[Code of Federal Regulations] [Title 42, Volume 2] [Revised as of October 1, 2002] From the U.S. Government Printing Office via GPO Access [CITE: 42CFR413.184] [Page 607-608] TITLE 42--PUBLIC HEALTH HUMAN SERVICES PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES--Table of Contents Subpart H--Payment for End-Stage Renal Disease (ESRD) Services and Organ Procurement Costs Sec. 413.184 Payment exception: Atypical service intensity (patient mix). (a) To qualify for an exception to the prospective payment rate based on atypical service intensity (patient mix)-- (1) A facility must demonstrate that a substantial proportion of the facility's outpatient maintenance dialysis treatments involve atypically intense dialysis services, special dialysis procedures, or supplies that are medically necessary to meet special medical needs of the facility's patients. Examples that may qualify under this criterion are more intense dialysis services that are medically necessary for patients such as-- (i) Patients who have been referred from other facilities on a temporary basis for more intense care during a period of medical instability and who return to the original facility after stabilization; (ii) Pediatric patients who require a significantly higher staff-to- patient ratio than typical adult patients; or (iii) Patients with medical conditions that are not commonly treated by ESRD facilities and that complicate the dialysis procedure. (2) The facility must demonstrate clearly that these services, procedures, or supplies and its per treatment costs are prudent and reasonable when compared to those of facilities with a similar patient mix. (3) A facility must demonstrate that-- (i) Its nursing personnel costs have been allocated properly between each mode of care; and (ii) The additional nursing hours per treatment are not the result of an excess number of employees. (b) Documentation. (1) A facility must submit a listing of all outpatient dialysis patients (including all home patients) treated during the most recently completed fiscal or calendar year showing-- (i) Patients who received transplants, including the date of transplant; (ii) Patients awaiting a transplant who are medically able, have given consent, and are on an active transplant list, and projected transplants; (iii) Home patients; (iv) In-facility patients, staff-assisted, or self-dialysis; (v) Individual patient diagnosis; (vi) Diabetic patients; [[Page 608]] (vii) Patients isolated because of contagious disease; (viii) Age of patients; (ix) Mortality rate, by age and diagnosis; (x) Number of patient transfers, reasons for transfers, and any related information; and (xi) Total number of hospital admissions for the facility's patients, reason for, and length of stay of each session. (2) The facility also must-- (i) Submit documentation on costs of nursing personnel (registered nurses, licensed practical nurses, technicians, and aides) incurred during the most recently completed fiscal year cost report showing-- (A) Amount each employee was paid; (B) Number of personnel; (C) Amount of time spent in the dialysis unit; and (D) Staff-to-patient ratio based on total hours, with an analysis of productive and nonproductive hours. (ii) Submit documentation on supply costs incurred during the most recently completed fiscal or calendar year cost report showing-- (A) By modality, a complete list of supplies used routinely in a dialysis treatment; (B) The make and model number of each dialyzer and its component cost; and (C) That supplies are prudently purchased (for example, that bulk discounts are used when available). (iii) Submit documentation on overhead costs incurred during the most recently completed fiscal or calendar year cost reporting year showing-- (A) The basis of the higher overhead costs; (B) The impact on the specific cost components; and (C) The effect on per treatment costs.