Applicability of Specific ESRD PPS Policies to AKI Dialysis

100.6 Applicability of Specific ESRD PPS Policies to AKI Dialysis (Rev. 13599, Issued: 01-30-26, Effective: 05-01-26, Implementation: 05-01-26) A. Dialysis Modality Beneficiaries with AKI can receive their dialysis via the most clinically appropriate in-facility modality. B. Uncompleted Dialysis Treatment Generally, CMS only pays for one treatment per day across all settings. However, similar to the policy applied under the ESRD PPS for treatments for patients with ESRD, in the interest of fairness and in accordance with Chapter 8, section 10.2 of the Medicare Claims Processing Manual, if a dialysis treatment is started, that is, a patient is connected to the machine and a dialyzer and blood lines are used, but the treatment is not completed for some unforeseen, but valid reason, for example, a medical emergency when the patient must be rushed to an emergency room, both the ESRD facility and the hospital would be paid. This is considered to be a rare occurrence that must be fully documented to the A/B MAC's satisfaction. C. Home and Self-Dialysis Due to the nature of AKI, dialysis treatments at home or self-dialysis in the dialysis facility are not permitted. Specifically, these patients require supervision by qualified staff during their dialysis and close monitoring through laboratory tests to ensure that they are receiving the necessary care to improve their condition and get off of dialysis. Therefore, the home dialysis benefit does not extend to beneficiaries with AKI. D. Vaccines and Their Administration Section 1881(b)(14)(B) of the Act specifically excludes vaccines covered under section 1861(s)(10) of the Act from the ESRD PPS. However, ESRD facilities are identified as an entity that can bill Medicare for vaccines and their administration. Therefore, ESRD facilities may furnish vaccines to beneficiaries with AKI and bill Medicare in accordance with billing requirements in the Medicare Claims Processing Manual (Pub. 100-04, Chapter 18 Preventive and Screening Services, section 10.2). The staff time associated with vaccine administration is covered in the AKI dialysis payment rate. E. Telehealth Since telehealth dialysis services are limited to renal dialysis services for home dialysis patients telehealth related to renal dialysis services is not available for beneficiaries with AKI. F. ESRD Conditions for Coverage (CfCs) The ESRD CfCs at 42 CFR part 494 are health and safety standards that all Medicare participating dialysis facilities must meet. These standards set baseline requirements for patient safety, infection control, care planning, staff qualifications, record keeping, and other matters to ensure that all patients, including ESRD and AKI patients, receive safe and appropriate care. Payment for Erythropoietin Stimulating Agents (ESAs) and the ESA Monitoring Policy for AKI Patients ESAs are included in the bundled payment amount for treatments administered to patients with AKI. The Non-ESRD HCPCS codes should be used (J0881, J0883, J0885, J0888, Q0138, Q5106) and reported using revenue code 0636. The ESA monitoring policy has not yet been extended to AKI patients receiving treatment in an ESRD facility. Since this policy is not applicable to these treatments, the value codes used to report hemoglobin and hematocrit levels are not required when billing for ESAs. 100.6.1. Dialysis Modality (Rev. 13599, Issued: 01-30-26, Effective: 05-01-26, Implementation: 05-01-26) Beneficiaries with AKI can receive their dialysis via the most clinically appropriate modality.