Validating the Billing of End Stage Renal Disease (ESRD) 50/50 Rule Modifier

CR 6683, advises that, effective with claims processed on or after April 5, 2010, Medicare will validate claims for AMCC ESRD-related tests provided to a beneficiary who is ESRD eligible to ensure compliance with billing instructions regarding the use of the ESRD 50/50 rule modifiers CD, CE, and CF.

The payment of certain ESRD laboratory services performed by an independent laboratory is included in the composite rate calculation for ESRD facilities. When billing Medicare for AMCC ESRD-related tests, laboratories must indicate which tests are or are not included within the ESRD facility composite rate to ensure proper reimbursement.

The ESRD 50/50 rule classifies AMCC ESRD-related tests according to the following categories:

1. AMCC test ordered by an ESRD facility (or MCP physician) that is part of the composite rate and is not separately billable;
2. AMCC test ordered by an ESRD facility (or MCP physician) that is a composite rate test but is beyond the normal frequency covered under the rate and is separately reimbursable based on medical necessity; and
3. AMCC test ordered by an ESRD facility (or MCP physician) that is not part of the composite rate and is separately billable.

When billing for AMCC ESRD-related tests, the laboratory must include the appropriate modifier for each test, as follows:

• Modifier “CD” – AMCC test has been ordered by an ESRD facility (or MCP physician) that is part of the composite rate and is not separately billable;
• Modifier “CE” – AMCC test has been ordered by an ESRD facility (or MCP physician) that is a composite rate test but is beyond the normal frequency covered under the rate and is separately reimbursable based on medical necessity; or
• Modifier “CF” – AMCC test has been ordered by an ESRD facility or MCP physician that is not part of the composite rate and is separately billable.