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
https://www.health.mil/rates.
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.