ESRD Clinic Services

Affected Providers

Medicare-certified ESRD facilities.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for ESRD clinic services is 0.5%, with a projected improper payment amount of $41.5 million.

Denial Reasons

Insufficient documentation accounted for 93.4% of improper payments for ESRD clinic services during the 2024 reporting period, while incorrect coding (3.8%) and other errors (2.9%) also caused improper payments. “Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials

Patient Assessment

The interdisciplinary team provides each patient with an individualized and comprehensive assessment of their needs. Use the comprehensive assessment to develop the patient’s treatment plan and care expectations, as described in 42 CFR 494.80.

Assessment Criteria

The patient’s comprehensive assessment must include, but isn't limited to:

• Lab profile, immunization history, and medication history
• Evaluation for referral to vocational and physical rehabilitation services
• Evaluation of:
  • Current health status and medical condition, including co-morbid conditions.
  • The proper dialysis prescription, blood pressure, and fluid management needs.
  • Factors associated with anemia, like hematocrit, hemoglobin, iron stores, and potential treatment plans for anemia, including erythropoiesis-stimulating agents.
  • Factors associated with renal bone disease.
  • Nutritional status by a dietitian.
  • Psychosocial needs by a social worker.
  • Dialysis access type and maintenance (for example, arteriovenous fistulas, arteriovenous grafts, and peritoneal catheters).
  • The patient’s abilities, interests, preferences, and goals, including the desired level of participation in the dialysis care process; the preferred modality (hemodialysis or peritoneal dialysis); the preferred setting (for example, home dialysis); and the patient’s expectations for care outcomes.
  • Suitability for a transplantation referral based on criteria developed by the prospective transplantation center and its surgeons. If the patient isn’t suitable for transplantation referral, document the basis for nonreferral in the patient’s medical record.
  • Family and other support systems.
  • Current patient physical activity level.

Assessment Frequency for Patients Admitted to the Dialysis Facility

Complete an initial comprehensive assessment on all new patients (all admissions to a dialysis facility), within the latter of 30 calendar days or 13 outpatient hemodialysis sessions, starting with the first outpatient dialysis session.

After completing the initial assessment, complete a follow-up comprehensive reassessment within 3 months to provide information to adjust the patient’s plan of care (POC), as specified in 42 CFR 494.90.

Assessment of Treatment Prescription

On an ongoing basis, assess the adequacy of the patient’s dialysis prescription, as described in 42 CFR 494.90(a)(1), as follows:

• Hemodialysis patients: At least monthly by calculating delivered Kt/V or an equivalent measure
• Peritoneal dialysis patients: At least every 4 months by calculating weekly delivered Kt/V or an equivalent measure

Patient Reassessment

According to 42 CFR 494.80(a)(1)–(a)(13), the ESRD clinic must conduct a comprehensive reassessment of each patient and a revision of the plan of care at least:

• Annually for stable patients
• Monthly for unstable patients, including, but not limited to, patients with 1 of the following:
  • Extended or frequent hospitalizations
  • Marked deterioration in health status
  • Significant change in psychosocial needs
  • Concurrent poor nutritional status, unmanaged anemia, and inadequate dialysis

Patient POC

The interdisciplinary team must develop and start a written, individualized comprehensive POC that specifies the services necessary to discuss the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and must include measurable and expected outcomes and estimated timetables to achieve those outcomes, as specified in 42 CFR 494.90.

The outcomes specified in the patient POC must be consistent with current evidence-based, professionally accepted clinical practice standards.

Patient POC Development

For each patient, the interdisciplinary team must develop a POC that addresses, but isn’t limited to, the following:

• Dose of dialysis: The interdisciplinary team provides the necessary care and services to manage the patient’s volume status and achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally accepted clinical practice standard for adequacy of dialysis.
• Nutritional status: The interdisciplinary team provides the necessary care and counseling services to achieve and sustain an effective nutritional status. Measure the patient’s albumin level and body weight at least monthly. The interdisciplinary team may also check other evidence-based, professionally accepted clinical nutrition indicators.
• Mineral metabolism: The interdisciplinary team provides the necessary care to manage mineral metabolism and prevent or treat renal bone disease.
• Anemia: The interdisciplinary team provides the necessary care and services to achieve and sustain the clinically proper hemoglobin/hematocrit level. Measure the patient’s hemoglobin/hematocrit at least monthly. The dialysis facility must evaluate the patient’s anemia management needs. For a home dialysis patient, the facility must evaluate whether the patient can safely, aseptically, and effectively administer erythropoiesis-stimulating agents and store this medication under refrigeration if necessary. Routinely check the patient’s response to erythropoiesis-stimulating agents, including blood pressure levels and use of iron stores.
• Vascular access: The interdisciplinary team provides vascular access monitoring and proper, prompt referrals to achieve and sustain vascular access. Evaluate the hemodialysis patient for the right vascular access type, taking into consideration comorbidity conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. Watch the patient’s vascular access to prevent access failure, including by checking arteriovenous grafts and fistulae for symptoms of stenosis.
• Psychosocial status: The interdisciplinary team provides the necessary monitoring and social work interventions. These include counseling services and referrals for other social services to help the patient in achieving and sustaining a proper psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more often on an as-needed basis.
• Modality:
  • Home dialysis: The interdisciplinary team identifies a plan for the patient’s home dialysis or explains why the patient isn’t a candidate for home dialysis.
  • Transplantation status: When the patient is a transplant referral candidate, the interdisciplinary team develops plans for pursuing transplantation. In the patient’s POC, include documentation of the:
    • Plan for transplantation if the patient accepts the transplantation referral
    • Patient’s decision if the patient is a transplantation referral candidate but declines the transplantation referral
    • Reasons for the patient’s nonreferral as a transplantation candidate as documented following 42 CFR 494.80(a)(10)
• Rehabilitation status: The interdisciplinary team must help the patient achieve and sustain the level of productive activity the patient wants, including the educational needs of pediatric patients (patients under age 18), and make rehabilitation and vocational rehabilitation referrals

Patient POC Implementation

The patient’s POC must be:

• Completed by the interdisciplinary team, including the patient if the patient wants
• Signed by team members, including the patient or the patient’s designee. If the patient chooses not to sign the POC, document their choice on the POC, along with the reason they didn’t sign

Start the initial POC within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions, starting with the first session. Start monthly or annual updates of the POC within 15 days of completing the other patient assessments specified in 42 CFR 494.80(d).

If the patient doesn’t achieve the expected outcome, the interdisciplinary team adjusts the patient’s POC to achieve the specified goals. When a patient is unable to achieve the desired outcomes, the team:

• Adjusts the plan of care to show the patient’s current condition
• Documents in the medical record the reasons why the patient was unable to achieve the goals
• Starts POC changes to address the issues identified in 42 CFR 494.90(b)(3)(ii)

A dialysis facility must make sure a physician, nurse practitioner, clinical nurse specialist, or physician’s assistant providing ESRD care sees all dialysis patients at least monthly, as shown by a monthly progress note placed in the medical record, and periodically sees hemodialysis patients while they’re getting in-facility dialysis.

Transplantation Referral Tracking

The interdisciplinary team:

• Tracks the results of each kidney transplant center referral
• Checks the status of any facility patients who are on the transplant wait list
• Communicates with the transplant center about patient transplant status at least annually and when the transplant candidate status changes

Patient Education & Training

The patient POC must include, as applicable, education and training for patients and family members or caregivers or both in aspects of the dialysis experience, dialysis management, infection prevention and personal care, home dialysis and self-care, quality of life, rehabilitation, transplantation, and the benefits and risks of various vascular access types.