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Medical Coding News Archives

New Quality Data Reporting for Renal Dialysis Facilities

February 23, 2010:

Renal dialysis facilities will be required to report new quality data for dialysis adequacy, infection, and vascular access on all end-stage renal disease (ESRD) and hemodialysis claims on or after July 1, 2010. The new data reported will enable the Centers for Medicare & Medicaid Services (CMS) to implement a specific quality incentive payment for dialysis providers.

The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) requires CMS to create a quality improvement program to ensure that high quality care is provided in all ESRD facilities by January 1, 2012. The program would provide financial incentives linked to improved dialysis quality and outcomes by tying a facility’s Medicare payment rate to the facility’s performance on quality-of-care measures. Facilities that do not meet or exceed minimum performance standards could face payment reductions of up to 2 percent for a specified year.

Currently, CMS captures data from ESRD claims on two monthly quality-of-care measurements:
  • Anemia management (hemoglobin or hematocrit)
  • Hemodialysis adequacy (urea reduction ratio or URR)
The anemia management quality measure is reported with value codes 48 or 49 on bill type 72x and the most recent hemoglobin or hematocrit lab value. The hemodialysis adequacy measure, which uses the current urea reduction ratio (URR) lab value, is reported with HCPCS modifiers G1–G6 on hemodialysis line items:
  • G1 Most recent URR reading of less than 60
  • G2 Most recent URR reading of 60 to 64.9
  • G3 Most recent URR reading of 65 to 69.9
  • G4 Most recent URR reading of 70 to 74.9
  • G5 Most recent URR reading of 75 or greater
  • G6 ESRD patient for whom fewer than six dialysis sessions have been provided in a month

Two additional quality measures for hemodialysis patients that could also be collected using HCPCS modifiers include the use of an arteriovenous fistula with two needles (considered the best vascular access due to lowest occurrence of infections) and the use of any vascular catheter (associated with the highest rate of infections).

Consequently, modifiers will be required with ESRD billing for reporting the adequacy of dialysis, the presence of infection, and the vascular access. For dates of service on or after July 1, 2010, ESRD claims for hemodialysis must indicate the type of vascular access used for the delivery of the hemodialysis at the last hemodialysis session of the month. One of the following codes is required to be reported for hemodialysis revenue code 0821:
  • Modifier V5: Vascular catheter
  • Modifier V6: Arteriovenous graft
  • Modifier V7: Arteriovenous fistula
ESRD claims with dates of service on or after July 1, 2010, must indicate whether an infection was present at the time of treatment with one of the following on each dialysis revenue code line:
  • Modifier V8: Infection present
  • Modifier V9: No infection present
ESRD claims with dates of service on or after July 1, 2010, must also indicate the applicable the result and date of the patient’s last Kt/V (i.e., K-dialyzer clearance of urea; t-dialysis time; V-patient’s total body water) reading.
  • Value code D5: Result of last Kt/V reading
  • Occurrence code 51: Date of last Kt/V reading

If no Kt/V reading was performed, the provider must report the D5 with a value of 9.99.

Medicare systems will return 72x bill types to the provider on or after July 1, 2010, when the latest line item date of service billing for revenue code 0821 does not contain one of the following modifiers: V5, V6, or V7. Modifiers V5 through V9 are effective January 1, 2010, and the Medicare Integrated Code Editor has been updated to allow these codes to be reported for claims with dates of service on or after January 1, 2010, allowing providers to voluntarily report these modifiers beginning with claims for dates of service on or after January 1, 2010.

Sarah A. Serling, CPC, CPC-H, CPC-I, CCS-P, CCS
Clinical/Technical Editor


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