View the Medicare ESRD Expected Reimbursement Detail

Use the following procedure to view the Expected Reimbursement Detail for a Medicare End Stage Renal Dialysis (ESRD) account. ESRD accounts are defined by a bill type of 72X.

Field Descriptions – End Stage Renal Dialysis (ESRD)

The following table describes each of the fields on the Expected Reimbursement Detail page for ESRD accounts.

Field	Description
Claim Error	Error code for the claim level
Claim Disposition	Disposition code for claim level
Reimbursement Type	Reimbursement type, either expected reimbursement or RA, if applicable (the latest RA is shown if there are multiple RAs)
Pre SR Total Payments / PPS Payment	The expected payment based on the ESRD PPS system before the sequestration reduction is applied. Note: This field is shown only if the Apply sequestration reduction option is selected on the reimbursement tool.
Sequestration Reduction (SR)	The 2% sequestration reduction for patients discharged on or after 04/01/2013. The reduction is applied to the expected payment for each line item after any applicable co-payment amounts are applied. Note: This field is shown only if the Apply sequestration reduction option is selected on the reimbursement tool.
New Tech Pass-Through Payments	Total reimbursement for certain high-cost items like implants, high cost drugs and biologicals for which the actual or higher cost is passed through to the payor
ESRD PPS with TDAPA / TPNIES	Sum of the line level detail columns for Adjusted Per Treatment Base Rate, Transitional Drug Add-on Payment, and Transitional Payment for New Innovative Equip and Supplies.
Home Dialysis Adjustment Amount	Sum of the Home Dialysis Adjustment reimbursement detail column.
Performance Payment Adjustment	Sum of the Performance Payment Adjustment reimbursement detail column.
Fee Schedule Amount	Sum of the Fee Schedule reimbursement detail column.
Total Deductible - RA, Only	The total deductible imported or retrieved from the Remittance Advice.
Total Claim Outlier Payments	Total amount for extraordinarily high cost (cost outlier) for that service date
Network Reduction	Sum of the Network Reduction reimbursement detail column.
Total Payments, Including Outliers	Total expected amount from Medicare
Total Medicare Payment	Total Medicare payment
Total Patient Responsibility	Patient co-payment, as stipulated by the rules
No.	Sequential reference number of the line item
Line Item Date of Service (LIDOS)	Dates the service was rendered
Revenue Code	Revenue code
CPT/HCPCS Codes & Modifiers	Associated CPT or HCPCS codes and modifiers
Payment Status Indicators	Used to explain the payment of the line item; defined in the Remittance Payment Codes table
Billed Units / Billed Units RA	Number of units billed
Charges / Charges RA	Billed amount for the listed service
Adjusted Per Treatment Base Rate	Displays the adjusted base rate.
Transitional Drug Add-on Payment Amount	Displays the add on payment amount for transitional drug.
Sequestration Reduction	The 2% sequestration reduction for patients discharged on or after 04/01/2013. The reduction is applied to the expected payment for each line item after any applicable co-payment amounts are applied. Note: This field is shown only if the Apply sequestration reduction option is selected on the reimbursement tool.
Transitional Payment for New Innovative Equip. and Supplies	Displays the transitional payment for new innovative equipment and supplies.
Home Dialysis Payment Adjustment Amount	Displays the Home Dialysis Payment Adjustment (HDPA) 3% in 2021, 2% in 2022, and 1% in 2023.
Payment Performance Adjustment Amount	Displays the Payment Performance Adjustment (PPA) for patients are 18 years of age before the first day of the month of the claim.
Fee Schedule	Line level fee schedule amount for any Drugs or Labs which are separately payable outside of ESRD PPS.
Outlier per Treatment	Line level Dialysis Outlier divided by the number of treatments.
Network Reduction	Lline level Network Reduction applied for the day’s Dialysis treatment.
Full PPS Exp Payment	The expected payment based on the ESRD PPS system. Note: This column is shown only if the Apply sequestration reduction option is not selected on the reimbursement tool.
Post SR PPS Expected Payment	The expected payment based on the ESRD PPS system after applying the sequestration reduction. Note: This column is shown only if the Apply sequestration reduction option is selected on the reimbursement tool.
Actual Base RA	The actual base payment used for Remittance Advice purposes.
Patient Co-Pay	The patient co-payment for each line item, as stipulated by the rules
Total Payment	The total payments posted to the account, as defined in the data.
Message & Error Codes	Repricing message and error codes
Payment Codes RA	Used to explain the payment of the account; defined in the Remittance Payment Codes table.
HDPA Amount	The adjusted ESRD per treatment base rate * HDPA percentage.
PPA Amount	The adjusted ESRD per treatment base rate * the PPA factor.
Line Item Error Definitions	Error code for the line-item level
Payment Status Code Definitions	Definitions of Payment Status Codes listed