the prior sentences.
The MACs, on behalf of CMS, establish prices for new and innovative renal dialysis
equipment and supplies, including certain CRA that are home dialysis machines, that
meet the TPNIES eligibility criteria using verifiable information from the following
sources of information, if available:
• 	the invoice amount, facility charges for the item, discounts, allowances, and
rebates;
• 	the price established for the item by other MACs and the sources of information
used to establish that price;
• 	payment amounts determined by other payers and the information used to
establish those payment amounts;
• 	charges and payment amounts required for other equipment and supplies that
may be comparable or otherwise relevant.
The TPNIES for CRA is paid for 2 calendar years, beginning on January 1 of the
approval year and ending on December 31 the following year. Following payment of the
TPNIES for CRA, the ESRD PPS base rate will not be modified and the new CRA that is
a home dialysis machine will not be an eligible outlier service as provided in § 413.237.
Beginning January 1, 2021 and continuing through dates of service before July 1, 2026,
ESRD facilities report the AX modifier (item furnished in conjunction with dialysis
services) with the HCPCS code for the CRA that is eligible to receive TPNIES payment
for CRA. The TPNIES for CRA pricing instructions apply when a HCPCS code on the
TPNIES CRA list is reported and one of the following revenue codes:
•0823, Hemodialysis Home Equipment
• 0833, Peritoneal Home Equipment
• 0843, Continuous Ambulatory Peritoneal Dialysis (CAPD) Home Equipment
• 0853, Continuous Cycling Peritoneal Dialysis (CCPD) Home Equipment
• 0889, Other Miscellaneous Dialysis (to be used for ultrafiltration home equipment).
For CRAs that are home dialysis machines used in the home for a single patient, the
MACs shall divide the annual allowance by the expected number of treatments to
calculate the annual allowance and the per treatment amount. The expected number of
treatments is always 156 per year. MACs shall assign an amount to value code QH (Total
TPNIES CRA amount) which totals the CRA for TPNIES per treatment amount
multiplied by the number of treatments on that claim.
The number of dialysis treatments for the month used in the CRA for TPNIES
calculation, is limited to the 13 to 14 allowable monthly treatments that are deemed
medically necessary. Dialysis treatments exceeding 13 to 14 per month (3 treatments per
week) that are determined reasonable and necessary by the Medicare contractors are
payable; however, treatments that exceed 13 to 14 per month shall not be considered for

separate pricing for CRA for TPNIES. ESRD facilities should not bill separate line items
for CRA for TPNIES in excess of 13 to 14 treatments per month. Regardless of the
number of treatments given per month, the adjusted CRA for TPNIES per treatment
amount will equal the adjusted CRA for TPNIES per treatment amount that is calculated
for 13 treatments per month. MACs shall not allow CRA for TPNIES in excess of 156
treatments per calendar year.
Pricer puts a payment at the dialysis line so that it is a per treatment payment. Therefore,
Pricer calculates the adjusted per treatment amount that is added to each dialysis line by:
1) dividing QH by the total number of administered dialysis treatments, 2) subtracting the
applicable offset amount, and 3) multiplying by 65 percent.
CRA for TPNIES is not applicable to the per treatment payment amount that is paid to
ESRD facilities for furnishing dialysis to individuals with Acute Kidney Injury (AKI).
20.1 – Calculation of the Basic Case-Mix Adjusted Composite Rate and
the ESRD Prospective Payment System Rate
(Rev. 12979; Issued: 11-22-24; Effective: 01-01-25; Implementation: 01-06-25)
A case mix methodology adjusts the composite payment rate based on a limited number
of patient characteristics. Variables for which adjustments will be applied to each
facility’s composite rate include age, body surface area (BSA), and low body mass index
(BMI). These variables are determined in the ESRD PRICER to calculate the final
composite rate (including all other adjustments).
Effective January 1, 2011 the ESRD PPS replaced the basic case-mix adjusted composite
rate payment system. See section 20 for information on the calculation of the ESRD PPS
per treatment payment amount.
20.1.1 - Calculation for Double Amputee Dialysis Patients
(Rev. 1389; Issued: 12-07-07; Effective: 01-01-08; Implementation: 01-07-08)
For dialysis treatments on or after January 1, 2006, we are revising the reporting
requirements for value codes A8 and A9 for double amputee dialysis patients.
Weight should be calculated based on pre-amputation weight using the following
formula: Pre-amputation weight = Actual weight x 1.15
Example: Current weight for double amputee patient = 75.5 kg.
Pre-Amputation weight = 75.5 x 1.15 = 89kg.
The results should be reported under value code A8.

Height should be reported under value code A9 as pre-amputation height. Where feasible
this measurement may be obtained from Form 2728.
20.2 - Pediatric Payment Model for ESRD PPS
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
The pediatric payment model applies to all dialysis patients that are under the age of 18.
The model uses the ESRD PPS base rate applicable to adult dialysis patients which is
then adjusted by separate adjusters based on two age groups (<13, 13-17), and dialysis
modality (HD, PD).
20.3 -End Stage Renal Disease Quality Incentive Program (ESRD QIP)
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
153c of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)
required The Centers for Medicare & Medicaid Services (CMS) to implement a quality
based payment program for dialysis services with payment consequences effective
January 1, 2012. The measures are defined in the annual dialysis facility report (DFR)
that each provider receives in addition to the final rule.
Contractors are notified annually through a Technical Direction Letter from CMS
identifying ESRD facilities subject to QIP payment reduction. Medicare contractors shall
update the outpatient provider specific file (OPSF) as indicated for the payment year
specified.
See chapter 4 of this manual for appropriate OPSF fields to update.
Valid values for ESRD facilities:
Blank = no reduction
1 = ½ percent payment reduction
2 = 1 percent payment reduction
3 = 1 ½ percent payment reduction
4 = 2 percent payment reduction
30 - Publication of the Prospective Payment System (PPS) Base Rate
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
The End Stage Renal Disease Prospective Payment System (ESRD PPS) regulations
require Centers for Medicare & Medicaid Services (CMS) to publish the Prospective
Payment System (PPS) base rate in a “Federal Register” notice when CMS incorporates
new cost data or wage index. When the PPS base rate is updated, a listing of the new
payment rates are published via Recurring Update Notifications. These rates are updated

and published as needed and are used when issuing a PPS base rate to a new or an
existing facility.
40 - Acute Kidney Injury (AKI) Claims
(Rev. 13740; Issued: 04-17-26; Effective: 07-01-26; Implementation: 07-06-26)
Effective January 1, 2017, ESRD facilities, both hospital based and freestanding are able
to furnish dialysis to AKI patients and receive payment under the ESRD PPS.
Medicare will pay ESRD facilities for the dialysis treatment using the ESRD PPS base
rate adjusted by the applicable ESRD PPS wage index. In addition to the dialysis
treatment, the ESRD PPS base rate pays ESRD facilities for other items and services
considered to be renal dialysis services as defined in 42 CFR §413.171. No separate
payment is made for those services considered to be renal dialysis services as payment is
included in the ESRD PPS base rate.
Other items and services that are furnished to beneficiaries with AKI that are not
considered to be renal dialysis services but are related to their dialysis as a result of their
AKI, would be separately payable, this includes drugs, biologicals, laboratory services,
and supplies that ESRD facilities are certified to furnish and that would otherwise be
furnished to a beneficiary with AKI in a hospital outpatient setting.
AKI claims are billed on the 072X type of bill with condition code 84. ESRD facilities
are required to include revenue code 082X, 083x, or 088x for the modality of dialysis
furnished with the Current Procedural Terminology (CPT) code G0491 (Dialysis
procedure at a Medicare certified ESRD facility for Acute Kidney Injury without
ESRD).
AKI claims do not receive payment adjustments for comorbidities, TDAPA, TPNIES or
outlier. When applicable, AKI claims receive the home dialysis training add-on payment
adjustment (see section 50.8). The ESRD network reduction is not applicable to AKI
claims.
Reporting additional condition codes:
• 	Effective January 1, 2025, AKI claims for dialysis in the home setting must also
include condition code 74.
• 	Effective January 1, 2025, AKI claims for training or re-training for AKI home
and self-dialysis must also include either condition code 73 or 87 as appropriate.
• 	Effective July 1, 2025, AKI claims for home dialysis patients who require an in-
center back-up dialysis treatment may also include condition code 76.
More information on dialysis provided for AKI patients including the required diagnosis
codes for billing AKI is available on the CMS website at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/AKI-
and-ESRD-Facilities.

50 - Dialysis Bill Processing Procedures
(Rev. 12517; Issued:02-22-24; Effective: 03-25-24; Implementation: 03-25-24)
General instructions for completing the claim are in Chapter 25. The following
instructions apply to facility reporting of ESRD services and to A/B MAC (A) processing
of in-facility dialysis claims.
The shared system checks the Common Working File (CWF) to determine if there is
Employer Group Health Plan (EGHP) insurance. Where the beneficiary is covered under
the EGHP insurance, see the Medicare Secondary Payer Manual.
50.1 - Laboratory Services Included in the End Stage Renal Disease
Prospective Payment System ESRD PPS
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
With the implementation of the End Stage Renal Disease Prospective Payment System
ESRD PPS, effective for claims with dates of service on or after January 1, 2011, all
ESRD-related laboratory services are included in the ESRD PPS base rate.
f the renal dialysis facility needs to report a lab service that was not related to the
treatment of ESRD, they must include the modifier AY to indicate the item or service is
not for the treatment of ESRD.
ESRD-related lab services that were separately paid under the basic case-mix composite
rate payment system are considered in the calculation of any applicable outlier payment
under the ESRD PPS.
50.1.1 - Laboratory Services Performed During Emergency Room
Service
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
For claims with dates of service on or after January 1, 2012, the consolidated billing edit
for laboratory services will be bypassed when billed in conjunction with an emergency
room service on a hospital outpatient claim and the AY modifier will not be necessary.
Allowing laboratory testing to bypass consolidated billing edits in the emergency room or
department does not mean that End Stage Renal Disease (ESRD) facilities should send
patients to the emergency room or department for routine laboratory testing or for the
provision of renal dialysis services that should be provided by ESRD facilities. The
intent of the bypass is to acknowledge that there are emergency circumstances where the
reason for the patient’s illness is unknown and the determination of a laboratory test as
being ESRD-related is not known.

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.
50.2 - Drugs and Biologicals Included in the End Stage Renal Disease
Prospective Payment System (ESRD (PPS)
(Rev. 12979; Issued: 11-22-24; Effective: 01-01-25; Implementation: 01-06-25)
With the implementation of the End Stage Renal Disease Prospective Payment System
(ESRD PPS), effective for claims with dates of service on or after January 1, 2011, all
ESRD-related injectable drugs and biologicals and oral equivalents of those injectable
drugs and biologicals are included in the ESRD PPS.
If the renal dialysis facility needs to report a drug that was furnished to an ESRD
beneficiary that was not related to the treatment of ESRD, they must include the modifier
AY to indicate the item or service is not for the treatment of ESRD.
ESRD-related drugs and biologicals that were separately paid under the basic case-mix
composite rate payment system, and those that were included in the case-mix composite
rate payment system, are considered in the calculation of any applicable outlier payment
under the ESRD PPS.
Beginning January 1, 2025, ESRD facilities are required to report discarded billing units
on a separate claim line containing a JW modifier for all renal dialysis drugs and
biological products from single-dose containers or single-use packaging. When a renal
dialysis drug or biological product from a single-dose container or single-use packaging
is reported on an ESRD claim and there is no discarded amount, ESRD facilities are
required to attest that there is no discarded amount by reporting a JZ modifier on the
claim line along with the amount of drug or biological product administered.
A list of HCPCS codes that represent renal dialysis drugs and biological products subject
to the JW and JZ reporting requirement can be found here:
https://www.cms.gov/medicare/medicare-fee-for-service-
payment/esrdpayment/consolidated_billing.
50.3 - Required Information for In-Facility Claims Paid Under the End
Stage Renal Disease Prospective Payment System ESRD PPS
(Rev. 13740; Issued: 04-17-26; Effective: 07-01-26; Implementation: 07-06-26)
The term Medicare beneficiary identifier (MBI) is a general term describing a
beneficiary’s Medicare identification number. For purposes of this manual, Medicare
beneficiary identifier references both the Health Insurance Claim Number (HICN) and
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition

period and after for certain business areas that will continue to use the HICN as part of
their processes.
The electronic form required for billing ESRD claims is the ASC X12 837 institutional
claim transaction. The paper form, where permissible, is Form CMS-1450.
The coding and related descriptions for the following items are identical for the ASC X12
837 institutional claim format and Form CMS-1450. See the related X12 implementation
guide or Chapter 25, respectively, for where the information is reported.
Type of Bill
Acceptable codes for Medicare are:
721 - Admit Through Discharge Claim - This code is used for a bill encompassing an
entire course of outpatient treatment for which the provider expects payment from the
payer.
722 - Interim - First Claim - This code is used for the first of an expected series of
payment bills for the same course of treatment.
723 - Interim - Continuing Claim - This code is used when a payment bill for the same
course of treatment is submitted and further bills are expected to be submitted later.
724 - Interim - Last Claim - This code is used for a payment bill which is the last of a
series for this course of treatment. The “Through” date of this bill (FL 6) is the discharge
date for this course of treatment.
727 - Replacement of Prior Claim - This code is used when the provider wants to correct
(other than late charges) a previously submitted bill. The previously submitted bill needs
to be resubmitted in its entirety, changing only the items that need correction. This is the
code used for the corrected or “new” bill.
728 - Void/Cancel of a Prior Claim - This code indicates this bill is a cancel-only
adjustment of an incorrect bill previously submitted. Cancel-only adjustments should be
used only in cases of incorrect provider identification numbers, incorrect Medicare
beneficiary identifier, duplicate payments and some OIG recoveries. For incorrect
provider numbers or Medicare beneficiary identifier, a corrected bill is also submitted
using a code 721.
Statement Covers Period (From-Through) - Hospital-based and independent renal
dialysis facilities:
The beginning and ending service dates of the period included on this bill. Note: ESRD
services are subject to the monthly billing requirements for repetitive services.

Condition Codes
Hospital-based and independent renal facilities complete these items. Note that one of
the codes 71-76 is applicable for every bill. Special Program Indicator codes A0-A9 are
not required.
Condition Code Structure (only codes affecting Medicare payment/processing are
shown).
02 - Condition is Employment Related - Providers enter this code if the patient alleges
that the medical condition causing this episode of care is due to environment/events
resulting from employment.
04 - Information Only Bill - Providers enter this code to indicate the patient is a member
of a Medicare Advantage plan.
59 – Non-Primary ESRD Facility – Providers enter this code to indicate that ESRD
beneficiary received non-scheduled or emergency dialysis services at a facility other than
his/her primary ESRD dialysis facility.
71 - Full Care in Unit - Providers enter this code to indicate the billing is for a patient
who received staff-assisted dialysis services in a hospital or renal dialysis facility.
72 - Self-Care in Unit - Providers enter this code to indicate the billing is for a patient
who managed his own dialysis in a hospital or renal dialysis facility.
73 - Self-Care in Training - Providers enter this code to indicate the billing is for special
dialysis services where a patient and his/her helper (if necessary) were learning to
perform dialysis.
74- Home-Providers enter this code to indicate the billing is for a patient who received
dialysis services at home.
76 - Back-up In-facility Dialysis - Providers enter this code to indicate the billing is for a
home dialysis patient who received back-up dialysis in a facility.
80- Home Dialysis-Nursing Facility – Home dialysis furnished in a SNF or Nursing
Facility (report with condition code 74).
84 – Acute Kidney Injury- Provider enters this code to indicate the claim is for an AKI
patient.
87 – Retraining – Provider enters this code to indicate the billing is for retraining of the
patient and his/her helper (if necessary) to perform self-care dialysis.
H3 – Reoccurrence of GI Bleed comorbid category

H4 – Reoccurrence of Pneumonia comorbid category
H5 – Reoccurrence of Pericarditis comorbid Category
Occurrence Codes and Dates
Codes(s) and associated date(s) defining specific events(s) relating to this billing period
are shown. Event codes are two alpha-numeric digits, and dates are shown as six
numeric digits (MM-DD-YY). When occurrence codes 01-04 and 24 are entered, make
sure the entry includes the appropriate value code, if there is another payer involved.
Occurrence and occurrence span codes are mutually exclusive. Occurrence codes have
values from 01 through 69 and A0 through L9. Occurrence span codes have values from
70 through 99 and M0 through Z9.
24 - Date Insurance Denied - Code indicates the date of receipt of a denial of coverage by
a higher priority payer.
33 - First Day of Medicare Coordination Period for ESRD Beneficiaries Covered by an
EGHP - Code indicates the first day of the Medicare coordination period during which
Medicare benefits are payable under an EGHP. This is required only for ESRD
beneficiaries.
51 – Date of last Kt/V reading. For in-center hemodialysis patients, this is the date of the
last reading taken during the billing period. For peritoneal dialysis patients and home
hemodialysis patients, this date may be before the current billing period but should be
within 4 months of the claim date of service.
Occurrence Span Code and Dates
Code(s) and associated beginning and ending dates(s) defining a specific event relating to
this billing period are shown. Event codes are two alpha-numeric digits and dates are
shown numerically as MM-DD-YY.
74 - Noncovered Level of Care - This code is used for repetitive Part B services to show a
period of inpatient hospital care or of outpatient surgery during the billing period. Use of
this code will not be necessary for ESRD claims with dates of service on or after April 1,
2007 due to the requirement of ESRD line item billing.
Document Control Number (DCN)
Required for all provider types on adjustment requests. (Bill Type/FL=XX7). All
providers requesting an adjustment to a previous processed claim insert the DCN of the
claims to be adjusted.

