Revenue Code – Procedure Code – Description
821 – 90935 Hemodialysis procedure with single physician evaluation. Limited to 156 units per year.
821 – 90937 Hemodialysis procedure requiring repeated evaluations with or without substantial revision of dialysis prescription. Limited to 156 units per year.
831 -841 – 851 – 90945 Dialysis procedure other than hemodialysis (e.g. peritoneal, hemofiltration) with single physician evaluation.
831 841 851 – 90947 Dialysis procedure other than hemodialysis (e. g. peritoneal, hemofiltration) requiring repeated evaluations with or without substantial revision of dialysis prescription.
831 851 841- 90993 Dialysis training, patient, including helper. Limited to 12 units per lifetime.250- Q4081 Injection, epogen
250- J0882 Injection, darbepoetin alfa
Hemodialysis
The following table lists Hemodialysis tests and frequency of coverage:
Frequency Covered Tests
Per treatment All hematocrit and clotting time tests furnished incidentally to dialysis treatments.
Weekly Prothrombin time for patients on anticoagulant therapy; serum creatinine, BUN.
Monthly Alkaline Phosphates LDH Serum Biocarbonate Serum Calcium
Serum Chloride
Serum Phosphorous
Serum Potassium
SGOT
Total Protein
All laboratory testing sites providing services to Medicaid recipients, either directly by provider or through contract, must be certified by Clinical Laboratory Improvement Amendments (CLIA) that they provide the required level of complexity for testing. Providers are responsible for assuring
Medicaid that they strictly adhere to all CLIA regulations and for providing Medicaid waiver certification numbers as applicable. Laboratories that do not meet CLIA certification standards are not eligible for reimbursement for laboratory services from Medicaid
Procedure Codes, Revenue Codes, and Modifiers
The
(837) Professional and Institutional electronic claims and the paper
claims have been modified to accept up to four Procedure Code Modifiers
Hospital Dialysis Services For Patients With and Without End Stage Renal Disease (ESRD)
Effective with claims with dates of service on or after August 1, 2000, hospital-based End Stage Renal Disease (ESRD) facilities must submit services covered under the ESRD benefit in 42 CFR 413.174 (maintenance dialysis and those items and services directly related to dialysis such as drugs, supplies) on a separate claim from services not covered under the ESRD benefit. Items and services not covered under the ESRD benefit must be billed by the hospital using the hospital bill type and be paid under the Outpatient Prospective Payment System (OPPS) (or to a CAH at reasonable cost). Services covered under the ESRD benefit in 42 CFR 413.174 must be billed on the ESRD bill type and must be paid under the ESRD PPS. This requirement is necessary to properly pay only unrelated ESRD services (those not covered under the ESRD benefit) under OPPS (or to a CAH at reasonable cost).
Medicare does not allow payment for routine or related dialysis treatments, which are covered and paid under the ESRD PPS, when furnished to ESRD patients in the outpatient department of a hospital. However, in certain medical situations in which the ESRD outpatient cannot obtain her or his regularly scheduled dialysis treatment at a certified ESRD facility, the OPPS rule for 2003 allows payment for non-routine dialysis treatments (which are not covered under the ESRD benefit) furnished to ESRD outpatients in the outpatient department of a hospital. Payment for unscheduled dialysis furnished to ESRD outpatients and paid under the OPPS is limited to the following circumstances:
• Dialysis performed following or in connection with a dialysis-related procedure such as vascular access procedure or blood transfusions;
• Dialysis performed following treatment for an unrelated medical emergency; e.g., if a patient goes to the emergency room for chest pains and misses a regularly scheduled dialysis treatment that cannot be rescheduled, CMS allows the hospital to provide and bill Medicare for the dialysis treatment; or
• Emergency dialysis for ESRD patients who would otherwise have to be admitted as inpatients in order for the hospital to receive payment.
In these situations, non-ESRD certified hospital outpatient facilities are to bill Medicare using the Healthcare Common Procedure Coding System (HCPCS) code G0257 (Unscheduled or emergency dialysis treatment for an ESRD patient in a hospital outpatient department that is not certified as an ESRD facility).
HCPCS code G0257 may only be reported on type of bill 13X (hospital outpatient service) or type of bill 85X (critical access hospital) because HCPCS code G0257 only reports services for hospital outpatients with ESRD and only these bill types are used to report services to hospital outpatients. Effective for services on and after October 1, 2012, claims containing HCPCS code G0257 will be returned to the provider for correction if G0257 is reported with a type of bill other than 13X or 85X (such as a 12x inpatient claim).
