ESRD Prospective Payment System (PPS) Base Rate

50 - ESRD Prospective Payment System (PPS) Base Rate (Rev. 13599, Issued: 01-30-26 , Effective: 05-01-26, Implementation: 05-01-26 ) Updates to the provisions under the ESRD PPS are discussed through rulemaking on a yearly basis. The updates are implemented through Recurring Update Notifications. A. Per Treatment Unit of Payment Under the ESRD PPS payment is made on a per treatment basis. The ESRD PPS base rate is the per treatment unit of payment that applies to both adult and pediatric patients. ESRD facilities furnishing dialysis treatments in-facility are paid for up to 3 treatments per week. ESRD facilities treating patients at home regardless of modality receive payment for 3 hemodialysis (HD) equivalent treatments per week. Payment for additional treatments may be considered when there is medical justification for more than 3 weekly treatments. For more information regarding home dialysis, see §30 of this chapter. ESRD facilities furnishing dialysis in-facility or in a patient’s home are paid for a maximum of 13 treatments during a 30 day month and 14 treatments during a 31 day month unless there is justification that additional treatments are reasonable and necessary. Frequency of Dialysis Sessions by Dialysis Modality and Treatment Setting* Dialysis Modality In-Facility Home Hemodialysis 3 per week Maximum of 3 per week regardless of frequency Hemofiltration 3 per week 3 per week Ultrafiltration 3 per week Maximum of 3 per week, regardless of frequency Peritoneal Dialysis (e.g., CAPD and CCPD) HD-equivalent sessions HD-equivalent sessions – Paid using the daily rate ** Intermittent Peritoneal Dialysis (IPD) 3 per week HD-equivalent sessions * Regardless of dialysis modality or treatment setting, payments for additional treatments may be made when they are reasonable and necessary. The A/B MAC (A) reviews the medical justification and is responsible for making the decision on the appropriateness of the extra treatment. ** Hemodialysis-equivalent home CCPD and CAPD is paid for using a daily rate. This daily rate is equal to 3/7ths of the payment amount for an in-center hemodialysis treatment, as one week of daily home CCPD or CAPD treatments is considered equivalent to 3 in-center hemodialysis treatments. 1. Hemodialysis: Payment Based on Standard of Three Treatments per Week Hemodialysis is typically furnished 3 times per week in sessions of 3 to 5 hours in duration. If the ESRD facility bills for any treatments in excess of this frequency, a medical justification that the treatment is reasonable and necessary is required to be furnished to the A/B MAC (A) and must be based upon an individual patient’s need. The A/B MAC (A) reviews the medical justification for each additional treatment and is responsible for making the decision on the appropriateness of the extra treatment(s) and payments for these additional treatments. When treatments are given in excess of 13 or 14 treatments per month (depending on the number of days in the month) without medical justification, the CG modifier shall be appended to the claim line for the date of service associated with the excess treatment. This modifier indicates that the facility attests the additional treatment does not meet medical justification requirements and should not be paid separately. 2. Hemofiltration Hemofiltration is an alternative to peritoneal dialysis and hemodialysis. Hemofiltration may be routinely performed either in an ESRD facility or at home in 3 weekly sessions. See §10.A.3 of this chapter. 3. Ultrafiltration When ultrafiltration is performed the same day as the dialysis treatment; there is no separate payment. When ultrafiltration is performed on a day other than the day of a dialysis treatment, the ESRD facility must document in the medical record why the ultrafiltration could not have been performed at the time of the dialysis treatment. For the ESRD facility to be paid for the ultrafiltration, the ESRD facility must report the appropriate diagnosis code and the A/B MAC (A) must verify the medical justification to determine that the ultrafiltration services were reasonable and necessary. If the A/B MAC (A) considers the justification appropriate, the ESRD facility will receive the ESRD PPS per treatment payment. For more information regarding ultrafiltration, see Pub. 100-04, Chapter 8, §50.7. 4. Peritoneal Dialysis: Payment Based on Hemodialysis Equivalent Sessions For home patients undergoing peritoneal dialysis (PD), the number of days of PD regardless of the number of dialysate exchanges performed each day, is converted to HD-equivalent sessions. This is accomplished by dividing the number of days of PD by 7 and multiplying the result by 3. Example: Joe is a home CCPD patient who undergoes PD for 24 days. The number of HD- equivalent sessions is 24/7 x 3 or 10.28571. The number of HD-equivalent sessions or treatments for which case-mix adjusted prospective payments are applicable, is 10.28571. Note: because home CAPD and CCPD patients generally receive dialysis treatments daily, these modalities are paid a daily rate, which is calculated by multiplying