CMS Pub. 100-04, ch. 8, § 10.1

• The End Stage Renal Disease (ESRD) Prospective Payment System (PPS) provides a

per treatment unit of payment. The per treatment unit of payment is the same base rate

that is paid for all dialysis treatment modalities furnished by an ESRD facility. The

policy allows for 3 PPS payments per week. When a beneficiary’s plan of care requires

more than three weekly dialysis treatments, whether HD or daily PD, claim edits are

applied to ensure that Medicare payment on the monthly claim is consistent with the 3-times weekly dialysis treatment payment limit. Thus, for a 30-day month, payment is

limited to 13 treatments, and for a 31-day month, payment is limited to 14 treatments,

with exceptions made for medical justification.

• ESRD facilities billing for more than 13 or 14 treatments per month must provide

medical justification as required by the Medicare Administrative Contractor in order to

receive payment for the additional treatments. Additional treatments provided without

meeting the medical justification required must include the modifier CG on the claim

line. This modifier indicates that the facility attests the additional treatment does not meet

medical justification requirements. Additional treatments billed without medical

justification do not receive payment. Non-covered treatments are not considered in the

outlier payment calculation.

• This policy does not apply for training and retraining treatments billed within the

allowable limits. See section 50.8 of this chapter for training and retraining treatments.