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This section includes information on coverage policy and billing for MHCP fee-for-service recipients receiving renal dialysis and related services for End-Stage Renal Disease (ESRD). DHS follows Medicare guidelines for coverage. For dually eligible Medicare patients, refer to the coverage policy and billing requirements from Medicare.
The following providers may enroll as ESRD providers with MHCP:
• Medicare approved ESRD facilities in hospitals
• Renal transplant centers
• Renal dialysis facilities and centers
• Outpatient hospitals
• Self-dialysis units
• Special purpose renal dialysis facilities
• Medical supply providers approved by DHS to provide ESRD services. DHS will approve only those medical suppliers who have provided home dialysis equipment and supplies to Medicare beneficiaries in the past 12 months.
All renal dialysis recipients must apply for Medicare benefits as soon as dialysis begins. Refer recipients as soon as possible to the Social Security Administration (SSA) to apply for Medicare.
• All MHCP recipients are eligible for acute and maintenance dialysis
• Medicare covered patients who have not reached age 65, who suffer from "end-stage renal disease." ESRD benefits include all Part A and B items and services covered under the Medicare program. For dually eligible Medicare/Medicaid recipients, MA pays the coinsurance and deductibles amounts.
• MA recipients under age 65 who do not meet the two year disability requirements, but need dialysis or renal transplantation for treatment of end-stage renal disease, may be eligible for Medicare when one of the following conditions are met:
• Entitlement begins after a three-month waiting period if a transplant or dialysis is not needed before the three-month period ends
• Entitlement begins before the three-month waiting period if the patient needs a transplant, receives self-dialysis training, and begins the first course of self-dialysis after
For recipients, age 18 or under, a Medicare application is not required if both parents are undocumented immigrants. The provider must keep a letter signed by the parents stating they are not applying for Medicare on behalf of their minor child because they are undocumented.
DHS covers dialysis services under either Method I or Method II.
• Method I composite claims are only billable by Medicare-approved ESRD facilities. Recipients may choose to receive their dialysis at a facility or perform their own home dialysis after receiving self-dialysis training certification.
• Method II claims for home dialysis equipment and supplies are only billable by medical suppliers who have been approved by DHS to provide dialysis equipment and supplies. A dialysis facility may bill for home dialysis support services but may not bill for home dialysis equipment and supplies under Method II.
ESRD Monthly Capitation Payment (MCP)
• MCP is a global physician service payment for outpatient dialysis and ongoing evaluation and management services related to outpatient dialysis
• Payment for physician services furnished to patients on continuous ambulatory peritoneal dialysis (CAPD), and continuous cycle peritoneal dialysis (CCPD) are covered under the MCP capitation rate. The monthly payment for CAPD and CCPD include:
• Payment for both supervisory and direct care services routinely provided in connection with an ordinary course of maintenance dialysis
• For services related to the renal care of the patient
• Interpretation of the following tests:
• Bone mineral density studies
• Non-invasive vascular diagnostic studies of hemodialysis access
• Nerve conduction studies
• Electromyography studies
• All non-dialysis procedures are excluded from the MCP
The monthly capitation payment (MCP) is a comprehensive monthly payment that covers all physician services provided in connection with uncomplicated and complicated renal dialysis sessions in outpatient maintenance facilities and at home.
• Physician services of a non-supervisory nature (non-routine) that represent treatment beyond those provided in connection with the ordinary course of renal dialysis treatments
• Specific surgical services
• Interpretation of tests (not included in the MCP) with a professional component (e.g., electrocardiograms, echocardiograms, biopsies, 24 hour blood pressure monitoring, spirometry, and complete pulmonary function test)
• Complete evaluation for renal transplantation. The physician assessment of whether the recipient meets preliminary criteria as a renal transplant candidate is included under the MCP, but the complete evaluation for renal transplantation is excluded from the MCP
• Evaluation of potential living transplant donors
• Non-renal related physician's services. These services may be furnished by the physician providing renal care or by another physician
• Training of recipients to perform home or self-dialysis
• Covered physician services furnished to hospital inpatients, including services related to inpatient dialysis, by a physician who elects not to continue to receive MCP during the period of inpatient stay. In these cases, the physician receives a prorated portion of the MCP for that month
• All physician services before the initiation of outpatient dialysis
• When inpatient dialysis is necessary, the physician can be paid on a fee-for-service basis if the condition for which the recipient was hospitalized was not chronic renal disease. If the recipient was only hospitalized to receive maintenance dialysis (e.g., the only diagnosis on the claim is ESRD), the dialysis is considered an outpatient service and reimbursed under the MCP
The following services are not included in the MCP and may be separately billed on a fee-for-service basis:
For Medicare recipients, follow transportation coverage guidelines as determined by Medicare. MHCP covers the least costly mode of transportation medically necessary for the recipient. Coverage policy and billing instructions are in the Transportation Services section of this manual.