Value Codes and Amounts
Code(s) and related dollar amount(s) identify monetary data that are necessary for the
processing of this claim. The codes are two alphanumeric digits and each value allows
up to nine numeric digits (0000000.00). Negative amounts are not allowed. Whole
numbers or non-dollar amounts are right justified to the left of the dollars and cents
delimiter. Some values are reported as cents, so refer to specific codes for instructions.
If more than one value code is shown for a billing period, show the codes in ascending
alphanumeric sequence.
Value Code Structure (Only codes used to bill Medicare are shown.):
06 - Medicare Blood Deductible - Code indicates the amount the patient paid for un-
replaced deductible blood.
13 - ESRD Beneficiary in the 30- Month Coordination Period with an EGHP - Code
indicates that the amount shown is that portion of a higher priority EGHP payment on
behalf of an ESRD beneficiary that applies to covered Medicare charges on this bill. If
the provider enters six zeros (0000.00) in the amount field, it is claiming a conditional
payment because the EGHP has denied coverage or there has been a substantial delay in
its payment. Where the provider received no payment or a reduced payment because of
failure to file a proper claim, this is the amount that would have been payable had it filed
a proper claim.
17 – Not submitted by the provider. The Medicare shared system will display this payer
only code on the claim when an outlier payment is being made. The value is the total
claim outlier payment.
19 – Not submitted by the provider. The Medicare shared system will display this payer
only code on the claim for low volume providers to identify the amount of the low
volume adjustment being included in the provider’s reimbursement.
37 - Pints of Blood Furnished - Code indicates the total number of pints of blood or units
of packed red cells furnished, whether or not replaced. Blood is reported only in terms of
complete pints rounded upwards, e.g., 1 1/4 pints is shown as 2 pints. This entry serves a
basis for counting pints towards the blood deductible. Hospital-based and independent
renal facilities must complete this item.
38 - Blood Deductible Pints - Code indicates the number of un-replaced deductible pints
of blood supplied. If all deductible pints furnished have been replaced, no entry is made.
Hospital-based and independent renal facilities must complete this item.
39 - Pints of Blood Replaced - Code indicates the total number of pints of blood donated
on the patient’s behalf. Where one pint is donated, one pint is replaced. If arrangements
have been made for replacement, pints are shown as replaced. Where the provider
charges only for the blood processing and administration, i.e., it does not charge a

“replacement deposit fee” for un-replaced pints, the blood is considered replaced for
purposes of this item. In such cases, all blood charges are shown under the 039x revenue
code series, Blood Administration. Hospital-based and independent renal facilities must
complete this item.
44 - Amount Provider Agreed To Accept From Primary Payer When This Amount is
Less Than Charges But Higher than Payment Received - Code indicates the amount
shown is the amount the provider was obligated or required to accept from a primary
payer as payment in full when that amount is less than the charges but higher than
amount actually received. A Medicare secondary payment is due.
47 - Any Liability Insurance - Code indicates amount shown is that portion from a higher
priority liability insurance made on behalf of a Medicare beneficiary that the provider is
applying to Medicare covered services on this bill. If six zeros (0000.00) are entered in
the amount field, the provider is claiming conditional payment because there has been
substantial delay in the other payer’s payment.
48 - Hemoglobin Reading - Code indicates the most recent hemoglobin reading taken
before the start of this billing period. This is usually reported in three positions with a
decimal. Use the right of the delimiter for the third digit. The blood sample for the
hemoglobin reading must be obtained before the dialysis treatment. If a hemoglobin
value is not available facilities must report the value 99.99.
49 - Hematocrit Reading - Code indicates the most recent hematocrit reading taken
before the start of this billing period. This is usually reported in two positions (a
percentage) to the left of the dollar/cents delimiter. If the reading is provided with a
decimal, use the position to the right of the delimiter for the third digit. The blood
sample for the hemoglobin reading must be obtained before the dialysis treatment. If a
hematocrit value is not available facilities must report the value 99.99
71 - Funding of ESRD Networks - Code indicates the amount of Medicare payment
reduction to help fund the ESRD networks. This amount is calculated by the A/B MAC
(A) and forwarded to CWF. (See §120 for discussion of ESRD networks).
79 – Not submitted by the provider. The Medicare shared system will display this payer
only code on the claim. The value represents the dollar amount for Medicare allowed
payments applicable for the calculation in determining an outlier payment.
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.
The measurement is required no less frequently than once per year but must be reported
on every claim. This height is as the patient presents.

D5 – Result of last Kt/V reading. For in-center hemodialysis patients this is the last
reading taken during the billing period. For peritoneal dialysis patients and home
hemodialysis this may be before the current billing period but should be within 4 months
of the claim date of service.
D6 – The number of minutes (rounded to the nearest whole minute) between the
beginning of dialysis treatment time (i.e. , when the start button on the blood pump is
pushed) and the end of dialysis treatment time (i.e., when the stop button on the blood
pump is pushed). ESRD facilities are not required to reduce the total count of minutes to
account for disruptions due to machine failures, bathroom breaks, or other stoppage, but
the number of minutes reported should not include time outside the start and end of the
dialysis session (for example, time when the patient is in-center waiting to be seated in a
chair). The time on dialysis machine duration begins when the actual dialysis treatment
starts and ends when the actual dialysis treatment is complete. The units reported must
exceed 1.
Q8 – Not submitted by the provider. The Medicare shared system will display this payer
only code on the claim. The value represents the dollar amount for the services
applicable to the calculation of the transitional drug add-on adjustment (TDAPA).
QG – Not submitted by the provider. The Medicare shared system will display this payer
only code on the claim. The value represents the dollar amount for the services
applicable to the calculation of the new innovative equipment and supplies add-on
adjustment (TPNIES).
QH – Not submitted by the provider. The Medicare shared system will display this payer
only code on the claim. The value represents the dollar amount for the services
applicable to the calculation of the new innovative equipment add-on for capital related
assets.
Revenue Codes
The revenue code for the appropriate treatment modality is billed (e.g., 0821 for
hemodialysis). Effective January 1, 2015, ESRD facilities are required to report on the
claim the drugs identified on the consolidated billing list provided at
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ESRDpayment/Consolidated_Billing.html
082X - Hemodialysis - Outpatient or Home Dialysis - A waste removal process
performed in an outpatient or home setting, necessary when the body’s own kidneys have
failed. Waste is removed directly from the blood. Detailed revenue coding is required.
Therefore, services may not be summed at the zero level.
0 - General Classification 	HEMO/OP OR HOME
1 – Hemodialysis/Composite or other rate 	HEMO/COMPOSITE
2 - Home Supplies 	HEMO/HOME/SUPPL

3 - Home Equipment 	HEMO/HOME/EQUIP
4 - Maintenance 100% 	HEMO/HOME/100%
5 - Support Services 	HEMO/HOME/SUPSERV
9 - Other Hemodialysis Outpatient 	HEMO/HOME/OTHER
Report hemodiafiltration sessions using revenue code 0829.
083X - Peritoneal Dialysis - Outpatient or Home - A waste removal process performed in
an outpatient or home setting, necessary when the body’s own kidneys have failed.
Waste is removed indirectly by instilling a special solution into the abdomen using the
peritoneal membrane as a filter.
0 - General Classification 	PERITONEAL/OP OR HOME
1 - Peritoneal/Composite or other rate 	PERTNL/COMPOSITE
2 - Home Supplies 	PERTNL/HOME/SUPPL
3 - Home Equipment 	PERTNL/HOME/EQUIP
4 - Maintenance 100% 	PERTNL/HOME/100%
5 - Support Services 	PERTNL/HOME/SUPSERV
9 -Other Peritoneal Dialysis 	PERTNL/HOME/OTHER
084X - Continuous Ambulatory Peritoneal Dialysis (CAPD) - Outpatient - A continuous
dialysis process performed in an outpatient or home setting, which uses the patient’s
peritoneal membrane as a dialyzer.
0 - General Classification 	CAPD/OP OR HOME
1 - CAPD/Composite or other rate 	CAPD/COMPOSITE
2 - Home Supplies 	CAPD/HOME/SUPPL
3 - Home Equipment 	CAPD/HOME/EQUIP
4 - Maintenance 100% 	CAPD/HOME/100%
5 - Support Services 	CAPD/HOME/SUPSERV
9 -Other CAPD Dialysis 	CAPD/HOME/OTHER
085X - Continuous Cycling Peritoneal Dialysis (CCPD) - Outpatient. - A continuous
dialysis process performed in an outpatient or home setting, which uses the patient’s
peritoneal membrane as a dialyzer.
0 - General Classification 	CCPD/OP OR HOME
1 - CCPD/Composite or other rate 	CCPD/COMPOSITE
2 - Home Supplies 	CCPD/HOME/SUPPL
3 - Home Equipment 	CCPD/HOME/EQUIP
4 - Maintenance 100% 	CCPD/HOME/100%
5 - Support Services 	CCPD/HOME/SUPSERV
9 -Other CCPD Dialysis 	CCPD/HOME/OTHER
088X - Miscellaneous Dialysis - Charges for Dialysis services not identified elsewhere.

0 - General Classification 	DAILY/MISC
1 – Ultrafiltration 	DAILY/ULTRAFILT
2 – Home dialysis aid visit 	HOME DIALYSIS AID VISIT
9 -Other misc. Dialysis 	DAILY/MISC/OTHER
HCPCS/Rates
All ESRD hemodialysis claims must include HCPCS 90999 on the line reporting revenue
code 082x. All AKI claims must include HCPCS G0491.
Modifiers
Modifiers are required with ESRD Billing for reporting the adequacy of dialysis and the
vascular access. For information on modifiers required for these quality measures see
50.9 of this chapter.
For information on reporting modifiers applicable to the Erythropoietin Stimulating
Agents refer to section 60.4 of this chapter.
Route of administration modifiers required are JA, JB and JE.
For information on reporting the AY modifier for services not related to the treatment of
ESRD, see sections 60.2.1.1 - Separately Billable ESRD Drugs and 60.1 - Lab Services.
For information on reporting the CG modifier for additional treatments provided without
medical justification, see section 10.1 of this chapter.
For information on reporting the JW and JZ modifiers for drugs and biologicals see
section 50.2.
ESRD facilities should not bill any renal dialysis service with the AX modifier, unless
otherwise notified by CMS, for dates of service on or after July 1, 2026.
Service Date
Report the line item date of service for each dialysis session and each separately payable
item or service.
Service Units
Hospital-based and independent renal facilities must complete this item. The entries
quantify services by revenue category, e.g., number of dialysis treatments. Units are
defined as follows:
0634 - Erythropoietin (EPO) - Administrations, i.e., the number of times an injection of
less than 10,000 units of EPO was administered. For claims with dates of service on or

after January 1, 2008, facilities use the units field as a multiplier of the dosage description
in the HCPCS to arrive at the dosage amount per administration.
0635 - Erythropoietin (EPO) - Administrations, i.e., the number of times an injection of
10,000 units or more of EPO was administered. For claims with dates of service on or
after January 1, 2008, facilities use the units field as a multiplier of the dosage description
in the HCPCS to arrive at the dosage amount per administration.
082X - (Hemodialysis) - Sessions
083X - (Peritoneal) - Sessions
084X - (CAPD) – Per Day
085X - (CCPD) – Per Day
Effective April 1, 2007, the implementation of ESRD line item billing requires that each
dialysis session be billed on a separate line. As a result, claims with dates of service on
or after April 1, 2007 should not report units greater than 1 for each dialysis revenue code
line billed on the claim.
Total Charges
Hospital-based and independent renal facilities must complete this item. Hospital-based
facilities must show their customary charges that correspond to the appropriate revenue
code. They must not enter their composite or the EPO` rate as their charge. Independent
facilities may enter their composite and/or EPO rates.
Neither revenue codes nor charges for services included in the composite rate may be
billed separately, but should be itemized on ESRD facility claims as appropriate.
Hospitals must maintain a log of these charges in their records for cost apportionment
purposes.
Services which are provided but which are not included in the composite rate may be
billed as described in sections that address those specific services.
The last revenue code entered in as 000l represents the total of all charges billed.
Principal Diagnosis Code
Hospital-based and independent renal facilities must complete this item and it should
include a diagnosis of end stage renal disease for patients with ESRD. For patients with
AKI see section 40 of this chapter.
Other Diagnosis Code(s)

For claims with dates of service on or after January 1, 2011 renal dialysis facilities report
the appropriate diagnosis code(s) for comorbidity conditions eligible for an adjustment.
50.4 - Line Item Detail Billing and Automated Claim Adjustments
(Rev. 1364, Issued: 11-02-07: Effective: 04-01-08; Implantation: 04-07-08)
The implementation of line item detail billing for ESRD claims effective on April 1, 2007
requires that each service be submitted on a separate line with the appropriate line item
date of service. The Medicare standard systems perform line item date of service
compare for RDFs claims with statement billing periods overlapping the statement billing
period of another processed claim. This prevents monthly claims from receiving
overlapping edits based on the statement billing period dates but rather, only when the
RDF claim has a line item that duplicates another processed claim or falls within the
dates of an inpatient hospital stay. Standard systems reject only those overlapping line
items while any line items not overlapping another claim continue to process for
payment. As a result of this logic, the RDFs no longer have to submit the occurrence
span code 74 on the monthly dialysis claim when an inpatient stay occurred during the
same month.
The initial line item detail billing instruction did not implement a process for rejecting
services on the RDF claim overlapping an inpatient stay when the RDF claim is received
before the inpatient hospital claim. A subsequent instruction implemented for April 1,
2008 requires the Medicare Common Working File (CWF) to create an informational
unsolicited response prompting the standard system to perform an automated adjustment
of the processed 72x claim that contains line item dates of service that are overlapping
dates of an incoming inpatient hospital claim. The admission and discharge dates of an
inpatient stay are not considered overlapping dates and may be payable to the RDF.
50.5 - Intermittent Peritoneal Dialysis (IPD) in the Facility
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
Payment for Intermittent Peritoneal Dialysis (IPD) in the facility is subject to the same
payment rules as hemodialysis.
50.6 - In-Facility Back-Up Dialysis
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
Back-up dialysis is an in-facility dialysis treatment furnished to a home dialysis patient.
Condition code 76 must appear as one entry in Form Locators (FLs) 24-30. The facility
must explain why any in-facility backup dialysis sessions (furnished on either an
inpatient or outpatient basis) are furnished to home dialysis patients who are covered
under the Prospective Payment System (PPS) base rate. If a backup session is furnished
because of a failure to furnish any of the required items or services, then it will be
covered only to the extent of a home dialysis session and reimbursed at the facility’s PPS

base rate. If the backup dialysis is furnished by an institution other than the home
patient’s End Stage Renal Disease (ESRD) facility, then the ESRD facility must assume
financial liability for any cost or charge in excess of the ESRD facility’s PPS base rate
except where the patient is traveling away from home.
50.6.1 - Payment for In-Facility Maintenance Dialysis Sessions
Furnished to Continuous Ambulatory Peritoneal Dialysis (CAPD)
/Continuous Cycling Peritoneal Dialysis (CCPD Home Dialysis Patients
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
Although Continuous Ambulatory Peritoneal Dialysis (CAPD) and Continuous Cycling
Peritoneal Dialysis (CCPD) patients are home dialysis patients, it may be necessary at
times to dialyze them in-facility as a substitute. In this case, the total weekly
reimbursement to the facility remains the same regardless of the type and frequency of in-
facility dialysis involved.
In order to furnish covered CAPD services, a facility must be a Medicare approved
ESRD facility and must meet additional standards established by CMS.
However, in rare instances an ESRD patient may require a combination of dialysis
techniques, on the same day, in order to achieve satisfactory results. In these situations,
Medicare pays for both types of dialysis services furnished on the same day. Medicare
A/B MACs (A) determine the medical necessity. In each case the A/B MAC (A) obtains
medical documentation from the facility that supports the use of back-up dialysis with
another treatment modality. If a CAPD patient frequently requires back-up sessions, the
A/B MAC (A)’s medical staff may request medical records to determine if this is the
appropriate mode of treatment to meet medical necessity requirement for payment
purposes and/or whether a different mode of treatment is more advantageous to the
beneficiary.
50.6.2 - Payment for Hemodialysis Sessions
(Rev. 13740; Issued: 04-17-26; Effective: 07-01-26; Implementation: 07-06-26)
Hemodialysis is typically furnished three times per week in sessions of three to five hours
duration. Each hemodialysis session equals one PPS base rate payment. Therefore, three
sessions per week is three PPS base rate payments. Dialysis furnished at this frequency is
paid without the need for a secondary diagnosis to justify payment. The justification
must support the medical necessity of the service(s) being rendered. Hemodiafiltration
sessions are paid identically to hemodialysis sessions.
50.7 - Ultrafiltration
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)

Ultrafiltration (revenue code 0881) is a process for removing excess fluid from the blood
through the dialysis membrane by means of pressure. It is not a substitute for dialysis.
Ultrafiltration is used in cases where excess fluid cannot be removed easily during the
regular course of hemodialysis. It is commonly done during the first hour or two of
hemodialysis on patients who, for example, have refractory edema.
Pre-dialysis Ultrafiltration - While the need, if any, for pre-dialysis ultrafiltration varies
from patient to patient, the facility’s PPS rate covers the full range of complicated and
uncomplicated outpatient dialysis treatments. Therefore, no additional charge is
recognized for pre-dialysis ultrafiltration.
Separate Ultrafiltration - Occasionally, medical complications require that
ultrafiltration be performed at a time other than when a dialysis treatment is given, and in
these cases an additional payment may be made. However, the need for separate
ultrafiltration must be documented in the medical record and a supporting other diagnosis
must be included on the claim.
50.8 - Training and Retraining
(Rev. 12979; Issued: 11-22-24; Effective: 01-01-25; Implementation: 01-06-25)
See Pub. 100-02 Medicare Benefit Policy Manual, Chapter 11, for coverage rules for
dialysis training.
Training services and supplies that are covered under the Prospective Payment System
(PPS) base rate includes personnel services, dialysis supplies and parenteral items used in
dialysis, written training manuals, material and laboratory tests.
End Stage Renal Disease Prospective Payment System (ESRD PPS) claims with dates of
service on or after January 1, 2011, and Acute Kidney Injury (AKI) claims with dates of
service on or after January 1, 2025, billing for dialysis training sessions will receive a
home dialysis training add-on payment.
The home dialysis training add-on payment is adjusted by the ESRD PPS wage index and
added to the PPS base rate. The home dialysis training add-on payment accounts for
nursing time for training treatments. The home dialysis training add-on payment applies
to both peritoneal dialysis (PD) and hemodialysis (HD) training treatments. Updates to
the home dialysis training add-on payment are published through rulemaking.
Hemodialysis (HD) Training (082X):
An ESRD facility may bill a maximum of 25 training sessions per patient for
hemodialysis training.
Intermittent Peritoneal Dialysis (IPD) Training (083X):
An ESRD facility is not reimbursed for more three IPD treatments in a single week, for a
total duration longer than 3 months.

