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Glossary

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QMS-only Terms

80/20 split
Refers to posting 80% of charges in primary facility and 20% of charges in the secondary. Thus, each month the patient has two separate accounts to balance.
Form Template
Contains the "fids" for each billing form or report form in an account. Form templates reside in the customer's account and begin with the letter "f".
Normal Account
Standard hemodialysis account which uses normal item codes (STD, CB, ADH) and prints UB04 bills.
Supply Account
Used for billing home supplies only. Codes used are A01, A02, B01, etc.; billing done on 1500 form usually.
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Bundling Terms

Actual Outlier Services
MAP per Treatment:

The actual average per treatment cost of separately billable items.
Add-On:
An additional payment that is added to the calculated reimbursement rate, to account for specific circumstances.
Adjusted Average Outlier Services MAP Amount:
This refers to the amount that CMS will use as the basis to calculate the predicted outlier services MAP per treatment, adjusted by patient-specific factors.
Base rate:
$229.63.  The amount represents the single Medicare payment for all services in the bundle prior to adjustments for case-mix and the wage index, including the former composite rate services and services that were previously separately billable, such as non-routine laboratory services and all ESRD-related Part B drugs and their equivalent forms covered under Part D.
Basic Case-Mix:
The methodology by which to calculate a patient’s reimbursement rate by considering their age, BSA, and BMI as corresponding factors that adjust a reimbursement rate.
Blended Payment:
The total reimbursement rate, as calculated based on the percentage of the PPS reimbursement rate plus the percentage of the “case-mix” reimbursement rate. This is only applicable to facilities that elect to phase-in PPS.
Co-Morbidity:
A diagnosis associated to the patient to identify conditions that may complicate their ESRD treatment.
Composite rate:
A flat rate reimbursement, adjusted by geographic index, for specified services that compose the basic dialysis treatment.
Exception Rates:
A reimbursement rate different from the usual composite rate. Section 623(b) of BIPA allows composite exception rates for pediatric facilities, defined as a facility wherein at least 50% of patients are under age 18.
FDL:
Fixed Dollar Loss represents the basic amount that CMS considers static when calculating the predicted outlier services MAP per treatment.
Low-volume facility:
A provider whose number of treatments does not exceed 4000 treatments per year. Facilities identified as low-volume facilities are eligible for an adjuster to their reimbursement rate.
MAP:
Medicare Allowable Payment. This value is used to calculate the Average Outlier Services “MAP” Amount per treatment.
Non-ESRD Related:
Drugs or labs that are administered or drawn for reasons other than the patient’s ESRD condition.
Onset of dialysis (or dialysis onset):
The date reported on the ESRD Medical Evidence Report Form identifying when the patient started received dialysis treatments.
Opt-In:
The ability for a facility to choose to be reimbursed using PPS at 100% as of January 1, 2011.
Outlier:
A patient that is deemed to be more expensive to treat and therefore whose treatments will be eligible for an outlier add-on.
Phase-In Schedule:
On 01/01/2011, reimbursement rates will be 25 % PPS and 75% “case-mix”.
On 01/01/2012, reimbursement rates will be 50 % PPS and 50% “case-mix”.
On 01/01/2013, reimbursement rates will be 75 % PPS and 25% “case-mix”.
As of 01/01/2014, PPS will be the sole reimbursement rate for ESRD providers.
Phase-In:
The ability for a facility to choose to be reimbursed using PPS over a period of time, by blending this value with the existing “case-mix” reimbursement rate.
PPS:
Prospective Payment System, also known as “bundle” or “bundling”. Refers to new federal regulations that mandate that all ESRD providers be reimbursed by Medicare one rate for all services provided.
Predicted Outlier Services MAP per Treatment:
The amount CMS predicts the cost of an outlier patient will be, per treatment. This is also referred to as the Outlier Threshold.
Previously Separately Billable:
A treatment item that was previously separately billable under Medicare Part B or Medicare Part D, prior to 01/01/2011, that will now be included in the bundle. In the case of Medicare Part B items, these items must be identified as they are considered in the outlier calculations.
Training add-on:
Targets payments for training to those ESRD facilities that actually conduct training treatments rather than including such training in the base rate for all facilities. A home dialysis training adjustment of $33.38 will be added on to the per treatment ESRD PPS payment each time training is conducted. The training adjustment will be adjusted by the geographical wage index based on the location of the ESRD facility. The home or self dialysis training adjustment is not available, however, during the four month new patient adjustment for the onset of dialysis.
Wage index:
A value associated to the Office of Management and Budget's CBSA-based geographic designations by which the base rate may be adjusted.
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Medical Billing Terms

Medicare
United States Government (taxpayer-funded) insurance since 1971. Dialysis payments are covered by disability allowance at the rate of 80%, balance paid by secondary payers.
Medicare Eligible
Hemodialysis patients become eligible for Medicare coverage in the 4th calendar month of dialysis treatment. CAPD patients become eligible for Medicare coverage in the 1st month of treatment. At age 65, all patients become covered by Medicare.
Method I
CAPD or CCPD patients only. Billing of home patients as if they were actually being treated at a unit. I.e., billing for the number of "treatment equivalents" they would have received if the patient had been treated in a dialysis unit. Reimbursement based on the normal composite rate.
Method II
CAPD or CCPD patients only. Billing of just supplies required for home dialysis. Reimbursement up to a fixed payment per month.
MSP
Medicare as secondary payer.
Co-insurance
Patient's own private health plan which picks up any costs not paid by Medicare. Typically a patient has Medicare as their primary payor, but that only pays 80% of the costs of dialysis.
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Medical Terms Associated with Kidney Disease

