Billing

ESRD Facilities: Clarifications for Providing Dialysis Services to Patients Acute Kidney Injury

Effective 1/1/2017. ESRD facilities (hospital-based and freestanding) may furnish renal dialysis services to beneficiaries with AKI (both adult and pediatric). An individual with AKI, is defined in the Social Security Act, Section 1834 (r)(2) to mean an individual who has acute loss of kidney function and does not receive renal dialysis services for which payment is made under Section 1881 (b) (14) of the Social Security Act.

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In-facility Dialysis is Required

Beneficiaries with AKI can receive their dialysis via the most clinically appropriate in-facility modality. 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 dialysis. Therefore, the home dialysis benefit does not extend to beneficiaries with AKI.

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Basic AKI Payment

All in-facility dialysis treatments, that is, hemodialysis and peritoneal dialysis, furnished to individuals with AKI in an ESRD facility will be paid the using the ESRD PPS base rate, adjusted by the wage index. The base rate covers all dialysis treatments as well as all items and services that are renal dialysis services as defined in 42 CFR Section 413.171. Renal dialysis services as defined in 42 CFR, Section 413.171 would be considered to be renal dialysis services for patients with AKI. Thus, all renal dialysis drugs, biologicals, laboratory services, and supplies are included in the ESRD PPS base rate for AKI and no separate payment is made. There are no billing limits for medically necessary AKI services provided during the month; however, only one payment for one treatment per day (except for an uncomplete treatment) is allowed. CMS expects that individuals with AKI will need renal dialysis services for a finite number of days since the intent of the dialysis for these patients is curative.

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Consolidated Renal Dialysis Services for Beneficiaries with Acute Kidney Injury

All items and services included in the ESRD consolidated billing list are included in the base rate payment for AKI. This includes erythropoietin stimulating agents billed with the ESRD-specific HCPCS or the non-ESRD specific HCPCS code.

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Other Items and Services That Are Not Renal Dialysis Services

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. However, items and services included on the consolidated billing list are not separately payable for patients with AKI.

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Billing for AKI Dialysis Services

For payment under Medicare, ESRD facilities should report all items and services furnished to Medicare beneficiaries with AKI by submitting a properly coded claim on a monthly basis as per the following guidelines:

AKI services are billed on a monthly claim, type of bill 72X, and must include:

  • Condition code 84 (Dialysis for AKI)
  • HCPCS code G0491 (Dialysis procedure at a Medicare-certified ESRD facility for AKI without ESRD)
  • Revenue code applicable to in-facility dialysis modality used (082X, 083X, 0881)
  • ICD-10 Codes
    • N17.0 Acute kidney failure with tubular necrosis
    • N17.1 Acute kidney failure with acute cortical necrosis
    • N17.2 Acute kidney failure with medullary necrosis
    • N17.8 Other acute kidney failure
    • N17.9 Acute kidney failure, unspecified
    • T79.5XXA Traumatic anuria, initial encounter
    • T79.5XXD Traumatic anuria, subsequent encounter
    • T79.5XXS Traumatic anuria, sequela
    • N99.0 Post-procedural (acute)(chronic) renal failure
  • ESAs, and additional anemia management drugs, are included in the bundled payment amount for treatments administered to patients with AKI. ESAs for AKI are reported with a non-ESRD HCPCS code and revenue code 0636 (Drugs requiring detailed coding). The following codes are applicable:
    • J0881 – Injection, darbepoetin alfa, 1 microgram (non-ESRD use)
    • J0883 – Injection, argatroban, 1 mg (for non-ESRD use)
    • J0885 – Injection, epoetin alfa, (for non-ESRD use), 1000 units
    • J0888 – Injection, epoetin beta, 1 microgram, (for non-ESRD use)
    • Q0138 – Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-ESRD use)
    • Q5106 – Injection, epoetin alfa, biosimilar, (Retacrit) (for non-esrd use), 1000 units)

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Ultrafiltration (Revenue Code 0881)

Ultrafiltration is a process for removing excess fluid from the blood through the dialysis membrane by means of pressure. 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. The AKI payment rate covers the full range of complicated and uncomplicated dialysis treatments; thus, predialysis ultrafiltration is not separately reimbursed.

Separate ultrafiltration may be medically indicated when medical complications require that ultrafiltration be performed separately, and at a different time than when a dialysis treatment is given. Medicare may provide additional payment in these cases. However, the medical necessity for separate ultrafiltration must be documented in the medical record and a supporting diagnosis must be included on the claim. Payment is made at the AKI payment rate.

Note: Claims for separate ultrafiltration should be submitted on a separate claim with revenue code 0881 and condition code 84, in order to receive payment.

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Uncompleted Dialysis Treatment

Generally, Medicare covers one dialysis treatment per day across all settings. However, if a dialysis treatment is started (meaning that 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 a rare occurrence.

Note: An uncompleted AKI dialysis treatment must be fully documented in the medical record.

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Additional Clarifications

  • Sequestration adjustment of 2% applies to claims for beneficiaries with AKI
  • ESRD Conditions for Coverage also apply to all ESRD facilities, including those providing AKI services
  • Telehealth services are not available for Medicare beneficiaries with AKI
  • ESRD Network reduction fee does not apply to AKI services
  • The AKI dialysis payment rate is not reduced for the ESRD Quality Incentive Program (QIP).
  • The Transitional Drug Add-on Adjustment (TDAPA) does not apply to AKI claims.
  • The ESRD outlier payment policy does not apply to AKI claims.
  • Not required to be reported by an ESRD facility for AKI services:
    • Modifiers G1–G6: Urea reduction
    • Modifiers V5–V7: Vascular access
    • Modifiers JA, JB and JE: Route of administration
    • Value code D5: Kt/v reading
    • Occurrence code 51: Date of the last Kt/v reading
    • Value codes A8 and A9: Patient’s height and weight
    • Value Code 48 (hemoglobin).and 49 (hematocrit)

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Billing for Physicians’ Services for Individuals with AKI

Physicians are able to bill separately for services provided to individuals with AKI. CMS expects providers to follow correct coding guidelines and use the appropriate HCPCS or CPT codes for the items and services provided to the patient.

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