Continuous Ambulatory Peritoneal Dialysis (CAPD) Training (84X):
An ESRD facility may bill a maximum of 15 training sessions per patient for CAPD
training. The A/B MAC (A) will make a determination whether or not to permit training
sessions in excess of 15.
Continuous Cycling Peritoneal Dialysis (CCPD) Training (085X):
An ESRD facility may bill a maximum of 15 training sessions per patient for CCPD
training. The A/B MAC (A) will determine whether or not training sessions over 15 are
medically necessary.
Retraining
A. General - Occasionally, it is necessary to furnish additional training to an ESRD
self-dialysis beneficiary after the initial training course is completed. Retraining
sessions are paid under the following conditions:
• 	The patient changes from one mode of dialysis to another, e.g., from
hemodialysis to CAPD;
• 	The patient’s home dialysis equipment changes;
• 	The patient’s dialysis setting changes;
• 	The patient’s dialysis partner changes; or
• 	The patient’s medical condition changes e.g., temporary memory loss due
to stroke, physical impairment.
The patient must continue to be an appropriate patient for self-dialysis.
B. Payment Rates - Retraining sessions are reimbursed at the same rate as the
facility’s training rate.
C. Duplicate Payments - No home dialysis training add-on payment is made for a
home dialysis treatment furnished on the same day as a retraining session. In the case
of a CAPD patient, the facility’s equivalent CAPD daily rate is not paid on the day(s)
of retraining.
50.9 - Coding for Adequacy of Dialysis, Vascular Access and Infection
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
A. 	Reporting the Urea Reduction Ratio (URR) for End Stage Renal Disease
(ESRD) Hemodialysis Claims
All hemodialysis claims must indicate the most recent Urea Reduction Ratio (URR) for
the dialysis patient. Code all claims using HCPCS code 90999 along with the appropriate
G modifier listed in section B.

Claims for dialysis treatments must include the adequacy of hemodialysis data as
measured by URR. Dialysis facilities must monitor the adequacy of dialysis treatments
monthly for facility patients. Home hemodialysis and peritoneal dialysis patients may be
monitored less frequently, but not less than quarterly. If a home hemodialysis patient is
not monitored during a month, the last, most recent URR for the dialysis patient must be
reported.
HCPCS code 90999 (unlisted dialysis procedure, inpatient or outpatient) must be reported
in field location 44 for all bill types 72X. The appropriate G-modifier in field location 44
(HCPCS/RATES) is used, for patients that received seven or more dialysis treatments in
a month. Continue to report revenue codes 0820, 0821, 0825, and 0829 in field location
43.
G1 - Most recent URR of less than 60%
G2 - Most recent URR of 60% to 64.9%
G3 - Most recent URR of 65% to 69.9%
G4 - Most recent URR of 70% to 74.9%
G5 - Most recent URR of 75% or greater
For patients that have received dialysis 6 days or less in a month, facilities use the
following modifier:
G6 - ESRD patient for whom less than seven dialysis sessions have been provided in a
month.
For services beginning January 1, 2003, and after, if the modifier is not present,
A/B/MACs (A) must return the claim to the provider for the appropriate modifier.
Effective April, 2007 due to the requirement of line item billing, at least one revenue
code line for hemodialysis on the claim must contain one of the URR modifiers shown
above. The URR modifier is not required on every hemodialysis line on the claim.
The techniques to be used to draw the pre- and post-dialysis blood urea Nitrogen samples
are listed in the National Kidney Foundation Dialysis Outcomes Quality Initiative
Clinical Practice Guidelines for Hemodialysis Adequacy, Guideline 8, Acceptable
Methods for BUN sampling, New York, National Kidney Foundation, 2000, pp.53-60.
B. 	Reporting the Vascular Access for End Stage Renal Disease (ESRD)
Hemodialysis Claims
ESRD claims for hemodialysis with dates of service on or after July 1, 2010 must
indicate the type of vascular access used for the delivery of the hemodialysis at the last
hemodialysis session of the month. One of the following codes is required to be reported
on the latest line item date of service billing for hemodialysis revenue code 0821. It may
be reported on all revenue code 0821 lines at the discretion of the provider.

Note: Modifier V5 must be entered if a vascular catheter is present even if it is not being
used for the delivery of the hemodialysis. In this instance 2 modifiers should be entered,
V5 for the vascular catheter and either V6 or V7 for the access that is being used for the
delivery of hemodialysis.
Modifier V5 - Any Vascular Catheter (alone or with any other vascular access),
Modifier V6 - Arteriovenous Graft (or other Vascular Access not including a vascular
catheter in use with two needles)
Modifier V7 - Arteriovenous Fistula Only (in use with two needles)
C. 	Reporting the Kt/V for ALL End Stage Renal Disease (ESRD) Claims
All End Stage Renal Disease (ESRD) claims with dates of service on or after July 1, 2010
must indicate the applicable Kt/V reading for the dialysis patient. The reading result and
the date of the reading must be reported on the claim using the following claim codes:
Value Code D5 – Result of last Kt/V reading. For in-center hemodialysis patients this is
the last reading taken during the billing period. For peritoneal dialysis patients and home
hemodialysis this may be before the current billing period but should be within 4 months
of the claim date of service.
• 	Hemodialysis: For in-center and home-hemodialysis patients prescribed for three
or fewer treatments per week, the last Kt/V obtained during the month must be
reported. Facilities must report single pool Kt/V using the preferred National
Quality Forum (NQF) endorsed methods for deriving the single pool Kt/V value:
Daugirdas II or Urea Kinetic Modeling (UKM). The reported Kt/V should not
include residual renal function.
A value of 8.88 shall be entered on the claim if the situation exists that a patient is
prescribed and receiving greater than three hemodialysis treatments per week for a
medically justified and documented clinical need. The 8.88 value is not to be used for
patients who are receiving “extra” treatments for a temporary clinical need (e.g. fluid
overload). A medical justification must be submitted for patients receiving greater than
13 treatments per month.
• 	Peritoneal Dialysis: When measured the delivered weekly total Kt/V (dialytic
and residual) should be reported.
This code is effective and required on all ESRD claims with dates of service on or after
July 1, 2010. In the event that no Kt/V reading was performed providers must report the
D5 with a value of 9.99.
Occurrence Code 51 – Date of last Kt/V reading. For in-center hemodialysis patients,
this is the date of the last reading taken during the billing period. For peritoneal dialysis

patients and home hemodialysis patients, this date may be before the current billing
period but should be within 4 months of the claim date of service. This code is effective
for ESRD claims with dates of service on or after July 1, 2010. This code not required
when reporting value code D5 with a value of 9.99 indicating no Kt/V reading is
available for reporting or value 8.88 to indicate the patient is prescribed and receiving
greater than 3 hemodialysis treatments per week for a medically justified and documented
clinical need.
D. 	Reporting of Infection for End Stage Renal Disease (ESRD) Claims
Effective April 1, 2012, the infection modifiers V8 and V9 were terminated. All End
Stage Renal Disease (ESRD) claims with dates of service on or after April 1, 2012, no
longer require reporting of infection modifiers V8 and V9.
60 - Separately Billable ESRD Items and Services
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
Payment for all items and services provided for the treatment of ESRD are included in
the ESRD PPS. ESRD facilities are required to itemize the ESRD related services
provided including drugs, laboratory tests and supplies that are eligible for outlier
consideration.
60.1 - Lab Services
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
See the Medicare Benefit Policy Manual, Chapter 11, for a description of lab services
included in the PPS rate.
Renal dialysis facilities must bill all lab tests provided for the treatment of ESRD. This is
true whether the tests were provided directly or under arrangements with an independent
lab. When lab tests are billed by providers other than the ESRD facility and the lab test is
provided for the treatment of ESRD, the claim will be rejected or denied. In the event
that a lab test usually provided for the treatment of ESRD was furnished to an ESRD
beneficiary for reasons other than for the treatment of ESRD, the provider may submit a
claim for separate payment using modifier AY.
ESRD facilities should only bill for lab tests related to the treatment of ESRD or other lab
tests performed by the dialysis facility (i.e. CLIA waived lab tests). Lab tests that are not
for the treatment of ESRD and are not performed by the ESRD facility are not to be
reported on the ESRD facility claim.
60.2 - Drugs Furnished in Dialysis Facilities
(Rev. 10640, Issued:08-06-21, Effective:09-07-2021, Implementation:09-07-21)
Effective January 1, 2011, section 153b of the MIPPA requires that all drugs and
biologicals used in the treatment of ESRD are included in the ESRD PPS payment
amount and must be billed by the ESRD facility.

60.2.1 - Billing Procedures for Drugs for Facilities
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
The following billing procedures apply to independent and hospital based ESRD
facilities.
Facilities identify and bill for drugs by HCPCS code, along with revenue code 0636,
“Drugs Requiring Specific Information.” Example below includes the HCPCS code and
indicates the dosage amount specified in the descriptor of that code. Facilities use the
units field as a multiplier to arrive at the dosage amount.
EXAMPLE:
HCPCS 	Drug 	Dosage (lowest denominator) 	Amount
J3360 	Valium 	5 mg 	$2.00
Actual dosage, 10 mg
On the bill, the facility shows J3360 and 2 in the units field (2 x 5 mg = 10 mg). For
independent facilities, A/B MACs (A) compare the price of $4.00 (2 x $2.00) to the billed
charge and pay the lower, subject to coinsurance and deductible. Effective January 1,
2006 payment is not subject to the lower of charges or fee. All separately payable drugs
for both hospital-based and independent facilities are paid at ASP+6% except vaccines.
For information on billing and payment for vaccines see section 60.6 of this chapter.
NOTE: When the dosage amount is greater than the amount indicated for the HCPCS
code, the facility rounds up to determine units. When the dosage amount is less than the
amount indicated for the HCPCS code, use one as the unit of measure. In the example
above, if the dosage were 7 mg, the facility would show 2 in the unit field, if the dosage
were 3 mg, the facility would show 1 in the unit field.
Facilities bill for supplies used to administer drugs with revenue code 0270,
“Medical/Surgical Supplies.” The number of administrations is shown in the units field.
EXAMPLE:
Revenue Code 	Units
0270 	3
The number of units for supply codes billed should match the number of injections billed
on the claim form.
Appropriate HCPCS codes for administration-supply of separately billable drugs would
include:

A4657: Injection Administration-supply Charge: include the cost of alcohol swab,
syringe, and gloves. Reimbursement for all ESRD facilities is based on a fee of
$0.50 per unit billed for A4657.
A4913: IV Administration-supply Charge: include the cost of IV solution
administration set, alcohol swab, syringe, and gloves. This code should only be
used when an IV solution set is required for a drug to be given. This rate will not
be paid for drugs that only require a syringe for administration.
60.2.1.1 – Separately Billable ESRD Drugs
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
Effective January 1, 2011, section 153b of the MIPPA requires that all drugs and
biologicals that are used in the treatment of ESRD be provided and billed by the ESRD
facility. When a drug or biological is billed by providers other than the ESRD facility
and the drug or biological furnished is designated as a drug or biological that is included
in the ESRD PPS ( renal dialysis service), the claim will be rejected or denied. In the
event that a drug or biological generally used in the treatment of ESRD was furnished to
an ESRD beneficiary for reasons other than for the treatment of ESRD, the provider may
report the drug on the claim with modifier AY and receive separate payment. For claims
with dates of service on or after July 1, 2013, when these drugs are administered through
the dialysate the provider must append the modifier JE (Administered via Dialysate).
All drugs reported on the renal dialysis facility claim are considered included in the
ESRD PPS, unless they are covered by an exception as discussed below. The list of drugs
and biologicals for consolidated billing are designated as always ESRD-related and
therefore no separate payment is made to ESRD facilities. However, CMS has
determined that some of these drugs warrant separate payment when they are used to treat
conditions other than ESRD.
Exceptions to “Always ESRD Related” Drugs:
The following drugs have been approved for separate payment consideration
when billed with the AY modifier attesting to the drug not being used for the
treatment of ESRD. The ESRD facility is required to indicate (in accordance with
ICD coding guidelines) the diagnosis code for which the drug is indicated.
• 	Vancomycin, effective January 1, 2012
• 	Daptomycin, effective January 1, 2013
Items and services subject to the consolidated billing requirements for the ESRD
PPS can be found on the CMS website at:
http://www.cms.gov/ESRDPayment/50_Consolidated_Billing.asp#TopOfPage
Other drugs and biologicals are separately payable to the dialysis facility if the drug was
not used for the treatment of ESRD. The facility must include the modifier AY to
indicate it was not for the treatment of ESRD.

Drugs are assigned HCPCS codes. If no HCPCS code is listed for a drug (e.g., a new
drug) the facility bills using HCPCS code J3490, “Unclassified Drugs,” and submits
documentation identifying the drug. To establish a code for the drug, the A/B MAC (A)
checks HCPCS to verify that there is no acceptable HCPCS code for billing and if a code
is not found checks with the local A/B MAC (B), which may have a code and price that is
appropriate. If no code is found the drug is processed under HCPCS code J3490. See
Chapter 17 for a complete description of drug pricing.
60.2.1.2 – Facilities Billing for ESRD Drugs and Biologicals Equivalent
to Injectable Drugs
(Rev. 10640, Issued:08-06-21, Effective:09-07-2021, Implementation:09-07-21)
The ESRD PPS includes some injectable drugs and biologicals that have oral equivalent
These drugs should be reported on the renal dialysis facility claim for consideration of
outlier payments. For the drugs and biologicals used in the treatment of ESRD that do
not have an assigned HCPCS, effective for dates of services on or after January 1, 2011,
ESRD facilities should bill using revenue code 0250 and report the national drug code
(NDC). The NDC is reported on the 837i claim transaction in loop 2410 line 03.
CMS will price these oral drugs based on a plan comparison for consideration in the
outlier payment. CMS will maintain a list of these drug categories by NDC and will post
the list on the CMS.gov website. Payment includes a mean dispensing fee and this
amount is updated via Recurring Update Notifications. This amount is applied to each
NDC included on the monthly claim. CMS limits 1 dispensing fee per NDC per month.
Providers should report the quantity in the smallest available unit. This is necessary
because Medicare is using the mean per unit cost in calculating the outlier. For example,
if the provider reports NDC 00054312041 Calcitriol 1 mcg/ml oral solution
(15/ml/bottle) and uses the full 15 ml bottle, the quantity is reported as 15, not 1. This
allows for the most accurate calculation for the outlier policy.
60.2.2 - Drug Payment Amounts for Facilities
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
Effective for claims with dates of service on or after January 1, 2011 all drugs and
biologicals used in the treatment of ESRD are reimbursed under the ESRD PPS payment
amount. For more information, please refer to Chapter 11 Benefit Policy Manual, section
20.3 Drugs and Biologicals.
60.2.3 - Facility Billing Requirements to the A/B MAC (A)
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
See Medicare Benefit Policy Manual, Chapter 11 for coverage and effective dates
applicable to intravenous iron therapy services.

For claims with dates of service on or after December 1, 2000, sodium ferric gluconate
complex in sucrose injection is covered by Medicare for first line treatment of iron
deficiency anemia in patients undergoing chronic hemodialysis who are receiving
supplemental erythropoeitin therapy. Payment is made on a reasonable cost basis for
claims with dates of service on or after December 1, 2000 in renal dialysis centers
(freestanding facilities). Payment is made pursuant to 42 CFR 405.517 for claims with
dates of service on or after January 1, 2001.
For claims with dates of service on or after October 1, 2001, Medicare also covers iron
sucrose injection as a first line treatment of iron deficiency anemia when furnished
intravenously to patients undergoing chronic hemodialysis who are receiving
supplemental erythropoeitin therapy. Payment is made under the outpatient prospective
payment system for hospital outpatient departments. Payment is made on a reasonable
cost basis in CAHs and in renal dialysis centers (freestanding facilities). See Chapter 17.
Deductible and coinsurance apply.
Facilities bill the A/B MAC (A) using type of bill 72X and revenue code 0636. For
claims with dates of service on or after December 1, 2000, report HCPCS code J3490
(Unclassified drugs) for sodium ferric gluconate complex in sucrose injection. For
claims with dates of service on or after January 1, 2001, facilities report HCPCS code
J2915 for sodium ferric gluconate complex in sucrose injection. Until a specific code is
developed for iron sucrose injection, report HCPCS code J3490 (Unclassified drugs).
60.2.4 - Physician Billing Requirements to the A/B MAC (B)
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
A. 	Sodium Ferric Gluconate Complex in Sucrose Injection
Sodium Ferric Gluconate Complex in sucrose injection may be payable for claims with
dates of service on or after December 1, 2000 when furnished intravenously, for first line
treatment of iron deficiency anemia in patients undergoing chronic hemodialysis who are
receiving supplemental erythropoeitin therapy. Physicians bill and A/B MACs (B) pay
for HCPCS code J1756 when submitted with a primary diagnosis for chronic renal failure
and a secondary diagnosis for iron deficiency anemia.
These diagnoses are listed below. Use ICD-9-CM or ICD-10-CM as applicable for the
service date.
Chronic Renal Failure (Primary Diagnosis)
• 	ICD-9-CM – 585
• 	ICD-10-CM – N18.3, N18.4, N18.5, N18.6,
Iron Deficiency Anemia (Secondary Diagnosis)
• 	ICD-9-CM – 280.0, 280.1, 280.8, or 280.9
• 	ICD-10-CM – D50.0, D50.1, D50.8, D50.9, or D63.1

This benefit is subject to the Part B deductible and coinsurance and should be paid per
current Medicare drug payment reimbursement rules.
B. 	Iron Sucrose Injection
Iron Sucrose injections are payable for claims with dates of service on or after October 1,
2001, when furnished intravenously, for first line treatment of iron deficiency anemia in
patients undergoing chronic hemodialysis who are receiving supplemental erythropoeitin
therapy. Until a specific code for iron sucrose injection is developed, providers must
submit HCPCS code J1756, with the appropriate explanation of drug name and dosage
entered on the claim. The primary diagnosis code for chronic renal failure and one of the
following secondary diagnosis codes for iron deficiency must be entered.
These diagnoses are listed below. Use ICD-9-CM or ICD-10-CM as applicable for the
service date.
Chronic Renal Failure (Primary Diagnosis)
• 	ICD-9-CM - 585
• 	ICD-10-CM - N18.3, N18.4, N18.5, N18.6,
Iron Deficiency Anemia (Secondary Diagnosis)
• 	ICD-9-CM – 280.0, 280.1, 280.8, or 280.9
• 	ICD-10-CM – D50.0, D50.1, D50.8, D50.9,D63.1
Iron sucrose injection is subject to the Part B deductible and coinsurance and should be
paid per current Medicare drug payment reimbursement rules. A/B MACs (B) may cover
other uses of this drug at their discretion.
C. 	Messages for Use with Denials
The contractor shall deny claims for sodium ferric gluconate complex in sucrose injection
or iron sucrose injection due to a missing diagnosis code.
The contractor shall use the following remittance advice messages and associated codes
when rejecting/denying claims under this policy. This CARC/RARC combination is
compliant with CAQH CORE Business Scenario Two.
Group Code: CO
CARC: 16
RARC: M76
MSN: 9.2

60.3 - Blood and Blood Products Furnished in Hospital Based and
Independent Dialysis Facilities
(Rev. 10640, Issued:08-06-2021, Effective:09-07-2021, Implementation:09-07-2021)
Effective January 1, 2011,blood and blood products remain separately payable under the
ESRD PPS. However, the staff time associated with administering blood and blood
products is included in the ESRD PPS payment amount.
60.4 - Erythropoietin Stimulating Agents (ESAs)
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
Coverage rules for ESAs are explained in the Medicare Benefit Policy Manual,
Publication 100-02, Chapter 11.
ESAs and their administration supplies and staff are included in the payment for the
ESRD PPS effective January 1, 2011. Providers must continue to report ESAs on the
claim. ESAs are eligible for outlier payment consideration. The Medicare allowed
payment (MAP) amounts for the outlier policy include the ESA rate provided on the
Average Sale Price (ASP) list.
60.4.1 - ESA Claims Monitoring Policy
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
Effective for services provided on or after April 1, 2006, Medicare has implemented a
national claims monitoring policy for ESAs administered in Medicare renal dialysis
facilities. This policy does not apply to claims for ESAs for patients who receive their
dialysis at home and self-administer their ESA.
While Medicare is not changing its coverage policy on erythropoietin use to maintain a
target hematocrit level between 30% and 36%, we believe the variability in response to
ESAs warrants postponing requiring monitoring until the hematocrit reaches higher
levels. For dates of services April 1, 2006, and later, the Centers for Medicare &
Medicaid Services (CMS) claims monitoring policy applies when the hematocrit level
exceeds 39.0% or the hemoglobin level exceeds 13.0g/dL. This does not preclude the
contractors from performing medical review at lower levels.
Effective for services provided on or after April 1, 2006, for claims reporting hematocrit
or hemoglobin levels exceeding the monitoring threshold, the dose shall be reduced by
25% over the preceding month. Providers may report that a dose reduction did occur in
response to the reported elevated hematocrit or hemoglobin level by adding a GS
modifier on the claim. The definition of the GS modifier is defined as: “Dosage of ESA
has been reduced and maintained in response to hematocrit or hemoglobin level.” Thus,
for claims reporting a hematocrit level or hemoglobin level exceeding the monitoring
threshold without the GS modifier, CMS will reduce the covered dosage reported on the
claim by 25%. The excess dosage is considered to be not reasonable and necessary.

