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Minnesota Department of Human Services Provider Manual
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Renal Dialysis Billing

Revised: 08-23-2017

Review Latest Manual Revisions to quickly see if MHCP coverage, rates and billing procedures have changed.

  • Overview
  • Composite Rate
  • Parenteral Medications-or Solutions
  • Excluded Drugs and Biologicals
  • Services Outside the Composite Rate
  • Billing
  • End Stage Renal Dialysis (ESRD) 50/50 Payment Rule
  • Outpatient ESRD-Related Services
  • Inpatient Billing/Non-CAP Payment
  • Fee-for-Service and Crossover Claims
  • Hemodialysis for fee-for-service recipients
  • Non-Crossover Claims
  • Documentation
  • Drugs Outside the Composite Rate
  • Overview

    Composite Rate

    Providers must furnish all items and services included under the composite rate, either directly or under arrangements, to all dialysis recipients. The end-stage renal disease (ESRD) facility must furnish all of the necessary dialysis services, equipment and supplies. The following items and services are included in the composite rate and providers cannot bill them separately:

  • • All dialysis services furnished by the facility's staff and the staff time used to:
  • • Administer blood
  • • Administer separately billable drugs and vaccines
  • • Non-routine parenteral care
  • • Treatment of medical complications
  • • Declot shunts and any supplies used to declot shunts
  • • Oxygen and the administration of oxygen
  • • Medically necessary dialysis equipment and dialysis support equipment for hemodialysis and peritoneal dialysis
  • • Use of IV pumps for convenience
  • • Medically necessary dialysis supplies
  • • Home dialysis support services including the delivery, installation, maintenance, repair and testing of home dialysis equipment and home support equipment
  • • Purchase and delivery of all medically necessary dialysis supplies and equipment
  • • Home health services provided in the home are included as support services
  • • Drugs used in the dialysis procedure and staff time to administer those drugs, (drugs that are used to accomplish the same effect are also covered under the composite rate)
  • • Antibiotics when used at home to treat an infection of the catheter site or peritonitis
  • • Oral medications, since the form of the drug is usually self-administered. If a physician gives a recipient an injection that usually is self-administered, for example insulin, the drug is administered in an emergency situation
  • Albumin used as a substitute for drugs covered under the composite rate or used to accomplish the same effect (for example, as a volume expander) is included in the composite rate payment for maintenance dialysis.

    The following laboratory services are included in the composite rate:

  • • Laboratory tests for recipients receiving hemodialysis, intermittent peritoneal dialysis (IPD) and continuous cycling peritoneal dialysis (CCPD)
  • • Routine ESRD laboratory services performed by either the facility staff or an independent laboratory are included in the composite rate at the following frequency:
  • • Per treatment: all hematocrit, hemoglobin and clotting time tests
  • • Weekly: prothrombin time for recipients on anticoagulant therapy and serum creatinine
  • • Weekly or thirteen per quarter: BUN
  • • Monthly: serum calcium, serum potassium, serum chloride, CBC, serum bicarbonate, serum phosphorous, total protein, serum albumin, alkaline phosphatase, AST, SGOT, LDH (Refer to the Laboratory section for billing instructions on organ and disease panels)
  • • Laboratory tests for recipients receiving continuous ambulatory peritoneal dialysis (CAPD)
  • • Monthly: serum calcium, serum bicarbonate, serum phosphorous, total protein, serum albumin, alkaline phosphatase, AST, SGOT, LDH, sodium, BUN-HTC, HGB, dialysate protein, magnesium, serum creatinine
  • Laboratory tests performed to monitor the efficiency of a facility's dialysis treatment system, for example, extra dialysis screening and kinetic modeling studies, are not separately billable.

