CMS Issues CY 2023 Final Rule for End Stage Renal Disease (ESRD) Prospective Payment System (PPS)

The Centers for Medicare and Medicaid Services (CMS) issued the final rule for the Medicare End Stage Renal Disease (ESRD) Prospective Payment System (PPS). This final rule covers renal dialysis services furnished to beneficiaries on or after January 1, 2023. Highlights are described below:

  • The finalized base rate for the ESRD PPS is $265.57, which applies to both ESRD and AKI patients receiving renal dialysis.
  • The finalized wage index values are based on the latest available data and CMS will be continuing the 2-year transition to the Office of Management and Budget (OMB) delineations as described in the September 14, 2018 OMB Bulletin No. 18–04.
  • The finalized labor-related share is 55.2 percent, based on the 2020-based ESRDB market basket.
  • Final updates to the requirements for the End-Stage Renal Disease Quality Incentive Program (ESRD QIP) include suppression of six clinical measures for short-term scoring and payment policies; adoption of special scoring and payment policies to ensure no facility would receive a payment reduction; and calculation of performance standards for CY 2023 using CY 2019 data rather than CY 2020 data. There were no changes to the measure suppression policy for the duration of the COVID-19 public health emergency (PHE).
  • Changes to the ESRD Treatment Choices (ETC) Model include rebasing and revising the ESRDB market basket to a 2020 base year; revisions to the home dialysis rate, transplant rate, Performance Payment Adjustment (PPA) benchmarking methodology and scoring, and Medicare waivers.
  • CMS finalized its proposal to revise the definition of oral-only drugs to include the word functional. The definition now reads: “drug or biological product with no functional equivalent or other form of administration other than an oral form.” This change will be implemented January 1, 2025.

The complete ESRD PPS proposed rule summary can be found on the GORE Coding Resource Center website under “Education – CMS Rules Updates”: https://gore.rccsclients.com/education/rules-updates/.