Health Reform WK-EDGE Proposed rule to increase ESRD PPS rates, allow payment for in-home equipment
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Friday, July 10, 2020

Proposed rule to increase ESRD PPS rates, allow payment for in-home equipment

By Cathleen Calhoun, J.D.

New and innovative equipment and supplies used for dialysis treatment of patients with ESRD in the home would qualify for an additional Medicare payment.

Changes would be made to the end stage renal disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2021, to the payment rate for renal dialysis services furnished by an ESRD facility to individuals with acute kidney injury (AKI), and to the requirements for the ESRD Quality Incentive Program (QIP), along with other changes, under a proposed rule to be published in the Federal Register on July 13, 2020.

Among the proposals, CMS would: (1) raise the calendar year (CY) 2021 ESRD PPS rate and the (CY) 2021 AKI payment rate, and include calciminetics in the PPS bundled payment; (2) update requirements for the ESRD Quality Incentive Program (QIP); (3) adopt the Office of Management and Budget (OMB) delineations (as described in the September 14, 2018 OMB Bulletin No. 18-04) beginning with the CY 2021 ESRD PPS wage index, including a cap on any decrease in an ESRD facility’s wage index; (4) update the outlier policy; (5) change the eligibility criteria for the transitional add-on payment adjustment for new and innovative equipment and supplies (TPNIES); and (6) expand the TPNIES to include new and innovative capital-related assets that are home dialysis machines when used in the home for a single patient.

ESRD PPS and AKI rate. For CY 2021, the proposed ESRD prospective payment system (PPS) rate and the (CY) 2021 AKI payment rate are $255.59, an increase of $16.26 to the current base rate of $239.33. CMS is proposing the methodology for modifying the ESRD PPS base rate to include calcimimetics in the ESRD PPS bundled payment.

ERSD QIP. The rule proposes updating the scoring methodology used to calculate the Ultrafiltration Rate reporting measure so that facilities are scored based on the number of eligible patient-months, instead of facility-months. A reduction of the number of records that facilities selected for National Health Safety Network (NHSN) validation are required to submit is also proposed. The timeline for facilities to make changes to their NHSN Bloodstream Infection (BSI) clinical measure and NHSN Dialysis Event reporting measure data for purposes of the ESRD QIP are also clarified under the proposed rule.

Update outlier policy. CMS is proposing to update the outlier services fixed-dollar loss (FDL) amounts for adult and pediatric patients and Medicare allowable payment (MAP) amounts for adult and pediatric patients for CY 2021 using CY 2019 claims data. CMS stated that based on the use of the latest available data, the proposed FDL amount for pediatric beneficiaries would increase from $41.04 to $47.73, and the MAP amount would increase from $32.32 to $33.08, as compared to CY 2020 values. For adult beneficiaries, the proposed FDL amount would increase from $48.33 to $133.52, and the MAP amount would increase from $35.78 to $54.26.

TPNIES eligibility criteria. CMS stated that is in light of the changes implemented in CY 2020 to provide bi-annual coding cycles for code applications for new Healthcare Common Procedure Coding System (HCPCS) Level II codes for DMEPOS items and services, it is proposing changes to the TPNIES eligibility criteria. Specifically, CMS is proposing that for purposes of eligibility for the TPNIES, the HCPCS code application must be submitted by the HCPCS Level II code application deadline for biannual Coding Cycle 2 for DMEPOS items and services as specified in the HCPCS Level II coding guidance on the CMS website.

Expansion of TPNIES. Eligibility for TPNIES would be expanded under the proposed rule and would include certain capital-related assets that are home dialysis machines when used in the home for a single patient. CMS would evaluate the application to determine whether the home dialysis machine represents an advance that substantially improves, relative to renal dialysis services previously available, the diagnosis or treatment of Medicare beneficiaries, and meets the other requirements under § 413.236(b). Medicare Administrative Contractors (MACs) would have to follow specific steps in order to establish the basis payment of the TPNIES home dialysis machines used in the home. CMS would pay 65 percent of the MAC-determined pre-adjusted per treatment amount for 2-calendar years. After the 2-year TPNIES period ends, CMS is proposing that the home dialysis machines would not become eligible outlier services and that no change would be made to the ESRD PPS base rate.

Comments on the proposed rule will be accepted through September 4, 2020.

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