    Parenteral Medications or Solutions

    The following parenteral medication or solutions, or both, are included in the monthly payment limit and are not separately billable:

  • • Heparin
  • • Heparin antidote (protamine)
  • • Mannitol
  • • Glucose (dextrose)
  • • Saline
  • • Local anesthetics
  • • Antiarrhythmics
  • • Antihypertensives
  • • Pressor drugs
  • • Antibiotics (when used to treat an infection of the catheter site or peritonitis associated with peritoneal dialysis)
  • Excluded Drugs and Biologicals

    Drugs and biologicals are generally covered outside the composite rate (separately bill) only if they meet the following requirements:

  • • They cannot be self-administered
  • • They are reasonable and necessary for the diagnosis or treatment of the illness or injury for which they are administered according to accepted standards of medical practice
  • • They meet all the general requirements for coverage of items as "incident to" a physician's services
  • The following drugs and biologicals are covered outside the composite rate:

  • • Hepatitis B vaccine
  • • Influenza vaccine
  • • Pneumovax (pneumococcal vaccine)
  • • Anabolics
  • • Analgesics
  • • Hematinic
  • • Muscle relaxants
  • • Non-routine parenteral care supplies
  • • Sedatives
  • • Supplies used to administer separately billable drugs and blood
  • • Tests to diagnose hepatitis B
  • • Tranquilizers
  • • Thrombolytic and thrombolysis (used to declot central venous catheters)
  • The following antibiotics are covered outside the composite rate:

    Ampicillin sodium

    Erythromycin gluceptate

    Ampicillin sodium/sulbactam

    Erythromycin lactobionate

    Azithromycin dihydrate, oral

    Flagyl

    Cefazolin sodium

    Garamycin, gentamicin

    Cefonicid sodium

    Kanamycin sulfate

    Cefotaxime sodium

    Ceftriaxone sodium

    Cefoxitin sodium

    Levofloxacin

    Ceftazidine

    Lincomycin HCL

    Ceftizoxime sodium

    Methicillin sodium

    Cephalothin sodium

    Oxacillin sodium

    Cephapirin sodium

    Oxytetracycline

    Chloramphenicol sodium suc

    Penicillin G benzathine

    Cilastatin sodium/imipenem

    Penicillin G benzathine and Penicillin G

    Colistimethate sodium

    Procaine

    Penicillin G potassium


    Services Outside the Composite Rate

    Separately billable ESRD laboratory services include all ESRD-related laboratory tests that are not covered under the composite rate. Billing of these tests must include medical documentation including the ICD-CM codes.

  • • For hemodialysis, IPD and CCPD:
  • • Serum Aluminum - limit of one every three months
  • • Serum Ferritin - limit of one every three months
  • • For CAPD:
  • • WBC, RBC, and platelet count limited to every three months
  • • Residual renal function, 24-hour urine volume limited to every six months
  • • Physician services (refer to the Physician Services for ESRD section)
  • Non-renal related services are not separately billable when provided in an independent dialysis facility.

    Billing

    Use the applicable modifier to identify whether or not tests are part of the composite rate.

    End Stage Renal Dialysis (ESRD) 50/50 Payment Rule

    Effective for dates of service on or after April 1, 2015, CMS eliminated the 50/50 payment rule that required providers to submit modifiers CD, CE and CF on ESRD laboratory services.

    For dates of service on or after April 1, 2015, do not report modifiers CD, CE or CF on laboratory services. MHCP will price ESRD laboratory services using the Clinical Laboratory Fee Schedule (CLFS) and the Automated Multi-Channel Chemistry (AMCC) payment methodology.

    Outpatient ESRD-Related Services

    The following billing instructions apply to ESRD-related services:

  • • Use ESRD CPT codes to bill for kidney disease related physician services
  • • Physicians must bill the full month or daily codes as appropriate
  • • A combination of the full month and daily MCP codes cannot be billed for ESRD-related services provided to a recipient in the same calendar month
  • • Bill all care provided to an ESRD recipient in a single calendar month on the same claim submission
  • • MHCP will deny subsequent claims received for care provided during the same calendar month
  • • Bill the appropriate full month CPT code (90951 - 90966) with one unit on the 837P claim format
  • • Use the actual date of service when billing a partial month; use CPT codes 90967-90970 on the 837P claim format
  • • Enter the number of days of ESRD-related care in the days/units field of the claim submission
  • • Claims for ESRD related care cannot be submitted until all care for the month is completed. The recipient's age at the end of the month must be used to determine the correct full month code to report
  • • Groups or associations billing for ESRD-related services under the monthly capitation option, must report the NPI of the physician who rendered or supervised the services
  • • If more than one physician in the group rendered or supervised the services throughout the month, it is not necessary to identify each providing physician for services included in the monthly charge. Report the identity of the recipient's attending physician within the group as the rendering physician for the MCP charge
  • Inpatient Billing and Non-CAP Payment

    There are circumstances where inpatient dialysis is medically appropriate and more intensive action or physician involvement is required.