Providers are reminded that the patient’s medical records should reflect
hematocrit/hemoglobin levels and any dosage reduction reported on the claim during the
same time period for which the claim is submitted.
Effective for dates of service provided on and after January 1, 2008, requests for
payments or claims for ESAs for ESRD patients receiving dialysis in renal dialysis
facilities reporting a hematocrit level exceeding 39.0% (or hemoglobin exceeding
13.0g/dL) shall also include modifier ED or EE. Claims reporting neither modifier or
both modifiers will be returned to the provider for correction.
The definition of modifier ED is “The hematocrit level has exceeded 39.0% (or
hemoglobin 1evel has exceeded 13.0g/dL) 3 or more consecutive billing cycles
immediately prior to and including the current billing cycle.” The definition of modifier
EE is “The hematocrit level has exceeded 39.0% (or hemoglobin level has exceeded
13.0g/dL) less than 3 consecutive billing cycles immediately prior to and including the
current billing cycle.” The GS modifier continues to be defined as stated above.
Providers may continue to report the GS modifier when the reported hematocrit or
hemoglobin levels exceed the monitoring threshold for less than 3 months and a dose
reduction has occurred. When both modifiers GS and EE are included, no reduction in
the covered dose will occur. Claims reporting a hematocrit or hemoglobin level
exceeding the monitoring threshold and the ED modifier shall have an automatic 50%
reduction in the covered dose applied, even if the claim also reports the GS modifier.
Below is a chart illustrating the resultant claim actions under all possible reporting
scenarios:
Hct Exceeds
39.0% or
Hgb Exceeds
13.0g/dL
ED
Modifier?
(Hct >39%
or Hgb
>13g/dL ≥3
cycles)
EE Modifier?
(Hct >39% or
Hgb >13g/dL
<3 cycles)
GS
Modifier?
(Dosage
reduced and
maintained)
Claim Action
No 	N/A 	N/A 	N/A Do not reduce
reported dose.
Yes 	No 	No 	No
Return to provider
for correction. Claim
must report either
modifier ED or EE.
Yes 	No 	No 	Yes
Return to provider
for correction. Claim
must report either
modifier ED or EE.
Yes 	No 	Yes 	Yes Do not reduce
reported dose.

Hct Exceeds
39.0% or
Hgb Exceeds
13.0g/dL
ED
Modifier?
(Hct >39%
or Hgb
>13g/dL ≥3
cycles)
EE Modifier?
(Hct >39% or
Hgb >13g/dL
<3 cycles)
GS
Modifier?
(Dosage
reduced and
maintained)
Claim Action
Yes 	No 	Yes 	No Reduce reported
dose 25%.
Yes 	Yes 	No 	Yes Reduce reported
dose 50%.
Yes 	Yes 	No 	No Reduce reported
dose 50%.
In some cases, physicians may believe there is medical justification to maintain a
hematocrit above 39.0% or hemoglobin above 13.0g/dL. Beneficiaries, physicians,
and/or renal facilities may submit additional medical documentation to justify this belief
under the routine appeal process. You may reinstate any covered dosage reduction
amounts under this first level appeal process when you believe the documentation
supports a higher hematocrit/hemoglobin level.
Providers are reminded that, in accordance with FDA labeling, CMS expects that as the
hematocrit approaches 36.0% (hemoglobin 12.0g/dL), a dosage reduction occurs.
Providers are expected to maintain hematocrit levels between 30.0 to 36.0% (hemoglobin
10.0-12.0g/dL). Hematocrit levels that remain below 30.0% (hemoglobin levels below
10.0g/dL)) despite dosage increases, should have causative factors evaluated. The
patient’s medical record should reflect the clinical reason for dose changes and
hematocrit levels outside the range of 30.0-36.0% (hemoglobin levels 10.0-12.0g/dL).
Medicare contractors may review medical records to assure appropriate dose reductions
are applied and maintained and hematological target ranges are maintained.
These hematocrit requirements apply only to ESAs furnished as an ESRD benefit under
§1881(b) of the Social Security Act.
Effective January 1, 2020, the EMP is discontinued under the ESRD PPS. Prescribing
practitioners should continue to prescribe ESAs in accordance with ESA dosing
guidelines and ESRD facilities should continue to report what they furnish.
The type of bill 72X will no longer be subject to dose reductions or ESA dose limitations.
ESRD facilities are not required to report the following modifiers:
1. GS - Dosage of erythropoietin stimulating agent has been reduced and maintained in
response to hematocrit or hemoglobin level
2. ED - Hematocrit level has exceeded 39% (or hemoglobin level has exceeded 13.0 g/dl)
for 3 or more consecutive billing cycles immediately prior to and including the current
cycle

3. EE - Hematocrit level has not exceeded 39% (or hemoglobin level has not exceeded
13.0 g/dl) for 3 or more consecutive billing cycles immediately prior to and including the
current cycle
Medically Unlikely Edits (MUE)
For dates of service on and after January 1, 2008, the MUE for claims billing for
Epogen® is reduced to 400,000 units from 500,000. The MUE for claims for Aranesp®
is reduced to 1200 mcg from 1500 mcg.
It is likely that claims reporting doses exceeding the threshold reflect typographical errors
and will be returned to providers for correction.
Effective January 1, 2020 the medically unlikely edits for ESAs exceeding the threshold
limits above are discontinued under the ESRD PPS.
60.4.2 - Facility Billing Requirements for ESAs
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
Hematocrit and Hemoglobin Levels
Renal dialysis facilities are required to report hematocrit or hemoglobin levels for their
Medicare patients receiving erythropoietin products. Hematocrit levels are reported in
value code 49 and reflect the most recent reading taken before the start of the billing
period. Hemoglobin readings before the start of the billing period are reported in value
code 48.
To report a hemoglobin or hematocrit reading for a new patient on or after January 1,
2006, the provider should report the reading that prompted the treatment of epoetin alfa.
The provider may use results documented on form CMS 2728 or the patient's medical
records from a transferring facility.
Effective January 1, 2012, ESRD facilities are required to report hematocrit or
hemoglobin levels on all ESRD claims. Reporting the value 99.99 is not permitted when
billing for an ESA.
The revenue codes for reporting Epoetin Alfa are 0634 and 0635. All other ESAs are
reported using revenue code 0636. The HCPCS code for the ESA must be included:

HCPCS 	HCPCS Description 	Dates of Service
Q4055 	Injection, Epoetin Alfa,
1,000 units (for ESRD on
Dialysis)
1/1/2004 through 12/31/2005
J0886 	Injection, Epoetin Alfa,
1,000 units (for ESRD on
Dialysis)
1/1/2006 through 12/31/2006
Q4081 	Injection, Epoetin alfa, 100
units (for ESRD on
Dialysis)
1/1/2007 to present
Q4054 	Injection, Darbepoetin Alfa,
1mcg (for ESRD on
Dialysis)
1/1/2004 through 12/31/2005
J0882 	Injection, Darbepoetin Alfa,
1mcg (for ESRD on
Dialysis)
1/1/2006 to present
J0890 	Injection, Peginesatide, 0.1
mg (for ESRD on Dialysis)
1/1/2013 through 7/1/2015
Q5105 	Injection, epoetin alfa,
biosimilar, (Retacrit) (For
ESRD on Dialysis), 100
units
7/1/2018 to present
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.
Route of Administration Modifiers
Patients with ESRD) receiving administrations of ESA for the treatment of anemia may
receive intravenous administration or subcutaneous administrations of the ESA. Effective for
claims with dates of services on or after January 1, 2012, all facilities billing for injections of
ESA for ESRD beneficiaries must include the modifier JA on the claim to indicate an
intravenous administration or modifier JB to indicate a subcutaneous administration. ESRD
claims containing ESA administrations that are submitted without the route of administration
modifiers will be returned to the provider for correction. Renal dialysis facility claims

including charges for administrations of the ESA by both methods must report separate lines
to identify the number of administration provided using each method.
Effective July 1, 2013, providers must identify when a drug is administered via the dialysate
by appending the modifier JE (administered via dialysate).
Maximum Allowable Administrations
The maximum number of administrations of EPO for a billing cycle is 13 times in 30
days and 14 times in 31 days.
The maximum number of administrations of Aranesp for a billing cycle is 5 times in 30/
31days.
Number of Units Administered - Subsequent claims may be submitted electronically.
Number of Units Administered - Subsequent claims may be submitted electronically.
60.4.4 - Payment Amount for Epoetin Alfa (EPO)
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
Payment for ESRD-related EPO is included in the ESRD PPS for claims with dates of
service on or after January 1, 2011.
60.4.4.1 - Payment for Epoetin Alfa (EPO) in Other Settings
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
With the implementation of the ESRD PPS, ESRD-related EPO is included in ESRD PPS
payment amount and is not separately payable on Part B claims with dates of service on
or after January 1, 2011 for other providers with the exception of a hospital billing for an
emergency or unscheduled dialysis session.
In the hospital inpatient setting, payment under Part A is included in the DRG.
In the hospital inpatient setting, payment under Part B is made on bill type 12x. Hospitals
report the drug units based on the units defined in the HCPCS description. Hospitals do
not report value code 68 for units of EPO. For dates of service prior to April 1, 2006,
report EPO under revenue code 0636. For dates of service from April 1, 2006 report
EPO under the respective revenue code 0634 for EPO less than 10,000 units and revenue
code 0635 for EPO over 10,000 units. Payment will be based on the ASP Pricing File.
In a skilled nursing facility (SNF), payment for EPO covered under the Part B EPO
benefit is not included in the prospective payment rate for the resident’s Medicare-
covered SNF stay.
In a hospice, payment is included in the hospice per diem rate when treatment is related
to the terminal illness.

For a service furnished by a physician or incident to a physician’s service, payment is
made to the physician by the A/B MAC (B) in accordance with the rules for ‘incident to”
services. When EPO is administered in the renal facility, the service is not an “incident
to” service and not under the “incident to” provision.
60.4.4.2 - Epoetin Alfa (EPO) Provided in the Hospital Outpatient
Departments
(Rev. 2582, Issued: 11-02-12, Effective: 04-01-13, Implementation: 04-01-13)
When ESRD patients come to the hospital for an unscheduled or emergency dialysis
treatment they may also require the administration of EPO. Effective January 1, 2005,
EPO will be paid based on the ASP Pricing File.
Hospitals use type of bill 13X (or 85X for Critical Access Hospitals) and report charges
under the respective revenue code 0634 for EPO less than 10,000 units and revenue code
0635 for EPO over 10,000 units. Hospitals report the drug units based on the units
defined in the HCPCS description. Hospitals do not report value code 68 for units of
EPO. Value code 49 must be reported with the hematocrit value for the hospital
outpatient visits prior to January 1, 2006, and for all claims with dates of service on or
after January 1, 2008.
60.4.5.1 - Self Administered ESA Supply
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
Initially, facilities may bill for up to a 2-month supply of an ESA for home dialysis
beneficiaries who meet the criteria for selection for self-administration. After the initial
two months’ supply, the facility will bill for one month’s supply at a time. Condition
code 70 is used to indicate payment requested for a supply of an ESA furnished a
beneficiary. Usually, revenue code 0635 would apply to EPO since the supply would be
over 10,000 units. Facilities leave FL 46, Units of Service, blank since they are not
administering the drug.
For claims with dates of service on or after January 1, 2008, supplies of an ESA for self-
administration should be billed according to the pre-determined plan of care schedule
provided to the beneficiary. Submit a separate line item for each date an administration is
expected to be performed with the expected dosage. In the event that the schedule was
changed, the provider should note the changes in the medical record and bill according to
the revised schedule. For patients beginning to self-administer an ESA at home receiving
an extra month supply of the drug, bill the one month reserve supply on one claim line
and include modifier EM defined as “Emergency Reserve Supply (for ESRD benefit
only)”.
When billing for drug wastage in accordance with the policy in chapter 17 of this manual,
section 40.1 the provider must show the wastage on a separate line item with the modifier
JW. The line item date of service should be the date of the last covered administration
according to the plan of care or if the patient dies use the date of death.

Condition code 70 should be reported on claims billing for home dialysis patients who
self-administer anemia management drugs including ESAs.
60.4.6.1 - Reserved for Future Use
( Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
60.4.6.2 - Reserved for Future Use
( Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
60.4.6.3 - Payment Amount for Darbepoetin Alfa (Aranesp)
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
Payment for ESRD-related Aranesp is included in the ESRD PPS for claims with dates of
service on or after January 1, 2011.
60.4.6.4 - Payment for Darbepoetin Alfa (Aranesp) in Other Settings
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
In the hospital inpatient setting, payment under Part A for Aranesp is included in the
DRG.
In the hospital inpatient setting, payment under Part B is made on bill type 12x when
billed with revenue code 0636. The total number of units as a multiple of 1mcg is placed
in the unit field. Reimbursement is based on the payment allowance limit for Medicare
Part B drugs as found in the ASP pricing file.
In a skilled nursing facility (SNF), payment for Aranesp covered under the Part B EPO
benefit is not included in the prospective payment rate for the resident’s Medicare-
covered SNF stay.
In a hospice, payment is included in the hospice per diem rate when treatment is related
to the terminal illness.
For a service furnished by a physician or incident to a physician’s service, payment is
made to the physician by the A/B MAC (B) in accordance with the rules for ‘incident to”
services. When Aranesp is administered in the renal facility, the service is not an
“incident to” service and not under the “incident to” provision.
With the implementation of the ESRD PPS, ESRD-related Aranesp is included in the
ESRD PPS payment amount and is not separately payable on Part B claims with dates of
service on or after January 1, 2011 for other providers, with the exception of a hospital
billing for an emergency or unscheduled dialysis session.
60.4.6.5 - Payment for Darbepoetin Alfa (Aranesp) in the Hospital
Outpatient Department

(Rev. 2582, Issued: 11-02-12, Effective: 04-01-13, Implementation: 04-01-13)
When ESRD patients come to the hospital for an unscheduled or emergency dialysis
treatment they may also require the administration of Aranesp. For patients with ESRD
who are on a regular course of dialysis, Aranesp administered in a hospital outpatient
department is paid the MMA Drug Pricing File rate. Effective January 1, 2005, Aranesp
will be paid based on the ASP Pricing File.
Hospitals use bill type 13X (or 85X for Critical Access Hospitals) and report charges
under revenue code 0636. The total number of units as a multiple of 1mcg is placed in the
unit field. Value code 49 must be reported with the hematocrit value for the hospital
outpatient visits prior to January 1, 2006, and for all claims with dates of service on or
after January 1, 2008.
60.5 - Intradialytic Parenteral/Enteral Nutrition (IDPN)
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
A. General
Parenteral/enteral nutrition (PEN) administered during dialysis may be covered under
Medicare, but it is not part of the Medicare ESRD benefit. Therefore, an ESRD facility or
PEN supplier may bill Medicare separately for PEN solution if the patient meets all of the
requirements for PEN coverage. (See Medicare Benefit Policy Manual for PEN coverage
requirements.) If the ESRD facility bills, it does so as a PEN supplier and bills the
appropriate DME MAC.
B. Staff Time
The ESRD facility staff time used to administer PEN solution is not covered by
Medicare, and, therefore, not included in the ESRD PPS. (PEN is considered a self-
administered therapy and generally administered in the patient’s home.) Since it is not
covered under Medicare, it is not part of the ESRD PPS nor may a facility bill Medicare
separately for it.
60.6 - Vaccines Furnished to ESRD Patients
(Rev. 10640, Issued:08-06-21, Effective:09-07-2021, Implementation:09-07-2021)
The Medicare program covers hepatitis B, influenza virus and Pneumococcal pneumonia
virus (PPV) vaccines and their administration when furnished to eligible beneficiaries in
accordance with coverage rules. Payment may be made for both the vaccine and the
administration. The costs associated with the syringe and supplies are included in the
administration fee: HCPCS code A4657 should not be billed for these vaccines.
Vaccines and their administration are reported using separate codes. See Chapter 18 of
this manual for the payment and codes required for billing vaccines and the
administration of the vaccine.

