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Case-Mix Adjusted End-Stage Renal Disease (ESRD)
The Medicare Prescription Drug Improvement and Modernization Act of 2003 required the establishment of a basic case-mix adjusted prospective payment system for dialysis services furnished to individuals in a facility and to individuals at home.
A case mix methodology adjusts the composite payment rate based on a limited number
of patient characteristics.
• The use of case-mix measure permits the targeting of greater payments to facilities that treat more costly and resource-intensive patients.
• An ESRD facility's average composite payment rate per treatment depends on its unique patients' case-mix.
• The patient characteristic variables that are used in determining an individual patient's case-mix adjusted composite payment rate include the following:
~ Five age groups,
~ Low Body Mass Index (BMI),
~ Body surface area (BSA), and
~ Patients under age 18.
These variables are used in the ESRD PRICER (Used by the MAC) to calculate the final composite rate (including all other adjustments).
This list contains required claim data used to calculate a final ESRD composite rate:
Through Date BOX 6 2300 | DTP 03
Charges --►Charge <From Date >and <To> (date)
Date of Birth BOX 10 2010CA | DMG02
Registration --►Regular --►Patient <DOB>
Condition Code (73 or 74) BOXES 18-24 2300 | HI01 - HI12 | BG |
Charges --►Encounter --►UB-Encounter <Condition Code 1>
Value Codes (A8 and A9) / Amounts BOXES 39-40 1 2300 | HI01 - HI12 | BE
Charges --►Encounter --►UB-Encounter <Value Code 1> and <Amount>
A8 – Weight of Patient – Code indicates the weight of the patient in kilograms. The weight of the patient should be measured after the last dialysis session of the month.
A9 – Height of Patient – Code indicates the height of the patient in centimeters. The height of the patient should be measured during the last dialysis session of the month. This height is as the patient presents.
Revenue Code (0821, 0831, 0841, 0851, 0880, or 0881) BOX 42 2400 | SV201
Utility --►Procedure --►Procedure <Revenue Code> as it was at the time the charge was posted.