ESRD PPS Consolidated Billing
Consolidated Billing Requirement
Medicare provides payment under the ESRD Prospective Payment System (PPS) for all renal dialysis services furnished to ESRD beneficiaries for outpatient maintenance dialysis. Therefore, ESRD facilities are responsible and paid for furnishing all renal dialysis services under the ESRD PPS directly or under arrangement.
Payment for Renal Dialysis Services Billed by Other Providers
The ESRD PPS implemented consolidated billing requirements for limited Part B items and services included in the ESRD facility’s bundled payment. Certain laboratory services, drugs and biologicals, equipment, and supplies are subject to consolidated billing and are no longer separately payable when provided to ESRD beneficiaries by providers other than the ESRD facility. Under consolidated billing, ESRD facilities are expected to furnish services, either directly, or under an arrangement with an outside supplier.
When a renal dialysis service is provided to an ESRD beneficiary by other providers, that provider should look to the ESRD facility for payment, as opposed to submitting a claim to their Medicare Administrative Contractor (MAC).
When a provider other than an ESRD facility provides renal dialysis services to an ESRD beneficiary for reasons not related to the treatment of ESRD, the submitted claim must include the AY modifier to allow for separate payment under Medicare. For example, if an ESRD beneficiary also has cancer and has a laboratory test done related to cancer treatment, the laboratory should submit the claim with an AY modifier in order to receive separate payment.
Note: An item or service furnished by an ESRD facility that is not for the treatment of ESRD must be submitted with an AY modifier to allow for separate payment outside of the ESRD PPS.