by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Jan 27th, 2022 - Reviewed/Updated Aug 15th
As of 2021, Medicare beneficiaries suffering from end-stage renal disease (ESRD) were permitted to enroll in Medicare Advantage (MA) plans. Prior to 1972, only people who had reached the age of 65 were permitted to enroll in the federal Medicare health program. However, in 1972, Congress passed the Social Security Amendments Act, which marked the first time individuals were allowed to enroll in Medicare based on a specific medical condition (e.g., ESRD) rather than age.
ESRD is the last stage of chronic kidney disease (CKD) in which the kidney’s gradual and sometimes not so gradual decrease in function ultimately leads to kidney failure requiring dialysis and ultimately a kidney transplant or death. ESRD-related services are costly, with the average patient requiring dialysis treatment three times a week as well as a kidney transplant, not to mention coverage for any other ESRD-related medical conditions (e.g., heart disease, diabetes). According to a Congressional Research Service report published in 2018, Susanne M. Kirchoff, an analyst in health care financing, reported that Medicare beneficiaries with ESRD have “higher-than-average health care costs” and “account for about 7% of Medicare fee-for-service (FFS) spending.”
In December of 2016, Congress passed the 21st Century Cures Act which was designed to help accelerate medical product development and new innovations and technological advances to the patients who need them quickly and in an efficient and safe manner, among other valuable benefits. Among the benefits produced by the Cures Act, Medicare-eligible individuals with ESRD would be allowed to enroll in MA plans beginning in 2021. MA plans are managed care plans that receive federal funding based on each enrolled Medicare beneficiary’s health risk score, which is determined by the beneficiary’s specific demographic information and the ICD-10-CM codes assigned to their medical records for diagnoses that have been identified through monitoring, evaluation, assessment, and treatments with a qualified healthcare provider.
MA plans differ from Medicare FFS in that they are tasked with the responsibility to identify, evaluate, monitor, and treat each beneficiary’s chronic conditions in a way that will reduce costs and hospitalizations while improving quality of care and overall health. The door is now wide open for MA plans to see what they can do for these high-risk Medicare beneficiaries who must have access to some of the costliest medical services to properly treat ESRD. You might think that ESRD patients would be less likely to make such a leap to a managed health care plan but from initial enrollments in 2021, we see that an approximate 40,000+ Medicare FFS patients with ESRD elected to enroll in MA plans during open enrollment.
This transfer of patient management from Medicare FFS to MA is likely to have substantial implications for stakeholders, as costs associated with ESRD patient care is estimated to be at least eight times higher than the average, non-ESRD Medicare beneficiary. MA plans also have access to different drugs used to treat kidney function, cost-sharing options, and supplemental benefits that may improve patient risk factors (e.g., social, activities of daily living assistance) that may be impactful to this subset of Medicare beneficiaries. For additional information on the various methods MA plans may use to address the special needs of Medicare beneficiaries with ESRD this article identifies various organizations that may partner with MA organizations to help with early identification of kidney disease and available support mechanisms to prevent or treat it before it reaches the level of ESRD.
MA plans will see an uptick in risk scores and reimbursements due to these enrollments and accurate clinical documentation will be vital for ICD-10-CM code selection. Begin now preparing for 2022 chart reviews, as audits are sure to follow any major changes such as this one.
About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.
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