ESRD, AKI billing changes to take effect July 1
CMS will no longer require end-stage renal disease (ESRD) facilities to report modifier -AX on claims eligible for certain add-on payment adjustments under the ESRD Prospective Payment System (PPS) starting July 1, 2026.
The ESRD PPS provides a single per-treatment payment to ESRD facilities to cover all resources used to furnish the patient’s outpatient dialysis. When appropriate, CMS applies the following add-on payment adjustments to the bundled payment:
- Transitional drug add-on payment adjustment (TDAPA) for certain new renal dialysis drugs and biological products
- Transitional payment for new and innovative equipment and supplies (TPNIES) for renal dialysis
The TPNIES does not apply to equipment considered to be a capital-related asset (CRA), unless it is a home dialysis machine for a single patient, according to CMS. The agency has historically required ESRD facilities that provide renal dialysis services that qualify for the TDAPA, TPNIES, and CRA TPNIES adjustment to report modifier -AX (item furnished in conjunction with dialysis services). However, starting July 1, these facilities are not to report the modifier for the following:
- New renal dialysis drugs and biological products eligible for the TDAPA
- Innovative equipment and supplies eligible for the TPNIES
- CRAs eligible for the CRA TPNIES
CMS will apply the pricing instructions for TDAPA and TPNIES when an ESRD facility reports a Healthcare Common Procedure Coding System (HCPCS) code on the applicable list with revenue code 0636 and 027X, respectively. For the CRA TPNIES, the instructions will apply when a facility reports a HCPCS code on the associated list with revenue code 0823, 0833, 0843, 0853, or 0889.
ESRD facilities are not to bill any renal dialysis services with modifier -AX for dates of service on or after July 1, 2026. CMS clarified that this change does not impact prior or remaining billing guidance for the TDAPA, TPNIES, and CRA TPNIES. This requirement change does not impact payments for renal dialysis services furnished to acute kidney injury (AKI) beneficiaries, which should not be reported with modifier -AX.
However, effective July 1, CMS will begin requiring ESRD facilities to use condition code 74 when billing AKI claims for dialysis in the home setting. These facilities are to use either condition code 76 or 87 when billing AKI claims for training/re-training for home dialysis and self-dialysis.
On the same date, CMS will begin requiring ESRD facilities to use revenue code 0829 and Current Procedural Terminology (CPT®) code 90999 when billing hemodiafiltration. The agency will pay these claims with revenue code 0829 at the same rate as hemodialysis claims. These facilities must continue to bill for only one treatment per day, and they are not to bill for hemodialysis and hemodiafiltration on the same date of service. They must also use both condition code 76 and 84 when billing for back-up in-facility dialysis for beneficiaries with AKI.
CMS noted that contractors will return claims submitted with more than one hemodialysis treatment on the same date of service on type of bill 072X with revenue code 0821 or 0829.
Revenue integrity professionals who work at facilities that furnish ESRD and AKI services must ensure all coding and billing staff are aware of the upcoming changes. Read Medicare Claims Processing Transmittal 13588 for more information.