1. If It’s JULY, It’s RULE TIME!
Update: PPS and QIP
Kathleen Smith, RN, BS, CNN
VP Government Affairs
Fresenius Medical Care

2. Take-Aways Equivalency Payment Mechanism (for more than 3 tmts/week)
Change in ESRD PPS Base Rate
Equivalency Payment Mechanism (for more than 3 tmts/week)
Retain medical justification for >3 tmts/week and training treatment limits
Budget neutral home dialysis training rate
Retain wage index floor of
Continue to set outlier percent target at 1%
Acute Kidney Injury

3. Important New Issue: Acute Kidney Injury
CMS changed the site of service for out-patient dialysis for individuals with AKI from the hospital outpatient department (HOPD) to outpatient dialysis facilities & HOPDs.
Payment rate is equal to ESRD PPS CY ($231.04)
Wage index adjustment will be applied
NO OTHER PAYMENT ADJUSTMENTS
Individuals with AKI are NOT PAID under the ESRD PPS
Facilities can bill for non-renal drugs/biologicals, lab services, and supplies that would have been furnished in the HOPD
No changes to Conditions for Coverage

4. Acute Kidney Injury (continued)
Utilization of services may differ for those with AKI, so…
CMS will pay for ALL hemodialysis treatments for AKI patients in a week
Home dialysis benefit will not be extended to AKI patients because of need for supervision
CMS seeks comment for future rulemaking as to whether revised Conditions for Coverage include:
Addressing AKI in the CfCs
Should care planning for AKI patients be addressed differently

5. Acute Kidney Injury (continued)
CMS intends to monitor utilization of dialysis, separately billable items & services.
Billing:
Specific condition code
AKI diagnosis
Appropriate revenue code
CPT code
Requirements will be issued in sub-regulatory guidance

6. Summary of Proposed PPS Rule
Increase PPS base rate by 0.35% = $231.04
Equivalency Payment Mechanism Implemented July 1, 2017: determines per treatment rate when >3 tmts/week on the claim
Retains medical justification for >3 tmts/week & training tmt limits
Increase home training payment by $45.41 to total payment of $95.97 in a budget neutral manner by reducing base rate $0.06
Modify claims and cost reports for better understanding of training costs

7. Equivalency Payment Mechanism for >3 treatments per week
CMS responded to concerns:
13 or 14 treatments/month can’t be reported on the claim
Equivalency Payment Mechanism (for more than 3 tmts/week)
Retain medical justification for >3 tmts/week and training treatment limits
Budget neutral home dialysis training rate
Retain wage index floor of
Continue to set outlier percent target at 1%

8. Equivalency Payment Mechanism for >3 treatments per week
Equivalency Payment Mechanism (for >3 tmts/week): e.g. 5 tmts/week
(Adjusted Base Rate * 3/5) + (Outlier Payment * 3/5) = per treatment payment
Retain medical justification for >3 tmts/week and training treatment limits
Budget neutral home dialysis training rate
Retain wage index floor of
Continue to set outlier percent target at 1%

9. CMS notes that…
… the intent of this proposal is to provide a mechanism for payment for evolving technologies that provide for a different schedule of treatments that accommodate a patent’s preference and thereby improve that patient’s quality of life. In the event that a beneficiary receives traditional HD treatments in excess of 3 per week without medical justification for the additional treatments, these additional treatments will not be paid.

10. CMS notes that…
This policy would not be applied to home and self-dialysis training treatments; facilities would receive the full ESRD PPS base rate during training. It is investigating payments and costs related to training and plans to refine the training payment in the future. (PD training limited to 15; HD training limited to 25.)

11. Training Add-on Payment Adjustment
Clarification:
CMS never intended that the training add-on payment would reimburse for all costs.
Add-on for RN training time + ESRD PPS amount = Medicare training treatment payment
Sub-regulatory guidance will be issued re retraining tmts.

12. Home Dialysis Training: CMS Plans…
In-depth analysis of cost report data elements
Comprehensive audits of cost reports (CR)
Updating the independent facility CR (more granularity)
Training time:
KDOQI guidelines - HD-4hrs, PD-2hrs
Current payment reflects 1.5 hrs
CMS proposes to increase the number of hours using a wtd avg formula until it has sufficient data re what adequate payment should be

13. HD Training Add-on: CMS Proposes…
…to base the payment for HD training on 2.66 hrs of treatment Based on weighted avg: 67% of tmts at 2 hrs/tmt and 33% of tmts at 4 hrs/tmt Result in training add-on increased by $45.41 to $ Will be made in a budget neutral manner, reducing base rate by $0.06.

14. Summary of PY QIP
PY 2018
Correct the description of the Small Facility Adjuster to clarify the definition of the national mean measure rate is set at the benchmark, which is the case with other measures

15. Summary of PY QIP
PY 2019
Add the expanded NHSN Dialysis Event Reporting Measure
Create a new NHSN BSI Measure Topic, weighting the NHSN BSI Clinical Measure at 60% and the NHSN Dialysis Event Reporting Measure at 40%
Create a new Safety Domain & change domain weights
Continue data validation studies

16. Summary of PY QIP
PY 2020
Replace the Mineral Metabolism Reporting Measure with a Serum Phosphorous Reporting Measure
Add a standardized Hospital Ratio Measure & an Ultrafiltration Rate Reporting Measure
Set the performance period at CY 2018, except for the NHSN Healthcare Personnel Influenza Vaccination Reporting Measure, which would be 10/1/16 through 3/31/17.

17. QIP Measure Process Remember, CMS goal for ESRD QIP measures
Promote high-quality care
Strengthen the goals of the National Quality Strategy
MIPPA requirement: Use National Quality Forum (NQF) endorsed measures when available
CMS may add measures if NQF endorsed measures do not exist or are not sufficient for the topic area
The law requires measures on anemia & adequacy

18. Knowledge Is Key Stay current with the QIP measures
Be sure ALL team members (RNs, PCTs, MSWs, RDs, & physicians) are aware of QIP and the implications for payment
You must meet the performance standard to avoid payment reduction: aim for much higher! It is the right thing to do.