Corporate Compliance

ESRD exception rates

Compliance Monitor, July 1, 2005

Q: Would you please clarify exception rates?

A: You have to apply for an exception rate and right now that window is not open to apply for the exception rate. In fact, it's my understanding that applying for an exception rate is mostly for pediatric facilities at this point. In the past, if you were an isolated facility or you had really high patient acuity, you could apply for an exception rate, but the process was pretty long, drawn out, and a lot of detail needed to go into the application.

Pediatric units are the only units that can have an exception rate, and it's an either/or situation right now. Either they have an exception rate or they use the new pediatric rate. As far as I know, nothing else has an exception window open, or will in the future.

Just to clarify, if you are a hospital-based program, or any program out there-and let's just say you were granted an exception rate under an isolated facility exception-you have the ability to choose either to continue with that exception rate or go to the new case-mix adjustment reimbursement. And what we have encouraged clients to do is to get the NRAA calculator [available to members at], put your patient population into that calculator, and that will help you determine whether your reimbursement is better under the exception rate v. under the new case-mix adjustment.

Editor's note: This question was answered by Carrie McGinnis, RN, MBA, and Sue Vogel, MHA, RN, CNN. To ask a question or volunteer your services for answering your peers' questions, please e-mail Managing Editor Matthew Paul at