ESRD Co-morbidity Conditions

Section 1881(b)(14)(D)(i) of the Act requires that the bundled ESRD PPS include a payment adjustment based on case-mix that may take into account patient co-morbidities.  The co-morbidity adjustment recognizes the increased costs associated with co-morbidities by providing additional payments for certain conditions that occur concurrently with the need for dialysis.  Co-morbidities are specific patient conditions that are secondary to the patient's principal diagnosis that necessitates dialysis, yet have a direct affect on dialysis.

The ESRD PPS provides adjustments for 3 chronic co-morbidity categories and 3 acute co-morbidity categories.  A single adjustment will be made to claims containing one or more of the co-morbidity categories.  The highest co-morbidity adjustment applicable will be applied to the claim. 

The 3 chronic co-morbidity categories that are eligible for the co-morbidity adjustment include:

1. Hereditary hemolytic or sickle cell anemia,
2. Myelodysplastic syndromes, and
3. Monoclonal gammopathy.

The 3 acute co-morbidity categories that are eligible for the co-morbidity adjustment include:

1. Bacterial pneumonias,
2. Gastrointestinal tract bleeding with hemorrhage, and
3. Pericarditis.

The 3 chronic co-morbidity category adjustments will be paid for as long as the diagnosis code is reported on the claim.  The 3 acute co-morbidity category adjustments will be paid for the month the diagnosis is reported on the ESRD facility's claim and then for the next 3 months, regardless if the diagnosis code is on the claim after the first month.  The acute co-morbidity adjustment may be paid no greater than 4 consecutive months for any reported acute co-morbidity category unless there is a reoccurrence of the condition.

It is important for ESRD facilities to report all patient co-morbidities accurately, regardless of whether or not these codes are or are not eligible for an ESRD PPS adjustment.  The ICD–9–CM diagnosis codes should be reported in compliance with coding requirements on the ESRD 72x claim as well as the official ICD–9–CM Coding Guidelines.