HCPCS code 90935 (Hemodialysis procedure with single physician evaluation) may be reported and paid only if one of the following two conditions is met:
1) The patient is a hospital inpatient with or without ESRD and has no coverage under Part A, but has Part B coverage. The charge for hemodialysis is a charge for the use of a prosthetic device. See Benefits Policy Manual 100-02 Chapter 15 section 120. A. The service must be reported on a type of bill 12X or type of bill 85X. See the Benefits Policy Manual 100-02 Chapter 6 section 10 (Medical and Other Health Services Furnished to Inpatients of Participating Hospitals) for the criteria that must be met for services to be paid when a hospital inpatient has Part B coverage but does not have coverage under Part A; or
2) A hospital outpatient does not have ESRD and is receiving hemodialysis in the hospital outpatient department. The service is reported on a type of bill 13X or type of bill 85X.
Procedure code 90945 (Dialysis procedure other than hemodialysis (e.g. peritoneal dialysis, hemofiltration, or other continuous replacement therapies)), with single physician evaluation, may be reported by a hospital paid under the OPPS or CAH method I or method II on type of bill 12X, 13X or 85X.
Medicaid Guide on End Stage Renal Disease – Dialysis
Treatment of end stage renal failure by dialysis, is to be rendered by a Medicare-certified dialysis facility which has met the standards for operation and maintenance of End Stage Renal Disease facilities in order to provide safe and effective services.
Covered Services for End Stage Renal Disease – Dialysis
a. Covered Revenue Codes for the facility are: Revenue Codes 821, 831, 841, OR 851634 Epoetin Alpha (EPO) < 10,000 units 635 EPO > 10,000 units or more
b. Covered physician CPT Procedure Codes are: 90935, 90937, 90945, 90947
DIALYSIS (HEMODIALYSIS AND PERITONEAL DIALYSIS)
MDHHS coverage and reimbursement is an all-inclusive rate for maintenance dialysis services for beneficiaries receiving hemodialysis or peritoneal dialysis. MDHHS follows the Medicare billing guidelines for hemodialysis and peritoneal dialysis. Individual services may not be billed separately. The rate is the same whether the beneficiary dialyzes in the facility or at home, and includes all necessary home and facility dialysis maintenance services, supplies, equipment and supportive services such as:
* Oxygen;
* Filters;
* Declotting of shunts;
* Staff time to administer blood or oxygen; and
* Routine parenteral items: Heparin, Protamine, Mannitol, saline, glucose, dextrose, topical anesthetics, and arrhythmics.
MDHHS reimburses the physician directly for professional services related to maintenance dialysis.
Nonroutine additional services must be billed using the appropriate supporting HCPCS code. The facility is responsible for making arrangements with a DME provider for supplies not available from the dialysis facility. MDHHS does not reimburse the medical supplier separately. The facility is responsible for payment to the supplier or independent lab for services provided.
DIALYSIS LABORATORY SERVICES
Payment for laboratory services related to maintenance dialysis is included in the composite rate regardless of whether the tests are performed in the facility or an independent laboratory. The following tests are considered to be a routine part of maintenance dialysis and may not be billed separately unless it is medically necessary to perform them in excess of the frequencies indicated.
Laboratory tests for Hemodialysis, Peritoneal Dialysis, and Continuous Cycling Peritoneal Dialysis (CCPD) that are included in the composite rate:
Per Treatment Weekly Monthly
* All hematocrit or hemoglobin tests and clotting time tests
* Prothrombin time for patients on anticoagulant therapy
* Serum Creatinine
* BUN
* CBC, including platelet count and additional indices
* Serum Calcium
* Serum Chloride
* Serum Potassium
* Serum Bicarbonate
* Serum Phosphorus
* Total Protein
* Serum Albumin
* Alkaline Phosphatase
* SGOT
* LDH
Laboratory tests for Continuous Ambulatory Peritoneal Dialysis (CAPD) that are included in the composite rate on a monthly basis include:
* Albumin
* Alkaline Phosphatase
* AST
* BUN
* Calcium Magnesium
* CO2
* Creatinine
* Dialysate Protein
* HCT
* Hgb
* LDH
* Phosphate
* Potassium
* SGOT
* Sodium
* Total Protein
Laboratory tests not listed above may be separately billed by the dialysis facility or Clinical Laboratory Improvement Amendments (CLIA)-certified lab performing the test.
DIALYSIS SELF-CARE TRAINING
MDHHS reimburses for dialysis self-care training provided by outpatient dialysis clinics.
* A session is considered as one training day and a complete course is considered 10-15 sessions.
* Sessions must be documented in the beneficiary’s medical record and are subject to post-payment review.
