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TRICARE Reimbursement Manual 6010.61-M, April 1, 2015
Freestanding End Stage Renal Disease (ESRD) Facility Reimbursement
Chapter 18
Section 1
Freestanding End Stage Renal Disease (ESRD) Facility Reimbursement
Issue Date:  May 31, 2023
Authority:  32 CFR 199.14(c)(2)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-69, May 31, 2023
1.0  Description
The contractor shall follow this policy to reimburse services provided by either network or non-network providers. However, the contractor may use alternative network reimbursement methodologies when approved by the Defense Health Agency (DHA) and the contractor specifically includes them in the network provider agreement.
2.0  Applicability
The reimbursement methods established in this section apply to freestanding ESRD facilities. See requirements in TRICARE Policy Manual (TPM), Chapter 11, Section 2.10. The contractor shall reimburse hospital-based ESRD facilities using other applicable reimbursement systems (e.g., the Outpatient Prospective Payment System (OPPS)).
3.0  Reimbursement
The contractor shall reimburse TRICARE authorized freestanding ESRD facilities rendering hemodialysis or peritoneal dialysis for the treatment of ESRD or Acute Kidney Injury (AKI), which is dependent on the treatment length.
3.1  The per session rate for treatment days 1-120 (day 1 is defined as the day the patient first received dialysis for an episode of care, e.g., AKI, or the first day of maintenance dialysis for patients with ESRD). The flat, per-session rate is calculated using the current Medicare base rate ($265.57 for Calendar Year (CY) 2023), multiplied by the current Medicare adjustment factor applied to individuals aged 60-69 (7% for CY 2023), and further multiplied by the current Medicare adjustment factor for the date of onset (32.7%). The days 0-120 per-session rate for CY 2023 is $377.08.
3.2  The per session rate for treatment days 121 and beyond. The flat, per-session rate is calculated using the current Medicare base rate, multiplied by the Medicare adjustment factor applied to individuals aged 60-69. The days 121-forward per-session rate for CY 2023 is $284.16.
3.3  Wage Adjustment. The per-session rates are composed of a labor and a non-labor portion. The contractor shall adjust these per-session rates by the ESRD facility’s wage index applied to the labor portion. The contractor shall use the same wage index values and labor and non-labor portions, as published by Medicare in their annual ESRD Final Rule, and posted on Centers for Medicare and Medicaid Services (CMS) ESRD Payment website. For CY 2023, the labor-related share is 55.2% and the non-labor share is 44.8%. The following example demonstrates the calculation for a wage-adjusted per-session rate for a facility with a wage index of 1.12:
•  Per session rate: $377.08
•  Labor share of per-session rate: $377.08 multiplied by 55.2% (or 0.552) = $208.15
•  Wage index adjusted labor share: $208.15 multiplied by 1.12 = $233.13
•  Non-labor share of per-session rate: $377.08 multiplied by 44.8% (or 0.448) = $168.93
•  Final waged adjusted per-session rate: $233.13 + $168.93 = $402.06
3.4  Annual Updates. The DHA will update and publish the per-session rates to the TRICARE website at The contractor shall implement the new pricing information within 10 days of publication on the TRICARE website.
3.5  Consistent with TRICARE’s statutory obligation to reimburse like Medicare, where practicable, the per-session rates apply to dialysis treatments rendered by a freestanding ESRD facility either in the clinic setting or in the home.
3.5.1  The contractor shall reimburse freestanding ESRD facilities treating patients in the facility or at home regardless of modality for a maximum of three sessions per week, unless there is medical justification for more than three weekly treatments.
3.5.2  The contractor shall review the medical justification and make the decision to allow or disallow payment for additional treatments.
3.5.3  Dialysis in the home (generally peritoneal dialysis) is typically rendered seven days per week, however, consistent with Medicare reimbursement rules, the contractor shall limit payment to the hemodialysis-equivalent of three sessions per week, regardless of the number of treatments performed each day. The daily rate for in home dialysis is the weekly rate divided by seven.
3.5.4  The contractor shall set the TRICARE-allowable amount to the full per-session rate (wage-adjusted), plus any eligible add-on payment, regardless of the facility’s billed charge.
3.6  Billing Requirements. The contractor shall ensure freestanding ESRD facilities use the Type Of Bill (TOB) 72X along with Current Procedural Terminology (CPT) procedure code 90999 (for ESRD claims) or G0491 (for AKI claims) to bill for the facility/institutional component of individual dialysis sessions as described in this section, or use a more appropriate code if the codes/descriptions are subsequently modified.
