CMS Pub. 100-04, ch. 8, § 50.3

Stage Renal Disease Prospective Payment System ESRD PPS

(Rev. 13740; Issued: 04-17-26; Effective: 07-01-26; Implementation: 07-06-26)

The term Medicare beneficiary identifier (MBI) is a general term describing a

beneficiary’s Medicare identification number. For purposes of this manual, Medicare

beneficiary identifier references both the Health Insurance Claim Number (HICN) and

the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition

period and after for certain business areas that will continue to use the HICN as part of

their processes.

The electronic form required for billing ESRD claims is the ASC X12 837 institutional

claim transaction. The paper form, where permissible, is Form CMS-1450.

The coding and related descriptions for the following items are identical for the ASC X12

837 institutional claim format and Form CMS-1450. See the related X12 implementation

guide or Chapter 25, respectively, for where the information is reported.

Type of Bill

Acceptable codes for Medicare are:

721 - Admit Through Discharge Claim - This code is used for a bill encompassing an

entire course of outpatient treatment for which the provider expects payment from the

payer.

722 - Interim - First Claim - This code is used for the first of an expected series of

payment bills for the same course of treatment.

723 - Interim - Continuing Claim - This code is used when a payment bill for the same

course of treatment is submitted and further bills are expected to be submitted later.

724 - Interim - Last Claim - This code is used for a payment bill which is the last of a

series for this course of treatment. The “Through” date of this bill (FL 6) is the discharge

date for this course of treatment.

727 - Replacement of Prior Claim - This code is used when the provider wants to correct

(other than late charges) a previously submitted bill. The previously submitted bill needs

to be resubmitted in its entirety, changing only the items that need correction. This is the

code used for the corrected or “new” bill.

728 - Void/Cancel of a Prior Claim - This code indicates this bill is a cancel-only

adjustment of an incorrect bill previously submitted. Cancel-only adjustments should be

used only in cases of incorrect provider identification numbers, incorrect Medicare

beneficiary identifier, duplicate payments and some OIG recoveries. For incorrect

provider numbers or Medicare beneficiary identifier, a corrected bill is also submitted

using a code 721.

Statement Covers Period (From-Through) - Hospital-based and independent renal

dialysis facilities:

The beginning and ending service dates of the period included on this bill. Note: ESRD

services are subject to the monthly billing requirements for repetitive services.

Condition Codes

Hospital-based and independent renal facilities complete these items. Note that one of

the codes 71-76 is applicable for every bill. Special Program Indicator codes A0-A9 are

not required.

Condition Code Structure (only codes affecting Medicare payment/processing are

shown).

02 - Condition is Employment Related - Providers enter this code if the patient alleges

that the medical condition causing this episode of care is due to environment/events

resulting from employment.

04 - Information Only Bill - Providers enter this code to indicate the patient is a member

of a Medicare Advantage plan.

59 – Non-Primary ESRD Facility – Providers enter this code to indicate that ESRD

beneficiary received non-scheduled or emergency dialysis services at a facility other than

his/her primary ESRD dialysis facility.

71 - Full Care in Unit - Providers enter this code to indicate the billing is for a patient

who received staff-assisted dialysis services in a hospital or renal dialysis facility.

72 - Self-Care in Unit - Providers enter this code to indicate the billing is for a patient

who managed his own dialysis in a hospital or renal dialysis facility.

73 - Self-Care in Training - Providers enter this code to indicate the billing is for special

dialysis services where a patient and his/her helper (if necessary) were learning to

perform dialysis.

74- Home-Providers enter this code to indicate the billing is for a patient who received

dialysis services at home.

76 - Back-up In-facility Dialysis - Providers enter this code to indicate the billing is for a

home dialysis patient who received back-up dialysis in a facility.

80- Home Dialysis-Nursing Facility – Home dialysis furnished in a SNF or Nursing

Facility (report with condition code 74).

84 – Acute Kidney Injury- Provider enters this code to indicate the claim is for an AKI

patient.

87 – Retraining – Provider enters this code to indicate the billing is for retraining of the

patient and his/her helper (if necessary) to perform self-care dialysis.

H3 – Reoccurrence of GI Bleed comorbid category

H4 – Reoccurrence of Pneumonia comorbid category

H5 – Reoccurrence of Pericarditis comorbid Category

Occurrence Codes and Dates

Codes(s) and associated date(s) defining specific events(s) relating to this billing period

are shown. Event codes are two alpha-numeric digits, and dates are shown as six

numeric digits (MM-DD-YY). When occurrence codes 01-04 and 24 are entered, make

sure the entry includes the appropriate value code, if there is another payer involved.

Occurrence and occurrence span codes are mutually exclusive. Occurrence codes have

values from 01 through 69 and A0 through L9. Occurrence span codes have values from

70 through 99 and M0 through Z9.

