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ESRD PPS CY 2021 Proposed Rule; COVID-19: New and Expanded Flexibilities for RHCs & FQHCs



Monday, July 6, 2020



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ESRD PPS CY 2021 Proposed Rule

On July 6, CMS issued a proposed rule that proposes to update payment policies and rates under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to beneficiaries on or after January 1, 2021. This rule also proposes updates to the Acute Kidney Injury (AKI) dialysis payment rate for renal dialysis services furnished by ESRD facilities to individuals with AKI and proposes changes to the ESRD Quality Incentive Program (QIP).

In addition to the annual technical updates for the ESRD PPS, the proposed rule proposes the following:

  • An addition to the ESRD PPS base rate to include calcimimetics in the ESRD PPS bundled payment
  • Changes to the eligibility criteria and determination process for the Transitional add-on Payment adjustment for New and Innovative Equipment and Supplies (TPNIES)
  • Expansion of the TPNIES to include new and innovative capital-related assets that are home dialysis machines
  • A change to the low-volume adjustment eligibility criteria and attestation requirement to account for the COVID-19 public health emergency
  • An update to the ESRD PPS wage index to adopt the new Office of Management and Budget delineations with a transition period
  • Information received from two manufacturers whose products, a dialyzer and a cartridge for a home dialysis machine, are being considered for TPNIES in CY 2021

Additionally, the proposed rule proposes the following updates to the ESRD QIP:

  • Scoring methodology changes to the ultrafiltration rate reporting measure
  • Updates to the National Healthcare Safety Network validation study

The proposed CY 2021 ESRD PPS base rate is $255.59, an increase of $16.26 to the current base rate of $239.33. This proposed amount reflects the application of the proposed wage index budget-neutrality adjustment factor (.998652), the proposed addition to the base rate of $12.06 to include calcimimetics, and a proposed productivity-adjusted market basket increase as required by section 1881(b)(14)(F)(i)(I) of the Act (1.8 percent), equaling $255.59 (($239.33 x .998652) + $12.06) x 1.018 = $255.59).

The proposed rule also includes:

  • Annual update to the wage index
  • Update to the outlier policy
  • Low-volume eligibility criteria and attestation requirement
  • Impact analysis

For More Information:

See the full text of this excerpted CMS Fact Sheet (issued July 6).


COVID-19: New and Expanded Flexibilities for RHCs & FQHCs during the Public Health Emergency

On July 6, CMS updated MLN Matters Article SE20016 (PDF) to clarify how Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) can apply the Cost Sharing (CS) modifier to preventive services furnished via telehealth. This update includes:

  • Additional claim examples
  • New section on the RHC Productivity Standard


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