Physician Dialysis Services

Physician Dialysis Services

Physician Dialysis Services

Section 1881(b)(14) of the Social Security Act requires a bundled payment system for renal dialysis services furnished to Medicare beneficiaries in a Medicare approved dialysis facility, or the patient’s home. The ESRD PPS is how Medicare approved dialysis facilities are paid for the care related to their dialysis patients. The monthly ESRD PPS payment includes treatment (dialysis), drugs, laboratory services, supplies, and capital-related costs related to furnishing maintenance dialysis. Claims for these services are billed under the Medicare approved dialysis facility’s NPI.

Dialysis services furnished to hospital inpatients are covered under Medicare Part A and paid in accordance with applicable payment rules.

The purpose of this job aid is to provide instruction for Medicare Part B physicians and nonphysician practitioners billing professional services provided to a Medicare beneficiary on dialysis.

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Monthly Capitation Payment

MCP is a payment made to physicians for most dialysis-related physician services furnished to Medicare ESRD patients on a monthly basis. The same monthly amount is paid to the physician for each patient supervised regardless of whether the patient dialyzes at home or as an outpatient in an approved ESRD facility.

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Coding

90951–90962 once per month in facility patients; depending on the number of face-to-face visits provided.
90963–90966 once monthly for home dialysis patients.

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Claim Submission Tips

The term ‘month’ means a calendar month. The first month in which the beneficiary begins dialysis treatment marks the beginning of treatments through the end of the calendar month. Thereafter, the term ‘month’ refers to a calendar month.
- Report the entire month for the “from and to” dates on the claim.
  - Example: For services provided in January, use the “from date” as January 1st and the “to date” as January 31.
- Reporting the dates of service to span the entire month allows other services, included or not included in the MCP, to process correctly.
One unit of service is billed per month regardless of the number of face to face visits; with the exception of a partial month billing.
Claims submitted without the GV or GW modifier will deny when patients are enrolled in hospice.
Use the appropriate procedure code for the patient's age and the number of visits for the month.
- The appropriate age for ESRD-related services code is based on the age of the beneficiary at the end of the month.
Visits must be furnished face-to-face by a physician, clinical nurse specialist, nurse practitioner, or physician’s assistant.
The physician or practitioner who provides the complete assessment, establishes the patient's plan of care and provides ongoing management should be the one who submits the claim for the monthly services:
- If a NPP performs the complete assessment and establishes the plan of care, the MCP service should be submitted under the PTAN of the clinical nurse specialist, nurse practitioner or physician’s assistant.
- The non-MCP physician or practitioner must be a partner, an employee of the same group practice, or an employee of the MCP physician or practitioner.
- If the MCP physician or practitioner relies on other physicians or qualified nonphysician practitioners to provide some of the visits during the month:
  - The MCP physician or practitioner does not have to be present when these other physicians or practitioners provide visits.

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Billing for a Partial Month

If a home dialysis patient was hospitalized during the month and at least one face-to-face outpatient visit and complete monthly assessment was furnished, the MCP practitioner should bill for the full home dialysis MCP service.

When billing for less than a full month of home dialysis, procedure code 90967, 90968, 90969 or 90970 should be used.

The physician or practitioner should bill for the age appropriate home dialysis MCP service for the home dialysis if the MCP practitioner provides the following services:

A complete monthly assessment of the ESRD beneficiary.
At least one face-to-face patient visit during the month.

Example: When a patient receives home dialysis for seven days and is hospitalized the remainder of the month, use the age appropriate CPT codes (90967–90970) and submit seven units.

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Documentation Requirements

Documentation for home dialysis visits must include the following:

Signed physician/nonphysician practitioner order.
Documentation to support the patient was trained to perform dialysis in the home environment.
Method, frequency and patient tolerance of dialysis session.
MUST support at least one face-to-face visit per month.
All labs/AMCC results for both current and previous month.

Documentation for hemodialysis and peritoneal dialysis hemodialysis:

Signed physician/nonphysician practitioner order.
Signed note for EACH face-to-face visit during the billing period.
The physician or practitioner, who provides the complete assessment, establishes the patient’s plan of care and provides ongoing management, should be the one who submits a claim for the monthly service.
Three sessions per week (if the number of sessions exceed this frequency medical justification is required.

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Physician Dialysis Services

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