24 - Date Insurance Denied - Code indicates the date of receipt of a denial of coverage by

a higher priority payer.

33 - First Day of Medicare Coordination Period for ESRD Beneficiaries Covered by an

EGHP - Code indicates the first day of the Medicare coordination period during which

Medicare benefits are payable under an EGHP. This is required only for ESRD

beneficiaries.

51 – Date of last Kt/V reading. For in-center hemodialysis patients, this is the date of the

last reading taken during the billing period. For peritoneal dialysis patients and home

hemodialysis patients, this date may be before the current billing period but should be

within 4 months of the claim date of service.

Occurrence Span Code and Dates

Code(s) and associated beginning and ending dates(s) defining a specific event relating to

this billing period are shown. Event codes are two alpha-numeric digits and dates are

shown numerically as MM-DD-YY.

74 - Noncovered Level of Care - This code is used for repetitive Part B services to show a

period of inpatient hospital care or of outpatient surgery during the billing period. Use of

this code will not be necessary for ESRD claims with dates of service on or after April 1,

2007 due to the requirement of ESRD line item billing.

Document Control Number (DCN)

Required for all provider types on adjustment requests. (Bill Type/FL=XX7). All

providers requesting an adjustment to a previous processed claim insert the DCN of the

claims to be adjusted.

Value Codes and Amounts

Code(s) and related dollar amount(s) identify monetary data that are necessary for the

processing of this claim. The codes are two alphanumeric digits and each value allows

up to nine numeric digits (0000000.00). Negative amounts are not allowed. Whole

numbers or non-dollar amounts are right justified to the left of the dollars and cents

delimiter. Some values are reported as cents, so refer to specific codes for instructions.

If more than one value code is shown for a billing period, show the codes in ascending

alphanumeric sequence.

Value Code Structure (Only codes used to bill Medicare are shown.):

06 - Medicare Blood Deductible - Code indicates the amount the patient paid for un-replaced deductible blood.

13 - ESRD Beneficiary in the 30- Month Coordination Period with an EGHP - Code

indicates that the amount shown is that portion of a higher priority EGHP payment on

behalf of an ESRD beneficiary that applies to covered Medicare charges on this bill. If

the provider enters six zeros (0000.00) in the amount field, it is claiming a conditional

payment because the EGHP has denied coverage or there has been a substantial delay in

its payment. Where the provider received no payment or a reduced payment because of

failure to file a proper claim, this is the amount that would have been payable had it filed

a proper claim.

17 – Not submitted by the provider. The Medicare shared system will display this payer

only code on the claim when an outlier payment is being made. The value is the total

claim outlier payment.

19 – Not submitted by the provider. The Medicare shared system will display this payer

only code on the claim for low volume providers to identify the amount of the low

volume adjustment being included in the provider’s reimbursement.

37 - Pints of Blood Furnished - Code indicates the total number of pints of blood or units

of packed red cells furnished, whether or not replaced. Blood is reported only in terms of

complete pints rounded upwards, e.g., 1 1/4 pints is shown as 2 pints. This entry serves a

basis for counting pints towards the blood deductible. Hospital-based and independent

renal facilities must complete this item.

38 - Blood Deductible Pints - Code indicates the number of un-replaced deductible pints

of blood supplied. If all deductible pints furnished have been replaced, no entry is made.

Hospital-based and independent renal facilities must complete this item.

39 - Pints of Blood Replaced - Code indicates the total number of pints of blood donated

on the patient’s behalf. Where one pint is donated, one pint is replaced. If arrangements

have been made for replacement, pints are shown as replaced. Where the provider

charges only for the blood processing and administration, i.e., it does not charge a

“replacement deposit fee” for un-replaced pints, the blood is considered replaced for

purposes of this item. In such cases, all blood charges are shown under the 039x revenue

code series, Blood Administration. Hospital-based and independent renal facilities must

complete this item.

44 - Amount Provider Agreed To Accept From Primary Payer When This Amount is

Less Than Charges But Higher than Payment Received - Code indicates the amount

shown is the amount the provider was obligated or required to accept from a primary

payer as payment in full when that amount is less than the charges but higher than

amount actually received. A Medicare secondary payment is due.

47 - Any Liability Insurance - Code indicates amount shown is that portion from a higher

priority liability insurance made on behalf of a Medicare beneficiary that the provider is

applying to Medicare covered services on this bill. If six zeros (0000.00) are entered in

the amount field, the provider is claiming conditional payment because there has been

substantial delay in the other payer’s payment.

48 - Hemoglobin Reading - Code indicates the most recent hemoglobin reading taken

before the start of this billing period. This is usually reported in three positions with a

decimal. Use the right of the delimiter for the third digit. The blood sample for the

hemoglobin reading must be obtained before the dialysis treatment. If a hemoglobin

value is not available facilities must report the value 99.99.

