Appeal type: unknown
Decision: unknown

 
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, for dialysis sessions that have been furnished 3 times (3X) per week, each line should be 
90999 without any modifiers appended. That is, when the hemodialysis-prescription is 3 times (3X) per week 
and each session is furnished, all of these sessions be billed as 90999 (no modifier appended) and they will be 
paid as routine conventional dialysis up to 13/14 per month. 
 
For each dialysis sessions furnished in addition to the 3 sessions per week that do not include medical 
documentation supporting a reasonable and necessary determination for payment, each line for these sessions 
should be billed as 90999 CG. Examples of when this could occur include short, more frequent treatments 
furnished for the convenience of the patient or staff, etc. Additional sessions need to be billed as 90999 CG 
when medical documentation has not been submitted to support the extra sessions as reasonable and necessary. 
The CG modifier indicates that the facility attests the additional treatment is not reasonable and necessary and 
should not receive additional payment. Each line billed as 90999 CG will be denied. However, the use of the 
modifier is used for data analysis. Please refer to CR 9989, Implementation of Modifier CG for Type of Bill 
72X, dated May 12, 2017. 
 
For each dialysis session furnished in addition to 3 sessions per week that includes medical documentation 
supporting a reasonable and necessary determination for payment, each line for these services should be billed 
as 90999 KX. These include medical conditions for acute and occasionally chronic conditions that have 
supporting documentation that the extra sessions are reasonable and necessary (e.g. through documents from 
recent hospital care, office visits, dialysis progress notes or MCP visits). These sessions must be reasonable and 
necessary for additional payment based on clinical conditions. On these claims, the 90999 lines without a 
modifier will be paid as 3X per week and those lines with 90999 KX will be considered for additional 
payments. Omission of the KX modifier will result in no additional payment for the line item. For diagnoses 
not listed in this article but felt to be reasonable and necessary, the KX modifier should be appended as well. A 
denial will occur on these lines, but the redetermination process (an appeal) will be available to submit 
supportive documentation for review.  
The expectation is that these three scenarios will be seen on monthly claims, i.e., claims with 90999 lines only, 
or those with lines of 90999 mixed with 90999 CG or KX modifier appended. Ongoing data analysis may 
trigger provider specific requests for documentation should unusual patterns occur, i.e., claims with only lines 
of 90999 KX submitted. 
 
You can find this rule at Local Coverage Article (LCA) A55672: Billing and Coding: Frequency of 
Hemodialysis. 
 
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.