  • • Use CPT codes 90935 - 90947 on the 837P claim format for dialysis sessions
  • • For inpatient dialysis, the physician must be physically present with the recipient at some time during the course of the dialysis procedure
  • Fee-for-Service and Crossover Claims

    MHCP fee-for-service claims and Medicare crossover claims bill using one of the following:

  • • HCPCS codes E1510 through E1699
  • • HCPCS codes A4650 through A4927
  • • To bill for unclassified injectable drugs, use HCPCS J3490 (Unclassified Drugs). Enter the procedure code description in the claim notes field on the 837I claim format
  • • Bill renal dialysis outpatient maintenance and home dialysis composite rate services on 837I claim format. Use one of the appropriate revenue codes:
  • • 821: Hemodialysis
  • • 831: Peritoneal
  • • 841: CAPD
  • • 851: CCPD
  • Hemodialysis for Fee-for-Service Recipients

    Bill according to the following:

  • • Composite rate with revenue code 821 on the first line item
  • • Laboratory services, drugs and blood products on subsequent line items with the date of service, the appropriate HCPCS code and number of units provided
  • Non-Crossover Claims

    Follow these billing guidelines:

  • • Hemodialysis Medicare and Medicaid claims that do not cross over: Bill the composite rate with revenue code 821, with the total amount indicated on the Medicare EOMB on one line
  • • DHS will deny services denied by Medicare on crossover claims
  • • Continuous cycling peritoneal dialysis (CCPD): Bill revenue code 851
  • • EPO administered in dialysis facility or at home
  • • Identify EPO and the number of injections with:
  • • Revenue code 634 for EPO administration under 10,000 units
  • • Revenue code 635 for EPO administration of 10,000 units or more
  • • Use value code:
  • • 48 for reporting the hemoglobin reading
  • • 49 for reporting the hematocrit reading
  • • 68 for reporting the EPO units administered during the billing period
  • • When billing both EPO supplies and administrations:
  • • Add the total units supplied with the units administered
  • • Bill the total unit as administrations only
  • • Show the total amount with Value Code 68
  • Round the number of units to the nearest 100 units of EPO furnished. One unit equals 1,000 units of EPO. (Follow Medicare guidelines for coverage, administration and billing of EPO.)

    Documentation

    Documentation requirements include the following:

  • • For dialysis recipients who do not have Medicare, maintain evidence that the recipient has applied for Medicare
  • • Attach documentation to the claim to establish medical necessity for maintenance dialysis when the frequency is more than three times per week
  • • DHS must receive documentation of Medicare coverage for ESRD recipients for drugs billable outside the composite rate
  • • When billing for an unclassified drug, enter a description of the drug in Billing/Claim Notes field on 837I claim format, including the:
  • • Date administered
  • • Name of drug or biological
  • • ICD-CM diagnosis code
  • • Route of administration
  • • Charge per dose (unit price)
  • • Statement of medical necessity
  • • Documentation of coverage for Medicare dialysis use
  • • Home dialysis recipients who use EPO must have a current care plan (the designated facility must maintain a copy of the plan)
  • • Laboratory tests for recipients receiving hemodialysis, intermittent peritoneal dialysis (IPD), and continuous cycling peritoneal dialysis (CCPD), as covered by Medicare and performed for dialysis recipients at a frequency greater than specified, are only covered if medically justified by accompanying documentation
  • Drugs Outside the Composite Rate

    Bill for allowable drugs outside the composite rate using the appropriate HCPCS code, along with revenue code 636 "Drugs Requiring Specific Information." Use the units field as a multiplier to arrive at the dosage amount.

    When the dosage amount of the drug is greater than the amount indicated for the HCPCS code, round up to determine units.

    To bill for supplies used to administer the drug, use revenue code 270 and Medical/Surgical Supplies HCPCS codes. Enter the number of administrations in the units field. This covers the cost of any size syringe, swabs, needles and gloves.

    The HCPCS code is used to identify a drug. For drugs requiring specific identification, electronically attach documentation with the claim to explain why this is billed separately from the composite rate.

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