Vaccines remain separately payable under the ESRD PPS.
60.7 – Reserved For Future Use
( Rev. 10640, Issued:08-06-21, Effective:09-07-2021, Implementation:09-07-21)
70 - Payment for Home Dialysis
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
Home dialysis is dialysis performed by an appropriately trained dialysis patient at home.
Hemodialysis, CCPD, IPD and CAPD may be performed at home. For renal all dialysis
services furnished by an ESRD facility, the facility must accept assignment, and only the
facility may be paid by the Medicare program.
For purposes of home dialysis, a skilled nursing facility (SNF) may qualify as a
beneficiary’s home. The services are excluded from SNF consolidated billing for its
inpatients. The home dialysis services are billed by the ESRD facility.
With the implementation of the ESRD PPS on January 1, 2011, payment for all home
dialysis services furnished to the ESRD beneficiary is made to an ESRD 	dialysis facility
whether services are provided directly or under arrangements.
70.1 – Overpayments
( Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
Any overpayments that occur are subject to recovery following the usual Medicare
program rules and procedures.
80 - Home Dialysis Method I Billing to the A/B MAC (A)
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
If an ESRD patient chooses home dialysis, the ESRD dialysis facility with which the
Medicare home patient is associated assumes responsibility for providing all home
dialysis equipment and supplies, and home support services. For these services, the
facility receives the same Medicare dialysis payment rate as it would receive for an in-
facility patient under the ESRD PPS. The beneficiary is responsible for paying any unmet
Part B deductible and the 20-percent coinsurance.
80.1 - Items and Services Included in the ESRD PPS payment for Home
Dialysis
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)

The following items are paid for and must be furnished under the PPS. The facility may
furnish them directly under arrangements, to all of its home dialysis patients. If the
facility fails to furnish (either directly or under arrangements) any part of the items and
services covered under the rate, then the facility cannot be paid any amount for the part of
the items and services that the facility does furnish.
• 	Medically necessary dialysis equipment and dialysis support equipment;
• 	Home dialysis support services including the delivery, installation, maintenance,
repair, and testing of home dialysis equipment, and home support equipment;
• 	Purchase and delivery of all necessary dialysis supplies;
• 	Routine ESRD related laboratory tests; and
• 	All dialysis services furnished by the facility’s staff.
The following items and services are included in the ESRD PPS and may not be billed
separately when furnished by a dialysis facility:
• 	Staff time used to administer blood;
• 	Declotting of shunts and any supplies used to declot shunts by facility staff in the
dialysis unit;
• 	Oxygen and the administration of oxygen furnished in the dialysis unit;
• 	Staff time used to administer separately billable parenteral items;
• 	Bicarbonate dialysate;
• 	Cardiac monitoring;
• 	Catheter changes (Ideal Loop);
• 	Suture removal;
• 	Dressing changes;
• 	Crash cart usage for cardiac arrest; or
• 	Staff time used to collect specimens for all laboratory tests.
Sometimes services that are not renal dialysis services (e.g., declotting of shunts, suture
removal, injecting separately billable ESRD related drugs) are furnished in a department
of the hospital other than the dialysis unit (e.g., the emergency room). These services may

be paid in addition to the ESRD PPS payment only if the services could not be furnished
in a dialysis facility or the dialysis unit of the hospital, due to the absence of specialized
equipment or staff, which can be found only in the other department. In the case of
emergency services furnished in the hospital emergency room (ER), the services are paid
separately subject to the additional requirement that there is a sudden onset of a medical
condition manifesting itself by acute symptoms of sufficient severity (including severe
pain) such that the absence of immediate medical attention in the ER could reasonably be
expected to result in either:
• 	Placing the patient’s health in serious jeopardy;
• 	Causing serious impairment to bodily functions; or
• 	Causing serious dysfunction of any bodily organ or part.
These situations are rare and, in the absence of documentation to the contrary, these
conditions are deemed to be not met.
80.3 - Calculating Payment for Intermittent Peritoneal Dialysis (IPD)
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
The value of a typical week of dialysis services generally serves as the maximum weekly
payment;.
While maintenance IPD is usually accomplished in sessions of 10-12 hours duration,
three times per week, it is sometimes accomplished in fewer sessions of longer duration.
Regardless of the particular regimen used, under the ESRD PPS IPD is paid based on a
weekly equivalence of three ESRD PPS payments rates per week.
IPD in the home is accomplished according to any one of several schedules. The total
weekly dialysis time varies from 50 to 80 hours. For example, home IPD may be
furnished every day for 10 hours per day, every other day for 15 hours per dialysis day,
every night for 8 hours per night, etc. Regardless of the particular regimen used, under
the ESRD PPS home IPD is paid based on a weekly equivalence of three ESRD PPS rates
per week.
Line item billing is required for all dialysis sessions. For intermittent home dialysis the
facility submits a separate line item for each dialysis session using the dates in the pre-
determined plan of care and the units reported on each line should be one. In the event
that the schedule was changed, the provider should note the changes in the medical
record and bill according to the revised schedule.
80.4 - Calculating Payment for Continuous Ambulatory Peritoneal
Dialysis (CAPD) and Continuous Cycling Peritoneal Dialysis (CCPD)

Under the ESRD PPS
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
CAPD and CCPD are furnished on a continuous basis, not in discrete sessions and,
therefore, are paid on a weekly or daily basis, not on a per treatment basis. Facilities are
required to report the number of days in the units field. A facility’s daily payment rate is
1/7 of three times the composite rate for a single hemodialysis treatment.
The equivalent weekly or daily IPD or CAPD/CCPD payment does not depend upon the
number of exchanges of dialysate fluid per day (typically 3-5) or the actual number of
days per week that the patient undergoes dialysis. The weekly (or daily) rate is based on
the equivalency of one week of IPD or CAPD/CCPD to one week of hemodialysis,
regardless of the actual number of dialysis days or exchanges in that week.
All home dialysis support services, equipment and supplies necessary for home IPD or
CAPD/CCPD are included in the ESRD PPS payment. No support services, equipment or
supplies may be paid in addition to the ESRD PPS.
Line item billing is required for all dialysis sessions. For claims billing for Continuous
Ambulatory Peritoneal Dialysis (CAPD) and Continuous Cycling Peritoneal Dialysis
(CCPD), the provider may submit a separate dialysis line for each day of the month. If
the provider is aware of an inpatient stay for the beneficiary within the month, the ESRD
facility may include the date of admission and date of discharge as a billable day for the
dialysis but should omit the dates within the inpatient stay. In the event that the ESRD
facility is unaware of an inpatient stay during the month, the Medicare system shall
detect the overlapping dates and reject only the line item dates within the inpatient stay
but pay the remainder of the claim for any dates that are not within the inpatient stay.
90 – Reserved for Future Use
( Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
100 - Dialysis Sessions Furnished to Patients Who are Traveling
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
A. Dialysis at Another Facility
All in-facility dialysis treatments furnished by and in a facility are billed by and paid to
that facility under the ESRD PPS. This is true even if the patient is only temporary at a
particular facility while traveling.
B. Temporary Home Dialysis
Patients who normally dialyze in a facility may wish to dialyze temporarily as home
dialysis patients while they travel or vacation.

Training services furnished to temporary home dialysis patients are covered and paid at
the training rate subject to the usual rules for reimbursement of training services.
100.1 - Physician’s Services Furnished to a Dialysis Patient Away From
Home or Usual Facility
( Rev. 10640, Issued:08-06-21, Effective:09-07-2021, Implementation:09-07-21)
When a dialysis patient whose attending physician receives a monthly payment receives
maintenance dialysis services of any kind outside the usual setting from any physician
who is neither the attending physician nor that physician’s substitute, the following
procedures apply:
• 	The physician who furnished the service submits a claim to the local A/C MAC
(B) of jurisdiction;
• 	The A/B MAC (B) will process the claim and send an MSN to the patient;
• 	The A/B MAC (B) that has jurisdiction over the usual dialysis setting adjusts the
MCP to the usual attending physician to account for the time the patient was
absent from the usual dialysis setting.
• 	The A/B MAC (B) that has jurisdiction over the usual dialysis setting adjusts the
MCP to the usual attending physician per §140.3.E below to account for the time
the patient was absent from the usual dialysis setting.
A/B MACs (B) must notify physicians that claims for services furnished to temporary
patients must be identified as a claim for a temporary patient. The physician must
indicate “temporary patient” on the claim.
110 - Reduction in Medicare Program Payment to Fund ESRD
Networks
(Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
A. General
Section 9335(j) of OBRA 1986 requires the Secretary to reduce the amount of each
payment for each treatment by 50 cents and to allocate these amounts to ESRD network
activities. This applies to all dialysis treatments furnished on or after January 1, 1987 for
all treatment modalities, including training treatments. All Medicare hospital-based and
independent ESRD facilities paid under the ESRD PPS are affected.
The ESRD network reduction is $.50 per covered treatment when the full ESRD PPS rate
is applicable. For ESRD claims billing for continuous modalities of dialysis performed in
the beneficiary’s home, the ESRD PPS rate is calculated at a daily per diem rate by
taking the full ESRD PPS rate multiplied by 3 for the weekly allowable total and dividing

by 7 to provide a daily treatment rate. The ESRD network reduction is also calculated at a
daily rate by multiplying the $.50 by 3 for the weekly total network reduction and
dividing by 7 for a daily network reduction of $.21.
The reduction amount is reported in the Provider Statistics and Reimbursement Report
(PS&R) and CWF using value code 71 to identify monies withheld to fund ESRD
networks.
The Medicare payment reduction allocated toward funding the ESRD networks for the
individual claims will be indicated on the remittance record to the facility.
Facilities may not claim the 50-cent reduction as an expense on their Medicare cost
reports.
C. Application of ESRD Network Funding to MSP Claims
The ESRD offset for network funding on MSP claims will be applied as follows:
• 	Where another payer, primary to Medicare, pays the claim in full, no ESRD offset
is applicable;
• 	Where another payer, primary to Medicare, makes a partial payment, the ESRD
offset is deducted for each treatment as described in subsection C2 from the
Medicare secondary payment; and
• 	Where the ESRD offset amount is greater that the secondary payment amount, the
entire Medicare secondary payment amount is applied towards the ESRD network
funding. No Medicare secondary payment is made to the facility in this situation
and no further ESRD offset is applicable. No additional ESRD offset for
treatments on this claim will be made against other payments to the facility on the
same remittance or on future payments for the same beneficiary.
120 - Renal Transplantation and Related Services
(Rev. 1341, Issued: 09-21-07, Effective: 06-28-07, Implementation: 10-22-07)
Renal transplantation is a principal form of treatment available to patients with end-stage
renal disease. See Medicare Provider Reimbursement Manual, Part I, §§2771, for a
description of related payment policies. For a list of approved facilities, refer to the
following Web site:
http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/Transplant.html
120.1 - Payment for Immunosuppressive Drugs Furnished to
Transplant Patients
(Rev. 1, 10-01-03)

A. General
Effective January 1, 1987, Medicare pays for FDA approved self-administered
immunosuppressive drugs. Generally, under this benefit, payment is made for self-
administered immunosuppressive drugs that are specifically labeled and approved for
marketing as such by the FDA, as well as those prescription drugs, such as prednisone,
that are used in conjunction with immunosuppressive drugs as part of a therapeutic
regimen reflected in FDA approved labeling for immunosuppressive drugs. This benefit
is subject to the Part B deductible and coinsurance provision. There is no time limitation
on the coverage of these drugs; however, if a beneficiary loses Medicare coverage as a
result of the transplant, the drugs are no longer covered. When the beneficiary reaches the
age of 65 and becomes entitled, that person can have the drugs covered again. The
hospital pharmacy must ask the physician to furnish the patient with a non-refillable 30-
day prescription for the immunosuppressive drugs. This is because the dosage of these
drugs frequently diminishes over a period of time, and it is not uncommon for the
physician to change the prescription from one drug to another because of the patient’s
needs. Also, these drugs are expensive, and the coinsurance liability on unused drugs
could be a financial burden to the beneficiary. Unless there are special circumstances, the
A/B MAC (A) and A/B MAC (B) do not consider a supply of drugs in excess of 30 days
to be reasonable and necessary and limits payment accordingly.
B. Payment
Payment is made on a reasonable cost basis if the beneficiary is the outpatient of a
participating hospital. In all other cases, payment is made on an allowable charge basis.
C. FDA Approved Drugs
Some of the most commonly prescribed immunosuppressive drugs are:
• 	Sandimmune (cyclosporine), Sandoz Pharmaceutical (oral or parenteral),
• 	Imuran (azathioprine), Burroughs Wellcome Vial (oral),
• 	Atgam (antithymocyte/globulin), Upjohn (parenteral); and
• 	Orthoclone OKT3 (muromonab - CD3) Ortho Pharmaceutical (parenteral).
Also covered are prescription drugs used in conjunction with immunosuppressive drugs
as part of a therapeutic regimen reflected in FDA approved labeling for
immunosuppressive drugs.
The payment for the drug is limited to the cost of the most frequently administered
dosage of the drug (adjusted for medical factors as determined by the physician).
Consult such sources as the Drug Topics Red Book, American Druggists Blue Book, and
Medispan, realizing that substantial discounts are available.

130 - Physicians and Supplier (Nonfacility) Billing for ESRD Services -
General
(Rev. 3053, Issued: 08-28-14, Effective: ICD-10: Upon Implementation of ICD-10;
ASC X12: 01-01, 12, Implementation ICD-10: Upon Implementation of ICD-10;
ASC X12: 09-30-14)
Payment for renal-related physicians’ services to ESRD patients is made in either of the
following ways:
• 	Under the Monthly Capitation Payment (MCP) (see §140 below for an
explanation of the MCP); or
• 	Using the daily codes for ESRD services (CPT codes 90922-90925) with units
that represent the number of days services were furnished.
• 	Under the Initial method (IM)
The A/B MAC (B) receives bills from physicians for services furnished ESRD
beneficiaries.
The A/B MAC (A) receives bills from ESRD facilities.
Lab bills from CLIA certified independent dialysis facilities were billed to the A/B MAC
(B) before September 1, 1997, and to the A/B MAC (A) beginning on that date. Other
certified labs bill the A/C MAC (B).
130.1 - Initial Method for Physician’s Services to Maintenance Dialysis
Patients
(Rev. 1, 10-01-03)
Under the Initial Method (IM), do not pay for physician’s routine professional dialysis
services. Instead, the dialysis facility’s A/B MAC (A) pays the dialysis facility for them
as part of the facility’s composite rate. Physician’s professional services that are not
routine professional dialysis services are billed to the contractor and paid in the same way
as any other Medicare covered physician professional service.
1. 	For the physician to be paid under the IM, the following requirements must be
met:
All physicians of the facility must choose the IM with respect to all of the patients treated
at the facility and all of the facility’s Method I home dialysis patients. (See §70.1 for a
description of Method I). All of the facility’s physicians must file a written statement
with their A/B MAC (B) and the facility’s A/B MAC (A) to this effect. For example:

The physicians practicing at ________________ dialysis facility are listed
below. The signature of each physician indicates the physician’s election
to be paid for their routine professional dialysis services under the Initial
Method. This election is effective for services furnished beginning with
the second month after the month in which this statement is filed with the
A/B MAC (B) and the facility’s A/B MAC (A).
This written statement must be signed and dated by each physician.
2. 	The physician may bill the A/B MAC (B) only those physician’s professional
services that are not routine professional dialysis services. (See paragraph 3 below).
The election of the IM is effective for services furnished beginning with the second
calendar month after the month in which all the physicians of a facility elect it. A
physician may terminate the election by written notice to the A/B MAC (B) and to the
facility’s A/B MAC (A) that the physician thereby terminates the IM. If the A/B MAC
(B) and the A/B MAC (A) receive the termination notice on or before November 1, it is
effective the following January 1. If the A/B MAC (B) or the A/B MAC (A) receives it
after November 1, it is effective January 1 of the second year after the calendar year in
which the notice of termination is received. Note that if the IM is terminated by one
physician, it is thereby terminated for all physicians at the same facility with respect to
the patients treated through that facility.
3. 	Definitions
A. 	Administrative Services
Physician services that are differentiated from routine professional services and other
physician services. They include supervision, as described in the definition of
“supervision of staff,” are not related directly to the care of an individual patient and are
supportive of the facility as a whole and of benefit to patients in general. Examples of
administrative services include supervision of staff, staff training, participation in staff
conferences and in the management of the facility, and advising staff on the procurement
of supplies.
B. 	Dialysis Session
The period of time that begins when the patient arrives at the facility and ends when the
patient departs from the facility. In the case of home dialysis, the period begins when the
patient prepares for dialysis and generally ends when the patient is disconnected from the
machine. In this context, a dialysis facility includes only those parts of the building used
as a facility. It does not include any areas used as a physician’s private office.
C. 	Medical Direction

Routine professional service that entails substantial direct involvement and the physical
presence of the physician in the delivery of services directly to the patient.
D. 	Routine Professional Services
Physicians’ services furnished during a dialysis session and all services listed under
“Types of routine professional services” that:
• 	Are personally furnished by a physician to an individual patient.
• 	Contribute directly to the diagnosis or treatment of an individual patient.
• 	Ordinarily must be performed by a physician.
E. 	Supervision of Staff
Administrative services that do not necessarily require the physician to be present at the
dialysis session. It is a general activity primarily concerned with monitoring performance
of and giving guidance to other health care personnel (such as nurses and dialysis
technicians) who deliver services to patients.
F. 	Types of Routine Professional Services
Routine professional services include at least the following services when medically
appropriate:
• 	Visits to the patient during dialysis, and in conjunction with review of
laboratory test results,
• 	Nurses’ notes and any other medical documentation, as a basis for:
o 	Adjustment of the patient’s medication, diet or the dialysis
procedure;
o 	Prescription of medical supplies; and
o 	Evaluation of the patient’s psychosocial status and the
appropriateness of the modality,
o 	Medical direction of staff in delivering services to a patient during
a dialysis session, and
o 	Pre-dialysis and post-dialysis examinations or examinations that
could have been furnished on a pre-dialysis or post-dialysis basis.
140 - Monthly Capitation Payment Method for Physicians’ Services
Furnished to Patients on Maintenance Dialysis
(Rev. 1456, Issued: 02-22-08, Effective: 03-24-08, Implementation: 03-24-08)