• Patients receiving maintenance dialysis on an outpatient basis do not generally require ambulance transportation
• Ambulance transportation must meet the criteria outlined in Transportation Services
• Ambulance transportation of ESRD patients to and from Medicare approved renal dialysis facilities may be covered when certain medical necessity conditions are met. Examples of such conditions include, but are not limited to, the patient being bed confined before and after the ambulance trip
• Physicians must determine the medical necessity for ambulance and special transportation for dialysis treatment
• Patients may receive special transportation with an approved Level of Need Assessment conducted by Minnesota Non-Emergency Medical Transportation (NEMT)
Recipients not eligible for special transportation may use common carrier transportation by contacting MNET (Metro) or their local county agency (Greater Minnesota). Refer to the Access Services section of this manual.
• MHCP covers dialysis and related services for the first three months of therapy under fee-for-service. Recipients must submit a formal application to the Social Security Administration to apply for Medicare coverage for dialysis services. If Medicare coverage is denied, attach a copy of the denial to the ESRD claim.
• When used in the treatment of life threatening drug overdose, hemoperfusion is a covered service for patients with or without renal dialysis. Hemoperfusion is also covered when used in conjunction with deferoxamine (DFO) to treat aluminum toxicity.
• Apheresis is covered in renal patients only when performed as plasma exchange in the treatment of glomerulonephritis associated with antiglomerular basement membrane antibodies and advancing renal failure or pulmonary hemorrhage.
• All E/M services related to the patient's ESRD, rendered on a day when dialysis is performed and all other patient care services rendered during the dialysis procedure are included in the dialysis procedure.
• If the facility fails to furnish any part of the items and services covered under the composite rate, either directly or under arrangements, payment cannot be made for any part of the services provided.
• Separately billable drugs must be approved for coverage by Medicare and may only be billed by an ESRD facility if they are actually administered in the facility by the facility staff.
• Payment may not be made directly to home health agencies for dialysis-related services provided in the home or a facility.
• EPO is not separately covered when administered in a renal dialysis facility under the "incident to" provision.
• Artificial kidney machines, accessories and dialysis supplies can only be used for dialysis patients. DHS pays for rental only, no purchase of equipment unless the recipient is denied Medicare coverage from SSA.
• Water purification systems are covered for patients on home hemodialysis. DHS will cover either a deionization or reverse osmosis system, but not both for the same patient at the same time.
The following are not covered when provided by a dialysis facility:
• Items or services not medically necessary for the diagnosis or treatment of ESRD or do not improve the patient's condition
• Hemoprofusion used to improve the results of hemodialysis or in conjunction with DFO to remove iron overload
• Apheresis used before or after kidney transplant services
• Missed appointments. If the facility prepares for a dialysis treatment, but the treatment is never provided, no payment is made
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
• Subsequent claims received for care provided during the same calendar month will be denied
• 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
• The number of days of ESRD-related care must be entered 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
There are circumstances where inpatient dialysis is medically appropriate, and more intensive action/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
Acute Dialysis: Dialysis given to patients who are not ESRD patients, but who require dialysis because of temporary kidney failure due to a sudden trauma; or ingestion of certain drugs or back-up dialysis under special circumstances.
Apheresis: Autologous procedure when performed as plasma exchange in the treatment of glomerulonephritis
Biological: A medicinal preparation made from the living organisms and their products. These include serum, vaccines, and antitoxins.
