RESOLVED: Calculation of the Transitional Drug Add-on Payment Adjustment (TDAPA) and Outlier

Current Status
3/27/2019: Resolved.  Palmetto GBA has completed the mass adjustment and there are no further issues.

Situation Identified November 29, 2018
Change Request 10851 (PDF, 89 KB) dated November 2, 2018, included additional changes to the 72X type of Bill (TOB). The Centers for Medicare & Medicaid Services (CMS) stated that dialysis treatments reported with the CG modifier and non-covered dialysis treatments should not be used for purposes of the TDAPA or outlier calculations. For purposes of the number of dialysis treatments for the month used in the TDAPA and outlier calculations, MACs should only consider those treatments that are reported and covered.

Impact to Provider:
Palmetto GBA will mass adjust ESRD 72X TOB claims as indicated below:

 Outlier claims with dates of service on or after October 1, 2017 through December 31, 2018 with: TDAPA claims with dates of service on or after January 1, 2018 through December 31, 2018 with:
  • Revenue code 0821 or 881
  • HCPCS code 90999 and CG modifier is present with non-covered lines

And

  • Value code 79 is present
  • Revenue code 0636; 
  • HCPCS code J0604 or J0606 and Modifier AX 
  • Value code Q8

And

  • Revenue code 0821 or 881 
  • HCPCS code 90999 and CG modifier is present with non-covered line
These mass adjustments will be completed within 90 days of implementation Change Request 10851 on January 7, 2019. 

Status:
3/27/2019:
Resolved.  Palmetto GBA has completed the mass adjustment and there are no further issues.

11/29/2018: Palmetto GBA will mass adjust ESRD 72X TOB claims.

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