Physicians and practitioners managing patients on dialysis (center based) are paid a
monthly capitation payment (MCP) for most outpatient dialysis-related physician
services furnished to a Medicare end stage renal disease (ESRD) beneficiary. The
payment amount varies based on the number of visits provided within each month and the
age of the ESRD beneficiary. Physicians and practitioners managing ESRD patients who
dialyze at home are paid a single monthly rate based on the age of the ESRD beneficiary,
regardless of the number of face-to-face physician or practitioner visits. The MCP is
reported once per month for services performed in an outpatient setting that are related to
the patients’ ESRD.
Physicians and practitioners may receive payment for managing patients on dialysis for
less than a full month of care in specific circumstances as discussed in section 140.2.
Payment for ESRD related services, less than a full month, is made on a per diem bases.
Payment for ESRD-related services is made at 80 percent of the Medicare approved
amount (lesser of the actual charge or applicable Medicare fee schedule amount) after the
beneficiary’s Part B deductible is met. The beneficiary is responsible for the Part B
deductible and the 20 percent coinsurance for physician and practitioner ESRD-related
services.
A. Services Included in Monthly Capitation Payment
The following physician services are included in the MCP:
• 	Assessment of the need for a specified diet and the need for nutritional
supplementation for the control of chronic renal failure. Specification of the
quantity of total protein, high biologic protein, sodium, potassium, and amount of
fluids to be allowed during a given time period. For diabetic patients with chronic
renal failure, the prescription usually specifies the number of calories in the diet.
• 	Assessment of which mode(s) of chronic dialysis (types of hemodialysis or
peritoneal dialysis) are suitable for a given patient and recommendation of the
type(s) of therapy for a given patient.
• 	Assessment and determination of which type of dialysis access is best suited for a
given patient and arrangement for creation of dialysis access.
• 	Assessment of whether the patient meets preliminary criteria as a renal transplant
candidate and presentation of this assessment to the patient and family.
• 	Prescription of the parameters of intradialytic management. For chronic
hemodialysis therapies, this includes the type of dialysis access, the type and
amount of anticoagulant to be employed, blood flow rates, dialysate flow rate,
ultrafiltration rate, dialysate temperature, type of dialysate (acetate versus
bicarbonate) and composition of the electrolytes in the dialysate, size of

hemodialyzer (surface area) and composition of the dialyzer membrane
(conventional versus high flux), duration and frequency of treatments, the type
and frequency of measuring indices of clearance, and intradialytic medications to
be administered. For chronic peritoneal dialysis therapies, this includes the type of
peritoneal dialysis, the volume of dialysate, concentration of dextrose in the
dialysate, electrolyte composition of the dialysate, duration of each exchange, and
addition of medication to the dialysate, such as heparin, and the type and
frequency of measuring indices of clearance. For diabetics, the quantity of insulin
to be added to each exchange is prescribed.
• 	Assessment of whether the patient has significant renal failure-related anemia,
determination of the etiology(ies) for the anemia based on diagnostic tests, and
prescription of therapy for correction of the anemia, such as vitamins, oral or
parenteral iron, and hormonal therapy such as erythropoietin.
• 	Assessment of whether the patient has hyperparathyroidism and/or renal
osteodystrophy secondary to chronic renal failure and prescription of appropriate
therapy, such as calcium and phosphate binders for control of hyperphosphatemia.
Based upon assessment of parahormone levels, serum calcium levels, and
evaluation for the presence of metabolic bone disease, the physician determines
whether oral or parenteral therapy with vitamin D or its analogs is indicated and
prescribes the appropriate therapy. Based upon assessment and diagnosis of bone
disease, the physician may prescribe specific chelation therapy with deferoxamine
and the use of hemoperfusion for removal of aluminum and the chelation.
• 	Assessment of whether the patient has dialysis-related arthropathy or neuropathy
and adjustment of the patient’s prescription accordingly. Referral of the patient
for any additional needed specialist evaluation and management of these end-
organ problems.
• 	Assessment of whether the patient has fluid overload resulting from renal failure
and establishment of an estimated “ideal (dry) weight.” The physician determines
the need for fluid removal independent of the dialysis prescription and
implements these measures when indicated.
• 	Determination of the need for and prescription of antihypertensive medications
and their timing relative to dialysis when the patient is hypertensive in spite of
correction of fluid overload.
• 	Periodic review of the dialysis records to ascertain whether the patient is receiving
the prescribed amount of dialysis and ordering of indices of clearance, such as
urea kinetics, in order to ascertain whether the dialysis prescription is producing
adequate dialysis. If the indices of clearance suggest that the prescription requires
alteration, the physician orders changes in the hemodialysis prescription, such as
blood flow rate, dialyzer surface area, dialysis frequency, and/or dialysis duration
(length of treatment). For peritoneal dialysis patients, the physician may order

changes in the volume of dialysate, dextrose concentration of the dialysate, and
duration of the exchanges.
• 	Periodic visits (at least one per month) to the patient during dialysis to ascertain
whether the dialysis is working well and whether the patient is tolerating the
procedure well (physiologically and psychologically). During these visits, the
physician determines whether alteration in any aspect of a given patient’s
prescription is indicated, such as changes in the estimate of the patient’s dry
weight. Review of the treatment with the nurse or technician performing the
therapy is also included. The frequency of these visits will vary depending upon
the patient’s medical status, complicating conditions, and other determinants.
• 	Performance of periodic physical assessments, based upon the patient’s clinical
stability, in order to determine the necessity for alterations in various aspects of
the patient’s prescription. Similarly, the physician reviews the results of periodic
laboratory testing in order to determine the need for alterations in the patient’s
prescription, such as changes in the amount and timing of phosphate binders or
dose of erythropoietin.
• 	Periodic assessment of the adequacy and function of the patient’s dialysis access
appropriate tests and antibiotic therapy.
• 	Interpretations of the following tests:
o 	Bone mineral density studies (CPT codes 76070, 76075, 78350, and
78351);
o 	Noninvasive vascular diagnostic studies of hemodialysis access (CPT
codes 93925, 93926, 93930, 93931, and 93990);
o 	Nerve conduction studies (CPT codes 95900, 95903, 95904, 95925,
95926, 95927, 95934, 95935, and 95936);
o 	Electromyography studies (CPT codes 95860, 95861, 95863, 95864,
95867, 95867, 95869, and 95872).
• 	Periodic review and update of the patient’s short-term and long-term care plans
with staff.
• 	Coordination and direction of the care of patients by other professional staff, such
as dieticians and social workers.
• 	Certification of the need for items and services such as durable medical
equipment and home health care services. Care plan oversight services described
by CPT code 99375 are included in the MCP and may not be separately reported.

B. Services Excluded from Monthly Capitation Payment
The following physician services furnished to the physician’s ESRD patients are
excluded from the MCP and should be paid in accordance with the physician fee
schedule:
1. Administration of hepatitis B vaccine.
2. Surgical services such as:
• 	Temporary or permanent hemodialysis catheter placement;
• 	Temporary or permanent peritoneal dialysis catheter placement;
• 	Repair of existing dialysis accesses;
• 	Placement of catheter(s) for thrombolytic therapy;
• 	Thrombolytic therapy (systemic, regional, or access catheter only;
hemodialysis or peritoneal dialysis);
• 	Thrombectomy of clotted cannula;
• 	Arthrocentesis;
• 	Bone marrow aspiration; and
• 	Bone marrow biopsy.
3. Interpretation of tests that have a professional component such as:
• 	Electrocardiograms (12 lead, Holter monitor, stress tests, etc.);
• 	Echocardiograms;
• 	24-hour blood pressure monitor;
• 	Biopsies; and
• 	Spirometry and complete pulmonary function tests.
4. Complete evaluation for renal transplantation. While the physician assessment of
whether the patient meets preliminary criteria as a renal transplant candidate is included
under the MCP, the complete evaluation for renal transplantation is excluded from the
MCP
5. Evaluation of potential living transplant donors.
6. The training of patients to perform home hemodialysis, self hemodialysis, and the
various forms of self peritoneal dialysis.
7. Non-renal related physician’s services. These services may be furnished by the
physician providing renal care or by another physician. They may not be incidental to
services furnished during a dialysis session or office visit necessitated by the renal
condition. The physician must provide documentation that the illness is not related to the
renal condition and that the added visits are required. The contractor’s medical staff
determines whether additional reimbursement is warranted for treatment of the unrelated

illness. For example, the medical management of diabetes mellitus that is not related to
the dialysis or furnished during a dialysis session is excluded.
8. Covered physician services furnished to hospital inpatients.
9. All physician services that antedate the initiation of outpatient dialysis.
10. Covered physician services furnished by another physician when the patient is not
available to receive the outpatient services as usual; for example, when the patient is
traveling out of town.
140.1 - Payment for ESRD-Related Services Under the Monthly
Capitation Payment (Center Based Patients)
(Rev. 2269, Issued: 08-05-11, Effective: 01-01-11, Implementation: 11-07-11)
Physicians and practitioners managing center based patients on dialysis are paid a
monthly rate for most outpatient dialysis-related physician services furnished to a
Medicare ESRD beneficiary. The payment amount varies based on the number of visits
provided within each month and the age of the ESRD beneficiary. Under this
methodology, separate codes are billed for providing one visit per month, two to three
visits per month and four or more visits per month. The lowest payment amount applies
when a physician provides one visit per month; a higher payment is provided for two to
three visits per month. To receive the highest payment amount, a physician or
practitioner would have to provide at least four ESRD-related visits per month. The
MCP is reported once per month for services performed in an outpatient setting that are
related to the patients’ ESRD.
The physician or practitioner who provides the complete assessment, establishes the
patient’s plan of care, and provides the ongoing management is the physician or
practitioner who submits the bill for the monthly service.
a. Month defined.
For purposes of billing for physician and practitioner ESRD related services, the term
‘month’ means a calendar month. The first month the beneficiary begins dialysis
treatments is the date the dialysis treatments begin through the end of the calendar month.
Thereafter, the term ‘month’ refers to a calendar month.
b. Determination of the age of beneficiary.
The beneficiary’s age at the end of the month is the age of the patient for determining the
appropriate age related ESRD-related services code.
c. Qualifying Visits Under the MCP
• 	General policy.

Visits must be furnished face-to-face by a physician, clinical nurse specialist, nurse
practitioner, or physician’s assistant.
• 	Visits furnished by another physician or practitioner (who is not the MCP
physician or practitioner).
The MCP physician or practitioner may use other physicians or qualified nonphysician
practitioners to provide some of the visits during the month. The MCP physician or
practitioner does not have to be present when these other physicians or practitioners
provide visits. In this instance, the rules are consistent with the requirements for hospital
split/shared evaluation and management visits. The non-MCP physician or practitioner
must be a partner, an employee of the same group practice, or an employee of the MCP
physician or practitioner. For example, the physician or practitioner furnishing visits
under the MCP may be either a W-2 employee or 1099 independent contractor.
When another physician is used to furnish some of the visits during the month, the
physician who provides the complete assessment, establishes the patient’s plan of care,
and provides the ongoing management should bill for the MCP service.
If the nonphysician practitioner is the practitioner who performs the complete assessment
and establishes the plan of care, then the MCP service should be billed under the PIN of
the clinical nurse specialist, nurse practitioner, or physician assistant.
• 	Residents, interns and fellows.
Patient visits by residents, interns and fellows enrolled in an approved Medicare graduate
medical education (GME) program may be counted towards the MCP visits if the
teaching MCP physician is present during the visit.
• 	Patients designated/admitted as hospital observation status.
ESRD-related visits furnished to patients in hospital observation status that occur on or
after January 1, 2005, should be counted for purposes of billing the MCP codes. 	Visits
furnished to patients in hospital observation status are included when submitting MCP
claims for ESRD-related services.
• 	ESRD-related visits furnished to beneficiaries residing in a SNF.
ESRD-related visits furnished to beneficiaries residing in a SNF should be counted for
purposes of billing the MCP codes.
• 	SNF residents admitted as an inpatient.

Inpatient visits are not counted for purposes of the MCP service. If the beneficiary
residing in a SNF is admitted to the hospital as an inpatient, the appropriate inpatient visit
code should be billed.
140.1.1 - Payment for Managing Patients on Home Dialysis
(Rev. 2269, Issued: 08-05-11, Effective: 01-01-11, Implementation: 11-07-11)
Physicians and practitioners managing ESRD patients who dialyze at home are paid a
single monthly rate based on the age of the beneficiary. The MCP physician (or
practitioner) must furnish at least one face-to-face patient visit per month for the home
dialysis MCP service. Documentation by the MCP physician (or practitioner) should
support at least one face-to-face encounter per month with the home dialysis patient.
Medicare contractors may waive the requirement for a monthly face-to-face visit for the
home dialysis MCP service on a case by case basis, for example, when the nephrologist’s
notes indicate that the physician actively and adequately managed the care of the home
dialysis patient throughout the month. The management of home dialysis patients who
remain a home dialysis patient the entire month should be coded using the ESRD-related
services for home dialysis patients HCPCS codes.
a. 	Month defined.
For purposes of billing for physician and practitioner ESRD related services, the term
‘month’ means a calendar month. The first month the beneficiary begins dialysis
treatments is the date the dialysis treatments begin through the end of the calendar month.
Thereafter, the term ‘month’ refers to a calendar month.
b. 	Qualifying Visits under the MCP
• 	General policy.
Visits must be furnished face-to-face by a physician, clinical nurse specialist, nurse
practitioner, or physician’s assistant.
• 	Visits furnished by another physician or practitioner (who is not the MCP
physician or practitioner).
The MCP physician or practitioner may use other physicians or qualified nonphysician
practitioners to provide the visit(s) during the month. The MCP physician or practitioner
does not have to be present when these other physicians or practitioners provide visit(s).
The non-MCP physician or practitioner must be a partner, an employee of the same group
practice, or an employee of the MCP physician or practitioner. For example, the
physician or practitioner furnishing visits under the MCP may be either a W-2 employee
or 1099 independent contractor.

When another physician is used to furnish some of the visits during the month, the
physician who provides the complete assessment, establishes the patient’s plan of care,
and provides the ongoing management should bill for the MCP service.
If the nonphysician practitioner is the practitioner who performs the complete assessment
and establishes the plan of care, then the MCP service should be billed under the PIN of
the clinical nurse specialist, nurse practitioner, or physician assistant.
• 	Residents, interns and fellows.
Patient visits by residents, interns and fellows enrolled in an approved Medicare graduate
medical education (GME) program may be counted towards the MCP visits if the
teaching MCP physician is present during the visit.
140.1.2 - Patients Who Switch Modalities (Center to Home and Vice
Versa)
(Rev. 1999, Issued: 07-09-10, Effective: 01-01-11, Implementation: 01-03-11)
If a home dialysis patient receives dialysis in a dialysis center or other outpatient facility
during the month, the MCP physician or practitioner is paid the management fee for the
home dialysis patient and cannot bill the ESRD-related services codes for managing
center based patients.
This situation should be coded using the ESRD–related services codes for a home
dialysis patient per full month. Physicians and practitioners should use the ESRD–related
services codes for a home dialysis patient per full month when billing for outpatient
ESRD-related services when a home dialysis patient receives dialysis in a dialysis center
or other outpatient facility during the month.
Physicians and practitioners should use the ESRD–related services codes for a home
dialysis patient per full month for patients that switch modalities regardless of whether
the ESRD beneficiary went from home dialysis to center-based dialysis, or vice versa,
and regardless of the proportion of the month that the beneficiary was receiving each
modality.
140.2 - Payment for ESRD-related services (Per Diem)
(Rev. 1456, Issued: 02-22-08, Effective: 03-24-08, Implementation: 03-24-08)
Physicians and practitioners may receive payment for managing patients on dialysis for
less than a full month of care in specific circumstances as discussed in this section.
Payment for ESRD related services, less than a full month, is paid on a per diem basis.
Per diem ESRD-related services should be coded using the ESRD related services (less
than full month), per day HCPCS codes for ESRD-related services furnished in the
situations described below.
• 	Home dialysis patients (less than full month);

• 	Transient patients – Patients traveling away from home (less than full month);
• 	Partial month where there was one or more face-to-face visits without a complete
assessment of the patient and the patient was either hospitalized before a complete
assessment was furnished, dialysis stopped due to death, or the patient had a
transplant.
• 	Patients who have a permanent change in their MCP physician during the month.
The ESRD-related services (less than full month), per day HCPCS codes should only be
used for the circumstances described above. The per diem codes may not be used for a
full month when a complete monthly assessment is not furnished.
140.2.1 - Guidelines for Physician or Practitioner Billing -- (Per Diem)
(Rev. 3311, Issued: 08-06-15, Effective: 01-01-15, Implementation: 09-08-15)
A. Home dialysis, transient patient and partial month
When submitting claims for ESRD-related services (less than full month) per day, the
physician or practitioner should specify the number of days he or she was responsible for
the beneficiary’s outpatient ESRD-related services during the month.
Only one code should be used to report the daily management of home dialysis patients,
transient patients, and for partial month scenarios. For example, if a home dialysis
patient receives dialysis at home for two weeks and is hospitalized for the remainder of
the month, then 14 units of the age appropriate ESRD-related per day code is billed. The
MCP service is not billed.
For transient patients, the physician or practitioner responsible for the transient patient’s
ESRD-related care should bill the appropriate ESRD-related services, per day code. Only
the physician or practitioner responsible for the traveling ESRD patient’s care is
permitted to bill for ESRD-related services using the per diem ESRD-related services
HCPCS codes.
For home dialysis patients (less than full month) if the MCP physician or practitioner
furnishes a complete monthly assessment of the ESRD beneficiary and at least one face-
to-face patient visit during the month, he or she should bill for the age appropriate home
dialysis MCP service. For example, if a home dialysis patient was hospitalized during
the month and at least one face-to-face outpatient visit and complete monthly assessment
was furnished, the MCP physician or practitioner should bill for the full home dialysis
MCP service.
For partial month scenarios resulting from hospitalization, kidney transplant, or the
patient expired, if the MCP physician or practitioner furnished a complete monthly

assessment of the patient, he or she should bill using the age appropriate MCP service
that reflects the number of visits furnished during the month.
Example #1: An ESRD beneficiary was hospitalized on the tenth through the twentieth
day of the month. On the third day of the month, the MCP physician or practitioner
furnished a face-to-face visit including a complete assessment and a subsequent
outpatient visit on the twenty-fifth day of the month. While the patient was hospitalized,
an inpatient ESRD-related visit was furnished.
In this scenario, the MCP physician or practitioner may bill for the appropriate outpatient
MCP service based on the age of the beneficiary and number of visits furnished during
the month. The physician or practitioner who furnished the inpatient visit may bill for the
appropriate inpatient ESRD-related service code.
Example #2: An ESRD beneficiary vacationing in Florida is away from his or her home
dialysis site from August fifteenth through September seventh. On August tenth, the
MCP physician furnishes a face-to-face visit. For the month of September, the MCP
physician furnishes a visit on the ninth and a subsequent visit on the twenty-fifth of the
month. A physician in Florida is responsible for the beneficiary’s ESRD-related care
from August fifteenth through September seventh.
In this scenario, the physician or practitioner responsible for the transient patient’s
ESRD-related care bills sixteen units of the age appropriate ESRD-related services for
dialysis less than full month, per day code for the month of August and seven units of the
per day code for the month of September. The MCP physician bills the MCP service
with one visit for the month of August and the MCP service with two to three visits for
the month of September.
If the transient beneficiary is under the care of a physician or practitioner other than his or
her regular MCP physician for an entire calendar month, the physician or practitioner
responsible for the transient patient’s ESRD-related care must furnish a complete
assessment and bill for ESRD-related services under the MCP.
B. Patient has a permanent change in their MCP physician during the month
ESRD-related services (less than full month) per day HCPCS codes should be billed in
situations where an ESRD beneficiary permanently changes their MCP physician during
the month. For example, the new MCP physician has the ongoing responsibility for the
evaluation and management of the patient’s ESRD-related care and is not part of the
same group practice or an employee of the first MCP physician. The new MCP physician
should use the appropriate per diem HCPCS code when submitting claims for ESRD-
related services for the remainder of the month, when the first MCP physician furnishes a
complete assessment of the beneficiary during the month.
If the first MCP physician does not furnish a complete assessment of the patient during
the month the patient permanently changes their MCP physician, the new MCP physician

may bill for the appropriate MCP service based on the age of the patient and number of
visits furnished and the first MCP physician may bill the appropriate per day HCPCS
code as discussed above.
Example: An ESRD patient residing in Virginia Beach, Virginia for the first 20 days of
the month, moves to Atlanta, Georgia. As a result, a different physician or practitioner is
now responsible for the ongoing management of the beneficiary’s ESRD-related care.
Both the first and second MCP physician furnishes a visit with a complete assessment of
the patient and establishes a monthly plan of care. In this situation, the first MCP
physician should bill the MCP service that reflects the number of visits he or she
furnished during the month and the second MCP physician should bill the age appropriate
per day ESRD-related services code. Thereafter, the new MCP physician would bill for
the MCP service.
In this example, if the first MCP physician does not provide a complete assessment of the
patient, he or she should bill 20 units of the per day ESRD-related services code, but may
not bill for the MCP during the month the beneficiary permanently changes his or her
MCP physician. The second MCP physician may bill for the MCP service after
furnishing a complete monthly assessment of the ESRD beneficiary that includes
establishing the patient’s plan of care and at least one face-to-face visit.
140.3 - Data Elements Required on Claim for Monthly Capitation
Payment
(Rev. 10236, Issued: 07-31-2020, Effective: 08-31-2020, Implementation: 08-31-2020)
On Form CMS-1500
A. Elements 1 through 13 of the Form CMS-1500 are completed in accordance with the
regular instructions
B. Elements 14 through 20 of the Form CMS-1500 are omitted.
C. Element 32 must contain the name and address of the facility involved with the
patient’s maintenance care or training, and 32a must contain the facility NPI.
D. Element 21 must show the diagnosis. Indicate in Element 19 whether the patient is in
training for self-dialysis.
E. Element 24A must show the dates of service during the month that are included in the
MCP. The period includes the full calendar month the MCP physician or practitioner
was responsible for the beneficiary's ESRD related care.
For the first month the beneficiary begins dialysis treatments, the first date the dialysis
treatments begin through the end of the calendar month should be used as the dates of
service.