Continuous Ambulatory Peritoneal Dialysis (CAPD): A variation of peritoneal dialysis, which is a continuous dialysis process using the patient's peritoneal membrane as a dialyze. The solution exchange is performed manually by the patient. The exchange is performed three to five times per day.
Continuous Cycling Peritoneal Dialysis (CCPD): A treatment modality which combines the advantages of long dwell, continuous steady state dialysis of CAPD and the advantages of automation inherent in intermittent peritoneal dialysis (IPD).
Continuous Renal Replacement Therapy (CRRT): A short-term treatment in critically ill patients with acute or chronic renal failure. It is an alternative treatment to the standard intermittent hemodialysis treatment. CRRT is covered only as an inpatient in the critically ill setting using FDA approved procedures and machines.
Dialysis: A process by which waste products are removed from the body by diffusion from one fluid compartment to another across a semi-permeable membrane. There are two types of renal dialysis:
• Hemodialysis: A process by which blood passes through an artificial kidney machine and the waste products diffuse across a man-made membrane into a bath solution, known as dialysate, after which the cleansed blood is returned to the patient's body
• Peritoneal Dialysis: A process by which fluid (dialysate) waste products pass from the patient's body through peritoneal membrane into the peritoneal abdominal cavity where the bath solution is introduced and removed periodically
Drugs: A substance recognized in an official pharmacopeia or formulary which is used in the diagnosis, cure, mitigation, treatment or prevention of disease.
End-Stage Renal Disease (ESRD): Or "chronic kidney failure" is a stage of renal impairment requiring either a regular course of dialysis or kidney transplantation to maintain life.
Epoetin (EPO): A biologically engineered protein which stimulates the bone marrow to make new red blood cells. Chronic renal failure patients with symptomatic anemia considered for EPO therapy should have a hematocrit less or equal to 36% or hemoglobin less than 10 grams when therapy is initiated.
Hemofiltration (diafiltration): A process that removes fluid, electrolytes, and other toxic substances from the blood by filtration through hollow artificial membranes. The process requires an arteriovenous access.
Hemoperfusion: A process which removes substances from the blood through the dialysis membrane by using a charcoal or resin artificial kidney.
Home Dialysis Equipment: Home dialysis equipment includes all the medically necessary home dialysis equipment prescribed by the physician including, but not limited, to artificial kidney and automated peritoneal dialysis machines, and support equipment.
Inpatient Dialysis: Dialysis furnished to ESRD patients on a temporary inpatient hospital basis.
Intermittent Peritoneal Dialysis (IPD): A process where waste products pass from the body through the peritoneal membrane into the peritoneal cavity where the dialysate is introduced and removed periodically by a machine.
Maintenance Dialysis: Dialysis treatments given to patients with ESRD in order to sustain life. Maintenance dialysis is generally required two to three times per week.
Method I - Composite Rate: A payment option for dialysis services to patients who receive staff-assisted dialysis or home dialysis treatment from a renal dialysis facility.
Method II: A payment option for dialysis services to patients who obtain all necessary supplies and equipment for home dialysis from a single home dialysis supplier.
Outpatient Dialysis: Dialysis provided on an outpatient basis at a renal dialysis center or facility. Includes:
• Staff-assisted dialysis
• Self dialysis
• Home dialysis
• Self-dialysis and home dialysis training
Renal Dialysis Facility: A Medicare certified facility where maintenance dialysis is furnished to outpatients.
Self-dialysis: Performed with little or no professional assistance by the ESRD patient including a helper, where applicable, who has completed an appropriate course.
Staff-assisted Dialysis: Dialysis performed by the staff of the center or facility.
Ultrafiltration: Process where excess fluid is removed through the dialysis membrane by means of pressure. Not a substitute for dialysis.
Minnesota Rules 9505.0170
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Minnesota Rules 9505.0210
Minnesota Rules 9505.0392
42 CFR 413 subp.A-I
42 CFR 414.300-414.335
42 CFR 405 subp.U, 405.2100-405.2184
CPT codes, descriptions and other data only are copyright 2002 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.