| (a) For services provided on or after the date that
the modernized Medicaid Management Information System (MMIS) becomes
operational, the reimbursement methodology for in-facility renal dialysis
treatment services and home renal dialysis treatment services is an
outpatient prospective payment system (OPPS). The OPPS used for reimbursement
is the 3M™ Enhanced Ambulatory Patient Grouping (EAPG) payment
methodology. EAPGs are a visit-based classification system intended
to reflect the type of resources utilized in outpatient encounters
for patients with similar clinical characteristics.
(b) For services prior to the date that the modernized
MMIS becomes operational, payment for in-facility renal dialysis treatment
services and home renal dialysis treatment services is based upon
the composite rate reimbursement methodology previously used by Medicare.
The composite rates reflect all changes enacted by the Balanced Budget
Refinement Act of 1999 (BBRA). Rates are based on available funds
and are subject to legislative appropriations.
(c) All required items and services included under
the composite rate must be made available by the facility, either
directly or under arrangements, for each dialysis patient. If the
facility fails to make available (either directly or under arrangements)
any item or service listed in this subsection, or any part of an item
or service listed in this subsection, then the facility cannot be
reimbursed any amount for items and services that the facility provides.
Required items and services include:
(1) medically necessary dialysis equipment and dialysis
support equipment;
(2) home dialysis support services including the delivery,
installation, maintenance, repair, and testing of home dialysis equipment,
and home support equipment;
(3) purchase and delivery of all necessary dialysis
supplies, except blood which is separately reimbursable under this
chapter;
(4) routine end-stage renal dialysis (ESRD) related
laboratory tests; and
(5) all dialysis services furnished by the facility's
staff.
(d) The following items and services also are included
in the composite rate and may not be billed separately when provided
by a dialysis facility:
(1) cardiac monitoring;
(2) catheter changes;
(3) crash cart usage for cardiac arrest;
(4) declotting of shunts by facility staff and any
supplies used to declot shunts;
(5) dialysate used during treatment;
(6) oxygen and administration of oxygen;
(7) staff time used to administer blood, inject separately
billable drugs, blood collection, and nonroutine peritoneal items;
(8) suture removal and dressing changes; and
(9) other items and services related to dialysis treatment,
as determined by HHSC.
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