the in-center hemodialysis payment rate for that patient by 3 and dividing by 7. This is an alternative method of paying a comparable rate for hemodialysis- equivalent sessions, which is more appropriate for these daily modalities. The daily rate is not paid for IPD, since IPD may not be furnished every day (as discussed in the next subsection). Although CAPD and CCPD patients are home dialysis patients, occasionally it may be necessary to perform dialysis in-facility. The number of HD-equivalent sessions for PD performed in-facility is limited to 3 weekly, regardless of the number of days PD is furnished in-facility. However, each day of in-facility PD is treated as one HD-equivalent session, up to a maximum of 3 per week. Example: Mary is a home CCPD patient. After 21 days on CCPD in a month, Mary’s cycler required repair. Mary received CCPD in-center for 4 consecutive days before returning to home CCPD. The number of HD-equivalent sessions for which payments under the ESRD PPS may be made is 12, determined as follows: Home CCPD HD-equivalent sessions 21/7 x 3 = 9 In-center PD HD-equivalent sessions (limited to 3) 3 Total HD-equivalent sessions 12 Mary’s ESRD facility would receive the case-mix adjusted ESRD PPS base rate for 12 treatments in the month. 5. Intermittent Peritoneal Dialysis (IPD) Maintenance Intermittent Peritoneal Dialysis (IPD) is usually accomplished in sessions of 10 to 12 hours in duration. Sometimes it is accomplished in fewer weekly sessions of longer duration. The payment applicable for maintenance IPD, as well as the ESRD facility’s actual payment for maintenance IPD, depends on the treatment setting (in-facility or at home). Payment for in-facility IPD follows the same payment rules as hemodialysis, i.e., 3 sessions per week (see Pub. 100-04, chapter 8, §50.5 and §50.6.2). Payment for home IPD is based on a weekly equivalence of 3 sessions per week (see Pub. 100-04, chapter 8, §80.3, §80.3.1, and §80.4). If additional dialysis beyond the usual weekly maintenance dialysis is required because of special circumstances, the ESRD facility’s claim for these extra services must be accompanied by a medical justification for payment to be made. 6. Uncompleted Dialysis Treatments under the ESRD PPS Medicare only pays for one completed dialysis treatment per day. If a dialysis treatment is started, (i.e., 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, (e.g., a medical emergency when the patient must be rushed to an emergency room), and the patient returns the same day and completes the treatment, the facility is paid for one treatment. When there is a sudden onset of acute symptoms during the dialysis treatment and there is an emergency, the ESRD facility does what is necessary to provide the beneficiary emergency care (including calling 911). The hospital outpatient department provides emergency care and if it is unlikely the patient is able to return to the ESRD facility, the hospital outpatient department furnishes the dialysis treatment for the day. Emergency renal dialysis services furnished in a hospital emergency room are separately paid, when justification that they are reasonable and necessary is submitted on the claim, and when the absence of immediate medical attention in the emergency room could reasonably be expected to result in either: • Placing the patient’s health in serious jeopardy; • Serious impairment to bodily functions; or • Serious dysfunction of any bodily organ or part. If a patient was taken to a hospital and was furnished a dialysis treatment while in the emergency room, then the ESRD facility will not receive payment for the treatment and only the hospital will be paid. See Pub.100-04, chapter 4, section 200.2 for additional information. Renal dialysis services, such as de-clotting of shunts, suture removal, or furnishing renal dialysis drugs that may be furnished in other settings such as a hospital outpatient department or physician’s office, are paid separately only if the services could not have been furnished in the ESRD facility. 7. Vaccines and Their Administration ESRD facilities may bill separately for both the vaccine and the administration of the vaccine under Chapter 18 of the Provider Reimbursement Manual (PRM) (Section 10.2.2.1). Independent ESRD facilities are paid at the Medicare Physician Fee Schedule rate, and Hospital Based ESRD facilities are paid reasonable cost. Vaccinations for COVID-19 are paid at a reasonable cost when performed at a renal dialysis facility. The general rates for COVID-19 vaccines do not apply for renal dialysis facilities. B. Market Basket For renal dialysis services furnished on or after January 1, 2012, CMS annually updates the ESRD PPS base rate by the ESRD bundled market basket percentage increase factor minus a productivity adjustment factor (the growth in the multifactor productivity is derived by subtracting the contribution of labor and capital input growth from output growth). The market basket is routinely rebased periodically so that the cost weights reflect changes between base periods in the mix of goods and services that ESRD facilities purchase to furnish ESRD treatment.