For outpatient ESRD-related services furnished for less than a full month, per day as
discussed in 140.2 (e.g. transient patients, partial month due to hospitalization, transplant,
or death), the first and last date the physician or practitioner was responsible for the
beneficiary’s ESRD-related care during the month should be used as the dates of service.
Non-continuous dates should be billed on separate claim lines, (e.g. 1/1/08 – 1/7/08 and
1/20/08 – 1/31/08). A separate monthly claim should be submitted when the duration of
ESRD-related services, per day, overlaps two different months as discussed in 140.21
(e.g. August 15 - September 7).
F. The remainder of the Form CMS-1500 is completed in accordance with the general
instructions.
On ASC X12 Professional Format
Instructions for completing the ASC X12 837 professional claim format are in the related
implementation guide, available on the official Washington Publishing Company
website.
140.4 - Controlling Claims Paid Under the Monthly Capitation Payment
Method
(Rev. 1456, Issued: 02-22-08, Effective: 03-24-08, Implementation: 03-24-08)
Contractors must be able to identify dialysis patient history records and physicians who
furnish services related to dialysis.
In processing claims reimbursed under this method, contractors must assure that:
• 	Only one monthly payment is made for any renal disease patient per month;
• 	The MCP payment is made after the month has passed; i.e., do not pay the MCP
in advance of the services actually furnished;
• 	The payment amount is based on the age of the beneficiary and the number of
visits furnished during a calendar month (center based patients);
• 	Duplicate charges billed as a duplicate MCP or as separate charges for services
covered by the monthly payment are denied;
• 	Where several physicians or practitioners form a team to provide the monthly
continuity of services to a group of patients, make only one monthly payment for
each patient.
• 	Concurrent services by another physician or practitioner who is part of the MCP
practice team are covered and reimbursed separately only for services not
included in the MCP (e.g. a visit not related to managing the patients ESRD); and

• 	If payment for inpatient hospital services is claimed in addition to the MCP, and
assignment is taken only with respect to the MCP, follow the instructions in Pub.
100-04, chapter 1, §30.3.12.3.
Contractors must conduct periodic review of a randomly selected sample of patients’
histories with reimbursement under the MCP method, to evaluate whether the number of
and types of services billed separately from the MCP are appropriate considering the
individual patient’s medical condition.
Make separate payments for medically necessary services that are included or bundled
into the MCP (e.g., test interpretations) when furnished by physicians other than the
monthly capitation payment physician. According to the Renal Physicians Association,
these test interpretations are billed separately only in rare circumstances.
150 - Physician’s Self-Dialysis Training Services
(Rev. 1, 10-01-03)
Pay physicians for physician training services furnished to dialysis patients undergoing
training by a flat fee of $500 (subject to the deductible and coinsurance requirements) for
each patient under the physician’s supervision during the training course. Pay this upon
completion of the training course in addition to the monthly capitation payment for
physician’s maintenance dialysis services. If the training period is not completed, such as
in instances where the patient can no longer be trained, prorate the training rate in
proportion to the number of training treatments completed, but not to exceed $500. For
purposes of this pro-ration, consider 25 training treatments as a complete course of
training. Therefore, for an incomplete training course, pay the physician for the training
services based on an amount of $20 per treatment times the number of treatments
completed. This rule applies to all modes of treatment, including CAPD.
Occasionally, it is necessary to furnish additional training to an ESRD self-dialysis
beneficiary after the initial training course is completed; e.g., because of a change from
hemodialysis to peritoneal dialysis, a change in equipment. The amount of additional
training required depends upon the transferability of the skills the patient has already
learned; subsequent training would normally be very limited. Physicians’ training
services furnished during subsequent training of an ESRD beneficiary are covered and
reimbursed in addition to the initial training fee.
Subsequent training sessions that are reimbursable under this rule must be distinguished
from the ongoing services for which the original training fee is considered payment in
full; e.g., answering the patient’s questions arising after home dialysis has begun about
the machine the patient has already been trained to use. No additional payment is made
after the initial training course unless the subsequent training is required because of a
change from the patient’s treatment machine to a machine that he had not been trained to
use in the initial training course, a change in the type of dialysis, or a change in setting or
dialysis partner.

160 - Payment for Physician’s Services Furnished to Dialysis Inpatients
(Rev. 1, 10-01-03)
The following instructions cover physicians services to inpatients for all types of dialysis
patients; e.g., hemodialysis, intermittent peritoneal dialysis (IPD), continuous ambulatory
peritoneal dialysis (CAPD), and continuous cycling peritoneal dialysis (CCPD). Note that
the hospitalization need not be related to dialysis.
Payment is made on the claim only if the place of service on the claims is inpatient
hospital. See §170 for proper HCPCS coding.
160.1 - Determining Whether Physician Services Furnished on Day of
Dialysis
(Rev. 1, 10-01-03)
If the patient is admitted to a hospital to receive dialysis for a reason not related to the
patient’s ESRD condition (e.g., there was no space available in the dialysis unit), the
dialysis is covered as an outpatient service. In this case, A/B MACs (B) do not pay
separately for any physicians’ ESRD services because these services are covered under
the physician’s MCP or under the add-on to the hospital’s composite rate for physicians
under the initial method. (See §130.1 for a description of the initial method.)
160.2 - Physicians’ Services Furnished on Day of Dialysis
(Rev. 1, 10-01-03)
B3-15062.1
Supervision or direction of a dialysis treatment by a physician does not ordinarily meet
the requirements for physicians’ services and, therefore, is not paid for as such under the
fee schedule. However, physicians are responsible for the medical care and treatment of
the dialysis patients. Physicians’ services furnished to those patients that meet the
requirements and are medically necessary are covered. The hospital medical record must
document the services furnished and the medical reasons for them.
Generally, claims from the physician receiving a procedure code payment for additional
services furnished to the same patient on the day of dialysis must be reviewed by medical
staff prior to payment. Follow §170.B for dialysis and evaluation and management
services performed on the same day.
Payment in addition to the procedure code payment is made only if the service is not
related to the treatment of the patient’s ESRD, and the service was not, and could not
have been, furnished during the dialysis treatment. However, an exception to this rule is
physicians’ surgical services; e.g., catheter insertion. Physicians’ surgical services are
generally billed under the appropriate procedure code for payment. If more than one
physician furnishes care to the same dialysis patient, follow the usual coverage rules on
concurrent care.

160.3 - Physicians’ Services Furnished on Non-Dialysis Days
(Rev. 1, 10-01-03)
Physicians’ services furnished on non-dialysis days are coded and paid under the same
rules as any other physicians’ services when non-renal related services are furnished.
Renal-related services may also be paid if the physician chooses to prorate the MCP
payment. Generally, these services are the physicians’ hospital visits and are coded and
paid as such.
160.4 - Requirements for Payment
(Rev. 1, 10-01-03)
A. 	General
When paying for physicians’ services furnished to dialysis inpatients, whether they are
ESRD patients or acute dialysis patients, there are several factors to consider.
• 	The payment must be for covered physicians’ services;
• 	The services must be medically necessary; and
• 	The payment for the services must be reasonably related to the nature of the
services actually furnished.
B. 	Physicians’ Services - Criteria for Procedure Codes
The procedure code covers the full range of physicians’ renal-related services furnished
during an inpatient dialysis treatment.
In order to be paid on the basis of a procedure code, the physician must have been
physically present with the patient at some time during the course of the dialysis, and the
medical record (e.g., the physician’s progress note or the nurse’s notes in the patient’s
hospital medical record) must document this.
If the physician visits the dialysis inpatient on a dialysis day, but not during the dialysis
treatment, do not pay the physician on the basis of a procedure code. The nature of these
services is the same as physicians’ services furnished to any inpatient during a hospital
visit. Therefore, use the same hospital visit codes that apply to any other physicians
treating hospital inpatients.
Physicians’ services furnished to patients who are dialyzed as inpatients because there is
no room in the outpatient dialysis units are covered under the MCP, and physicians are
not paid amounts in addition to or in place of the MCP.

Effective January 1, 1995, all evaluation and management services provided on the same
day as inpatient dialysis codes should be denied without review with the exception of
CPT codes 99221-99223, 99251-99255, and 99238. These codes may be billed with
modifier “-25” and reviewed for possible allowance if the evaluation and management
service is unrelated to the treatment of ESRD and was not and could not have been
furnished during the dialysis treatment.
C. 	Peritoneal Dialysis
Peritoneal dialysis is typically furnished in extended periods. For example, CAPD is
continuous, and the patient may actually be dialyzed seven days per week. IPD may be
furnished in extended periods of 30 hours or more. The fact that a patient is dialyzed
continuously for an extended period does not justify payment in excess of the average
weekly allowance made for hemodialysis services. Payment in excess of this amount is
made only if it is determined that the same kind and intensity of physicians’ hemodialysis
treatment beyond the number ordinarily furnished in a 7-day period, and the patient’s
condition was similar to that of a hemodialysis patient who would have required these
additional services.
170 - Billing Physician Dialysis Services (codes 90935 - 90999) and
Related Payment
(Rev. 1, 10-01-03)
Except when the MCP applies claims for physicians’ inpatient dialysis services furnished
to ESRD or acute dialysis patients are processed using physicians’ inpatient dialysis
services procedure codes 90935, 90937, 90945, and 90947. All A/B MACs (B) must use
these codes for these services.
A/B MACs (B) make payment on the basis of ESRD procedure codes, i.e., codes 90935,
90937, 90945, or 90947, only if the place of service on the claim is inpatient hospital.
This is because all physicians’ outpatient renal-related services are included in payment
made under the monthly capitation payment.
A. ESRD Monthly Capitation Payments
Effective January 1, 1995, monthly capitation payments are made under the physician fee
schedule. For their adult patients, physicians may bill either the monthly code (CPT code
90921) or the daily code (CPT code 90922) with units that represent the number of days
in a single month, but may not bill both.
To bill for a month of services for pediatric patients, providers should bill the appropriate
monthly code (CPT codes 90919, 90920, or 90921). To bill for less than a month of
service, providers bill the appropriate daily code (CPT codes 90923-90925) and units that
represent the number of days. Providers may bill either the monthly code or the daily
code, but not both. Since billing is done at the conclusion of the month, the patient’s age
at the end of month is the age of the patient for billing purposes.

B - Inpatient and Outpatient Dialysis Services On Same Date As An Evaluation and
Management Service
CPT codes 90935 and 90937 are used to report inpatient ESRD hemodialysis and
outpatient hemodialysis performed on non-ESRD patients (e.g., patients in acute renal
failure requiring a brief period of dialysis prior to recovery). CPT codes 90945 and 90947
are used to report all non-hemodialysis procedures. All four of these codes include
payment for any evaluation and management services related to the patients renal disease
that are provided on the same date as the dialysis service. Therefore, payment for all
evaluation and management services is bundled into the payment for 90935, 90937,
90945, and 90947, except for the following evaluation and management services which
may be reported on the same date as a dialysis service with the use of the –25 modifier
and they are significant and separately identifiable and met any medical necessity
requirements:
99201-99205 	Office or Other Outpatient Visit for a New Patient
99211-99215 	Office or Other Outpatient Visit for an Established Patient
99221-99223 	Initial Hospital Care for a New or Established Patient
99238-99239 	Hospital Discharge Day Management Services
99241-99245 	Office or Other Outpatient Consultations, New or Established
Patient
99251-99255 	Initial Inpatient Consultations, New or Established Patient
99291-99292 	Critical Care Services
In the absence of one of these codes being reported with the –25 modifier and meeting
the other requirements listed above, pay only the dialysis service and deny the evaluation
and management service. Furthermore, payment is not allowed for more than one dialysis
service per day.
180 - Noninvasive Studies for ESRD Patients - Facility and Physician
Services
(Rev. 3650, Issued: 11-10-16, Effective: 02-10-17, Implementation: 02-10-17)
For Medicare coverage of noninvasive vascular studies, see the Medicare Benefit Policy
Manual, Chapter 11.
For dialysis to take place there must be a means of access so that the exchange of waste
products may occur. As part of the dialysis treatment, ESRD facilities are responsible for
monitoring access, and when occlusions occur, either declot the access or refer the patient
for appropriate treatment. Procedures associated with monitoring access involve taking
venous pressure, aspirating thrombus, observing elevated recirculation time, reduced urea
reduction ratios, or collapsed shunt, etc. All such procedures are covered under the
composite rate.

ESRD facilities may not monitor access through noninvasive vascular studies such as
duplex and Doppler flow scans and bill separately for these procedures. Noninvasive
vascular studies are not covered as a separately billable service if used to monitor a
patient’s vascular access site.
Medicare pays for the technical component of the procedure in the composite payment
rate.
Where there are signs and symptoms of vascular access problems, Doppler flow studies
may be used as a means to obtain diagnostic information to permit medical intervention
to address the problem. Doppler flow studies may be considered medically necessary in
the presence of signs or symptoms of possible failure of the ESRD patient’s vascular
access site, and when the results are used in determining the clinical course of the
treatment for the patient.
The only Current Procedural Terminology (CPT) billing code for noninvasive vascular
testing of a hemodialysis access site is 93990. A/B MACs (B) must deny separate billing
of the technical component of this code if it is performed on any patient for whom the
ESRD composite rate for dialysis is being paid, unless there is appropriate medical
indication of the need for a Doppler flow study.
When a dialysis patient exhibits signs and symptoms of compromise to the vascular
access site, Doppler flow studies may provide diagnostic information that will determine
the appropriate medical intervention. Medicare considers a Doppler flow study medically
necessary when the beneficiary’s dialysis access site manifests signs or symptoms
associated with vascular compromise, and when the results of this test are necessary to
determine the clinical course of treatment.
Examples supporting the medical necessity for Doppler flow studies include:
a. 	Elevated dynamic venous pressure >200mm HG when measured during dialysis
with the blood pump set on a 200cc/min.,
b. 	Access recirculation of 12 percent or greater,
c. 	An otherwise unexplained urea reduction ration <60 oercebtm abd
d. 	An access with a palpable “water hammer” pulse on examination, (which implies
venous outflow obstruction).
Unless the documentation is provided supporting the necessity of more than one study,
Medicare will limit payment to either a Doppler flow study or an arteriogram
(fistulogram, venogram), but not both.
An example of when both studies may be clinically necessary is when a Doppler flow
study demonstrates reduced flow (blood flow rate less than 800cc/min or a decreased

flow of 25 percent or greater from previous study) and the physician requires an
arteriogram to further define the extent of the problem. The patient’s medical record(s)
must provide documentation supporting the need for more than one imaging study.
This policy is applicable to claims from ESRD facilities and all other sources, such as
independent diagnostic testing facilities, and hospital outpatient departments.
A/B MACs (B) shall develop LMRP for Doppler flow studies if this service meets the
criteria listed in the Medicare Program Integrity Manual, Chapter 1. This provides
guidance to contractors on the scope, purpose, and meaning of LMRP.
The professional component of the procedure is included in the monthly capitation
payment (MCP) (See §140 above.) The professional component should be denied for
code 93990 if billed by the MCP physician. Medically necessary services that are
included or bundled into the MCP (e.g., test interpretations) are separately payable when
furnished by physicians other than the MCP physician.
The contractor shall use the following remittance advice messages and associated codes
when rejecting/denying claims under this policy. This CARC/RARC combination is
compliant with CAQH CORE Business Scenario Four.
Group Code: CO
CARC: 24
RARC: N/A
MSN:16.32
Billing for monitoring of hemodialysis access using CPT codes for noninvasive vascular
studies other than 93990 is considered a misrepresentation of the service actually
provided and contractors will consider this action for fraud investigation. They will
conduct data analysis on a periodic basis for noninvasive diagnostic studies of the
extremities (including CPT codes 93922, 93923, 93924, 93925, 93926, 93930, 93931,
93965, 93970, 93971). Contractors should handle aberrant findings under normal
program safeguard processes by taking whatever corrective action is deemed necessary.
190 - Appeal Rights for Denied Claims
For appeal rights if the claim is denied see Chapter 29.
200 – Utilization of REMIS for A/B MAC (B) Claims Adjudication
(Rev. 82, 02-06-04)
Renal Management Information System (REMIS) determines the Medicare coverage
periods for ESRD patients and serves as the primary mechanism to store and access
information in the ESRD Program Management and Medical Information System
Database. REMIS is used by CMS and the renal community to monitor the Medicare

status, transplant activities, dialysis activities, and Medicare utilization of ESRD patients
and their Medicare provider.
The following fields are contained in the (Dialysis) auxiliary file:
• 	ESRD Coverage Start Date (The date on which the beneficiary is entitled to
Medicare, in some part, because of a diagnosis of End Stage Renal Disease.)
• 	ESRD Coverage Source Code (The source of the information that establishes
Medicare-based End-Stage Renal Disease Coverage; A= Part A and Dialysis
Training, B= Part A and Dialyzing (No 3 month wait), C= Part A and 3 months
after Dialysis, D= Part A and Functioning Transplant, E= Part A and Month of
Pre-Transplant Stay, F= Part A and ESRD (Verified Source), Blank= No ESRD
Involvement.)
• 	ESRD Coverage Termination Date (The date on which the beneficiary is no
longer entitled to Medicare under ESRD Provisions.)
• 	ESRD Coverage Termination Reason (A code that indicates the reason
Medicare-based End-Stage Renal Disease Coverage was terminated; codes: A=
Month of transplant plus 36 months, B=Last month of chronic dialysis, C= Part A
termination, D=Death, E=ESRD ended: other verified source.)
• 	ESRD Dialysis Start Date (A date that indicates when ESRD dialysis started.)
• 	ESRD Dialysis Stop Date (A date that indicates when ESRD dialysis ended.)
• 	ESRD Transplant Start Date (A date that indicates when a kidney transplant
operation occurred.)
• 	ESRD Transplant Stop Date (A date that indicates when a kidney transplant
failed.)
The above data elements are in CWF and stored in the dialysis auxiliary file, which can
be used to identify a beneficiary’s ESRD eligibility. This data source will assist carriers
in reviewing overpayment determination and accurately processing claims.

