ESRD PPS Patient-Level Adjustments

The ESRD Prospective Payment System (PPS) patient-level adjustments are patient-specific case-mix adjusters developed from a two-equation regression analysis that encompasses the composite rate and separately billable items and services.

Patient Age

There are 5 age categories for adults (18-44; 45-59; 60-69; 70-79; and 80 and above) in the ESRD PPS and each category has a separate case-mix adjuster. Note that, when a beneficiary reaches a birthday that results in a different age category, the age change is effective from the first day of the birthday month, regardless of the date the birthday occurs in that month.

Body Surface Area (BSA)*

BSA is associated with higher costs due to more time on the dialysis machine.

Low Body Mass Index (BMI)*

Low BMI is associated with higher costs due to additional resources that may be necessary to address malnutrition or frailty.

*Note: Low BMI and BSA are two measures used to estimate body size. Both measures are strong predictors of variation in costs and are closely associated with the duration and intensity of dialysis necessary to achieve a therapeutic dialysis target for ESRD patients. Both are objective measures computed from height and weight data located on the patient claim. All beneficiaries have BMI and BSA measures calculated.

Comorbidity Categories

What is a Comorbidity?

A comorbidity is a specific patient condition that is secondary to the patient's principal diagnosis that necessitates dialysis, yet have a significant, direct effect on resource use during dialysis.

Section 1881(b)(14)(D)(i) of the Social Security Act requires that the bundled ESRD PPS include a payment adjustment based on case­mix that may take into account patient comorbidities. The comorbidity adjustment recognizes the increased costs associated with comorbidities by providing adjustments for specific conditions that occur concurrently with the need for dialysis.

Chronic and Acute Comorbidity Categories Eligible for Adjustment

Chronic Comorbidities:

The ESRD PPS provides adjustments for two chronic comorbidity categories and two acute comorbidity categories. Claims containing one or more of the comorbidity categories will have the highest single adjustment applied.

The two chronic comorbidity categories eligible for a payment adjustment:

  • Hereditary hemolytic or sickle cell anemia and
  • Myelodysplastic syndromes

CMS may make payment for the two chronic comorbidity category adjustments as long as the provider reports the diagnosis code on the claim.

Acute Comorbidities:

The two acute comorbidity categories that are eligible for the comorbidity adjustment are:

  • Gastrointestinal tract bleeding with hemorrhage, and
  • Pericarditis

CMS may make payment for the two acute comorbidity category adjustments for the month as long as the provider reports the diagnosis on the ESRD facility's claim and then for the next three months, regardless of whether or not the diagnosis code is on the claim after the first month. This adjustment applies for no greater than four consecutive months for any reported acute comorbidity category, unless there is a reoccurrence of the condition.

Note: It is important for ESRD facilities to report all patient comorbidities accurately, regardless of whether or not these codes are or are not eligible for an ESRD PPS adjustment. Report the ICD–10–CM diagnosis codes in accordance with coding requirements on the ESRD 72x claim, as well as the official ICD–10–CM Coding Guidelines.

Onset of Dialysis

An onset of dialysis adjustment is available for the patient’s first 120 Medicare-eligible days after the start of chronic renal dialysis.  When the onset of dialysis adjustment is applicable, adjustments for the comorbidity categories and training are not applied.

Pediatric Patient Level Adjustments

Age category and modality are the two adjustments applied to claims for pediatric patients. The adult case-mix adjusters discussed above do not apply to pediatric patients.

Page Last Modified:
12/08/2016 01:41 PM