Loading...Loading...End-Stage Renal Disease (ESRD) – a medical condition in which a person's kidneys cease functioning on a permanent basis, leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life.
Prospective Payment System (PPS) – a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount.
ESRD facilities and providers are responsible to service the member for all renal dialysis services under consolidated billing. Some lab services, equipment, drugs and biologicals and supplies are subject to consolidated billing and are not separately payable when provided to the beneficiary of ESRD treatment. ESRD facilities and providers are responsible for supplying these services, directly or under special arrangement with external suppliers and providers.
When a renal dialysis service or item is provided for a patient for ESRD, the provider that is rendering the service or item should receive payment from the ESRD facility or provider. A claim should not be submitted to the insurer directly.
Services and items that should not be submitted for separate payment (including but not limited to):
- injectable drugs and biologicals including administration
- laboratory tests
- supplies
- Durable Medical Equipment (DME)
other items and services provided for the treatment of ESRD
If an item or service is furnished by an ESRD facility or provider that is not for the treatment of ESRD, it may be submitted with an AY modifier to allow for separate payment outside of the ESRD PPS.
Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.