Rate(s) Determination

(1) Rates paid to providers will be subject to the following adjustments and limitations. (a) In a case where the established charge(s) is lower than the dialysis rate(s) and is not based upon an established income-related sliding fee scale for self-payers, the established charge(s) is the rate(s) paid to the provider. (b) If home training is included as part of a provider’s dialysis program, governmental purchasers and purchasers under M.G.L. c. 152 who choose to purchase the service must pay the dialysis rate(s) plus an add-on listed in 101 CMR 337.03(3) under the appropriate service code. (2) Rates for Dialysis Treatment and Treatment for Acute Kidney Injuries Procedure Code Description Rate Unlisted dialysis procedure, inpatient or outpatient (all- inclusive service per dialysis treatment per patient) G0491 Dialysis procedure at a Medicare certified end stage renal disease (ESRD) facility for acute kidney injury without ESRD Procedure Code Description Rate Sevelamer carbonate (Renvela or therapeutically equivalent), oral, 20 mg (for ESRD on dialysis) Sevelamer carbonate (Renvela or therapeutically equivalent), oral, powder, 20 mg (for ESRD on dialysis) Sevelamer hydrochloride (Renagel or therapeutically equivalent), oral, 20 mg (for ESRD on dialysis) Sucroferric oxyhydroxide, oral, 5 mg (for ESRD on dialysis) Lanthanum carbonate, oral, 5 mg (for ESRD on dialysis) Lanthanum carbonate, oral, powder, 5 mg, not therapeutically equivalent to J0607 (for ESRD on dialysis) Ferric citrate, oral, 3 mg ferric iron (for ESRD on dialysis) Calcium acetate, oral, 23 mg (for ESRD on dialysis) The all-inclusive rate identified in 101 CMR 337.03(2) covers all services and supplies as defined in 42 CFR § 410.50, with the exception of physician services and applicable procedure codes in 101 CMR 337.03(3). (3) The following codes and add-ons must be used when the treatment includes these services: Procedure Code Description Rate Dialysis training, patient, including helper where applicable, any mode, completed course Procedure Code Description Rate Dialysis training, patient, including helper where applicable, any mode, course not completed, per training session Cinacalcet, oral, 1 mg (for ESRD on dialysis)