CMS Eliminates 50-50 Payment Rule for ESRD Lab Services

Effective April 1, 2015, laboratory services provided in end-stage renal disease (ESRD) facilities will no longer be paid in accordance with the 50-50 rule. The Medicare ESRD benefit previously provided payment for dialysis and some dialysis-related services under a per-treatment composite rate. Separate payment for automated multichannel chemistry laboratory tests was determined according to the 50-50 rule where separate payment for the lab services was subject to whether 50 percent or more of the tests performed were in excess of the composite rate. ESRD facilities were required to report the following modifiers:

• CD to indicate if the laboratory test was included in the composite rate;
• CE to indicate the laboratory tests exceeded the frequency of the composite rate; or
• CF to indicate the laboratory test was not included in the composite rate.

In addition, ESRD facilities were required to itemize on the claim the individual lab Current Procedural Terminology codes rather than reporting disease panel codes. With the implementation of the ESRD Prospective Payment System (PPS), ESRD lab services are no longer paid in accordance with the 50-50 rule. Change request 8957, issued Nov. 6, 2014, instructs that for ESRD claims with dates of service on or after April 1, 2015, ESRD facilities will no longer be required to submit the 50-50 rule modifiers CD, CE, and CF. The ESRD PPS requires that all renal dialysis laboratory services be paid in the ESRD facility bundled payment and therefore may only be billed by the ESRD facility. In addition, ESRD facilities should report organ or disease-oriented panel codes on Type of Bill 072X for codes listed in the following table when performed for an ESRD beneficiary if:

• These codes best describe the laboratory services provided to the beneficiary, which are paid under the ESRD PPS; or
• The test is not related to the treatment of ESRD, in which case the facility would append modifier “AY” and the service may be paid separately from the ESRD PPS.

 

ESRD Test Codes
HCPCS/CPT Code	Description
80047	Metabolic anel ionized CA
80048	Metabolic panel total CA
80051	Electrolyte panel
80053	Comprehen metabolic panel
80061	Lipid panel
80069	Renal function panel
80076	Hepatic function panel
Source: CMS Change Request 8957.

  Transmittal R3116CP (CR 8957) is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2014-Transmittals.html Takeaway: Effective April 1, 2015, all renal dialysis laboratory services will be paid in the ESRD facility bundled payment.