Clarifications and Further Changes to 2021 ESRD PPS

From the Field 

Shortly after I submitted last month’s edition of From the Field, the Centers for Medicare & Medicaid Services (CMS) released an updated change request in which they rescinded the requirement for reporting the total monthly minutes of dialysis provided to a patient (see Change request 12011 for details). On the one hand, I am relieved these data will not be required on claims; however, I am not looking forward to updating training documents to remove the short-lived condition code D6.

As we discussed in the last edition of From the Field, the other substantial change to the ESRD PPS for 2021 is the reimbursement and billing requirements for calcimimetics. Effective with January 2021 dates of service, CMS will no longer reimburse calcimimetics under the Transitional Drug Add-On Payment Adjustment (TDAPA). Rather, oral and injectable calcimimetics will be eligible for an outlier adjustment, and reimbursement will be included in the ESRD PPS base rate just like oral vitamin D and erythropoietin stimulating agents.

At the time of this writing, one point that seems to be unclear is the exact billing requirements for reporting oral calcimimetics on a ESRD facility claim now that they are no longer reimbursed under TDAPA. During the time that calcimimetics were reimbursed under TDAPA, CMS required oral cinacalcet to be reported with revenue code 0636, HCPCS (Healthcare Common Procedure Coding System) code J0604 and modifier AX. In late 2020 and early 2021, Medicare released some guidance to dialysis facilities that indicates cinacalcet should be billed similarly to other oral medications that have been eligible for outlier payment for many years now. Additionally, there was guidance issued to Medicare Administrative Contractors to “Discontinue processing the TDAPA for J0604 and J0606 when billed with modifier AX” for date of service on or after January 1, 2021. While the exact requirements are unclear at the time of this writing, I am confident that the ambiguity will be resolved quickly.

2021 ESRD PPS Calcimimetics Reimbursement

The biggest reimbursement changes in the 2021 ESRD PPS were the terminating reimbursement for oral and injectable calcimimetics under TDAPA and adding calcimimetics to the list of items that qualifies for an outlier adjustment. Under TDAPA, CMS reimbursed dialysis facilities for the number of units of calcimimetics they administered to their patients. In lieu of reimbursing calcimimetics under TDAPA, CMS increased the 2021 ESRD PPS base rate amount by $14, $10 of which was earmarked for calcimimetics.

In conjunction with adding calcimimetics to the list of items that qualify for an outlier adjustment, CMS significantly increased the Fixed Dollar Loss (FDL) amount for 2021. For an adult dialysis claim to be eligible for an outlier payment, the average per treatment allowed amount for the drugs, labs, and supplies eligible for an outlier included on the claim must exceed approximately $174 per treatment (this number is comprised of the adult 2021 MAP of $50.92 and FDL of $122.49).

When CMS released the proposed rule for the 2021 ESRD PPS, my company completed analyses of our clients’ calcimimetics utilization and reimbursement so they would have an idea what the fiscal impact of incorporating calcimimetics reimbursement into the ESRD PPS would be. The common theme was that all the dialysis programs that were utilizing calcimimetics in their Medicare patient populations were receiving, on average, more than the additional $9.93 per treatment allotted in the 2021 base rate—but less than the amount needed to qualify for an outlier payment adjustment.

Of the dialysis programs that my company bills for, there are several programs that have not incorporated calcimimetics. For dialysis programs such as these, the increase in the ESRD PPS will be a very welcome increase in revenue. However, in dialysis programs that have incorporated calcimimetics into their patient’s medications, it will be important to the facility’s fiscal well-being to monitor the cost, utilization, and reimbursement of calcimimetics.

Sarah Tolson is the director of operations for Sceptre Management Solutions, Inc., a company specializing in billing for outpatient ESRD dialysis programs, nephrology practices, and vascular access. Your questions are welcome and she can be reached at [email protected], 801.775.8010, or via Sceptre’s website,