ESRD PPS Outlier Services

Outlier Payment Adjustment

An ESRD facility that treats beneficiaries with unusually high resource requirements, as measured by their use of identified services beyond a specified threshold, are entitled to outlier payments. That is, additional payment beyond the otherwise applicable adjusted prospective payment amount.

The ESRD Prospective Payment System (PPS) includes a payment adjustment for high cost outliers when there are unusual variations in the type or amount of medically necessary care, such as an unusual anemia management erythropoiesis stimulating agents (ESAs) utilization.

CMS designed the outlier payment policy to protect an ESRD facility from significant financial losses due to unusually high costs. The outlier payment is added to the patient and facility-­level adjusted ESRD PPS per treatment payment amount. 

What are considered ESRD Outlier Services?

ESRD outlier services are the following items and services that are included in the ESRD PPS bundle: 

  • Drugs and biologicals used for the treatment of ESRD that were or would have been, prior to January 1, 2011, separately billable under Medicare Part B;
  • Laboratory tests used for the treatment of ESRD that were or would have been, prior to January 1, 2011, separately billable under Medicare Part B;
  • Medical/surgical supplies used to administer drugs and biologicals used for the treatment of ESRD that were or would have been, prior to January 1, 2011, separately billable under Medicare Part B; and
  • Drugs and biologicals used for the treatment of ESRD that were or would have been, prior to January 1, 2011, covered under Medicare Part D*.

 * Statute requires the delay of the implementation of the oral-only renal dialysis service policy until January 1, 2025. 

What are not considered ESRD Outlier Services?

Items and services not included in the ESRD PPS that remain separately payable, including:

  • Blood and blood processing;
  • Preventive vaccines;
  • Telehealth services;
  • Items and services reported on claims with the modifier; and
  • Items and services included in the composite rate portion of the ESRD PPS bundle.

Note: Since outlier payment computations rely on a statistically accepted model of predicted values for items and services that prior to the PPS were separately billable services, the separately billable case­mix adjusters are used for the outlier calculation.

Page Last Modified:
12/09/2019 09:22 PM