Transmittals Issued for this Chapter
Rev # 	Issue Date 	Subject 	Impl
Date
CR #
R13740CP 	04/17/2026 Completion of Changes to Remove Reliance
on the AX Modifier to Accurately Pay End
Stage Renal Disease (ESRD) Claims
07/06/2026 	14354
R13588CP 	01/28/2026 Completion of Changes to Remove Reliance
on the AX Modifier to Accurately Pay End
Stage Renal Disease (ESRD) Claims-
Rescinded and replaced by Transmittal
13740
07/06/2026 	14354
R12979CP 	11/22/2024 Implementation of System Changes for the
End Stage Renal Disease (ESRD)
Prospective Payment System (PPS) and
Payment for Renal Dialysis Services
Furnished to Individuals with Acute Kidney
Injury (AKI) for Calendar Year (CY) 2025
01/06/2024 	13686
R12957CP 	11/08/2024 Implementation of System Changes for the
End Stage Renal Disease (ESRD)
Prospective Payment System (PPS) and
Payment for Renal Dialysis Services
Furnished to Individuals with Acute Kidney
Injury (AKI) for Calendar Year (CY) 2025
Rescinded and replaced by Transmittal
12979
01/06/2025 	13686
07/18/2024 Implementation of System Changes for the
End Stage Renal Disease (ESRD)
Prospective Payment System (PPS) and
Payment for Renal Dialysis Services
Furnished to Individuals with Acute Kidney
Injury (AKI) for Calendar Year (CY) 2025
(SENSITIVE CONTROVERSIAL-DO
NOT POST) - Rescinded and replaced by
Transmittal 12957
01/06/2025 	13686
R4202CP 	01/18/2019 	Update to Pub. 100-04 Chapters 8, 20, and
24 to Provide Language-Only Changes for
the New Medicare Card Project
02/19/2019 	10964
R4105CP 	08/03/2018 	System Changes to Implement Epoetin Alfa
Biosimilar, Retacrit for End Stage Renal
01/07/2019 	10839

Rev # 	Issue Date 	Subject 	Impl
Date
CR #
Disease (ESRD) and Acute Kidney Injury
(AKI) Claims
R4010CP 	03/23/2018 	Revisions to Medicare Claims Processing
Manual for End Stage Renal Disease
06/26/2018 	10541
R3650CP 	11/10/2016 	Updates to Pub. 100-04, Chapters 8, 13 and
14 to Correct Remittance Advice Messages
02/10/2016 	9841
R3311CP 	08/06/2015 	End Stage Renal Disease (ESRD) Home
Dialysis Policy
09/08/2015 	9265
R3139CP 	12/02/2014 	Implementation of Changes in the End-
Stage Renal Disease Prospective Payment
System (ESRD PPS) for Calendar Year
(CY) 2015
01/05/2015 	8978
R3125CP 	11/14/2014 	Implementation of Changes in the End-
Stage Renal Disease Prospective Payment
System (ESRD PPS) for Calendar Year
(CY) 2015 – Rescinded and replaced by
Transmittal 3139
01/05/2015 	8978
R3116CP 	11/06/2014 	Elimination of the 50/50 Payment Rule for
Laboratory Services on End Stage Renal
Disease (ESRD) Claims
04/06/2015 	8957
R3053CP 	08/28/2014 	Update to Pub. 100-04, Chapters 7 and 8 to
Provide Language-Only Changes for
Updating ICD-10 and ASC X12
09/30/2014 	8579
R2905CP 	03/14/2014 	Update to Pub. 100-04, Chapters 7 and 8 to
Provide Language-Only Changes for
Updating ICD-10 and ASC X12 –
Rescinded and replaced by Transmittal 3053
10/01/2014 	8579
R2839CP 	12/13/2013 	Implementation of Changes in the End-
Stage Renal Disease Prospective Payment
System (ESRD PPS) for Calendar Year
(CY) 2014
01/06/2014 	8472
R2831CP 	11/29/2013 	Implementation of Changes in the End-
Stage Renal Disease Prospective Payment
System (ESRD PPS) for Calendar Year
01/06/2014 	8472

Rev # 	Issue Date 	Subject 	Impl
Date
CR #
(CY) 2014 – Rescinded and replaced by
Transmittal 2839
R2688CP 	04/26/2013 	Reporting End Stage Renal Disease (ESRD)
Drugs Administered Through the Dialysate
07/01/2013 	8256
R2545CP 	01/31/2013 	Changes Applicable to the Billing of Drugs
on ESRD Claims
07/012013 	8174
R2582CP 	11/02/2012 	New Erythropoietin Stimulating Agent
(ESA) Peginesatide Requirements for End
Stage Renal Disease (ESRD)
04/01/2013 	8050
R2577CP 	11/01/2012 	Update to the Fiscal Intermediary Shared
Systems (FISS) for the End Stage Renal
Disease (ESRD) Quality Incentive Program
(QIP) Adjustments for Children’s Hospitals
04/01/2013 	8066
R2588CP 	11/05/2012 	Implementation of Changes to the End-
Stage Renal Disease (ESRD) Prospective
Payment System (PPS) Consolidated Billing
Requirements and a Clarification of Outlier
Services for Calendar Year 2013
01/07/2013 	7869
R2504CP 	08/02/2012 	Implementation of Changes to the End-
Stage Renal Disease (ESRD) Prospective
Payment System (PPS) Consolidated Billing
Requirements and a Clarification of Outlier
Services for Calendar Year 2013 –
Rescinded and replaced by Transmittal 2588
01/07/2013 	7869
R2361CP 	11/25/2011 	Clarification and Revisions for Claims
Submitted for End Stage Renal Disease
(ESRD) Patients
04/02/2012 	7593
R2347CP 	11/18/2011 	Recoupment of Incorrect Payments Made
Under the End Stage Renal Disease (ESRD)
Prospective Payment System (PPS) for
Low-Volume Payment Adjustment
01/03/2012 	7626
R2335CP 	10/28/2011 	Clarification and Revisions for Claims
Submitted for End Stage Renal Disease
(ESRD) Patients – Rescinded and replaced
by Transmittal 2361
04/02/2012 	7593

Rev # 	Issue Date 	Subject 	Impl
Date
CR #
R2311CP 	09/23/2011 	Implementation of the MIPPA 153c End
Stage Renal Disease (ESRD) Quality
Incentive Program (QIP) and Other
Requirements for ESRD Claims
01/03/2012 	7460
R2281CP 	08/19/2011 	Implementation of Changes to the End
Stage Renal Disease (ESRD) Prospective
Payment System (PPS) Outlier Payment
Policy and Changes to the ESRD PPS
Consolidated Billing Requirements for
Laboratory Services Furnished in a Hospital
Emergency Room or Department
01/03/2012 	7471
R2269CP 	08/05/2011 	Clarification of Payment for ESRD-Related
Services Under the Monthly Capitation
Payment
11/07/2011 	7520
R2266CP 	07/29/2011 	Implementation of Changes to the End
Stage Renal Disease (ESRD) Prospective
Payment System (PPS) Outlier Payment
Policy and Changes to the ESRD PPS
Consolidated Billing Requirements for
Laboratory Services Furnished in a Hospital
Emergency Room or Department –
Rescinded and replaced by Transmittal
2281.
01/03/2012 	7471
R2262CP 	07/29/2011 	Implementation of the MIPPA 153c End
Stage Renal Disease (ESRD) Quality
Incentive Program (QIP) and Other
Requirements for ESRD Claims –
Rescinded and replaced by Transmittal 2311
01/03/2012 	7460
R2195CP 	04/22/2011 	End Stage Renal Disease (ESRD) Low
Volume Adjustment and Establishing
Quarterly Updates to the ESRD Prospective
Payment System (PPS)
10/03/2011 	7388
R2134CP 	01/14/2011 	End Stage Renal Disease (ESRD)
Prospective Payment System (PPS) and
Consolidated Billing for Limited Part B
Services
01/03/2011 	7064

Rev # 	Issue Date 	Subject 	Impl
Date
CR #
R2094CP 	11/17/2010 	End Stage Renal Disease (ESRD)
Prospective Payment System (PPS) and
Consolidated Billing for Limited Part B
Services – Rescinded and replaced by
Transmittal 2134
01/03/2011 	7064
R2033CP 	08/20/2010 	End Stage Renal Disease (ESRD)
Prospective Payment System (PPS) and
Consolidated Billing for Limited Part B
Services - Rescinded and replaced by
Transmittal 2094
01/03/2011 	7064
R1999CP 	07/09/2010 	ESRD Home Dialysis MCP 	01/03/2011 	7003
R1932CP 	03/17/2010 	Dialysis Adequacy, Infection and Vascular
Access Reporting
07/06/2010 	6782
R1898CP 	01/29/2010 	Dialysis Adequacy, Infection and Vascular
Access Reporting - Rescinded and replaced
by Transmittal 1932
07/06/2010 	6782
R1655CP 	12/31/2008 	End Stage Renal Disease (ESRD) Medicare
Claims Processing Manual Clarification
02/02/2009 	6245
R1648CP 	12/12/2008 	Implementation of Changes in End Stage
Renal Disease (ESRD) Payment for
Calendar Year 2009
01/05/2009 	6216
R1581CP 	08/29/2008 	Discarded Erythropoietin Stimulating
Agents for Home Dialysis
12/01/2008 	6133
R1503CP 	05/16/2008 	Revisions to the Billing Requirements for
ESRD-Related Epoetin Alfa (EPO) and
Darbepoetin Alfa (Aranesp) Administration
Provided During Unscheduled or
Emergency Dialysis Treatments in the
Outpatient Hospital Setting
10/06/2008 	6047
R1472CP 	03/06/2008 	Update of Institutional Claims References 	04/07/2008 	5893
R1456CP 	02/22/2008 	Manualization of Payment for Outpatient
ESRD-Related Services
03/24/2008 	5931

Rev # 	Issue Date 	Subject 	Impl
Date
CR #
R1421CP 	01/25/2008 	Update of Institutional Claims References -
Rescinded and Replaced by Transmittal
1472
04/07/2008 	5893
R1412CP 	01/11/2008 	Reporting of Hematocrit or Hemoglobin
Levels on All Claims for the Administration
of Erythropoiesis Stimulating Agents
(ESAs), Implementation of New Modifiers
for Non-ESRD Indications, and Reporting
of Hematocrit/Hemoglobin Levels on all
Non-ESRD, Non-ESA Claims Requesting
Payment for Anti-Anemia Drugs
04/07/2008 	5699
R1389CP 	12/07/2007 	Implementation of Change in End Stage
Renal Disease (ESRD) Payment for
Calendar Year 2008
01/07/2008 	5827
R1364CP 	11/02/2007 	Common Working File (CWF)
Informational Unsolicited Responses for
RDF Claims Overlapping Patient Hospital
Stays
04/07/2008 	5768
R1341CP 	09/21/2007 	New Web Site for Approved Transplant
Centers
10/22/2007 	5724
R1307CP 	07/20/2007 	Modification to the National Monitoring
Policy for Erythropoietic Stimulating
Agents (ESAs) for End-Stage Renal Disease
(ESRD) Patients Treated in Renal Dialysis
Facilities
01/07/2008 	5700
R1285CP 	07/13/2007 	Renal Dialysis Facility Line Item Billing
Requirements for Epoetin Alfa (EPO)
Submitted on End Stage Renal Disease
(ESRD) Claims
01/07/2008 	5545
R1212CP 	03/30/2007 	Requirements for Providing Route of
Administration Codes for Erythropoiesis
Stimulating Agents (ESAs)
06/29/2007 	5480
R1043CP 	08/25/2006 	Revisions to the EPO/ Aranesp Monitoring
Policy
10/02/2006 	5251

Rev # 	Issue Date 	Subject 	Impl
Date
CR #
R1041CP 	08/25/2006 	(HCPCS) for Renal Dialysis Facilities and
Hospitals Billing for End Stage Renal
Disease (ESRD) Related Epoetin Alfa
(EPO)
01/01/2007 	5216
R1007CP 	07/28/2006 	(HCPCS) for Renal Dialysis Facilities and
Hospitals Billing for End Stage Renal
Disease (ESRD) Related Epoetin Alfa
(EPO)
01/02/2007 	5216
R849CP 	02/10/2006 	Update to the ESRD Composite Payment
Rates
02/13/2006 	4291
R797CP 	12/30/2005 	Full Replacement of CR 4095, Diagnosis
Code Requirements for Method II Home
Dialysis Claims
01/30/2006 	4227
R781CP 	12/16/2005 	Revised Manual Instructions for Processing
End Stage Renal Disease Exceptions Under
the Composite Rate Reimbursement System
01/17/2006 	4188
R774CP 	12/02/2005 	Implementation of Change in End Stage
Renal Disease Payment for Calendar Year
2006
01/03/2006 	4196
R771CP 	12/02/2005 	Revisions to Pub. 100-04, Medicare Claims
Processing Manual in Preparation for the
National Provider Identifier
01/03/2006 	4181
R751CP 	11/10/2005 	National Monitoring Policy for EPO and
Aranesp for End Stage Renal Disease
Patients Treated in Renal Dialysis Facilities
04/03/2006 	4135
R737CP 	10/31/2005 	New ICD-9-CM Code for Beneficiaries with
Chronic Kidney Disease and new HCPCS
for Reporting Epoetin Alfa and Darbepoetin
Alfa
04/03/2006 	4108
R736CP 	10/31/2005 	Clarification and Update to Hospital Billing
Instructions and Payment for Epoetin Alfa
and Darbepoetin Alfa for Beneficiaries with
End Stage Renal Disease
04/03/2006 	4103

Rev # 	Issue Date 	Subject 	Impl
Date
CR #
R725CP 	10/21/2005 	New ICD-9-CM Code for Beneficiaries with
Chronic Kidney Disease
04/03/2006 	4108
R721CP 	10/21/2005 	Use of Value Codes 48 and 49 on End Stage
Renal Disease Bills
01/03/2006 	4087
R719CP 	10/21/2005 	Clarification and Update to Hospital Billing
Instructions and Payment for Epoetin Alfa
and Darbepoetin Alfa (Aranesp) for
Beneficiaries with End Stage Renal Disease
04/03/2006 	4103
R701CP 	10/07/2005 	New Diagnosis Code Requirements for
Method II Home Dialysis Claims
11/07/2005 	4095
R634CP 	08/03/2005 	Guidelines for Payment of Vaccines
(Pneumococcal Pneumonia Virus, Influenza
Virus, and Hepatitis B Virus) and their
Administration at Renal Dialysis Facilities
01/03/2006 	3936
R610CP 	07/22/2005 	Guidelines for Payment of Vaccines
(Pneumococcal Pneumonia Virus, Influenza
Virus, and Hepatitis B Virus) and their
Administration at Renal Dialysis Facilities
01/03/2006 	3936
R598CP 	06/27/2005 	Implementation of Carrier Guidelines for
End Stage Renal Disease Reimbursement
For Automated Multi-Channel Chemistry
Test Supplemental To Change Request 2813
01/01/2006 	3890
R595CP 	06/24/2005 	Implementation of Carrier Guidelines for
End Stage Renal Disease Reimbursement
For Automated Multi-Channel Chemistry
Tests Supplemental To Change Request
2813
07/25/3005 	3890
R477CP 	02/18/2005 	New Case-Mix Adjusted End Stage Renal
Disease Composite Payment Rates and New
Composite Rate Exceptions Window for
Pediatric ESRD Facilities
04/04/2005 	3720
R447CP 	01/21/2005 	CWF Editing for Method Selection on
DMERC Claims for EPO and Aranesp
07/05/2005 	3547

Rev # 	Issue Date 	Subject 	Impl
Date
CR #
R373CP 	11/19/2004 	New ESRD Composite Payment Rates
Effective January 1, 2005
01/03/2005 	3554
R370CP 	11/19/2004 	New Case-Mix Adjusted End Stage Renal
Disease Composite Payment Rates and New
Composite Rate Exceptions Window for
Pediatric ESRD Facilities
04/04/2005 	3572
R257CP 	07/30/2004 	Informs the FISS to carry at least two
Payments Limits for ESRD
01/03/2005 	3332
R197CP 	06/04/2004 	Epoetin Alfa 	10/04/2004 	3184
R146CP 	04/23/2004 	Dialysis Provider Number Series 	10/04/2004 	3176
R118CP 	03/05/2004 	Epoetin Alfa 	04/05/2004 	2984
R116CP 	03/05/2004 	DMERC Claims Processing Instructions 	04/05/2004 	3019
R110CP 	02/27/2004 	Drugs Furnished in Dialysis 	03/29/2004 	3078
R101CP 	02/20/2004 	Processing Requests for Composite Rate
Exception
04/01/2004 	3119
R082CP 	02/06/2004 	Utilization of REMIS for Carrier Claims
Adjudication
07/06/2004 	3066
R031CP 	11/21/2003 	Dialysis Provider Number Series 	N/A 	2877
R001CP 	10/01/2003 	Initial Publication of Manual 	NA 	NA
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