3.7  Claim Forms. The contractor shall ensure freestanding ESRD facilities bill on the CMS 1450 UB-04 claim form for dialysis services furnished on day of dialysis and for all home dialysis services, whether such services are provided directly or under arrangements.
3.8  Claim Splitting. The contractor shall split a single claim into one or more claims to separate charges for services provided on or after the effective date established in Interim Final Rule (IFR) 4 with comment (88 FR 1992, January 12, 2023) from those services provided prior to the effective date of IFR 4.
3.8.1  Consistent with IFR4, all freestanding ESRD facility Corporate Service Provider (CSP) participation agreements terminated on January 12, 2023, and no new CSP participation agreements will be accepted for coverage of ESRD services on or after January 12, 2023 (i.e., only those ESRD services furnished by hospital-based ESRD facilities and TRICARE authorized freestanding ESRD facilities will qualify as TRICARE covered services on or after January 12, 2023).
3.8.2  Freestanding ESRD facilities may no longer be reimbursed as CSPs for services on or after January 12, 2023.
Note:  For reimbursement of hospital-based (i.e., not freestanding) ESRD services, refer to Chapter 13.
4.0  Services And Supplies Included In The Per Session Rate
The Per Session Rate represents a composite rate for all facility and professional services and supplies, except those listed in paragraph 5.0. The contractor shall not separately reimburse the following services and supplies outside of the Per Session Rate.
4.1  Institutional charges (e.g., charges for facility use, use or treatment rooms, and general nursing services), to include the services of technicians, nurses, and other staff involved in establishing, monitoring, or discontinuing the dialysis session.
4.2  Laboratory services related to the dialysis session.
4.3  Pharmaceuticals and supplies related to the dialysis session.
4.4  Dialysis training add-on payment for treatment days 1-120. Because of the onset adjustment factor of 32.7% is applied to the per-session rate for treatment days 1-120, the contractor shall not apply the training add-on payment to these claims, consistent with Medicare.
Note:  The contractor may use Medicare’s ESRD PPS consolidated billing file to identify those services and supplies included within the per-session rate, and not eligible for separate payment.
5.0  Services Which May Be Billed Separately
The contractor may reimburse the following services outside of the per-session fee using existing reimbursement methodology established in this manual.
5.1  Evaluation and Management (E&M) services provided by authorized individual professional providers (e.g., the professional services of a nephrologist to evaluate and monitor the patient).
5.2  Drugs, supplies, and devices listed by Medicare as eligible for transitional drug add-on payment adjustment and transitional add-on payment adjustment for new and innovative equipment and supplies under the Medicare ESRD PPS.
5.3  Professional services, supplies, and pharmaceuticals unrelated to dialysis care (e.g., if a flu shot is administered at the same time as dialysis treatment).
5.4  Dialysis training (CPT codes 90989 and 90993). Dialysis training services and supplies are included in the flat, per-session rate, and the contractor shall not reimburse them separately. To account for training services and supplies, the contractor shall apply a training add-on payment ($95.60 for CY 2023) to the per-session rate for treatment days 121 and after, for dialysis claims billed with either condition codes 73 or 87 or revenue codes 829, 839, 849, or 859. For both hemodialysis and peritoneal dialysis training treatments, the contractor shall adjust the training add-on payment by the ESRD facility’s wage index.
5.5  In cases where the contractor pays billed charges for services under paragraph 5.0, the contractor shall ensure all provisions of policy are met, including that charges are not abusive or excessive, in accordance with 32 CFR 199.9.
6.0  Exclusions
6.1  Institutional and/or facility charges for services provided under paragraph 5.0. The contractor shall reimburse professional services rendered under paragraph 5.0 using the CMAC methodology (see Chapter 5). The contractor shall reimburse Injectable drugs, supplies, and equipment, using the appropriate reimbursement system (e.g., Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)). The contractor shall not reimburse additional institutional or facility charges for services provided under paragraph 5.0 (e.g., an institutional charge billed on a claim form UB-04 for an E&M visit with an attending nephrologist shall not be cost-shared).
6.2  Additional charges for staff-assisted dialysis in the home. The contractor shall limit reimbursement for home dialysis services rendered by freestanding ESRD facilities to the rates and methods established by this section.
7.0  Effective Date
The provisions of this policy are effective for dialysis services rendered in freestanding ESRD facilities with dates of service on or after January 12, 2023.
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