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Acute Kidney Injury and ESRD Facilities

Beginning January 1, 2017, End Stage Renal Disease (ESRD) facilities will be able to furnish dialysis services to acute kidney injury (AKI) patients.

The provision provides Medicare coverage and payment to both hospital based and freestanding ESRD facilities for renal dialysis services furnished to beneficiaries with AKI. Medicare will pay ESRD facilities for the dialysis treatment using the ESRD Prospective Payment System (PPS) base rate adjusted by the wage index. In addition to the dialysis treatment, the ESRD PPS base rate pays ESRD facilities for the items and services that are renal dialysis services and there will be no separate payment for those services. Specifically, this includes renal dialysis drugs, biologicals, laboratory services, and supplies that are included in the ESRD PPS base rate when furnished by an ESRD facility to an individual with AKI. 

Drugs, biologicals, laboratory services, and supplies that ESRD facilities are certified to furnish, but that are neither ESRD renal dialysis services, nor AKI-related dialysis services, may be paid for separately when furnished to individuals with AKI.

There are no billing limits for treatments during a monthly billing cycle. However, there will only be payment for one treatment per day across settings, except in the instance of uncompleted treatments. 

AKI Claim Criteria

For payment under Medicare, ESRD facilities shall report all items and services furnished to beneficiaries with AKI by submitting the 72x type of bill with condition code 84 - Dialysis for Acute Kidney Injury (AKI) on a monthly basis. Since ESRD facilities bill Medicare for renal dialysis services by submitting the 72x type of bill for ESRD beneficiaries, condition code 84 will differentiate an ESRD PPS claim from an AKI claim. AKI claims will require one of the following diagnosis codes:

1. N17.0 Acute kidney failure with tubular necrosis

2. N17.1 Acute kidney failure acute cortical necrosis

3. N17.2 Acute kidney failure with medullary necrosis

4. N17.8 Other acute kidney failure

5. N17.9 Acute kidney failure, unspecified

6. T79.5XXA Traumatic anuria, initial encounter

7. T79.5XXD Traumatic anuria, subsequent encounter

8. T79.5XXS Traumatic anuria, sequela

9. N99.0 Post-procedural (acute)(chronic) renal failure

In addition, ESRD facilities are required to include revenue code 082X, 083x, 084x, or 085x for the modality of dialysis furnished with the Current Procedural Terminology (CPT) code G0491 (Dialysis procedure at a Medicare certified ESRD facility for Acute Kidney Injury without ESRD).

AKI claims will not have limits on how many treatments can be billed for the monthly billing cycle, however, there will only be payment for one treatment per day across settings, except in the instance of uncompleted treatments: If a dialysis treatment is started, that is, a patient is connected to the machine and a dialyzer and blood lines are used, but the treatment is not completed for some unforeseen, but valid reason, for example, a medical emergency when the patient must be rushed to an emergency room, the facility is paid based on the full base rate. This is a rare occurrence and must be fully documented to the A/B MAC (A)’s satisfaction.