If you are billing and coding for hemodialysis, you need to review some new important guidelines to keep getting paid. Although most of us look for our coding changes to be announced early, CMS announced this change just recently - on February 20th.
The End-Stage Renal Disease (ESRD) Medicare payment for dialysis services is based on a fixed amount, known as the composite rate. The composite rate provides a single payment that includes the cost of some drugs, laboratory tests, and other items and services furnished to Medicare beneficiaries who are receiving dialysis. In addition to payment for the composite rate, separate payment is made for certain laboratory tests and drugs.
Section 153c of the Medicare Improvements for Patients and Providers Act (MIPPA) requires CMS to implement a quality-based payment program for dialysis services effective January 1, 2012. CMS currently collects two monthly measurements of quality of care via the ESRD claims submitted by dialysis providers: hemoglobin or hematocrit as a measure of anemia management, and urea reduction ratio (URR) as a measure of hemodialysis adequacy.
These two quality measures meet the minimum requirements as mandated in MIPPA section 153c. However, the URR measure of dialysis adequacy does not provide data for the entire ESRD dialysis population. Not having dialysis adequacy data for a segment of the dialysis population (peritoneal dialysis patients) is problematic in the development of a quality-based payment program that will decrease provider payment by up to 2% based on quality outcome data because, with the missing data, CMS will not be able to assess all ESRD dialysis providers based on the same criteria.
MIPPA §153c also requires the use of quality measures endorsed by a consensus organization. CMS recently reexamined and received National Quality Forum (NQF) endorsement for the ESRD quality measures. Both CMS and NQF found that dialysis adequacy is best measured by Kt/V for both hemodialysis and peritoneal dialysis patients. The National Quality Forum granted time-limited endorsement of URR for hemodialysis patients and recommended that CMS drop it in favor of Kt/V as soon as possible. Although dialysis adequacy is measured monthly for in-center hemodialysis patients, dialysis adequacy is measured less frequently for peritoneal dialysis patients (at least every four months). Therefore, it is necessary to track both the date of the most recent measurement and the result of the most recent measurement.
Finally, MIPPA §153c provides for the use of additional quality measures for the quality-based payment program as determined by the Secretary of Health and Human Services. Two additional quality measures could be collected easily using HCPCS modifiers for hemodialysis patients to record vascular access. The first measure is use of an arteriovenous fistula with two needles, which is recognized as the best vascular access because it is associated with the least infections. The second measure is the use of any vascular catheter, which is recognized as the worst vascular access because it is associated with the most infections. Collecting vascular access data will allow CMS to develop a more robust quality-based payment program to implement national policy without additional data collection burden on dialysis providers, who are already required to collect these data under the Fistula First Initiative.
Medicare is poised to begin denying dialysis services beginning July 1 if those services are not reported with a combination of new modifiers V5, V6, V7, V8 and V9.
These modifiers, which were part of the January 1 release of new HCPCS codes from CMS, describe circumstances regarding the patient's hemodialysis access:
V5 Vascular catheter
V6 Arteriovenous graft
V7 Arteriovenous fistula
V8 Infection present
V9 No infection present
This change requires new reporting for dialysis adequacy, infection and vascular access and will allow CMS to implement an accurate quality incentive payment for dialysis providers by January 1, 2012, as required by MIPPA. The reporting of the modifiers is effective January 1, 2010; however, reporting is considered voluntary until July 1.
Don't wait for mandatory dates to begin reporting these modifiers. Medicare is set to return your claims beginning July 1, 2010. It's important to begin using them now to maintain compliance, and to make sure you are ready for reporting dates.
There is a ESRD fact sheet available for reference at http://www.cms.hhs.gov/MLNProducts/downloads/ESRDpaymtfctsht08-508.pdf to help us learn more about the payment systems for ESRD
MLN article(MM6782), explaining the changes, can be found at http://www.cms.hhs.gov/mlnmattersarticles/2010mman/itemdetail.asp?itemid=CMS1232707 .
Author:
Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC, Vice President, Business and Member Development, American Academy of Professional Coders
Rhonda Buckholtz is vice president of business and member development at the American Academy of Professional Coders (AAPC). She has more than 20 years experience in health care, working in the reimbursement, billing and coding sector. Before joining the AAPC, she was the administrator for a five-location practice in Pennsylvania. She is a lead member of the AAPC's ICD-10 training and education team, which is charged with the development and training of curriculum on ICD-10 implementation and preparation for providers, facilities and health plans. She has authored many articles for health care publications and has spoken at conferences across the country.
