Mike Burney addressed the QMS Users Group in Las Vegas, NV, just hours ago. Take a look at what he had to say.
As you know, MIPPA 2008 required implementation of a new ESRD bundled payment system to be effective January 1, 2011. The Secretary is required to establish a payment system under which a single payment, after applicable adjustments, is made to renal dialysis facilities in lieu of any other payment. The term renal dialysis services is defined to include separately billable diagnostic lab services used for the treatment of ESRD currently billable under the basic case mix composite rules.
The proposed rule that came out in the Fall of 2009 stated that all testing ordered by the MCP (physician receiving monthly capitation payments) would be included. Inadvertently, CMS created a situation where the MCP physicians would be discouraged from treating the dialysis patients for non ESRD conditions such as diabetes because the resources would be included in the bundle. It is possible that the MCP physicians would have directed the patient back to a primary physician or sent the patient to the hospital for treatment for what had normally been handled in the dialysis center environment. This would have caused the patients to make even more visits to health care facilities and increased the burden on the ill patients and on the Medicare program.
Fortunately, after a multitude of comments to the proposed rule from patient advocacy groups, dialysis organizations, laboratory associations, and individual care givers, CMS accepted a more condensed list of lab tests to be included in the bundle. The Kidney Care Council had submitted a list of tests that comprised approximately 95% of the normal testing for dialysis patients. The CMS final list includes 53 ESRD related laboratory tests that will be subject to the new ESRD Prospective Payment System. The list appears to have been developed based on ESRD related care, including mandated testing for disease control in a dialysis setting. Notable testing not included in the list was Prothrombin Time testing, diabetic monitoring, therapeutic drug monitoring, non access related cultures, PSA testing for male patients over 50 years of age, and lipid testing.
A very important part of the new bundling rule was the requirement for all MCP ordered laboratory tests provided for the patient to be included on the dialysis center’s claim form. Those tests that are not related to ESRD will be identified by modifiers and a separate payment will be allowed. CMS released the modifiers two hours ago. It is important to note that CMS was clear that it will not preclude ESRD facilities from drawing non-ESRD related lab tests for the benefit of the patients. The language could also lead one to believe that the lab is responsible for submitting claims to CMS similar to the way that non-composite testing is reimbursed today. Also, the facilities can choose to go “all in” on January 1, 2011 or do a partial conversion. Regardless, laboratories will not be able to seek reimbursement from Medicare for ESRD related testing. We are awaiting clarification from CMS regarding this matter. Everyone that I have talked with expects that the dialysis facility claim form will require all ESRD related lab testing be included for informational purposes.
Lastly, the dialysis and lab industries argued that the lab portion of the bundle should not be subject to a 20% copay because of previous mandates. CMS has argued that the ESRD bundle includes lab charges related to the care of dialysis patients and that because this portion is now part of “dialysis related services”, the 20% copay does apply. The rate set for lab testing that is included in the bundle is $8.40 per treatment before deducting the 20% copayment. Assuming 12.5 treatments per month for the average patient, the lab portion of the new bundle equals $84 after the deduction for copayments.
How will laboratories provide the necessary information to the dialysis billing functions? At this time, I understand that lab providers are working with dialysis facility administration to design a standard file that will allow for the electronic transfer of this information. Presently, very little of this functionality exists and if the new regulations were required now, the lab providers could only supply the information on a report that would need to be manually entered by the dialysis provider’s billing department.