Acute
In a disease, temporary severe symptoms. In dialysis treated with Heparin.
Ambulatory
A patient able to walk.
Anemia
Low red blood cell count, causes fatigue and nausea.
Calcijex
Vitamin D type medication.
CAPD
Continuous Ambulatory Peritoneal Dialysis; every 6 hours drain & refill.
CCPD
Continuous Cycle Peritoneal (abdomen) Dialysis; at night continuous cycling.
Chronic
Constant, re-occurring.
Colloids
Molecules dispersed and suspended within a gaseous, liquid or solid medium and resisting diffusion, filtration and sedimentation.
Creatinine
A nitrogen-based solute which is elevated in uremia.
Dialysate
That part of the mixture that passes through the dialyzer membrane.
Dialysis
Separation of substances in solution by means of their unequal diffusion through membranes, such as separation of colloids from solubles. See also 1. Renal Dialysis, 2. Hemodialysis, 3. IPD, 4. CAPD, 5. CCPD, 6. Peritoneal Dialysis
Dialyzer
A membrane for use in dialysis.
EPO
Synthetic (man-made) erythropoietin.
Erythropoietin
Protein secreted by normal functioning kidney, and when combined with iron and amino acid in bone marrow, produces red blood cells. When kidneys fail, erythropoietin is not produced, red blood cells are not produced and therefore the patient becomes anemic. EPO is a synthetic (man-made) erythropoietin given to many ESRD patients to cure anemia.
ESRD
End Stage Renal Disease
Hematocrit
(or just "crit"). The percentage of red blood cells in a patient's body:
(red blood cells)/ (total blood) Normal for an average person is 40%-45%. Normal for ESRD patient is around 20% when not treated with EPO; approximately 30% when treated with EPO.
Hemodialysis
Purification by dialysis (i.e., using a kidney dialysis machine, a.k.a. mechanical kidney).
Heparin
Anti-coagulant.
Imferon
Iron-Dextran, given to iron-deficient patients in conjunction with EPO to stimulate production of red blood cells.
IPD
Intermittent Peritoneal Dialysis
KT/V
Dialyzer filtration coefficient (ml/min/mmHg). It depends on many complex variables and is related to the bulk and liquid flow rate in the blood.
Menatol
Acts like Na (sodium) ion by bringing water into the blood.
Morbidity
Condition describing patient who becomes sick, hospitalized.
Mortality
Rate of death.
Nephron
[Greek Nephros: kidney] The functional unit of the kidney.
Nephrology
The branch of medical science that specializes in study and treatment of kidneys.
Peritoneal
Abdomen.
Peritoneal Dialysis
A home dialysis method. Dialysate flows directly into patients abdominal cavity . See also CAPD, CCPD.
Renal
Relating to kidney or kidneys.
Renal Dialysis
Removes urea and other impurities from the blood system that are due to kidney failure.
Soluble
Capable of being dissolved.
Uremia
Disease of urea build-up caused by dysfunction of the kidneys.
URR
Urea Reduction Ratio - lab result used to determine the effectiveness of dialysis.
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Miscellaneous Terms

A/R
Accounts receivable
Aging
Accounts receivable report.
Ancillary Service
Supplements the main area or service.
CMS
Centers for Medicare & Medicaid Services — formerly called HCFA, it governs Medicare and Medicaid programs.
Composite Rate
A single dollar amount which covers a package of dialysis related treatments and services.
CPT Code
Current Procedural Terminology. The nomenclature for HCPC's for standardized billing of laboratory procedures.
Cross-over
Identical to secondary billing.
DOS
Dates of Service — date range on the claim.
DSO
Days Service Outstanding — number of days from the date of service until payment is received.
ECS
Electronic Claims Submission — generating all claims into an electronic file and then transmit that file to paying entity (Medicare, private insurance).
EOB/EOMB
See RA
ERA
Electronic Remittance Advice — payor pays on claims and gives the dialysis unit payments in an electronic format to import into the billing system.
HCFA
Health Care Financing Administration. Formerly the Federal agency in charge of Medicare.
HCPC
5-digit price codes used for standardized medical billing. Each code stands for a specific dose of a specific medication. The prices for HCPC's may vary from state to state.
HIPAA
Health Insurance Portability and Accountability Act of 1996.
Medi-Cal
California's state-run medical insurance.
Medicaid
Each of the states' state-run medical insurance, except for California's Medi-Cal.
Nomenclature
System of terms used in a particular science, discipline or art.
Primary Insurance
Patient's main insurance carrier.
RA
Remittance Advice. It's received from Medicare, and it states how much money is being paid for a batch of bills that were sent, and which of those bills (if any) were rejected and why. Also referred to as EOB and EOMB.
SUB04
A supplemental page attached to the UB04, which expands the billing information and shows justifications.
TAR
Treatment Authorization Request — authorization number given by insurance companies prior to treatment in order for them to pay for the treatments.
TOS
Type of Service
UB04
The standard claim form sent to Medicare for payment for medical treatment.
UPIN
Doctor's unique "Personal Identification Number."
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