CY 2021: Low-Volume Payment Adjustment (LVPA) for End-Stage Renal Disease

Published 12/21/2020

The End-Stage Renal Disease Prospective Payment System (ESRD PPS) includes a payment adjustment for facilities providing a low volume of services.

To receive the low-volume payment adjustment (LVPA), an ESRD facility must submit a written attestation statement each year to its A/B Medicare Administrative Contractor (MAC). This statement must attest that the ESRD meets the criteria in the regulation as found at 42 CFR 413.232.

The CY 2021 Attestation Statement includes these changes.

Please email, fax or mail the CY 2021 Attestation Statement (or similar format) to Palmetto GBA. Due to the PHE we have extended the deadline to December 31, 2020.

 Email (preferred)
 Fax Number  (803) 935-0262


U.S. Postal Service Address
Overnight Address
Palmetto GBA
Attn: Provider Reimbursement
Mail Code: AG-330
PO Box 100144
Columbia, SC 29202-3144 
Palmetto GBA 
Attn: Provider Reimbursement
Mail Code: AG-330
2300 Springdale Drive, Bldg. 1
Camden, SC 29020-1728


  • Facility names should reflect the advertised name of the facility. Addresses must be exact and should include the building number, suite or room number, etc.
  • Treatments are defined as total hemodialysis (HD) equivalent treatments (Medicare and non-Medicare). For peritoneal dialysis (PD) patients, one week of PD is considered equivalent to 3 HD treatments.
  • Prior periods are the three 12-month cost reporting periods ending on or before December 31, 2020. As an example for a facility operating on a calendar year, the prior periods would be 12/31/2020, 12/31/2019 and 12/31/2018.
  • If the latest prior period has not ended (or the cost report has not been filed), estimate the number of treatments by annualizing year-to-date data
  • If, after being approved for LVPA (it is determined that treatment volumes are increasing and will be in excess of 4,000 for the year) please notify us so payments can be adjusted

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