49 - Hematocrit Reading - Code indicates the most recent hematocrit reading taken

before the start of this billing period. This is usually reported in two positions (a

percentage) to the left of the dollar/cents delimiter. If the reading is provided with a

decimal, use the position to the right of the delimiter for the third digit. The blood

sample for the hemoglobin reading must be obtained before the dialysis treatment. If a

hematocrit value is not available facilities must report the value 99.99

71 - Funding of ESRD Networks - Code indicates the amount of Medicare payment

reduction to help fund the ESRD networks. This amount is calculated by the A/B MAC

(A) and forwarded to CWF. (See §120 for discussion of ESRD networks).

79 – Not submitted by the provider. The Medicare shared system will display this payer

only code on the claim. The value represents the dollar amount for Medicare allowed

payments applicable for the calculation in determining an outlier payment.

A8 – Weight of Patient – Code indicates the weight of the patient in kilograms. The

weight of the patient should be measured after the last dialysis session of the month.

A9 – Height of Patient – Code indicates the height of the patient in centimeters. The

height of the patient should be measured during the last dialysis session of the month.

The measurement is required no less frequently than once per year but must be reported

on every claim. This height is as the patient presents.

D5 – Result of last Kt/V reading. For in-center hemodialysis patients this is the last

reading taken during the billing period. For peritoneal dialysis patients and home

hemodialysis this may be before the current billing period but should be within 4 months

of the claim date of service.

D6 – The number of minutes (rounded to the nearest whole minute) between the

beginning of dialysis treatment time (i.e. , when the start button on the blood pump is

pushed) and the end of dialysis treatment time (i.e., when the stop button on the blood

pump is pushed). ESRD facilities are not required to reduce the total count of minutes to

account for disruptions due to machine failures, bathroom breaks, or other stoppage, but

the number of minutes reported should not include time outside the start and end of the

dialysis session (for example, time when the patient is in-center waiting to be seated in a

chair). The time on dialysis machine duration begins when the actual dialysis treatment

starts and ends when the actual dialysis treatment is complete. The units reported must

exceed 1.

Q8 – Not submitted by the provider. The Medicare shared system will display this payer

only code on the claim. The value represents the dollar amount for the services

applicable to the calculation of the transitional drug add-on adjustment (TDAPA).

QG – Not submitted by the provider. The Medicare shared system will display this payer

only code on the claim. The value represents the dollar amount for the services

applicable to the calculation of the new innovative equipment and supplies add-on

adjustment (TPNIES).

QH – Not submitted by the provider. The Medicare shared system will display this payer

only code on the claim. The value represents the dollar amount for the services

applicable to the calculation of the new innovative equipment add-on for capital related

assets.

Revenue Codes

The revenue code for the appropriate treatment modality is billed (e.g., 0821 for

hemodialysis). Effective January 1, 2015, ESRD facilities are required to report on the

claim the drugs identified on the consolidated billing list provided at

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/ESRDpayment/Consolidated_Billing.html

082X - Hemodialysis - Outpatient or Home Dialysis - A waste removal process

performed in an outpatient or home setting, necessary when the body’s own kidneys have

failed. Waste is removed directly from the blood. Detailed revenue coding is required.

Therefore, services may not be summed at the zero level.

0 - General Classification HEMO/OP OR HOME

1 – Hemodialysis/Composite or other rate HEMO/COMPOSITE

2 - Home Supplies HEMO/HOME/SUPPL

3 - Home Equipment HEMO/HOME/EQUIP

4 - Maintenance 100% HEMO/HOME/100%

5 - Support Services HEMO/HOME/SUPSERV

9 - Other Hemodialysis Outpatient HEMO/HOME/OTHER

Report hemodiafiltration sessions using revenue code 0829.

083X - Peritoneal Dialysis - Outpatient or Home - A waste removal process performed in

an outpatient or home setting, necessary when the body’s own kidneys have failed.

Waste is removed indirectly by instilling a special solution into the abdomen using the

peritoneal membrane as a filter.

0 - General Classification PERITONEAL/OP OR HOME

1 - Peritoneal/Composite or other rate PERTNL/COMPOSITE

2 - Home Supplies PERTNL/HOME/SUPPL

3 - Home Equipment PERTNL/HOME/EQUIP

4 - Maintenance 100% PERTNL/HOME/100%

5 - Support Services PERTNL/HOME/SUPSERV

9 -Other Peritoneal Dialysis PERTNL/HOME/OTHER

084X - Continuous Ambulatory Peritoneal Dialysis (CAPD) - Outpatient - A continuous

dialysis process performed in an outpatient or home setting, which uses the patient’s

peritoneal membrane as a dialyzer.

