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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the following are required information for in-facility claims paid under the End Stage Renal 
Disease Prospective Payment System (ESRD PPS): 
48 - Hemoglobin Reading - Code indicates the most recent hemoglobin reading taken before the start of 
this billing period. This is usually reported in three positions with a decimal. Use the right of the 
delimiter for the third digit. The blood sample for the hemoglobin reading must be obtained before the 
dialysis treatment. If a hemoglobin value is not available facilities 
must report the value 99.99. 
49 - Hematocrit Reading - Code indicates the most recent hematocrit reading taken before the start of 
this billing period. This is usually reported in two positions (a percentage) to the left of the dollar/cents 
delimiter. If the reading is provided with a decimal, use the position to the right of the delimiter for the 
third digit. The blood sample for the hemoglobin 
reading must be obtained before the dialysis treatment. If a hematocrit value is not available facilities 
must report the value 99.99. 
You can find this information in the Centers for Medicare & Medicaid Services Medicare Claims Processing 
Manual, Chapter 8, Section 50.3. 
 
The rules say that all End Stage Renal Disease (ESRD) claims with dates of service on or after July 1, 2010 
must indicate the applicable Kt/V reading for the dialysis patient. The reading result and the date of the reading 
must be reported on the claim using the following claim codes: 
 Value Code D5: Result of last Kt/V reading. For in-center hemodialysis patients this is the last reading 
taken during the billing period. For peritoneal dialysis patients and home hemodialysis this may be 
before the current billing period but should be within 4 months of the claim date of service. 
* Hemodialysis: For in-center and home-hemodialysis patients prescribed for three or fewer treatments per 
week, the last Kt/V obtained during the month must be reported. Facilities must report single pool Kt/V using 
the preferred National Quality Forum (NQF) endorsed methods for deriving the single pool Kt/V value: 
Daugirdas II or Urea Kinetic Modeling (UKM). The reported Kt/V should not include residual renal function. 
A value of 8.88 shall be entered on the claim if the situation exists that a patient is prescribed and receiving 
greater than three hemodialysis treatments per week for a medically justified and documented clinical need. 
The 8.88 value is not to be used for patients who are receiving extra treatments for a temporary clinical need 
(e.g. fluid overload). A medical justification must be submitted for patients receiving greater than 13 treatments 
per month. 
* Peritoneal Dialysis: When measured the delivered weekly total Kt/V (dialytic and residual) should be 
reported. 
This code is effective and required on all ESRD claims with dates of service on or after July 1, 2010. In 
the event that no Kt/V reading was performed providers must report the D5 with a value of 9.99. 
Occurrence Code 51: Date of last Kt/V reading. For in-center hemodialysis patients, this is the date of the last 
reading taken during the billing period. For peritoneal dialysis patients and home hemodialysis patients, this 
date may be before the current billing period but should be within 4 months of the claim date of service. This 
code is effective for ESRD claims with dates of service on or after July 1, 2010. This code not required when 
reporting value code D5 with a value of 9.99 indicating no Kt/V reading is available for reporting or value 8.88 
to indicate the patient is prescribed and receiving greater than 3 hemodialysis treatments per week for a 
medically justified and documented clinical need. 
You can find this rule in the Centers for Medicare & Medicaid Services Medicare Claims Processing Manual, 
Chapter 8, Section 50.9. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.