Medical Billing and Coding Healthcare Blog

The Centers for Medicare & Medicaid Services has issued a final rule that updates payment policies and rates under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to beneficiaries on or after January 1, 2017.

The rule also finalizes new quality measures for dialysis facilities treating patients with ESRD.

Here are some of the highlights of the final rule:

  • CMS projects that the updates for CY 2017 will increase the total payments to all ESRD facilities by 0.73% compared with CY 2016. For hospital-based ESRD facilities, CMS projects an increase in total hospital lab billing service payments of 0.9%, while for freestanding facilities, the projected increase in total payments is 0.7%.
  • CMS increased the base Medicare reimbursement rate to $231.55 — a $1.16 increase from 2016 rates.
  • For pediatric beneficiaries, the fixed-dollar loss amount will rise from $62.19 to $68.49, while the Medicare Allowable Payments amount will decrease from $39.20 to $38.29. For adult beneficiaries, the fixed-dollar loss amount will decrease from $86.97 to $82.92 and the Medicare Allowable Payments amount will decline from $50.81 to $45.00.
  • CMS will increase the home and self-dialysis training add-on payment adjustment. The increase was based on the average treatment times and weights for each modality, and then CMS used those times and weights as proxies for the total time spent by nurses training beneficiaries for home or self-dialysis. Using an updated RN hourly wage of $35.94 and an increase to the hours of nurse training time from 1.5 hours to 2.66 hours, the CY 2017 home and self-dialysis training add-on payment adjustment is $95.60, an increase of $45.44 from the current training add-on amount of $50.16.
  • ESRD Medicare spending is projected to increase by $80 million from CY 2016 to CY 2017.
  • CMS finalized implementation of the Trade Preferences Extension Act of 2015. This will provide coverage and Medicare reimbursement for renal dialysis services furnished on or after Jan. 1, 2017, by an ESRD facility to acute kidney injury patients. The Medicare reimbursement will be the ESRD Prospective Payment System base rate adjusted by the wage index.
  • Drugs, biologicals, laboratory services and supplies that ESRD facilities are certified to furnish, but that are not renal dialysis services, may be paid for separately when furnished to individuals with acute kidney injury.
  • CMS finalized the creation of a new Safety Measure Domain as a third category of measures for payment year (PY) 2019. CMS finalized the inclusion of the National Healthcare Safety Network (NHSN) Dialysis Event reporting measure into the ESRD Quality Incentive Program measure set for PY 2019, and then combined this measure with the existing NHSN Bloodstream Infection (BSI) clinical measure in a new NHSN BSI Measure Topic, which will be the only measure topic in this new Safety Measure Domain.
  • CMS finalized two substantive changes to the Hypercalcemia clinical measure for PY 2019 to ensure that the measure remains in alignment with the measure specifications endorsed by the National Quality Forum. These changes involve updating the measure's technical specifications for PY 2019 and future years to include plasma as an acceptable substrate in addition to serum calcium. First, CMS added plasma as an acceptable substrate in addition to serum calcium. Second, CMS changed the calculation of the revised measure to include patient-months with missing values in order to minimize any incentive for a facility to avoid reporting serum calcium data.
  • The Quality Incentive Program will include two new measures in 2020 — a standardized hospitalization ratio clinical measure and an ultrafiltration rate reporting measure.

Struggling with the laboratory medical billing process? Contact PGM to find out how our team works closely with labs like yours to develop a customized billing strategy that is designed to meet the strategic business objectives of your practice.

The Centers for Medicare & Medicaid Services has announced the awarding of the next round of Medicare Fee-for-service recovery audit contractor (RAC) contracts.

The Medicare Recovery Audit Program's mission is to identify and correct improper Medicare medical billing payments through the detection and collection of overpayments made on claims of healthcare services provided to Medicare beneficiaries, and the identification of underpayments to providers so that the CMS can implement actions that will prevent future improper payments.

The new RAC contracts were awarded to:

  • Region 1 — Performant Recovery
  • Region 2 — Cotiviti
  • Region 3 — Cotiviti
  • Region 4 — HMS Federal Solutions
  • Region 5 — Performant Recovery

The RACs in Regions 1-4 will perform postpayment review to identify and correct Medicare claims that contain improper payments (overpayments or underpayments) that were made under Part A and Part B, for all provider types other than durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) and home health/hospice.

The Region 5 RAC will be dedicated to the postpayment review of DMEPOS and home health/hospice claims nationally.

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