0 - General Classification CAPD/OP OR HOME

1 - CAPD/Composite or other rate CAPD/COMPOSITE

2 - Home Supplies CAPD/HOME/SUPPL

3 - Home Equipment CAPD/HOME/EQUIP

4 - Maintenance 100% CAPD/HOME/100%

5 - Support Services CAPD/HOME/SUPSERV

9 -Other CAPD Dialysis CAPD/HOME/OTHER

085X - Continuous Cycling Peritoneal Dialysis (CCPD) - Outpatient. - A continuous

dialysis process performed in an outpatient or home setting, which uses the patient’s

peritoneal membrane as a dialyzer.

0 - General Classification CCPD/OP OR HOME

1 - CCPD/Composite or other rate CCPD/COMPOSITE

2 - Home Supplies CCPD/HOME/SUPPL

3 - Home Equipment CCPD/HOME/EQUIP

4 - Maintenance 100% CCPD/HOME/100%

5 - Support Services CCPD/HOME/SUPSERV

9 -Other CCPD Dialysis CCPD/HOME/OTHER

088X - Miscellaneous Dialysis - Charges for Dialysis services not identified elsewhere.

0 - General Classification DAILY/MISC

1 – Ultrafiltration DAILY/ULTRAFILT

2 – Home dialysis aid visit HOME DIALYSIS AID VISIT

9 -Other misc. Dialysis DAILY/MISC/OTHER

HCPCS/Rates

All ESRD hemodialysis claims must include HCPCS 90999 on the line reporting revenue

code 082x. All AKI claims must include HCPCS G0491.

Modifiers

Modifiers are required with ESRD Billing for reporting the adequacy of dialysis and the

vascular access. For information on modifiers required for these quality measures see

50.9 of this chapter.

For information on reporting modifiers applicable to the Erythropoietin Stimulating

Agents refer to section 60.4 of this chapter.

Route of administration modifiers required are JA, JB and JE.

For information on reporting the AY modifier for services not related to the treatment of

ESRD, see sections 60.2.1.1 - Separately Billable ESRD Drugs and 60.1 - Lab Services.

For information on reporting the CG modifier for additional treatments provided without

medical justification, see section 10.1 of this chapter.

For information on reporting the JW and JZ modifiers for drugs and biologicals see

section 50.2.

ESRD facilities should not bill any renal dialysis service with the AX modifier, unless

otherwise notified by CMS, for dates of service on or after July 1, 2026.

Service Date

Report the line item date of service for each dialysis session and each separately payable

item or service.

Service Units

Hospital-based and independent renal facilities must complete this item. The entries

quantify services by revenue category, e.g., number of dialysis treatments. Units are

defined as follows:

0634 - Erythropoietin (EPO) - Administrations, i.e., the number of times an injection of

less than 10,000 units of EPO was administered. For claims with dates of service on or

after January 1, 2008, facilities use the units field as a multiplier of the dosage description

in the HCPCS to arrive at the dosage amount per administration.

0635 - Erythropoietin (EPO) - Administrations, i.e., the number of times an injection of

10,000 units or more of EPO was administered. For claims with dates of service on or

after January 1, 2008, facilities use the units field as a multiplier of the dosage description

in the HCPCS to arrive at the dosage amount per administration.

082X - (Hemodialysis) - Sessions

083X - (Peritoneal) - Sessions

084X - (CAPD) – Per Day

085X - (CCPD) – Per Day

Effective April 1, 2007, the implementation of ESRD line item billing requires that each

dialysis session be billed on a separate line. As a result, claims with dates of service on

or after April 1, 2007 should not report units greater than 1 for each dialysis revenue code

line billed on the claim.

Total Charges

Hospital-based and independent renal facilities must complete this item. Hospital-based

facilities must show their customary charges that correspond to the appropriate revenue

code. They must not enter their composite or the EPO` rate as their charge. Independent

facilities may enter their composite and/or EPO rates.

Neither revenue codes nor charges for services included in the composite rate may be

billed separately, but should be itemized on ESRD facility claims as appropriate.

Hospitals must maintain a log of these charges in their records for cost apportionment

purposes.

Services which are provided but which are not included in the composite rate may be

billed as described in sections that address those specific services.

The last revenue code entered in as 000l represents the total of all charges billed.

Principal Diagnosis Code

Hospital-based and independent renal facilities must complete this item and it should

include a diagnosis of end stage renal disease for patients with ESRD. For patients with

AKI see section 40 of this chapter.

Other Diagnosis Code(s)

For claims with dates of service on or after January 1, 2011 renal dialysis facilities report

the appropriate diagnosis code(s) for comorbidity conditions eligible for an adjustment.